Every finding on record at Rayburn Health Care & Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 2 of 2 medication carts (Medication Cart L and Medication Cart R) reviewed for labeling and storage. The facility failed to ensure Medication Aide A's (the only assigned staff for medication administration on the secure unit.) assigned medication cart's (Medication cart L, and Medication cart R) were kept locked and under direct observation where 13 residents and unauthorized staff could not access it when left on the hall of the secure unit for four minutes. This failure could place residents at risk of gaining access to and swallowing medications not prescribed for them.Findings included: During an observation on 02/11/2026 from 4:00 p.m. to 4:04 p.m., Medication Aide A's Medication Carts R and L were noted to be unsecured and unsupervised on the secure unit. The Medication Cart R was front facing against the wall with the drawers facing the hallway with the lock mechanism out with the keys inside (indicating it was unlocked). Medication Cart L was front facing against the wall with the second drawer open. Medication Cart L was observed with one white pill in a medication cup on top of the unattended and unsupervised medication cart. Observation of Medication Cart L indicated it had a medication cup with white crushed specks with a brown substance and a wooden spoon inside left unattended and unsupervised. The secure unit housed 13 residents. There was one visitor and 4 residents (sitting in chairs talking to each other.) in the hallway approximately 15 feet from medication cart R and L. the medication cart. Further observation indicated at 4:04 p.m. Medication Aide A was observed exiting the employee break room approximately 75 feet away from the unlocked medication carts (R and L). Further observation of Medication Carts R and L, with Medication Aide A, indicated inside the Medication Cart L and R Drawer #1 were OTC (over the counter) aspirin, vitamins, minerals and eye drops and drawer #2 contained multiple resident's individual bubble-blister packets that contained medications. During an interview on 02/11/2026 at 4:05 p.m., Certified Medication Aide A said she was in charge of the carts. She said she administered medication on the secure unit. Certified Medication Aide A said she was sorry for leaving the cart open, I shouldn't have left the keys there either. Certified Medication Aide A said she went to the employee break room to get a drink of water. Certified Medication Aide said she forgot to lock both carts (R and L) and take the keys out of the lock on Medication Cart R before she stepped away from it. Certified Medication Aide A said the cart should not be unlocked and unattended because anyone walking on the secure unit could get into the medications and risk medication theft or diversion. She said she was setting up medications and went to get a drink of water and that was the reason she left the medications on top of Medication Cart L. She said the reason Medication Cart R was left with the keys inside the lock was due to her getting trash bags out for the trash cans. Certified Medication Aide A said she was in-serviced on keeping the medication cart locked at all times when not in use. During an interview on 02/11/2026 at 4:20 p.m., the DON said she expected the certified medication aides to follow the facility policy and procedure for medication pass and drug safety. She said the medication carts should be locked if staff walked away from it or turned their back to it. The DON said the certified staff member that was in charge of the medication cart (nurse or certified medication aide) was responsible for making sure the medication carts were locked at all times when not in use. She said she had in-serviced nursing staff to keep the medication cart locked at all times. She said medication aides were trained during orientation, annually and as needed, on medication administration and securing medications. During an interview on 02/11/2026 at 4:30 p.m., the Administrator said her expectation was that staff would follow medication safety policy and procedures related to locking and securing the medication cart when not in use. She said all nursing staff, including medication aides, were responsible for securing medications when not in use. She said the potential risk of unsecured medication cart was residents or visitors getting into the cart. Record review of the facility's Security of Medication Cart policy and procedure, dated April 2007, Policy Statement: The medication cart shall be secured during medication passes.

Based on observation, interviews and record review, the facility failed to review and revise resident's comprehensive care plans based on changing goals, preferences and needs of the resident and in response to current interventions for 4 of 18 (Residents #1, #3, #35, and #41) residents reviewed for comprehensive care plans.1.The facility failed to ensure Resident #1's care plan was updated to indicate Resident #1 had a diet change of Low Concentrated Sweets, pureed textures with nectar/mildly thick consistency on 06/15/2025.2. The facility failed to ensure Resident #3's care plan was updated for her change from Full Code to DNR on 01/07/26.3. The facility failed to ensure Resident #35's care plan was updated to indicate d Resident #35 had oxygen on 01/11/26. 4. The facility failed to ensure Resident #41's care plan was updated to indicate Resident #41 had an immobilizer applied to her (l) shoulder, upper arm and elbow on 1/9/2026. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs. Findings Included: 1.Record review of Resident #1's admission Record dated 01/20/2026 indicated she was an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included pneumonia (inflammation and fluid in your lungs caused by a bacterial, viral or fungal infection), dementia (loss of cognitive functioning), cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), dysphagia (difficulty swallowing) following cerebral infarction, and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #1's quarterly MDS assessment, dated 11/26/2025, indicated she was unable to complete an interview for BIMS score because she was rarely/never understood. She had short- and long-term memory loss and severely impaired cognitive skills for daily decision making. She rarely/never made herself understood and rarely/never understood others. She had behaviors of inattention (difficulty focusing attention, easily distracted or having difficulty keeping track of what was being said) indicated during the 7-day look back period prior to completing the MDS assessment. The functional abilities self-care indicated she is dependent with all tasks. Her functional abilities mobility indicated she is dependent with all tasks. She used a manual wheelchair for mobility dependent on staff. Her nutritional approach indicated Mechanical altered therapeutic diet. Record review of Resident #1's physician order dated 06/12/2025 indicated a Low concentrated sweet diet with pureed texture, nectar/mildly thick consistency. Record review of Resident #1's care plan, revision dated 07/21/2024, indicated her diet was a therapeutic or altered consistency diet of low concentrated sweet diet, no salt on table mechanical soft texture with nectar thick liquids/chopped meats. The care plan did not indicate Resident #1 had an updated or revised care plan for new diet order on 06/12/2025 indicated a Low concentrated sweet diet with pureed texture, nectar/mildly thick consistency. Further review of care plan indicated no interventions added since 07/21/2024. During an observation on 1/19/2026 at 12:45 p.m., revealed Resident #1 was being fed a pureed diet with nectar/mildly thick consistency by CNA C and the SLP was standing by monitoring the feeding process. During an interview on 1/19/2026 at 12:46 p.m., CNA C said Resident #1 was on a pureed diet and must be fed and encouraged to swallow the food and not pocket it. CNA C said Resident #1 did not seem to pocket her food much at breakfast but tended to pocket food at lunch, but staff must monitor her closely and encourage her to swallow food at each meal. During an interview on 1/19/2026 at 12:50 p.m., the SLP said she had been working with Resident #1 since December 2025 after returning to facility following a hospital stay. She said Resident #1's dementia had progressed, and she was holding or pocketing food and forgetting to swallow the food during some meals. The SLP said she monitored Resident #1 during some meals and instructed staff on encouraging Resident #1 to swallow the food to avoid food pocketing and aspiration (when food, liquid, salvia, or stomach contents enter the airway and lungs instead of esophagus/tube to stomach). The SLP said Resident #1 had been on a pureed textured diet with mildly thick consistency since December 2025. 2. Record review of a face sheet dated 01/19/26 indicated Resident #3 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), hypotension (a condition in which the force of the blood against the artery walls is too low), cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), hypertension heart disease (heart problems that arise due to prolonged high blood pressure), and kidney failure (condition where the kidney reaches advanced state of loss of function). Record review of an OOH-DNR dated 01/07/26 indicated Resident #3 wished to have no CPR (an emergency lifesaving procedure performed when the heart stops beating), transcutaneous cardiac pacing, defibrillation (a non-invasive emergency procedure used to temporarily stimulate the heart in patients), advanced airway management (procedures used to ensure a patient is receiving adequate oxygen), or artificial ventilation (a medical procedure used to assist or stimulate breathing in individuals who are unable to breathe adequately on their own). Record review of physician orders for January 2026 indicated Resident #3 had an order dated 01/14/26 for DNR but the care plan was not updated as of 01/19/26 to include the DNR. Record review of a care plan reviewed on 12/23/25 indicated Resident #3 was care planned as a Full Code-one who has chosen to receive all possible life-saving treatments in the event of cardiac or respiratory arrest. During an observation and interview on 01/19/2026 at 09:05 a.m. Resident #3 was sitting in the common area in the hallway. She said she was doing fine. She was not able to answer any questions regarding her DNR status. During an interview on 01/21/2026 at 10:17 the MDS Nurse said she was responsible for updated care plans. She said she was made aware of Resident #3's DNR and had updated the care plan as of 01/20/26 (after surveyor intervention). 3. Record review of a face sheet dated 01/20/26 indicated Resident #35 was an [AGE] year-old male admitted on [DATE]. Her diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), lung disorder (health conditions that affect your airways (tubes leading into your lungs) or tissue that makes up your lungs), and kidney disease (condition where the kidney reaches advanced state of loss of function). During an observation and interview on 01/19/2026 at 09:02 a.m. Resident #35 was in his bed in his room. An oxygen concentrator was at the bedside with a nasal cannula attached. Resident #35 said he was doing fine and had no issues. Record review of an MDS dated [DATE] indicated Resident #35 had severely impaired cognition with a BIMS of 01 out of 15 and he had no oxygen use for the look back period. Record review of the Nurse Notes with entry dated 01/11/2026 at 08:29 a.m. Resident #35 was non-responsive. His pupils were pinpoint and non-reactive. His vital signs were BP 110/52, P 48, RR 18, Oxygen saturation was 95% on room air. Hospice was notified. The RP was notified. The nurse with hospice indicated a hospice nurse would come to assess Resident #35. Oxygen at 2 liters per nasal cannula was applied. Record review of the care plan reviewed 01/09/26 indicated Resident #35 was care planned for shortness of breath and was revised on 03/20/25. There was no intervention of oxygen use. Resident #35 was not care planned the use of oxygen and how much, O2 tubing and humidifier changing. During an interview on 01/20/2026 at 01:15 p.m. LVN H said she received a verbal order from the hospice nurse to place Resident #35 on oxygen on 01/11/26 due to a decline in condition. During an interview on 01/21/2026 at 10:17 a.m. the MDS Nurse said she was responsible for updated care plans. She said she was not aware of Resident #35's order for oxygen. She said she was not aware of Resident #35's oxygen order. She said the care plans should be updated when an order was received from the physician. Record review of an Oxygen Administration policy revised October 2010 indicated Preparation: .2. Review the resident's care plan to assess for any special needs of the resident. 4. Record review of Resident #41's admission Record dated 01/20/2026 indicated she was an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included senile degeneration of brain (mental deterioration associated with aging), atherosclerotic heart disease (a condition where the blood vessels become narrowed and hardened due to buildup of fats in the blood vessel wall), hypertension (a condition in which the force of the blood against the artery walls is too high), hypertensive heart disease (is a condition with damage to your heart from years of unmanaged or undermanaged high blood pressure), fracture of shaft of left humerus (broken bone upper arm), and osteoporosis (condition in which bones become weak and brittle). Record review of Resident #41's quarterly MDS assessment, dated 11/11/2025, indicated she had a BIMS score of 09 indicating that she was moderately impaired cognitively. She made herself understood and usually understood others. She required maximum assistance for self-care of toilet hygiene, upper and lower body dressing, and putting on/taking off footwear. She required set up and clean up assistance with eating, oral hygiene and personal hygiene. She required maximum assistance for mobility of sit to lying, lying to sitting, sit to stand, and chair/bed to chair transfer. She required moderate assistance to roll left and right and supervision or touch assistance with toilet transfer. She uses a manual wheelchair for mobility with moderate assistance from staff. Record review of Resident #41's progress note dated 01/05/2026 indicated the nurse was summoned to resident's room, and the resident was observed on the floor in supine position. She had a hematoma (localized swelling of blood that occurs when a vessel ruptures) with laceration to right side of head. She stated she was reaching for water bottle on the floor and fell. She complained of pain, pain medication administered. She was able to move all extremities. She was transferred to local ER by local ambulance service for evaluation and treatment. Record review of Resident #41's progress note dated 01/09/2026 indicated she returned to the facility and readmitted . She was able to move all extremities with limitations, and a splint to her left arm was in place. Record review of Resident #41's care plan, revision dated 08/20/2025, indicated she had a risk for falls and a fracture of left humerus (upper arm bone) related to fall prior to admission. The care plan did not indicate Resident #1 had an updated or revised care plan for 01/09/2026 for a fall on 01/05/2026 or new intervention for fracture of shaft of left humerus or for immobilizer/splint to (l) shoulder, arm, and elbow until after surveyors' intervention. Further review of care plan indicated no interventions added since 08/20/2025 for fall interventions and intervention of splint to remain in place until follow up appointment added 1/20/2026 (after surveyors' intervention). During an interview and observation on 01/19/2026 at 10:26 a.m., revealed Resident #41 was up in a wheelchair in the hallway, requesting staff to place her shirt/blouse on. Staff informed Resident #1 due to the immobilizer that her shirt/blouse sleeve would not fit over the splint/immobilizer. Resident #41 said she had a sling on her (l) arm and after her recent fall a new splint/immobilizer was applied. She said she thought the local ER applied the splint/immobilizer. During an interview on 1/19/2026 at 10:28 a.m., CNA E said Resident #41 was admitted to the facility with a fractured (l) arm and had a recent fall (01/05/2026) and was sent to the local ER and returned several days later with the splint/immobilizer to her (l) shoulder, upper arm, and elbow. She said that Resident #41 had a sling prior to the fall on 01/05/2026 and she could wear her blouses but now that she had the immobilizer/splint her blouse sleeves would not fit over the splint. CNA E said she had the splint/immobilizer since she returned from the hospital about 1 to 1.5 weeks ago. During an interview on 01/20/2026 at 11:00 a.m., the Administrator said Resident #41 had fallen on 01/05/2026 and was sent to the local ER for evaluation. She said Resident #41 was transferred to an inpatient hospice facility after her ER visit. She said Resident #41 returned to the local ER for pain from the inpatient facility and was transferred back to the facility. She said Resident #41 returned to the facility on [DATE] with the new immobilizer/splint to (l) shoulder, arm, elbow. She said hospice informed the facility that family had decided to have Resident #41 seen by an orthopedic for the (l) arm/shoulder injury and an orthopedic visit was scheduled by hospice. During an interview on 01/21/2026 at 12:15 p.m., LVN A said she was the nurse for Resident #41. She said Resident #41 was admitted to the facility with a fractured (l) arm and she was supposed to wear a sling but was not compliant with wearing the sling. She said today (01/21/2026) was her first day back on the hall and she was not aware Resident #41 had a new immobilizer/splint to her (l) shoulder/arm/elbow. She said Resident #41 was out of the facility at an orthopedic appointment for a reevaluation for her (l) shoulder, arm, elbow this morning and was awaiting her return. She said when residents had changes in care, the care plans were revised or updated by the MDS Coordinator or DON. During an interview on 01/21/2026 at 1:15 p.m., the MDS Nurse said she participated in morning meetings, reviewed orders, 24-hour reports and incident reports and allegations. She said those were discussed during the morning meeting, if residents' care plans required updating and/or an IDT care plan meeting she would schedule it, if applicable. She said she recently took over the responsibilities of the MDS Coordinator when the previous MDS Coordinator retired. She said that Resident #1's care plan should have been updated with the current diet texture and Resident #41's care plan should have included interventions related to the splint/immobilizer to (l) shoulder, arm, and elbow when she returned from the hospital on [DATE]. She said not updating the residents' care plans could place residents at risk of not receiving appropriate interventions to meet their current needs. She said she was responsible for updating or revising care plans and the DON reviews the care plans for completion. She said if care plans were not updated or revised, the care plan would not reflect the current residents' needs. During an interview on 01/21/2026 at 01:30 p.m., the Regional Nurse said the MDS Coordinator was responsible for updating or revising resident care plans when needed. She said DON was responsible for reviewing for accuracy. She said that Resident #1's care plan should have been updated with the correct diet texture and Resident #41's care plan interventions should have included the splint/immobilizer to the (l) arm, and she had added it to Resident #41's care plan on 01/20/2026. She said if care plans were not updated or revised, the care plan would not reflect the current residents' needs. During an interview on 01/21/2026 at 1:40 p.m., the DON said that all incidents and allegations were discussed during morning meetings (including herself, Assistant DONs, Administrator, department heads, MDS Coordinator, and Regional Nurse per phone if needed) and the MDS coordinator was notified of any changes requiring care plan revisions, and she was responsible for updating the care plans. She stated new interventions should be added to the care plan regarding Resident #1's diet change and Resident #41's (l) shoulder, arm, and elbow immobilizer. She said the MDS Coordinator was responsible for updating and revising the care plan as indicated. She said she was responsible for monitoring and ensuring that the care plans were completed and updated by the MDS Coordinator. She said if care plans were not updated or revised, the care plan would not reflect the current residents' needs. During an interview on 01/21/2026 at 02:00 p.m., the Administrator said she expected staff to update and revise residents care plans to accurately reflect the residents' needs. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised in 2023 indicated; Policy statement: A comprehensive, person-centered care plan that includes measurable objects and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 11. Assessments of residents are ongoing, care plans are revised as information about the residents and residents'' condition change.

