Every finding on record at Rehabilitation Center of South Georgia

Based on observations, staff interviews, record review, and review of the facility's policies titled Self-Administration of Medications and Storage of Medications, the facility failed to ensure three of 36 sampled residents (R), (R88, R95, R41) did not have unauthorized, unsecured medications at bedside. This deficient practice had the potential to allow unauthorized access to medications to R88, R95, and R41, other residents, unauthorized staff, and visitors. Findings include:Review of the facility policy titled Self-Administration of Medications, dated 2/8/2021, revealed the Policy Statement stated, Resident in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. The Policy Interpretation and Implementation section included, . 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of the resident permitted to self-administer will be stored in a central medication cart or in the resident's medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. The nurse will have a key to the storage container.Record review of the facility policy titled Storage of Medications, dated 2/8/2022, revealed the Policy Statement stated, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The Policy Interpretation and Implementation section included, . 2. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.1. Observation on 12/1/2025 at 1:34 pm of R88's room revealed a tube of zinc oxide cream on the overhead bedside table, within open view of residents and visitors.Review of the electronic health record (EHR) for R88 revealed diagnoses including, but not limited to, unspecified dementia, cerebral palsy, and chronic pulmonary disorder disease. Review of the Quarterly Minimum Data Set (MDS) assessment for R88, dated 9/10/2025, revealed that Section C (Cognitive Patterns) assessed a Brief Interview Mental Status (BIMS) score of six, indicating moderate cognitive impairment.Review of the care plan for R88 revealed no focus area for self-administering medications.Review of the Physician Order Form for R88 revealed no order for zinc oxide or for self-administration of medication.Record review of the clinical record for R88 revealed that a medication self-administration assessment was not completed.During an observation and interview on 12/3/2025 at 2:24 pm in R88's room, with the Director of Nursing (DON), the DON confirmed the zinc oxide cream in R88's room and removed it. The DON stated that staff used the zinc oxide cream for preventative care. 2. Observation on 12/1/2025 at 10:56 pm and 11:05 pm of R95's room revealed a tube of zinc oxide cream sitting on the rolling bedside table, within open view of residents and visitors.Review of the EHR for R95 revealed diagnoses including, but not limited to, dementia, Alzheimer's, atrial fibrillation, and chronic kidney disease. Review of the Quarterly MDS for R95, dated 11/18/2025, revealed that Section C (Cognitive Patterns) assessed a BIMS score of 00, indicating severe cognitive impairments.Review of the Physician Order Form for R95 revealed no order for zinc oxide or for self-administration of medication.Record review of the clinical record for R95 revealed that a medication self-administration assessment was not completed.During an interview and observation on 12/3/2025 at 11:53 am in R95's room, with the DON, the DON confirmed cream zinc oxide ointment in the resident room. She stated that the cream was a topical cream and should be stored on a treatment cart. She reported that the risk was that the cream would be accessible to a wandering resident with low cognition, and that a resident could possibly eat or rub the product in his/her eyes. The DON stated she would provide in-services to the nursing staff regarding leaving medication products in resident rooms.3. Observations on 12/1/2025 at 10:56 pm and 11:05 pm of R41's room revealed a tube of zinc oxide cream on R41's bedside stand, within open view of residents and visitors.Review of the EHR for R41 revealed diagnoses including, but not limited to, unspecified dementia, unspecified severity with other behavioral disturbances, heart failure, and type 2 diabetes with diabetic neuropathy.Record review of the Quarterly MDS assessment for R41, dated 10/8/2025, revealed Section C (Cognitive Patterns) assessed a BIMS score of 13, indicating little to no cognitive impairment.Review of the care plan for R41 revealed no focus area for self-administering medications.Review of the Physician Order Form for R41 revealed no order for zinc oxide or for self-administration of medication.Record review of the clinical record for R41 revealed that a medication self-administration assessment was not completed.During an observation and interview on 12/3/2025 at 2:24 pm, the DON confirmed the zinc oxide cream in the resident room and removed it. The DON reported that R41 did not have a current wound or skin condition that required application of the cream.

Based on observations, staff interviews, record review, and review of the facility policy titled Care Plans-Comprehensive, the facility failed to follow care plans for one of 36 sampled residents (R) (R77). This deficient practice had the potential to place R77 at risk of not receiving treatment and/or care in accordance with their needs. Findings include:Record review of the facility policy titled Care Plans-Comprehensive, dated 2/2/2025, revealed the Policy Statement stated An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident 's medical, nursing, mental, and psychological needs is developed for each resident. The Policy Interpretation and Implementation section included, . 3. Each resident's comprehensive care plan is designed to: . (e) Reflect treatment goals, timetables, and objectives in measurable outcomes; (f) identify the professional services that are responsible for each element of care.Review of the electronic health record (EHR) for R77 revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, emphysema, cardiomegaly, and hypertension. Review of the Quarterly Minimum Data Set (MDS) for R77, dated 9/30/2025, revealed that Section O (Special Treatment Procedures, Program) revealed the resident received oxygen therapy.Record review of the care plan for R77 revealed a Focus area, last revised 5/19/2021, of the resident has altered respiratory status/difficulty breathing related to anxiety, asthma, and COPD. The Goal was for the resident to have no complications related to shortness of breath. The Interventions included, but were not limited to, oxygen via nasal cannula as ordered. Review of the physician orders for R77 revealed an order dated 1/11/2024 for oxygen at two liters per minute (LPM) via (by) nasal cannula continuous as the resident will allow. Observations on 12/2/2025 at 12:23 pm, 2:20 pm, and 4:15 pm revealed R77 lying in bed receiving oxygen by an oxygen concentration via a nasal cannula with the flow rate set to four LPM.During an observation on 12/2/2025 at 4:15 pm with the Assistant Director of Nursing (ADON), the ADON confirmed that the oxygen was set to four LPM and adjusted it to two LPM.In an interview on 12/4/2025 at 1:16 pm, the MDS Coordinator reported that her expectation was for staff to review the care plan to ensure it was followed. Cross-Reference F695

Based on observations, staff interviews, and record review, the facility failed to ensure that one of six residents (R) (R84) receiving nourishment via a tube feeding received water flushes as ordered by the physician. This deficient practice had the potential to place R84 at increased risk of medical complications.Findings include: Review of the admission Record for R84 revealed diagnoses including, but not limited to, adult failure to thrive, dysphagia, chronic kidney disease, stage four, and type 2 diabetes mellitus. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed that Section GG (Functional Abilities and Goals) documented that the resident was dependent with eating. Section K (Swallowing/Nutritional Status) documented that the resident had a feeding tube while a resident and received two to 501 cubic centimeters (cc) of fluid intake per day via the feeding tube. Review of the physician's orders for R84 revealed an order dated 7/25/2025 for Glucerna 1.5 at 40 cubic centimeters (cc) per hour and purified water flush of 50 cc per hour via pump. Review of the Medication Administration Record (MAR), dated 12/1/2025 through 12/31/2025, for R84 revealed an order dated 7/25/2025 for Glucerna 1.5 at 40 cubic centimeters (cc) per hour and purified water flush of 50 cc per hour via pump. The MAR was marked as the ordered feeding and flushes were administered as ordered. Observations on 12/2/2025 at 1:16 pm, 12/3/2025 at 11:26 am, and 12/4/2026 at 10:08 am revealed R84 receiving Glucerna 1.5 tube feeding at 40 cc per hour and water flush at 40 cc per hour via a feeding pump. In an interview on 12/04/2025 at 11:00 am, Licensed Practical Nurse (LPN) DD confirmed that the feeding pump for R84 was set to 40 cc per hour for the water flush. She confirmed the physician's order for the water flush was 50 cc per hour and changed the setting on the feeding pump. LPN DD stated the rate should have been updated when the order was changed. She stated that if the resident doesn't receive the appropriate amounts of fluids, it could lead to dehydration. In an interview on 12/4/2025 at 12:04 pm, the Director of Nursing (DON) stated that she expected the nurse to check tube feeding and flush rates every shift. She stated that there was an order that staff sign off on each shift that they had assessed the tube feeding. She further stated that incorrect rates of feeding tube flushes could lead to dehydration or fluid overload. In an interview on 12/4/2025 at 12:26 pm, the Administrator stated that she expected nurses to follow the physician's orders when setting rates for tube feedings and flushes. She stated that if the rates were lower than ordered, it could lead to dehydration.

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to ensure that one of 19 residents (R) (R77) receiving oxygen was administered oxygen therapy in accordance with the physician orders. This deficient practice had the potential to place R77 at risk for respiratory complications and a diminished quality of life.Findings include:Review of the facility policy titled Oxygen Administration, dated 2/25/2024, revealed the Policy Statement was, The purpose of this procedure is to provide guidelines for safe oxygen administration. The Policy Interpretations and Implementation section included, 1. Verify that there is a physician's order for this procedure. Review the physician 's orders or facility protocol for oxygen administration.Review of the electronic health record (EHR) for R77 revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) with (acute) exacerbation, emphysema, cardiomegaly, and hypertension. Review of the Quarterly Minimum Data Set (MDS) for R77, dated 9/30/2025, revealed that Section O (Special Treatment Procedures, Program) revealed the resident received oxygen therapy. Review of the physician orders for R77 revealed an order dated 1/11/2024 for oxygen at 2 liters per minute (LPM) via (by) nasal cannula continuous as the resident will allow. Observations on 12/2/2025 at 12:23 pm, 2:20 pm, and 4:15 pm revealed R77 lying in bed receiving oxygen by an oxygen concentration via a nasal cannula with the flow rate set to four LPM.During an observation on 12/2/2025 at 4:15 pm, with the Assistant Director of Nursing (ADON), the ADON confirmed that the oxygen was set to four LPM and adjusted it to two LPM. The ADON stated that if a resident with a diagnosis of COPD received too much oxygen, it placed them at risk for adverse effects, including hypercapnia.

Based on observations, staff and family interviews, and review of the facility's policy titled, Food Serving Temperatures, the facility failed to provide food at a safe and appetizing temperature for one observed meal. This failure had the potential to affect the satisfaction of food and palatability for 115 of 119 residents consuming food from one of one kitchen at the facility. Findings include: Review of the facility's undated policy titled, Food Serving Temperatures, under the section titled, Policy revealed, Foods will reach proper temperature to insure food safety. Foods will be maintained at proper holding temperature to insure (sic) food safety. Foods at point of service will be served to insure (sic) food safety. Under the section titled, Holding Temperatures revealed, The cook is responsible to see that all foods maintain proper holding temperatures . 2. The temperature of hot foods will have a minimum holding temperatures of 140 degrees F (Fahrenheit) . Under the section titled, Point of Service Temperatures revealed, Food is at an acceptable temperature at point of service of the resident. 1. The point of service temperature to residents will be within the range of 120-140 degrees and or based on resident's preference . During a phone interview on 7/1/2024 at 2:05 pm, Family Member (F) 13 stated, when I visit [R13] during mealtimes her food is always cold. During an observation on 7/3/2024 at 11:25 am, the temperature of the lunch items on the steam table being served were taken by staff under the supervision of the Dietary Manager (DM). Staff used the facility digital thermometer for the readings. The temperatures taken during the observation were as follows: Beef tips measured 200 degrees F for regular texture, 183 degrees F for mechanically altered, and 185 F degrees for pureed texture: Mashed potatoes measured 166 degrees F: Lima beans measured 198 degrees F for regular and mechanical, and 206 degrees F for pureed texture. All temperatures were confirmed by the DM. Observation on 7/3/2024 at 11:35 am revealed lunch service was started for residents eating in the main dining room. Dining room service ended at 11:50 am and service of the 500 hallway was started. Service of the 500 hallway was ended and a test tray was requested and plated at 11:55 am. The test tray plate was taken to the 500 Hallway which was the first resident hallway to be served. The cart was delivered to the hallway at 11:58 am and delivery of the trays began at 11:59 am. Food service ended at 12:06 pm. The test tray was the last tray served and was removed from the cart by the DM. The tray was taken to a nearby counter and the DM then took the temperature of the food items using a different analog thermometer that she had recently calibrated. The temperatures of the test tray were taken at 12:07 pm and were as follows: -Beef tips measured 100 degrees F: -Mashed potatoes measured 130 degrees F; and -Lima beans measured 104 degrees F. All temperatures were taken and confirmed by the DM. The items were evaluated alongside the DM, who reported the food items were found to be cold to warm. During an interview on 7/3/2024 at 12:07 pm the DM stated, The food items are found to be below acceptable levels using a reasonable person standard and were considered cold and in need of reheating. During an observation on 7/3/2024 at 12:20 pm, the different thermometers revealed a difference in readings of 45 degrees with the analog being 45 degrees cooler. The analog was rechecked for proper calibration using the ice water method and was found to be properly calibrated. These results were confirmed by the DM.

