Every finding on record at Renaissance Terrace

Based on facility policy review, medical record review, resident trust accounts review, and interview, the facility failed to notify the resident or resident representatives when the amount in the residents' trust account exceeded the eligibility limit for 3 residents (Residents #7, #13, and #27) of 26 residents reviewed for resident trust accounts. The findings include: Review of facility's undated policy titled, Resident Trust Fund Policy & Agreement, revealed .The facility must notify each resident receiving medical assistance under Title XIX (Medicaid) when the amount in the resident's account reaches $200 less than the SSI resource limit to remain eligible for Medicaid long term care benefits, The notice must include the fact that if the amount in the account in addition to the value of the resident's other nonexempt resources reaches the applicable resource limits, the resident may lose eligibility for Medicaid or SSI . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Frontal Lobe and Executive Function Deficit, Altered Mental Status, Aphasia, Cerebral Infarction, and Schizophrenia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 had modified independence for cognitive skills for daily decision making. Review of the Resident Fund Statement for Resident #7 for the period of 4/1/2026 - 7/2/2026, revealed a balance of $3,957.98. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including Hemiplegia and Hemiparesis, Aphasia, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed Resident #13 was independent in cognitive skills for daily decision making. Review of the Resident Fund Statement Resident #13 for the period of 4/1/2026 - 7/2/2026, revealed a balance of $4,581.83. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Type 2 Diabetes, Dementia and Chronic Obstructive Pulmonary Disease. Review of an annual MDS assessment dated [DATE], revealed Resident #27 scored a 15 on the Brief Interview for Mental Status assessment which indicated the resident was cognitively intact. Review of the Resident Fund Statement Resident #27 for the period of 4/1/2026 - 7/2/2026, revealed a balance of $3,296.67. During an interview on 7/7/2026 at 1:37 PM, the Business Office Manager (BOM) stated the Medicaid eligibility limit was $2,000. The BOM confirmed there was no documentation to reflect the Resident or Resident Representative had been notified of the Medicaid eligibility requirements and being at risk for losing benefits for being over resources for Resident #7, #13, and #27 with balances exceeding eligibility limits. During an interview on 7/8/2026 at 11:15 AM, Resident #27 stated she was not aware of being at risk of losing Medicaid eligibility due to being over resources. During an interview attempt on 7/8/2026 at 11:25 AM, Resident #7 was unable to communicate a clear understanding of Medicaid eligibility being at risk due to resource limits. During an interview attempt on 7/8/2026 at 11:32 AM, Resident #13 was unable to communicate a clear understanding of Medicaid eligibility being at risk due to resource limits. During an interview on 7/8/2026 at 1:15 PM, the Administrator stated that it was her expectation Residents or Representatives be notified if they were within $200 of the Medicaid eligibility limit of $2000. The Administrator confirmed the facility had no documentation to reflect Resident #7, #13, and #27 had been notified of their statement balance and they were over the Medicaid eligibility limit of $2000.

Based on facility policy review, Mosby Basic Nursing Essentials for Practice Fifth Edition review, medical record review, facility investigation review, witness statement review, and interviews, the facility failed to ensure accurate accountability of controlled substances for 1 resident (Resident #48) of 37 residents reviewed for accurate controlled substance count. The findings include: Review of an undated facility policy titled, Medication- Controlled substances Policy and Procedure, revealed .To monitor and administer controlled substances medications as ordered by the physician .Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations .Accurate accountability of the inventory of all controlled drugs is always maintained .Nurses are to perform a count of all controlled substances at the beginning and the end of every shift . Review of the Basic Nursing Essentials for Practice Fifth Edition by Mosby dated 2003, revealed .Guidelines for Safe Narcotic Administration and Control .Keep all Narcotics in a locked, secure place .During an institution's change of shift, a nurse going off duty counts all narcotics with a nurse coming on duty .Both nurses sign the narcotic sign the narcotic record, indicating the count is correct . Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus and Polyneuropathy. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #48 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of a Physician's order for Resident #48 dated 5/15/2026, revealed the resident was prescribed Gabapentin (a medication used to treat nerve pain) 600 milligram (mg) three times a day. Review of a witness statement by Licensed Practical Nurse (LPN) C dated 5/17/2026, revealed .I came into my shift on Sunday 6p-6a [6:00 PM-6:00 AM]. [Registered Nurse (RN) A] was the nurse on floor. We counted A and B cart [Medication Cart] 1st and signed off count. We counted C and D cart [Medication Cart] and found that the bottle of Gabapentin for [Resident #48] was missing 3 pills. Counted 76 and count sheet was 79. Notified DON [Director of Nursing] and waited further instructions. Advised to write out statements . Review of a witness statement by Registered Nurse (RN) A dated 5/17/2026, revealed .[RN B] has been vomiting since approx [approximately] 11 [11:00 AM] today. She [RN B] ask me to take over her cart [Medication Cart] at around 4:30-5 [4:30 PM- 5:00 PM]. We [RN B and RN A] did count but she was still vomiting. We [RN B and RN A ] did not count the bottle of Gabapentin [for Resident #48] .She [RN B] was growing increasingly sick and left. I did not pull pills out to count .[RN B] left and I went to help with trays, pass meds, do dining room .counted cart [Medication Cart] with [LPN C] this evening. Count in book was 79, count in bottle was 76. [LPN C] notified [Director of Nursing] . Review of a facility document titled, Summary/ Conclusion: Missing Medication 05/17/26, dated 5/21/2026, revealed .On 5/17/26 [5/17/2026], I [Previous Administrator] was notified by the Director of Nursing that there was a discrepancy in the count on a resident [Resident #48] of 3 Gabapentin pills .We proceeded contact nurses who had worked cart in past 48 hours and get statements .DON [Director of Nursing] entered building and did a count and audit of all residents receiving this medication .[RN B] left building sick during shift and passed cart [Medication Cart] to [RN A]. They [RN B and RN A] counted all of the medications except for the bottle [which contained gabapentin] for [Resident # 48] .[RN B] and [RN A] were both contacted as they both were responsible for cart during period of discrepancy .Medication replaced at Facility cost . Review of a comprehensive care plan for Resident #48 dated 6/1/2026, revealed .Diabetes-the resident has chronic pain related Diabetic Neuropathy .administer analgesics as per orders . During a telephone interview on 7/7/2026 at 1:34 PM, RN A stated she took over for RN B on 5/17/2026 at approximately 4:30 PM. RN A stated RN A and RN B counted all narcotics on the cart except a bottle of gabapentin for Resident #48. RN A further stated RN B was sick and was in a hurry to leave. RN A confirmed RN A and RN B did not count the bottle of gabapentin for Resident #48 prior to RN B leaving the facility. RN A stated when RN A and Licensed Practical Nurse (LPN) C (the oncoming nurse for nightshift) counted the bottle of gabapentin for Resident #48 there was a discrepancy which revealed 3 pills of gabapentin which were unaccounted for when compared with the narcotic log. During a telephone interview on 7/7/2026 at 1:47 PM, the Director of Nursing (DON) confirmed she was aware of the incident which involved Resident #48 missing 3 pills of gabapentin on 5/17/2026. The DON confirmed during the facility investigation it was determined RN A and RN B failed to count the bottle of gabapentin for Resident #48 prior to RN B leaving the facility. The DON further confirmed it was the facility's expectations that all nurses should visually lay eyes on and count all controlled substances when changing shifts. During a telephone interview on 7/8/2026 at 8:16 AM, RN B stated on 5/17/2026 during her shift she had become ill and had to leave the facility. RN B stated at approximately 4:45 PM, RN A (who was already in the facility) took over the medication cart and relieved RN B so she could leave the facility. RN B confirmed she and RN A did not count the bottle of gabapentin for Resident #48 prior to RN B leaving the facility on 5/17/2026. During an interview on 7/8/2026 at 12:35 PM, the Administrator confirmed it was the facility's expectation for all nurses to count all controlled substances prior to one nurse taking over a medication cart from another nurse and the number of controlled substances should match the number listed in the narcotic log.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to provide hand hygiene for 3 residents (Resident #33, #20, and #10) prior to the lunch meal service. Review of the facility policy titled, Handwashing /Hygiene, dated 8/2019, revealed .This facility considers hand hygiene the primary means to prevent the spread of infections .residents .will be encouraged to practice hand hygiene .before .eating or handling food . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Vascular Dementia, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #33 required set-up assistance with meals and partial/moderate assistance with personal hygiene. During an observation on 7/6/2026 at 11:53 AM, Certified Nursing Assistant (CNA) G entered Resident #33's room with the lunch meal tray and placed it on the bedside table. The CNA opened the beverage containers and left the room. CNA G did not offer or assist the resident with hand hygiene.Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Weakness, and need for assistance with personal care. Review of an annual MDS assessment dated [DATE], revealed the resident scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #20 required set-up assistance with meals and personal hygiene. During an observation on 7/6/2026 at 11:55 AM, CNA G entered Resident #20's room with the lunch meal tray and placed it on the bedside table. The CNA opened the beverage containers and left the room. CNA G did not offer or assist the resident with hand hygiene.Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarct, Aphasia, Severe Protein Malnutrition and Palliative Care.Review of an admission MDS assessment dated [DATE], revealed the resident scored an 11 on the Brief Interview for BIMS assessment which indicated the resident had mild cognitive impairment. Further review revealed Resident #10 had upper extremity impairment and required supervision or touching assistance with eating and personal hygiene. During an observation on 7/6/2026 at 11:57 AM, CNA G entered Resident #10's room with the lunch meal tray and placed it on the bedside table. The CNA opened the beverage containers and left the room. CNA G did not offer or assist the resident with hand hygiene. During an interview on 7/6/2026 at 12:00 PM, CNA G confirmed she had not offered or provided hand hygiene to Resident #33, Resident #20, and Resident #10 prior to the lunch meal service. and stated.During an interview on 7/8/2026 at 9:38 AM, The Regional Director of Nursing confirmed the expectation was for residents to be offered and assisted with hand hygiene prior to the meal service.

Based on an Online Professional Journal review, medical record review, and interviews, the facility failed to follow established clinical guidelines related to urinary catheterization of using silicone coated latex urinary catheters in persons with known latex allergies for 1 resident (Resident #9) of 8 residents reviewed for urinary catheters.The findings include: Review of the Clinical Standards of Practice as Published in the Online Professional Journal titled Urology and Continence Care Today, dated 2/2026, with an article titled .Best Practice in the use of indwelling catheterization . revealed .Polytetrafluorethylene (PTFE, a type of silicone) coated catheters .These are latex catheters coated in PTFE, which is smoother than latex and can be useful in reducing encrustation and discomfort for the wearer .There is still risk of latex allergy and, therefore, PTFE coated catheters must be avoided in patients with a known allergy or sensitivity . Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Paraplegia, Cervical Spinal Stenosis, Cervical Disorder at C-4-C-5 Level with Radiculopathy (a condition cause by a pinched nerve in the spine), Post Laminectomy Syndrome, Flaccid Neuropathic Bladder, Urinary Tract Infection, and Anxiety Disorder. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored 15 on the Brief Interview of Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Resident #9 required use of a latex free indwelling urinary catheter for urinary elimination. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #9 dated 4/2025, revealed .Latex was listed as an allergy. Review of a nurse's note for Resident #9 dated 8/6/2025, revealed .Resident continues on EBP [enhanced barrier precautions] for foley [indwelling urinary catheter] care .foley leaking and has sediment present .This nurse and CNA [Certified Nursing Assistant] cleansed resident and replaced with new .foley catheter using sterile technique .No resistance felt .10ml [milliliter] bulb filled .Resident denied pain .cloudy yellow urine returned with foul odor .MD [Medical Doctor] notified .N.O. [new order] to collect urine and obtain UA [urinalysis] .Clean catch urine obtained and placed on ice . Review of a nurse's note for Resident #9 dated 8/11/2025 at 1:24 PM, revealed .Resident continues EBP for foley care .Resident voices she wants to be sent out to the hospital due to having a latex foley in, the only foleys available at this time .MD notified .DON [Director of Nursing] notified .MD approved resident to be sent out per resident request .This nurse asked resident where she wanted to go .Resident stated .I know they [the hospital] won't admit me .This nurse asked, 'You want to be admitted ' .Resident stated 'Yea (yeah/yes) because I don't want to come back here' Review of a nurse's note for Resident #9 dated 8/11/2025 at 1:58 PM, revealed Resident picked up by Emergency Medical Services (EMS), .no S/S [signs symptoms] of distress during discharge . Review of hospital records for Resident #9 dated 8/11/2025 at 8:38 PM, revealed . Chief Complaint .Pt [patient] [Resident #9] from [the facility] and has a latex allergy .had foley in and was removed due to it being clogged .reports staff placed a latex catheter back in .she is now burning and itching and feels like she is having a reaction . Continued review of the hospital records revealed .Patient [Resident #9] .neurogenic bladder with chronic foley and recurrent catheter associated UTI [urinary tract infection] .She presented to the ED [Emergency Department] from the long term care facility] complaining of urethral discomfort .stated that a latex catheter was inserted 4 days ago and she is allergic to latex .In the ED her urinary catheter was replaced .her UA was negative for Pyuria (the presence of pus or signs of inflammation in urine). The patient then stated she refused to be returned to [the facility] because she feels unsafe there .given this, patient being admitted to the hospital for further treatment and evaluation .Fear for Personal Safety .patient refused to go back to [the facility] will consult case management .Catheter change required .a non-latex catheter was placed in the ED; I was told by staff that there was no erythema of her urethra (urinary opening at catheter insertion site) seen during the exchange .Wound of left groin .Muscle spasms of both lower extremities .She will be given parenteral VTE (venous thrombosis) prophylaxis .she will be admitted to a medical bed . Review of a nurse's note for Resident #9 dated 8/14/2025, revealed .resident is being DC [discharged ] from facility [long term care facility] to .[another rehabilitation/skilled nursing facility] center .She [Resident #9] has requested to not come back to this facility . Review of the hospital discharge summary for Resident #9 dated 8/14/2025, revealed Resident #9 was diagnosed with recurrent chronic UTI's. There was no evidence in records reviewed Resident #9 sustained an allergic reaction or other complications due to use of the latex catheter inserted at the facility on 8/6/2025. Resident #9's chronic UTI was stabilized in the hospital, and the resident was transferred to an alternate long term care center at her request, upon discharge. During an observation of the facility medical storerooms on 2/10/2026, revealed the facility routinely stocked PTFE silicone coated latex catheters, and latex free devices made of 100 % silicone materials to be utilized for residents with latex sensitivity or allergies. During interview on 2/10/2026 at 2:12 PM, the DON stated based on the review of the hospital documentation and facility nursing notes, on 8/6/2025, the facility nurse inserted a stock silicone coated latex catheter into Resident #9 in error. The DON confirmed the facility failed to follow recognized standards of care related to the use of latex containing devices in persons with known latex sensitivity.

Based on the facility admission agreement review, medical record review, and interview the facility failed to timely disburse resident refunds due the responsible party for 1 resident (Resident #6) of 3 residents reviewed for resident funds. The findings include: Review of the admission agreement dated [DATE], revealed .Refunds due to you .If you are discharged or transferred, we will refund you any credit balance minus any outstanding private insurance balance within a reasonable time not to exceed thirty (30) days after we have applied such balances towards outstanding fees for services provided by us . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Unspecified Cerebral Infarction (Stroke), Chronic Congestive Heart Failure, and Metabolic Encephalopathy. Review of the medical and financial records for Resident #6 revealed the responsible party for Resident #6 was listed on the admission documents, admission face sheet, financial records, and included authorizations for healthcare decision making, care plan participation, emergency contact status, healthcare representative status, and the management of Resident #6's financial liabilities. The responsible party was an authorized party on Resident #6's private bank accounts to pay the resident's liability to the facility under a private pay status for the monthly liabilities. Resident #6 died of natural causes at the facility on [DATE]. Review of the facility business office records and the resident account documents revealed at the time of Resident #6's death, $1995.00 (one thousand nine hundred and ninety-five dollars) were owed to the Responsible Party to settle the account. Continued review of the business office records revealed the facility failed to disburse the funds from Resident #6's account to the responsible party until after the facility received a notarized Heirship Affidavit issued by the local court on [DATE]. After receipt of the requested notarized document, the facility delayed actual disbursement of Resident #6's refund until [DATE], (41 days later and over 5 months after Resident #6's death). The refund was issued from the facility by paper check made out to the responsible party and mailed. During interview on [DATE] at 3:00 PM, the Administrator confirmed, according to the facility's admission agreement, the facility should have disbursed the monetary refund due to Resident #6's responsible party within 30 days of the resident's death. The Administrator confirmed there was a delay in the issuance of Resident #6's refund to the responsible party by the former Administration and the admission Agreement had not been followed.