Based on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 1 Medication Storage room and 1 of 3 medication carts (Hall 400 medication cart) reviewed for pharmacy services.The facility failed to remove expired normal saline (sodium chloride) vials that expired on 04/2025 from Hall 400 medication cart. The facility failed to ensure 2 individual prefilled 0.9 % normal saline (sodium chloride) vials for injection with an expiration date of [DATE], 13 red top plastic lab vials (small sealed container to store, transport and analyze liquid or solid samples in scientific settings) with an expiration date of [DATE] and 5 light green top plastic lab vials with an expiration date of [DATE] were removed from use in the Medication storage room.These failures could place residents at risk for not receiving the intended therapeutic response of medications and items which could result in diminished health and well-being.Findings included:During an observation and interview on [DATE] at 9:10 a.m., an inspection of Hall 400 medication cart with LVN A indicated 2 opened 0.9% sodium chloride 15 ml vials (typically used for cleansing, irrigation or wound care or washing eyes) with an expiration date of 04/2025 and 3 unopened 0.9% sodium chloride 15 ml vials with an expiration date of 04/2025. LVN A said she was responsible for Hall 400 medication cart today. She said the nurse that gave medication from the medication cart was responsible for checking for expired medication and items and the ADON double checked the medication carts monthly for expired medication and items. She said they were overlooked. LVN A said she had not given any of the expired medication or items today, and today ([DATE]) was her first day back on the cart after time off during her shift rotation. She said she was in-serviced to check her medication cart for expired medication and items. LVN A said the resident risk of expired medication and items on the medication cart was they may potentially not be as effective as they should be. During an observation and interview on [DATE] at 9:40 a.m., an inspection of the facility medication storage room with the MDS Nurse indicated 2 individual prefilled 0.9 % normal saline (sodium chloride) vials for injection (typically used for intravenous administration) 6.0 ml with an expiration date of [DATE] and 13 red top plastic lab vials (small sealed container to store, transport and analyze liquid or solid samples in scientific settings) with an expiration date of [DATE] and 5 light green top plastic lab vials of 4.5 ml with an expiration date of [DATE]. The MDS Nurse said the facility was no longer using the lab facility that used those vials, they had changed lab companies recently. She said the administrative nurses, ADON, MDS Nurse and DON were responsible for ensuring the medication room did not have expired medication and items and the pharmacy consultant was the backup that checked the medication carts and medication room monthly. She said she was in-serviced recently on ensuring the medication storage room did not have expired medication and supplies. She said the expired items should have been removed from the medication storage room. The MDS Nurse said the resident risk of expired medication and items was they potentially could be used on a resident and not be as effective as should be and the labs could be inaccurate. During an interview on [DATE] at 9:49 a.m., the ADON said she was responsible for reviewing the medication room for expired medication and items and drug destruction. She said she last checked the medication room yesterday ([DATE]) but the expired items were overlooked. The ADON said the facility recently changed lab facilities and were no longer using the found expired lab vials. She said the nurses that gave medication off the medication carts were responsible for the medication carts and she made random checks for expired medication on the medication carts. The ADON said she had not checked the medication carts this week. She said the nurses and MAs were educated to monitor medication carts for expired medication. She said the potential resident risk was abnormal lab values if the expired lab vials were used and the expired medication may not be as effective as they should be. During an interview [DATE] at 9:54 a.m., the DON said she started working at the facility Tuesday ([DATE]) of last week. She said the nurses giving medication were responsible for ensuring all expired medication was removed from the medication carts. The DON said the ADON, MDS and DON were the back up to double check the medication carts. The DON said the nurses were responsible for ensuring the medication room was tidy and all expired medication and items were removed and the ADON, MDS and DON were the back up and would check monthly and as needed. She said the staff were in-serviced on removal of expired medication and items. She said the resident risk of expired medication and items was the medication may not be as effective and not take care of what it was meant to take care of. The DON said they were overlooked. She said her expectation was medication or items that were out of date to be removed from service before expiration. During an interview on [DATE] at 10:05 a.m., the Administrator said the nurses were responsible for medication carts with monthly checks by the pharmacy consultant and the ADON was responsible for the medication room with the DON as a backup to double check for expired medication and items. She said the staff were educated on reviewing the medication room and medication carts for expired medication and items. The Administrator said the expired medication and items were overlooked. She said the resident risk of expired medication and items in use was they may potentially not be as effective. The Administrator said her expectation was the medication room and medication carts be clean and organized with no expired medication or items. Record review of the Executive Summary of Consultant Pharmacist's Medication Regimen Review dated [DATE] indicated, .Overall, the carts/medication room were found secured, clean, and organized. Continue to secure internal/external medication stored separately. The staff is doing a good job removing expired/ discontinued medications with very few expectations. Continue to ensure medications requiring a date opened are dated. Record review of a facility policy revised [DATE], titled, Administering Medications: indicated, . 12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 12 residents (Residents #8, #28, #35 and #39) observed for Infection Control. 1. The facility failed to implement EBP for Resident #8 during a G-tube dressing change on 01/20/2026.2. The facility failed to immediately implement Contact Isolation Precautions for Resident #28 when she admitted on [DATE], for MRSA of a wound.3. The facility failed to ensure the enhanced barrier precaution signage was posted on Resident #39's door. 4. The facility failed to ensure Resident #35's oxygen tubing was labeled and dated and the nasal cannula was not laying on the floor. 1. Record review of admission Record dated 01/20/2026, indicated Resident #8 was [AGE] years old with diagnosis including protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), dysphagia (difficulty swallowing) and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food) tube status. Record review of Resident #8's quarterly MDS assessment dated [DATE] indicated she had a BIMS score of 15 indicating that she was intact cognitively. She usually made herself understood and usually understood others. She required maximum assistance for self-care and mobility tasks. She receives nutrition and water by tube feeding. Record review of Resident #8's care plan, dated 08/06/2024, indicated Resident #8 required tube feeding related to dysphagia and protein-calorie malnutrition and enhance barrier precautions. Interventions included gowns and gloves are recommended when performing high-contact resident care activities, residents are not restricted to their rooms and do not require placement in a private room, and EBP do not impose the same activity and room placement restrictions as contact precautions, they are intended to be longer-term approach to managing individuals colonized with targeted pathogens. Record review of physician's orders for Resident #8 dated 10/17/2025 indicated requirements: 1. Gowns and gloves are recommended when performing high-contact resident care activities, 2. Residents are not restricted to their rooms and do not require placement in a private room, 3. EBP do not impose the same activity and room placement restrictions as contact precautions, they are intended to be longer-term approach to managing individuals colonized with targeted pathogens every shift. USE for residents with any of the following (when contact precautions do not otherwise apply): wounds or indwelling medical devices regardless of MDRO colonization status infection or colonization with MDRO During an observation on 01/19/2026 at 10:55 a.m., revealed outside Resident #8's room was an EBP signage. There was a 3-drawer PPE cart located at entrance to Resident #8's room. During an interview on 01/19/2026 at 10:56 a.m., Resident #8 said that facility staff performed her G-tube dressing change on the night shift, usually late night or early morning. She thought they wore gowns and gloves during the care, but she usually slept through the procedure. During an observation on 01/20/2026 at 2:26 p.m., revealed LVN B provided G-tube dressing change. LVN B did not wear a gown during the dressing change/direct contact with Resident #8. During an interview on 01/20/2026 at 2:40 p.m., LVN B said that she failed to follow the EBP because she forgot to wear a gown during the G-tube dressing change. She said she had been trained on EBP and should have applied a gown prior to entering the room to perform care to Resident #8's G-tube but forgot. She said that not wearing a gown during the G-tube dressing change could spread infection or cross contamination. During an interview on 01/21/2026 at 1:40 p.m., the DON said she was recently hired at the facility. She said her expectations were for staff and visitors to perform hand hygiene upon entering and when leaving a resident's room, and when hands were soiled. She said EBP should be followed by staff with direct care provided to residents with MDROs, wounds, and indwelling devices. The DON said the risk of failing to perform EBP could lead to spread of infection to other residents or even staff. During an interview on 01/21/2026 at 3:26 p.m., the Administrator said her expectations were that all staff adhere to the EBP when providing high contact care for residents with MDROs, wounds, and indwelling devices. She said not following EBP as required could cause spread of infection or cross contamination. 2. Record review of Resident #28's admission Order Summary Report dated 12/29/2025, indicated Resident #28 was [AGE] years old with diagnosis including a cutaneous abscess of buttock. Physician's orders included Contact Isolation Precautions related to abscess to left buttock. In addition, Contact Isolation for MRSA of a wound. (Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections.) (Contact precautions are infection control measures designed to prevent the spread of germs transmitted through direct or indirect contact with a patient or their environment. Essential steps include placing patients in private rooms, wearing gloves and gowns for all interactions, and performing hand hygiene before entering and upon leaving the room). Record review of Resident #28's admission MDS assessment dated [DATE] indicated a surgical wound requiring applications of nonsurgical dressings. Resident #28 was on antibiotics, opioid pain medication, and isolations precautions while a resident. Record review of Resident #28's Care Plan Report dated 12/30/2025 indicated Resident #28 had an abscess. Interventions included Contact Isolation. During an observation on 01/19/2026 at 09:00 a.m., noted outside Resident #28's room was EBP signage. A white sign was on the opened door that reflected to check at the nurse station before entering. There was a 3-drawer PPE cart located at entrance to Resident #28's room. The PPE cart did not contain the necessary PPE items such as isolation gowns, a stethoscope and blood pressure cuff, or digital thermometer. There was one partially empty box of disposable gloves sitting on top of the PPE cart. During an observation and interview on 01/19/2026 at 12:00 noon, CNA D was observed entering Resident #28's room without donning PPE. She went into the room and gave Resident #28 a beverage. While in the room, she used Resident #28's cell phone to text her family member for her and then placed the phone on the overbed table. CNA D exited the room without performing hand hygiene. CNA D said she had been employed at the facility for approximately 2 years on a PRN (as needed) basis. She said she had been educated on infection control and on EBP and contact isolation precautions. CNA D acknowledged the lack of isolation gowns in the PPE cart at Resident #28's door. She said she thought she was to use PPE if only in direct contact such as bathing or assisting with clothing. She said she did not know who was responsible for stocking PPE carts and she could use PPE from any cart on the hall. During an observation and interview on 01/19/2026 at 3:45 p.m., the ADON said she was the Infection Control Preventionist for the facility. She said Resident #28 was on contact isolation precautions for MRSA of a wound to her buttock. She acknowledged the EBP signage at Resident #28's room was unacceptable, and she should have had a Contact Isolation Precaution sign posted. She said the sign with instructions to check at nurse station before entering was intended for contact precautions. She said she was responsible for ensuring the PPE carts were stocked with adequate supplies. The ADON said she was responsible for in-service training of the staff regarding Infection Control. During an interview on 01/21/2026 at 08:30 a.m., NP G said Resident #28 was on contact isolation for a wound with MRSA to her buttock. She said staff should be wearing full PPE and performing hand hygiene when entering and exiting the room. NP G said failure to follow the contact isolation protocols could result in an increased risk of spreading infections. She said the entrance to Resident #28's room should indicate the type of isolation and PPE usage needed. During an interview on 01/21/2026 at 08:45 a.m., the Regional Nurse said her expectations were for the PPE carts to be always stocked with necessary supplies. She said not utilizing proper PPE could lead to the spread of germs. She said she expected staff and visitors to perform hand hygiene upon entering and exiting an isolation room as well as any time visibly soiled. The Regional Nurse said the transmission of MRSA could be transmitted to others by not following proper Infection Control protocols. During an interview on 01/21/2026 at 1:40 p.m., the DON said she was recently hired at the facility. She said her expectations were for staff and visitors to perform hand hygiene upon entering and when leaving a resident's room, and when hands were soiled. She said gloves should be changed frequently when performing care with each resident. The DON said the risk of failing to perform hand hygiene or following specific isolation protocols could lead to other residents or even staff becoming ill. 3. Record review of a face sheet dated 01/21/2026 indicated Resident #39 was an [AGE] year-old female admitted on [DATE]. Her diagnosis included end stage renal disease (permanent failure of kidney function requiring hemodialysis or transplant for survival). Record review of Resident #39's Order Summary Report dated upon admission on [DATE] indicated she had a right chest catheter port (an indwelling medical device used for hemodialysis) which was provided as an outpatient on Mondays, Wednesdays, and Fridays. A physician's order dated 01/06/2026 indicated EBP precautions to be followed due to indwelling medical devices. Record review of the admission MDS dated [DATE] indicated Resident #39 was receiving hemodialysis and she was cognitively intact with a BIMS score of 14 out of 15. During an observation and interview on 01/19/2026 at 09:15 a.m., revealed Resident #39 was observed exiting her room with her walker to ambulate in hallway. The surveyor noticed a dressing on her right chest wall. Resident #39 said it was her dialysis catheter and that she went to dialysis on Mondays, Wednesdays, and Fridays. During an observation and interview on 01/19/2026 at 12:00 PM, CNA D said she was aware Resident #39 received hemodialysis 3 times per week but was unaware that she should be on EBP. She said she went by the signage placed on each resident's door to their room. During an observation and interview on 01/19/2026 at 3:45 p.m., the ADON said she was the Infection Control Preventionist for the facility. She said Resident #39 was recently admitted to the facility and had been receiving hemodialysis 3 times per week. She said Resident #39 was on EBP precautions and should have signage attached to her door indicating precautions. She acknowledged there was no signage indicating Resident #39 was on EBP precautions and it must have been overlooked. Record review of facility policy Enhanced Barrier Precautions dated August 2022 indicated the following: . Enhanced barrier precautions are utilized to prevent the spread of multi-drug-resistant organisms to residents.10.) Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 11.) PPE is available outside of the resident rooms. 12.) Residents, families and visitors are notified of the implementation of EBPs throughout the facility. Record review of facility policy Handwashing/Hand Hygiene dated 2001 indicated the following: . This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Administrative Practices to Promote Hand Hygiene.2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors.Indications for Hand Hygiene: Hand hygiene is indicated: a) immediately before touching a resident. b) before performing an aseptic task c) after contact with blood, body fluids, or contaminated surfaces d) after touching a resident; e) after touching the resident's environment; g) immediately after glove removal. Record review of facility policy Isolation – Categories of Transmission-Based Precautions dated 2001 indicated the following: . Transmission Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Contact Precautions: .1) Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the residence environment. 7) Staff and visitors wear gloves when entering the room. a.) while caring for a resident staff will change gloves after having contact with infective material for example when drainage b.) gloves are removed and hand hygiene performed before leaving the room c.) staff avoid touching potentially contaminated environmental surfaces or items in the residence room after gloves are removed. 8) staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated environmental surfaces or atoms in the residence room after gloves are removed) 4. Record review of a face sheet dated 01/20/26 indicated Resident #35 was an [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), lung disorder (health conditions that affect your airways (tubes leading into your lungs) or tissue that makes up your lungs), and kidney disease (condition where the kidney reaches advanced state of loss of function). During an observation and interview on 01/19/2026 at 09:02 a.m. Resident #35 was in his bed in his room. An oxygen concentrator was at the bedside with oxygen tubing and a nasal cannula attached. The oxygen tubing and nasal canula was lying on the floor and not bagged. Resident #35 said he was doing fine and had no issues. He was not able to answer questions appropriately. Record review of an MDS dated [DATE] indicated Resident #35 had severely impaired cognition with a BIMS of 01 out of 15 and he had no oxygen use for the look back period. During an observation and interview on 01/20/2026 1:30 p.m. the O2 tubing was on Resident #35 with no date on the tubing or the bag. LVN H said the O2 tubing should have a date on it or on the bag, so it was known when it was placed. She said the O2 tubing was to be changed weekly on Sunday nights by night shift. She said since this O2 tubing had no date on it then it was not known if it was the tubing surveyor saw on 01/19/26 during initial tour. During an interview on 01/20/26 at 02:13 p.m. the DON said she expected the nurses to label the O2 tubing, O2 tubing was to be bagged when not in use and should not touch the floor. She said the tubing touching the floor could contaminate it and cause respiratory infection. Record review of an Oxygen Administration policy revised October 2010 provided at the request of the surveyor had no indication of infection control procedures of the oxygen tubing and devices when not in use.

