Every finding on record at River Oaks Retirement Manor

Based on observations, interviews and record review, the facility failed to ensure services provided meet professional standards as evidenced by the nurse failing to follow the facility's policy for verbal orders for 1(#3) of 34 sampled residents. Findings:Review of the facility's policy titled, Verbal Orders Policy read in part, Policy: Physician orders may be received by telephone, by a licensed nurse or other licensed or registered health care specialist who are legally authorized to do so .3. Enter the order into the medical record manually or electronically .Review of Resident #3's comprehensive MDS (Minimum Data Set) dated 12/03/2025 revealed she was admitted to the facility on [DATE]. Her active diagnoses include, but not limited to stroke, dementia, and UTI (urinary tract infection). Her BIMS (Brief Interview of Mental Status) was 3, severe cognitive impairment. On 12/10/2025 at 10:30 a.m., a review of Resident #3's November 2025 MAR (Medication Administration Record) revealed the following medications: 1. Invanz (antibiotic) Injection Solution Reconstituted 1 gm (gram)-inject 1 gram intramuscularly one time a day for UTI for 5 days, with a discontinue date 11/16/2025 at 1535 (3:35 p.m.), 2. Invanz (antibiotic) Injection Solution Reconstituted 1 gm (gram)-inject 1 gram intramuscularly one time a day for UTI for 5 days, with a discontinue date 11/16/2025 at 1544 (3:44 p.m.), 3. Lidocaine HCL (Hydrochloride) injection solution 1% (Lidocaine HCL (Local Anesth. (anesthetic))---inject 3.2ml (milliliter) intramuscularly one time a day for Abx (antibiotic) for 5 days mix 3.2ml with Invanz injection, with a discontinue date of 11/16/2025 at 1635 (4:35 p.m.), and4. Sodium Chloride intravenous (into or within a vein) solution 0.9%--Use 1 liter intravenously one time a day for AKI (Acute Kidney Injury) at 100ml(milliliter) per hour with a discontinue date of 11/14/2025 at 1241 (12:41 p.m.)Further review of Resident #3's electronic medical record, including physician orders, progress notes/nurse assessment notes failed to reveal written physician orders for the above mentioned medication.On 12/10/2025 at 10:35 a.m., an interview and record review was conducted with S1DON (Director of Nursing). S1DON reviewed Resident #3's electronic medical record and confirmed there was no written physician orders for the above mentioned medications on the MAR. S1DON was asked what the facility's process was when the nurse takes a verbal order from the doctor or the NP (Nurse Practitioner). She stated the nurse should write the order on a progress note and/or the nurse's assessment. The nurse then should enter the order in the computer, which populates to the physician order form and the order goes to the pharmacy. The nurse should put the order on the resident's MAR. S1DON reviewed the resident's electronic medical record and confirmed that there was no written physician order by the nurse on a progress note and/or nurse assessment for the Sodium Chloride on 11/14/2025 and Invanz on 11/16/2025.

Based on observation and interview, the facility failed to ensure the daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors. This deficient practice had the potential to affect the 69 residents residing in the facility. Findings: A review of the facility's policy titled Posting Direct Care Daily Staffing Numbers which was last reviewed on 04/05/2025, read in part, Policy Interpretation and Implementation: 1. The number of licensed nurses (Registered Nurses, Licensed Practical Nurses, and Licensed Vocational Nurses) and the number of unlicensed nursing personnel (Certified Nursing Assistants and Nurses Assistants) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. On 12/08/2025 3:45 p.m., observations were made throughout the main prominent areas of the facility in the attempt to locate daily staffing information. This surveyor was unable to locate the staffing hours visually. After asking assistance from a staff member, this surveyor was directed to the location of the daily staffing information in a small alcove off of a main walk area. The alcove was small with bulletin boards mounted on a side and back wall with various postings, and the staff clock-in device was mounted on the remaining side wall. This surveyor had to walk into the alcove to visualize the staffing information posted on the back wall bulletin board. On 12/08/2025 at 4:32 p.m., an observation was made with S1DON (Director of Nursing) of the daily nurse staffing information posted on the inner wall of an alcove where the employee time clock was located, near a main hallway. The alcove was connected to a small hall that contained three doors with signs that read, Laundry, Boiler Room, and Employees Only. The staffing information was not easily visible from the main walk area located outside of the alcove. On 12/09/2025 at 1:43 p.m., an interview was conducted with S1DON. S1DON stated that she could see how the location used to post daily nurse staffing information would be perceived as not a very visible area.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections as evidenced by failing to ensure staff removed PPE (Personal Protective Equipment) prior to exiting a resident's room that was on enhanced barrier precautions for 1 (Resident #28) out of 34 sampled residents.Findings: Review of the facility's Enhanced Barrier Precautions Policy last reviewed on 04/05/2025 read in part, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents . 3. Implementation of Enhanced Barrier Precautions: d. Position a trash can inside the resident room for discarding PPE after removal. On 12/09/2025 at 8:50 a.m., S2TN (Treatment Nurse) was observed completing wound care/treatment. S2TN was observed exiting out of Resident #28's room wearing PPE (gown and gloves) that was used throughout the resident's wound care/treatment. S2TN was asked by the surveyor if she should have exited out of the resident's room wearing the used PPE. S2TN responded no. During this observation, S3ADON (Assistant Director of Nurses) was present standing in the hall outside Resident #28's room. S3ADON observed S2TN exit the resident's room wearing the PPE. S3ADON confirmed that S2TN should have removed and discarded the used PPE in the resident's room prior to exiting the room. On 12/10/2025 at 10:30 a.m., an interview was conducted with S1DON (Director of Nurses). S1DON reviewed the enhanced barrier precautions policy and confirmed that PPE should be discarded in a trash can inside the resident's room. The DON confirmed the used PPE should be discarded in the resident's room and not after exiting out of the room.