Based on observation, staff interview, and review of the facility's policy titled, Garbage and Rubbish Disposal, the facility failed to ensure garbage was properly disposed of and contained for two of three dumpsters with the side doors pushed back and left open. This had the potential to attract pests and affect the residents and staff at the facility. The facility census was 119 residents. Findings include: Review of the facility's policy titled, Garbage and Rubbish Disposal, dated 1/8/2009 under the Policy Statement revealed, Garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters. Under the section titled, Policy Interpretation and Implementation revealed, . 5. Garbage and rubbish containing food wastes shell be stored so as to be inaccessible to vermin . 8. Outside dumpsters provided by garbage pickup services must be kept closed and free of litter around the dumpster area. Observation on 7/1/2024 at 9:40 am, with the Dietary Manager (DM) of the area in the parking lot, behind the kitchen where the trash dumpster was located, revealed two of three dumpsters used to contain the facility trash and recycling material were open. The side doors were pushed back and left open. This exposed boxes and bags of trash. During an interview on 7/1/2024 at 9:40 am, the DM stated, The dumpsters should be closed, others use the dumpsters but it's our responsibility to keep them closed.

Based on observations, staff interviews, record review, and review of the facility policy titled, Activities and Social Services, the facility failed to provide an ongoing activity program to meet the individual interests and needs to enhance the quality of life for four of six residents (Residents (R) 101, R60, R93, and R55), who resided on the memory care unit and reviewed for activities. This failure had the potential for residents with diagnoses of dementia, to be disruptive to other residents and staff due to the lack of engagement in daily activities. Findings include: Review of the facility's policy titled, Activities and Social Services, dated 2008, indicated .Residents shall have the right to choose the types of activities and social events in which they wish to participate .Residents who wish to meet with or participate in the activities of social, religious, and other community groups, at or away from the facility, will be encouraged to do so .Activities will be scheduled throughout the day, as well as during evenings, weekends, and holidays . 1. Review of R101's electronic medical record (EMR) Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia. Review of R101's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/30/2024, indicated the staff was unable to determine the Brief Interview for Mental Status (BIMS) and the resident was severely cognitively impaired. The assessment revealed the resident was ambulatory. The assessment indicated the resident's representative stated it was very important for the resident to listen to music she liked and to participate in religious activities. The resident's representative stated it was somewhat important for the resident to have access to books and magazines and to participate in activities that she enjoyed. 2. Review of R60's EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of R60's EMR admission MDS with an ARD of 1/25/2024 indicated the BIMS score was zero out of 15 which indicated the resident was severely cognitively impaired. The assessment revealed the resident was ambulatory. The assessment indicated the resident's representative stated it was very important for the resident to listen to music she liked and to participate in religious activities. The resident's representative stated it was somewhat important for the resident to do things with groups of people. 3. Review of R93's EMR Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia. Review of R93's EMR admission MDS with an ARD of 8/21/2023 indicated the resident was severely cognitively impaired. The assessment revealed the resident was ambulatory. The assessment indicated the resident's representative stated it was very important for the resident to go outside and to participate in religious activities. The resident's representative stated it was somewhat important for the resident to listen to music she liked, to do things with groups of people, and to participate in activities she liked. 4. Review of R55's EMR Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia. Review of R55's EMR admission MDS with an ARD of 11/15/2023 indicated the BIMS score was two out of 15 which indicated the resident was severely cognitively impaired. The assessment indicated the resident was ambulatory. The assessment revealed the resident stated it was very important to her to have books and magazines for her to read and to keep up with the news. The resident stated it was somewhat important to her to listen to music and to participate in religious activities. Review of an activity calendar, for the secured unit, dated 7/2024, indicated group activities such as Bible study, music, and crafts were scheduled once a day at 2:00 pm. There were no weekend activities identified on the calendar. During an observation on 7/2/2024 from 9:12 am through 10:25 am, residents were observed lined up on each side of the television/dining area, sitting in chairs. The television was on. The television had the Hallmark station on. During an observation on 7/2/2024 from 11:57 am through 1:15 pm, the residents were lined up against two walls, opposite from each other. The television was still on the Hallmark station. At 12:01 pm, staff moved tables to the center of the area and assisted residents to the tables in preparation for the lunch meal. R60 was being assisted with her lunch meal by staff. The television continued to play the Hallmark station. During an observation on 7/2/2024 from 4:09 pm through 4:43 pm, the television was on. Residents again were lined up on opposite sides of the television/dining area sitting in chairs. Four residents were sleeping while sitting in their chairs. Certified Nurse Assistant (CNA) 2 entered a resident room and showed where the activity calendars were for the residents. According to CNA2 the posted activity calendar was for the residents off the secured unit. CNA2 stated she was not sure if the posted activities were for residents who may come off the secured unit and into the general population. The television/dining area continued to have the Hallmark station on. CNA2 was asked if the activity department provided items for the residents on the memory care unit. CNA2 stated the activity department did not. CNA2 entered an adjacent room for staff and opened the cabinets. There were no items for the residents to be engaged with, such as puzzles, arts and crafts, or other items that might be appropriate for cognitively impaired residents. At 4:40 pm, the staff moved tables to the center of the room and began to assist the residents to sit at the tables in preparation for the dinner meal. During an observation on 7/3/2024 from 8:56 am through 10:30 am, Licensed Practical Nurse (LPN) 1 stated she was regularly placed on the memory care unit. LPN1 stated that she and the staff would dance with the residents and take them for walks to keep the residents busy. LPN1 stated she has not seen the activity department do individual activities for the residents. LPN1 stated she has seen the activity department do group activities. At 9:04 am, the residents were observed eating breakfast and music was playing from the television. Some of the residents who had completed breakfast were sitting back against the wall lined up facing the center of the room. At 9:29 am, the Activity Director (AD) brought in tambourines for some of the residents. The Activity Director asked questions from the Bible and sang a few hymns with the residents. R60 smiled and was observed to dance to religious music. Multiple residents were lined up against two walls which faced the center of the room. At 9:51 am, the Activity Director ended the activity for the residents. Music was turned back on from the television. Staff were observed to walk with R60. During an interview on 7/3/2024 at 2:19 pm, the AD stated she has been in her position for the past five months. The AD stated for the residents on the memory care unit, the department provided music on one day, on another day it would be arts and crafts. The AD stated she was aware of the residents who resided on the memory care unit and some of them had behaviors and were difficult to engage. The AD stated she has not implemented the weekend schedule for the memory care unit, since the facility just recently hired two new employees. The AD stated there needed to be activity staff on the unit to be the hands for these residents. The AD stated the television was on all the time and on channels which had music. The AD stated the facility participated in Music and Memory (a non-profit program trained individuals to set up music tracks on IPODs for adults with poor cognition) and showed the equipment that would be offered to a resident with memory impairments. The AD stated the facility had not implemented this program yet. The AD stated she was attempting to implement individual activities for the five residents but had only focused on the residents outside of the memory care unit. The AD stated the implementation of more activities was a goal for her on the memory care unit. During an interview on 7/3/2024 at 4:28 pm, the Administrator stated she was new to her position. The Administrator stated there used to be a staff member from the activity department scheduled in the memory care unit. The Administrator stated she was unsure what happened to the previous staff member and was aware the current Activity Director was attempting to bring activities to the memory care unit and stated she had identified the lack of activities on the secured unit last week. The Administrator stated there was no performance improvement plan that currently addressed this issue. The Corporate Nurse was present during this interview.

28306 Based on observation, record review, interview, and review of the facility's policy titled, Care Plans-Comprehensive, the facility failed to implement a person-centered comprehensive plan of care with measurable goals and plans related to fall and activity interventions for five of six residents (R) R43, R84, R60, R55, and R101) reviewed for care plans. This failure had the potential for residents with a diagnosis of dementia to be disruptive to other residents and staff due to the lack of engagement in daily activities and had the potential for injury without proper fall interventions in place as directed by the plan of care. Findings include: Review of the facility's policy titled, Care Plans-Comprehensive, dated 4/18/2017, indicated .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs is developed for each resident . Review of the facility's policy titled, Activities and Social Services, dated 2008, indicated .When developing the resident's activity and social care plans, the resident will be given an opportunity to choose when, where, and how he or she will participate in activities and social events. Activities, social events, and schedules will be developed in conjunction with the resident's interests, assessment, and plan of care . 1. a. Review of R43's electronic medical record (EMR) Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R43's EMR Care Plan located under the Care Plan tab, dated 11/1/2018, directed the staff to place the bed in the lowest position since the resident was at risk for falls and had a history of rolling herself off the bed. Review of R43's care plan indicated the resident was dependent on staff for all activities of daily living. Observations were made on the following dates of R43's bed not placed in the lowest position: 7/1/2024 at 9:52 am, 7/1/2024 at 12:30 pm, 7/1/2024 at 2:46 pm, and on 7/2/2024 at 1:42 pm. During an interview on 7/3/2024 at 1:40 pm, Registered Nurse (RN) 1 confirmed she was the unit manager for the 300 and 400 units. RN1 stated she was familiar with R43. RN1 stated she was the one who updated the care plans and Certified Nurse Aides (CNA) were to implement the care plan for R43 and to have the resident's bed at the lowest position since she was considered a fall risk. b. Review of R84's undated Face Sheet located under the Profile tab in the EMR, revealed R84 was originally admitted to the facility on [DATE] and then readmitted to the facility on [DATE] with diagnoses of dementia and history of falling. Review of R84's Care Plan, dated 1/22/2024 located in the EMR under the Care Plan tab, revealed fall mats were to be placed on the resident's right side of the bed when R84 was in the bed. Observations were made on 7/1/2024 at 4:37 pm and on 7/2/2024 at 2:01 pm of the fall mat placed at the foot of the bed with R84's wheelchair parked on top of the fall mat. During an interview on 7/2/2024 at 2:46 pm, CNA 6 stated, The fall mat should be on the right side of the bed, and it is not in the right place right now. CNA 6 confirmed observation of the fall mat at the end of the bed with a wheelchair parked on top of it. During an interview on 7/3/2024 at 4:25 pm the corporate nurse confirmed the fall mat should have been placed on the right side of the bed for R84. 2. a. Review of R60's EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE]. The resident resided in the memory care unit. Review of R60's EMR Care Plan located under the Care Plan tab, dated 1/25/2024, indicated R60 was dependent on staff for meeting emotional, intellectual, and social needs due to a diagnosis of Alzheimer disease progresses. b. Review of R55's EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] and resided in the memory care unit. Review of R55's EMR Care Plan located under the Care Plan tab, dated 11/15/2023, indicated the resident preferred to watch television movies and news programs. The care plan also revealed the resident enjoyed socializing with the facility staff and her family. c. Review of R101's EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] and resided in the memory care unit. Review of R101's Care Plan located under the Care Plan tab, dated 7/6/2023 indicated the resident's preferred activities included to read, watch television. and to listen to music. Observations were made on the memory care unit on 7/2/2024 and 7/3/2024. The residents were observed to be lined up against two walls which faced each other. There was limited engagement from the staff who were present. On 7/2/2024, the television was on during the observations. On 7/3/2024 music was playing on a television station. There were no games, programs, or other simple, personalized engagement activities which would meet the individual activity needs of the residents. During an interview on 7/4/2024 at 2:59 pm, Licensed Practical Nurse (LPN) 5 confirmed she was the Unit Manager for the 500 and 600 units. LPN 5 stated the expectations were for staff to implement care plan interventions for the residents.