Based on observation, interview, and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were completely documented for 2 of 7 residents reviewed for complete medical records. (Residents # and #35)* The facility did not have orders for Residents #4 to reside on the secured unit. * The facility did not have orders for Resident #35 having oxygen This failure could place residents at risk of restraint, isolation, and not receiving the care needed. Findings included:1. Record review of a face sheet dated 01/19/26 indicated Resident #4 was a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (loss of cognitive functioning), Alzheimer's disease (progressive disease that destroys memory and other important mental functions), mood disorder (mental disorders that primarily affect a person's emotional state), psychosis (a severe mental condition in which thoughts and emotions are so affected that contact is lost with external reality), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of the admission MDS dated [DATE] indicated Resident #4 had severely impaired cognition with a BIMS of 00 out of 15; had potential indicators of psychosis of hallucinations and delusions; physical behavioral symptoms directed at others for 1 to 3 days of the look back period; other behavioral symptoms not directed at others daily of the look back period; Put the resident at significant risk for physical illness or injury; Significantly interfere with the resident's care; Significantly interfere with the resident's participation in activities or social interactions; Resident had rejection of care behavior daily; wandering behavior daily; and wandering significantly intrude on the privacy or activities of others. During an observation and interview on 01/19/2026 at 09:03 a.m. Resident #4 was on the secured unit. He was in his room with many personal pictures hanging on the walls of the room. He was lying in bed. He said he had no issues. He was able to answer simple questions. Resident #4 got up and walked around his room. Record review of a Nurse Note for Resident #4 with an entry dated 10/01/2025 at 11:43 a.m. indicated Elopement Evaluation : History of elopement while at home: Yes. Wandering behavior a pattern or goal-directed: Yes. Wanders aimlessly or non-goal-directed: Yes. Wandering behavior likely to affect the safety or well-being of self / others: No. Wandering behavior likely to affect the privacy of others: No. Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 5.0. Record review of the care plan dated 10/07/25 indicated Resident #4 was at risk for wandering/elopement identified-secured unit with appropriate interventions. Record review of the physician orders for January 2026 indicated Resident #4 did not have a physician order to reside on the secured unit. During an interview on 01/20/2026 at 01:15 p.m. LVN H said she was not aware of Resident #4 not having an order to reside on the secured unit. She said he was placed on the unit when he admitted . A record review of the undated Memory and Secure Care Unit Program Disclosure policy indicated .23.C.3. admission and discharge: Facilities with Memory and Secure Care Units shall have a written policy of preadmission screening, admission and discharge procedures. admission criteria shall require, at a minimum, a physician's diagnosis Alzheimer's Disease and/ or other Dementia, Cognitive Memory condition and/or exit seeking or wandering. The facility will obtain medical records, history and physical, medication administration record, lab reports. A physical assessment may be necessary based on the medical records. The policy shall include criteria for moving residents from within the facility, into or out of the unit. If a resident of the nursing facility exits or attempts to exit the facility and the resident has cognitive or safety concerns, the IDT team will evaluate the resident for placement on the Memory and Secure Unit. 2. Record review of a face sheet dated 01/20/26 indicated Resident #35 was an [AGE] year-old male admitted on [DATE]. Her diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), lung disorder (health conditions that affect your airways (tubes leading into your lungs) or tissue that makes up your lungs), and kidney disease (condition where the kidney reaches advanced state of loss of function). Record review of an MDS dated [DATE] indicated Resident #35 had severely impaired cognition with a BIMS of 01 out of 15 and he had no oxygen use for the look back period. During an observation and interview on 01/20/2026 1:30 p.m. the O2 tubing was not on the floor but the O2 tubing was on Resident #35 with no date on the tubing. Resident #35 said he was doing fine and had no issues. Record review of the Nurse Notes with entry dated 01/11/2026 at 08:29 a.m. Resident #35 was non-responsive. His pupils were pinpoint and non-reactive. His vital signs were BP 110/52, P 48, RR 18, Oxygen saturation was 95% on room air. Hospice was notified. The RP was notified. The nurse with hospice indicated a hospice nurse would come to assess Resident #35. Oxygen at 2 liters per nasal cannula was applied.Record review of the physician orders for January 2026 indicated Resident #35 did not have a physician order During an interview on 01/20/2026 at 01:15 p.m. LVN H said she received a verbal order from the hospice nurse to place Resident #35 on oxygen on 01/11/26 due to a decline in condition. She said the orders for the oxygen were put in today. She said she should have transcribed the verbal order into the chart when she received it. She said if an order was not transcribed a resident could not receive the care needed. During an interview on 01/20/26 at 02:13 p.m. the DON said she expected the nurses to transcribe orders or a resident could not receive the care needed or be inappropriately placed on the secured unit. Record review of an Oxygen Administration policy revised October 2010 indicated Preparation: 1.Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. The facility failed to close, label and date a box of biscuits and bag of tater tots in freezer #4, to prevent exposure to air. This failure placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.Findings include: During initial observation and interview on 01/19/2026 at 08:33 a.m., revealed freezer #4 in the kitchen contained the following: *an open unlabeled (missing the name of the food item, the open date, the expiration or use by date) original cardboard box containing a clear plastic bag of frozen biscuits that was not properly sealed and exposed to the elements. The Dietitian Manager said the bag contained frozen biscuits. *an open, unlabeled (missing the name of the food item, the open date, the expiration or use by date), clear plastic bag of frozen tater tots that was not properly sealed and exposed to the elements. The Dietitian Manager said the bag contained frozen tater tots. During an interview on 01/19/2026 at 08:40 a.m., the Dietitian Manager said that she was not aware that the frozen biscuits had to be resealed once original cardboard box was opened. She said that the plastic bag of tater tots should have been resealed and labeled with name of the food item, the open date, the expiration or use by date) once opened. She said moving forward her expectations were all products in the kitchen be stored correctly. She said packages of food items should be sealed so not to expose food to the elements. The Dietitian Manager said it was the responsibility of all the dietary staff to ensure products were labeled and stored correctly. She said she did spot checks periodically in kitchen to be sure everything was working in kitchen and completed a walk-through checking for sanitary conditions. She said not storing and preparing food appropriately could cause contamination and/or freezer burn affecting the freshness and quality of resident's food. During an interview on 01/19/2026 at 8:45 a.m., [NAME] F said she did not know who left the bags of food opened in the freezer, and used bags of food being stored should be sealed or they could cause freezer burn. She said she had been trained to ensure that after opening a food item, it should be labeled with the open date and stored in a sealed container. During an interview on 01/21/2026 at 3:24 p.m., the Administrator said she was the direct supervisor of the Dietary Manager, and she expected kitchen staff to follow policies on food storage and preparation including all open items to be closed/sealed, labeled/dated when open and discarded when expired. She said not storing and preparing food appropriately could cause freezer burn, affecting the freshness and quality of resident's food. Review of a facility policy, revised November 2022, on Food Receiving and Storage indicated Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Refrigerated/Frozen Storage: 1. All foods sored in the refrigerator or freezer are covered, labeled and dated ( used by date) . 8. Frozen foods are maintained at a temperate to keep the food frozen solid. Wrappers of frozen foods must stay intact until thawing. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 01/21/2026 indicated: 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers .(B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 of 7 residents (Resident #39) reviewed for new admissions.The facility did not accurately complete a baseline care plan within 48 hours of admission for Resident #39 to address EBP (Enhanced Barrier Precautions) related to hemodialysis (a procedure that acts as an artificial kidney to filter waste products, toxins, and excess fluid from the blood when the kidneys are no longer functioning properly).This failure could lead to residents not receiving necessary care and decreased quality of life.Record review of Resident #39's face sheet dated 01/21/2026 indicated Resident #39 was an [AGE] year-old female admitted on [DATE]. Her diagnosis included end stage renal disease (permanent failure of kidney function requiring hemodialysis or transplant for survival). Record review of Resident #39's Order Summary Report dated upon admission on [DATE] indicated she had a right chest catheter port (an indwelling medical device used for hemodialysis) which was provided as an outpatient on Mondays, Wednesdays, and Fridays. A physician order dated 01/06/2026 indicated EBP precautions to be followed due to indwelling medical devices. Record review of the admission MDS dated [DATE] indicated Resident #39 was receiving hemodialysis and she was cognitively intact with a BIMS score of 14 out of 15.Record review of a Baseline Care Plan dated 01/05/2026 gave no indication Resident #39 was on EBP while a resident. Section 3A, 1h Isolation or quarantine was left unchecked. Section 3F, 2 indicated Resident #39 required hemodialysis. During an observation and interview on 01/19/2026 at 09:15 a.m., Resident #39 was observed exiting her room with her walker to ambulate in hallway. The surveyor noticed a dressing on her right chest wall. Resident #39 said it was her dialysis catheter and that she went to dialysis on Mondays, Wednesdays, and Fridays. During an interview on 01/21/2026 at 01:30 p.m., the Regional Nurse said the admission nurses usually filled out the baseline care plans when the residents were admitted . She said the DON was responsible for reviewing for accuracy. She said Resident #39 was a dialysis patient and was on EBP. The Regional DON said the baseline should have reflected Resident #39 having been on isolation precautions and it was important for staff to be aware protecting Resident #39 from possible infections.During an interview on 01/21/2026 at 1:40 p.m., the DON said admission nurses input assessments of the baseline care plans. She said baseline care plans should be accurate and complete, and Resident #39's baseline should have included EBP. During an interview on 01/21/2026 at 02:00 p.m. the Administrator said she expected staff to be professional and complete information for the baseline care plan to accurately reflect the residents' needs. Record review of a Care Plans-Baseline policy dated March 2022 indicated. Policy Statement: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following: a. Initial goals based on admission orders and discussion with the resident/representative; b. Physician orders.

Based on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 2 residents reviewed for resident rights. (Resident #26) * The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Resident #26. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included: Record review of physician orders for [DATE] indicated Resident #26 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning), atrial fibrillation (a type of irregular heartbeat), diastolic heart failure (a condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly), and convulsions (rapid, involuntary muscle contractions that can cause uncontrollable shaking and limb movement). An order dated [DATE] indicated Resident #26 had a DNR order. Record review of a quarterly MDS dated [DATE] indicated Resident #26 had adequate hearing, she had unclear speech, she was able to make herself understood sometimes, she was able to understand others sometimes, and she had severely impaired cognition with a BIMS of 3 out of 15. Record review of a Care Plan for Resident #26 indicated a care plan for Code Status: DNR with a problem start date of [DATE] and reviewed [DATE]. Record review of the OOH-DNR form dated [DATE] for Resident #26 indicated the Two Witnesses had the second witness with no date of when the witness signed the form. During an observation and interview on [DATE] at 09:14 a.m. Resident #26 was in bed in her room. She said she was doing fine. She was able to answer simple questions. She said she had no issues. During an interview on [DATE] at 02:32 p.m. the SW said she did some of the OOH-DNRs but not all of them. She said an OOH-DNR should be complete. She said Resident #26's OOH-DNR was missing the date of the second witness's signature. She said it would not be a valid OOH-DNR and the resident would be considered a full code. She said if a resident did not have a valid OOH-DNR the staff would have to initiate CPR. During an interview on [DATE] at 02:52 p.m. the DON said an OOH-DNR that was not complete was not valid and the resident was considered a full code. She said CPR would have to be initiated against a resident's wishes. Record review of a Do Not Resuscitate Order policy dated 2001 indicated Policy Statement: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Policy Interpretation and Implementation1. Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record.2. A Do Not Resuscitate (DNR} order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law} and placed in the front of the resident's medical record.a. Use only state-approved DNR forms.b. If no state form is required, use facility-approved form.3. In addition to the advance directive and DNR order form, state-specific forms may be used to specify whether to administer CPR in case of a medical emergency. State-specific forms include:a. Physician Orders for Life-Sustaining Treatment {POLST};b. Physician Orders for Scope of Treatment {POST};c. Medical Orders for Life-Sustaining Tre'atment {MOLST};d. Medical Orders for Scope of Treatment {MOST};e. Clinicians Orders for Life Sustaining Treatment {COLST}; andf. Transportable Physician Orders for Patient Preference {TPOPP}.4. Should the resident be transferred to the hospital, a photocopy of the DNR order form must be provided to the personnel transporting the resident to the hospital.5. Do not resuscitate {DNR} orders will remain in effect until the resident {or legal surrogate} provides the facility with a signed and dated request to end the DNR order.a. Verbal orders to cease the DNR will be permitted when two {2} staff members witness such request.b. Both witnesses must have heard the request and both individuals must document such information on the physician's order sheet.c. The attending physician must be informed of the resident's request to cease the DNR order.6. The interdisciplinary care planning team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives.7. The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes.8. Inquiries concerning do not resuscitate orders/requests should be referred to the administrator, director of nursing services, or to the social services director. Record review of the INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER revised [DATE] indicated .In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR Order in the presence of a notary public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses. Witness or notary signatures are not required when two physicians execute the OOH-DNR Order in section F. The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals.

Based on interview and record review, the facility failed to use the services of a registered nurse for 8 at least consecutive hours 7 days a week (140 days) and have a DON licensed in her state of residency (since [DATE]) reviewed for sufficient staffing. The facility failed to ensure they had a full time DON licensed in Texas and failed to ensure there was an RN for 8 consecutive hours 7 days a week. These failures could place residents at risk of lack of nursing oversight and a higher level of care. Findings included: Record review of the personnel file from 09/01/23 through 10/23/24 indicated the DON had a valid Florida license for RN and assume the DON position on 09/01/23. She had an active LVN license in Texas. Her driver's license indicated a Texas address. Record review of a list of no RN coverage based off time sheets provided by the facility from 09/01/23 through 10/23/24 indicated there was no RN coverage for the following months: September 2023 for 9 days; October 2023 for 14 days; November 2023 for 10 days; December 2023 for 11 days; January 2024 for 13 days; February 2024 for 12 days; March 2024 for 13 days; April 2024 for 13 days; May 2024 for 11 days; June 2024 for 12 days; July 2024 for 14 days; August 2024 for 13 days; September 2024 for 12 days; October 2024 for 8 days. During an interview on 10/23/24 at 10:30 a.m., the staff member of the BON said the nurse should have applied for a Texas licensed. She said there had been some schools in Florida involved in fraud. She said if this nurse had gone to the school involved in fraud this would need to be reported. She said the BON would investigate this matter after it was reported to determine if license was a case of fraud. Record review of the BON website on 10/23/24 at 10:45 a.m., indicated the RN license was required to be in the state of the nurse's residency. During an interview on 10/23/24 at 11:44 a.m., DON said she had gone to school and tested in Texas and had a Florida RN license. She said she resided in both states and during her time in college and there was on a waiver because of COVID. She said during the training, the college had her to travel more frequently to Florida during her training. She denied notifying the BON for assistance or for application for Texas license and said some of her classmates had trouble getting a Texas license. She said she was going to check into it but never did. She denied having any knowledge of any wrongdoing on her part. She said she went to Florida once a month for her classes for almost 2 years. She said the name of her school was College AA. She said she had transcripts and her license at home. Record Review obtained on 10/23/24 from the internet site of the Texas BON indicated College AA was on the top of the list of the schools that were involved in fraud during the operation nightingale. During an interview on 10/23/24 at 12:00 p.m., the Administrator said she was not aware the college that the DON went to was involved in fraud and was unaware that nurses had to be licensed in the state they live in. She said they had checked the nursysnurses website to verify licensure status prior to her being the DON. She said the system indicated a Florida license was active and multi state so she could work in Texas because Texas was compact state and so was Florida. She said she and HR were responsible for checking backgrounds prior to hire. She said if RN license was not good, they did not have RN coverage 8 hour a day. During an interview on 10/23/24 at 12:45 p.m., DON said she did not try to obtain her license illegally/fraudulently and she earned her license and would investigate this matter with the Texas board of Nursing. The list of days without RN coverage provided by Administrator was attached to this survey. Record review of the undated Job Description - Director of Nursing indicated . He/She must be a graduate of an accredited school of nursing currently registered with the state agency for nursing licensure and hold a valid licensed in the state he/she is employed. Must have and maintain a License according to the Board of Nursing Examiners.

Based on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 3 of 19 residents reviewed for accuracy of assessments. (Resident #s 21, 23 and 27) The facility did not accurately complete the MDS assessment to indicate Resident #21 did not have a restraint. The facility did not accurately complete the MDS assessment to indicate Resident #23 did not have a restraint. The facility did not accurately complete the MDS assessment to indicate Resident #27 did not have a restraint. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of a face sheet dated 10/21/24 indicated Resident #21 was a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (group of thinking and social symptoms that interfere with daily function) and glaucoma (a group of eye conditions that can cause blindness). Record review of the physician's orders dated 10/21/24 indicated Resident #21 was prescribed Geri-chair (large, padded chair that provides support and comfort for people with limited mobility) for poor trunk control every shift with a start date of 06/03/24. Record review of Resident #21's October 2024 MAR indicated Geri-chair for out of bed every shift with documentation he was in the Geri-chair every shift with a start date of 06/03/24. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #21 had a BIMS score of 3 indicating moderately impaired cognition and was totally dependent on staff to transfer resident from chair to bed or chair to chair. The assessment indicated Resident #21 had a physical restraint used in chair or out of bed as other used daily during the last 7 days. Record review of Resident #21's care plans initiated 06/11/24 indicated Resident #21 required the use of enablers related to the inability to safely transfer self, poor positioning, high risk for falls, poor cognition, and poor redirection with interventions including Geri-chair for out of bed stimulation. During an observation on 10/21/24 at 11:00 a.m., Resident #21 was lying in a Geri-chair in the television room. He was non-interviewable and appeared comfortable with no signs of distress. During an interview on 10/21/24 at 1:30 p.m., the MDS Nurse said Geri-chairs were restraints because residents could not put the foot of it down themselves. She said she was taught by a previous MDS nurse who had told her Geri-chairs were always restraints. During a phone interview on 10/23/24 at 8:00 a.m., the NP said Geri-chairs were not considered restraints regarding Resident #21. She said she did not know why the facility would think they were because Resident #21 had never attempted to get out of the Geri-chair. During a joint interview on 10/23/24 at 8:49 a.m., LVN A and LVN F said Resident #21 had never made any attempt to get out of the Geri-chair. They said they did not consider it a restraint. 2. Record review of a face sheet dated 10/21/24 indicated Resident #23 was a [AGE] year-old male admitted on [DATE]. His diagnoses included dementia (group of thinking and social symptoms that interfere with daily function) and cerebral vascular accident (stroke). Record review of the physician's orders dated 10/21/24 indicated Resident #23 was prescribed Geri-chair (large, padded chair that provides support and comfort for people with limited mobility) for poor trunk control every shift with a start date of 08/30/23. Record review of Resident #23's October 2024 MAR indicated Geri-chair for out of bed every shift with documentation he was in the Geri-chair every shift with a start date of 08/30/23. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #23 had a BIMS score of 99 indicating severely impaired cognition and was total dependent on staff to transfer resident from chair to bed or chair to chair. The assessment indicated Resident #23 had a physical restraint used in chair or out of bed as other used daily during the last 7 days. Record review of Resident #23's care plans initiated 06/06/24 indicated Resident #23 required the use of enablers related to the inability to safely transfer self, poor positioning, high risk for falls, poor cognition, and poor redirection with interventions including Geri-chair for out of bed stimulation. During an observation on 10/22/24 at 10:00 a.m., Resident #23 was lying in a Geri-chair in the television room. He was non-interviewable and appeared comfortable. During an interview on 10/21/24 at 1:30 p.m., the MDS Nurse said Geri-chairs were restraints because residents could not put the foot of it down themselves. She said she was taught by a previous MDS nurse who had told her Geri-chairs were always restraints. During a phone interview on 10/23/24 at 8:00 a.m., the NP said Geri-chairs were not considered restraints regarding Resident #23. She said she did not know why the facility would think they were because Resident #23 had never attempted to get out of the Geri-chair. During a joint interview on 10/23/24 at 8:49 a.m., LVN A and LVN F said Resident #23 had never made any attempt to get out of the Geri-chair. They said they did not consider it a restraint. 3. Record review of a face sheet dated 10/21/24 indicated Resident #27 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (group of thinking and social symptoms that interfere with daily function), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and heart disease (heart conditions that include diseased vessels, structural problems, and blood clots). Record review of the physician's orders dated 10/21/24 indicated Resident #27 was prescribed Geri-chair for out of bed stimulation every shift with a start date of 06/19/23. Record review of Resident #27's October 2024 MAR indicated Geri-chair for out of bed stimulation every shift with documentation she was in the Geri chair every shift with a start date of 06/19/24. Record review of the most recent quarterly MDS assessment dated [DATE] indicated Resident #27 had a BIMS score of 8 indicating moderately impaired cognition and was total dependent on staff to transfer resident from chair to bed or chair to chair. The assessment indicated Resident #27 a physical restraint used in chair or out of bed as other used daily during the last 7 days. Record review of Resident #27's care plans initiated 06/06/24 indicated Resident #27 required the use of enablers related to the inability to safely transfer self, poor positioning, high risk for falls and poor cognition with interventions including Geri-chair for out of bed stimulation. During an observation and interview on 10/21/24 at 02:04 p.m., Resident #27 was lying in Geri-chair near the nurse's station. She said she was treated well, the staff provided needed care and her chair was comfortable. During an interview on 10/22/24 at 3:33 p.m., the MDS Nurse said she was responsible for all MDSs in the facility and her back up was the Regional RN. She said she was educated on completion of MDS, frequently watched Webinar trainings, and could call her Regional RN for any questions. She said Resident #'s 21, 23, and 27 were captured on their MDSs as restrained but after surveyor intervention and consultation with her Regional RN they were incorrect. She said she was confused about documentation of Geri-chairs related to the RAI but received confirmation from the Regional RN. The MDS nurse said the risk to residents captured as restrained that were not restrained was an inaccurate reporting of the resident. During an interview on 10/23/24 at 8:35 a.m., LVN A said she was providing care for Resident #27 today. She said Resident #27 did not try to get out of the Geri chair. She said it was an enabler not a restraint. During an interview on 10/23/24 at 8:40 a.m., the Regional RN said the MDS nurse was responsible for all MDSs in the facility and was educated on completion and accuracy of MDSs. The Regional RN said she was the back up and signed all the MDSs for completion and checked for accuracy. She said Resident #'s 21, 23 and 27's MDSs captured for restraints related to Geri chairs were overlooked and should not have been captured as restraints. The Regional RN said the risk of an MDS marked as restraints and resident did not have restraints was an inaccuracy of an MDS. During an interview on 10/23/24 at 09:02 a.m., the DON said the MDS Nurse was responsible for all MDSs in the facility and the Regional RN was her back up to double check MDSs and signed the completed MDSs. She said the MDS nurse was educated on completion and accuracy of MDSs. The DON said Geri chairs were not used as restraints they were enablers in this facility. She said the MDS nurse misunderstood and thought since the residents could move their arms all Geri chairs were restraints but after a consult with the Regional RN, she modified Resident #21, 23 and 27's MDSs to indicate no restraints. The DON said her expectation was all MDS to be completed accurately. During an interview on 10/23/2024 at 10:00 a.m., the Administrator said the MDS nurse was responsible for all MDS in the facility and the Regional RN was her back up. She said the MDS nurse was educated on completion and accuracy of MDSs. The Administrator said her expectation was all MDS completed accurately. She said the risk of a resident captured on the MDS having a restraint that did not have a restraint was an inaccurate picture of the resident. Record review of a facility policy dated November 2019, titled, Certifying Accuracy of the Resident Assessment indicated, . Any person completing a portion of the Minimum Data Set/ MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 indicated, . P0100: Physical Restraints Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restrict freedom of movement or normal access to one's body Coding: 1. Not used 2. Used less than daily 2. Used daily . Used in chair or Out of Bed . D. Other . For resident who have no ability to transfer independently, the geriatric chair does not meet the definition of a restraint and should not be coded at P0100 G - Chair Prevents Rising. 41057 44596