Based on observation, record review and interviews, the facility failed to ensure resident rights were maintained as evidenced by: 1. Failing to ensure the results of the most recent complaint survey dated 08/08/2024 was available for residents, visitors or other individuals to review; and 2. Failing to ensure residents were aware of where to locate state inspection results to review for 4 (#4, #41, #49, and #71) out of 4 (#4, #41, #49, and #71) residents that attended the Resident Council meeting. The facility census was 79. Findings: Review of Resident #4's Quarterly MDS (Minimum Data Set) dated 09/04/2024 revealed the Brief Interview for Mental Status (BIMS) score of 15, indicating her cognition was intact. Review of Resident #41's Annual MDS (Minimum Data Set) dated 08/03/2024 revealed the Brief Interview for Mental Status (BIMS) score of 15, indicating her cognition was intact. Review of Resident #49's Quarterly MDS (Minimum Data Set) dated 06/18/2024 revealed the Brief Interview for Mental Status (BIMS) score of 15, indicating her cognition was intact. Review of Resident #71's Quarterly MDS (Minimum Data Set) dated 07/09/2024 revealed the Brief Interview for Mental Status (BIMS) score of 10, indicating his cognition was moderately intact. On 09/16/2024 at 1:45 p.m., a Resident Council meeting was conducted with Residents #4, #41, #49, and #71. Each resident stated they were unaware of the results of the state inspection surveys were available to read and where this information was located. An observation was made on 09/16/2024 at 3:15 p.m. of the facility's binder labeled, Annual State Survey Results located near the entrance of the facility on top of a high dresser. Further review of the facility's binder revealed no documented evidence of the survey results from the most recent complaint survey dated 08/08/2024 was available for review. On 09/16/2024 at 3:25 p.m., an interview was conducted with S2ADM (Administrator) who stated it was S1DON's (Director of Nursing) responsibility to update the survey results binder. On 09/16/2024 at 3:30 p.m., an interview was conducted with S1DON. S1DON stated it was her responsibility to update the survey results binder. She confirmed the most recent complaint survey results dated 08/08/2024 was not in the survey results binder for residents, visitors, or other individuals to review.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and homelike environment for 2 (#47 and #74) of 4 (#25, #47, #74 and #78) residents investigated for environment in a final sample of 36 residents as evidenced by: 1. failing to ensure clean bed linen was provided for Resident #47, and 2. failing to ensure the toilet was in good repair for Resident #74. Findings: On 09/17/2024, a review of the facility's policy titled Homelike Environment with a last reviewed date of 09/06/2024, read in part . Policy Statement: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Policy Interpretation and Implementation: . 4. The facility will provide and maintain bed and bath linens that are clean and in good condition . Resident #47: Review of Resident #47's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Paraplegia, Muscle Wasting and Atrophy, and Unspecified Dementia. On 09/16/2024 at 10:45a.m., an observation was made of Resident #47's bed. The resident's flat sheet and fitted sheet revealed multiple areas of dark red stains. On 09/16/2024 at 12:52 p.m., a second observation was made of Resident #47's bed. The multiple areas of dark red stains were still on the bed linen. On 09/17/2024 at 1:57 p.m., a third observation was made of Resident #47's bed. The resident's bed linen was still stained. On 09/17/2024 at 2:01 p.m., an interview and observation of Resident #47's room was conducted with S7CNA (Certified Nursing Assistant) and S8CNA. They confirmed the multiple areas of dark red stains on Resident #47's flat sheet and fitted sheet. They confirmed there should not be any stains on the residents' bed linen and it should have been changed before the bed was made. On 09/17/2024 at 2:40 p.m., an interview was conducted with S1DON (Director of Nursing). S1DON confirmed bed linens should be changed and cleaned at all times if stains are noted. Resident #74: Review of Resident #74's record revealed he was admitted to the facility on [DATE], with diagnoses which included, but were not limited to, Cerebral Infarction, Hemiplegia and Hemiparesis, and Dysphagia. Review of Resident #74's Annual MDS (Minimum Data Set) dated 07/02/2024, revealed in Section G - Functional Status: Toilet Use 2. One person physical assist. On 09/16/2024 at 9:17 a.m., an observation and interview was conducted with Resident #74. Resident #74 walked to the toilet in his bathroom and picked up the toilet seat cover and seat which revealed part of the toilet seat cover and seat were detached from the toilet. Resident #74 shook his head yes when asked if he had notified staff of his toilet seat cover and seat not attached securely to the toilet. On 09/17/2024 at 2:05 p.m., an observation of Resident #74's toilet and an interview was conducted with S7CNA and S8CNA. They stated that Resident #74 used the toilet by himself at times. S7CNA and S8CNA confirmed that part of the toilet seat cover and seat were detached from the toilet. On 09/17/2024 at 2:14 p.m., an observation of Resident #74's toilet and an interview was conducted with S6MS (Maintenance Supervisor). S6MS stated that he had not been making periodic rounds in any of the residents' rooms or bathrooms to check on their environment. He stated he only went in residents' rooms when staff wrote maintenance concerns in the maintenance work order binder. S6MS confirmed that Resident #74's toilet seat cover and seat were partially detached from the toilet and should have been completely attached to the toilet. He confirmed this was not a homelike environment.

Based on interviews and record review, the facility failed to initiate a grievance for 1 (Resident #21) of 1 sampled residents reviewed for grievances in a final sample of 36 residents. Findings: Review of the facility's policy, Grievance/Complaint Policy, with a review date of 09/06/2024, revealed in part . residents have the right to file grievances either orally or in writing, to the facility staff. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident 1. Any resident, may file a grievance or complaint to the facility that hears grievances concerning theft of property, and other concerns regarding their LTC (Long Term Care) facility stay . 4. Upon receipt of a grievance and/or complaint, the grievance official will ensure prompt investigation and resolution of the allegations. Review of Resident #21's clinical record revealed an admitted [DATE]. Review of Resident #21's Quarterly MDS (Minimum Data Set) dated 08/27/2024 revealed Resident #21 had a BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition. On 09/17/2024 at 2:34 p.m., an interview was conducted with Resident #21. She reported that a pair of her brown pants had been missing for four months. Resident #21 stated she informed a laundry employee about her missing brown pants. On 09/18/2024 at 8:58 a.m., an interview was conducted with S3LAUN (Laundry). She stated she did recall that Resident #21 had mentioned she was missing brown pants approximately four months ago, and she was unable to locate them for the resident. S3LAUN admitted she forgot to report the missing item to the SSD (Social Services Director) for her to create a grievance for the missing item. On 09/18/2024 at 9:10 a.m., an interview was conducted with S4SSD. She confirmed that she had not been informed by S3LAUN about Resident #21's missing brown pants. S4SSD confirmed Resident #21 had an inventory log of brown pants that were labeled with her name. She also stated that grievances raised by residents should be reported to the SSD so that an official grievance can be filed and addressed, which did not happen in this situation.

Based on observations, interview, and record review, the facility failed implement the resident's plan of care by not following a physician's order to ensure the resident's indwelling catheter was the correct size for 1 (#25) out of 2 (#19 and #25) residents investigated with Urinary Tract Infection out of a total sample of 36 residents. Findings: A review of Resident #25's record revealed the resident was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Retention of Urine, Overactive bladder and Hydonephrosis with Renal and Ureteral Calculous Obstruction, and Urinary Tract Infection. A review of Resident #25's physician's orders revealed an order written on 09/10/2024 which read: Indwelling Catheter draining to GU (Genitourinary) bag. Change q (every) month and PRN (as needed) every day shift every 1 month(s) starting on the 14th for 1 day(s) for BPH w/ LUTS ( Benign Prostatic Hyperplasia with Lower Urinary Tract symptoms) 16 Fr(French) /10 cc (cubic centimeter) bulb AND every 24 hours as needed for BPH w/ LUTS 16 Fr/10 cc bulb. On 09/18/2024 at 8:14 a.m., an observation was made of S5CNA (Certified Nursing Assistant) performing Resident #25's indwelling catheter care. She stated the resident had a 16 Fr/5 cc bulb catheter. On 09/18/2024 at 8:56 a.m., an observation of resident #25's indwelling catheter was made with S1DON (Director of Nursing). She confirmed the resident had a 16 Fr/5 cc bulb catheter. On 09/18/2024 at 9:05 a.m., S1DON confirmed that the nurse should have used a 16Fr/10cc bulb catheter per the doctor's order. S1DON reviewed the resident's medical record and confirmed that there was no new order for the resident to have a 16Fr/5cc bulb catheter.