Based on staff interview, record review, and review of the facility policy titled, Consultant Pharmacist Reports, the facility failed to ensure pharmacy medication regimen reviews (MRR's) included appropriately monitored medication regimens to include antibiotic usage and ensure that medications received were clinically indicated for one of six residents (Resident (R) 63) reviewed for medication regimens. The failure had the potential to affect resident safety related to antibiotic use. Findings include: Review of the facility's policy titled, Consultant Pharmacist Reports, dated 5/1/2007, revealed The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimizes adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing and the attending physician, and if appropriate, the medical director and /or the administrator. Reivew of the facility's policy titled, Antibiotic Stewardship Program Overview, dated 8/11/2022, revealed under Drug Expertise: The Pharmacy Consultant will be engaged to review and report antibiotic usage data to the team. Review of R63s Admission Record located under the Profile tab of the electronic medical record (EMR), revealed R63 was admitted to the facility on [DATE] with diagnoses that included diabetes, chronic kidney disease, dementia, psychotic disorder with hallucinations, and a personal history of urinary tract infections (UTI) during stay with an onset date of 3/13/2024. Review of R63's MRR's from 6/2023 to 6/2024 did not contain any information about antibiotic use, or the number of antibiotics prescribed with the number of residents treated each month. Review of R63's Progress Notes located under the Progress Notes tab of the EMR, revealed that on 3/28/2024, the resident was sent to the hospital for altered mental status and dysuria (discomfort, pain, or burning while urinating). The emergency room doctor started R63 on the antibiotic Bactrim from 3/28/2024 until 4/4/2024. This antibiotic was not susceptible to Escherichia Coli (E-Coli) and Extended Spectrum Beta-Lactamase (ESBL) which are enzymes produced by some bacteria that may make them resistant to some antibiotics. The facility then started R63 on Macrobid for E-Coli ESBL Positive from 4/15/2024 to 4/25/2024. During an interview on 7/3/2024 at 4:27 pm, the Corporate Nurse was asked if she could get the number for the Consultant Pharmacist. On 7/4/2024 at 8:07 am, the Corporate Nurse stated that she had sent the Consultant Pharmacist a message through Facebook and that she was now off for the day and tomorrow (7/4/2024) and was unavailable to talk to the survey team. The pharmacist would be available after the survey on 7/5/2024. During an interview on 7/4/2024 at 9:44 am, the Infection Preventionist (IP) revealed Pharmacy does monthly medication reviews, but it does not include antibiotic reviews. For [R63], we missed the big picture. We did not see the timeline of all the catheterizations and antibiotics. Every time a straight catheterization is completed, it is a possibility for an infection. We missed the wrong antibiotic administered and we must make changes. The infection control program in the EMR does not keep an order of events.

Based on observation, interviews, record review, and review of the facility's policy titled, Medication Administration-General Guidelines, the facility failed to ensure one of six medication carts were locked and a cup of medications was not readily accessible while left unattended with the potential to affect one of two residents (R) R79. This failure had the potential for R79 to have access to medications that were not prescribed for him that could lead to adverse side effects. Findings include: Review of the pharmacy policy titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES, dated 5/1/2020 revealed .During administration of medications, the medication cart is kept closed and locked when out of sight if the medication nurse or aide. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward side must be inaccessible to residents or others passing by . Review of R79's undated Face Sheet located in the EMR under the Profile tab, revealed R79 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnoses of diabetes, bipolar disorder, and heart failure. During observation on 7/4/2024 at 8:32 am, Licensed Practical Nurse (LPN) 9 was preparing the medication to be administered to R106 when R79 wheeled up to the medication cart and began to sit there in the hallway. LPN 9 left the cart unlocked and proceeded to go inside the doorway of a resident's room and asked her how she would like her powder medication mixed this morning. LPN 9 returned to the cart and started preparing the medication. At 8:42 am, LPN 9 locked the medication cart but left the medicine cup of pills on top of the medication cart and went to the doorway of the resident's room to ask the resident a question. R79 continued to sit at the medication cart while the medicine cup of pills was sitting on top of the medication cart unattended. R79 had access to the drawers on the medication cart as well as the cup of pills that were left on top of the medication cart unsupervised. During an interview on 7/4/2024 at 8:51 am, LPN 9 was asked if she could see the front side of the medication cart when it was left unlocked and if she could see the medicine cup of pills that were left unattended on top of the medication cart when she went into the doorway to talk with another resident. LPN 9 went inside of the doorway and turned around to come back to the medication cart and confirmed she could not see the front side of the medication cart, nor could she see the cup of medications that were left when she was talking to the other resident. During an interview on 7/4/2023 at 9:03 am, LPN 5 stated, The cart should always be locked when you (nurse) are not with it.

Based on observation, staff interviews, record review, and review of the facility policies titled, Crushing Medications, and Administrating Oral Medications, the facility failed to ensure a medication error rate below five percent. During medication administration two medication errors for one resident (Residents (R) 77) were made of 27 opportunities during medication administration resulting in a medication error rate of 7.41 percent. These failures had the potential to increase or decrease the effectiveness of these medications. Findings include: Review of the facility's policy titled, Crushing Medications, dated 3/22/2017, revealed Medications shall be crushed only when it is appropriate to do so . Review of the facility's policy titled, Administrating Oral Medications, dated 3/22/2017, revealed .Check the label on the medication and confirm the medication name and dose with the eMAR [Electronic Medication Administration Record]. Review of R77's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed R77 was admitted to the facility with the diagnoses of dementia, constipation, and cardiac murmur. Review of R77's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 4/1/2024 revealed R77's Brief Interview for Mental Status (BIMS) score was five out of 15 which indicated R77 was severely cognitively impaired. Review of R77's Physician Orders located in the EMR under the Orders tab, revealed an order dated 3/31/2023 for aspirin (pain reliever) 81 mg (milligram) chewable tablet one time a day and an order dated 3/31/2023 for Colace (laxative) 100 mg one time a day. There was also a banner on the top of the computer screen which stated to Crush meds (medications). During an observation on 7/3/2024 at 9:03 am, Licensed Practical Nurse (LPN) 6 prepared aspirin enteric coated 81 mg and crushed this medication. LPN6 stated, [R77] always refuses the Colace and proceeded to document the mediation was refused by R77 on the Medication Administration Record (MAR). LPN6 then administered the crushed aspirin to R77. During an interview on 7/3/2024 at 9:21 am, LPN6 stated, I gave the wrong aspirin. It should have been the one you can crush. I knew that [R77] always refused the Colace, so I went ahead and documented that [R77] refused to take the Colace. When asked when the nurse should document the refusal of any medication, LPN6 stated, I guess I should have asked her before I documented that she had refused to take the Colace. During an interview on 7/3/2024 at 2:18 pm, the Corporate Nurse confirmed the enteric coated aspirin could not be crushed and the nurse should have asked the resident if he/she wanted to take a certain medication that was often refused and then go back to the medication cart and document the resident refused the medication. During an interview on 7/4/2024 at 4:30 pm, the Administrator was asked her expectation of the nursing staff when administrating medications and the Administrator stated, the nurses are to give the medications correctly.

Based on observations, interviews, and review of the facility policy titled, Exercise of Rights, the facility failed to honor residents' rights to be able to get out of bed as the resident chooses for one of 25 sample residents (Resident (R) 36). This failure resulted in the potential for R36 not being able to get out of bed due to the facility not having the available equipment. Findings include: Review of the facility's policy titled, Exercise of Rights, dated 11/29/2022, revealed Residents have the freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care .Our facility will not hamper, compel by force, treat differently, or retaliate against a resident for exercising his or her rights. Review of R36's electronic medical record (EMR) Face Sheet located under the Profile tab, revealed R36 was originally admitted to the facility with diagnoses which included multiple sclerosis, and contracture of left hand, wrist, and elbow. Review of R36's EMR quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 4/26/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which represented R36 was cognitively intact. R36 was also coded for having impairment on side of the upper and lower extremities, used a wheelchair, required substantial/maximal assistance in bed mobility, and was dependent on staff to transfer from the bed to a chair/wheelchair. Review of R36's care plan, dated 6/13/2019 and located in the EMR under the Care Plan tab, revealed .the resident requires the assistance by staff to turn and reposition in the bed . and required the use of a mechanical lift with two staff assistance for transfers. During observations during the survey period from 7/1/2024 through 7/3/2024 R36 was not observed to be out of bed during this period. During an interview on 7/1/2024 at 12:22 pm, R36 stated he had not been out of the bed for five days. R36 also stated they (staff) tells me they don't have any pads (lift pads) to use to get me out of the bed. During an interview on 7/2/2024 at 2:47 pm, Certified Nurse Assistant (CNA) 6 stated, This happens frequently and we [staff] have to tell [R36] that we [staff] cannot get him up because we don't have any lift pads .the unit manager has been told about this and we are told to go and look and see if we [staff] can find any .I have been told the DON (Director of Nursing) knows but I have not told her personally. During an interview on 7/2/2024 at 2:57 pm, CNA7 stated, We [staff] don't have Hoyer lift pads to use to get [R36] up today and that is the only way that we can get [R36] up. During an interview on 7/2/2024 at 3:03 pm, Licensed Practical Nurse (LPN) 7 stated, [R36] is a Hoyer lift. There are times that we cannot get [R36] up because we do not have any lift pads to use. We look in the laundry room and if there aren't any in there, then we won't be able to get [R36] up. During an interview on 7/2/2024 at 3:15 pm, Registered Nurse/Unit Manager (RN) 1 for 300 and 400 hallways stated as I was leaving yesterday, they [staff] stated they had borrowed it [lift pad] to weigh residents and brought it back to [R36]. They should not have borrowed it because each resident has their own lift pads in their rooms. During an interview on 7/2/2024 at 4:04 pm, the Housekeeping Supervisor (HS) stated, After we wash the Hoyer lift pads and dry them, we put them in a bin so when staff bring us a soiled one, we can give them a clean lift pad. Right now, I do not have any to trade out to give them (staff). I have had to tell staff that I do not have anything to give them (staff), and it breaks my heart because I know someone cannot get up because of that. I know that Central Supply orders them, so we just don't know where they go after that. During an interview on 7/2/2024 at 4:12 pm, the Central Supply (CS) 1 stated, I have ordered them, but we don't know where the (lift pads) go. During an interview on 7/2/2024 at 5:15 pm, R36 stated, I cannot get up and go anywhere like I would like to. I like to get out in the facility and talk to other people here or go to Bingo. Right now, I cannot do any of that if I cannot get up. I sit in here and look at the four walls. When asked if he feels isolated because he cannot get out of bed, R36 replied, Yes I do. During an interview on 7/3/2024 at 4:39 pm with the Administrator and the Corporate Nurse, they were notified that R36 had not been out of bed for seven days and R36 stated he felt isolated because he could not get out of bed. The Administrator stated, I was not made aware of this. We have bought 150 lift pads since November 2023. When asked what the expectation of staff was in regard to having enough lift pads so R36 could get out of bed, the Administrator stated, Staff need to let me know when they don't have the equipment to use for the residents and we will make sure this equipment is obtained and can be used for resident care.