Based on facility policy review, observation, and interview the facility failed to ensure frozen food products were labeled and dated appropriately while stored in 1 of 2 freezers observed which had the potential to affect all 40 residents of the facility. The findings include: Review of the facility policy titled, Food Receiving and Storage, dated 7/24/2023, showed .Foods shall be received and stored in a manner that complies with safe food handling practices .All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee according to state-specific requirements . During the initial kitchen tour observation on 8/28/2023 at 10:45 AM, with the Dietary Manager (DM) #1 showed the vertical freezer had items without labels or opened/use by dates. A zip-locked pack (transferred from original packaging) of 4 pork-chops was noted without proper labeling of contents, date opened, or use by date. A commercial food sized bag of 1-inch meatballs which was 3/4 full and open to air while stored in the horizontal freezer. The meatballs were noted without proper labeling of contents, date opened, or use by date. During an interiew on 8/28/2023 at 11:30 AM, Dietary Manager (DM) #1 confirmed items were unlabeled, and no opened date or used by date was present on either food item. DM #1 confirmed the pork chops, and the meatballs were available for resident consumption and should have been labeled, stored, dated, or left open to air.

Based on review of The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, observation, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 19 residents (Resident #8, #10, #11, #12, #13, #14, #18, #19, #20, #21, #22, #23, #27, #30, #31, #32, #37, #38, and #39) for use of side rails, 2 residents (Resident #11 and #23) for dental needs, 2 residents (Resident #11 and #30) for respiratory care, and 1 resident (Resident #21) for significant weight loss of 19 residents reviewed for MDS assessments. The findings include: Review of the Resident Assessment Instrument (RAI) Manual dated 10/2019, showed .The RAI process has multiple regulatory requirements .the assessment accurately reflects the resident's status .a registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals .the assessment process includes direct observation, as well as communication with the resident and direct care staff . Resident #8 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis following Cerebrovascular Accident, Aphasia, Dysphagia, Dementia, and Pseudobulbar Affect. Review of a quarterly MDS assessment dated [DATE], showed bed rails were not used for Resident #8. During an observation on 8/28/2023 at 1:00 PM, showed Resident #8 had bed rails in use. During an observation on 8/31/2023 at 10:00 AM, showed Resident #8 had bed rails in use. Resident #10 was admitted to the facility on [DATE] with diagnoses to include Cerebrovascular Disease, Type 2 Diabetes, Atrial Fibrillation, and Long-Term Use of Insulin. Review of a quarterly MDS assessment dated [DATE], showed bed rails were not used for Resident #10. During an observation on 8/28/2023 at 12:00 PM, showed Resident #10 had bed rails in use. During an observation on 8/31/2023 at 10:32 AM, showed Resident #10 had bed rails in use. Resident #11 was admitted to the facility on [DATE] with diagnoses to include Neuromuscular Dysfunction of Bladder, Obstructive Sleep Apnea, and Paraplegia. Review of a Dental Clinic Visit note dated 4/14/2023, showed Resident #11 had been evaluated and treated multiple times .multiple root tips and fractured teeth that are broken below the bone . Review of Resident #11's comprehensive care plan dated 4/27/2023, showed .use [Continuous Positive Airway Pressure] CPAP [device used to keep airway open] . Review of a quarterly MDS assessment dated [DATE], showed Resident #11 scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact, required supervision with eating, bed rails were not used, and there was no documentation of oral/dental concerns, or CPAP usage. Review of Resident #11's current Physician Orders, showed Peridex (oral rinse) Solution Give 10 cubic centimeters (cc) by mouth three times a day for oral cavity and CPAP at bedtime related to Obstructive Sleep Apnea. During an interview on 8/28/2023 at 11:50 AM, Certified Nursing Assistant (CNA) #1 stated Resident #11 had dental issues and had mouth wash ordered. During an interview on 8/28/2023 at 11:47 AM, Resident #11 stated he had multiple dental issues, had been evaluated by the contract dentist at the facility multiple times, had multiple teeth pulled, and he used the CPAP machine at night. During an observation on 8/28/2023 at 12:50 PM, showed Resident #11 had bed rails in use. During an interview on 8/29/2023 at 10:02 AM, the Director of Medical Records stated Resident #11 had dental issues and had been treated multiple times by the contract dentist at the facility. During an observation on 8/31/2023 at 10:10 AM, showed Resident #11 had bed rails in use. Resident #12 was admitted to the facility on [DATE] with diagnoses to include Hypertension, Chronic Kidney Disease, Localized Edema, and Anxiety Disorder. Review of a quarterly MDS assessment dated [DATE], showed bed rails were not used for Resident #12. During an observation on 8/28/2023 at 1:05 PM, showed Resident #12 had bed rails in use. During an observation on 8/31/2023 at 10:05 AM, showed Resident #12 had bed rails in use. Resident #13 was admitted to the facility on [DATE] with diagnoses to include Dementia, Psychotic Disturbance, Mood Disturbance, and Major Depressive Disorder. Review of an admission MDS assessment dated [DATE], showed bed rails were not used for Resident #13. During an observation on 8/28/2023 at 1:15 PM, showed Resident #13 had bed rails in use. During an observation on 8/31/2023 at 10:20 AM, showed Resident #13 had bed rails in use. Resident #14 was admitted to the facility on [DATE] with diagnoses to include Hypertensive Urgency, Severe Intellectual Disabilities, Impulse Disorder, and Cognitive Communication Deficit. Review of a quarterly MDS assessment dated [DATE], showed bed rails were not used for Resident #14. During an observation on 8/28/2023 at 1:30 PM, showed Resident #14 had bed rails in use. During an observation on 8/31/2023 at 10:43 AM, showed Resident #14 had bed rails in use. Resident #18 was admitted to the faciliy on 12/28/2020 with diagnoses to include Chronic Obstructive Pulmonary Disease, Dementia, Anxiety, and Major Depressive Disorder. Review of a quarterly MDS assessment dated [DATE], showed bed rails were not used for Resident #18. During an observation on 8/28/2023 at 12:55 PM, showed Resident #18 had bed rails in use. During an observation on 8/31/2023 at 10:15 AM, showed Resident #18 had bed rails in use. Resident #19 was admitted to the facility on [DATE] with diagnoses to include Chronic Respiratory Failure with Hypoxia, Cellulitis of Left Lower Limb, Chronic Venous Hypertension with Ulcer of Left Lower Extremity, Lymphedema, and Need for Assistance with Personal Care. Review of a quarterly MDS assessment dated [DATE], showed bed rails were not used for Resident #19. During an observation on 8/28/2023 at 12:57 PM, showed Resident #19 had bed rails in use. During an observation on 8/31/2023 at 10:35 AM, showed Resident #19 had bed rails in use. Resident #20 was admitted to the facility on [DATE] with diagnoses to include, Encephalopathy, Dementia, Psychotic Disturbance, Adult Failure to Thrive, and Type 2 Diabetes. Review of a quarterly MDS assessment for Resident #20 dated 4/11/2023, showed bed rails were not used for Resident #20. During an observation on 8/28/2023 at 1:19 PM, showed Resident #20 had bed rails in use. During an observation on 8/31/2023 at 11:22 AM, showed Resident #20 had bed rails in use. Resident #21 was admitted to the facility on [DATE] with diagnoses to include Dementia, Encephalopathy, Anxiety Disorder, Major Depressive Disorder, Pseudobulbar Affect, and Severe Protein- Calorie Malnutrition. Review of Resident #21's comprehensive care plan initiated 3/14/2023, showed .nutritional problem or potential nutritional problem r/t [related to] .pureed texture .hospice status and advanced dementia .report .significant weight loss .serve diet as ordered .Monitor intake and record q [every] meal . Review of Resident #21's weights showed the following: 4/26/2023 the resident weighed 103.5 pounds and 7/26/2023 the resident weighed 95.6 pounds which is a 7.63 % loss in 3 months. Review of a Dietitian Progress Note dated 7/4/2023, .[Resident #21] has had a significant weight loss of 5.9% [percent] X [times] 30 days .[Resident #21] has advanced dementia and weight loss is anticipated with disease progression . Review of a significant change MDS assessment dated [DATE], showed Resident #21 weight was 96 pounds with no significant weight loss identified and bed rails were not used. During an observation on 8/28/2023 at 1:22 PM, showed Resident #21 had bed rails in use. During an observation on 8/31/2023 at 11:25 AM, showed Resident #21 had bed rails in use. Resident #22 was admitted to the facility on [DATE] with diagnoses to include Major Depressive Disorder, Dementia, Hemiplegia, and Atrial Fibrillation. Review of a quarterly MDS assessment dated [DATE], showed bed rails were not used for Resident #22. During an observation on 8/28/2023 at 1:43 PM, showed Resident #22 had bed rails in use. During an observation on 8/31/2023 at 11:25 AM, showed Resident #22 had bed rails in use. Resident #23 was admitted to the facility on [DATE] with diagnoses to include Malignant Neoplasm of Ovary, Type 2 Diabetes, Major Depressive Disorder, Morbid Obesity, and Malignant Neoplasm of Lung. Review of an admision MDS dated [DATE], showed Resident #23 scored a 15 on the BIMS which indicated the resident was cognitively intact, had no oral or dental concerns, and bed rails were not used. During an observation on 8/28/2023 at 12:59 PM, showed Resident #23 had bed rails in use. During an interview and observation on 8/29/2023 at 7:38 AM, Resident #23 stated she had poor dentation and stated she had to soak potato chip to eat due to discomfort when eating hard items and had advised the facility when she was admitted . Observation showed Resident #23 had black discolored and missing teeth. Resident #23 denied pain at the time of the interview. During an observation on 8/31/2023 at 10:39 AM, showed Resident #23 had bed rails in use. Resident #27 was admitted to the facility on [DATE] with diagnoses to include Encephalopathy, Dementia, Dysphagia, and Muscle Weakness. Review of a quarterly MDS assessment dated [DATE], showed bed rails were not used for Resident #27. During an observation on 8/28/2023 at 1:29 PM, showed Resident #27 had bed rails in use. During an observation on 8/31/2023 at 11:50 AM, showed Resident #27 had bed rails in use. Resident #30 was admitted to the facility on [DATE] with diagnoses to include Chronic Congestive Heart Failure (CHF), Permanent Atrial Fibrillation, Morbid Obesity and Angina. Review of a significant change MDS assessment dated [DATE], showed Resident #30 had a BIMS score of 15 which indicated the resident was cognitively intact, bed rails and oxygen were not used. Review of Resident #30's comprehensive care plan revised on 7/10/2023, showed oxygen therapy related to Obstructive Sleep Apnea Review of Resident #30's Physician Orders showed Oxygen at 2 liters via (by) nasal cannula. During an observation on 8/28/2023 at 11:45 AM, Resident #30 had oxygen via nasal cannula in use. During an interview on 8/30/2023 at 9:48 AM, Resident #30 stated he always used oxygen. During an observation on 8/28/2023 at 11:16 AM, showed Resident #30 had bed rails in use. During an observation on 8/31/2023 at 1:27 PM, showed Resident #30 had bed rails in use. Resident #31 was admitted to the facility on [DATE] with diagnoses to include Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety Disorder, Major Depressive Disorder, and Hallucinations. Review of a quarterly MDS assessment dated [DATE], showed bed rails were not used for Resident #31 During an observation on 8/28/2023 at 2:00 PM, showed Resident #31 had bed rails in use. During an observation on 8/31/2023 at 12:35 PM, showed Resident #31 had bed rails in use. Resident #32 was admitted to the facility on [DATE] with diagnoses to include Cerebral Infarction, Hemiplegia, Hemiparesis following Cerebral Vascular Accident, Heart Failure, and Vascular Dementia. Review of an admission MDS assessment dated [DATE], showed bed rails were not used for Resident #32. During an observation on 8/28/2023 at 11:46 AM, showed Resident #32 had bed rails in use. During an observation on 8/31/2023 at 1:32 PM, showed Resident #32 had bed rails in use. Resident #37 was admitted to the facility on [DATE] with diagnoses to include Post-Traumatic Stress Disorder, Psychotic Disorder with Hallucinations, and Parkinson's Disease. Review of a quarterly MDS assessment dated [DATE], showed bed rails were not used for Resident #37. During an observation on 8/28/2023 at 2:06 PM, showed Resident #37 had bed rails in use. During an observation on 8/31/2023 at 12:37 PM, showed Resident #37 had bed rails in use. Resident #38 was admitted to the facility on [DATE] with diagnoses to include Wedge Compression Fracture of Vertebra, Paraplegia, Atrial Fibrillation, Mood Disorder, and CHF. Review of an admission MDS assessment dated [DATE], showed bed rails were not used for Resident #38. During an observation on 8/28/2023 at 1:46 PM, showed Resident #38 had bed rails in use. During an observation on 8/31/2023 at 11:36 AM, showed Resident #38 had bed rails in use. Resident #39 was admitted to the facility on [DATE], with diagnoses to include Cerebral Infarction, Hemiplegia affecting Right Dominant Side, Dementia, Major Depressive Disorder, and Anxiety Disorder. Review of a quarterly MDS assessment dated [DATE], showed bed rails were not used for Resident #39. During an observation on 8/28/2023 at 2:10 PM, showed Resident #39 had bed rails in use. During an observation on 8/31/2023 at 12:38 PM, showed Resident #39 had bed rails in use. During an interview on 8/31/2023 at 6:02 PM, the Interim (temporary) Director of Nursing (IDON)/Regional Nurse Consultant (RNC) confirmed Residents #8, #10, #11, #12, #13, #14, #18, #19, #20, #21, #22, #23, #27, #30, #31, #32, #37, #38 and #39's use of bed rails, Residents #11 and #23 dental concerns, Resident #11's use of a CPAP, Resident #30's use of oxygen, and Resident #21's significant weight loss had not been coded on the MDS assessment.