Based on record review, observations and interview, the facility failed ensure correct use and installation of bed rails to avoid the risk of entrapment. The facility failed to: 1. Identify and use appropriate alternatives prior to using bed rails; 2. Ensure appropriate dimensions of the bed based on the resident's size and weight to ensure the resident's bed frame, mattress, and bed rails were compatible prior to instillation; 3. Ensure correct installation of bed rails including adherence to manufacturer's recommendations and/or specifications for adaptive devices to prevent entrapment; 4. Adequately assess the residents' risk for entrapment and safety prior to applying modified side rails with wooden boards that were not recommended per the manufacturer; 5. Appropriately monitor and supervise residents with bed rails in place. This failed practice occurred for 5 (#1, #R1, #R2, #R3, and #R4) of 5 (#1, #R1, #R2, #R3, and #R4) residents with these modified bed rails. This deficient practice resulted in an Immediate Jeopardy on 07/28/2024 at 1:00 p.m. when Resident #1 attempted to climb over the boarded side rail and became entrapped between the air mattress and the modified boarded bed rail attached to the resident's bed. An x-ray revealed the resident sustained a left femoral neck fracture which required transfer to the local hospital. Resident #1 underwent surgery for a closed reduction and percutaneous pinning for the left femoral neck fracture. Resident #1's bed was replaced upon his return from the hospital on 07/30/2024, but there continued to be a likelihood for severe harm, injury or death for Residents #R1- #R4 whose beds were still equipped with air mattresses with wooden boards attached to the outside of bilateral bed rails. These modified boarded bed rails were attached in the middle of the bed in the horizontal position spanning one third width of the side of the bed. S1DON (Director of Nursing) and S2ADM (Administrator) were notified of an Immediate Jeopardy situation on 08/07/2024 at 1:25 p.m. The Immediate Jeopardy was removed on 08/08/2024 at 5:13 p.m., as confirmed by onsite verification through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: On 08/08/2024 , a review of the facility's policy titled, Bed Safety and Bed Rails with a revision date of 08/06/2024 read in part: 4. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks .Use of Bed Rails .4. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include: a. roll guards; b. foam bumpers; c. lowering the bed; and/or d. use of concave mattresses to reduce rolling of the bed .6. The resident assessment to determine risk of entrapment includes, but is not limited to: a. medical diagnosis, conditions, symptoms, and/or behavioral symptoms; b. size and weight; c. sleep habits; d. medication(s); e. acute medical or surgical interventions; f. underlying medical conditions; g. existence of delirium; h. ability to toilet self safely; i. cognition; j. communication; k. mobility (in and out of bed); and l. risk of failing. 7. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following: a. Accident hazards: Review of the Bed Rail Entrapment Risk Notification Guide and Owner's Operator and Maintenance Manual for the facility's beds read in part: Proper patient assessment, equipment selection , frequent patient monitoring, and compliance with instructions, warnings, and this Bed Rail Entrapment Risk Notification Guide is essential to reduce the risk of entrapment. Accessories have been developed in the industry to reduce the openings in existing bed systems that could cause entrapment. Any modification through the use of accessories must be used in conjunction with proper patient assessment prior to intervention .Use of other manufacturer's products in conjunction with an .homecare bed , may significantly increase the risk of entrapment; as such .does not recommend their use. Mattresses must fit bed frame and assist rails snugly to reduce the risk of entrapment. Review of Resident #1's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE]. The resident's diagnoses included Anxiety Disorder, Alzheimer's disease, Lack of Coordination, and Age Related Osteoporosis without Current Pathological Fracture. Review of Resident #1's annual MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) of 3, indicating the resident's cognition was severely impaired. Review of Resident #1's plan of care, with a target date of 09/30/2024, revealed the following in part: Resident has self-care performance deficits and requires staff supervision and/or assistance with ADLs (Activities of Daily Living) and range of motion to maintain quality of life r/t (related to) generalized weakness, impaired mobility, dx (diagnosis) of lobar pneumonia, major recurrent depressive disorder, anxiety disorder, Alzheimer's disease . intervention for bilateral assist rails to HOB (head of bed). Further review of the resident's plan of care did not include interventions for the use of the bilateral bed rails including specific direct monitoring and supervision during use of the bed rails and interventions for safety to reduce the risk for resident entrapment. Review of Resident 1's EHR revealed a document, MDS Bar/Side Rail Assessment, dated 07/02/2024, with the following: Section A. Assessment: History of falls; currently using side rails for positioning or support. The facility did not document or assess the resident's cognition, size and weight, medical diagnoses, conditions, symptoms, and/or behavioral symptoms. Review of Section B. Interventions revealed no interventions had been attempted before device use. Review of Section C. Recommendations revealed bilateral assist rails were indicated to provide a sense of security. Further review of the assessment revealed the comments section read: bilateral boarded assist rails for security. Further review of Resident #1's record did not reveal any evidence of ongoing monitoring for safe use of the boarded side rails. Review of Resident #1's nursing progress notes, dated 07/28/2024 at 4:34 p.m., read in part .While sitting at desk, inform resident stated his leg was hurting. Resident did try and climb OOB (out of bed) sometime after lunch. CNA (Certified Nursing Assistant) was able to put him in w/c (wheelchair) before climbing out, but leg was in between the mattress and footboard. Resident has been sitting in w/c without s/s (signs or symptoms) of pain. Resident c/o (complaints of) LLE (left lower extremity) pain during brief change per CNA @ (at) this time. Informed S1DON . Review of Resident #1's hospital record, dated 07/28/2024, revealed in part: resident presented after a fall after he got trapped in the railings of his bed. Patient severely altered at baseline due to his dementia .Left femoral neck fracture identified. Review of the resident's hospital discharge summary dated 07/30/2024 read in part .Patient seen by Ortho team and had a closed reduction and percutaneous pinning left femoral neck fracture. Review of a witness statement written by S4CNA, dated 07/28/2024, read in part: When I got in the room and I saw him laying on his left side with his legs stuck between the side rail and mattress. I asked if he was hurting, and he said no. I then stood on the side of the bed and moved the side rail while holding his legs. I then moved his legs back on the bed. And was able to get him to sit up on the side of the bed and he stood and I assisted him in sitting in his wheelchair .I then brought him near the nurses station the rest of the day until me and my partner went to change him around 3:30 p.m. We were putting him back in the wheelchair when he started to look like he was in pain when he stood up. When we finished, were brought him back to the front and told the nurse. On 08/06/2024 at 9:26 a.m., an interview was conducted with S4CNA. She stated that she worked with Resident #1 on 07/28/2024. She went into the resident's room because she heard his bed alarm going off, and found him stuck between his mattress and the side rail of the bed. His left leg was caught under the rail and his right leg was positioned as if he was trying to climb over or get out. She then removed his legs and body from in between the side rail and mattress, stood the resident up, and placed him in the wheelchair. The resident did not complain of pain at this time. She then notified the nurse. S4CNA stated the resident had the side rails because he could have fallen out of the bed without them and they were in place for his safety. She stated that she was in-serviced on not moving a resident if they were stuck in the side rails of the bed after the incident occurred, but the facility did not train her on what to do in that situation prior to that incident. On 08/06/2024 at 9:58 a.m., an interview was conducted with S1DON (Director of Nursing). She stated that the side rails on the bed had the ability to be positioned vertically or horizontally. She stated that with the facility's older beds, mattresses, like the air mattresses, required assist rails with wooden boards attached to keep the mattress in place and for the resident to be able to turn and reposition due to the height of the mattress. The rails on the older beds were not tall enough, and the resident needed the boarded bed rails to increase the height of the rails to assist with turning and repositioning. S1DON also confirmed that Resident #1 had poor condition overall, and his cognition had been that way since he was admitted . S1DON also stated Resident #1 could potentially have rolled out of bed if he did not have those boarded bed rails in place with the older bed. S1DON stated that the CNAs were in-serviced on not moving a resident if they became entrapped in the side rails of the bed after the incident with the Resident #1. However, a situation like this had never occurred and was not common so there was no specific training on what to do if a resident became entrapped in the bed rails. S1DON also stated that the CNAs and nurses ensured that the bed rails were in place and residents were safe during their rounds by direct observation. Their charting on the MARs (Medication Administration Record) and CNA task records only required that they document that the bed rails were in place as ordered. Resident #1's care plan was then reviewed with S1DON. She confirmed that the use of bilateral bed rails was an intervention for the resident, but there were no specific interventions for monitoring or safety interventions for the use of the bed rails. Resident #R1. Review of Resident # R1's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE]. The resident had diagnoses including, but not limited to, Other Genetic Related Intellectual Disability, Gastrostomy Status, and Conversion Disorder with Seizures and Convulsions. Review of Resident #R1's Annual MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) Score of 5, indicating his cognition was severely impaired. Review of Resident #R1's August 2024 physician's orders revealed an order dated 07/07/2024 that read: Bilateral Boarded Assist Rails to HOB (Head of Bed) to aide in bed mobility and positioning due to low air loss mattress. Review of Resident #R1's plan of care revealed the following in part: Resident has self- care performance deficits and requires staff supervision and/or assistance with ADL'S (Activities of Daily Living) and range of motion to maintain quality of life with an intervention for bilateral assist bars to HOB to aide bed mobility, turning/repositioning while in bed. Further review of the resident's plan of care failed to include interventions for the use the bilateral assist rails including specific direct monitoring and supervision during use of the assist rails and interventions for safety to reduce the risk for resident entrapment. Resident #R2. Review of Resident #R2's EHR revealed she was admitted to the facility on [DATE]. The resident's diagnoses included, but not limited to, Anxiety Disorder, and Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non Dominant Side. Review of Resident #R2's August 2024 physician's orders revealed an order, dated 06/25/2024, read: Low air loss pressure reducing mattress on bed. An order, dated 07/07/2024, read: Bilateral Boarded Assist Rails to HOB to aide in bed mobility and positioning. Low air loss pressure reducing mattress on bed. Review of Resident #R2's plan of care revealed the following in part: Resident has Self- care performance deficits and requires staff supervision and/or assistance with ADL'S and range of motion to maintain quality of life r/t (related to) CVA (Cerebrovascular Accident) with left sided hemiplegia, flaccid left extremities, non-ambulatory . with an intervention for bilateral assist bars to HOB to aide bed mobility, turning/repositioning while in bed. Further review of the resident's plan of care revealed no interventions for the use bilateral assist rails including specific direct monitoring and supervision during use of the assist rails and interventions for safety to reduce the risk for resident entrapment. Resident #R3. Review of Resident #R3's EHR revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to: Non ST Elevation Myocardial Infarction, Unspecified Lack of Coordination, and Anxiety Disorder. Review of Resident #R3's August 2024 physician's orders revealed an order, dated 05/02/2023, and discontinued on 08/06/2024, that read: Bilateral Boarded Assist Rails to HOB to aide in bed mobility and positioning per resident request. Further review revealed an order, dated 06/24/2024, and discontinued on 08/06/2024, that read: Boards to assist rails every shift for safety. Resident #R3 also had an order, dated 06/24/2024, that read: Low air loss pressure reducing mattress on bed. Review of Resident #R3's plan of care, with an initiation date of 06/11/2024, revealed the following in part: Resident has self-care performance deficits and requires staff supervision and assist for ADLs r/t generalized weakness, history of falls, decreased mobility .with an intervention for bilateral boarded assist bar in use to HOB due to low air loss mattress to bed. Further review of the resident's plan of care revealed no interventions for the use the bilateral assist rails including specific direct monitoring and supervision during use of assist rails and interventions for safety to reduce the risk for resident entrapment. Resident #R4. Review of Resident #R4's EHR revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to: Acquired Absence of Right Leg Above Knee, Anxiety Disorder, and Dementia. Review of Resident #R4's comprehensive MDS Assessment, dated 07/16/2024, revealed the Resident did not have a BIMS score because the resident was rarely or never understood. Review of Resident #R4's August 2024's physician's orders revealed an order, dated 07/16/2024, and discontinued on 08/06/2024, read: Bilateral Boarded Assist Rails to HOB to aide in bed mobility and positioning d/t (due to) low air loss mattress in use. Further revealed an order, dated 07/30/2024, and discontinued on 08/07/2024, that read: Bilateral Boarded Assist Rails to bed every shift. Review of Resident #R4's plan of care with an initiation date of 04/24/2024 revealed the following in part: Resident has self-care performance deficits and requires staff supervision and/ or assistance with ADLs and range of motion to maintain quality of life r/t impaired mobility .with an intervention for bilateral assist bars to HOB to aide in bed mobility/ turning and repositioning. Further review revealed no interventions for the use the bilateral assist rails including specific direct monitoring and supervision during use of the assist rails and interventions for safety to reduce the risk for resident entrapment. Review of Residents #R1- #R4's MDS Bar/Side Rail Assessments, all dated 07/29/2024, revealed the facility did not assess each resident's size and weight to ensure bed dimensions were appropriate for the residents. Review of Section B - Interventions of the residents' assessments revealed interventions tried before device used- none of the above was documented. The facility did not assess Resident #R2's medical diagnoses, or behavioral symptoms, and did not assess Resident #R3 and #R4's cognition, medical diagnoses, or behavioral symptoms as indicated in Section A of the assessment. Further review of Residents #R1-#R4's records revealed no evidence of ongoing monitoring for safe use of the boarded side rails. On 08/06/2024 at 11:13 a.m., observations were made of Residents #R1- #R4's rooms. Observations revealed each residents' bed with an air mattresses and bilateral bed rails with wooden boards attached to the outside of the bed rails. These modified boarded bed rails were attached in the middle of the bed in the horizontal position spanning one third width of the side of the bed. On 08/06/2024 at 2:01 p.m. a joint interview was conducted with S1DON (Director of Nursing) and S2ADM (Administrator). S1DON stated that after Resident #1 became entrapped between the boarded bed rail and air mattress, Resident #1's bed was replaced with a new bed without boarded bed rails upon his return from the hospital on 07/30/2024. She and the MDS (Minimum Data Set) nurses assessed the residents who had air mattresses for safety. S1DON also stated there was a risk for any resident with bed rails to become entrapped between the bed rails and the mattress, but they felt the benefits of the boarded bed rails outweighed the risks of having them removed. She further stated the boarded bed rails were safe even if a resident was able to roll and become entrapped between the air mattress and boarded rail. She stated that maintenance installed the bed rails and attached the wooden boards to the rails for the residents with air mattresses as ordered. S1DON was asked if the facility utilized the manufacturer's guidelines to ensure the air mattresses were appropriate mattresses for the bed frames and bed rails. She replied that she would have to find those guidelines. S1DON then stated the air mattresses with bed rails with wooden boards attached had been in place when she began working at the facility over one year ago. S2ADM stated the facility was in the process of replacing the older beds in stages, but because of the cost, Residents #R1-#R4 were not given any of the new beds. S1DON confirmed that these 4 residents remained in the old beds with wooden boarded bed rails attached because those residents were just ordered to be on air mattresses within the last 1 to 2 months. S2ADM stated that there had not been any more orders for new electric beds as of 08/06/2024. S1DON also stated that the CNAs and nurses ensured that the bed rails were in place and residents were safe during their rounds by direct observation. Their charting only required that they document that the bed rails were in place as ordered. Resident #1's plan of care was then reviewed S1DON. She confirmed that the use of bilateral bed rails was an intervention for the resident, but there were no specific interventions or safety interventions for the use or monitoring of the bed rails prior to his accident. On 08/06/2024 at 3:04 p.m., a joint interview was conducted with S1DON and S3MDSLPN (Minimum Data Set, Licensed Practical Nurse). S3MDSLPN stated that the MDS nurses were responsible for completing the bed rail assessments and creating and updating care plans for all residents who utilized bed rails. Review of the assessments for Residents #1, #R1-#R4 was reviewed with S3MDSLPN who confirmed the assessment was not completed appropriately to include assessments of the residents' height and weight and bed dimensions. She confirmed the assessment failed to include other interventions that had been attempted prior to the use of the bed rails. Residents #1, #R1-#R4's care plans failed to reveal any interventions for the safe use of bilateral bed rails with a wooden board attachment including increased monitoring or safety interventions to prevent entrapment. It was confirmed there was evidence of ongoing monitoring for safe use of the boarded side rails for these residents after Resident #1's accident. S3MDSLPN stated had worked at the facility for several years and the process of using the air mattress and wooden boarded bed rails had always been in place. S1DON asserted that there was no issue with use of the mattresses and boarded bed rails at this time. S1DON was asked again to provide the manufacturer's guidelines for the beds and mattresses, but she could not provide them. On 08/07/2024 at 8:57 a.m., an interview was conducted with S5MAINTSUP (Maintenance Supervisor). He stated that he had been in maintenance for two years at the facility, and they have always used the boarded bed rails for beds with air mattresses. He stated that due to the height of the mattress, the boarded side rails were needed as a fail-safe, to keep residents from falling out of bed. He stated maintenance attached the boards to the bed rails of the beds. He did not refer to any manufacturer's guidelines or recommendations for the mattresses or beds to ensure they were compatible, safe, and approved by the manufacturer. He stated he simply did what the facility had always done which was attach wooden boards to the outside of the side rails for those residents who required air mattresses. He received the orders for the air mattresses from the administrative nurses, and placed the mattresses on the beds and was not sure if they had referred to any manufacturer instructions. S5MAINTSUP further stated that maintenance routinely inspected the side rails to ensure they were functioning properly, but he did not have any documented evidence of the inspection. On 08/07/2024 at 6:16 p.m., an interview was conducted with S6REP (Medline -Mattress Representative). He stated that the mattresses were compatible with the bed frames and assist rails. However, the mattress stabilizers on the four corners of the beds were optional so they were currently being removed by maintenance, allowing the mattress to be flush to the bed frame. On 08/07/2024 at 7:00 p.m., an interview was conducted with administrative staff. S1DON, S2ADM, S3MDSLPN, S7ADON (Assistant Director of Nursing), S8SSD (Social Services Director), S9CNASUP (Certified Nursing Assistant Supervisor), S10MR (Medical Records), and S11IP (Infection Preventionist) were all present for the interview. S1DON stated MDS nurses were responsible for creating and updating resident care plans. S3MDSLPN denied there was anything in care plan that addressed monitoring the residents with boarded bed rails more frequently, nor any specific safety interventions related to the boarded rails in Residents #R1- #R4's care plan. S2ADM stated that the intervention to attach the wooden boards to the side rails of the beds for residents who required air mattresses was already in place when he became the administrator. He was not aware of the manufacturer's guidelines for the air mattress, the bed frame, or the manufacturer's safety recommendations for entrapment prevention when side rails were in use. He also stated that did question the wooden boards when he became administrator, but just went with it because there were no resident complaints or issues. He never checked the manufacturer's guidelines to ensure that the wooden boards were an appropriate attachment for the side rails. S2ADM confirmed the wooden boards were not an appropriate intervention to apply to the side rails. S2ADM confirmed S6REP (Medline Representative) reported that mattress stabilizers were on the corners of Resident #R1-#R4's bed that prevented the air mattress from lying flush on the bed frame causing the mattress to be unstable. S2DM confirmed these stabilizers were removed on 08/07/2024. It was unknown if Resident #1's bed had these stabilizers attached at the time of the accident.