Based on observation, interview, and record review, the facility failed to provide a clean and comfortable environment for 1 of 1 secured unit reviewed for environmental concerns. The facility failed to ensure that floors were clean and devoid of dirt and debris in the secured unit. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. The findings included: During observations on 10/21/24 from 8:45 a.m. to 9:25 a.m. in the secured unit indicated the following: *The hall floor was dusty and had bits of debris. There was a thick buildup of grime 3 inches wide along the edges of the hallway and sitting area. *The dining room floor / activity room was dirty with debris and spilled beverages. There was a medication patch stuck in the middle of the floor covered with dirt. The patch was deteriorated, unable to read the label on the patch. The edges of the activity/dining room had a buildup of grime. *Resident room [ROOM NUMBER] had wheelchair tracks with dirt all over the floor beside the bed and the perimeter of the room had buildup of grime. *Resident room [ROOM NUMBER] had trash behind the night side table and was covered with heavy dust layer. The door into the room had dirt, grime and a dead spider behind the door. During an interview on 10/22/24 at 1:00 p.m., Housekeeper C said she had been trained and was aware to sweep and mop all halls and resident rooms. She said the secure unit was cleaned by 2 housekeepers each day. During an interview on 10/22/24 at 1:30 p.m., Housekeeper D said she had been trained in cleaning resident rooms, halls and common areas on hire. She said there were 4 housekeepers for the building each day. During an interview on 10/22/24 at 2:30 p.m., the Administrator said her expectations were for the halls and resident's rooms to be cleaned each day. During an interview on 10/23/24 at 12:30 p.m., the Housekeeping Supervisor said his expectation was for the secure unit to be clean and free of buildup of grime. He said the housekeepers were to sweep and mop all rooms and halls each day. He said he was responsible for ensuring the facility was clean. He said the floors were not clean in the secure unit. He said each room and hall should be kept clean. He said the floors on the secure unit needed to be cleaned better. Record review of the facility's Operations Policies and Procedures manual that was dated 2001, section Homelike Environment, indicated Residents are provide a safe, clean, comfortable and homelike environment .

Based on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 10 residents reviewed for medications. (Resident #32) The facility failed to ensure: Resident #32 missed 3 doses of hydrocodone 10/325mg (12:00 p.m., 4:00 p.m., and 8:00 p.m. doses) on 10/20/2024. These failures could cause increased pain and decreased quality of life Resident #32 Findings included: Record review of an undated face sheet indicated Resident #32 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), pain(physical suffering or discomfort caused by illness or injury), and rheumatoid arthritis (a chronic inflammatory disorder that can affect more than just your joints. In some people, the condition can damage a wide variety of body systems, including the skin, eyes, lungs, heart, and blood vessels). Record review of Resident #32's admission MDS assessment dated [DATE] indicated she had a BIMS of 13 and required substantial to maximum assistance for toileting, transfer, and hygiene. The MDS indicated Resident #32 had pain almost constantly and it was rated a 9 on a pain scale of 1-10. Record review of Resident #32's care plan dated 08/21/2024 indicated she had chronic pain related to rheumatoid arthritis. The intervention was to administer hydrocodone-APAP as ordered. Record review of Resident #32's MAR dated October 2024 indicated she received hydrocodone/ APAP 10/325 mg (1) tablet 4 times daily from 10/01/2024 through 10/19/2024. The MAR revealed Resident #32 received the 8 a.m. dose of hydrocodone/APAP 10/325mg (1) tab on 10/20/2024. Resident #32's MAR indicated she missed the 12:00 p.m., 4:00 p.m., and 8:00 p.m. doses of hydrocodone/APAP 10/325mg. Record review of Resident #32's narcotic count sheet for October 2024 indicated the final last hydrocodone/APAP 10/325mg (1) was administered at 8:00 a.m. on 10/20/2024. The count was zero after the 8:00 a.m. dose was administered on 10/20/2024. During an interview on 10/21/2024 at 8:15 a.m., Resident #32 stated she was in pain and had not slept well because the facility was out of her pain medication. Resident #32 stated she currently had a pain level of 4-5. She stated it was excruciating but it made it hard to rest. She stated she had not gotten her routine pain medication but one time yesterday and the medication nurse this morning (10/21/2024) told her it had not come in yet. She stated she always had pain because of her rheumatoid arthritis, but she could function normally if her pain was between 2-3. She stated her pain had not kept her from eating breakfast, had not kept her for walking with her walker in her room and taking herself to the bathroom. During an interview on 10/21/2024 at 2:00 p.m., LVN B stated Resident #32 was out of hydrocodone/APAP 10/325mg (1) this morning (10/21/2024) when she counted the cart. She stated Resident #32 was not happy this morning when she had to tell her she was still out of her routine hydrocodone. She stated the resident told her the prn morphine was not working to keep her pain under control. Resident #32 stated her pain was a 4. She stated Resident #32 said it was not excruciating pain, just dull and annoying and keeping her from resting. LVN B stated she called the pharmacy at 9:00 a.m. and they stated the courier was in route to the facility with the medication. She stated the courier arrived 15 minutes later and the resident received her morning dose of hydrocodone/APAP 10/325 (1) tablet. LVN B stated had she not been able to get the medication so quickly, the facility had an emergency narcotic box that she could have gotten the medication from. During an interview on 10/22/2024 at 10:00 a.m., LVN A stated she called the MD for Resident #32 on 10/20/2024 around 10:00 a.m. and requested a refill of hydrocodone. She stated the MD sent a refill prescription to the pharmacy at that time. She stated she gave prn morphine per the resident's request at 12:00 p.m. and 8:00 p.m. on 10/20/2024 when she assessed her pain, and she said her pain was a 5. She stated when she reassessed her pain an hour after the morphine at 1:00 p.m. and 9:00 p.m., both times it was a 3. She stated in order to get into the emergency narcotic box a hard copy of the prescription for the narcotic had been faxed to the pharmacy and the pharmacist gives you a code to retrieve the needed narcotic. She stated there was no way to get a hard copy of the narcotic prescription from the MD on a Sunday evening. During an interview on 10/22/2024 at 2:15 p.m., the DON stated Resident #32's hydrocodone/APAP 10/325mg was missed for 3 doses on 10/20/2024. She stated Resident #32 was given prn morphine while she was without the hydrocodone. She stated the facility had an emergency narcotic kit for times when the resident's need the medication and the facility is without. She stated she asked LVN A why she had not attempted to get a narcotic prescription for Resident #32's hydrocodone to use the emergency narcotic box because she had no way to get the prescription to fax to the pharmacy to be able to get the hydrocodone out of the emergency kit. During an interview on 10/23/2024 at 12:20 p.m., the ADM stated she was made aware of the 3 missed doses of the hydrocodone/APAP 10/325mg on 10/21/2024 by the DON. She stated she expected the resident's medication to be ordered in a timely manner to ensure they were not without any medication. She stated Resident #32 was given morphine in the time she was without hydrocodone and had not complained of pain to the nursing staff. Record review of policy dated April 2019 was documented Administering Medications, Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interview, and record review, the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 resident reviewed for pain management. (Resident #32) The facility failed to ensure Resident #32 had effective pain management by failing to have routine pain medication available. This failure could place residents at risk for increased pain and decreased quality of life. Findings included: Record review of an undated face sheet indicated Resident #32 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), pain(physical suffering or discomfort caused by illness or injury), and rheumatoid arthritis (a chronic inflammatory disorder that can affect more than just your joints. In some people, the condition can damage a wide variety of body systems, including the skin, eyes, lungs, heart, and blood vessels). Record review of Resident #32's admission MDS assessment dated [DATE] indicated she had a BIMS score of 13 and required substantial to maximum assistance for toileting, transfer, and hygiene. The MDS indicated Resident #32 had pain almost constantly and it was rated a 9 on a pain scale of 1-10. Record review of Resident #32's care plan dated 08/21/2024 indicated she had chronic pain related to rheumatoid arthritis. The intervention was to administer hydrocodone-APAP as ordered and to maintain a pain level of 3 or below on a scale of 1-10. Record review of Resident #32's MAR dated October 2024 indicated she received hydrocodone/ APAP 10/325 mg (1) tablet 4 times daily from 10/01/2024 through 10/19/2024. The MAR revealed Resident #32 received the 8 a.m. dose of hydrocodone/APAP 10/325mg (1) tab on 10/20/2024. Resident #32's MAR indicated she missed the 12:00 p.m., 4:00 p.m., and 8:00 p.m. doses of hydrocodone/APAP 10/325mg. Resident #32's MAR indicated she received Morphine Sulfate 20mg/ml 0.75ml twice on 10/20/2024 at 12:00 p.m. and 8:00 p.m. and once the morning of 10/21/2024 at 7:00 a.m. Record review of Resident #32's narcotic count sheet for October 2024 indicated the final last hydrocodone/APAP 10/325mg (1) was administered at 8:00 a.m. on 10/20/2024. The count was zero after the 8:00 a.m. dose was administered on 10/20/2024. During an interview on 10/21/2024 at 8:15 a.m., Resident #32 stated she was in pain and had not slept well because the facility was out of her pain medication. Resident #32 stated she currently had a pain level of 3-4. She stated it was not excruciating but it made it harder to rest. She stated she woke up twice and it took her about 15 minutes each time to get comfortable and go back to sleep. She stated she had not gotten her routine pain medication but one time yesterday (10/21/2024) and the medication nurse this morning (10/21/2024) told her it had not come in yet. She stated she always had pain because of her rheumatoid arthritis, but she could function normally if her pain was between 2-3. She stated her pain had not kept her from eating breakfast, had not kept her from walking with her walker in her room and taking herself to the bathroom. Resident #32 stated she was given morphine sulfate that she had ordered prn while she was out of hydrocodone, and it helped take the edge off. During an interview on 10/21/2024 at 2:00 p.m., LVN B stated Resident #32 was out of hydrocodone/APAP 10/325mg (1) this morning (10/21/2024) when she counted the cart. She stated Resident #32 was not happy this morning when she had to tell her she was still out of her routine hydrocodone. She stated the resident told her the prn morphine was not working to keep her pain under control. Resident #32 stated her pain was a 4. She stated Resident #32 said it was not excruciating pain, just dull and annoying and keeping her from resting. LVN B stated she called the pharmacy at 9:00 a.m. and they stated the courier was in route to the facility with the medication. She stated the courier arrived 15 minutes later and the resident received her morning dose of hydrocodone/APAP 10/325 (1) tablet. LVN B stated had she not been able to get the medication so quickly, the facility had an emergency narcotic box that she could have gotten the medication from. During an interview on 10/22/2024 at 10:00 a.m., LVN A stated she called the MD for Resident #32 on 10/20/2024 around 10:00 a.m. and requested a refill of hydrocodone. She stated the MD sent a refill prescription to the pharmacy at that time. She stated she gave prn morphine per the resident's request at 12:00 p.m. and 8:00 p.m. on 10/20/2024 when she assessed her pain, and she said her pain was a 5. She stated when she reassessed her pain an hour after the morphine at 1:00 p.m. and 9:00 p.m., both times it was a 3. She stated to get into the emergency narcotic box a hard copy of the prescription for the narcotic had been faxed to the pharmacy and the pharmacist gives you a code to retrieve the needed narcotic. She stated there was no way to get a hard copy of the narcotic prescription from the MD on a Sunday evening. During an interview on 10/22/2024 at 2:15 p.m., the DON stated Resident #32's hydrocodone/APAP 10/325mg was missed for 3 doses on 10/20/2024. She stated Resident #32 was given prn morphine while she was without the hydrocodone. She stated the facility had an emergency narcotic kit for times when the resident's need the medication and the facility was without. She stated she asked LVN A why she had not attempted to get a narcotic prescription for Resident #32's hydrocodone to use the emergency narcotic box because she had no way to get the prescription to fax to the pharmacy to be able to get the hydrocodone out of the emergency kit. During an interview on 10/23/2024 at 12:20 p.m., the ADM stated she was made aware of the 3 missed doses of the hydrocodone/APAP 10/325mg on 10/21/2024 by the DON. She stated she expected the resident's medication to be ordered in a timely manner to ensure they were not without any medication. She stated Resident #32 was given morphine in the time she was without hydrocodone and had not complained of pain to the nursing staff. Review of a facility policy dated 2001 indicated the general guidelines for pain management were defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals Acute pain should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained free of accident hazards for 1 of 4 Halls (Hall 200). There was lighter fluid stored closer than 20 feet to the outside of Hall 200. This failure could place the residents at risk of accidents. Finding included: During an observation of the outside of the building on 10/22/24 at 1:50 p.m., a barbeque pit was approximately 10 feet down the sidewalk which had a shelf with 2 bottles of lighter fluid with approximately 4 ounces in each bottle. The bottles were labeled Flammable and Keep out of reach of children. The bottles were approximately 2 feet from the wall of the building (Hall 200). This area was accessible to residents and visitors from Hall 200. During an interview on 10/22/24 at 1:58 p.m., the Maintenance Supervisor said flammable chemicals needed to be at least 20 feet away from the building, to prevent accidents and fires. He said any flammable chemical was to be stored offsite at his office. He said he was responsible for making sure flammable chemicals were 20 feet away from the building. He said he knew to keep flammable chemicals at least 20 feet away from the building. He said he was not sure who left the lighter fluid there. During an interview on 10/22/24 at 2:15 p.m., the Administrator said she wanted chemicals stored correctly or stored off site to prevent accidents. Record review of the policy titled Fire Safety and Prevention indicated All personnel must learn methods of fire prevention and must report condition(s)that could result in a potential fire hazard.Flammable items: . e Store paints, thinners and other flammable liquids away from resident living areas. F. Store flammable liquids in a locked metal cabinet.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to include measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 19 residents reviewed for care plans. (Resident #'s 16). The facility did not follow the physician orders for Resident #16's LCS (low concentrated sweet) diet. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of admission report dated 10/22/24 indicated Resident #16 was admitted on [DATE] was [AGE] years old with diagnoses of diabetes (high blood glucose), stroke and altered mental status. Record review of the physician orders dated October 2024 indicated Resident #16 had a diet order for LCS/NSOT (No salt on tray) Mechanical Soft Texture with Nectar Thick Liquids/Chopped Meats diet with start date of 11/09/2023. The orders did not include a health shake. Record review of a care plan dated 07/21/2024 indicated Resident #16 had diabetes mellitus (Type 2): with interventions including to monitor nutritional intake. Therapeutic or altered consistency diet with interventions including LCS/NSOT (No salt on tray) mechanical soft texture with nectar thick liquids/chopped meats, offer snacks within diet limits and serve diet as ordered and offer subs if less than 75% is eaten, monitor intake. Care plan did not address the health shake. Record review of a progress notes for Resident #16 dated 09/01/24 to 10/21/24 indicated no documentation of physician being notified of the need for a change in the plan of care for regular health shakes or about the resident's refusing meals or diabetic health shakes. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #16 received oral diabetic medications and a therapeutic diet. No behaviors of rejection of care were noted. During an observation on 10/21/24 at 12:38 p.m., Resident #16 refused her lunch meal. LVN E went and got the resident a regular chocolate health shake (nutritional shake high in protein and calories) from the kitchen. Resident #16's tray card indicated her diet was an LCS diet. During an interview on 10/21/24 at 12:40 p.m., LVN E said Resident #16 was on an LCS diet . She said, I gave her the chocolate health shakes today. She said the resident did not like diabetic health shakes, she gives her the regular health shake. She said she should have called the physician to obtain approval for the regular health shakes because of the high sugar. She said when a resident refuses a meal, they would offer a substitute and if substitute was not taken would give a health shake. During an interview on 10/21/24 at 12:42 p.m., the DM said residents on LCS diet would receive diabetic shakes because the regular health shake was high in sugar. During an interview on 10/21/24 at 12:44 p.m., Resident #16 said she would try the diabetic shake. During an interview on 10/23/24 at 9:30 a.m., the Administrator said her expectation was for the nurse to follow physician's orders or to notify the physician of the need to change his plan of care/orders. Record review of the health shakes labels obtained from the website per the internet the regular health shakes contained 19 grams of sugar and the diabetic health shake contained 3 grams of sugar. Record review of the Care Plans, Comprehensive Person - Centered policy dated 2001 indicated A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 4. d. request revisions to the plan of care.g. receives the services and or items included in the plan of care.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission including the minimum healthcare information necessary to properly care for 1 of 3 residents reviewed for new admissions (Resident #267). The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #267. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of an undated face sheet revealed Resident #267 was a [AGE] year-old male admitted [DATE] with the diagnoses of prostate cancer, hypertension (high blood pressure), and PVD (refers to any disease or disorder of the circulatory system outside of the brain and heart). Record review of an admission MDS for Resident #267 was incomplete. Record review of the baseline care plan 10/21/2024 for Resident #267 indicated no baseline care plan was initiated prior to survey intervention. Record review of the MD orders dated October 2024 for Resident #267 indicated he was on oxygen at 2 liters per minute via nasal cannula continuously. MD orders indicated Resident #267 was taking Celexa (antidepressant) for depression/ Record review of the comprehensive care plans 10/21/2024 for Resident #267 indicated no comprehensive care plan was initiated. During an interview on 10/21/2024 at 9:50 a.m., Resident #267 stated he had plans to return home and was unsure why he could not go now. Resident #267 stated he had cancer and wore hearing aids. Resident #267 was unable to answer any further questions. During an interview on 10/21/2024 at 10:20 a.m., the DON stated the floor nurses were to complete the baseline care plan on admission as part of the admission process within 24 hours of admission. The DON reviewed Resident #267's record and stated, Resident #267 had no baseline care plan completed prior to 10/21/2024 at 10:20 a.m. During an interview on 10/22/2024 at 12:45 p.m., the Administrator said she expected the staff members to do their part to complete the baseline care plans. She felt baseline care plans were important information to help the staff care for each resident. The Administrator said it was hard to care for new residents without having an outline of their needs and the baseline care plan gave the staff an outline until the MDS was completed and the comprehensive care plan was created to guide resident care. Record review of the policy dated 11/08/2023 titled Baseline Care Plan, indicated the baseline care plan are developed and implemented within 48 hours of a resident's new admission Baseline care plans are developed by the Registered Nurses and other healthcare team members.