Based on facility policy review, review of Quality Assurance Performance Improvement (QAPI) documents, and interview, the facility's QAPI committee failed to monitor, implement appropriate plans to correct, and track the identified concerns related to a homelike environment with resident rooms being in disrepair and the use of side (bed) rails to ensure routine/scheduled maintenance assessments were completed which had the potential to affect all 40 residents of the facility. The findings include: Review of the facility policy titled, Quality Assessment and Performance Improvement, undated, showed .the facility will implement and maintain a Quality Assessment and Performance Improvement program .The program should address all systems of care and management practices while emphasizing safety .The primary purpose .is to identify and analyze actual or potential quality issues .and implement appropriate plans to improve performance .The minutes of the monthly QAPI meeting will be reviewed with the Medical Director .PERFORMANCE IMPROVEMENT PLANS AND PROJECTS (PIP) .may include but not limited to .Improvement to the physical plant .will contain specific steps to be taken, assignment of responsibility for each step, and the timeframe for completion .Processes to revise plans as needed to achieve desired results .Monitoring of the effectiveness of the PIP will be reviewed through continued gathering and review of the data . Review of the facility policy titled, Bed Rails, dated 5/10/2017, showed .A side rail assessment screen is completed on each resident upon admission, quarterly, and as needed .The assessment and documentation .includes .measuring the gaps between the rail(s) themselves and the gaps between the bed-rail and the mattress .Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks .The maintenance department shall provide a copy of inspections to the Administrator and report results to the QAPI committee for appropriate action . During an annual recertification and complaint survey conducted from 8/28/2023-9/1/2023, deficient practice was identified for the facility's failure to provide a homelike environment and failure to ensure routine/scheduled maintenance assessments for bedrails had been completed. Review of QAPI meeting minutes dated 7/12/2023, showed .Side Rails and Bed .Includes measuring gaps between the rail . themselves and the gaps between the rail and mattress. A visual review performed to assess that the mattress doesn't shift/slide allowing for an increased gap between the bed and the bed rail and are within the dimensions established .Inspect bed, rails .ensure bed rails are properly installed and ensure proper fit .(This should be done upon admission and quarterly for every resident/bed) . Documentation showed a PIP had not been put into place after the concerns had been identified. Review of the QAPI sign in sheet dated 7/12/2023, showed the Medical Director, Environmental Services Director, and Maintenance Director were in attendance. Review of a Monthly Unit Inspection document dated 8/1/2023, showed room [ROOM NUMBER]'s (Resident #38's) walls had been patched and waiting for paint. room [ROOM NUMBER]'s (Resident #14s) walls needed patched and painted. Review of a QAPI meeting sign in sheet dated 8/9/2023, showed the Medical Director in attendance. The Environmental Services Director and Maintenance Director did not attend the meeting. The Monthly Unit Inspection document dated 8/1/2023 was attached to the 8/9/2023 QAPI sign in sheet. During an interview on 8/31/2023 at 5:38 PM, the Interim (temporary) Director of Nursing (IDON)/Regional Nurse Consultant (RNC) stated a QAPI meeting was held on 7/12/2023. Side (bed) rails were discussed to include measuring gaps between the rails themselves and the gaps between the bed rails and mattress. The IDON/RNC confirmed the facility had identified a bed rail concern and failed to ensure routine/scheduled maintenance assessments had been completed. During an interview on 9/1/2023 at 10:50 AM, the Environmental Services Director stated she had been employed at the facility since 8/2022. She stated she performed monthly room inspections and documented the findings on the Monthly Unit Inspection Form, which was presented to the QAPI team. The Environmental Services Director also stated the Monthly Inspection Forms had not been reviewed or discussed in the QAPI meetings, was unaware of a plan to correct the identified problems, and the Maintenance Director was responsible for painting, maintaining the rooms, and the hallways. During an interview on 8/29/2023 at 2:15 PM, the Maintenance Director stated the facility had not informed him to assess side rails/mattresses. The Maintenance Director confirmed he had not assessed or documented side rail assessments to include visible gaps or measurements between the mattress and side rails. During a tour of the facility with the Maintenance Director on 8/31/2023 starting at 5:30 PM and ending at 6:45 PM, the Maintenance Director confirmed the facility failed to maintain resident rooms and hallways in good repair. During an interview on 9/1/2023 at 11:18 AM, the Maintenance Director stated he had attended the QAPI meetings. Resident rooms had not been discussed in QAPI, but the Environmental Services Director informed him of resident rooms with holes identified in the walls .holes are top priority . He also stated the previous Administrator had identified some of the resident rooms which needed walls repaired and painted (unable to give a date or specific rooms). The goal was for 1 room to be completed every week, but the Maintenance Director had only been able to complete 1 room a month and had only completed 6 rooms, currently. During a telephone interview on 9/1/2023 at 12:07 PM, the Medical Director stated he attended QAPI meetings at the facility and he had attended the 7/12/2023 meeting. He also stated he recalled a discussion regarding side rails and measuring for gaps between the rails and mattresses. The Medical Director stated it was his understanding, the Maintenance Director oversaw the task. During an interview on 8/31/2023 at 5:42 PM, the IDON/RNC stated she was not aware of the disrepair of the residents' rooms and confirmed side (bed) rails had been discussed during the QAPI meetings and the facility had failed to implement appropriate action plans to correct the identified concern.

Based on facility policy review, observations, and interviews the facility failed to ensure routine and regular scheduled side rail assessments were completed to identify the risk of entrapment for 19 residents (Resident #8, #10, #11, #12, #13, #14, #18, #19, #20, #21, #22, #23, #27, #30, #31, #32, #37, #38, and #39) of 19 residents reviewed for side rail assessments. The findings include: Review of the facility policy titled, Bed Rails, dated 5/10/2017, showed .A side rail assessment screen is completed on each resident upon admission, quarterly, and as needed .The assessment and documentation .includes .measuring the gaps between the rail(s) themselves and the gaps between the bed-rail and the mattress .Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks . Resident #8 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis, Speech and Language Deficits, Dementia, Pseudobulbar Affect, Psychosis, Major Depressive Disorder, and Anxiety Disorder. During an observation on 8/28/2023 at 1:00 PM, showed Resident #8 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 10:00 AM, showed Resident #8 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #10 was admitted to the facility on [DATE] with diagnoses to include Cerebrovascular Disease, Type 2 Diabetes, Atrial Fibrillation, and Long-Term Use of Insulin. During an observation on 8/28/2023 at 12:00 PM, showed Resident #10 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 10:32 AM, showed Resident #10 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #11 was admitted to the facility on [DATE] with diagnoses to include Contracture of muscle left and right lower leg, Chronic Pain Syndrome, and Arthritis Right Knee. During an observation on 8/28/2023 at 12:50 PM, showed Resident #11 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 10:10 AM, showed Resident #11 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #12 was admitted to the facility on [DATE] with diagnoses to include Hypertension, Chronic Kidney Disease, Localized Edema, and Anxiety Disorder. During an observation on 8/28/2023 at 1:05 PM, showed Resident #12 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 10:05 AM, showed Resident #12 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #13 was admitted to the facility on [DATE] with diagnoses to include Dementia, Psychotic Disturbance, Mood Disturbance, and Major Depressive Disorder. During an observation on 8/28/2023 at 1:15 PM, showed Resident #13 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 10:20 AM, showed Resident #13 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #14 was admitted to the facility on [DATE] with diagnoses to include Hypertensive Urgency, Severe Intellectual Disabilities, Impulse Disorder, and Cognitive Communication Deficit. During an observation on 8/28/2023 at 1:30 PM, showed Resident #14 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 10:43 AM, showed Resident #14 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #18 was admitted to the facility on [DATE] with diagnosis to include Chronic Obstructive Pulmonary Disease, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, and Major Depressive Disorder. During an observation on 8/28/2023 at 12:55 PM, showed Resident #18 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 10:15 AM, showed Resident #18 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #19 was admitted to the facility on [DATE] with diagnoses to include Chronic Respiratory Failure with Hypoxia, Cellulitis of Left and Right Lower Limb, and Muscle Weakness. During an observation on 8/28/2023 at 12:57 PM, showed Resident #19 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 10:35 AM, showed Resident #19 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #20 was admitted to the facility on [DATE] with diagnoses to include Encephalopathy, Dementia, Adult Failure to Thrive, Type 2 Diabetes, Protein Calorie Malnutrition, and Contractures of the Left and Right Knee During an observation on 8/28/2023 at 1:19 PM, showed Resident #20 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and the side rails. During an observation on 8/31/2023 at 11:22 AM, showed Resident #20 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and the side rails. Resident #21 was admitted to the facility on [DATE] with diagnoses to include Dementia, Encephalopathy, Anxiety Disorder, and Pseudobulbar Affect. During an observation on 8/28/2023 at 1:22 PM, showed Resident #21 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 11:25 AM, showed Resident #21 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #22 was admitted to the facility on [DATE] with diagnoses to include Major Depressive Disorder, Dementia, Hemiplegia, and Atrial Fibrillation. During an observation on 8/28/2023 at 1:43 PM, showed Resident #22 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 11:25 AM, showed Resident #22 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #23 was admitted to the facility on [DATE] with diagnoses to include Malignant Neoplasm of Ovary, Type 2 Diabetes, Major Depressive Disorder, Morbid Obesity, and Malignant Neoplasm of Lung. During an observation on 8/28/2023 at 12:59 PM, showed Resident #23 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 10:39 AM, showed Resident #23 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #27 was admitted to the facility on [DATE] with diagnoses to include Encephalopathy, Dementia, Insomnia, and Dysphagia. During an observation on 8/28/2023 at 1:29 PM, showed Resident #27 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 11:50 AM, showed Resident #27 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #30 was admitted to the facility on [DATE] with diagnoses to include Chronic Diastolic Congestive Heart Failure, Permanent Atrial Fibrillation, Morbid Obesity, and Angina. During an observation on 8/28/2023 at 11:16 AM, showed Resident #30 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 1:27 PM, showed Resident #30 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #31 was admitted to the facility on [DATE] with the diagnosis to include Dementia, Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Major Depressive Disorder, and Hallucinations. During an observation on 8/28/2023 at 2:00 PM, showed Resident #31 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 12:35 PM, showed Resident #31 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #32 was admitted to the facility on [DATE] with diagnoses to include Cerebral Infarction, Hemiplegia, Heart Failure, and Vascular Dementia. During an observation on 8/28/2023 at 11:46 AM, showed Resident #32 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 1:32 PM, showed Resident #32 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #37 was admitted to the facility on [DATE] with diagnoses to include Post Traumatic Stress Disorder, Psychotic Disorder with Hallucinations, and Chronic Pain Syndrome. During an observation on 8/28/2023 at 2:06 PM, showed Resident #37 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 12:37 PM, showed Resident #37 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #38 was admitted to the facility on [DATE] with diagnoses to include Wedge Compression Fracture of Vertebra, Paraplegia, Atrial Fibrillation, Mood Disorder, and Congestive Heart Failure. During an observation on 8/28/2023 at 1:46 PM, showed Resident #38 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 11:36 AM, showed Resident #38 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. Resident #39 was admitted to the facility on [DATE] with diagnoses to include Cerebral Infarction, Essential Hypertension, Muscle Weakness, and Paralytic Gait. During an observation on 8/28/2023 at 2:10 PM, showed Resident #39 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 12:38 PM, showed Resident #39 had bed rails in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an interview on 8/29/2023 at 2:15 PM, the Maintenance Director stated the facility had not informed him to assess side rails/mattresses for the risk of entrapment. The Maintenance Director confirmed he had not assessed or documented side rail assessments to include visible gaps or measurements between the mattress and side rails. During an interview on 8/31/2023 at 5:38 PM, the Interim (temporary) Director of Nursing/Regional Nurse Consultant confirmed the facility failed to ensure routine/scheduled maintenance assessments had been completed.

Based on observation and interview, the facility failed to maintain resident rooms and hallways in good repair and in a homelike environment for 18 resident rooms (#23, #8, #21, #20, #27, #100, #30, #9, #101, #18, #5, #32, #31, #102, #103, #104, #13, #38, #10, #105, #106, and #14) of 34 rooms observed of 37 total rooms and 3 of 4 hallways observed which affected 22 residents. The findings include: During an environment tour of 4 Halls and 37 rooms on, 8/28/2023 starting at 10:00 AM and ending at 12:00 PM, the following concerns were observed: room [ROOM NUMBER]A (Resident #23) was observed to have scratched/gouged/scuffed walls and missing paint. room [ROOM NUMBER]B (Resident #8) was observed to have a dirty privacy curtain with circular brown stains. room [ROOM NUMBER]A (Resident #21) was observed to have scuffed walls and cracked sheet rock around the air conditioner (A/C) unit. room [ROOM NUMBER]A (Resident #20) was observed to have large scratches in the dry wall and missing paint on the wall over the bed. room [ROOM NUMBER]B (Resident #27) was observed to have scratched/scuffed walls, missing paint, and cracked sheet rock around the A/C unit. room [ROOM NUMBER]B (Resident #100) was observed to have cracked sheet rock around the A/C unit, and the laminate on top of the nightstand was chipped. room [ROOM NUMBER]'s (Resident #30) entry doorway had chipped paint, a scuffed wall bedside the bathroom door, cracked sheet rock around the A/C unit, and gouged/chipped areas to the closet door. room [ROOM NUMBER] (Resident #101) was observed to have a golf ball sized hole in the wall, covered with tape behind the entrance door, cracked sheet rock around the A/C unit, and chipped paint around the bathroom door frame. room [ROOM NUMBER] (Resident #18) was observed to have scuff marks to the closet door, cracked sheet rock around the A/C unit, scratches/gouges on walls behind both residents' headboards with missing paint: and a 2-inch hole in the wall next to the sink. room [ROOM NUMBER]'s (Resident #5) entry doorway had chipped paint, and wallpaper coming off the bottom of the wall next to the bathroom door. room [ROOM NUMBER] (Resident #32) was observed to have a ceiling with chipped plaster. room [ROOM NUMBER] (Resident #31 and Resident #102) was observed with a entry doorway with chipped paint and the wallpaper was coming off above the door. room [ROOM NUMBER] (Resident #103 and Resident #104) was observed with an entry doorway with scratched/scuffed areas with chipped paint. room [ROOM NUMBER]B (Resident #13) was observed to have a damaged overbed table with missing laminate stripping around the table's perimeter/edge that exposed chipped/splintered composite wood. room [ROOM NUMBER]B (Resident #38) was observed to have a dry wall patch in need of painting on a wall near the window . room [ROOM NUMBER]B (Resident 310) was observed to have the wall near the entrance doorway of the room, behind the recliner, and the wall behind the head of the bed with peeled/chipped paint on the walls. room [ROOM NUMBER] (Resident #105) was observed to have chipped/cracked sheet rock around the A/C unit and the wall near the window had chipped paint. room [ROOM NUMBER]B (Resident #106) was observed to have the wall near the entrance doorway with chipped paint. room [ROOM NUMBER]B (Resident #14) was observed to have the wall near the entrance doorway of the room and the wall behind the bed's headboard with scratched/gouged/scuffed walls. Observation of hallways A, B, and D showed multiple areas with plaster chipping off the ceiling, areas not painted, and paint coming off the walls. Observation of hallways A and B showed the hallways had tears in the wallpaper ranging from 1 inch to 6 inches in length and needed repaired. During a tour of the facility with the Maintenance Director on 8/31/2023 starting at 5:30 PM and ending at 6:45 PM, the Maintenance Director confirmed the facility failed to maintain resident rooms and hallways in good repair. During an interview on 9/1/2023 at 10:50 AM, the Environmental Services Director stated she had been employed at the facility since 8/2022. The Environmental Services Director also stated the Maintenance Director was responsible for painting and maintaining the rooms and hallways. During an interview on 9/1/2023 at 11:18 AM, the Maintenance Director stated the previous Administrator had identified some of the resident rooms which needed walls repaired and painted (unable to give a date or specific rooms). The Maintenance Director stated the previous administrator had a goal for 1 room to be completed every week, but the Maintenance Director had only been able to complete 1 room a month and had only completed 6 rooms, currently.

Based on facility policy review, observation, and interview, the facility failed to provide a person-centered activities program which affected 4 of 4 residents (Resident #5, #19, #23, and #36) reviewed for activities which had the potential to affect all 40 residents in the facility. The findings include: Review of the facility policy titled, Life Connection Program, dated 3/2023, showed .Life connections programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident .the life connections program is ongoing and includes facility-organized group activities, independent individual activities, and assisted individual activities .activities are scheduled 7 days per week .scheduled activities are posted on the resident bulletin board .activity scheduled are also provided individually . Resident #5 was admitted to the facility on [DATE] with diagnoses to include Chronic Ischemic Heart Disease and Hypothyroidism. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. During an interview on 8/29/2023 at 3:20 PM, Resident #5 stated he did not know what or when activities were occurring, there was no consistent out of room activities, and the last BINGO group activity was over 2 weeks ago. Resident #5 stated he did not know who was supposed to complete activities since the previous Activity Director quit. Resident #19 was admitted to the facility on [DATE] with diagnoses to include Chronic Respiratory Failure and Morbid Obesity. Review of the quarterly MDS assessment dated [DATE], showed Resident #19 had a BIMS score of 15 which indicated the resident was cognitively intact. During an interview and observation on 8/29/2023 at 3:15 PM, Resident #19 stated she was not sure when the last time an activities calendar was placed in her room or on the community bulletin board. The resident also stated she did not know what or when activities were occurring, there were no consistent out of room activities, and the last BINGO activity was over 2 weeks ago. Resident #19 stated she was not aware of a specific staff member assigned to complete activities since the previous Activity Director quit. Observation showed Resident #19 did not have an activities calendar in her room. Resident #23 was admitted to the facility on [DATE] with diagnoses to include Malignant Neoplasm of Lung, Malignant Neoplasm of Ovary, Type 2 Diabetes Mellitus, Major Depressive Disorder, and Anxiety Disorder. Review of an admission MDS assessment dated [DATE], showed Resident #23 scored a 15 on the BIMS which indicated the resident was cognitively intact. During an interview and observation on 8/28/2023 at 10:30 AM, Resident #23 stated she was not aware the facility had an activities program and had not been offered activities since her admission on 8/4/2023. Observation showed Resident #23 did not have an activities calendar present in the room. Resident #36 was admitted to the facility on [DATE] with diagnoses to include Hypothyroidism and Essential Hypertension. Record review of a quarterly MDS assessment dated [DATE], showed Resident #36 had a BIMS score of 15 which indicated the resident was cognitively intact. During an observation on 8/29/2023 at 2:45 PM, the BINGO group activity was scheduled for 2:00 PM in the main dining room, however no staff member was present to complete the activity program. Continued observation showed a sign posted on the community bulletin board which stated BINGO today [8/29/2023] at 2:00 PM During an interview on 8/29/2023 at 3:17 PM, Resident #36 stated there had been no activity calendars placed in her room or in the common area, there were no consistent out of room activities, and the last BINGO activity was over 2 weeks ago. Resident #36 stated she was not aware of a specific staff member assigned to complete the activities programs since the previous Activity Director had resigned. Further interview showed Resident #36 had inquired about the BINGO activity that was scheduled for today (8/29/2023) and was told by staff the BINGO group activity was cancelled due to staffing. During an interview on 8/29/2023 at 3:45 PM, Certified Nursing Assistant (CNA) #1 stated the facility had not completed activities for the residents in over 2 weeks. CNA #1 also stated the facility had scheduled a BINGO group activity today (8/29/2023) and had to be cancelled due to staff inavailability. During an interview on 8/30/2023 at 9:57 AM, CNA #4 stated the facility had not been offering consistent activities to residents .the Activities Director had quit and no one had been doing them . During an interview on 8/30/2023 at 10:04 AM, the Administrator stated the previous Activity Director had quit on 8/18/2023. The Administrator confirmed there had not been anyone specifically assigned to complete the activities programs for the residents in the facility and had not met the activity needs or interests of the residents.