Based on interviews and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to provide appropriate oversight to ensure the well-being of residents. The facility failed to have a system in place for residents to ensure the appropriate use, assessment, and monitoring of bed rails according to mattress manufacturer's guidelines to prevent resident entrapment for 5(#1, #R1, #R2, #R3, and #R4) of 5 (#1, #R1, #R2, #R3, and #R4) residents. This lack of administrative oversight resulted in an Immediate Jeopardy on 07/28/2024 at 1:00 p.m. when Resident #1 attempted to climb over the boarded side rail and became entrapped between the air mattress and the modified boarded bed rail attached to the resident's bed. An x-ray revealed the resident sustained a left femoral neck fracture which required transfer to the local hospital. Resident #1 underwent surgery for a closed reduction and percutaneous pinning for the left femoral neck fracture. The Immediate Jeopardy continued as Residents #R1- #R4 had the same type of bed, air mattress and modified bed rail as Resident #1. The facility failed refer to the manufacturer's recommendations for the proper use of bed rails, and appropriately assess and monitor the four remaining residents for the high likelihood of entrapment leaving the residents vulnerable to serious injury, serious harm, serious impairment or death. S1DON (Director of Nursing) and S2ADM (Administrator) were notified of an Immediate Jeopardy situation on 08/07/2024 at 1:25 p.m. The Immediate Jeopardy was removed on 08/08/2024 at 5:13 p.m., as confirmed by onsite verification through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Findings: Cross Reference F700 Review of the facility's policy titled, Administration, with a last revised date of 08/07/2024, read in part: Policy Interpretation and Implementation .1. a. managing the day - to - day functions of the facility .i. ensuring manufacturing recommendations are being followed by staff. On 08/06/2024 at 2:01 p.m. a joint interview was conducted with S1DON and S2ADM. S1DON stated that after Resident #1 became entrapped between the boarded bed rail and air mattress, Resident #1's bed was replaced with a new bed without boarded bed rails upon his return from the hospital on 07/30/2024. She and the MDS (Minimum Data Set) nurses assessed the residents who had air mattresses for safety. S1DON also stated there was a risk for any resident with bed rails to become entrapped between the bed rails and the mattress. The facility's administration felt the benefits of the boarded bed rails outweighed the risks of having them removed. She stated the facility's administration still felt the boarded bed rails were safe even if a resident was able to roll and become entrapped between the air mattress and boarded rail. She stated that maintenance installed the bed rails and attached the wooden boards to the rails for the residents with air mattresses as ordered. S1DON was asked if the facility utilized the manufacturer's guidelines to ensure the air mattresses were appropriate mattresses for the bed frames and bed rails. She replied that she would have to find those guidelines. S1DON then stated the air mattresses with bed rails with wooden boards attached had been in place when she began working at the facility over one year ago. S2ADM stated the facility was in the process of replacing the older beds in stages, but because of the cost, Residents #R1-#R4 were not given any of the new beds. S1DON confirmed that these 4 residents remained in the old beds with wooden boarded bed rails attached because those residents were just ordered to be on air mattresses within the last 1 to 2 months. S2ADM stated that there had not been any more orders for new electric beds as of 08/06/2024. S1DON further stated that CNAs (Certified Nursing Assistants) were in-serviced on not moving a resident if they become entrapped in the side rails of the bed after the incident occurred with Resident #1, however there was no specific training on resident entrapment prior to or after Resident #1's accident. S1DON also stated that the CNAs and nurses ensured that the bed rails were in place and residents were safe during their rounds by direct observation. Their charting only required that they document that the bed rails were in place as ordered. Resident #1's plan of care was then reviewed S1DON. She confirmed that the use of bilateral bed rails was an intervention for the resident, but there were no specific interventions or safety interventions for the use or monitoring of the bed rails prior to his accident. On 08/06/2024 at 3:04 p.m., a joint interview was conducted with S1DON and S3MDSLPN (Minimum Data Set, Licensed Practical Nurse). S3MDSLPN stated that the MDS nurses were responsible for completing the bed rail assessments and creating and updating care plans for all residents who utilized bed rails. Review of the assessments for Residents #1, #R1-#R4 was reviewed with S3MDSLPN who confirmed the assessment was not completed appropriately to include assessments of the residents' height and weight and bed dimensions. She confirmed the assessment failed to include other interventions that had been attempted prior to the use of the bed rails. Residents #1, #R1-#R4's care plans failed to reveal any interventions for the safe use of bilateral bed rails with a wooden board attachment including increased monitoring or safety interventions to prevent entrapment. It was confirmed there was evidence of ongoing monitoring for safe use of the boarded side rails for these residents after Resident #1's accident. S3MDSLPN stated had worked at the facility for several years and the process of using the air mattress and wooden boarded bed rails had always been in place. S1DON asserted that there was no issue with use of the mattresses and boarded bed rails at this time. S1DON was asked again to provide the manufacturer's guidelines for the beds and mattresses, but she could not provide them. On 08/07/2024 at 8:57 a.m., an interview was conducted with S5MAINTSUP (Maintenance Supervisor). He stated that he had been in maintenance for two years at the facility, and they have always used the boarded bed rails for beds with air mattresses. He stated that due to the height of the mattress, the boarded side rails were needed as a fail-safe, to keep residents from falling out of bed. He stated maintenance attached the boards to the bed rails of the beds. He did not refer to any manufacturer's guidelines or recommendations for the mattresses or beds to ensure they were compatible, safe, and approved by the manufacturer. He stated he simply did what the facility had always done which was attach wooden boards to the outside of the side rails for those residents who required air mattresses. He received the orders for the air mattresses from the administrative nurses, and placed the mattresses on the beds and was not sure if they had referred to any manufacturer instructions. S5MAINTSUP further stated that maintenance routinely inspected the side rails to ensure they were functioning properly, but he did not have any documented evidence of the inspection. On 08/07/2024 at 7:00 p.m., an interview was conducted with administrative staff. S1DON, S2ADM, S3MDSLPN, S7ADON (Assistant Director of Nursing), S8SSD (Social Services Director), S9CNASUP (Certified Nursing Assistant Supervisor), S10MR (Medical Records), and S11IP (Infection Preventionist) were all present for the interview. S1DON stated MDS nurses were responsible for creating and updating resident care plans. S3MDSLPN denied there was anything in care plan that addressed monitoring the residents with boarded bed rails more frequently, nor any specific safety interventions related to the boarded rails in Residents #R1- #R4's care plan. S2ADM stated that the intervention to attach the wooden boards to the side rails of the beds for residents who required air mattresses was already in place when he became the administrator. He was not aware of the manufacturer's guidelines for the air mattress, the bed frame, or the manufacturer's safety recommendations for entrapment prevention when side rails were in use. He also stated that did question the wooden boards when he became administrator, but just went with it because there were no resident complaints or issues. He never checked the manufacturer's guidelines to ensure that the wooden boards were an appropriate attachment for the side rails. S2ADM confirmed the wooden boards were not an appropriate intervention to apply to the side rails. S2ADM confirmed S6REP (Medline Representative) reported that mattress stabilizers were on the corners of Resident #R1-#R4's bed that prevented the air mattress from lying flush on the bed frame causing the mattress to be unstable. S2DM confirmed these stabilizers were removed on 08/07/2024. It was unknown if Resident #1's bed had these stabilizers attached at the time of the accident.