Based on staff interviews, record review, and review of the facility policy titled, Abuse Prohibition Policy and Procedures, the facility failed to protect the residents' right to be free from physical abuse by another resident for four out of 25 residents (Residents (R) R60, R55, R101, and R93) that were reviewed for abuse. Findings include: Review of the facility's policy titled, Abuse Prohibition Policy and Procedures dated 1/2017, indicated .It is the intent of this facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse or misappropriation of resident property. We believe that each resident has the right to be free from verbal, sexual, physical and mental abuse .Abuse .means the willful infliction of injury . 1. a. Review of R60's electronic medical records (EMR) Admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of early Alzheimer's disease. Review of R60's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/26/2024 indicated the resident had a Brief Interview for Mental Status (BIMS) score of zero out of 15 which revealed the resident was severely cognitively impaired. The assessment revealed the resident was ambulatory. The assessment indicated the resident had physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing) during one to three days of the assessment period. The assessment indicated the resident had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) during one to three days of the assessment period. Review of R60's EMR Care Plan located under the Care Plan tab, dated 2/7/2024, indicated the resident had a mood problem related to dementia with mood disturbances. The care plan, dated 3/25/2025, indicated the resident had the potential to be physically aggressive (hitting) related to her diagnosis of dementia. The intervention of the care plan was to administer her psychotropic medications as ordered. b. Review of R101's EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia. Review of R101's EMR annual MDS with an ARD of 5/30/2024 indicated the resident had a BIMS score of zero out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident had no behaviors directed towards others. Review of R101's EMR Care Plan located under the Care Plan tab, dated 7/12/2023, indicated the resident had impaired cognitive function related to her diagnosis of dementia. Review of a document titled Facility Incident Report Form, dated 3/18/2024, indicated R60 was screaming and yelling and went up to R101 and slapped her in the face. R60 was immediately directed by staff. R101 was assessed by the staff and there were no injuries. The investigation revealed there were two witnesses Certified Nurse Assistant (CNA) 2 and Licensed Practical Nurse (LPN) 4. On the cover of this form there was a section marked resident-to-resident abuse. Review of a document untitled, dated 3/25/2024, indicated the facility completed a five-day investigative report to the State Survey Agency (SSA). The report reflected the initial 3/18/2024 incident. The investigative summary indicated the residents' responsible parties and physician were notified. The investigation substantiated that R101 was slapped by R60. 2. Review of R93's EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia. Review of R93's EMR quarterly MDS with an ARD of 3/20/2024 indicated the resident had a BIMS score of score of zero out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident hallucinated and had delusions but did not have any physical/verbal behaviors directed to others identified during the assessment period. The assessment indicated the resident was able to ambulate. Review of R93's Care Plan located under the Care Plan tab, dated 10/5/2023, indicated the resident has been physically and verbally aggressive towards staff and other residents. The intervention of the care plan was to administer her psychotropic medications. Review of a document Facility Incident Form, dated 5/26/2024, indicated R93 suddenly became agitated and grabbed the face/jaw of R60. The form indicated staff were able to remove R93's hand from the face/jaw of R60. On the cover of this form there was a section marked resident-to-resident abuse. Review of a document titled Physical Aggression, dated 5/26/2024, indicated R93 was busy cleaning a table in the main area of the memory care unit. The report indicated R60 was sitting at a table next to R93 when R93 grabbed the face/jaw of R60 and shook it. LPN4 removed the hand of R93 from R60's face. Both residents were assessed and there were no injuries. Both residents' representatives and the physician were notified. 3. Review of R55's EMR Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of unspecified dementia. Review of R55's EMR quarterly MDS with an ARD of 2/15/2024 indicated staff could not determine the resident's BIMS score. The assessment revealed the resident had no behavior directed towards others. The assessment indicated the resident ambulated with the assistance of a walker. Review of R55's EMR Care Plan located under the Care Plan tab, dated 11/15/2023, indicated the resident had limited activity involvement due to poor cognition. Review of a document Facility Incident Form, dated 4/30/2024, indicated R60 attempted to take tea from R55 and when R55 attempted to take her tea back R60 hit and grabbed R55 by the arm. On the cover of this form there was a section marked resident-to-resident abuse. Review of a document Physical Aggression Initiated, dated 4/30/2024, indicated R60 was making verbal threats to residents. R60 attempted to remove R55's tea and when R55 attempted to retrieve the tea back, R60 hit and grabbed R55's right arm and dug her nails into R55's skin. Both residents were separated by LPN1. Both residents were assessed and there were no injuries or skin tears on R55's arm. Review of a document Physical Aggression, dated 4/30/2024, indicated R60 attempted to move a cup of tea from R55. When R55 attempted to retrieve the tea from R60. R60 then hit R55's right arm and then grabbed her right arm and purposefully dug her nails into R55's arm. R55 sustained no injuries. R60 was immediately removed from R55. The resident's representative and physician were notified of the incident. During an interview on 7/3/2024 at 10:57 am, LPN4 stated she observed R60 slap R101 and did not consider the incident abuse but behavior. LPN4 stated she was a mandated reporter. LPN4 stated both residents were not in their right mind and had no ability to understand their actions. LPN4 stated she was a witness when R93 grabbed the face of R60. LPN4 stated R93 shook the face of R60 but did not leave any mark. LPN 4 stated she reported the incident between R93 and R60 immediately and stated it was behavior and not abuse. During an interview on 7/3/2024 at 4:28 pm, the Administrator stated abuse could happen between two residents. The Administrator stated the actions of R60 and R55 were abusive but not intentional abuse since the residents did not understand their actions. The Corporate Nurse was present during this interview. (Cross Reference F610)

Based on staff interviews, record review, and review of the facility policy titled, Abuse Prohibition Policy and Procedures, the facility failed to implement their abuse policy related to employee screening. The facility failed to ensure references were checked prior to employment for three of ten employees whose employee files were reviewed. Findings include: Review of the facility's policy titled, Abuse Prohibition Policy and Procedures, dated January 2017, revealed The facility will conduct a thorough investigation of the histories of individuals being considered for hire, in addition to the inquiry of the State Nurse Aide Registry or licensing authorities. All reasonable efforts will be made to check references and information from previous and/or current employers to uncover information about any criminal prosecutions. Review of documents provided by the facility, referred to as the employee file, for the Administrator indicated the date of hire was 10/19/2023 and the file failed to include reference checks for employment. Review of documents provided by the facility, referred to as the employee file, for Director of Nursing (DON) indicated the date of hire was 12/01/2014 and the file failed to include reference checks for employment. Review of documents provided by the facility, referred to as the employee file, for Certified Nursing Assistant (CNA) 5 indicated the date of hire was 11/19/2010 and the file failed to include reference checks for employment. During an interview on 7/3/2024 at 10:42 pm, Human Resources (HR) confirmed there were no employment reference checks for the above-named staff. Human Resources stated there was a previous Human Resource employee who had not completed references on employees, and she identified this when she completed an audit of the employee files. During an interview on 7/3/2024 at 3:47 pm, the Administrator stated that reference checks were completed to determine if the applicants were suited to work in the residents' home. The Administrator stated their expectation was for the references to be completed prior to hire.

Based on staff interviews, record review, and review of the facility policy titled, Abuse Investigation the facility failed to ensure thorough investigations were conducted of resident-to-resident incidents for four of 25 residents (Residents (R) 60, R55 R90, and R68) reviewed for abuse. This lack of investigation had the potential to place other dependent residents at risk for abuse/neglect. Findings include: Review of the facility's policy titled, Abuse Investigation dated 2008, indicated .All reports of resident abuse, neglect, misappropriation of resident property, and injuries of an unknown source shall be promptly and thoroughly investigated .An interview with the person(s) reporting the incident .Interviews with any witnesses to the incident .Witness reports shall be reduced to writing. Witnesses will be required to sign and date such reports. These reports will be sent in with other investigation information . 1. Review of R60's electronic medical records (EMR) Admission Record indicated the resident was admitted to the facility on [DATE]. Review of R60's EMR quarterly Minimum Data Set (MDS) located under the MDS tab with an Assessment Reference Date (ARD) of 4/26/2024 indicated the resident had a Brief Interview for Mental Status (BIMS) score of zero out of 15 which revealed the resident was severely cognitively impaired. 2. Review of R55's EMR Admission Record indicated the resident was admitted to the facility on [DATE]. Review of R55's EMR quarterly MDS with an ARD of 2/15/2024 indicated staff could not determine the resident's BIMS score. 3. Review of R90's EMR Admission Record indicated the resident was admitted to the facility on [DATE]. Review of the R90's EMR quarterly MDS with an ARD of 2/26/2024 indicated the staff could not determine the resident's BIMS score and determined the resident was cognitively impaired. 4. Review of R68's EMR Admission Record indicated the resident was admitted to the facility on [DATE]. Review of R68's EMR quarterly MDS with an ARD of 4/16/2024 indicated the resident had a BIMS score of zero out of 15 which indicated the resident had severely impaired cognition. Review of the facility's investigation dated 5/7/2024 and provided by the facility, which involved R55 and R60, failed to contain written statements collected from witnesses/staff. Review of the facility's investigation dated 5/10/2024 and provided by the facility, which involved R90, R68, and R60, failed to contain written statements collected from witnesses/staff. During an interview on 7/3/2024 at 8:58 am, Licensed Practical Nurse (LPN) 1 confirmed she witnessed the incident among R60, R90, and R68 and stated she was not interviewed by the Administrator. LPN1 stated she documented what she witnessed in the clinical records. During an interview on 7/3/2024 at 4:28 pm, the Administrator stated she could not locate any interviews conducted with witnesses/staff for any of the resident-to-resident incident files. The Administrator stated she would have interviewed witnesses and collected statements.

Based on record review, staff interviews, and review of the facility's policy titled, Discharging the Resident, the facility failed to provide the receiving facility with documentation regarding the transfer for one of five resident (R) (R86) reviewed for hospitalization . This failure had the potential to affect the care provided by the receiving facility by not informing them of the resident's medical needs or the residents wishes for ongoing care. Findings include: Review of the facility's policy titled, Discharging the Resident, dated 1/18/2023, under the Policy Statement revealed, The purpose of this procedure is to provide guidelines for the discharge process. Under the section titled, Policy Interpretation and Implementation revealed, . 6. If the resident is being discharged to a hospital or another facility, ensure that a transfer summary is completed, and telephone report is called to the receiving facility . Review of R86's undated Admission Record located in the Electronic Medical Record (EMR) under the Profile tab, revealed R86 was admitted to the facility on [DATE] with diagnoses that included but not limited to nonrheumatic mitral (valve) insufficiency, occlusion and stenosis of right carotid artery, and hypertension. Review of R86's Progress Notes located under the Notes tab, revealed a change in condition note, dated 6/26/2024, which revealed resident had another episode where she suddenly yells out this noise and becomes unresponsive . Sternum rub brought resident back to consciousness .NP [Nurse Practitioner] ordered to send her out for Syncope (a sudden drop-in heart rate and blood pressure leading to fainting) evaluation . Further review of R86's EMR failed to reveal any documentation or record of information that had been provided to the receiving facility. During an interview on 7/3/2024 at 10:15 am with the Corporate Nurse (CN), when asked if there was documentation indicating what information was sent with the resident to the hospital, stated, When a resident is sent to the hospital we complete and print out the transfer form. Looking at the resident record there is no documentation showing what was sent to the hospital with the resident. During an interview on 7/3/2024 at 10:15 am, Licensed Practical Nurse (LPN) 5 stated, We give verbal updates to the hospital, there is no documentation of what was sent with the resident. Cross Reference F623