Based on observation, and interview, the facility failed to ensure sufficient staff to provide person-centered activities for 4 of 4 residents (Resident #5, #19, #23, and #36) reviewed for activities and 3 of 4 residents (Resident #5, #19, and #36) reviewed for communal dining service which had the potential to affect all 40 residents present in facility. The findings include: Resident #5 was admitted to the facility on [DATE] with diagnoses to include Chronic Ischemic Heart Disease and Hypothyroidism. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. During an interview on 8/29/2023 at 3:20 PM, Resident #5 stated he did not know what or when activities were occurring, there were no consistent out of room activities, and the last BINGO group activity was over 2 weeks ago due to the lack of sufficient staff. Resident #5 also stated the dining room had been closed due to lack of staffing and would like to dine with other residents. Resident #19 was admitted to the facility on [DATE] with diagnoses to include Chronic Respiratory Failure and Morbid Obesity. Review of a quarterly MDS assessment dated [DATE], showed Resident #19 had a BIMS score of 15 which indicated the resident was cognitively intact. During an interview on 8/29/2023 at 3:15 PM, Resident #19 stated she did not know what or when activities were occurring, there were no consistent out of room activities, and the last BINGO activity was over 2 weeks ago. Resident #19 stated there were no activities and the dining room had been closed due to the lack of staffing. Resident #19 stated she .would like to eat in the dining room with other residents . Resident #23 was admitted to the facility on [DATE] with diagnoses to include Malignant Neoplasm of Lung, Malignant Neoplasm of Ovary, Type 2 Diabetes Mellitus, Major Depressive Disorder, Anxiety Disorder, Morbid Obesity, Neoplasm related Pain, and Cellulitis of Right Lower Limb. Review of an admission MDS assessment dated [DATE], showed Resident #23 had a BIMS score of 15 which indicated the resident was cognitively intact. During an interview and observation on 8/28/2023 at 10:30 AM, Resident #23 stated she was not aware the facility had an activities program and had not been offered activities since her admission on 8/4/2023. Observation of Resident #23's room showed no activities calendar present. Resident #36 was admitted to the facility on [DATE] with diagnoses to include Hypothyroidism and Essential Hypertension. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #36 had a BIMS score of 15 which indicated the resident was cognitively intact. During an interview on 8/29/2023 at 3:17 PM, Resident #36 stated the previous Activity Director had resigned and did not know who was completing the activities program. Resident #36 stated the last BINGO activity was over 2 weeks ago and the dining room had been closed due to staffing issues and stated she would like to dine with other residents. During multiple observations on 8/28/2023 through 9/1/2023, showed the main dining room had not been used for the residents' communal dining for any of the meals. During an observation on 8/29/2023 at 2:45 PM, the BINGO group activity was scheduled for 2:00 PM, in the main dining room, however no staff member was present to complete the activity program. During an interview on 8/29/2023 at 3:45 PM, the Certified Nursing Assistant (CNA) #1 stated the facility had not completed activities for residents for over 2 weeks due to the lack of staff. Further interview showed since there were only 2 CNAs assigned for the dayshift, there was not enough staff to complete communal dining services in the main dining room. During an interview on 8/30/2023 at 9:57 AM, CNA #4 stated the facility had not been offering consistent activities to the residents and .the Activities Director quit and no one has been doing them [the activities] . Further interview with CNA #4 confirmed the dining room had been closed due to staffing issues. During an interview on 8/30/2023 at 10:04 AM, the Administrator stated the previous Activity Director quit on 8/18/2023 and the facility had experienced a large amount of staff turnover including the department heads. The Administrator stated the facility did not have consistent staff to ensure dining and activities services were being conducted. The Administrator confirmed the facility had not provided sufficient staffing to meet the residents' activities and communal dining needs. During an interview on 8/30/2023 at 4:12 PM, the Interim Director of Nursing (IDON)/ Regional Nurse Consultant (RNC) confirmed the facility had experienced major staff turnover which affected the dining and activity services.

Based on facility policy review, observation, and interview the facility failed to maintain infection control practices while delivering meal trays to residents on 1 hallway of 4 hallways observed. The findings include: Review of the facility policy titled, Handwashing/Hand Hygiene, last revised 6/2010, showed .This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .Employees must wash their hands .under the following conditions .Before and after direct resident contact .After removing gloves .In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled .Before and after direct contact with residents .Before donning .gloves .After contact with objects .in the immediate vicinity of the resideny . During an observation of meal delivery on 8/28/2023 at 11:48 AM, on the A hallway, showed the following: Certified Nursing Assistant (CNA) #3 was observed in room [ROOM NUMBER] with gloved hands, the CNA exited the room, and removed the gloves without washing or sanitizing the hands. CNA #3 applied a new pair of gloves, retrieved a tray from the meal cart, entered room [ROOM NUMBER], placed the meal tray on the overbed table, exited the room, and did not remove the gloves. The CNA retrieved a tray from the meal cart, entered room [ROOM NUMBER], placed the tray on the overbed table, opened food items, touched the silverware handles, placed the overbed table in reach of the resident, exited the room, removed the gloves at the meal cart, discarded the gloves, and did not wash or sanitize the hands. Further observation showed CNA #3 applied a new pair of gloves, retrieved a tray from the food cart, entered room [ROOM NUMBER]B, placed the food tray on the overbed table, placed the table in reach of the resident, and exited the room without removing the gloves or sanitizing the hands. CNA #3 retrieved a tray from the food cart, entered room [ROOM NUMBER]B, placed the tray on the overbed table, touched the bed linens, exited the room with gloved hands, retrieved a towel from the clean linen cart, re-entered room [ROOM NUMBER]B, and placed the towel over the resident's chest area. Continued observation showed CNA #3 exited the room, retrieved sugar from the meal cart, re-entered room [ROOM NUMBER]B, placed the sugar in the resident's tea, exited the room, removed the gloves, and did not wash or sanitize the hands. During an interview on 8/28/2023 at 11:59 AM, CNA #3 stated it was the expectation of the facility to wash or sanitize the hands after gloves are removed and after each resident contact. CNA #3 confirmed she failed to follow infection control practices during meal delivery. During an observation of meal delivery on 8/29/2023 at 7:36 AM on A hallway, showed the following: Licensed Practical Nurse (LPN) #3 entered room [ROOM NUMBER]B with gloved hands and a breakfast tray, the LPN positioned the bedside table, pulled the light cord to turn on the light, opened utensils, exited the room into the hallway, removed gloves, and did not wash or sanitize the hands. LPN #3 applied a new pair of gloves, retrieved a tray from the meal cart, entered room [ROOM NUMBER]A, turned on the light switch over the sink, positioned the bedside table, touched the bed controller, assisted the resident out of the bed into the wheelchair, opened condiments, and placed on the food. LPN #3 exited the room into the hallway, removed the gloves, and did not wash or sanitize the hands. During an interview on 8/29/2023 at 7:43 AM, LPN #3 stated she was not aware hand hygiene should be completed prior to applying gloves, removing gloves, and after touching resident care items. The LPN stated it was the facility's hand hygiene protocol to sanitize the hands after every 3rd resident encounter. During an interview on 8/29/2023 at 8:01 AM, the Director of Nursing confirmed hand hygiene was to be performed before and after each direct resident contact, before applying/after removing gloves, and after contact with objects in the resident rooms.

Based on facility policy review, medical record review, and interview the facility failed to develop a comprehensive care plan for 1 resident (Resident #11) for dental concerns of 16 residents reviewed for dental concerns, and for 2 residents (Resident #13 and #14) for use of bed/side rails of 19 residents reviewed. The facility failed to implement the comprehensive care plan for 1 resident (Resident #38) related to identifying and documenting behaviors and side effects of psychotropic medications of 5 residents reviewed for unnecessary medications.The facility also failed to implement the comprehensive care plan related to falls for 1 resident (Resident #27) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, Care Plan-Comprehensive, undated, showed .It is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives .to meet the resident's medical, nursing .needs .The comprehensive care plan had been designed to .Incorporate identified focus areas .Incorporate risk factors associated with identified problems .Care plans are revised as changes in the resident's condition dictates . Review of the facility policy titled, Behavioral Assessment, Intervention and Monitoring, last reviewed 10/2022, showed .Behavioral symptoms will be identified using facility-approved behavioral screening tools .The nursing staff will identify, document .specific details regarding .behavior .including .frequency of behavioral symptoms .behavior will be documented .When medications are prescribed .monitoring for .adverse consequences .document .worsening in the individual's behavior, mood .New .symptoms will be documented . Resident #11 was admitted to the facility on [DATE] with diagnoses to include Neuromuscular Dysfunction of Bladder, Obstructive Sleep Apnea, and Paraplegia. Review of Resident #11's current Physician Orders dated 11/11/2022 showed Peridex (mouth rinse) Solution Give 10 cubic centimeters (cc) by mouth three times a day for oral cavity. Review of a Dental Clinic Visit note dated 4/14/2023, showed Resident #11 had been seen and treated multiple times for .multiple root tips and fractured teeth that are broken below the bone . Review of Resident #11's comprehensive care plan dated 4/27/2023, showed .ADL [Activities of Daily Living] self-care performance deficit related to Paraplegia . Further review showed the facility had not developed a care plan for Resident #11 related to dental concerns. Review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact and required supervision with eating. During an interview on 8/28/2023 at 11:47 AM, Resident #11 stated he had several dental issues and had been seen by the contract dentist at the facility multiple times to have teeth pulled. During an interview on 8/28/2023 at 11:50AM, Certified Nursing Assistant (CNA) #1 stated Resident #11 had dental issues and had mouth wash ordered. During an interview on 8/29/2023 at 10:02 AM, the Director of Medical Records stated Resident #11 had dental issues and had been treated multiple times by the contract dentist at the facility. Resident #13 was admitted to the facility on [DATE] with diagnoses to include Dementia, Psychotic Disturbance, Mood Disturbance, and Major Depressive Disorder. Review of Resident #13's comprehensive care plan initiated 7/18/2023, showed the facility had not developed a care plan related to the use of side rails. During an observation on 8/28/2023 at 1:15 PM, showed Resident #13 had bed rails in use. During an observation on 8/31/2023 at 10:20 AM, showed Resident #13 had bed rails in use. Resident #14 was admitted to the facility on [DATE] with diagnoses to include Hypertensive Urgency, Severe Intellectual Disabilities, Impulse Disorder, and Cognitive Communication Deficit. Review of Resident #14's comprehensive care plan initiated 7/18/2023, showed the facility had not developed a care plan related to the use of side rails. During an observation on 8/28/2023 at 1:30 PM, showed Resident #14 had bed rails in use. During an observation on 8/31/2023 at 10:43 AM, showed Resident #14 had bed rails in use. Resident #38 was admitted to the facility on [DATE] with diagnoses to include Wedge Compression Fracture Vertebra, Paraplegia, Atrial Fibrillation, Mood Disorder, and Congestive Heart Failure (CHF). Review of Resident #38's admission MDS assessment dated [DATE], showed the resident was cognitively intact, received anti-psychotic and anti-depressant medications. Review of the comprehensive care plan dated 8/12/2023, showed the resident was on antidepressant and psychotropic medications related to mood disorder. Interventions placed were to observe, document, and report any adverse side effects of the medications. Further review showed an intervention to observe and record occurrence of target behavior symptoms and document. Review of Resident #38's current Physician Orders for 8/2023 showed the resident had orders for Duloxetine (a medication used to treat depression/mood disorders), and Invega (a psychotropic medication used to treat mood disorders). Review of Resident #38's Medication Administration Record (MAR) for 8/2023, showed psychotropic medication side effects and behavior monitoring had not been placed on the MAR. During an interview on 8/30/2023 at 1:45 PM, the IDON/RNC stated the facility documented psychotropic medication side effects and behavior monitoring on the MAR. The IDON/RNC confirmed the facility failed to follow the care plan related to Resident #38's behavior monitoring and side effects of antidepressant and psychotropic medications. Resident #27 was admitted to the facility on [DATE] with diagnoses to include Encephalopathy, Dementia, Dysphagia, and Muscle weakness. Review of a quarterly MDS assessment dated [DATE], showed Resident #27 had severe cognitive impairment, required extensive assistance of 2 staff for toileting and transfers, and the resident had 1 fall since the previous assessment with no injury. Review of Resident 27's comprehensive care plan dated 7/15/2022, showed . I have had multiple FALLS .Attempt to keep Resident in sight of staff if in wheel chair as resident allows .Resident is not to have any loose items or blankets while in the WC .12/26/2022 .Resident cannot be in her room [unsupervised] while in WC [wheelchair] .1/26/2022 . During an observation and interview on 8/29/2023 at 3:42 PM, Resident #27 was observed in her room, up in a wheelchair and out of sight of supervision. IDON/RNC confirmed the facility failed to follow the fall interventions on the care plan for Resident #27 which included up in wheelchair out of sight of supervision. During an interview on 8/29/2023 at 4:00 PM, CNA #1 and LPN #3 were unable to verbalize or identify all fall interventions for Resident #27. Continued interview showed CNA #1 and LPN #3 were unable to locate the resident's fall interventions in the resident's medical record. CNA #1 and LPN #3 stated they were not aware Resident #27 was not to be in her room while up in the wheelchair unsupervised. During an interview and observation on 8/30/2023 at 7:40 AM,showed Resident #27 was up in wheelchair unsupervised with a blanket in her lap. CNA #4 confirmed Resident #27 was up in a wheelchair with a blanket over her lap and was unsupervised. The CNA stated she was not aware the resident was not to be left unsupervised in the room in a wheelchair and have loose items or blankets over her lap. During an interview on 8/30/2023 at 7:57 AM, LPN #1 confirmed Resident #27 was seated in a wheelchair with a blanket over her lap in the residents room, unsupervised. During an interview on 8/31/2023 at 6:02 PM, the IDON/RNC confirmed the facility failed to develop a comprehensive care plan related to dental concerns for Resident #11, and side rails for Residents #13 and #14. She also confirmed the facility failed to implement the comprehensive care plan related to related to identifying and documenting behaviors and side effects of psychotropic medications for Resident #38. The IDON/RNC confirmed the facility failed to implement the comprehensive care plan related to falls for Resident #27.