Based on observation, record review, and interview, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents during provision of care for 1 (#21) of 4 (#18, #21, #55, #60) residents investigated for accidents, of a total sample of 33 residents. This deficient practice resulted in an actual harm for Resident #21 on 07/28/2023 when S7CNA and S8CNA failed to adequately supervise the resident when they lowered the side rails of the bed and walked away from the resident during ADL (Activities of Daily Living) care. S7CNA and S8CNA failed to raise the resident's side rails when they moved away from the bed and Resident #21 fell out of his bed onto the floor. Resident #21 was sent to the ER (emergency room ) for evaluation after displaying excruciating pain. On 07/28/2023 an x-ray revealed that Resident #21 had a Trimalleolar fracture to his Left ankle. Resident #21 had an immobilizer with a boot to his lower Left extremity as the physicians have determined that the fracture is inoperable due to his non- ambulatory status and diagnoses. The facility implemented corrective actions prior to the State Agency's survey, thus it was determined to be a Past Noncompliance citation. Findings: A review of Resident #21's record revealed an admitted [DATE] and diagnoses including End Stage Dementia, Parkinson's disease, tremors, and a history of stroke. A review of Resident #21's MDS (Minimum Data Set) assessment dated [DATE] revealed that he was totally dependent on 2 persons for bed mobility, and transfers. A review of Resident #21's Care plan revealed that he was at risk for falls and/or fall related injuries. He was care planned for 2 person assistance. Interventions/tasks included: 7/28/23 fall with major injury from during resident care; transferred to ER for evaluation and treatment; Returned to facility with diagnosis of left ankle fracture secondary to fall related injury; left foot ankle brace as indicated. He was assessed with impaired neurological function and required assistance with ADLs (Activities of Daily Living), and Fall Precautions by staff. Resident #21's Care plan included that he had Self-Care Performance Deficits and required staff supervision and /or assistance with ADL's with interventions that included bilateral padded assist rails to HOB (Head of Bed) to aide in bed mobility/turning and repositioning. A review of written physician's orders dated 07/28/2023 revealed in part: Night staff responded during change of incontinence pad, patient fell from bed patient guarding right ankle is edematous .patient with poor verbalization, butt wincing . will transport to ER for evaluation .signed by physician. A review of a Nurse Incident and Accident Report revealed: Fall without injury 7/28/23 00:40 (12:40 a.m.). S7CNA and S8CNA reported the incident. Further review revealed CNAs were changing him and he pulled himself to the edge of the bed and fell off onto the floor. Left side. Diagnoses: Closed tri-malleolar fracture of left ankle. Page 3 of 5 included #5. Contributing factors: side rail put down too early. A hospital report dated 07/28/2023 included: Chief Complaint: patient presents with ankle pain, fell out of bed last night while getting changed at nursing home patient grimaces in pain . An X-ray report dated 07/28/2023 at 2:19 p.m., revealed that Resident #21 had sustained a left Trimalleolar ankle fracture. A review of an office visit note by the orthopedic surgeon dated 08/10/2023 was conducted. The note included, in part: left ankle injury, patient with displaced bi-malleolar ankle fracture. Plan: Pt with bi-malleolar ankle fracture which by definition we would benefit from operative intervention. Given his non-ambulatory status as well as end-stage dementia we discussed this with daughter, despite will attempt non-operative treatment. We will place him in a boot. On 08/21/2023 at 8:45 a.m., an observation of Resident #21 was conducted. He was in his bed, on his right side. An immobilizer and boot were noted to the lower extremity of left leg. S4LPN stated that he had fallen in July and fractured his ankle. S10CNA was present in the resident's room and stated that she has been working with him since May 2023. She stated that he was totally dependent on staff for repositioning and turning in his bed. She further stated that Resident #21 was not able to get out of bed on his own. On 08/21/2023 at 10:05 a.m., an interview with S10CNA was conducted. She stated that on 07/28/2023 she had received report from two agency aides that were going off duty earlier that morning Resident #21 had fallen. She stated that later that morning she and S9CNA were getting the resident ready for his bath. She took off his sock and she noticed he was in excruciating pain, and he grabbed her hand and would not let go. On 08/21/2023 at 1:40 p.m., an interview was conducted with S9CNA. She stated that when she went to put Resident #21's socks on he hollered and yanked back. S9CNA stated that she noticed that his left ankle was swollen and she informed S6LPN. On 08/21/2023 at 1:50 p.m., an interview was conducted with S6LPN. She stated that on 07/28/2023, she had received report from the off going nurse that Resident #21 had fallen in the night. She stated that she had been informed that 2 aides were changing the resident's brief, they rolled him to change him and he ended up out of bed. S6LPN stated that he had not been sent to the ER (emergency room ) at that point, but later that day the aide came to report that his ankle was swollen. S6LPN stated that when she assessed him he grimaced and flinched. She stated that orders were obtained by the physician to send to him to the ER for evaluation and he was diagnosed with a fracture to his left ankle. On 08/22/2023 at 10:34 a.m., a telephone interview was conducted with agency CNA, S8CNA. She confirmed that she was familiar with Resident #21 and was working with him on 07/28/2023 when he fell out of bed. She stated that she was working with another aide, who had put his bed side rail down and had moved away from the side of the bed. She stated that Resident #21 rolled out of bed on the side with no bed rail and fell on to the floor. On 08/22/2023 at 10:40 a.m., a telephone interview was conducted with agency CNA, S7CNA. She confirmed that she worked with Resident #21 on 07/28/2023 when he fell out of bed, and further stated that this was the first time she had worked with him. She stated that another agency aide was working with her that morning. Resident #21 had scooted to the bottom of his bed, nearer to the foot of the bed. She stated that she was on the left side of his bed and she had lowered the left bed side rail, and then she moved away from the side of the bed to assist the other CNA. S7CNA stated that she had not raised the rail when she left the side of the bed, and the resident turned to the left and fell out of the bed onto the floor. On 08/22/2023 at 12:44 p.m., S18HR provided personnel files for agency CNA's, S7CNA and S8CNA and stated that all training provided to them was included in the files. A review of S7CNA and S8CNA's personnel files failed to reveal proficiencies and/or competencies in providing safe ADL care to prevent accidents during repositioning in bed or transferring. Further review of the personnel files failed to reveal competencies on ensuring side rails are kept up during ADL care so residents will not roll out of bed. On 08/22/23 1:00 p.m., concurrent interviews were conducted with S1DON and S2ADON. The facility's Incident and Report for Resident #21` dated 07/28/2023 was reviewed. Both confirmed the staff in-services included that when changing Resident #21 if you put down both side rails then one person needs to be on each side of resident to ensure resident does not roll out of bed. If only one person changing then the side you are turning res towards you need to keep side rail up to protect res from rolling off bed. S21ADON confirmed that she had conducted the in-service with the staff related to Resident #21 rolling out of his bed during ADL care. S1DON confirmed that no competencies had been conducted on the agency aides S7CNA and S8CNA, ensuring that they were competent in skills and techniques necessary to care for residents' needs in a manner to prevent accidents. Review of in-services, CNA competencies, interviews with multiple CNAs, and observations during the survey revealed the following Corrective Action Plan was implemented. The facility has implemented the following actions to correct the deficient practice: 07/28/2023- Continuous Quality Assessment and Improvement Corrective Action Plan: 07/28/2023- In-service conducted for all staff to ensure side rails are up during ADL care for the resident, and dealing with combative residents. 07/28/2023- CNA Competency, including agency CNAs, on skills including remaining with resident when side rails are down and raising side rails if moving away from the resident. The facility staff were trained on 07/28/2023. All staff were trained before beginning their shifts. Agency and new staff are trained upon entrance to the facility. Substantial compliance was obtained on 07/28/2023. Monitoring of staff ongoing until 09/21/2023.