Based on record review and interview the facility failed to ensure the Arbitration Agreement included the provision of a neutral arbitrator and a convenient venue for 1 of 1 facility reviewed for Arbitration Agreements . The facility failed to ensure the provision of a neutral arbitrator. The facility failed to ensure the Arbitration Agreement contained a section indicating the provision of a convenient venue. These failures could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of undated Admission Agreement included: .29. ARBITRATION Pursuant to the Federal Arbitration Act, any action, dispute, claim or controversy of any kind (.e.g., whether in agreement or in tort, statutory or common law, legal equitable, or otherwise) now existing or hereafter arising between the parties in any way arising out of, pertaining to or in connection with the provision of health care services, any agreement between the parties, the provision of any good or services by the Health Care Center or other transactions, agreements or agreements of any kind whatsoever, any past present or future incidents, omissions, acts, errors, practices or occurrence causing injury to either party whereby the other party or its agents, employees or representative may be liable, in whole or in part or any other aspect of the past, present, or future relationships between the parties shall be resolved by binding arbitration administered by the National Arbitration Forum . Record review of an undated Dispute Resolution Plan did not indicate the provision of a neutral arbitrator and a section indicating the provision of a convenient venue . During an interview on 08/30/23 at 1:44 p.m., the Administrator said there were no residents active in the arbitration process. She said arbitration agreements were signed when the admission packet was completed. She said the Dispute Resolution Plan was part of the admission packet. She said she verbally explained the agreement to the resident or the resident's representative and that they have a choice to sign or not. She said no residents had asked to rescind the agreement in 30 days. She said she had not been in the position to have to select a neutral venue and there was no process for that. She said residents could refuse to sign and would still be admitted to the facility. An email was sent to the Administrator of the facility on 08/31/23 at 12:32 p.m. requesting a policy concerning Arbitration Agreements. No response was received.

Based on record review and interview the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements. The facility did not ensure the arbitration agreement contained the required elements: *Failed to provide the right to rescind in 30 calendar days of signing This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues. Findings included: Record review of undated Admission Agreement included: .29. ARBITRATION Pursuant to the Federal Arbitration Act, any action, dispute, claim or controversy of any kind (.e.g., whether in agreement or in tort, statutory or common law, legal equitable, or otherwise) now existing or hereafter arising between the parties in any way arising out of, pertaining to or in connection with the provision of health care services, any agreement between the parties, the provision of any good or services by the Health Care Center or other transactions, agreements or agreements of any kind whatsoever, any past present or future incidents, omissions, acts, errors, practices or occurrence causing injury to either party whereby the other party or its agents, employees or representative may be liable, in whole or in part or any other aspect of the past, present, or future relationships between the parties shall be resolved by binding arbitration administered by the National Arbitration Forum . Record review of an undated Dispute Resolution Plan did not indicate the resident or the resident's representative had the right to rescind the agreement within 30 calendar days of signing the agreement. During an interview on 08/30/23 at 1:44 p.m., the Administrator said there were no residents active in the arbitration process. She said arbitration agreements were signed when the admission packet was completed. She said the Dispute Resolution Plan was part of the admission packet. She said she verbally explained the agreement to the resident or the resident's representative and that they had a choice to sign or not. She said no residents had asked to rescind the agreement in 30 days. She said she had not been in the position to have to select a neutral venue and there was no process for that. She said she had gotten the agreement from another facility and did not know it did not reflect the right to rescind within 30 days. She said residents could refuse to sign and would still be admitted to the facility. An email was sent to the Administrator of the facility on 08/31/23 at 12:32 p.m. requesting a policy concerning Arbitration Agreements. No response was received.

Based on observation, interview, and record review, the facility failed to ensure the right to be free from any physical restraints imposed for purposes of convenience and not required to treat medical symptoms for 4 of 21 residents reviewed for restraint use (Resident #56, Resident #12, Resident #23, and Resident #27). The facility failed to ensure Resident #56 was free from physical restraints in the form of a merry walker/merry chair (a wheeled walker with a seat used for use by individuals with balance or walking disabilities) and a bed alarm (devices that contain sensors that trigger an alarm or warning light when they detect a change in pressure). The facility failed to ensure Resident #12, Resident #23, and Resident #27 were free from physical restraints in the form of bed alarms and tab chair alarms (alarms with a pull-string that attaches magnetically to the alarm with a garment clip to the resident). This failure could place residents at risk for a decreased quality of life, a decline in physical functioning and injury. Findings included: 1. Record review of a face sheet dated 08/30/23 revealed Resident #56 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses including reduced mobility, unsteadiness on feet, and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). Record review of the most recent MDS dated [DATE] indicated Resident #56 was rarely to never understood and rarely to never understood others. The MDS indicated a BIMS (Brief Interview for Mental Status) interview was not conducted due to Resident #56 being rarely to never understood. The MDS indicated daily use of Restraints in chair/out of bed: other and Bed Alarm. Record review of a care plan last revised on 06/14/23 indicated Resident #56 required the use of enablers related to high risk for falls, poor cognition, and poor redirection. There were interventions for bed alarms at all times and may have merry walker. Record review of the physician's orders for Resident #56 indicated an order with a start date of 05/05/23 for May have a merry chair. There was no stop date for the order. There was an order with a start date of 05/05/23 for Bed alarms at all times. There was no stop date for the order. Record review of a Pre-restraining Evaluation dated 08/10/23 indicated Resident #56 was not alert and oriented. The evaluation indicated a history of falls and loss of balance. During an observation on 08/28/23 at 10:44 a.m., revealed Resident #56 was resting in bed. There was an alarm hanging on the side of the bed. There was a sensory pad attached to the alarm. The sensory pad was between the sheet and absorbent under-pad . During an observation and interview on 08/28/23 at 11:15 a.m., revealed Resident #56 was sitting up in the common area. Resident #56 was sitting inside a merry walker. The resident was sitting on the seat of the merry walker surrounded by 4 sides of the walker. There was a strap from the seat, wrapped around the bar across the front of the walker several times. The strap was positioned between the resident's legs. The strap was closed with a plastic clasp. The bar had a spring bolt holding it in the closed position. The resident was confused and did not answer questions appropriately. During an observation on 08/28/23 at 12:06 p.m., revealed Resident #56 was in the dining room in a merry walker. Lunch was being served to Resident #56 on a bedside table placed just above the merry walker. During an observation on 08/29/23 at 9:28 a.m., revealed Resident #56 was sitting up in the common area. Resident #56 was sitting inside a merry walker. The resident was sitting on the seat of the merry walker surrounded by 4 sides of the walker. There was a strap from the seat, wrapped around the bar across the front of the walker several times. The strap was positioned between the resident's legs. The strap was closed with a plastic clasp. The bar had a spring bolt holding it in the closed position. When the resident was asked if she could remove the strap and open the bar to the merry walker, she only laughed. Resident #56 never attempted to follow commands. The residents in the common area were being observed by Medication Aide G. During an interview on 08/29/23 at 9:32 a.m., Medication Aide G said Resident #56 was able to stand and walk around in the merry walker. She said Resident #56 was not capable of opening up the bar on the merry walker. She said the resident had falls before the merry chair was used. She said staff had been using the merry chair approximately 6 months for Resident #56. During an observation on 08/30/23 at 9:48 a.m., revealed Resident #56 was sitting in a merry walker in the common area. During an observation and interview 08/30/23 at 9:55 a.m., revealed Resident 56's bed was made. There was an alarm hanging on the side of the bed. There was a sensory pad attached to the alarm. The sensory pad was between the sheet and absorbent under-pad. Medication Aide G said staff always used a bed alarm on Resident #56's bed. 2. Record review of a face sheet dated 08/30/23 revealed Resident #12 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses including senile degeneration of the brain (a decrease in cognitive abilities or mental decline), generalized muscle weakness, and kidney disease. Record review of the most recent MDS dated [DATE] indicated Resident #12 was usually understood and usually understood others. The MDS indicated a BIMS of 2 indicating Resident #12 was severely cognitively impaired. The MDS indicated daily use of a Chair Alarm. The MDS did not indicate a bed alarm. Record review of a care plan last revised on 08/09/23 indicated Resident #12 required the use of enablers related to the inability to safely transfer, poor positioning, high risk of falls, poor cognition, and poor redirection. There were interventions for a chair alarm . The care plan did not indicate a bed alarm. Record review of the physician's orders for Resident #12 indicated an order with a start date of 05/04/23 for Chair alarm to chair while OOB. There was no stop date for the order. There was not an order for a bed alarm. Record review of a Pre-restraining Evaluation dated 07/18/23 indicated Resident #12 was alert and oriented. The evaluation indicated a history of falls and loss of balance. During an observation and interview on 08/30/23 at 10:00 a.m., Resident #12's bed was made. There was an alarm hanging on the side of the bed. There was a sensory pad attached to the alarm. The sensory pad was between the sheet and the mattress. Medication Aide G said staff always used a bed alarm on Resident #12's bed. During an observation and interview on 08/30/23 at 10:21 a.m., revealed Resident #12 was sitting in a wheelchair participating in an activity. There was a tab alarm hanging on the chair with a clip attached to the resident's shirt. The resident did not answer questions. The resident was confused and said, I don't know who brought me in here. 3. Record review of a face sheet dated 08/30/23 revealed Resident #23 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses including dementia (a general decline in cognitive abilities), anxiety disorder, and stroke. Record review of the most recent MDS dated [DATE] indicated Resident #23 was understood and understood others. The MDS indicated a BIMS of 2 indicating Resident #23 was severely cognitively impaired. The MDS indicated daily use of a Chair Alarm and a bed alarm. Record review of a care plan last revised on 08/09/23 indicated Resident #12 required the use of enablers related to the inability to safely transfer, poor positioning, high risk of falls, poor cognition, and poor redirection. There were interventions for a chair alarm and a bed alarm. Record review of the physician's orders for Resident #23 indicated an order with a start date of 05/05/23 for a bed alarm on at all times. There was no stop date for this order. There was an order with a start date of 05/05/2023 for May have chair alarm on at all times. There was no stop date for this order. Record review of a Pre-restraining Evaluation dated 07/12/23 indicated Resident #23 was alert and oriented. The evaluation indicated a history of falls and loss of balance. During an observation on 08/28/23 at 10:24 a.m., revealed Resident #23 was sitting in a wheelchair in the common area. There was a tab alarm attached to the back of the wheelchair and clipped to the back of her shirt. During an observation and interview on 08/30/23 at 9:50 a.m., revealed Medication Aide G was observing the residents in the locked unit common area. She said there were two residents that used the chair alarms on the locked unit. She said the residents that used the chair alarms were Residents #12 and Resident #23. She said Residents #56, Resident #12, and Resident #23 had bed alarms. She said the merry walker, the bed alarms, and the chair alarms were all used as a fall prevention for each resident. During an observation and interview on 08/30/23 at 9:58 a.m., revealed Resident #12's bed was made. There was an alarm hanging on the side of the bed. There was a sensory pad attached to the alarm. The sensory pad was between the sheet and the mattress. Medication Aide G said staff always used a bed alarm on Resident #12's bed. 4. During a record review the resident face sheet dated 08/30/2023 indicated Resident #27 was a 91- year- old male, admitted to the facility on [DATE] with diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), depression (a group of conditions associated with the elevation or lowering of a person's mood), and anxiety (a feeling of fear, dread, and uneasiness). During the record review, the MDS assessment dated [DATE] indicated Resident #27 had a BIMS of 03, which indicated severe cognitive impairment. The MDS indicated the required extensive assistance with 2 staff members for bed mobility, and transfer. The MDS indicated Resident #27 was totally dependent for sitting in a chair to standing. The MDS indicated Resident #27 had no falls since admit or entry. The MDS indicated daily use of a restraint in chair on out of bed, daily use of bed alarms, and chair alarms. During the record review the care plan for Resident #27 revealed it did not indicate the use of restraints, bed alarms or chair alarms During the record review of the consolidated physician orders for Resident #27 dated August 2023 did not indicate the use of restraints, bed alarms or chair alarms During the record review the quarterly physical restraint evaluation dated 07/04/223 indicated Resident #27 used a Geri chair (a chair used for those with mobility issues and can also be used for bedridden patients who have difficulty sitting upright in a conventional wheelchair) for poor trunk control, a bed alarm, and a chair alarm to prevent falls. During an observation on 08/28/23 at 9:20 a.m., revealed Resident #27 was noted to be reclined in Geri chair sitting in the dining room while activity was being conducted. Resident #27 was noted to have a clip alarm pinned to the back of his sweatshirt while in the Geri chair. During an observation on 08/28/23 at 2:50 p.m., revealed Resident #27 was noted to be in bed with a bed alarm on under the incontinent pad on the mattress, bed lowered to the floor and a mattress on the floor beside the bed as a fall mat. During an observation on 08/29/23 at 10:00 a.m., revealed Resident #27 was noted to be up in Geri chair in a reclined position with a clip alarm pinned to the back of his shirt. During an interview on 08/30/23 at 12:48 p.m., LVN E said he was the nurse for hall 1 and the left side of hall 3. LVN E said he was not aware of any residents with restraints. LVN E said he knew of 5 residents that had alarms. LVN E said Resident #27 had a chair alarm and a bed alarm. He said the Resident #27 was bad about getting up and trying to get out of bed himself. LVN E said Resident #27 had not moved nearly as much for the last 6 months since getting the alarms. LVN E said he provided care to Resident #56 on the locked unit. He said he made observations on the locked unit every 1 - 2 hours. He said those observations were not charted. He said restraint evaluations were completed quarterly. He said he did not consider the merry walker a restraint. He said he considered wrist constraints a restraint. He said he thought Resident #56's family pushed for her to use the merry walker because she was having falls. He said Resident #56 could crawl out of the merry walker but could not open the merry walker. He said she was able to crawl out by getting a leg over the strap and slipping under the walker. During an interview on 08/30/23 at 1:02 p.m., LVN A said there were residents with bed alarms. She said she had 5 or 6 total with alarms. She said some were on beds and some on chairs. She said all the residents with alarms were a fall risk and that was why the alarms were used. She said some had falls and they were trying to prevent falls. She said some residents were getting out of the bed. She said Resident #56, she used to walk in the merry walker. She said it kept her from falling. She said the merry walker was a restraint. She said a restraint could keep the resident from ambulating and doing certain things. She said Resident #56 could not open the bar of the merry walker by herself. She said nursing staff did document on poor trunk control for Geri chairs. She said nursing staff did not chart specific observations on restraints. During an interview on 08/30/23 at 1:14 p.m., the MDS Coordinator said a restraint was anything that limited a resident's movement such as getting out of bed or walking. She said the Geri chair and alarms were restraints for Resident #27 . She said both were used daily. She said Resident #56's merry walker and bed alarm were coded as restraints. She said Resident #56 had falls in the past and she thought that was why she was in the merry walker. She said the nurses completed the restraint assessments. She said she would consider an alarm a restraint . She said Resident #23's alarms were being used for fall prevention. She said Resident #12 had an alarm. She said the alarm was used for fall prevention. During an interview on 08/30/23 on 1:28 p.m., the DON said a restraint was anything that would prevent a resident from moving around and physically be mobile. She said there were no residents in the facility with physical restraints. She said they only put residents in Geri chairs with poor trunk control. She said Resident #56 was very mobile in her merry walker. She said she had the merry walker awhile and she had been able to get out of it. She said the merry walker was because she was having a lot of falls. She said she thought she had the merry walker over a year or two. She said personal alarms were not considered restraints. She said they did not keep anyone from getting up. She said it just alerted the staff and they were only placed after the resident had had several falls. She said she was not familiar with the regulation concerning restraints. During an interview on 08/30/23 at 1:44 p.m., the Administrator said she did not feel there were any restraints in the building. She said a restraint was something that prevented a resident from doing something they would normally do independently. She did not consider the merry walker a restraint. She said when Resident #56 was first admitted she had back-to-back falls. With the merry chair she was able to walk. She felt it was more helpful for her to prevent major injuries from falls. She said she did not know if she could walk without the merry chair. She said she did not know if she could lift herself out of the merry chair. She said she did not feel chair alarms and bed alarms were restraints. She said they were not the first go to intervention and was the last intervention as a fall prevention. Review of a Use of Restraints facility policy dated April 2017 indicated, .Use of Restraints .Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls . Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached to the resident's body that the individual cannot remove easily, which restricts freedom of movement .If the resident cannot remove a device in the same manner in which staff applied it given the resident's physical condition .and this restricts his/her typical ability to change position or place, that device is considered a restraint .Examples of devices that are/or may be considered physical restraints include .Geri-chairs .orders for restraints will not be enforced for longer than twelve (12) hours, unless the resident's condition requires continued treatment . Record review of an Abuse, Grievances, and Restraints facility in-service dated 03/07/23 indicated, .Use of Restraints .Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls . Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached to the resident's body that the individual cannot remove easily, which restricts freedom of movement .If the resident cannot remove a device in the same manner in which staff applied it given the resident's physical condition .and this restricts his/her typical ability to change position or place, that device is considered a restraint .orders for restraints will not be enforced for longer than twelve (12) hours, unless the resident's condition requires continued treatment . 44596