Based on record review, staff interviews, and review of the facility's policy titled, Notice of Transfer/Discharge, the facility failed to notify the resident and/or resident's responsible party and the Ombudsman of a transfer or discharge in writing for one of five resident (R) (R86) reviewed for hospitalization . This created a potential for the resident or their representative to have incomplete information, misunderstand the reason, and process for transfer or discharge, and the discharge appeal process. Findings include: Review of the facility's policy titled, Notice of Transfer/Discharge, dated March 2017, under the Policy Statement revealed, It is the intent of this facility to ensure an orderly transfer and/or discharge to another living environment in the event it is the choice or best interest of the resident. Under the section titled, Policy Interpretation and Implementation revealed, Immediate Transfer/Discharge: 1. Notice of Transfer and Discharge will be made as soon as practicable when .f. An immediate transfer or discharge is required by the resident's urgent medical needs. 2. The notice will include the following: a. The reason for the transfer or discharge; b. The effective date of the transfer or discharge; c. The location to which the resident is to be transferred or discharged , d. An explanation or the residents right to appeal the transfer or discharge to the State, and e. The name, address, and telephone number of the state long-term care ombudsman . 3. A copy of the notice will go with the resident in the package of information to the Hospital and contact with the resident/responsible party as soon as practical Further review of the policy revealed that it failed to address providing written information to the resident and/or the resident representative and the Ombudsman regarding the need or transferring the resident. Review of the undated Admission Record, for R86 located in the Electronic Medical Record (EMR) under the Profile tab, revealed R86 was admitted to the facility on [DATE] with diagnoses that included nonrheumatic mitral (valve) insufficiency, occlusion and stenosis of right carotid artery, and hypertension. Review of the EMR Progress Notes for R86 located under the Notes tab, revealed a change in condition note, dated 6/26/2024, which revealed resident had another episode where she suddenly yells out this noise and becomes unresponsive . Sternum rub brought resident back to consciousness .NP [Nurse Practitioner] ordered to send her out for Syncope (a sudden drop-in heart rate and blood pressure leading to fainting) evaluation . Further review of the record revealed no documentation that written notification containing information as to the reason for the hospital transfer was provided to the resident, the resident's responsible party, or the Ombudsman. During an interview on 7/3/2024 at 10:15 am the Corporate Nurse (CN) stated, we do verbal notification to the families. We do not notify the Ombudsman when residents are transferred to the hospital. During an interview on 7/3/2024 at 10:15 am, Licensed Practical Nurse (LPN) 5 stated, We only give verbal updates to the families regarding the reason for transfer. Cross Reference F622

Based on interview, record review, and review of the facility policy titled, Bed Hold Policy, the facility failed to ensure one of five residents (R) R86 reviewed for hospital transfers was given a written copy of a bed hold notice prior to or within 24-hours of emergency transfer to the hospital. This failure created the potential for the resident and/or responsible parties to not have the information needed to safeguard their return to the facility. Findings include: Review of the facility's policy titled, Bed Hold Policy, dated 1/19/2022 revealed, Policy Statement: Our facility informs residents of our bed-hold policy upon admission and prior to a transfer for hospitalization or therapeutic leave. Policy Interpretation and Implementation: 1. Information concerning our bed-hold policy is found in the body of the admission agreement and is provided to the resident and/or resident representative upon admission to the facility. 2. At the time a resident is transferred to the hospital or going on therapeutic leave, the facility will provide the resident with information regarding holding bed space. 3. When emergency transfers are necessary, the facility will provide the resident or representative (sponsor) with information concerning our bed-hold policy within twenty-four (24) hours of such transfer via telephone or mail. 4. The bed-hold information will include any charges that the resident may incur as well as the time limit established by the State Medicaid Plan for which the facility will reserve the resident's bedspace . 12. A copy of the Transfer/Discharge Notice will be sent with the resident to the hospital. A copy will be sent to the Business Office. The Business office/designee will contact the resident and/or responsible party by mail or by phone in order to ascertain the resident/responsible party's wishes regarding holding the bed privately . Review of R86's undated Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed R86 was admitted to the facility on [DATE]. Review of the EMR Progress Notes located under the Notes tab, revealed a change in condition note, dated 6/26/2024, which revealed resident had another episode where she suddenly yells out this noise and becomes unresponsive . Sternum rub brought resident back to consciousness .NP [Nurse Practitioner] ordered to send her out for Syncope (a sudden drop-in heart rate and blood pressure leading to fainting) evaluation . Further review of the resident EMR failed to reveal documentation that the resident and/or the resident's representative were given written notice that specified the duration of the facility's bed hold policy. During an interview on 7/3/2024 at 10:15 am, the Financial Coordinator (FC) stated, If the resident is out three days or more then I usually give the resident representative a phone call on the third day to see if they want to do a bed hold. We do not send them anything in writing concerning the bed hold notice.

28306 Based on observations, interview, record review, and review of the facility's policy titled, Fall Management, the facility failed to ensure an accident prevention measure (bed in lowest position and/or fall mat in place) was implemented for two of five residents (R) R43 and R84. This failure had the potential to cause harm if the residents fell from their bed and the proper fall interventions were not in place. Findings include: Review of the facility's policy titled, Fall Management, dated 5/17/2017, revealed .staff will provide a safe environment for all residents .The facility will assess residents for fall risk, will evaluate each resident individually and provide, to the best of the facility's ability, interventions to decrease the likelihood of falls . 1. Review of R43's electronic medical record (EMR) Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with a diagnosis of other paralytic syndrome following a cerebral infarction (stroke). Review of R43's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/11/2024 indicated the resident had a Brief Interview for Mental Status (BIMS) score of zero out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the R43 was dependent on staff for all activities of daily living (ADLs) and had no recent falls. Review of R43's EMR Care Plan located under the Care Plan tab, dated 11/1/2018, directed the staff to place the bed in the lowest position since the resident was at risk of falls and had a history of rolling herself off the bed. Review of R43's care plan indicated the resident was dependent on staff for all activities of daily living. Review of R43's EMR Fall Risk located under Evaluations tab, dated 6/5/2024, indicated the resident was considered a high fall risk. Review of R43's EMR undated Kardex located on the dashboard, directed the Certified Nurse Assistant (CNA) to place the resident's bed in the lowest position. During observations on 7/1/2024 at 9:52 am, at 12:30 pm, at 2:46 pm and on 7/2/2024 at 1:42 pm, R43 was in bed and her bed was not in the lowest position. During an interview on 7/3/2024 at 8:49 am, CNA 1 stated she did not work the 300 unit in which R43 was on, but entered the resident's room and confirmed the bed was not in the lowest position. CNA 1 stated she would learn about a resident's status or change when she documented, and the change of the resident came up through the care plan and/or the Kardex. During an interview on 7/3/2024 at 1:40 pm, Registered Nurse (RN) 1 who was the Unit Manager for 300 and 400 units, stated R43 was a fall risk. RN 1 confirmed the resident's bed was to be in the lowest position to prevent her from being injured if the resident fell from her bed. RN1 stated her expectation was for the CNA staff to ensure the bed was in the lowest position to prevent injuries. During an interview on 7/3/2024 at 4:26 am, the corporate nurse stated her expectation was for staff to implement accident prevention measures. During an interview on 7/4/2024 at 1:28 pm, RN 1 stated she would walk the units once or twice a shift to ensure residents were getting the things they needed. RN 1 stated she did not complete any audit of placement of a resident's bed who was considered a fall risk. 2. Review of R84's undated Face Sheet located under the Profile tab in the EMR revealed R84 was originally admitted to the facility on [DATE] and then readmitted to the facility on [DATE] with diagnoses of dementia and history of falling. Review of R84's quarterly MDS with an ARD date of 3/15/2024 located in the EMR under the MDS tab, revealed R84 had a BIMS score of three out of 15 which represented R84 was severely cognitively impaired. The MDS also coded R84 as having one fall since admission to the facility which resulted in an injury. Review of R84's Care Plan, dated 1/22/2024 and located in the EMR under the Care Plan tab, revealed fall mats were to be placed on the resident's right side of the bed when R84 was in the bed. Review of R84's Fall Assessment, dated 6/8/2024 and located in the EMR under the Evaluations tab, revealed R84 had a score of 14 out of 15 which indicated R84 was a high risk for falls. During observations on 7/1/2024 at 4:37 pm and on 7/2/2024 at 2:01 pm the fall mat was placed at the foot of the bed with R84's wheelchair parked on top of the fall mat. During an interview on 7/2/2024 at 2:46 pm, CNA 6 stated, The fall mat should be on the right side of the bed, and it is not in the right place right now. CNA 6 confirmed observation of the fall mat at the end of the bed with a wheelchair parked on top of it. During an interview on 7/2/2024 at 2:55 pm CNA 7 confirmed the fall mat was at the foot of the bed with a wheelchair parked on top of the fall mat. During an interview on 7/2/2024 at 3:00 pm, Licensed Practical Nurse (LPN) 7 stated, The fall mat should be on the right side of the bed and not at the foot of the bed like it is now. During an interview on 7/2/2024 at 3:12 pm, RN 1 confirmed the fall mat should have been on the right side of the bed and the observation at this time revealed the fall mat was at the foot of the bed with a wheelchair parked on top of the fall mat. During an interview on 7/3/2024 at 4:25 pm, Corporate Nurse confirmed the fall mat should have been placed on the right side of the bed for R84.

Based on observation, staff interview, record review, and review of the facility policy titled, Medication Ordering and Receiving from Pharmacy, the facility failed to have a physician ordered medication available for administration for one of seven residents (Resident (R) 9) during the medication administration observation. This failure had the potential to decrease the effectiveness of the medication rivastigmine (Exelon) patch which was used for dementia. Findings include: Review of the facility's policy titled, Medication Ordering and Receiving from Pharmacy, dated 5/1/2020, revealed .Reorder medication four to five days in advance of need .to assure an adequate supply is on hand .The refill order is called in, faxed, sent electronically or otherwise transmitted to the pharmacy . Review of R9's undated Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed R9 was originally admitted to the facility on [DATE] and then readmitted to the facility on [DATE] with the diagnoses of Alzheimer's disease with late onset and dementia. Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/2/2024 revealed R9 had a Brief Interview for Mental Status (BIMS) score of four out of 15 which indicated R9 was severely cognitively impaired. Review of R9's Physician Orders located in the EMR under the Orders tab, revealed an order dated 6/25/2024, for rivastigmine (Exelon) 24-hour 4.6 mg (milligram) per 24 hours apply one patch transdermally one time a day for dementia. During the Medication Administration observation on 7/3/2024 at 8:43 am, Licensed Practical Nurse (LPN) 6 stated, The medication was never ordered, and I do not have a patch to replace the one that I removed. During an interview on 7/3/2024 at 2:18 pm, the Corporate Nurse stated, If you are down to one or two patches, you should be reordering these [patches].