Based on record review interview, and observations, the facility failed to ensure the resident's care plan and physician's order(s), were followed for 4 (#2, #18, #21, #44) out of 33 sampled residents. This was evidenced when the: 1. Facility failed to ensure Resident #21 had a right heel protector. 2. Facility staff failed to ensure Resident #2 did not exceed his 24 hour 1000 ml (Milliliters) fluid restriction. 3. Facility failed to ensure Resident #44 had bilateral hand rolls. 4. Facillity failed to ensure Resident #18 had a bed alarm. Findings: Resident #21: A review of Resident #21's record revealed an admitted [DATE]. A review of wound care documentation revealed that Resident #21 had pressure ulcers to his bilateral buttocks, his right knee, right inner thigh, and right shin. A review of Resident #21's 07/21/2023 MDS (Minimum Data Set) assessment revealed that he was totally dependent on 2 staff for bed mobility and for transfers. A review of Resident #21's Care Plan revealed that he had self-care performance deficits and required staff supervision and or assist with ADLs (Activities of Daily Living) related to impaired mobility. An intervention for staff to ensure a heel protector to Resident #21's right foot at all times, was noted. A review of orders and task descriptions for the aides revealed right heel protector on at all times. On 08/20/2023 at 12:23 p.m., an observation was conducted of Resident #21 in his bed. An observation of an immobilizer with a boot with a hard bottom was noted to his left lower leg. No heel protector was noted on his right foot. On 08/21/2023 at 8:45 a.m., an observation was conducted of Resident #21 during wound care. No heel protector was noted to his right foot. On 08/21/2023 at 10:05 a.m., an observation was conducted of Resident #21. No heel protector was noted to his right foot. On 08/22/2023 at 11:20 a.m., an observation of Resident #21 was conducted concurrent with an interview with S10CNA. No heel protector was observed on Resident #21's right foot. S10CNA confirmed that no heel protector was on the resident's right heel. She reviewed the task list for Resident #21, and confirmed that the order was to ensure the right heel protector was on at all times. On 08/22/2023 at 11:30 a.m., an interview was conducted with S2ADON. She confirmed the order for placement of a right heel protector on at all times for Resident #21, and stated that the order was started on 01/28/2023. She conducted an observation of the resident and confirmed that no heel protector had been placed on the right heel. S2ADON confirmed that staff had failed to follow the order to place the right heel protector to Resident #21's at all times to his right heel. 41419 Findings: Resident #2 Review of Resident #2's electronic clinical record revealed an admitted [DATE] with diagnoses that included Stage 4 kidney disease, Anemia, Type 2 diabetes, Hypertension, and Edema. Review of Resident #2's physician orders revealed the following order dated 05/02/2020: Fluid restriction of 1 Liter which is 1000 milliliters (ml) per day every shift. Review of Resident #2's Care Plan dated 08/11/2023 revealed the following in part: Impaired renal function related to Chronic kidney disease. Intervention: observe for adequate intake and output every shift; 1000 ml fluid restriction. Review of a document titled Nurse Intake & Output Record (3 shifts) revealed: On 08/09/2023 total intake for 24 hours was 1060 ml On 08/10/2023 total intake for 24 hours was 1140 ml On 08/12/2023 total intake for 24 hours was 1040 ml On 08/13/2023 total intake for 24 hours was 1040 ml On 08/17/2023 total intake for 24 hours was 1140 ml On 08/18/2023 total intake for 24 hours was 1200 ml On 08/19/2023 total intake for 24 hours was 1170 ml On 08/20/2023 total intake for 24 hours was 1140 ml On 08/22/2023 at 3:45 p.m., an interview was conducted with S15LPN (Licensed Practical Nurse) who stated that Resident #2 had a 24 hour 1000 ml fluid restriction. She confirmed that the resident should not have received more than 1000 ml of fluids per day. 47123 Resident # 44 Findings: Review of Resident #44's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Cervical Disc Disorder, Spinal Stenosis, , Schizophrenia, Bipolar Disorder, Unspecified Asthma Review of Resident #44's care plan revealed the following in part: Resident has an alteration in musculoskeletal function; is at risk for joint discomfort/pain, contracture formation, fractures and or complications r/t (related to) decreased mobility, dx (diagnosis) of age related osteoporosis, myotonic disorders, cervical myelopathy, ulnar neuropathy of left upper extremity, spinal stenosis of cervical region, cervical myelopathy. Interventions: hand roll to bilateral hands at all times except during bathing. On 08/20/2023 at 03:25 p.m., an observation was conducted of Resident #44. Her left hand was contracted. No hand rolls were observed to the resident's hands. On 08/21/2023 at 12:12 p.m., a second observation was conducted of Resident #44 in the dining room. There was a hand roll to the resident's left hand. There was no hand roll to the resident's right hand. On 08/21/2023 at 3:39 pm., an observation and interview was conducted with Resident #44. A hand roll was in the resident's left hand. Resident #44 stated she only had 1 hand roll. On 08/21/2023 at 3:59 p.m., an interview and observation was conducted with S15LPN (Licensed Practical Nurse). She entered Resident #44's room and observed only a left hand roll. S15LPN searched the Resident's room, and was not able to find the other hand roll. S15LPN confirmed Resident #44 should have bilateral hand rolls at all times to prevent further contractures, and did not. 47251 Resident #18 Findings: Review of Resident #18's electronic health record revealed he was admitted on [DATE] with a diagnosis that included Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease affecting right dominant side. Review of Resident#18 Quarterly MDS (Minimum Data Set) dated 06/21/2023 revealed a BIMS (Brief Interview of Mental Status) of 9 indicating moderately impaired cognition. Review of Resident's care plan interventions for falls included an intervention for bed alarm used daily. On 08/22/2023 at 10:50 a.m., an observation and interview with S10CNA (Certified Nursing Assistant) revealed that Resident #18 did not have a bed alarm. S10CNA stated that Resident #18 did not have a bed alarm or chair alarm. On 08/22/2023 at 10:55 a.m., an interview was conducted with S6LPN. She stated that Resident #18 did not have a bed alarm or chair alarm and has not had any alarms that she was aware of. On 08/22/2023 at 11:10 a.m., an interview and observation was conducted with S1DON, who stated that Resident #18 did not have a bed alarm. An observation of Resident #18's current care plan was conducted with S1DON who confirmed that the interventions for the resident were not implemented.