Based on interview and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of one resident (Resident #22) reviewed for dialysis services. The facility failed to develop a process to communicate with the dialysis facility, where Resident #22 received hemodialysis services. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #22's face sheet, dated 08/30/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included severe intellectual disabilities (term used when there are limits to a person's ability to learn at an expected level and function in daily life), anxiety disorder (persistent and excessive worry that interferes with daily activities), and chronic kidney disease, stage 5 (a disease that has progressed to a stage where the kidneys have lost nearly all their ability to do their job effectively). Record review of Resident #22's annual MDS assessment, dated 07/25/23, indicated he had a BIMS score of 99 which indicated the resident was unable to complete the brief interview for mental status. He did not exhibit behaviors of wandering or rejection of care. He required supervision assist for bed mobility, transfers, walking in room and corridor, locomotion on and off unit, eating, and toileting. He required limited assistance for dressing, and personal hygiene. The assessment indicated he received dialysis as a resident at the facility. Record review of Resident #22's physician's orders, active as of 08/30/23, indicated he had these orders: *Dialysis every Tuesday, Thursday, Saturday at [dialysis facility] at 10:40 AM. The start date was 5/22/23. *Remove pressure dressing at bedtime on dialysis days. The start date was 5/9/23. *check for bruit (a sound heard through a stethoscope) and thrill (a vibration caused by blood flowing through a dialysis access site) every shift. The start date was 5/18/23. Record review of Resident #22's care plan, dated 08/30/23, indicated a care plan for renal disease: requires dialysis. The goal was to resolve without complications. Interventions included provide and coordinate transportation to the dialysis center, monitor shunt for patency (bruit and thrill), and remove pressure dressing at bedtime on dialysis days, dialysis on Tuesday's, Thursday's, Saturday's. During an interview on 08/30/23 at 07:50 AM, LVN E said he was the nurse assigned to Resident #22 on 08/30/23. He said he does not send any sort of communication sheet to dialysis when Resident #22 goes to dialysis. He said he did not call dialysis or receive any communication about how the dialysis session went. He said they do not receive a sheet after dialysis with any information. He said the dialysis center does not reach out to the facility after dialysis to communicate any information. During an interview on 08/30/23 at 8:00 AM, LVN A said she was not assigned to Resident #22 on 08/30/23. She said she did not take care of him often, but she thought there was a dialysis communication sheet when they used paper charts, and she thought they communicated with the dialysis center electronically through the electronic medical record. During an interview on 08/30/23 at 08:10 AM, the DON said they did not typically communicate with the dialysis company. She said they received calls from the dialysis company if there was a complication, but otherwise there was not typically any communication. She said they did not receive or request communication about vital signs, weights, or how the dialysis session went. During an interview on 08/30/23 at 08:17 AM, the DON said they did not use anything to communicate with the dialysis company each visit. She said they did an in-service with both nurses on shift on 08/30/23 and they will now print out a dialysis communication sheet to send with Resident #22 when he goes to dialysis. During an interview on 08/30/23 at 09:54 AM, the dialysis center clinic manager said she was the clinic manager for the dialysis center that Resident #22 attended for dialysis sessions. She said the facility never sent a communication form for them to fill out. She said if he had complications during a session they call the facility, but otherwise they had no communication with the facility. During an interview on 08/30/23 at 12:49 PM, the ADON said she expected the nurses to call and discuss with the kidney center about Resident #22's dialysis sessions. She expected the nurses to obtain information that included any complications, vital signs, whether there were issues with his shunt access, and any change in condition. She said the risk to the resident was that the facility would not know if the kidney center had trouble accessing his shunt, or if his vital signs were out of normal limits. She said if they did not know those things it would put the resident at risk of harm. During an interview on 08/30/23 at 12:51 PM, the DON said she expected the nurses to communicate with the dialysis center via telephone. She expected the nurses to communicate any pain, abnormal vital signs, and any complications. She said the resident could suffer sickness or possible harm since they did not facilitate communication with the dialysis center During an interview on 08/30/23 at 12:53 PM, the Administrator said she expected the nurses to follow the policy and communicate with the dialysis center. She said the resident could suffer harm, or critical labs. She said now they would change and communicate with a sheet of paper to be filled out by the dialysis center. She said if they did not get the sheet of paper back from the kidney center then the nurse would call the kidney center to get the information. Record review of the facility's policy, care of a resident with end-stage renal disease, revised September 2010, stated: .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care . .4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: . .b. how information will be exchanged between facilities; Record review of the facility's dialysis contract, effective 12/20/19, stated: .This Agreement is made by and between [facility owner] (hereinafter referred to as the Owner) and [dialysis center owner] (hereinafter referred to as the Company). Effective upon the date of last signature . .3. Interchange of information. The Long-Term Care Facility shall provide for the interchange of information useful or necessary for the care of the ESRD Residents. Including a contact person at the Long-Term Care Facility whose responsibilities include assisting with the coordination of Renal Dialysis Services for ESRD residents

Based on observation, interview and record review, the facility failed to ensure residents were free from physical restraints which were not required to treat medical symptoms for 4 of 9 residents reviewed for restraint use. (Resident #s 17, 62, 72, and 50) *Resident #17 sustained a [MEDICAL CONDITION] when she fell out of bed with the side rails up. The facility did not assess Resident #17 for a pre-restraining assessment for the side rails, develop a care plan to ensure Resident #17 was safe in a bed with side rails, attempt other less restrictive measures prior to using side rails, or change safety interventions after Resident #17's fall. She was placed back in a bed with full side rails up after her return from the hospital where she received surgical correction of the fracture. *Resident #s 62, 72, and 50 had full side rails on their beds. The facility did not: *re-assess for side rail use or had accurate side rail assessments; *have medical symptom related to the restraint used; *have evidence less restrictive safety measures were attempted prior to the utilization of side rails. An Immediate Jeopardy situation was identified on 10/20/14. The Immediate Jeopardy was removed on 10/23/14. The facility remained out of compliance at a pattern of actual harm due to the facility's need to ensure all in-service training was completed and the effectiveness of the corrective systems was evaluated. This failure could place the 65 residents with side rails at risk for compression injuries, fractures, suffocation and death. Findings included: These failures contributed to Resident #17's [MEDICAL CONDITION]. 1. Physician orders [REDACTED].#17, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The resident had orders for "may have full side rails up x (times) 2 to aid in turning and repositioning." There was no documented medical indication for the side rails. The most recent MDS dated [DATE] indicated Resident #17 was alert, confused and rarely/never understood. The resident was totally dependent on staff for ADLs and side rails were used daily. A care plan dated 8/8/14 titled, "Resident had a fall" indicated the approach for Resident #17 was to "evaluate resident for fall risk and measures to maintain safety, check resident frequently, and assure of repositioning/toileting/range of motion every 2 hours and as needed." A care plan updated 8/10/14 titled, "Requires use of restraints/enabler" indicated Resident #17 required "side rails x 2 while in bed to aid in turning and repositioning and establish boundaries" ... "related to: inability to safely transfer self, poor positioning, high risk for falls, poor cognition and poor direction." The goal was to "have the least restrictive environment possible through next review date." The approaches included were to: *"check every 2 hours and PRN; *prompt incontinent care; *release and reposition every 2 hours; *screen quarterly/PRN for restraint/enabler reduction or change in POC; and *assist with proper bed positioning." A "Side rail Safety Assessment" dated 8/10/14 indicated Resident #17 had the verbal ability to call for help, was not restless in bed, did not have paralysis, and her extremities could not become wedged between side rails and mattress. The intervention checked as applying to the resident was, "Full side rails up for positioning, bed boundaries." There was no documentation of a medical indication for the side rails. An undated and incomplete "Pre-restraining Evaluation" did not indicate the type of restraint Resident #17 required or the medical symptom for the restraint. The evaluation indicated the resident had a fall and required surgery. The section titled, "Referrals and Recommendations" did not have documentation to indicate there were recommendations or alternatives attempted prior to the use of the side rails. During observation and interview on 10/19/14 at 2:15 p.m., Resident #17 was lying in bed with full side rails up on both sides and the top of the mattress was in a high position approximately 36 inches from the floor. CNA S said the resident fell out of the bed while the full side rails were up and the resident sustained [REDACTED]. A plan of care dated 8/14/14 indicated Resident #17 had a "fall resulting in a right [MEDICAL CONDITION]". The approaches were to: "*evaluate resident for fall risk and measures to maintain safety; *check resident frequently during shift for positioning and safety; ... and *monitor and document any s/s of complications of resident's injury." An incident report dated 8/14/14 at 9:00 p.m. indicated Resident #17 was observed on the floor next to the bed. "Holding arm and guarding." The "type" of injury was listed as "Fall right hip pain." The section titled, "Resident" did not have documentation to indicate if the resident had side rails ordered, if they were present, if they were up or down or if the bed was in low position. The plan of action to prevent future incidents/accidents was to "ensure bed alarm and chair alarms are always in place. Make frequent checks on resident." A nursing note dated 8/14/14 at 9:00 p.m. indicated Resident #17 was "observed on the floor next to the bed. The alarm was in place and in use. Guarding right hip after placing resident back in bed. ... Sending to ER. New order for right hip x-ray received. ..."There was no other documentation in the nursing notes until 8/15/14 at 10:35 a.m., when the hospice nurse documented the staff reported to her the resident was in pain when moved and an x-ray had been performed "this a.m."... . During an interview on 10/20/14 at 2:20 p.m., LVN T said he was called down to Resident #17's room by a CNA where the resident was found lying on the floor on her back. LVN T said the side rails were up on both sides of the bed and the alarm pad was "scooted" down to the end of the bed. He said he, LVN U, and a CNA, whom he could not remember, picked the resident up and placed her back in the bed. LVN T said Resident #17 began guarding her right hip. LVN T said the side rails were up on both sides of the bed due to the resident trying to get out of the bed. LVN T said Resident #17 had a history of [REDACTED]. LVN T said the facility did not have or use low beds with mats as alternatives to side rails. During an interview on 10/20/14 at 2:55 p.m., LVN U said he assisted LVN T on 8/14/14 in standing Resident #17 and putting her back in the bed. He said the resident was in pain and they did not send the resident out to the hospital for evaluation that night. During an interview on 10/21/14 at 5:08 p.m., CNA X said she and CNA V heard Resident #17's alarm sound, but by the time they got to her she was on the floor. She said the side rails were up on both sides to keep her from falling out of the bed. During an interview on 10/22/14 at 11:50 a.m., CNA V said she and CNA X went in to check on Resident #17 when the bed alarm sounded. The resident was lying on her side next to bed B, approximately 3 to 4 feet from her bed. She was grimacing in pain. She said she, LVN T, LVN U, and CNA X assisted with putting the resident back in the bed and placing the side rails back up on both sides. She said the side rails were used for Resident #17's protection; to keep her from falling out of the bed. A nursing note dated 8/15/14 indicated Resident #17's x-ray report showed a right [MEDICAL CONDITION]. New orders were given for a pain medication every 2 hours as needed. A nursing note dated 8/15/14 at 1:40 p.m. indicated Resident #17 was transported to the hospital by ambulance. A re-admission order dated 8/19/14 indicated Resident #17 had an ORIF of the right hip on 8/16/14, UTI, altered mental status, and [MEDICAL CONDITION]. The orders indicated if side rails were present then the type/frequency/reason was to be documented. A "Side rail Safety Assessment" dated 8/19/14 indicated Resident #17 was "restless in bed." The interventions for the side rails were not checked indicating the resident did not require interventions. There was no documentation of a medical indication for the side rails. A care plan dated 8/26/14 titled, "Resident with recent fracture" indicated the approach for Resident #17 was to "...assist with ADLs as needed." During an interview on 10/20/14 at 11:55 a.m., the DON said the facility was restraint free but she did have residents with side rails in place for positioning and turning. She said the incident report for Resident #17 dated 8/14/14 was incomplete. She said Resident #17 could not turn herself in bed. During an interview on 10/20/14 at 12:15 p.m., the responsible party for Resident #17 said LVN T called to report the resident fell out of bed the night of 8/14/14, but reported the resident was not hurt. During the following interviews, the CNAs, who had cared for Resident #17, said the residents had side railss to protect them from falling out of bed and there was no other alternative to the side rails being used. The CNAs said Resident #17 had been seen throwing her legs over the side railss on multiple occasions: *on 10/20/14 at 3:05 p.m., CNA R; *on 10/20/14 at 3:07 p.m., CNA S; *on 10/21/14 at 3:00 p.m., CNA Y; *on 10/21/14 at 3:07 p.m., CNA Z; *on 10/21/14 at 4:28 p.m., CNA AA; *on 10/21/14 at 4:54 p.m., CNA BB *on 10/21/14 at 5:08 p.m., CNA X; *on 10/22/14 at 11:35 a.m., CNA CC; *on 10/22/14 at 11:40 a.m., CNA K; and *on 10/22/14 at 11:50 a.m.; CNA V. During an interview on 10/23/14 at 11:00 a.m., the DON said she became aware of Resident #17's fall with fracture on 8/15/14 and they continued the use of side rails when the resident returned from the hospital. She said actual harm of a fracture did occur. The DON said the immediate jeopardy occurred when the facility failed to protect Resident #17 and placed her back in the bed with side rails after her fall with injury. During an interview on 10/23/14 at 11:15 a. m., the administrator said he did not see a problem with the side rails and did not think the incident was at an immediate jeopardy level. He said Resident #17 still had side rails after her fall with injury. 2. physician's orders [REDACTED].#62, readmitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Full side rails were ordered for positioning. The most recent MDS dated [DATE] indicated Resident #62 required the assistance of two people for bed mobility and transfers. Resident #62 occasionally resisted care, had no pain, and was unable to make her needs known. A care plan updated 10/16/13 titled, "Requires use of restraints/enabler" indicated Resident #62 required "side rails x 2 while in bed to aid in turning and repositioning and establish boundaries" ... "related to: inability to safely transfer self, poor positioning, high risk for falls, poor cognition and poor redirection." The goal was to "have the least restrictive environment possible through next review date." The approaches included were to: *"check every 2 hours and PRN; *prompt incontinent care; *release and reposition every 2 hours; *screen quarterly/PRN for restraint/enabler reduction or change in POC; and *assist with proper bed positioning." A "Side rail Safety Assessment" dated 8/18/14 indicated Resident #62 had the verbal ability to call for help, was not restless in bed, did not have paralysis, and her extremities could not become wedged between side rails and mattress. The intervention checked as applying to the resident was, "Full side rails up x 2 for positioning, non-weight bearing, total care." There was no documentation of a medical indication for the side rails. During an observation on 10/19/14 at 2:58 p.m., Resident #62 was in bed on her back; the bed was in a high position and had two raised, unpadded full side rails. During an interview on 10/21/14 at 11:30 a.m. CNAs B and C said Resident #62 did not use the side rails to assist with turning and that the rails were on the bed to prevent falling. CNA B said only side rails and alarms were used and there were no low beds or special mattresses. CNA C said the resident kicked her legs in the air and to the side when she was awake. CNA B said the resident was occasionally found with her legs sticking through the bed rail. During an interview on 10/23/14 at 3:00 p.m., the DON said she was not aware Resident #62 kicked her legs in bed and was occasionally found with her legs through the bed rail. During an interview on 10/23/14 at 3:07 p.m., RN G said she did not care plan Resident #62's kicking because she felt it was not a behavior but just something she did. She also said she was not aware the resident put her legs through the bed rail. 3. physician's orders [REDACTED].#72, readmitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Side rails were ordered to aid with turning and positioning. The most recent MDS dated [DATE] indicated Resident #72 required the assistance of one person for bed mobility and transfers. Resident #72 did not resist care, had some back pain, and was able to understand others and make herself understood. A nursing care plan dated 3/3/14 indicated Resident #72 required side rails for positioning, turning and to establish bed boundaries. During an observation and interview on 10/19/14 at 2:27 p.m., Resident #72 was in bed on her back; the bed was in a high position and both side rails were raised. Resident #72 said she used the rails to help her turn side to side. The resident said the facility had not provided a less restrictive device and she wouldn't mind using a shorter rail. During an interview on 10/20/14 at 11:30 a.m., CNA B said Resident #72 had side rails to prevent falling. CNA B said Resident #72 did not attempt to climb over the side rails. During an interview on 10/23/14 at 3:00 p.m., the DON said Resident #72 had side rails to assist with turning and repositioning. 4. Physician orders [REDACTED].#50, re-admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. Resident #50 had an order for [REDACTED]. A telephone physician order [REDACTED]. There was no reason, [DIAGNOSES REDACTED]. During an observation on 10/21/14 at 10:55 a.m., Resident #50 was transferred from a wheelchair to the bed by 2 staff members. During incontinent care, Resident #50 did not hold onto or use the siderails to assist with turning or repositioning. The staff person raised the full side rails up on both sides after completing the incontinent care. A "Side Rail Safety Assessment" for Resident #50 dated 8/21/14 indicated "Full side rails up times 2 for positioning." An undated "Resident Status Sheet", which is the CNA care plan, for Resident #50 indicated she required the assistance of 2 people for position changes. An "ADL Flow Sheet" dated October 2014 indicated Resident #50 required turning and repositioning every two hours. Every shift was initialed indicating the resident had been repositioned and turned every two hours. A "Physical Restraint Informed Consent" form for Resident #50 signed and dated 7/23/14 by staff and the resident's responsible party did not list any less restrictive alternative, non-restraint approaches that proved to be ineffective. Under "Restraint Type, Frequency", it lists "Full side rails up x (times) 2" to aid in positioning and turning. The "Medial Symptoms" listed "Falls." The statement of consent was checked to indicate: "...I agree to the use of a full side rail up times 2 physical restraint." During interviews on 10/21/14 at 10:57 a.m., CNA S and CNA R said they provide care for Resident #50. Both CNAs said Resident #50 is unable to use the side rails for positioning and said they did not know why the side rails were up. During an interview on 10/21/14 at 5:05 p.m., CNA S said she didn't know why Resident #50 had full side rails. She said Resident #50 could not use the side rails for positioning and was unable to transfer without maximum assistance. During an interview on 10/21/14 at 9:19 a.m., Resident #50's responsible party said the resident fell out of bed over the side rails once. She was unable to remember the date of the occurrence. During an interview on 10/22/14 at 3:50 p.m., Physical Therapy Aide HH said Resident #50 could not use side rails as an enabler to assist with turning and repositioning. She said she did not know why the side rails were being used. During an interview on 10/23/14 at 12:20 p.m., the DON said the only medical [DIAGNOSES REDACTED].#50 being treated with the use of side rails was lupus. She said the disease makes the joints stiff and painful and it would not require full side rails if they were used for turning and positioning. During an interview on 10/21.14 at 12:35 p.m., the owner acknowledged side rails were being used to prevent falls. He stated, "I know better, just got focused on other things. This was not paid attention to." During an interview on 10/22/14 at 12:20 p.m., the administrator acknowledged side rails were being used without medical justification. He stated, "I guess I became de-sensitized to them." A restraint policy dated December 2008 stated, "Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience or for the prevention of falls. The facility's policy titled "Proper Use of Side Rails" dated October 2010 indicated the purpose was "...to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms." General guidelines included: "1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed).... 2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents.... 7. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 8. The risks and benefits of side rails will be considered for each resident.... 10. The resident will be checked periodically for safety relative to side rail us." On 10/20/14 at 4:28 p.m., it was determined these failures constituted an Immediate Jeopardy situation. The administrator, DON, and corporate nurse were notified at this time an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 10/22/14 at 5:10 p.m. and included: *" Resident #17 was assessed for side rails, pain, fall risk, environmental factors, preventative devices, bed position, side rail fitting. *Side rails were removed, bed placed in low position, mat placed on floor, sitter with resident on days and during night, 30 minute checks for 30 days, if no falls in 30 days return to routine monitoring. *All staff in-serviced on what a restraint is and accidents and supervision. *All residents with side rails are being assessed, all charts audited, and ongoing education until all staff are in-serviced on restraints/accident/supervision. *New admits who are at high risk for falls will be assessed for least restrictive alternatives to restraint. *Alternatives to side rails will be implemented as indicated, including low beds,fall mats, Bolster mattresses, personal alarms, and grab bars." On 10/23/14, the surveyors confirmed the plan of removal had been implemented sufficiently to remove the IJ by: *A "Side rail Safety Assessment" updated 10/22/14 indicated Resident #17 was "restless in bed" with possibility of extremities or head becoming wedged between mattress and pad. The resident interventions of a bolster mattress with fall mat, very 30 minute checks and one on one care at bedside. *A "Pre-Restraining Evaluation" for side rails dated 10/20/14 indicated Resident #17 was to be placed in a bolster mattress with a fall mat. *A "Plan of Care" dated 10/22/14 for Resident #17 indicated the resident had a potential for falls, required a bolster mattress, every 30 minute checks and one on one care at bedside. *Observations on 10/22/14 at 1:20 p.m. and on 10/23/14 at 8:15 a.m. indicated Resident #17 was in a low bed with a fall mat on each side. *Ten CNAs were interviewed and said they had been in-serviced beginning on 10/21/14. They were able to voice what a restraint was, alternative interventions and new fall prevention program. *Nine LVN nurses were interviewed and said they had been in-serviced beginning on 10/21/14. The nurses were able to voice what a restraint was, alternative interventions, and the new fall program. *The DON was interviewed and was able to voice what a restraint was, alternative interventions, and the new fall program. *The MDS RN was interviewed and was able to voice what a restraint was, alternative interventions, and the new fall program. *One MA was interviewed and was able to voice what a restraint was, alternative interventions, and the new fall program. On 10/23/14 at 9:58 a.m., the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to ensure all in-service training was completed and evaluation of the effectiveness of the corrective systems. A list dated 10/20/14 provided by DON indicated 65 residents had side rails.