Based on interview and record review, the facility failed to implement interventions in a timely manner to prevent further injury from the use of side rails for one resident ((R) R B) from a total sample of eight residents. Actual harm was identified when R B was found with a bruise with swelling to the top of the head on 7/6/22 after previously receiving an abrasion/bruise to head on 7/4/2022 as the result of hitting head on upper assist rail on bed. Findings include: Resident (R) B was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's, dementia with behavior disturbance, osteoarthritis, diabetes, major depressive disorder and anxiety disorder. There was a physician's order, dated 1/7/20, for 1/4 assist rails on both sides of the bed to assist with bed mobility, transfers, and/or define bed parameters. Facility nursing staff had completed a Quarterly Assist Device Assessment (side rails) on 6/2/22. The assessment included that 1/4 assist/enabler rails were utilized. A review of the clinical record revealed that R B was observed with injuries to her forehead on 7/4/22 and 7/6/22 that the facility determined were from the upper assist rails on her bed. A 7/4/22 2:51 a.m. Skin Assessment documented that R B had a red spot on the left forehead from lying against the side rail. A 7/4/22 6:38 a.m. nurse's note also documented the resident was noted to have a red spot with abrasion on the left side of the forehead without bruising. During an interview on 9/21/22 at 1:59 p.m., Registered Nurse (RN) AA (who completed the 7/4/22 skin assessment and 6:38 a.m. nurse's note) confirmed that she worked 7/3/22 from 11:00 p.m. to 7/4/22 7:00 a.m. She stated that during her shift the Certified Nursing Assistant (CNA) reported a spot of blood on the sheet on R B's bed and when she observed the resident, she was lying in the bed on her side with her head against the side rail. RN AA stated that she pulled the resident back a little and observed a small red spot on her forehead but that was not the source of the blood. RN AA stated that the area was a red abrasion, like how you get a raspberry, the skin was not broken. She assumed the source of the blood was from R B picking at her arm or leg, which is something the resident would do, but she did not discover the source of the blood. RN AA further stated that R B was lying against the side rail all night and she kept trying to put pillows there and move her head but she was set on having her head against the rail. On 7/4/22 at 12:45 p.m., Licensed Practical Nurse (LPN) GG documented that the CNA alerted the nurse to look at R B and the nurse observed a goose egg- like area on the left side of the forehead, with discoloration and some blood. R B's pillow was noted to have some blood on it also from the forehead. The note further documents that a fall was suspected but then the skin assessment was viewed (that was completed by RN AA from the night shift) that stated the area had previously been observed from R B having her head up against her bed side rail. The nurse's note entry includes that the physician was notified, and neurological checks were initiated. On 7/6/22 at 12:40 p.m., RN AA documented in a nurse's note that R B had a bruise with swelling on the top of her head, just within the front hair line. The note further documented that the abrasion from 7/4/22 was showing bruising across the top of the forehead. Although the neurological checks were completed on 7/4/22 and 7/5/22 with no changes noted, the Nurse Practitioner was notified and determined R B should be evaluated at the hospital to ensure that nothing was missed. The nurse's note further documented that based on proximity, the newly discovered bruising and swelling could have occurred in the same way and time as the abrasion on her forehead and would be consistent with her hitting her head on the side rails. RB was sent to the hospital emergency roiagnom on [DATE] and returned to the facility the following morning, on 7/7/22. A review of the ED Note Physician documentation revealed that the physical exam documented bruising only noted to scalp frontal area with an abrasion. The hospital documentation included that a CT of the head showed no acute brain injury, and that R B was at her baseline mental status. Although the facility identified the possible cause of R B's forehead injuries on 7/4/22 to be from the upper assist rails on her bed, there was no evidence in the clinical record that interventions were implemented to prevent further injury prior to additional swelling and bruising to the forehead being identified on 7/6/22, which resulted in an emergency room visit. On 7/8/22 the facility initiated a trial of removing the upper assist rails from R B's bed. Review of the care plan revealed that the care plan was revised to include that R B was previously using 1/4 side rails on both sides of the bed to define bed parameters and that a trial of discontinuing the side rails started 7/8/22 due to injury consistent with siderails. During an interview with RN AA on 9/21/22 at 1:59 p.m., when questioned regarding if any interventions were implemented to protect R B's head from the side rails between 7/4/22 when the reddened area to the forehead as first identified and 7/8/22 when the side rails were removed, RN AA stated no. During an interview on 9/21/22 at 10:50 a.m. when questioned regarding the cause of R B's forehead injuries, the Director of Nursing (DON) stated that she thinks R B hit her head on the side rail on 7/4/22. When questioned if she thought R B hit her head again on 7/6/22 when the additional areas were identified, the DON stated yes; that R B was always fidgeting and picking at things. During a subsequent interview on 9/28/22 at 2:58 p.m. the DON stated that she did not see where they had done anything else between 7/4/22 and 7/8/22 with the side rails, other than send R B to the emergency roiagnom on [DATE], treated her for a urinary tract infection on 7/6/22, put down fall mats on 7/8/22, and remove the side rails on 7/8/22.

Based on record review, observation and staff interview, it was determined that the facility failed to evaluate the effectiveness and appropriateness of care plan interventions to address recurrent falls and the potential hazard from the continued use of the half side rails and to revise the care plan for one resident (#47), to address weight loss for one resident (#84) and to reflect interventions to be provided or the current status of a pressure ulcer for two residents (#92 and #121) from a sample of 33 residents. Despite resident #47 having fallen out of bed 11 times between 1/02/12 and 5/3/12 and entrapping his/her lower extremities in the half side rails during three (3) of those eleven (11) falls, the facility failed to assess the continued use of the half side rails. The resident was found on the floor on 3/3/2012 with his/her left foot entrapped between the half side rail and the bed and was unable to free himself/herself. The facility failed to assess the effectiveness of continuing a care plan intervention to prevent resident #47 from falling by using the call light to request assistance. The facility's failure to evaluate the effectiveness of intervention being used to prevent resident #47 from falling had the likelihood of resulting in serious harm, injury or death. Therefore, it was determined that an immediate jeopardy to the health and safety of resident #47 existed from 3/03/12 to 05/04/12 when, it was verified that the facility had implemented a plan to remove the jeopardy situation. Findings include: 1. Resident #47 had [DIAGNOSES REDACTED]. He/She had a care plan since at least 5/25/10 to address his/her risk for falls which included an intervention for staff to encourage/remind the resident to use the call light to call for assistance when in bed. The care plan developed by the staff did not include his/her continued use of side rails, but staff elevated them when in he/she was bed. There was an intervention to encourage the resident to use the call light to call for assistance. However, nursing staff documented on the care plan on 1/18/12 that the resident was very confused and refused to call for help. There was not any staff documentation that the resident had attempted to use the call light to request any assistance when he/she fell out of bed 11 times. In an interview on 5/2/12 at 10:45 a.m., nursing staff "BB" said that he/she had never seen the resident use the call light. During an interview at 10:55 a.m. that day, licensed nurse "CC" said that even though nursing staff reminded the resident to use the call light at least daily, the resident did not use it . Although using the call light to request assistance was an intervention which required a response that, based on his/her comprehensive assessment, staff interviews and documentation about his/her behavior the resident was not capable, the facility continued to include that intervention in his/her care plan to prevent falls. Staff coded the resident's MDS dated [DATE] and 4/24/11 to indicated that his/she did not use side rails. Although the use of side rails had been included on a care plan developed in May, 2010, their use was not included on the current care plan. During an interview on 4/30/12 at 3:20 p.m., licensed nurse "DD" said that the resident's care plan for falls dated 4/3/12 was just continuing the care plan. She said that, although half side rails were not listed on the care plan for the resident but, half side rails continued to be used for the resident. The resident was observed in bed with half side rails elevated on both sides of the bed on 5/1/12 at 7:00 a.m. The mattress was approximately 20 inches from the floor. In an interview on 5/2/12 at 10:45 a.m., nursing staff "BB" said that the resident had gotten his/her foot or leg wedged in the side rails and staff had to help him/her to get out of it. In an interview on 4/30/12 at 3:20 p.m., nurse "EE" said that the resident's half side rails were elevated when he/she was in bed. On 5/12/12 at 10:55 a.m., nurse "CC" said that the resident had scooted around the (half) side rails to get out of bed. According to nursing staff's documentation in the nurses note, the resident was found lying on the floor on 4/6/12 with his/her foot wedged between the bed and side rail. However, there was not any evidence that the use of the half side rails had been evaluated or included on care plan revisions as a means to prevent accidents for resident #47 or to determine what supervision would be required for their use or for monitoring of their use. . There was not any evidence that staff had provided adequate supervision for resident #47 to ensure a safe environment. Staff did not identify the potential risk for a preventable accident for resident #47 from a fall or the continued use of the had half side rails which had the potential to cause serious injury, harm or death for him. Staff observed and documented since at least 1/2/12 that the resident fell out of bed with the half side rails elevated. Staff had seen and documented that on 3/3/12, 3/13/12 and 4/6/12 that the resident's body parts had been entrapped by the side rails. . Despite staff reminders to use the call light to request assistance, there was not any evidence that the resident used it. The intervention to encourage the resident #47 to use the call light to ask for assistance was inappropriate for that resident because, it required a response of which the resident was not capable based on his/her assessments and demonstrated documented behavior. The facility failed to identify the half side rails as a hazard for resident #47 or the potential for their use resulting in serious injury, harm or death. Although the resident fell on [DATE], was found on 1/14/2012 having scooted down in the bed below the half side rails and laying with his hands on the floor and legs on the bed, and was entrapped by the half side rails on 3/312, the facility had failed to monitor and evaluate the effectiveness of the continued use of half side rails to prevent an avoidable accident and the care plan intervention for the resident to use the call light. The facility failed to revise the resident's care plan to include staff's use of the half side rail on the resident's bed so that their implementation could be monitored and evaluated for resident #47, who had recurrent falls and had been entrapped by the half side rails three (3) times, to ensure his/her adequate supervision for their, to reduce the risk of an avoidable accident and to protect the resident from sustaining serious harm, injury or death. . . See F323 for additional information regarding resident #47. 2. Resident #84 had [DIAGNOSES REDACTED]. According to staff's documentation, he/she had a gradual weight loss of 7.25 % from 10/15/2011 (138 pounds) to 04/15/2012 (128 pounds). His/her care plan since 6/8/11 included his/her problem of alteration in nutrition related to his/her need for a mechanically altered diet. There were interventions for the provision of staff assistance with eating or encouraging the resident to eat, to give the prescribed diet, to serve the appropriate food texture, to encourage him/her to eat at least 75% of all meals, to provide a substitute food as needed and to weigh him/her every month and as needed. However, there was not any evidence in the clinical record of an evaluation of the resident's gradual weight loss or that his/her care plan had been revised to address it. During an interview on 5/3/12 at at 4:55 p.m., an administrative nursing staff stated that she did not know if the care plan had been revised. 3. Resident #121 had a [DIAGNOSES REDACTED]. The facility had developed a 2/17/12 care plan to address the resident's skin problems including pressure ulcers. The staff documented that the actual stage 2 sacral pressure ulcer was related to the resident's vascular disease and limited mobility. Nursing staff consulted the resident's attending physician on 3/28/12 about an unstageable deep tissue injury on the resident's heel. However, the facility failed to revise resident's care plan to include that wound and any interventions for the care and services to be provided by staff for the resident's heel. 4. Resident #92 had [DIAGNOSES REDACTED]. According to the 11/27/12 nursing notes, nursing staff had identified a 3.5 centimeter (cm) by 3 cm blister on the resident's /her right heel. On the 12/06/12 treatment record, the nurse had described the wound as a 3 cm by 6 cm unstageable deep tissue injury (DTI). However, the facility failed to revise the resident's plan of care to include the change in the wound from a blister to an unstageable DTI and a description of that heel wound. The immediate and serious threat to resident health and safety was determined to have been removed on 5/04/12 but, the noncompliance continues. The noncompliance continues in order to monitor following action steps: staff have been in-serviced on the revisions to resident #47's plan of care; nursing personnel are completing a side rail assessment for any resident who has a fall in connection with their bed and/or side rails within 24 hours of the fall; residents who fall are assessed and care plan interventions revised as warranted; every bed with side rails continues to be evaluated for safety issues; skilled therapy staff performs a screen on every resident who has a fall and provides nursing with written recommendations; skilled therapy and nursing staff make recommendations for safety measures and present them to the medical director for approval; body alarms, pressure sensitive devices and non-skid socks remain available at each nurses' station for use as appropriate in case of a resident fall; the planned meetings of administrative personnel continue to update care plans and approaches for any resident who falls, to review the time, place and circumstances of falls, to ensure that the physicians are consulted by the Patient Care Coordinators about recommendations regarding fall interventions, to continue the AA committee meetings with the Medical Director having input into all problems and potential solutions and to present small group in-services for changes in approaches, policies and care plans when needed. Therefore, the scope and severity of the deficiency was reduced from a "J" level to a "D" level when the facility implemented the following plan (allegation of jeopardy removal). 1. The Patient Care Coordinator was terminated as unable to perform job. 2. The Medical Director was informed of the immediate jeopardy and the reason for it. The plan of correction was reviewed by the Medical Director. He attends the monthly QAA committee meeting and will give input on ongoing problems as they arise. Completed 5/03/12. 3. A side rail assessment was done for resident #47. This assessment indicated that there was no benefit from the side rail usage for this resident. Completed 5/02/12. 4. The care plan for resident #47 was revised. He/She was placed on a bed on the floor with no side rails. An alarm was added to his/her wheelchair when out of bed. Completed 5/02/12. 5. All residents with a history of falling were reviewed and care plans revised as warranted. No major changes were needed. Completed 5/02/12. 6. Changes in the plan of correction were reviewed with caregivers. Any caregivers not on duty May 2, 2012 or May 3, 2012 will review the plan of correction before they return to work. Each employee signed acknowledgement of understanding the changes in care plan. As of 5/04/12, there are two employees not in-serviced. One will be trained on 5/05/12 by the weekend supervisor. The other one will be in-serviced on 5/04/12 after 3 p.m. Completed 5/04/12. 7. Each bed with side rails was evaluated for distance between the mattress and side rail. Any problems were addressed immediately. Completed 5/02/12. All side rails will be inspected weekly by maintenance and repositioned, repaired or replaced at that time. The Maintenance supervisor will check monthly for correct location, spacing and security. This will become a permanent part of the safety checks done each month. 8. Nursing staff reviewed the side rail assessment of all residents with side rails. Changes were made if indicated. Completed 5/04/12. 9. Nursing personnel will do a side rail assessment for any resident who has a fall in connection with their bed and/or side rails within 24 hours of the fall. All side rail assessments will be reviewed quarterly and as needed. Completed 5/03/12. 10. Therapy will perform a screen on every resident who has a fall and will provide nursing with a written recommendation. 11. Nursing will do a new fall assessment after any fall, quarterly and as needed. 12. Therapy and nursing will make recommendations for safety measures and present them to the MD for approval. 13. Body alarms, pressure sensitive devices and non-skid socks will be available at each nurses' station for use in case of a resident fall. 14. Permission may be given by the LPN on duty for placement of a residents' mattress on the floor if the resident has experienced a fall out of his/her bed. 15. A CNA may be assigned to care for a resident one-to-one if current available interventions are ineffective to prevent a fall until further interventions can be found. 16. All staff educated on the intervention changes as seen in #9 and on what to do if a resident falls on their shift. Any off duty staff will be in-serviced prior to returning to duty. 17. The QA coordinator, Director of Nursing (DON) and Patient Care Coordinators (PCCs) will meet 5 days a week, after morning meeting, to update care plans and approaches for any resident who fell since the previous meeting. 18. The weekend Supervisor will review the care plan for anyone who fell in the past 24 hours and add/change interventions as warranted. This Supervisor will be aware of the changes in care plans and the interventions available before working a weekend. She will initiate immediate interventions and leave information on the daily report sheet for the PCC to follow-up on. 19. The Fall Committee, consisting of the DON, the QA administrator, the PCCs, and the Director of Therapy, met on 5/02/12. They will meet weekly, on Fridays, and review the time and place of falls as well as the circumstances. They will make recommendations regarding fall interventions at that time. All recommendations will go to the Patient Care Coordinator who will consult with the attending physicians and initiate changes. A copy of the Fall Committee Meeting minutes will go to the Administrator and the Medical Director. 20. The QAA committee met on 5/02/12. The committee will meet monthly, on the first Wednesday. Called meetings will be held as needed. A report of the Fall Committee findings, recommendations, and new interventions will be made monthly at the QAA meetings by the chairman of the Fall Committee. The Medical Director will attend all QAA meetings and have input into all problems and potential solutions. Changes in approaches, policies, and care plans will be presented to the staff in small group in-services when needed