Based on observation, record review, and interview, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services to prevent new ulcers from developing for 1 (#21) of 3 (#21, #43, #60) residents investigated for pressure ulcers, of a total sample of 33 residents. Findings: A review of Resident #21's record revealed an admitted [DATE] and diagnoses including Parkinson's disease, tremors, and a history of stroke. A review of Resident #21's care plan was conducted and included that he was planned for Pressure Ulcers/Skin Impairment related to decreased mobility, fragile aged skin, and history of skin impairment. Interventions included to use positional devices as needed i.e. foam wedges, pillow, etc. A review of S17NP's wound assessment on Resident #21 dated 08/16/2023 revealed that the NP (Nurse Practitioner) had identified and assessed 4 wounds; right buttock, left buttock, right knee, and right inner thigh. No identification of a wound to Resident #21's right mid shin was noted. A review of Resident #21's progress notes and skin assessments were conducted and included, in part: 8/14/2023 weekly skin assessment head to toe: unstageable pressure ulcer noted to left buttocks, stage 4 pressure ulcer right buttocks, skin tear to right knee, blister to inner right thigh - ruptured, abrasions noted to left shin, left ankle swollen entry by S5LPN. 08/16/2023 at 2:10 p.m. skin wound note: S17NP did wound care rounds to resident and noted: 1- R buttocks unstageable, 2- lateral l buttocks stage 4, 3- R knee skin tear, 4- R inner thigh stage 2. No mention of a wound to Resident #21's right mid shin was documented .entry by S5LPN; and 08/21/2023 at 8:41 a.m. Lamb's wool ordered per -MD name--for skin integrity .entry by S5LPN. Further review of the progress notes failed to reveal evidence of a wound to Resident #21's right mid shin. A review of orders and task descriptions for the aides revealed Lamb's wool to be placed between legs at all times while in bed. On 08/20/2023 at 12:05 p.m., an observation of Resident #21 in his bed was conducted. He was lying on his right side. Both knees were drawn up towards his stomach, and appeared contracted. Lamb's wool was noted placed partially between his legs. A wound dressing dated 08/20/2023 was noted to his right mid shin area. The boot of his immobilizer was noted to be sitting on the mid shin dressing. The lamb's wool was not covering the dressing nor was it preventing the boot of the immobilizer on his right leg to come into contact with his left leg. On 08/21/23 at 8:45 a.m., an interview with S5LPN, wound care nurse, concurrent with an observation of wound care conducted on Resident #21 was made. S10CNA was present assisting with the positioning of the resident during wound care. S5LPN stated that she had been providing wound care to the resident since April 2023. She stated that Resident #21 currently had multiple pressure ulcers and wounds that she was providing wound care to. She stated that the resident had a pressure ulcer to each buttock, one skin tear to his right ankle, a blister that had ruptured to his right inner thigh, and skin tear to his right knee. She that Resident #21 had an immobilizer with a boot on his lower left extremity and stated that staff were to place the lamb's wool between the resident's legs, ensuring that the boot did not come into contact with the resident's right leg to prevent further skin issues. During the provision of wound care the lamb's wool was observed not situated between the entirety of his lower extremities and the boot of the immobilizer was sitting on a dressing dated 08/20/2023, located to his right mid shin area. S5LPN stated that she has not seen the wound to his mid shin area before, that this was a new wound that she had not seen before now. She confirmed that the boot was sitting on the dressing dated 08/20/2023. S5LPN confirmed that lamb's wool was not covering the resident's entire right leg and not protecting it from the boot on his left foot. S10CNA confirmed that the lamb's wool had not been placed between the resident's legs to prevent the left foot boot from coming into contact with the resident's right leg. On 08/22/2023 at 11:15 a.m., an interview was conducted with S5LPN. She stated that on 08/09/2023 the physician ordered the lamb's wool to be placed between the resident's legs at all times while in bed to prevent further pressure ulcer formation. On 08/21/2023 at 2:11 p.m., an interview was conducted with S2ADON. She reviewed the S17NP's wound care note dated 08/16/2023 for Resident #21. She confirmed that S17NP had not identified a wound to resident's right mid shin area. S2ADON confirmed that a new wound had developed to this area between the NP's assessment on 08/16/2023 and 08/20/2023.