Based on observation, interview, and record review, the facility failed to provide supervision and utilize assistive devices to prevent accidents for 3 of 6 residents reviewed with full side rails (Resident #s 17, 62, and 50); 1 of 1 resident reviewed with portable oxygen tanks (Resident #41), and 2 of 4 halls reviewed for accident hazards. (Halls 200 and 400) 1. Resident #17 sustained a fractured hip when she fell out of bed with the side rails up. The facility did not assess Resident #17 for side rail safety, develop a care plan to ensure Resident #17 was safe in a bed with side rails, attempt other less restrictive measures prior to using side rails, or change safety interventions after Resident #17's fall. She was placed back in a bed with full side rails up on both sides after her return from the hospital where she received surgical correction of the fracture. Resident #s 62 and 50 had side rails on their beds. The facility did not ensure residents: *were free from physical injury such as fractures and bruises; *were re-assessed for full side rail use or had accurate side rail assessments; *had a medical symptom related to the restraint use; and *had evidence less restrictive safety measures were attempted prior to the utilization of side rails. An Immediate Jeopardy situation was identified on 10/20/14. The Immediate Jeopardy was removed on 10/23/14. The facility remained out of compliance at a pattern of actual harm due to the facility's need to ensure all in-service training was completed and the effectiveness of the corrective systems was evaluated. This failure could place the 65 residents with side rails at risk for compression injuries, fractures, suffocation, or death. Non-Immediate Jeopardy 4. Resident #41 received an abrasion to his leg when an unsecured oxygen cylinder was left standing by his bed; The facility failed to ensure the oxygen bottle was secured at all times to prevent injuries. This failure could place 23 residents with oxygen at risk of injury from unsecured oxygen tanks. 5. The floor tech mopped the floors on Halls 200 and 400 from one side to the other instead of ensuring a safe area to walk. This failure could place the 35 residents living on Halls 200 and 400, staff, and visitors at risk of falls or injury. Findings included: These failures contributed to Resident #17's fractured hip. 1. Physician orders [REDACTED].#17, admitted [DATE], was [AGE] years old with diagnoses of altered mental status, UTI (urinary tract infection), Alzheimer's disease, anxiety, and dementia. The resident had orders for "may have full side rails up x (times) 2 to aid in turning and repositioning. " There was no documented medical indication for the side rails. The most recent MDS dated [DATE] indicated Resident #17 was alert, confused and rarely/never understood. The resident was totally dependent on staff for ADLs and side rails were used daily. A care plan updated 8/10/14 titled, "Requires use of restraints/enabler" indicated Resident #17 required "side rails x 2 while in bed to aid in turning and repositioning and establish boundaries" ... "related to: inability to safely transfer self, poor positioning, high risk for falls, poor cognition and poor direction." The goal was to "have the least restrictive environment possible through next review date." The approaches included were to: *"check every 2 hours and PRN; *prompt incontinent care; *release and reposition every 2 hours; *screen quarterly/PRN for restraint/enabler reduction or change in POC; and *assist with proper bed positioning. " A "Side rail Safety Assessment" dated 8/10/14 indicated Resident #17 had the verbal ability to call for help, was not restless in bed, did not have paralysis, and her extremities could not become wedged between side rails and mattress. The intervention checked as applying to the resident was, "Full side rails up x 2 for positioning, bed boundaries." There was no documentation of a medical indication for the side rails. An undated and incomplete "Pre-restraining Evaluation" did not indicate the type of restraint Resident #17 required or the medical symptom for the restraint. The evaluation indicated the resident had a fall and required surgery. The section titled, "Referrals and Recommendations" did not have documentation to indicate there were recommendations or alternatives attempted prior to the use of the side rails. During observation and interview on 10/19/14 at 2:15 p.m., Resident #17 was lying in bed with full side rails up on both sides and the top of the mattress was in a high position approximately 36 inches from the floor. CNA S said the resident fell out of the bed while the full side rails were up and the resident sustained [REDACTED]. A care plan dated 8/14/14 indicated Resident #17 had a "fall resulting in a right hip fracture". The approaches were to: " *evaluate resident for fall risk and measures to maintain safety; *check resident frequently during shift for positioning and safety; ... and *monitor and document any s/s of complications of resident's injury." An incident report dated 8/14/14 at 9:00 p.m. indicated Resident #17 was observed on the floor next to the bed. "Holding arm and guarding." The "type" of injury was listed as "Fall right hip pain." The section titled, "Resident" did not have documentation to indicate if the resident had side rails ordered, if they were present, if they were up or down or if the bed was in low position. The plan of action to prevent future incidents/accidents was to "ensure bed alarm and chair alarms are always in place. Make frequent checks on resident." A nursing note dated 8/14/14 at 9:00 p.m. indicated Resident #17 was "observed on the floor next to the bed. The alarm was in place and in use. Guarding right hip after placing resident back in bed. ... Sending to ER. New order for right hip x-ray received. ..." There was no other documentation in the nursing notes until 8/15/14 at 10:35 a.m., when the hospice nurse documented the staff reported to her the resident was in pain when moved and an x-ray had been performed "this a.m."... . During an interview on 10/20/14 at 2:20 p.m., LVN T said he was called down to Resident #17's room by a CNA where the resident was found lying on the floor on her back. LVN T said the side rails were up on both sides due to her trying to get out of the bed and the alarm pad was "scooted" down to the end of the bed. He said he, LVN U, and a CNA, whom he could not remember, picked the resident up and placed her back in the bed. LVN T said Resident #17 began guarding her right hip. LVN T said the side rails were up on both sides of the bed due to the resident trying to get out of the bed. LVN T said Resident #17 had a history of [REDACTED]. LVN T said Resident #17 was not sent to the ER until the next day and he should have sent the resident out when he found her on the floor. LVN T said the facility did not have or use low beds with mats as alternatives to side rails. During an interview on 10/20/14 at 2:55 p.m., LVN U said he assisted LVN T on 8/14/14 in standing Resident #17 and putting her back in the bed when she fell out of the bed with the full side rails up. During an interview on 10/21/14 at 5:08 p.m., CNA X said she and CNA V heard Resident #17's alarm sound, but by the time they got to her she was on the floor. She said the side rails were up on both sides to keep her from falling out of the bed. During an interview on 10/22/14 at 11:50 a.m., CNA V said she and CNA X went in to check on Resident #17 when the bed alarm sounded. The resident was lying on her side next to bed B, approximately 3 to 4 feet from her bed. She was grimacing in pain. She said she, LVN T, LVN U, and CNA X assisted with putting the resident back in the bed and placing the side rails back up on both sides. She said the side rails were used for Resident #17's protection; to keep her from falling out of the bed. A nursing note dated 8/15/14 indicated Resident #17's x-ray report showed a right hip fracture. New orders were given for a pain medication every 2 hours as needed. A nursing note dated 8/15/14 at 1:40 p.m. indicated Resident #17 was transported to the hospital by ambulance. A re-admission order dated 8/19/14 indicated Resident #17 had an ORIF of the right hip on 8/16/14, UTI, altered mental status, and Alzheimer's disease. The orders indicated if side rails were present then the type/frequency/reason was to be documented. A "Side rail Safety Assessment" dated 8/19/14 indicated Resident #17 was "restless in bed." The interventions for the side rails were not checked indicating the resident did not require interventions. There was no documentation of a medical indication for the side rails. A care plan dated 8/26/14 titled, "Resident with recent fracture" indicated the approach for Resident #17 was to "...assist with ADLs as needed." During an interview on 10/20/14 at 11:55 a.m., the DON said the facility was restraint free but she did have residents with side rails in place for positioning and turning. She said the incident report for Resident #17 dated 8/14/14 was incomplete. She said Resident #17 could not turn herself in bed. During an interview on 10/20/14 at 12:15 p.m., the responsible party for Resident #17 said LVN T called to report the resident fell out of bed the night of 8/14/14, but reported the resident was not hurt. During the following interviews, the CNAs, who had cared for Resident #17, said the residents who had side rails were to protect them from falling out of bed and there was no other alternative to the side rails being used. The CNAs said Resident #17 had been seen throwing her legs over the side rails on multiple occasions: *on 10/20/14 at 3:05 p.m., CNA R; *on 10/20/14 at 3:07 p.m., CNA S; *on 10/21/14 at 3:00 p.m., CNA Y; *on 10/21/14 at 3:07 p.m., CNA Z; *on 10/21/14 at 4:28 p.m., CNA AA; *on 10/21/14 at 4:54 p.m., CNA BB *on 10/21/14 at 5:08 p.m., CNA X; *on 10/22/14 at 11:35 a.m., CNA CC; *on 10/22/14 at 11:40 a.m., CNA K; and *on 10/22/14 at 11:50 a.m.; CNA V. During an interview on 10/23/14 at 11:00 a.m., the DON said she became aware of Resident #17's fall with fracture on 8/15/14 and they continued the use of side rails when the resident returned from the hospital. She said actual harm of a fracture did occur. The DON said the immediate jeopardy occurred when the facility failed to protect Resident #17 and placed her back in the bed with side rails after her fall with injury. During an interview on 10/23/14 at 11:15 a. m., the administrator said he did not see a problem with the side rails and did not think the incident was at an immediate jeopardy level. He said Resident #17 still had side rails after her fall with injury. 2. physician's orders [REDACTED].#62, readmitted [DATE], was [AGE] years old with diagnoses of Alzheimer's disease, epilepsy, high blood pressure and coronary artery disease. Side rails were ordered for use as necessary for positioning. The clinical record for Resident #62 did not contain documentation to indicate the resident had a pre-restraining assessment. The most recent MDS dated [DATE] indicated Resident #62 required the assistance of two people for bed mobility and transfers. Resident #62 occasionally resisted care, had no pain, and was unable to make her needs known. Side rails were used daily. A care plan updated 10/16/13 titled, "Requires use of restraints/enabler" indicated Resident #62 required "side rails x 2 while in bed to aid in turning and repositioning and establish boundaries" ... "related to: inability to safely transfer self, poor positioning, high risk for falls, poor cognition and poor redirection." The goal was to "have the least restrictive environment possible through next review date." The approaches included were to: *"check every 2 hours and PRN; *prompt incontinent care; *release and reposition every 2 hours; *screen quarterly/PRN for restraint/enabler reduction or change in POC; and *assist with proper bed positioning." A "Side rail Safety Assessment" dated 8/18/14 indicated Resident #62 had the verbal ability to call for help, was not restless in bed, did not have paralysis, and her extremities could not become wedged between side rails and mattress. The intervention checked as applying to the resident was, "Full side rails up x 2 for positioning, non-weight bearing, and total care." There was no documentation of a medical indication for the side rails. During an observation on 10/19/14 at 2:58 p.m., Resident #62 was in bed on her back; the bed was in a high position and contained two unpadded full side rails. Nurse notes dated 10/1614 at 9:30 p.m. indicated a CNA reported to the charge nurse that Resident #62 was grimacing and saying, "Don't touch me " while being transferred from a Geri-chair to the bed. The charge nurse instructed staff to let her rest for a few minutes then attempt to continue care. At 10:00 p.m. the CNA reported Resident #62 was complaining of increased pain in her right leg. The resident was medicated for pain and hospice notified. An assessment found Resident's right thigh to right knee slightly swollen and painful. The physician was notified and an x-ray ordered. The x-ray was positive for a hip fracture. Resident was sent to the hospital for evaluation. During an interview on 10/21/14 at 11:00 a.m., CNA B said that during the day shift on 10/16/14 Resident #62 was noted to be profusely sweating. She notified LVN F who completed an assessment and found no reason for the sweating. During an interview on 10/21/14 at 11:30 a.m., CNA B and CNA C said they laid the resident down at 2:30 p.m. and then got her up again at 4:30 p.m. for supper. CNA B and C said they did not notice any swelling or bruises on the resident and the resident did not act as though she was in pain. CNAs B and C said Resident #62 does not use the side rails to assist with turning and that the rails are on the bed to prevent falling. CNA B said only side rails and alarms were used and there were no low beds or special mattresses. CNA C said the resident would kick her legs up in the air and to the side when she is awake. CNA B said the resident was occasionally found with her legs sticking out of the bed rail. During an interview on 10/22/14 at 3:18 p.m., CNAs W and DD said as they transferred Resident #62 on 10/16/14 at 9:30 p.m., she began to yell not to touch her and had a grimace on her face. They informed the charge nurse who told them to let her rest for a while the try to continue care. They said when they attempted to care for the resident she began grimacing and showing signs of pain in her leg. The CNAs said they informed the charge nurse. CNA W said the resident didn't appear any different from her usual self. During an interview on 10/23/14 at 3:07 p.m., RN G said she did not care plan Resident #62's kicking because she felt it was not a behavior. She also said she was not aware the resident put her legs through the side rail. 3. Physician orders [REDACTED].#50, re-admitted [DATE], was [AGE] years old, with diagnoses of renal failure, lupus and heart failure. Resident #50 had an order for [REDACTED]. A telephone physician order [REDACTED].? side rails were to be discontinued and the resident was to have full side rails on both sides. There was no [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #50 was alert, confused and required extensive assistance with ADLs. The resident was to have side rails daily. A care plan dated 7/24/14 indicated Resident #50 would have side rails up on both sides while in bed and would have the least restrictive environment. A "Side Rail Safety Assessment" for Resident #50 dated 8/21/14 indicated "Full side rails up times 2 for positioning." An "ADL Flow Sheet" dated October 2014 indicated Resident #50 required turning and repositioning every two hours. Every shift was initialed indicating the resident had been repositioned and turned every two hours. A "Physical Restraint Informed Consent" form for Resident #50 signed and dated 7/23/14 by staff and the resident's responsible party did not list any less restrictive alternative, non-restraint approaches that proved to be ineffective. Under "Restraint Type, Frequency", it lists "Full side rails up x (times) 2" to aid in positioning and turning. The "Medial Symptoms" listed "Falls." The statement of consent was checked to indicate: " ...I agree to the use of a full side rail up times 2 physical restraints." During an observation on 10/21/14 at 10:55 a.m., Resident #50 was transferred from a wheelchair to the bed by 2 staff members. During incontinent care, Resident #50 did not hold onto or use the siderails to assist with turning or repositioning. The staff person raised the full side rails up on both sides after completing the incontinent care. During interviews on 10/21/14 at 10:57 a.m., CNA S and CNA R said they provided care for Resident #50. Both CNAs said Resident #50 was unable to use the side rails for positioning and said they did not know why the side rails were up. During an interview on 10/21/14 at 5:05 p.m., CNA S said she didn't know why Resident #50 had full side rails. She said Resident #50 could not use the side rails for positioning and is unable to transfer without maximum assistance. During an interview on 10/21/14 at 9:19 a.m., Resident #50's responsible party said the resident fell out of bed over the side rails once. She was unable to remember the date of the occurrence. During an interview on 10/22/14 at 3:50 p.m., Physical Therapy Aide HH said Resident #50 could not use side rails as an enabler to assist with turning and repositioning. She said she did not know why the side rails were being used. During an interview on 10/23/14 at 12:20 p.m., the DON said the only medical [DIAGNOSES REDACTED].#50 for the use of side rails was lupus. She said the disease makes the joints stiff and painful and it would not require full side rails if they were used for turning and positioning. During an interview on 10/21.14 at 12:35 p.m., the facility owner acknowledged side rails were being used to prevent falls. He stated, "I know better, just got focused on other things. This was not paid attention to." During an interview on 10/22/14 at 12:20 p.m., the administrator acknowledged side rails were being used without medical justification. He stated, "I guess I became de-sensitized to them." A restraint policy dated December 2008 stated, "Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience or for the prevention of falls. On 10/20/14 at 4:28 p.m., it was determined these failures constituted an Immediate Jeopardy situation. The administrator, DON, and corporate nurse were notified at this time an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 10/22/14 at 5:10 p.m. and included: *"Resident #17 was assessed for side rails, pain, fall risk, environmental factors, preventative devices, bed position, side rail fitting. *Side rails were removed, bed placed in low position, mat placed on floor, sitter with resident on days and during night, 30 minute checks for 30 days, if no falls in 30 days return to routine monitoring. *All staff in-serviced on what a restraint is and accidents and supervision. *All residents with side rails are being assessed, all charts audited, and ongoing education until all staff are in-serviced on restraints/accident/supervision. *New admits who are at high risk for falls will be assessed for least restrictive alternatives to restraint. *Alternatives to side rails will be implemented as indicated, including low beds,fall mats, Bolster mattresses, personal alarms, and grab bars." On 10/23/14, the surveyors confirmed the plan of removal had been implemented sufficiently to remove the IJ by: *A "Side rail Safety Assessment" updated 10/22/14 indicated Resident #17 was "restless in bed" with possibility of extremities or head becoming wedged between mattress and pad. The resident interventions of a bolster mattress with fall mat, very 30 minute checks and one on one care at bedside. *A "Pre-Restraining Evaluation" for side rails dated 10/20/14 indicated Resident #17 was to be placed in a bolster mattress with a fall mat. *A "Plan of Care" dated 10/22/14 for Resident #17 indicated the resident had a potential for falls, required a bolster mattress, every 30 minute checks and one on one care at bedside. *Observations on 10/22/14 at 1:20 p.m. and on 10/23/14 at 8:15 a.m. indicated Resident #17 was in a low bed with a fall mat on each side. *Ten CNAs were interviewed and said they had been in-serviced beginning on 10/21/14. They were able to voice what a restraint was, alternative interventions and new fall prevention program. *Nine LVN nurses were interviewed and said they had been in-serviced beginning on 10/21/14. The nurses were able to voice what a restraint was, alternative interventions, and the new fall program. *The DON was interviewed and was able to voice what a restraint was, alternative interventions, and the new fall program. *The MDS RN was interviewed and was able to voice what a restraint was, alternative interventions, and the new fall program. *One MA was interviewed and was able to voice what a restraint was, alternative interventions, and the new fall program. On 10/23/14 at 9:58 a.m., the IJ was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to ensure all in-service training was completed and evaluation of the effectiveness of the corrective systems. Non-Immediate Jeopardy 4. Physician orders [REDACTED].#41, admitted [DATE], was [AGE] years old with diagnoses of diabetes, kidney disease with dialysis, poor vision, poor circulation and ulcer of the foot with gangrene. He was to receive oxygen continuously. The most recent MDS dated [DATE] indicated Resident #41 required extensive assistance with all ADLs and had a right below knee amputation (BKA). A care plan dated 7/2/14 indicated Resident #41 had self-care deficits due to weakness and amputation and required extensive assistance. During an observation and interview on 10/20/14 at 11:00 a.m., alert, oriented Resident #41 was up in his wheelchair at bedside. An oxygen cylinder in a black cover was lying on the floor in front of the night stand. The resident said it had been there since sometime last week. He said it fell over and scraped his leg when his oxygen tubing got tangled around it. Raising his left pants leg he indicated a gauze wrap to his lower leg. An incident report dated 10/20/14 at 6:30 a.m. indicated Resident #41 was found with an abrasion to the left shin. During an observation and interview on 10/20/14 at 10:55 a.m., the ADON acknowledged an oxygen bottle was lying beside Resident #41's bed and should be secured. During an observation of wound care on 10/21/14 at 9:15 a.m., Resident #41 had a raw abrasion area approximately 1 cm (centimeter) wide x 20 cm long on his left shin. The lower leg above the foot was reddened and the resident complained of pain in the area. During an interview on 10/21/14 at 10:30 a.m., Resident #41's wife said a few days ago, staff took the oxygen bottle off the resident's wheelchair and left it standing by his bed. 5. During an observation on 10/20/14 at 8:10 a.m., Maintenance Staff H mopped across the width of Hall 200. A yellow caution sign was in the center of the hall. During an observation on 10/20/14 at 8:20 a.m., Maintenance Staff H continued mopping across the entire width of Hall 200 to the end by the nursing station and dining room. During an interview on 10/20/14 at 8:22 a.m., Maintenance Staff H acknowledged he mopped both sides of the hall at once and it was a hazard, but said "It's a long hall. I'm trying to hurry." He acknowledged he was supposed to mop one side at a time and leave a side dry so people could walk safely. During an observation and interview on 10/20/14 at 9:35 a.m., Maintenance Staff H mopped the entire width of Hall 400. The administrator acknowledged only one side should be mopped at a time. The facility safety manual indicated the facility would provide a safe and healthful environment for employees and residents. All employees were responsible for observing for and reporting hazards immediately. A list dated 10/20/14 provided by DON indicated 65 residents had side rails. A list provided by the DON on 10/27/14 indicated 23 residents used oxygen. A resident roster dated 10/19/214 indicated 35 residents resided on Hall #s 200 and 400.