Based on record review, observations and staff interviews, it was determined that the facility failed to ensure that staff provided adequate supervision and monitoring for the effectiveness and appropriateness of one resident's (#47) continued use of half side rails or evaluate their potential as a hazardous device after resident #47's recurrent falls out of bed with the half side rails elevated and having been entrapped in the half side rails from a sample of 33 residents and, failed to ensure potentially hazardous chemicals were secured on the secured units (men's and women's) and on one of two wings (Wing 1) in the facility. The facility's failure to provide adequate supervision and monitoring the continued use of the side rails resulted in the determination that an immediate jeopardy to the health and safety of resident #47 which existed from 3/3/12 to 5/04/12 when, it was verified that the facility had implemented a plan to remove the jeopardy situation. Findings include: According to the DePaul Journal of Health Care Law, "The Legal and Medical Aspects of Physical Restraints and Bed Side rails and Their Relationship to Falls and Fall-Related Injuries in Nursing Homes," because bed rails were attached to the beds, the possibility existed for their inappropriate and frequent use. Bed side rail use was based on the mistaken belief that side rails prevented falls and fall-related injuries. However, the most common form of injury to persons occurred when the resident climbed over an elevated side rail and fell at the bedside. Side rails were used to remind the person to call for assistance; however, most persons for whom side rails were used lack the cognitive ability to correctly interpret their intended use. Entrapments (of resident's) occurred through the side rail bars; through the space between split side rails; between the side rail and mattress; or between the head or footboard, side rail and mattress. The Food and Drug Administration has issued a safety alert (1995) about specifically about serious injuries and even death resulting as a result of the use of bed rails (also called side rails). The 1995 alert noted that the residents most at risk for entrapment are the frail or elderly or those with agitation, delirium or confusion who may try to move in the bed or get out of it. According to his/her medical record, resident #47's [DIAGNOSES REDACTED]. However, the facility failed to identify the risk from the resident's use of the half side rails, to evaluate the effectiveness and the severity of the potential hazard of his/her continued use of side rails. 1. Licensed nursing staff coded the resident's 11/03/11 and the 4/24/12 Minimum Data Set (MDS) assessments to describe him/her as having delusions, requiring extensive staff assistance with bed mobility and transfers, always incontinent, and as having had two or more falls without injury since his/her admission. The staff had developed a care plan for the resident that since at least 5/25/10 to address his/hr risk for falls. It included an intervention to prevent the resident from falling which was for the staff to remind the resident to use the call light to ask for assistance. Licensed nursing staff did not code the resident as using side rails on either of the above assessments. Although not included on the current (4/12) care plan or the previous care plans since 1/1/12, the 5/25/10 care plan had included an intervention for the staff to keep both side rails elevated on his/her bed when the resident was in bed. Licensed nursing staff documented that the resident had fallen out of bed and been found on the floor eleven (11) times between 1/01/12 and 4/10/12. They described on 3/3/12, 3/13/12 and 4/6/12 that they had found the resident with his/her foot or leg "caught" (entrapped) between the side rail and the bed. There was not any evidence that the resident was capable of freeing his/her foot or leg during those episodes of entrapment. However despite staff noting that the resident had become entrapped in the side rail during those avoidable accidents, there was not any evidence that facility staff had identified the half side rail as a hazard to the the resident's safety or evaluated the potential severity of their use for resident #47. The resident was observed in bed with half side rails positioned in the middle of the bed and elevated on both sides of the bed on 5/1/12 at 7:00 a.m. During that observation the bottom of the mattress was approximately 20 inches above the floor. There was not a floor mat on either side of the bed. The nursing staff had noted in the 3/13/2012 nurses notes that the resident's bed was in the low position. There was no evidence in the nurses' notes that a mat had been placed beside the resident's bed. A. Nursing staff documented on 1/01/12 that the resident had been on the floor and they assisted him back into bed then raised the side rails. Nursing staff documented on 1/02/12 at 5:30 a.m. and on 1/06/12 at 1:30 a.m., that the resident was lying on the floor. The nurses noted that at that time that the resident's bed was in a low position with both side rails elevated. After those falls out of bed with the half side rails being used, nursing staff documented on the care plan on 1/2/12 to continue the previous interventions. They wrote on the care plan on 1/6/12 to continue previous interventions and to encourage the resident to use the call light to request assistance.. The nurses documented on 1/14/12 at 10:15 p.m., that the resident had been found lying on the floor. They described his/her lower extremities having been on the bed but his/her upper extremities were on the floor beside the bedside stand. The nurse noted that both side rails were elevated. Staff wrote on the care plan on 1/14/12 to continue previous interventions. The nurse noted on the care plan on 1/18/12 that the resident was very confused and refused to call for help. After the resident fell on [DATE], 1/6/12 and on 1/14/12, nursing staff did not examine specific information about each of his falls out of bed despite the use of the half side rails or evaluate their continued use. They reviewed his/her care plan and noted on it to continue the interventions. After the 1/6/12 fall, nursing staff also noted that they should remind and encourage the resident to use the call light to request assistance. There was also a 1/23/12 physical therapy screening of the resident's functional status because of the falls. The therapist noted that the resident needed the assistance of one person to transfer but noted that physical therapy services were not recommended or needed. B. Staff found the resident on his/her knees on the floor on 2/05/12 at 6:30 p.m. The nurse documented that he/she was assisted back to bed by two staff. The nurse wrote that the resident said that he was trying to put the head of the bed down. Staff wrote on the care plan on 2/5/12 to continue the previous intervention. C. Staff found the resident on the floor on 3/03/12 at 5 a.m. The nurse described the resident as having his/her hands on the floor but, his/her left foot wedged between the bed's side rail and the bed. The nurse noted that he/she was assisted to stand then into a wheelchair. Staff wrote on the care plan on 3/3/12 to continue the previous interventions. D. On 3/11/12 at 3:30 p.m., the resident was found lying on the floor with his/her hands on the floor while his/her legs remained on the bed. The nurse noted that it took three staff to assist him/her into wheelchair at that time. The nurse wrote that the resident was unable to explain why he/she was climbing out of bed. Staff wrote on the care plan to encourage the resident to use the call light. E. Nursing staff found the resident lying on the floor between his bed and night stand on 3/13/12 at 2 a.m. The nurse noted that the resident's left leg was wedged between the side rail and the bed. The documentation noted that two staff assisted him/her back to bed and both side rails were elevated and the call light was within reach. The nurse noted that the resident would continue to be monitored. Staff wrote on the care plan to continue the previous interventions. F.. The resident was found on 4/3/12 at 12 a.m. with his/her hands on the floor and his/her lower body in bed. The nurse noted that three staff assisted him/her to bed. Both side rails were documented as elevated and he/she "was encouraged to remain in bed and to call for assist before getting out of bed." G. Staff found the resident on the floor on 4/06/12 at 3:50 a.m. with his/her foot wedged between the side rail and the bed. The nurse noted that he/she was assisted back to bed by two staff, both side rails were elevated and the call light was within reach. H.. Staff found the resident with his/her hands on the floor on 4/10/12 at 6 a.m. The nurse noted that both side rails were elevated and the call light was within reach. Although the resident continued to fall out of bed with half side rails elevated and had his leg or foot entrapped between the half side rail and the bed, staff reviewed his/her plan of care interventions on 1/02/12, 1/14/12, 2/05/12, 3/03/12, and 3/13/12 but failed to identify the potential hazard for the resident from his/her use of the half side rail and develop interventions targeted to meet his/her needs and assessed functional status. The nurse described the resident as confused and refusing to use the call light on 1/18/12. However, on 1/06/12 and 3/11/12, nursing staff was supposed to encourage and remind the resident to use the call light to call for assistance. According to notes on the care plan on 1/2/12, 1/14/12, 2/5/12, 3/3/12, and 3/13/12 staff was supposed to continue previous interventions which included encouraging the resident to use the call light for assistance to get out of bed. There was not any evidence that the resident had attempted to use the call light or called for assistance prior to any of the falls. Although staff noted that the resident had been found with a body part (leg or foot) wedged between the side rail and the bed on 3/3/12, 3/16/12 and 4/16/12, they elevated the side rails after freeing the body part on two of those dates. Despite the staff's awareness of resident's recurrent falls from bed with the half side rails elevated from January to April, his/her failure to request assistance and having been entrapped by the side rails, there was not any evidence of staff's justification to continue the previous interventions or monitoring their effectiveness to prevent future falls or their identifying the potential risk for serious harm or death from entrapment of body parts between the half side rails or the half side rails and the bed. There was documentation that the physical therapist had screened the resident for his/her functional status and the need for skilled therapy services on 1/23/12, 3/5/12, 3/12/12, 4/4/12 and 4/6/12 because of his/her falls. However, the skilled therapist had noted that skilled therapy services were not needed and/or recommended. The therapist documented on 1/23/12 and 3/5/12 screening forms that the resident required moderate to minimum assistance for transfers and continued to need one assist for transfers. There was not any evidence that the physical therapist's screening of the resident after his/her falls included any knowledge of the relationship between those falls and any type of environmental hazard such as the use of the half side rail. I. It was observed on 5/2/12 at 11:00 a.m. that the half side rail on the right side of the resident's bed was loose. When that half side rail was elevated, there was a five (5)inch gap between the bed and half side rail on one end and a two (2) inch gap at the other end. The loose half side rail and the increased space between the side rail and the bed increased the potential risk of entrapment of the resident's body parts. However, there was not any evidence that the facility staff had identified the defective half side rail or the potential risk of serious injury, harm or impairment or death as a result the resident's body parts becoming entrapped by the defective half side rails. J. Nursing staff interviews below confirmed that despite being reminded to use the call light to request assistance, resident #47 did not use it. Two nursing staff said that they were aware that the resident scooted to the bottom of the bed in order to