Based on medical record review, observations, and interview, the facility failed to follow a physician's order for 1 resident (Resident #10) to obtain a Prothrombin Time/International Normalized Ratio (PT/INR-blood test which shows how how long it takes for your blood to clot) of 2 residents reviewed for PT/INR, failed to obtain a Physician's Order for pressure ulcer wound care for 1 resident (Resident #10) of 1 resident reviewed for wounds, and failed to obtain a Physician's Order for side rails for 5 residents (Resident #8, #11, #13, #14, and #30) of 19 residents reviewed for side/bed rails. The findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses to include Cerebrovascular Disease, Type 2 Diabetes, Atrial Fibrillation, and Long-Term Use of Insulin. Review of a Physician's Order dated 8/22/2023, showed .Draw INR [PT/INR] on 08/29/2023 . Review of Resident #10's laboratory (lab) results showed a PT/INR result had not been obtained on 8/29/2023 as ordered. During an interview on 8/30/2023 at 10:24 AM, Licensed Practical Nurse (LPN) #1 stated she was the nurse who obtained the Physician Order on 8/22/2023 for Resident #10's PT/INR to be collected on 8/29/2023. It was the nurse's responsibility who obtained the Physician Order to place the ordered lab in the computer and the laboratory personnel would come to the facility to obtain the PT/INR. LPN #1 also stated she had placed the lab in the computer .I'm not sure what happened but I follow protocol . LPN #1 confirmed Resident #10's PT/INR had not been obtained as ordered by the Physician on 8/29/2023. Review of a health status note dated 8/10/2023 by the previous Director of Nursing (DON), showed .[Resident #10] with 5cm [centimeter] x 7cm pressure ulcer to coccyx with skin rolling up and 4 small areas are open. Cleansed and applied dressing .Dtr [Daughter] .present and is aware of area . Review of current Physician Orders for 8/2023, showed Resident #10 did not have an order to treat the pressure ulcer coccyx wound. Review of a health status note dated 8/11/2023 by LPN #1, showed .Treatment [non specific] to coccyx done. Resident placed on left side .pressure off of coccyx . During an observation and interview on 8/30/2023 at 3:05 PM, Certified Nursing Assistant (CNA) #1 stated Resident #10 had an open wound (pressure ulcer) to the coccyx, but the wound was currently closed. Observation of the resident's coccyx area showed no open wounds and CNA #1 applied a protective barrier after incontinence care had been provided. During an interview on 8/30/2023 at 3:55 PM, LPN #1 (regular nurse for Resident #10) stated the resident had an open wound (pressure ulcer) to the coccyx, and the wound was currently closed (unsure of the date wound was healed). The wound was identified on 8/10/2023, the previous DON who no longer worked at the facility initiated a wound treatment. LPN #1 confirmed she had performed wound care (was non specific on type of wound care) daily when she was on duty to Resident #10's coccyx wound. LPN #1 stated she did not recall the exact wound care provide except for cleansing the wound and applying a dry dressing daily. LPN #1 confirmed she had not observed a physicians order for the pressure ulcer wound care and confirmed she had performed the wound care under the direction of the previous DON. Resident #8 was admitted to the facility on [DATE] with diagnoses to include Hemiplegia and Hemiparesis, Aphasia, Dysphagia, Dementia, Psychosis, and Major Depressive Disorder. Review of Resident #8's current Physician Orders for 8/2023, showed no order for side rails. During an observation on 8/28/2023 at 1:00 PM, showed Resident #8 had bed rails in use with no obvious visible gaps. During an observation on 8/31/2023 at 10:00 AM, showed Resident #8 had bed rails in use with no obbious visible gaps. Resident #11 was admitted to the facility on [DATE] with diagnoses to include Paraplegia, Chronic Pain Syndrome, Morbid Obesity, and Major Depressive Disorder. Review of Resident #11's current Physician Orders for 8/2023, showed no order for side rails. During an observation on 8/28/2023 at 12:50 PM, showed Resident #11 had bed rails in use with no obvious visible gaps. During an observation on 8/31/2023 at 10:10 AM, showed Resident #11 had bed rails in use with no obvious visible gaps. Resident #13 was admitted to the facility on [DATE], with diagnoses to include Dementia, Psychotic Disturbance, Mood Disturbance, and Major Depressive Disorder. Review of Resident #13's current Physician Orders for 8/2023, showed no order for side rails. During an observation on 8/28/2023 at 1:15 PM, showed Resident #13 had bed rails in use with no obvious visible gaps. During an observation on 8/31/2023 at 10:20 AM, showed Resident #13 had bed rails in use with no obvious visible gaps. Resident #14 was admitted to the facility on [DATE] with diagnoses to include Hypertensive Urgency, Severe Intellectual Disabilities, Impulse Disorder, and Cognitive Communication Deficit. Review of Resident #14's current Physician Orders for 8/2023, showed no order for side rails. During an observation on 8/28/2023 at 1:30 PM, showed Resident #14 had bed rails in use with no obvious visible gaps. During an observation on 8/31/2023 at 10:43 AM, showed Resident #14 had bed rails in use with no obvious visible gaps. Resident #30 was admitted to the facility on [DATE] with diagnoses to include Congestive Heart Failure (CHF), Morbid Obesity, Chronic Pain Syndrome, and Obstructive and Reflux Uropathy. Review of Resident #30's current Physician Orders for 8/2023, showed no order for side rails. During an observation on 8/28/2023 at 11:16 AM, showed Resident #30 had bed rails in use with no obvious visible gaps. During an observation on 8/31/2023 at 1:27 PM, showed Resident #30 had bed rails in use with no obvious visible gaps. During an interview on 8/30/2023 at 4:10 PM, the Interim (temporary) Director of Nursing (IDON)/Regional Nurse Consultant (RNC) confirmed the facility did not have a physician's order to treat Resident #10's wound when it had been identified on 8/10/2023. During a telephone interview on 8/31/2023 at 2:03 PM, the Medical Director stated he was aware Resident #10 had an open area to the coccyx. He was not aware the facility had treated the wound without a physician's order, and he would expect the facility to obtain an order to treat the wound. During an interview on 8/31/2023 at 5:50 PM, the IDON/RNC confirmed the facility failed to obtain a PT/INR as ordered by the physician on 8/29/2023, failed to obtain a physician order related to wound care for Resident #10, and failed to obtain a physician order for side rails for Residents #8, #11, #13, #14, and #30.

Based on facility policy review, review of manufacturer guidelines, medical record review, observation, and interview, the facility failed to complete side (bed) rail assessments, failed to accurately assess all bed frames, mattresses, and bed rails for the risk of entrapment for 18 residents (Residents #8, #10, #11, #12, #13, #14, #18, #19, #20, #21, #22, #27, #30, #31, #32, #37, #38, and #39) and failed to obtain consents for side rails for 5 residents (Residents #8, #13, #14, #20, and #21) of 19 residents reviewed for side rails. The findings include: Review of the facility policy titled, Bed Rails, dated 5/10/2017, showed .Before using a side rail for any reason, the staff shall inform the resident and or family/responsible party .A side rail assessment screen is completed on each resident upon admission, quarterly, and as needed .The assessment and documentation .includes .measuring the gaps between the rail(s) themselves and the gaps between the bed-rail and the mattress . Review of the Medline Operation and Maintenance Manual revised 1/9/2017, showed .REDUCING THE RISK OF ENTRAPMENT .Medline side rails .meet the dimensional requirements .Key zones of the bed .Dimensions .Gaps within the rail (Zone 1) < [less than] .[4 3/4 [inch]) .Under the rail, between rail supports or next to a single rail support .(Zone 2) .< (4 3/4) .Between rail and mattress .(Zone 3) .< (4 3/4) .Under the rail, at the ends of the rail . (Zone 4) .(< 2 3/8) AND >60 [degree] angle .Zone 1 .entrapment within rail .Zone 2 .Entrapment between top of compressed mattress to bottom of rail, between rail and supports .Zone 3 .Entrapment in horizontal space between rail and mattress .Zone 4 .Entrapment between top of compressed mattress and bottom of rail at end of rail . Resident #8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Hemiplegia and Hemiparesis, Speech and Language Deficits, Dementia, Pseudobulbar Affect, Psychosis, Major Depressive Disorder, and Anxiety Disorder. Review of Resident #8's medical record showed no current documentation of a Bed Safety Action Grid form (side rail assessment to show measurements for entrapment risk) had been completed. Continued review showed a SAFETY DEVICE EVALUATION, dated 11/18/2007, showed no measurements were obtained prior to the bed rail placement to assess for the resident's entrapment risk. Continued review showed no consent for the use of side rails had been obtained. Further review showed the resident did not have a fall potential documented for the previous 90 days or had a history of falls. The evaluation showed the interventions attempted prior to the bed rail in 2007 was increased supervision (nonspecific) and a Physical Therapy/Occupational Therapy referral. Review of the bed rail quarterly Evaluation Bundle dated 6/21/2023, showed Resident #8 had expressed a desire and had requested the use of bed rails to aid positioning, safety, and mobility, was able to get out of bed safely, did not have a history of falls, and was cognitively intact. During an observation on 8/28/2023 at 1:00 PM, showed Resident #8 had 1/2 bed rails x (times) 2 in use with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 10:00 AM, showed Resident #8 had 1/2 bed rails x 2 in use with no obvious visible gaps between the mattress and the bed rails. Resident #10 was admitted to the facility on [DATE] with diagnoses to include Cerebrovascular Disease, Type 2 Diabetes, Atrial Fibrillation, and Long-Term Use of Insulin. Review of Resident #10's Bed Safety Action Grid form dated 3/27/2019, showed the form had not been completed and the measurements had been omitted. Medical record review showed no alternative device attempted for Resident #10 prior to the installation of the bed rails. Review of the bed rail quarterly Evaluation Bundle dated 8/12/2023, showed Resident #10 had expressed a desire and had requested the use of bed rails, did not have a history of falls, had left side weakness, was able to get out of bed safely, and was cognitively intact. During an observation on 8/28/2023 at 12:00 PM, showed Resident #10 had 1/2 bed rails x 2 in use with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 10:32 AM, showed Resident #10 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. Resident #11 was admitted to the facility on [DATE] with diagnoses to include Contracture of muscle left and right lower leg, Chronic Pain Syndrome, and Arthritis Right Knee. Review of a bed rail quarterly Bundle Evaluation dated 8/10/2023, showed Resident #11 had expressed a desire and had requested the use of bed rails to promote independence, and to aid positioning, safety, and mobility. The resident was able to get out of bed safely, did not have a history of falls, and was cognitively intact. During an observation on 8/28/2023 at 12:50 PM, showed Resident #11 had 1/8 bed rails (also known as grab bars) x 2 in use, in the up position, with no obvious visible gaps between the mattress and side rails. During an observation on 8/31/2023 at 10:10 AM, showed Resident #11 had 1/8 bed rails (also known as grab bars) x 2 in use, in the up position, with no obvious visible gaps between the mattress and side rails. Medical record review showed no documentation a Bed Safety Action Grid form for Resident #11 had been completed prior to the placement of the bed rails. Continued review showed no alternative device attempted prior to the installation of the bed rails. Resident #12 was admitted to the facility on [DATE] with diagnoses to include Hypertension, Chronic Kidney Disease, Localized Edema, and Anxiety Disorder. Review of Resident #12's medical record showed no documentation of a Bed Safety Action Grid form. Continued review showed no alternative device attempted prior to the installation of the bed rails. Review of a bed rail quarterly Evaluation Bundle dated 8/21/2023, showed Resident #12's family had expressed a desire and had requested the use of bed rails due to poor balance or trunk control. The resident was unable to get out of bed, did not have a history of falls, and had severe cognitive impairment. During an observation on 8/28/2023 at 1:05 PM, showed Resident #12 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 10:05 AM, showed Resident #12 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. Resident #13 was admitted to the facility on [DATE] with diagnoses to include Dementia, Psychotic Disturbance, Mood Disturbance, and Major Depressive Disorder. Review of Resident #13's Bed Safety Action Grid dated 7/14/2023, showed the form had not been completed and the measurements were omitted. Further review showed no consent was obtained for the use of side rails with no obvious visible gaps between the mattress and the bed rails. Review of the bed rail quarterly Evaluation Bundle dated 7/15/2023 for Resident #13, showed the bed rails were used for positioning, safety, and mobility. The resident was able to get out of bed, there was no possibility for the resident to climb over the bed rails, and the resident had requested use of the bed rails. Continued review showed no alternative device was attempted prior to the installation of the bed rails. During an observation on 8/28/2023 at 1:15 PM, showed Resident #13 had 1/4 bed rails x 2 in use with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 10:20 AM, showed Resident #13 had 1/4 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. Resident #14 was admitted to the facility on [DATE] with diagnoses to include Hypertensive Urgency, Severe Intellectual Disabilities, Impulse Disorder, and Cognitive Communication Deficit. Review of Resident #14's medical record showed no documentation of a Bed Safety Action Grid and a consent for bed rails had not been obtained. Further review showed no alternative device was attempted prior to the installation of the bed rails. Review of the bed rail quarterly Evaluation Bundle dated 8/2/2023, showed Resident #14 had expressed a desire and had requested the use of bed rails to aid positioning, safety, and mobility, was able to get out of bed safely, did not have a history of falls, and had severe cognitive impairment. During an observation on 8/28/2023 at 1:30 PM, showed Resident #14 had 1/4 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 10:43 AM, showed Resident #14 had 1/4 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. Resident #18 was admitted to the facility on [DATE] with diagnosis to include Chronic Obstructive Pulmonary Disease, Dementia, Psychotic Disturbance, Mood Disturbance, Anxiety, and Major Depressive Disorder. Review of Resident #18's medical record showed the Bed Safety Action Grid form dated 12/28/2020 had not been completed and the measurements had been omitted. Continued review showed an alternative device had not been attempted prior to the installation of the bed rails. Review of the bed rail quarterly Evaluation Bundle dated 7/18/2023, showed Resident #18 had expressed a desire and requested the use of bed rails for positioning, safety, and mobility, was able to get out of bed safely, did not have a history of falls, and had severe cognitive impairment (the quarterly MDS dated [DATE], showed the BIMS was unable to conducted due to severe cognitive impairment). During an observation on 8/28/2023 at 12:55 PM, showed Resident #18 had 1/4 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 10:15 AM, showed Resident #18 had 1/4 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. Resident #19 was admitted to the facility on [DATE] with diagnosis to include Chronic Respiratory Failure with Hypoxia, Cellulitis of Left and Right Lower Limb, and Muscle Weakness. Review of Resident #19's medical record showed the Bed Safety Action Grid form, undated, had not been completed and the measurements had been omitted. Review of the bed rail quarterly Evaluation Bundle dated 6/23/2023, for Resident #19, showed the resident had expressed a desire for the use of bed rails, the resident was able to get out of bed safely, and did not have a history of falls. Continued review showed the bed rails aided the resident with positioning or support. Further review showed no alternative device had been attempted prior to the installation of the bed rails. During an observation on 8/28/2023 at 12:57 PM, showed Resident #19 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 10:35 AM, showed Resident #19 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. Resident #20 was admitted to the facility on [DATE] with diagnoses to include Encephalopathy, Dementia, Adult Failure to Thrive, Type 2 Diabetes, Protein Calorie Malnutrition, and Contractures of the Left and Right Knee. Review of Resident #20's medical record showed no documentation of a Bed Safety Action Grid Form and a signed consent had not been obtained. Review of the bed rail quarterly Evaluation Bundle dated 7/11/2023 showed the resident did not have a cognitive deficit (the Brief Interview for Mental Status (BIMS) score dated 7/11/2023 showed Resident #20 scored a 3 which indicated the resident had severe cognitive impairment). The form showed the resident was able to get out of bed and used the bed rails for positioning or support (MDS dated [DATE], showed the resident had lower extremity impairment of both limbs, the activities of standing from a seated position was not applicable, and walking had not occurred). Continued review showed an alternative device had not been attempted prior to the installation of the bed rails. During an observation on 8/28/2023 at 1:19 PM, showed Resident #20 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 11:22 AM, showed Resident #20 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. Resident #21 was admitted to the facility on [DATE] with diagnoses to include Dementia, Encephalopathy, Anxiety Disorder, Major Depressive Disorder, Muscle Weakness, and Cerebral Infarction. Review of Resident #21's medical record showed no documentation of a Bed Safety Action Grid form and a signed consent had not been obtained. Review of the bed rail quarterly Evaluation Bundle dated 3/16/2023, for Resident #21 showed the resident expressed a desire for the use of bed rails (the assessment showed Resident #21 scored a 0 on the BIMS which indicated severe cognitive impairment), the resident was unable to get out of bed without assistance, used the bed rails for positioning or support, and the resident did not have the ability to climb over the bed rails. Continued review showed an alternative device had not been documented prior to the installation of the bed rails. During an observation on 8/28/2023 at 1:22 PM, showed Resident #21 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. Continued observation showed the resident used a concave mattress for positioning. During an observation on 8/31/2023 at 11:25 AM, showed Resident #21 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. Continued observation showed the resident used a concave mattress for positioning. Resident #22 was admitted to the facility on [DATE] with diagnoses to include Major Depressive Disorder, Dementia, Hemiplegia, and Atrial Fibrillation. Review of Resident #22's medical record showed the Bed Safety Action Grid form dated 6/10/2021 had not been completed and the measurements had been omitted. Continued review showed an alternative device had not been attempted prior to installation of the bed rails. Review of the bed rail quarterly Evaluation Bundle dated 7/3/2023, showed Resident #22 expressed a desire and had requested the use of bed rails to aid positioning, safety, and mobility, the resident was able to get out of bed safely, had right sided weakness, and was cognitively intact. During an observation on 8/28/2023 at 1:43 PM, showed Resident #22 had 1/2 bed rails x2 in use, in the upright position, with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 11:25 AM, showed Resident #22 had 1/2 bed rails x 2 in use, in the upright position, with no obvious visible gaps between the mattress and the bed rails. Resident #27 was admitted to the facility on [DATE] with diagnoses to include Encephalopathy, Dementia, Dysphagia, and Muscle Weakness. Review of Resident #27's medical record showed no documentation of a Bed Safety Action Grid. Review of a bed rail quarterly Evaluation Bundle dated 6/8/2023 showed Resident #27 had expressed a desire for the use of bed rails for positioning, safety, and mobility (the quarterly MDS assessment dated [DATE], showed the resident scored a 3 on the BIMS which indicated the resident had severe cognitive impairment and required 2 staff extensive assistance for bed mobility). The Evaluation Bundle showed the resident scored a 0 on the BIMS assessment), was able to get out of bed safely, and did not have a history of falls, (the resident was not ambulatory (and had a fall on 6/5/2023). During an observation on 8/28/2023 at 1:29 PM, showed Resident #27 had 1/2 bed rails in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 11:50 AM, showed Resident #27 had 1/2 bed rails in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. Resident #30 was admitted to the facility on [DATE] with diagnoses to include Chronic Diastolic Congestive Heart Failure, Permanent Atrial Fibrillation, Morbid Obesity, and Angina. Review of Resident #30's medical record showed the Bed Safety Action Grid form dated 3/18/2023 had not been completed and the measurements were omitted. Review of a bed rail quarterly Evaluation Bundle dated 5/8/2023, showed Resident #30 had expressed a desire for the use of bed rails to aid positioning, safety, and mobility. The assessment showed the resident was able to get out of bed safely, did not have a history of falls, was cognitively intact, and used the bed rails as an enable to promote independence. During an observation on 8/28/2023 at 11:16 AM, showed Resident #30 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 1:27 PM, showed Resident #30 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. Resident #31 was admitted to the facility on [DATE] with diagnoses to include Dementia, Anxiety Disorder, and Need for Assistance with Personal Care. Review of Resident #31's medical record showed the Bed Safety Action Grid form dated 4/24/2020 had not been completed and the measurements were omitted. Review of a bed rail quarterly Evaluation Bundle dated 3/27/2023, showed Resident #31 had expressed a desire for bed rails to aid positioning and bed mobility, had requested the bed rails, the resident was able to get out of bed safely, and had a history of falls. The assessment showed the resident scored a 0 on the BIMS which indicated the resident had severe cognitive impairment. Review of a bed rail quarterly Evaluation Bundle dated 6/22/2023, showed Resident #31 had a cognitive deficit, was able to get out of bed safely, had a history of falls, did not have a problem with balance or trunk control, did not have the possibility of climbing over the side rails, and the resident had not requested the use of bed rails. Continued review showed .Type of rail in use .none . During an observation on 8/28/2023 at 2:00 PM, showed Resident #31 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 12:35 PM, showed Resident #31 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. Resident #32 was admitted to the facility on [DATE] with diagnoses to include Cerebral Infarction, Hemiplegia, Heart Failure, and Vascular Dementia. Review of Resident #32's medical record showed the Bed Safety Action Grid form dated 5/18/2021 had not been completed and the measurements were omitted. Review of a Side Rail Evaluation dated 7/18/2023, showed Resident #32 had expressed a desire and had requested the use of bed rails to aid positioning and support, did not have a history of falls, was able to get out of bed safely, and was cognitively intact. During an observation on 8/28/2023 at 11:46 AM, showed Resident #32 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 1:32 PM, showed Resident #32 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an interview on 9/20/2023 at 1:20 PM, Resident #32 stated he did not have any concerns with the bed rails and used at night for positioning. Resident #37 was admitted to the facility on [DATE] with diagnoses to include Post Traumatic Stress Disorder, Psychotic Disorder with Hallucinations, and Chronic Pain Syndrome. Review of Resident #37's medical record showed the Bed Safety Action Grid form dated 4/5/2023 had not been completed and the measurements were omitted. Review of a bed rail quarterly Evaluation Bundle dated 7/13/2023, showed Resident #37 had expressed a desire and requested the use of bed rails to aid in positioning, safety, and mobility, was able to get out of bed safely, had a history of falls, and had moderate cognitive impairment. During an observation on 8/28/2023 at 2:06 PM, showed Resident #37 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 12:37 PM, showed Resident #37 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. Resident #38 was admitted to the facility on [DATE] with diagnoses to include Wedge Compression Fracture of Vertebra, Paraplegia, Atrial Fibrillation, Mood Disorder, and Congestive Heart failure. Review of Resident #38's medical record showed no documentation of a Bed Safety Action Grid form. Review of a bed rail quarterly Evaluation Bundle dated 8/2/2023, showed Resident #38 expressed a desire and had requested the use of bed rails for positioning and safety. The resident had a history of falls, was able to get out of bed safely and was cognitively intact. During an observation on 8/28/2023 at 1:46 PM, showed Resident #38 had 1/4 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 11:36 AM, showed Resident #38 had 1/4 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an observation and interview on 9/20/2023 at 12:39 PM, Resident #38 was seated in bed with 1/4 bed rail x 1 in the up position. Resident #38 was alert and oriented and had no concerns related to the beds. Resident #38 stated she used bed rails x 2 at night and 1 during day and she used the rails for positioning. Resident #39 was admitted to the facility on [DATE] with diagnosis to include Cerebral Infarction, Essential Hypertension, Muscle Weakness, and Paralytic Gait. Review of Resident #39's medical record showed a Bed Safety Action Grid form 3/4/2022 had not been completed and the measurements were omitted. Review of a bed rail quarterly Evaluation Bundle dated 7/25/2023, showed Resident #39 had expressed a desire and requested the use of bed rails to aid in positioning, safety, and mobility, was able to get out of bed safely, had right side weakness, did not have the possibility of climbing over the rails ,was cognitively intact, and the bed rails were used as an enable to promote independence. During an observation on 8/28/2023 at 2:10 PM, showed Resident #39 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an observation on 8/31/2023 at 12:38 PM, showed Resident #39 had 1/2 bed rails x 2 in use, in the up position, with no obvious visible gaps between the mattress and the bed rails. During an interview on 8/29/2023 at 2:15 PM, the Maintenance Director stated the facility had not informed him to assess side rails/mattresses before the side rails were placed on the residents' beds and confirmed he had not performed regular side rail assessments to include measuring or observing for visible gaps between the mattresses and side rails for any of the side rails in use. During an interview on 8/31/2023 at 6:30 PM, the Interim Director of Nursing/Regional Nurse Consultant confirmed the side rail assessments had not been completed and/or obtained including measuring for the risk of entrapment for Residents #8, #10, #11, #12,#13, #14, #18, #19, #20, #21, #22, #27, #30, #31, #32, #37, #38, and #39, and the side rail consents had not been obtained for Residents #8, #13, #14, #20, and #21. Continued interview confirmed the side rail assessments did not include alternative devices used prior to the application of the side (bed).