Based on interview and record review, the facility failed to ensure residents were provided the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being for 1 of 13 residents reviewed for pain. (Resident #17) Resident #17 was in pain after she fractured her hip from falling out of bed with the side rails up. She did not receive pain medication for 15 hours and 30 minutes after exhibiting signs/symptoms of pain. This failure could place 65 residents with side rails at risk for experiencing an alteration in comfort and a decline in physical, mental and psychosocial well-being. Findings included: 1. Physician orders [REDACTED].#17, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. The resident had orders for "may have full side rails up x (times) 2 to aid in turning and repositioning." The most recent MDS dated [DATE] indicated Resident #17 was alert, confused and rarely/never understood. The resident was totally dependent on staff for ADLs and side rails were used daily. "Pain Evaluation" assessments dated 2/12/14, 5/14/14, and 8/10/14 indicated Resident #17 had no signs or symptoms of pain present. A care plan dated 8/14/14 indicated Resident #17 had a "fall resulting in a right [MEDICAL CONDITION]" with "right hip pain". The approaches were to: *evaluate resident for fall risk and measures to maintain safety; *check resident frequently during shift for positioning and safety; *assure of repositioning/toileting/range of motion every 2 hrs and PRN; *monitor and document any signs/symptoms of complications of resident's injury; and *notify physician and family of changes." An undated "Pain Evaluation" assessment indicated Resident #17 had a "recent [MEDICAL CONDITION] and decubitus ulcer". The assessment had written on it "unable to answer next to the section titled, "Ask Resident". The sections titled, "additional symptoms associated with pain" and "Pain is increased by" were blank. The section titled "Body Language" indicated Resident #17 was "tense, distressed, pacing, and fidgeting". During observation and interview on 10/19/14 at 2:15 p.m., Resident #17 was lying in bed with full side rails up on both sides and the top of the mattress was in a high position approximately 36 inches from the floor. CNA S said the resident fell out of the bed while the full side rails were up and the resident sustained [REDACTED]. An incident report dated 8/14/14 at 9:00 p.m. indicated Resident #17 was observed on the floor next to the bed. "Holding arm and guarding." The "type" of injury was listed as "Fall right hip pain." A nursing note dated 8/14/14 at 9:00 p.m. indicated Resident #17 was "observed on the floor next to the bed. The alarm was in place and in use. Guarding right hip after placing resident back in bed. ... Sending to ER. New order for right hip x-ray received. ..." There was no other documentation in the nursing notes until 8/15/14 at 10:35 a.m., when the hospice nurse documented the staff reported to her the resident was in pain when moved and an x-ray had been performed "this a.m."... . During an interview on 10/20/14 at 2:20 p.m., LVN T said he was called down to Resident #17's room by a CNA where the resident was found lying on the floor on her back. LVN T said the side rails were up on both sides due to her trying to get out of the bed and the alarm pad was "scooted" down to the end of the bed. He said he, LVN U, and a CNA, whom he could not remember, picked the resident up and placed her back in the bed. LVN T said Resident #17 began guarding her right hip. LVN T said the side rails were up on both sides of the bed due to the resident trying to get out of the bed. LVN T said Resident #17 had a history of [REDACTED]. LVN T said Resident #17 was in pain when turned during the night and he should have sent the resident out when he found her on the floor. LVN T said the facility did not have or use low beds with mats as alternatives to side rails. During an interview on 10/20/14 at 2:55 p.m., LVN U said he assisted LVN T on 8/14/14 in standing Resident #17 and putting her back in the bed. He said the resident was in pain and they did not send the resident out to the hospital for evaluation that night. During an interview on 10/21/14 at 5:08 p.m., CNA X said she and CNA V heard Resident #17's alarm sound, but by the time they got to her she was on the floor. She said the side rails were up on both sides to keep her from falling out of the bed. During an interview on 10/22/14 at 11:50 a.m., CNA V said she and CNA X went in to check on Resident #17 when the bed alarm sounded. The resident was lying on her side next to bed B, approximately 3 to 4 feet from her bed. She was grimacing in pain. She said she, LVN T, LVN U, and CNA X assisted with putting the resident back in the bed and placing the side rails up on both sides. She said the side rails were used for Resident #17's protection; to keep her from falling out of the bed. A nurse note dated 8/15/14 indicated Resident #17's x-ray report showed a right femoral neck fracture. New orders were given for [MEDICATION NAME] (pain medication) 15 mg 1/2 tablet by mouth every 2 hours as needed for pain. A nurse note dated 8/15/14 at 1:20 p.m. indicated Resident #17's son was in the facility and wanted the resident sent to the ER. The [MEDICATION NAME] was given to the resident at 12:30 p.m. A MAR indicated [REDACTED]. The medication administration documentation on the back of the MAR indicated [REDACTED]. There was no documentation the resident received pain medication on 8/14/14, the night of the fall with injury. A nurse note dated 8/15/14 at 1:40 p.m. indicated Resident #17 was transported to the hospital by ambulance. A re-admission order dated 8/19/14 indicated Resident #17 had an ORIF of the right hip on 8/16/14, UTI, altered mental status, and [MEDICAL CONDITION]. The orders indicated if side rails were present then the type/frequency/reason was to be documented. A care plan dated 8/26/14 titled, "Resident with recent fracture" indicated the approach for Resident #17 was to "...assist with ADLs as needed." During an interview on 10/20/14 at 11:55 a.m., the DON said the facility was restraint free but she did have residents with side rails in place for positioning and turning. She said the incident report for Resident #17 dated 8/14/14 was incomplete. She said Resident #17 could not turn herself in bed. During an interview on 10/20/14 at 12:15 p.m., the responsible party for Resident #17 said LVN T called to report the resident fell out of bed the night of 8/14/14, but reported the resident was not hurt. During an interview on 10/22/14 at 9:00 a.m., the DON said LVN T should not have transferred Resident #17 back to the bed and the resident should have been sent to ER when she was found on the floor. The DON acknowledged the resident was left in pain all night on 8/14/14. A policy titled, "Administering Pain Medications", dated 2001, indicated "... Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals... ." A "Pain Assessment and Management" policy dated 2001 indicated "Pain management is a multidisciplinary care process which includes the following: ... b. effectively identifying the presence of pain... d. addressing the underlying causes of the pain... e. developing and implementing approaches to pain management... g. monitoring for the effectiveness of interventions... Conduct a comprehensive pain assessment...when there is a significant change in condition... Observe resident for physiologic and behavioral signs of pain... groaning, crying... grimacing... guarding... ." The CMS 672 indicated a census of 72.

Based on interview and record review, the facility failed to provide the care and services in accordance with the comprehensive assessment and plan of for 1 of 2 residents reviewed for wounds. (Resident #1) The facility did not assess or treat Resident #1's surgical wound from admission on 02/03/14 through 02/11/14, 8 days. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place the one resident admitted with wounds at risk for not receiving treatment. Findings included: A hospital discharge summary dated 02/03/14 indicated Resident #1 was [AGE] years old and had [DIAGNOSES REDACTED]. She underwent two surgeries, 1/9/14, left total hip arthroplasty and 1/29/14 to complete a revision of her left total hip arthroplasty. After the surgery, Resident #1 had an anterior groin wound that had a "little bit of a dehiscence." The physician indicated he wanted to "discharge her to a rehab facility with continued wound care and therapy." Admission physician orders [REDACTED]. An admission nurse note for Resident #1 dated 02/03/14 at 6:00 p.m. indicated, "On left leg there is a guaze (sic) covered bandage from hip replacement surgical site (groin area). On outside left hip is a padded bandaged from hip revision on 01/28/14." There was no documentation of a wound assessment or wound care in the clinical record for Resident #1 from 02/03/14 through 02/11/14. A non-pressure skin condition report for Resident #1 dated 02/03/14 indicated, "Groin incision site covered with a bandage." And "(L) ext hip bandage covered site from 2nd revision." A skin assessment for Resident #1 dated 02/05/14 indicated, "Incision site to groin with bandage intact. Incision site to (L) hip with bandage intact." During an interview on 02/18/14 at 1:45 p.m., LVN A said she completed the admission assessment on 02/03/14 for Resident #1. She said she did a head to toe assessment, but did not remove any dressings. LVN A said she called the physician to see if they were to continue the wound vac (a vacuum device to the wound bed to enhance circulation and promote healing) to the groin area, but did not inquire about any other orders for the surgical wounds. During an interview on 02/18/14 at 12:35 p.m., LVN B said she did a skin assessment on Resident #1 on 02/05/14. She said for some reason she did not take any dressings off to look at the wounds. She said she dropped the ball. During an interview on 02/18/14 at 1:40 p.m., LVN C said she was the one who discharged Resident #1 to another facility. She said she documented the dressings were intact and the skin surrounding the dressings had no signs of infection. She said she should have looked at the wounds, but did not. During an interview on 02/18/14 at 10:15 a.m., the DON said they had received a call from the DON at the facility where Resident #1 had been discharged to. They were inquiring about treatment orders for Resident #1's surgical wounds. She said they began an investigation and determined Resident #1 was at the facility from 02/03/14 -02/11/14 and did not have her surgical wounds assessed or treated. She said they immediately completed skin assessments on every resident in the facility and did not find any wounds they were not aware of. She educated the nurses regarding new admissions and skin assessments. She had a wound care company give an in-service on wounds and assessments. She said the admission nurse was to complete a skin assessment by removing all dressings and briefs at the time of admission, and then contact the physician for orders to treat any skin issues. The treatment nurse is to complete a skin assessment the next day, if she is not working at the time of the admission, and then the DON will follow-up with a skin assessment to ensure all skin issues are identified. During the eight days the resident was in the facility, the DON said she was not aware of Resident #1's wounds. She had terminated two nurses during the course of her investigation. During an interview on 02/18/14 at 12:15 p.m., the DON from the facility where Resident #1 was discharged to said Resident #1 was only in her facility for approximately three hours when she was sent to the hospital due to the left groin wound looking infected. The skin assessment from the new facility Resident #1 was admitted to dated 02/11/14 indicated the left groin wound was dehisced, and had yellow, green, and bloody drainage with undermining. The wound measured 12.5 cm X 1.2 cm and unable to determine the depth. It had 100% yellow slough wound bed. A consultation with the surgeon for Resident #1 dated 02/12/14 indicated, "She has been at rehab and has come back and it got a little bit more purulence to it and given the fact that we have a total hip underneath this, I would be aggressive about this wound and so I suggest an irrigation and debridement of this. I think local wound care might be effective for her, but we have tried that before and the seems to be inconsistent, so I would suggest being a little bit more aggressive and just cleaning this up and hopefully doing a definitive procedure and therefore help decrease the risk of involving the hip joint itself." A consultation with the infectious disease physician for Resident #1 dictated 02/16/14 indicated "Wound was draining some discharge, and the patient was seen by the surgeon and finally decided to do the irrigation and debridement of the wound, which is done and cultures are growing the Acinetobacter which is resistant to mutliple medications, and for that reason, patient was admitted and consult was called." The Centers for Disease Control website http://www.cdc.gov accessed 02/28/14 indicated Acinetobacter "typically occurs in ill patients and can either cause or contribute to death in these patients ..." and " is often resistant to many commonly prescribed antibiotics." During interview on 02/18/14 at 10:15 a.m, the DON said there had only been one resident admitted with wounds since the investigation.