get out of it when the half side rails were elevated. Nursing staff documented documented the resident having been found on the floor or body parts entrapped in the half side rails. One CNA said that he/she had seen the resident's lower extremities entrapped by the side rail and the resident could not release it without assistance.. (1). During an interview with licensed nursing staff on 4/30/12 at 1:14 p.m., she stated that side rails were in use for the resident but, he/she was not able of getting out of bed on his/her own. However, nursing staff had recorded the resident as having been found out of bed 11 times between 1/1/12 and 4/10/12. (2) On 5/01/12 at 4:00 p.m., registered nurse "EE" stated that the care plan for falls dated 4/3/12 was just a continuation of the rest of the care plan, and even though the side rails were not listed as an intervention, the use of side rails continued for the resident. (3) During an interview on 5/2/12 at 10:40 a.m., CNA "AA" stated that she had worked at the facility about a month and did not know of the resident having ever called for assistance using the call light. She stated that the resident was told to use the call light when he/she was in bed but, he/she did not use it. (4) During an interview on 5/2/12 at 10:45 a.m., Certified Nursing Assistant (CNA) "BB" stated that he/she had been an employee for a year and had never known resident #47 to use a call light even though staff reminded him/her daily to use it. He /She stated that, at times, the resident would yell out when in bed and wanted something. CNA "BB" stated that he/she had seen the resident get his/her foot or leg wedged in the side rail and staff had to assist him/her to get out of it. (5) During an interview on 5/2/12 at 10:55 a.m., licensed nurse "CC" stated that he /she had never seen resident #47 use the call light. "CC" stated that the resident was reminded by staff at least daily to call for assistance by using the call light but, he/she did not use it. She stated that the resident scooted around the side rails to get out of bed. (6) During an interview on 5/2/12 at 7:15 p.m., CNA "BB" stated that the resident could not put the side rails down. She stated that he/she scooted his/her body around the side rails to get out of bed. There was not evidence that staff had provided adequate supervision for resident #47 to ensure a safe environment. Staff did not identify the potential risk a preventable accident for resident #47 from a fall or having body parts entrapped by the continued use of the half side rails which had the potential to cause serious injury, harm or death to him. Staff observed and documented since at least 1/2/12 that the resident fell out of bed with the side rails elevated. The nursing staff documented that when they put the resident back in bed the side rails were elevated. Although nursing staff elevated the resident's side rail every day, there was no evidence that they identified that it was defective which increased the risk for the entrapment of body parts. Staff had seen and documented that on 3/3/12, 3/13/12 and 4/6/12 that the resident's body parts had been entrapped by the side rails. However, they did not identify the side rail as a hazard or demonstrate an understanding that entrapment of his body parts presented a potential for serious injury, harm or death to this resident. After they freed the resident's body parts from being entrapped by the (half) side rails on 3/3/12 and 4/16/12, nursing staff put the resident back in bed and elevated half side rails . Despite staff reminders to use the call light to request assistance, there was not any evidence that the resident used it. The intervention to encourage the resident #47 to use the call light to ask for assistance was inappropriate for that resident because, it required a response of which the resident was not capable based on his/her assessments and demonstrated documented behavior. The facility failed to identify the side rails as a hazard for resident #47 or the potential for its use resulting in serious injury, harm or death. Since at least March 3, 2012 when nursing staff first documented that the resident had become entrapped in the siderail, the facility had failed to monitor and evaluate the effectiveness of the continued use of half side rails and the intervention for the resident to use the call light. The facility failed to develop and implement appropriate interventions to promote the resident's safety, to eliminate environmental hazards such as recurrent falls from bed with the side rails elevated and immanent likelihood of entrapment of his/her body parts in the half side rails. 2. The following observations were on 5/3/12 between 12:20 p.m. and 3:30 p.m.: a. A bottle of Comet cleaner with bleach was being stored in an set of drawers in the Men's Alzheimer's Unit. There was a warning label on it to " Keep out of reach of children, eye irritant and if swallowed to call a physician immediately." b. There was a hole in the sitting area of the courtyard outside the Men's Alzheimers Unit. which was approximately two feet in diameter and one foot deep. c. The unlocked storage closet in the 2B Shower Room that contained two spray cans of foaming disinfectant cleaner with a warning label that included "hazard to humans causes moderate eye irritation." d. The Wing 1 soiled linen room on was unlocked and unsupervised. There were multiple cleaners in a dispensing system: Spic and Span disinfectant, Comet Bathroom cleaner, and Mr Clean floor cleaner. An unlocked cabinet in that room contained baseboard stripper, two bottles of spray nine cleaner, Comet cleaner with bleach, Easy Task Thermoplastic Spray Buff and a spray bottle of stainless steel cleaner. e. The soiled linen room outside the Women's Locked Unit was unlocked and unsupervised. It contained a bottle of rust stain remover, a bottle of Hot Shot ant killer and a large plastic bag full of bottles of chemicals that were too numerous to count. The immediate and serious threat to resident health and safety was determined to have been removed on 5/04/12 but, the noncompliance continues. The noncompliance continues in order to monitor following action steps: staff have been in-serviced on the revisions to resident #47's plan of care; nursing personnel are completing a side rail assessment for any resident who has a fall in connection with their bed and/or side rails within 24 hours of the fall; residents who fall are assessed and care plan interventions revised as warranted; every bed with side rails continues to be evaluated for safety issues; skilled therapy staff performs a screen on every resident who has a fall and provides nursing with written recommendations; skilled therapy and nursing staff make recommendations for safety measures and present them to the medical director for approval; body alarms, pressure sensitive devices and non-skid socks remain available at each nurses' station for use as appropriate in case of a resident fall; the planned meetings of administrative personnel continue to update care plans and approaches for any resident who falls, to review the time, place and circumstances of falls, to ensure that the physicians are consulted by the Patient Care Coordinators about recommendations regarding fall interventions, to continue the AA committee meetings with the Medical Director having input into all problems and potential solutions and to present small group in-services for changes in approaches, policies and care plans when needed. Therefore, the scope and severity of the deficiency was reduced from a "J" level to a "D" level when the facility implemented the following plan (allegation of jeopardy removal). 1. The Patient Care Coordinator was terminated as unable to perform job. 2. The Medical Director was informed of the immediate jeopardy and the reason for it. The plan of correction was reviewed by the Medical Director. He attends the monthly QAA committee meeting and will give input on ongoing problems as they arise. Completed 5/03/12. 3. A side rail assessment was done for resident #47. This assessment indicated that there was no benefit from the side rail usage for this resident. Completed 5/02/12. 4. The care plan for resident #47 was revised. He/She was placed on a bed on the floor with no side rails. An alarm was added to his/her wheelchair when out of bed. Completed 5/02/12. 5. All residents with a history of falling were reviewed and care plans revised as warranted. No major changes were needed. Completed 5/02/12. 6. Changes in the plan of correction were reviewed with caregivers. Any caregivers not on duty May 2, 2012 or May 3, 2012 will review the plan of correction before they return to work. Each employee signed acknowledgement of understanding the changes in care plan. As of 5/04/12, there are two employees not in-serviced. One will be trained on 5/05/12 by the weekend supervisor. The other one will be in-serviced on 5/04/12 after 3 p.m. Completed 5/04/12. 7. Each bed with side rails was evaluated for distance between the mattress and side rail. Any problems were addressed immediately. Completed 5/02/12. All side rails will be inspected weekly by maintenance and repositioned, repaired or replaced at that time. The Maintenance supervisor will check monthly for correct location, spacing and security. This will become a permanent part of the safety checks done each month. 8. Nursing staff reviewed the side rail assessment of all residents with side rails. Changes were made if indicated. Completed 5/04/12. 9. Nursing personnel will do a side rail assessment for any resident who has a fall in connection with their bed and/or side rails within 24 hours of the fall. All side rail assessments will be reviewed quarterly and as needed. Completed 5/03/12. 10. Therapy will perform a screen on every resident who has a fall and will provide nursing with a written recommendation. 11. Nursing will do a new fall assessment after any fall, quarterly and as needed. 12. Therapy and nursing will make recommendations for safety measures and present them to the MD for approval. 13. Body alarms, pressure sensitive devices and non-skid socks will be available at each nurses' station for use in case of a resident fall. 14. Permission may be given by the LPN on duty for placement of a residents' mattress on the floor if the resident has experienced a fall out of his/her bed. 15. A CNA may be assigned to care for a resident one-to-one if current available interventions are ineffective to prevent a fall until further interventions can be found. 16. All staff educated on the intervention changes as seen in #9 and on what to do if a resident falls on their shirt. Any off duty staff will be in-serviced prior to returning to duty. 17. The QA coordinator, Director of Nursing (DON) and Patient Care Coordinators (PCCs) will meet 5 days a week, after morning meeting, to update care plans and approaches for any resident who fell since the previous meeting. 18. The weekend Supervisor will review the care plan for anyone who fell in the past 24 hours and add/change interventions as warranted. This Supervisor will be aware of the changes in care plans and the interventions available before working a weekend. She will initiate immediate interventions and leave information on the daily report sheet for the PCC to follow-up on. 19. The Fall Committee, consisting of the DON, the QA administrator, the PCCs, and the Director of Therapy, met on 5/02/12. They will meet weekly, on Fridays, and review the time and place of falls as well as the circumstances. They will make recommendations regarding fall interventions at that time. All recommendations will go to the Patient Care Coordinator who will consult with the attending physicians and initiate changes. A copy of the Fall Committee Meeting minutes will go to the Administrator and the Medical Director. 20. The QAA committee met on 5/02/12. The committee will meet monthly, on the first Wednesday. Called meetings will be held as needed. A report of the Fall Committee findings, recommendations, and new interventions will be made monthly at the QAA meetings by the chairman of the Fall Committee. The Medical Director will attend all QAA meetings and have input into all problems and potential solutions. Changes in approaches, policies, and care plans will be presented to the staff in small group in-services when needed.