Based on facility policy review, medical record review, and interview, the facility failed to maintain an accurate medical record as evidenced by failure to ensure the Advance Directive Acknowledgement Form had been completed for 5 residents (Resident #18, #20, #22, #32, and #38) and failed to complete an accurate side (bed) rail assessment for 2 residents (Resident #20 and #27) of 19 residents reviewed and failed to fully complete fall investigations for 2 residents (Resident #21 and #27) of 3 residents reviewed for falls. The findings include: Review of the facility policy titled, Bed Rails, dated 5/10/2017, showed .Before using a side rail for any reason, the staff shall inform the resident and or family/responsible party .A side rail assessment screen is completed on each resident upon admission, quarterly, and as needed .The assessment and documentation .includes .measuring the gaps between the rail(s) themselves and the gaps between the bed-rail and the mattress . Review of the facility policy titled, Advance Directives, last reviewed 11/2022, showed .The resident has the right to formulate an advance directive .The resident or representative is provided with .information concerning the right .to formulate an advance directive .Written information .to formulate an advance directive is provided in a manner that is easily understood . Resident #18 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease, Dementia, Anxiety, and Major Depressive Disorder. Review of an Advance Directive Acknowledgement Form for Resident #18 dated 12/28/2020, showed the section .I have received the information on Advance Directives . of the form was left blank. The section .I have received this facility's written policy's respecting the implementation of my rights under the Patient's Self Determination Act of 1990, and the Tennessee State Law . was left blank. The section of the form which stated an Advance Directive had been .executed in Tennessee . was left blank. In addition, the form had been signed by the resident's responsible party and the section which stated .If residet is unable to sign, state the reason . was left blank. Resident #20 was admitted to the facility on [DATE] with diagnoses to include Dementia, Type 2 Diabetes, Major Depressive Disorder, and Anxiety Disorder. Review of an Advance Directive Acknowledgement Form for Resident #20 dated 4/20/2021, showed the section .I have received the information on Advance Directives . of the form was left blank. The section .I have received this facility's written policy's respecting the implementation of my rights under the Patient's Self Determination Act of 1990, and the Tennessee State Law . was left blank. The section of the form which stated an Advance Directive had been .executed in Tennessee . was left blank. In addition, the form had been signed by the resident's responsible party and the section which stated .If residet is unable to sign, state the reason . was left blank. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #20's cognitive skills for daily decision making was severely impaired. Review of a Bed Rail Evaluation for Resident #20 dated 7/30/2023, showed the resident did not have a cognitive deficit, and showed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The form was inaccurate due to the MDS assessment showed the resident was severly impaired. Resident #21 was admitted on [DATE] with diagnoses to include Dementia with Behavioral Disturbance, Anxiety Disorder, Pseudobulbar Affect, and Major Depressive Disorder. Review of a Fall Investigation form for Resident #21 dated 5/14/2023, showed the form had not been signed by Licensed Practical Nurse (LPN) #3 until 8/23/2023 (105 days after the incident) and the Supervisor signature had been omitted. Review of a Fall Investigation form for Resident #21 dated 8/11/2023, showed the form had not been signed by LPN #1 until 8/20/2023 (9 days after the incident) and the Supervisor signature had not been documented. Resident #22 was admitted to the facility on [DATE] with diagnoses to include Major Depressive Disorder, Dementia, Hemiplegia, and Atrial Fibrillation. Review of an Advance Directive Acknowledgement Form for Resident #22 dated 6/9/2021, showed the section .I have received the information on Advance Directives . of the form was left blank. The section .I have received this facility's written policy's respecting the implementation of my rights under the Patient's Self Determination Act of 1990, and the Tennessee State Law . was left blank. The section of the form which stated an Advance Directive had been .executed in Tennessee . was left blank. In addition, the form had been signed by the resident's responsible party and the section which stated .If residet is unable to sign, state the reason . was left blank. Resident #27 was admitted to the facility on [DATE] with diagnoses to include Dementia with Behavioral Disturbance, Insomnia, Pulmonary Fibrosis, and History of Falling. Review of a Fall Investigation form for Resident #27 dated 6/5/2023, showed the form had not been signed by LPN #1 until 8/23/2023 (83 days after the incident) and the Supervisor signature had been omitted. Review of a quarterly MDS assessment dated [DATE], showed Resident #27's cognitive skills for daily decision making was severely impaired. Review of a Bed Rail Evaluation for Resident #27 dated 6/8/2023, showed the resident did not have a cognitive deficit (Resident #27's BIMS score was 0, which indicated the resident had severe cognitive impairment). Further review showed the resident did not have a history of falls (the resident had a fall on 6/5/2023). The form was inaccurate due to the MDS assessment showed the resident was severly impaired and the Bed Rail Evaluation showed no falls. Resident #32 was admitted to the facility on [DATE] with diagnoses to include Vascular Dementia, Cerebral Infarction, and Major Depressive Disorder. Review of an Advance Directive Acknowledgement Form for Resident #32 dated 5/18/2021, showed the section .I have received the information on Advance Directives . of the form was left blank. The section .I have received this facility's written policy's respecting the implementation of my rights under the Patient's Self Determination Act of 1990, and the Tennessee State Law . was left blank. The section of the form which stated an Advance Directive had been .executed in Tennessee . was left blank. In addition, the form had been signed by Resident #32 but was incomplete. Resident #38 was admitted to the facility on [DATE] with diagnoses to include Wedge Compression Fracture of Vertebra, Paraplegia, Atrial Fibrillation, Mood Disorder, and Congestive Heart Failure. Review of an Advance Directive Acknowledgement Form for Resident #38 dated 8/2/2023, showed the section .I have received the information on Advance Directives . of the form was left blank. The section .I have received this facility's written policy's respecting the implementation of my rights under the Patient's Self Determination Act of 1990, and the Tennessee State Law . was left blank. The section of the form which stated an Advance Directive had been .executed in Tennessee . was left blank. In addition, the form had been signed by Resident #38 but was incomplete. During an interview on 8/30/2023 at 1:32 PM, the Social Worker confirmed Resident #18 and #32's Advance Directive Acknowledgement Form was incomplete. During an interview on 8/31/2023 at 6:30 PM, the Interim (temporary) Director of Nursing (IDON)/Regional Nurse Consultant/RNC confirmed Resident #20, #22, and #38's Advance Directive Acknowledgement Forms were incomplete, Resident #20 and #27's Bed Rail Evaluations were inaccurate or incomplete, and Resident #21 and #27's fall investigations were incomplete.

Based on facility policy review, observation, and interview, the facility failed to provide education to formulate an Advanced Directives for 1 resident (Resident #8) of 16 residents reviewed. The findings include: Review of the facility policy titled, Advanced Directives, dated 11/2022, showed .The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy .Advance Directive .a written instruction, such as a living will or durable power of attorney for healthcare, recognized by state law (whether statutory or as recognized by the courts of the state) .relating to the provisions of health care when the individual is incapacitated .The resident or representative is provided with written information concerning the right .to formulate an advance directive if he or she chooses to do so .If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative . Resident #8 was admitted to the facility on [DATE], with diagnoses to include, Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting Right Dominant Side, Aphasia, Dysphagia, Dementia, and Pseudobulbar Affect. Review of the medical record showed no evidence the resident or the resident representative had been provided information to formulate an advance directive. During an interview on 8/30/2023 at 10:51 AM, the Social Worker (SW) confirmed Resident #8 or the resident's representative had not been provided information to formulate an advance directive.

Based on facility policy review, medical record review, facility documentation, local law enforcement investigation, observation, and interview the facility failed to protect the resident's right to be free from physical abuse by Certified Nursing Assistant (CNA) #2 for 1 resident (Resident #39) of 3 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, updated 10/2022, showed .Residents have the right to be free from abuse .This includes but not limited to freedom from .mental .or physical abuse .Protect residents from abuse .by anyone including .facility staff .other residents . Resident #39 was admitted to the facility on [DATE], with diagnoses to include Cerebral Infarction, Hemiplegia, Unspecified affecting Right Dominant Side, Dementia with Behavioral Disturbance, Major Depressive Disorder, and Anxiety Disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident scored 14 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Further review showed the resident required extensive assistance of 2 staff members for bed mobility, toileting, dressing and transfers. Review of Resident #39's comprehensive care plan dated 7/24/2023, showed .I have a behavior problem cursing, yelling at staff, throwing urine in his room from his urinal, crying loudly [wished to go to Michigan to be with family], refusing to follow instructions even for safety .I will have no evidence of behavior problems .Anticipate and meet The resident's needs .Assist the resident to develop more appropriate methods of coping and interacting .Encourage the resident to express feelings appropriately .Intervene as necessary to protect the rights and safety of others .Approach/Speak in a calm manner .Divert attention . Review of the current electronic physicians' recapitulation orders for 8/2023, showed Resident #39 was prescribed the following: .Zoloft [antidepressant] Tablet 50 MG [milligram] Give 1 tablet by mouth one time a day for MDD [Major Depressive Disorder] .start date 7/23/2022 .Antipsychotic Behaviors Monitor for the following behaviors every shift .Physically combative .Continuous screaming/crying .Hallucination .Delusion .Depakote [mood stabilizer] Oral Tablet Delayed Release 250 MG Give 1 tablet by mouth at bedtime for mood .start date 6/8/2023 .Aricept [medication that aids in slowing symptoms of Dementia] Tablet 5 MG Give 2 tablet by mouth one time a day for dementia .start date 8/25/2023 . Review of facility documentation dated 8/22/2023 at 1:14 PM, showed .Nursing Description [of event]: Day shift Certified Nursing Assistant [CNA #1] .stated that during ADL [Activities of Daily Living] care this resident was verbally aggressive as evidence by calling her a f------b---- and slapped her hand away during care. The resident requires assistance of two for most ADL's. The other CNA [CNA #2] present during care grabbed the resident's arm and slapped his hand .Resident Description [of event]: Resident stated that during care he became upset/frustrated and slapped her hand away. [CNA #2] .grabbed his arm and slapped his hand and told him No. you don't do that . Further review showed the immediate action taken by the facility was CNA #2 was removed from all patient care areas and suspended pending investigation. Review of a typed statement written by the IDON/RNC dated 8/22/2023, showed .When asked to come to the .office to provide information regarding [Resident #39] hitting [CNA #1] .[CNA #2] tearfully stated .I slapped [Resident #39's] hand. [Resident #39] called [CNA #1] a F------ b---- and slapped her hand .I slapped his hand .[CNA #2] continued to cry . Review of a witness statement written by CNA #1 dated 8/23/2023, showed .I [CNA #1] and [CNA#2] went into [Resident #39's] room to do patient care, [Resident #39] wanted a pillow under his arm .[CNA #1] told him that it was already there .[Resident #39] called me [CNA #1] a F-----B---- .[Resident #39] slapped my [CNA #1] hand .[CNA #2] grabbed [Resident #39] hand and slap it . Review of a Social Service Director (SSD) progress note dated 8/23/2023, showed .met with resident .was asked if he had any concerns regarding his care or with the staff assisting with his care. The resident replied .no, I don't . Review of a Psychiatric follow up progress note dated 8/25/2023, showed Nurse Practitioner (NP) #1 documented .I was asked to see him [Resident #39] today regarding an incident where he had slapped a CNA and another CNA apparently was trying to intervene and slapped [Resident #39] hand back away from the other CNA .[Resident #39] said he was very angry at both CNA's because they were telling me what to do .He said he was sorry that he hit the other CNA [CNA #1] .He denies any distress or trauma related to being slapped on the hand .He denies any injury and said it did not hurt at all .He does say that the second CNA [CNA #2] was just trying to get him to put his hands down . During an interview on 8/28/2023 at 1:55 PM, showed Resident #39 stated he asked to have a pillow placed under his left arm, CNA #1 informed the resident a pillow was already under his arm, the resident became argumentative and swatted CNA #1's hand. The resident stated CNA #2 grabbed his hand and smacked it and said something to him (resident could not recall what was said). During an interview on 8/28/2023 at 3:00 PM, CNA #1 stated she and CNA #2 entered Resident #39's room to provide care, Resident #39 became argumentative and cursed at CNA #1 when asking for a pillow to be placed under his arm. CNA #1 confirmed Resident #39 hit her on the hand and CNA #2 grabbed the resident's wrist and smacked his hand. During an interview on 8/28/2023 at 3:15 PM, the IDON/RNC stated after she became aware of the physical contact between Resident #39 and CNA #2, she began an investigation. The IDON/RNC stated she suspended CNA #2 until the facility investigation had been completed. During a telephone interview on 8/29/2023 at 2:23 PM, the Psychiatric NP #1 stated she had a good rapport with Resident #39. Resident had a personal history of CVA (cerebral vascular accident-stroke) with Impulse Control Issues. NP #1 stated she visited Resident #39 on the Friday after the abuse allegation (8/25/2023). The NP also stated Resident #39 became emotional and tearful and had advised the Psychiatric NP #1 he was remorseful, and upset he had struck CNA #1. During an interview on 8/29/2023 at 2:55 PM, CNA #2 stated she had provided care for Resident #39 and had been a CNA for [AGE] years. CNA #2 stated she had completed education for Dementia Care, Abuse, and Neglect while at the facility. CNA #2 stated there had been physical contact from Resident #39 towards CNA #1 while they were providing care. CNA #2 stated Resident #39 became argumentative during care, he asked for a pillow to be placed under his arm. CNA #2 stated CNA #1 voiced to the resident that a pillow was already in place and pointed at the pillow under his arm. CNA #2 stated Resident #39 hit CNA #1 on the arm, CNA #2 stated she had grabbed Resident #39's wrist and slapped his hand, .I did it without thinking . CNA #2 stated she voiced to Resident #39 .You don't hit women . During an interview on 9/20/2023 at 12:44 PM, CNA #1 reported she and CNA #2 were rendering personal care to Resident #39 when the resident asked for pillow to be placed beneath his right arm which is paralyzed from a stroke. CNA #1 stated she advised Resident #39 a pillow was already in place, and before she could ask if he was uncomfortable, Resident #39 began to swear and slapped CNA #1 across the face on the right cheek with his left hand. CNA #1 stated the blow to the cheek was sufficient to knock her backward and leave a mark on the face. CNA #1 stated she moved out of the resident's range as her coworker, CNA #2 slapped the resident on his left hand and told him to stop hitting and said .you don't slap women . CNA #1 stated .it wasn't really a slap .it was really more like a tap, but it made a noise .CNA #1 stated Resident #39's arm was raising up to strike another blow to CNA #1 when his hand and CNA #2's hand struck which made a noise that sounded like a slap, but it was soft, not loud .[CNA #2] grabbed [Resident #39's] arm and stopped him from hitting me [CNA #1] again . CNA #1 stated she and CNA #2 ceased care and left the room to report the situation to the nurse. CNA #1 stated Resident #39 did not show signs of distress and did not acknowledge the fact he had been slapped by CNA #2. CNA #1 stated when CNA #2 tapped the resident's arm with open hand, she had pushed the resident's arm down gently and stated .you don't slap women . CNA #1 confirmed she and CNA #2 had left the room together and CNA #2 was not left in the room alone with Resident #39. CNA #1 stated Resident #39 continues to ask her to provide care, and she had explained to him why she can no longer care for him. During an observation and interview on 9/20/2023 at 3:01 PM, Resident #39 was seated in a wheelchair. Resident #39 stated he had resided at the facility for 2 years. Resident #39 stated he had slapped CNA #1 and regretted the interaction. Resident #39 stated he slapped the CNA and acted impulsively. The resident stated he felt safe in the facility and had no other concerns.

Based on facility policy review, observation, and interview, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 2 residents (Resident #11 and #30) of 11 residents reviewed for respiratory care. The findings include: Review of the facility policy titled, Oxygen Administration, dated 8/25/2014, showed .check the mask .to be sure they are in good working order and securely fastened .observe resident upon setup and periodically thereafter .used supplies into designated containers . Resident #11 was admitted to the facility on [DATE] with diagnoses to include Obstructive Sleep Apnea and Paraplegia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #11 was cognitively intact, and had an active diagnosis for Obstructive Sleep Apnea. Review of Resident #11's comprehensive care plan dated 4/27/2023, showed use of Continuous Positive Airway Pressure (CPAP) related to Obstructive Sleep Apnea. Review of Resident #11's current Physician's Orders dated 8/30/2023, showed CPAP at bedtime for Obstructive Sleep Apnea. During an observation on 8/28/2023 at 11:03 AM, Resident #11's CPAP facemask was hanging on the resident's bed rail, open to air. During an interview on 8/28/2023 at 12:05 PM, the Interim Director of Nursing (IDON)/ Regional Nurse Consultant (RNC) stated CPAP and Bilevel Positive Airway Pressure (BiPap) facemasks were to be dated and stored in a designated bag when not in use per facility protocol. During an interview on 8/28/2023 at 12:11 PM, in Resident #11's room, the Director of Nursing (DON) confirmed the CPAP mask was not stored in a sanitary manner and were to be stored in a designated storage bag. Resident #30 was admitted to the facility on [DATE] with diagnoses to include Chronic Diastolic Heart Failure and Obstructive Sleep Apnea. Review of a significant change MDS assessment dated [DATE], showed a BIMS score of 15, which indicated Resident #30 was cognitively intact, and had an active diagnosis for Obstructive Sleep Apnea. Review of Resident #30's comprehensive care plan revised 7/10/2023, showed oxygen therapy related to Obstructive Sleep Apnea .BiPAP with settings .while sleeping . Review of the current Physician's Orders dated 8/30/2023, for Resident #30 showed BiPAP with settings while sleeping for Obesity Hypoventilation Syndrome, Oxygen at 2 liters. During an observation on 8/28/2023 at 11:45 AM, Resident #30's BiPAP facemask was lying on the floor beside the bed. During an interview on 8/28/2023 at 12:12 PM, in Resident #30's room, the DON confirmed the BiPAP mask was not stored in a sanitary manner and was to be stored in the designated storage bag.

Based on review of facility policy, medical record review, review of the facility investigation, weather reports, satellite data, observations and interviews, the facility failed to maintain secure exits (functional door alarms or magnetic locking mechanisms) on 2 of 5 units (C Wing and East Wing) which resulted in the elopement of 1 resident, (Resident #1), an ambulatory, cognitively impaired resident with a history of wandering, of 5 residents reviewed for elopement risks. The facility's failure placed Resident #1 in Immediate Jeopardy (IJ, a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when on 5/8/2023 around 7:30 AM, Resident #1 exited the C Wing clinical unit via an alarmed door in which the alarm malfunctioned and did not sound and entered the unoccupied East Wing undetected to a delayed egress door whose magnetic locking mechanism malfunctioned, and exited to the outside of the building. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J, which is Substandard Quality of Care (SQC). The Director of Nursing (DON) and the Corporate Nurse were notified of the Immediate Jeopardy on 5/23/2023 at 1:19 PM in the conference room. The IJ was effective 5/8/2023. A corrective action plan was implemented and the IJ was removed on 5/9/2023. The corrective actions were validated onsite by the surveyor on 5/18/2023 to 5/23/2023. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction (POC). The findings included: Review of the facility policy Emergency Procedure, Missing Resident (undated) revealed .Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure safety . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Major Depression, Unspecified Hallucinations, Insomnia, Unspecified Anxiety Disorder, Pseudobulbar Affect, and Hypertension. Medical record review of an annual Minimum Data Set (MDS) dated [DATE] showed Resident #1 was ambulatory, severely cognitively impaired with altered thought processes, moderate signs of depression, impaired communication, and a history of wandering. Resident #1 was dependent upon one person for all activities of daily living (ADLs). Resident #1 was care planned as at risk for elopement due to wandering, impaired safety awareness and packing her suitcase on 5/1/2020 with interventions implemented. Review of the facility investigation dated 5/8/2023 showed Resident #1 was last seen wandering about in her customary fashion on the West Wing A hallway around 7:20 AM on 5/8/2023. Around 7:30 AM, Resident #1 was spotted outside the rear of the facility, by staff members who were located near an exit door in the centrally located dining room, adjacent to the centrally located nursing station. Staff members called for assistance as they immediately went outside, retrieved Resident #1, then escorted her back inside the building through the rear entrance of the dining hall, where she was then escorted to her room and assessed by the attending nurse, as an investigation was launched. Review of the facility staffing data, cross referenced against the time sheets and punch reports, showed at the time of Resident #1's elopement, 2 Certified Nurse Assistants (CNAs) and 3 Licensed Nurses were on duty, assigned to care for 39 residents. Review of National Weather Service (NWS) online data compiled by the weather underground online database (www.weatherchannel.com) showed at the time of the elopement, weather conditions in the facility's area were as follows: Temperature, 62 degrees Fahrenheit, with 6 mile per hour (MPH) winds from the south, scattered clouds, with scattered light rain. Review of satellite imaging of the facility and surrounding terrain, cross referenced to its physical address and Global Positioning System (GPS) Coordinates as compiled from Google Earth (www.googleearth.com) showed the facility was situated between Highway 382 ( a heavily traveled 2 lane state highway) to the west and Watts Bar Lake (a large Tennessee Valley Authority managed reservoir) located between 583 and 630 feet to the east, behind the building. The facility was bordered by a small condominium complex situated approximately 166 feet east to the rear of the facility, between the facility property and the lake. The area beyond the condominium complex was bordered by heavily wooded and rolling terrain extending in a north by northwesterly direction bordered by the lake, as well as a wood line which extended north/ northeasterly and south/southeasterly along the lake bank. Continued review showed the facility was also bordered by an access road (Jonelle Court) which ran west to east, parallel to and behind the facility, directly beside the building, a few feet away, which led to the condominium complex entrance. Across the access road, up a small vegetation covered embankment, approximately 34 feet away from the exit door where Resident #1 left the building, was a large tract of mowed pastureland with a heavily wooded border which measured 638 feet from its northwestern edge nearest the facility, which extended [NAME] towards a local college baseball field and athletic complex several acres in size. The pasture also extended westward parallel to the facility, ending with its border with highway 382, situated approximately 810 feet away from the elopement site, and northward to the wood line bordering the lakebed, 720 feet away from the location where Resident #1 exited the building. Continued review of the satellite data, cross referenced to the facility layout, facility investigation, and witness interviews, revealed on 5/8/2023 sometime around 7:20 AM Resident #1 ambulated from her last known location inside the building, roughly 143 feet to the junction of the East Wing hallway and the C Wing clinical unit, where she passed through an audibly alarmed door. The alarm malfunctioned and did not sound. Resident #1 exited the clinical unit undetected into the East Wing hallway to the rear of the facility, which was not in use. Resident #1 then turned right, (eastward) and ambulated another 189 feet to a delayed egress door located at the end of the East Wing. Resident #1 then exited the facility undetected, through the delayed egress door, which also malfunctioned and was not locked as a result. Once outside, Resident #1 turned right again, this time in a westward direction. Resident #1 followed the sidewalk around the rear corner of the building, bore right again and wandered approximately 100 feet from the exit point, down the sidewalk to an area behind the building, which was situated close to the central courtyard enclosed by a chain link fence, an adjacent grassy area, the employee parking lot, and access road. Resident #1 was spotted by staff inside, who intercepted her and escorted her back inside. Interview with Licensed Practical Nurse (LPN) #1 on 5/18/2023 at 11:48 AM in the conference room, revealed LPN #1 reported Resident #1's elopement was due to multiple door malfunctions which occurred simultaneously. LPN #1 reported the facility investigation of the incident initially focused on the failed audible alarm on the doorway between the C Wing hallway and East Wing which staff suspected but could not prove had been switched off/ deactivated by a resident, who by then, had discharged back home. LPN #1 reported the facility investigation determined the alarm was intact and working on the prior night shift, but no definitive cause of the mechanical failure was identified on the morning the incident occurred. LPN #1 reported the faulty audible alarm was replaced. Continued interview revealed LPN #1 reported the East Wing delayed egress door system malfunctioned due to a bent door hinge which prevented it from locking closed and arming the exit alarm and that was discovered minutes later during a systematic search of the facility after Resident #1 was returned inside, in which the door was found ajar and alarm silent. LPN #1 reported facility staff were aware Resident #1 wandered about the facility as part of her normal routine but were surprised she had exited the facility, as she did not usually exit seek, and on the morning of the occurrence had not exhibited unusual behaviors. LPN #1 confirmed facility staff were not aware Resident #1 had eloped both the clinical unit and the building until she was found outside. LPN #1 reported the facility Quality Assurance (QA) team evaluated the incident. LPN #1 reported the QA committee considered the incident a critical occurrence which placed Resident #1 at risk of serious injury, harm or worse, and multiple interventions were put in place afterwards to address the situation. Interview with the Maintenance Director on 5/18/2023 at 12:12 PM in the East Wing hallway, revealed on 5/8/2023, examination of the C Wing door alarm which malfunctioned showed the sliding power switch was not in the on position when examined by staff as they conducted door checks throughout the facility after Resident #1 was brought back inside. The Maintenance Director reported though no definitive evidence the unit had been manually turned off by someone was found, it was suspected that had occurred, as when the unit's sliding switch was moved back to the proper position fully engaged, it functioned as designed. Continued interview revealed the Maintenance Director reported nevertheless, he replaced the alarm with a new unit, with the sliding switch superglued into place in the on position to prevent any inadvertent dislodgements and performed the same modification to all other identical devices in use on other doors throughout the facility the same day. The Maintenance Director reported no other malfunctioning units were identified. Continued interview revealed the Maintenance Director reported the East Wing delayed egress door had malfunctioned due to misalignment of its magnetic locking mechanism, which had been caused by a sagging upper door hinge, which was not noted when the door was last checked on 5/4/2023, during routine weekly alarm checks. The Maintenance Director reported the defective hinge prevented the door from locking securely, allowing Resident #1 to open it without pushing on the release bar in the center of the door, which would have triggered an alarm. This was discovered on 5/8/2023, during the facility investigation, which began immediately after Resident #1's elopement occurred. The Maintenance Director reported staff determined Resident #1 eloped through the East Wing door as it was slightly opened and the alarm silent, when observed a few minutes after the incident. Interview with the Administrator on 5/18/2023 at 12:40 PM in the conference room, revealed the Administrator corroborated LPN #1's interview as related to the East Wing delayed egress door malfunction which led to Resident #1's elopement. The Administrator reported there was no conclusive evidence the malfunctioning audible alarm on the C Wing exit door inside the facility leading to the East Wing hallway had been deliberately manually deactivated by anyone as reported by LPN #1. He confirmed the unit was replaced. The Administrator confirmed staff inside the facility failed to detect Resident #1's elopement from the clinical area and confirmed her eventual exit from the East Wing also went undetected. The Administrator acknowledged Resident #1 was discovered outside, around 7:30 AM, 10 minutes after she was last seen inside, by a staff nurse, who had elected to take a break. The Administrator confirmed given the terrain around the facility and the fact Resident #1 was severely cognitively impaired those factors placed Resident #1 at risk of severe harm, injury, impairment, or death under the circumstances, despite the short duration of the incident. Interview with CNA #1 on 5/22/2023 at 1:35 PM in the conference room, revealed CNA #1 and CNA #2, along with three nurses LPN #1, LPN #2, and Registered Nurse (RN) #1, were assigned to the floor on the day Resident #1 eloped from the facility. CNA #1 reported the incident occurred near the conclusion of the morning tray pass/breakfast meal which usually began around 6:30 AM and ended by 7:30 AM. CNA #1 reported at the time she and CNA #2 were engaged in resident care, nursing staff were also active on the floor, as they passed morning medications and assisted the CNAs. CNA #1 reported at the time of the incident she was located near the A Wing kiosk charting on a resident. CNA #1 reported the staff on duty were familiar with Resident #1 and her routine of wandering about or briefly socializing in the halls near the nursing station after breakfast. CNA #1 stated she did not recall seeing Resident #1 approach any exits or testing doors that morning. CNA #1 reported that morning she did not recall hearing the C Wing door alarm sound. CNA #1 stated she last saw Resident #1 inside sometime between 6:30 AM and 7:00 AM on the B Wing where she lived, eating breakfast. CNA #1 stated she was aware LPN #1 was at the nursing station charting when Resident #1 was found. CNA #1 reported the facility usually staffed 5 persons in the morning for around 40 residents, and usually 3 of those personnel were CNAs, but on the day of the elopement, only 2 CNAs were present with 3 nurses instead. CNA #1 reported at the time of the incident Resident #1 was clothed but was not wearing shoes. CNA #1 reported Resident #1 usually wore socks instead. CNA #1 reported none of the floor staff were aware Resident #1 eloped until she was found outside by LPN #2. Interview with CNA #2 on 5/22/2023 at 2:00 PM in the conference room revealed she was also very familiar with Resident #1. CNA #2 recalled on the morning of the incident, she and CNA #1 were performing tray returns or tending to 4 or 5 of the facility's residents who were dependent for feeding. CNA #2 reported that morning all 3 nurses present were also assisting the CNAs while they performed their morning assessments and medication passes. CNA #2 stated around 7:30 AM, LPN #2 took a short break, but on her way to the break area saw Resident #1 outside, called for help, and went to recover the resident. CNA #2 reported it was raining lightly that morning, the sky was overcast, and the temperature was cool. CNA #2 reported when Resident #1 was returned inside, her hair was damp, she did not wear shoes normally, and her nonskid socks and the bottoms of her pajama pant legs were wet. CNA #2 stated she noted Resident #1 was shivering slightly when taken back to her room, where she was examined by RN #1 and changed into warm, dry clothing. CNA #2 reported afterwards, Resident #1 took a nap. CNA #2 reported she last observed Resident #1 in her room on the B Wing sometime between 6:30 AM and 7:00 AM during tray pass. CNA #2 also reported she did not recall hearing the audible alarm on the C Wing hall activate that morning and confirmed she too was unaware Resident #1 eloped until the resident was found outside by the nurse. Interview with RN #1 on 5/22/2023 at 4:00 PM in the conference room, revealed she was the nurse assigned to Resident #1 on the day she eloped. RN #1 reported she observed Resident #1 around 6:30 AM and again shortly after 7:00 AM on the B Wing hallway during medication pass. RN #1 reported Resident #1 did not appear anxious or agitated and was walking about the unit consistent with her usual daily routine. RN #1 reported LPN #2 found Resident #1 outside the rear of the facility around 7:25 AM and brought her back inside. RN #1 reported she was certain of the time, as she noted the time on her watch while the resident was brought back inside. RN #1 reported she assessed Resident #1 in her room immediately after she was returned to the facility. RN #1 reported the resident was not wearing shoes (as was customary), was dressed, but was damp. RN #1 stated she did not detect signs of injury or any evidence Resident #1 had fallen. RN #1 reported she did not recall hearing any door alarms sound that morning before the elopement. RN #1 reported a facility investigation was immediately launched and staff discovered the malfunctioning audible alarm on the door leading to the East Wing, which cued them to follow into the empty East Wing where they discovered the malfunctioning delayed egress door at the far end of the hall near where Resident #1 was found. RN #1 reported the delayed egress door was ajar, and no alarm was sounding there as well. RN #1 confirmed none of the clinical staff on duty that morning was aware Resident #1 had gotten outside until she was spotted by LPN #2 and brought back inside. Interview with the DON on 5/23/2023 at 1:00 PM in the conference room revealed the DON confirmed the facility investigation determined Resident #1 eloped due to door malfunctions at 2 different locations and staff on duty at the time were unaware Resident #1 was outside until she was located by LPN #2 around 7:30 AM. The DON reported she arrived at the facility as the incident was unfolding and initiated an investigation within minutes of Resident #1's recovery. The DON confirmed the C Wing door switch was in the off position and was immediately switched back on, but the facility could not conclude as to how that had occurred after interviewing all the night shift nurses from the previous shifts and the day shift staff on duty at the time. The DON reported there was no conclusive evidence a resident had deactivated the alarm. The DON reported she interviewed all alert and oriented residents on the C Wing who denied they had manipulated the alarm switch or heard it go off that morning. The DON also confirmed she observed the delayed egress door on the East Wing could be opened by simply pushing on the door, and it appeared the magnetic locking system there had also malfunctioned. The DON confirmed the facility investigation determined Resident #1 eloped from the facility via the East Wing delayed egress door to the rear of the building undetected by staff and the facility failed to ensure doors were secured. The DON confirmed Resident #1's elopement placed the cognitively impaired resident at risk of serious harm, injury, or death. Interview with LPN #2 on 5/23/2023 at 2:45 PM in the conference room, revealed LPN #2 reported on the day of the incident, she had completed her medication pass early and stated she usually never took her break early in the shift, but on 5/8/2023, decided to take a brief break to smoke, in the central courtyard, beneath a gazebo located outside the main dining area side doors. Continued interview revealed LPN #2 reported as she approached the dining area exit, she saw Resident #1 outside, as Resident #1 wandered on the sidewalk behind the closed East Wing, outside the chain link fenced in central courtyard, near the East Wing patio white wooden fence, adjacent to the parking lot. LPN #2 stated she and an orientee called out for assistance (missing resident code W), the orientee went inside to summon staff, she went outside, through a gate in the courtyard chain link fence, intercepted Resident #1 on the sidewalk, then held hands with her and conversed with the resident, as she escorted Resident #1 back inside, through the parking area, to the rear door of the main dining area. LPN #2 reported Resident #1 was profoundly confused as was her baseline, was shoeless, wore nonskid socks, was damp from drizzle, but returned inside without incident. LPN #2 acknowledged though Resident #1 was severely cognitively impaired, she was very mobile and may have traveled considerable distance from the facility in a short time span, had she not been intercepted. LPN #2 confirmed she had not heard an alarm sound that morning on the clinical unit, and nobody inside the facility was aware Resident #1 had eloped. The facility corrective actions included: 1. Corrective actions for the impacted resident: A. Resident #1 was immediately assessed by the RN upon return to the building on 5/8/2023 with no injuries noted. The responsible party, physician, psychiatric nurse practitioner and Administrator were advised of her status within minutes of the incident. No changes to Resident #1's medical regimen were required. Medical record review confirmed all notifications were made and Resident #1 was assessed for injury, with no injury noted. B. Resident #1 was placed on 1 to 1 observation after return to the building. She was transitioned to every 15- minute checks for 3 days upon order of the physician on 5/8/2023. Every 15-minute checks were completed until the morning of 5/11/2023. Review of facility documentation and interviews with staff confirmed Resident #1 was monitored as documented by the facility. C. Resident #1's path of egress was identified on 5/8/2023 at 7:40 AM. The doors were secured. Checks of all other exits were performed with no irregularities noted. The Maintenance Director assessed all doors and alarms at 8:00 AM, then replaced the defective alarm on the C Wing, and implemented temporary repairs to the East Wing door to correct misalignment (door shims) which were completed by 12:00 PM. A secondary alarm was added to the East Wing door as well. The door contractor was called to assess the East Wing door on 5/8/2023 after it was temporarily re-secured. Observations conducted during the survey confirmed all alarms were functioning and doors were secure. D. An ad hoc Quality Assurance (QA) meeting which involved all department heads and facility leadership was held at 8:15 AM on 5/8/2023. A root cause analysis of the incident was initiated by the DON. Additional interventions to address all persons potentially impacted by the incident were initiated. Corporate leadership was notified of the incident. Mandated reporting procedures were initiated. Interviews of involved staff were completed by the DON/designee. Review of facility documentation and interviews with staff confirmed the ad hoc QA was held as documented by the facility. E. Resident #1 was already care planned as at risk for elopement at the time of the incident. The elopement risk assessment was updated. The care plan was enhanced with additional interventions for wandering added on 5/8/2023 shortly after the incident occurred. Review of the elopement risk assessment and Resident #1's care plan confirmed the updates and interventions. Observations conducted of Resident #1 during the survey confirmed all care planned interventions were in place. F. Staff education related to the new care plan interventions specific to Resident #1 began on 5/8/2023 and were completed for all clinical employees by 5/11/2023. Interviews conducted with CNAs, LPNs and RNs during the survey showed all employees were knowledgeable of the care planned interventions for Resident #1. G. Reassessment of Resident #1's medications and medical regimen was completed by 9:30 AM on 5/8/2023. Review of the medical record confirmed Resident #1 was assessed by the provider. H. The facility began elopement drills and in-service retraining of all staff related to the missing resident procedure (Code W) across all shifts on 5/8/2023. Training related to the door alarms, recent door failures, and twice per shift door and alarm checks with corresponding logs were implemented. Review of facility documentation confirmed elopement drills were conducted on all shifts, including evenings and weekends. Interviews conducted with facility staff confirmed staff's understanding of the education provided. Review of facility documentation confirmed twice per shift door and alarm checks were performed and continued to be performed. I. Resident #1 was re-examined by the Medical Director on 5/10/2023 with no changes to her medications or medical regimen required. Review of the medical record confirmed Resident #1 was assessed by the Medical Director. 2. Interventions for other residents potentially impacted by the deficient practice: A. The facility performed elopement risk reassessments for all residents which began on 5/8/2023 and were completed on 5/11/2023. Any residents with new identified risks were added to the facility elopement risk book and additional care plan modifications were initiated consistent with facility policy. Review of facility documentation and medical record reviews confirmed elopement risks and care plans were updated for those residents identified as at risk. B. All residents identified as at risk for elopement had their identification bands checked on 5/8/2023 to ensure yellow bands were in place per the facility policy. No irregularities were noted. The elopement risk book was evaluated and found to be in order and up to date on 5/8/2023. Observations of Resident #1 and other residents identified as at risk confirmed the presence of yellow identification bands to alert staff of residents at increased risk of elopement. Review of the elopement risk book showed the book to be up to date. C. Elopement drills continued on all shifts 5/9/2023-5/13/2023 and included evening/night/weekend shift drills with continued training on the facility policy and procedures for missing persons and alarm checks/door checks twice per shift and prevention of elopements/identification of at- risk behaviors. Elopement drills were then randomized and continued at least once daily through 5/17/2023. The facility continued to perform spot check elopement drills on random shifts/intervals. Review of facility documentation confirmed elopement drills were performed, door and door alarm checks continued. Interviews conducted with the staff responsible for completing the door and door alarm checks confirmed their understanding of the checks. Interviews conducted with facility staff confirmed understanding and knowledge of elopement procedures. D. A second ad hoc QA meeting was held on 5/9/2023 to review progress of corrective actions to date and additional interventions identified for implementation going forward. 3. Systemic Measures Implemented: A. The door contractor visited the facility on 5/8/2023 and plans to replace the East Wing delayed egress door assembly were arranged. Corporate officials were advised, and the repair authorized. The necessary door assembly and hardware were ordered directly from the manufacturer by the contractor. A timeline for installation was made. The contractor evaluated temporary repairs made by the facility and deemed them sufficient to keep the East Wing door secure until a new replacement was installed. Multiple observations by the surveyor of the East Wing door during the survey confirmed the door was secure and alarm was functional. B. The offices for activities therapy department and Admissions Coordinator were moved from the front of the building to the East Wing to increase monitoring/visibility of the unoccupied section of the building on 5/8/2023. Observation by the surveyor confirmed the relocation of the offices to the East Wing. C. The QA committee reviewed the incident, findings to date and additional interventions moving forward on 5/13/2023. Convex mirrors were installed near the nursing station on the B/C Wing hallway to improve visibility of the impacted C Wing door. A convex mirror for the A/D Wing hall was also ordered and was installed immediately upon its receipt. The QA committee added review of the incident and corresponding interventions to the monthly agenda for 3 months through August 2023, and to re-evaluate the need for continued monitoring afterwards. Observation of the B/C Wing hallway confirmed the installation of the convex mirror to aid in visibility. D. The facility equipped all staff with walkie talkies on 5/16/2023. Appropriate charging stations and back up units were also acquired. Staff were trained on their use which was completed by 5/17/2023. Observation and interviews with staff during the survey confirmed the use of the walkie talkies and education provided on the use of the walkie talkies. E. Stop signs and secondary audible alarms were added to all facility exit doors as an added layer of security by 5/17/2023. Door checks twice per shift continued with no additional irregularities noted. The DON was responsible for monitoring alarm and door checks twice per shift were conducted. Observations of all egress doors confirmed the presence of the stop signs and secondary alarms. Review of facility documentation confirmed door and door alarm checks were conducted twice per shift. F. The facility altered its employee entrance/exit procedures and prohibited use of doors on the East Wing to be used to access the facility. All staff were notified via memo and oral instructions to department heads and daily morning meetings they were to enter the building at the front entrance or rear entrance by the dining hall only (for those who parked in the rear lot) on 5/10/2023. Compliance monitoring by Department Heads was ongoing. Observation by the surveyor during the survey showed no staff entering the facility through the East Wing door.