Based on record review and interview, the facility failed to provide the estimated cost for services for which the residents may be responsible for paying for 2 residents (#337 and #338) of 3 sampled residents for Advanced Beneficiary Notice of Non-Coverage (ABN). Findings: Residents #337 and #338 were both issued ABN notices which included elected services and reasons why Medicare may not pay for these services. Residents #337 and #338 elected Option 1. Which included in part, I want the services listed above. I understand that if Medicare does not pay, I am responsible for payment. The estimated cost for these services on the notices were incomplete. On 08/22/2023 at 9:25 a.m., an interview was conducted with S3SSD (Social Services Director) who stated that she did not include an estimated cost for services for Residents #337 and #338's ABN notices. She agreed that the residents should be notified of the amount of cost for services that they may be responsible to pay. S3SSD confirmed that there was not an estimated cost for services on the ABN signed by the resident/responsible party and should have been.

Based on record review and interview, the facility failed to ensure a Discharge Minimum Data Set (MDS) assessment was completed timely for 1(#64) out of 22 total sampled residents. Findings: Review of Resident #64's medical record revealed he was admitted on [DATE] and discharged from the facility on 05/19/2023. Review of Resident #64's electronic clinical record failed to reveal that a Discharge MDS assessment was completed and transmitted within 14 days after the resident was discharged from the facility. On 08/21/2023 at 4:10 p.m., an interview and record review of Resident #64's EHR (electronic health record) was conducted with S11MDSLPN. She confirmed that Resident #64's did not have a discharge MDS assessment. She confirmed that a discharge MDS assessment should have been completed and transmitted within 14 days after a resident is discharged from the facility on 05/19/2023.

Based on record review and interview, the facility failed to refer residents with newly diagnosed mental disorders or had a significant change in their mental condition to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) for evaluation and determination for 1 resident ( #9) of 3 (#9,#18, #20) residents investigated for PASARR in a final sample of 33 residents. Findings: Resident #9 was admitted to the facility on [DATE] with diagnosis not limited to Anxiety Disorder. Review of Resident #9's health record revealed she was diagnosed with a new diagnosis of Major Depressive Disorder Recurrent Severe with Psychotic Symptoms on 08/17/2021. Further review of Resident #9's health record failed to reveal a Level II PASARR had been submitted to the appropriate state-designated authority. On 08/21/2023 at 10:31 a.m., an interview was conducted with S3SSD (Social Services Director). She stated Resident #9 had a Level 1 PASSR on 01/22/2020 . She confirmed Resident #9 had a new diagnosis of Major Depressive Disorder Recurrent Severe with Psychotic Symptoms on 08/17/2021. S3SSD stated a new Level 1 PASARR should have been completed with the new diagnosis.

Based on record review and interview, the facility failed to ensure residents identified with Mental Disorder and/or Intellectual Disability had a (PASARR) Pre-admission Screening and Resident Review Level I and/or Level II for 1 (#20) of 3 (#9, #18, #20) residents reviewed for PASAAR screening. Findings: Review of Resident #20's clinical record revealed he was admitted on [DATE] with diagnoses that include: Essential Hypertension, Major Depressive Disorder- Recurrent Unspecified, and Paranoid Schizophrenia. Further review of Resident #20's clinical record revealed he was diagnosed with Schizophrenia on 02/22/2016. Review of Resident #20's quarterly MDS (Minimum Data Set) assessment, dated 07/11/2023, revealed a diagnosis of Schizophrenia. Further review of Resident #20's clinical record failed to reveal a completed PASSAR screening. On 08/21/2023 at 10:31 p.m., an interview was conducted with S3SSD (Social Services Director), who was responsible for ensuring PASARR screenings were completed. She stated Resident #20 was a transferred from another facility on 04/17/2013. She stated there was no PASARR in his records. S3SSD stated one should have been completed when Resident #20 was admitted .

Based on observations, records reviews, and interviews the facility failed to ensure respiratory equipment was properly stored when not in use for 1 (#44) of 1 (#44) residents investigated for respiratory care out of a total sample of 33 residents. Findings: Review of the facility's policy titled Administering Medication through a Small Volume (Handheld) Nebulizer) read in part: Steps in the Procedure .27. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Resident #44 was admitted to the facility on [DATE] with a diagnosis in part: Unspecified Asthma Review of Resident #44's August 2023 Physician's Orders revealed Duoneb Solution 0.5-2.5 mg (milligrams)/3ml (milliliter) 1 vial inhale orally two times a day for COPD (Chronic Obstructive Pulmonary Disease) On 08/20/2023 at 09:33 a.m., an observation was made of Resident #44's nebulizer machine. It was observed on the bedside table with the tubing and the mask on the table and not in a bag. On 8/20/2023 at 11:21a.m., a second observation was made of Resident #44's room. The Nebulizer machine was observed on the bedside table with the tubing, and the mask was on the table and not in a bag. On 8/20/2023 at 3:22 p.m., a third observation was made of Resident # 44's room. The Nebulizer machine was observed on the bedside table with the tubing on the table along with the mask and not stored in a bag. On 8/20/2023 at 3:22 p.m., an interview was conducted with S2ADON. She confirmed the nebulizer tubing and mask was on the resident's bedside table and not stored in a bag. She stated after the resident uses the mask, it should be placed in a plastic bag when it is not in use. S2ADON confirmed that Resident #44 was not capable of applying or removing her nebulizer mask without assistance.

Based on interview and record review, the facility failed to collaborate with a hospice agency to ensure a resident had a Hospice Plan of Care for 1 (Resident #17) out of 2 (#17, #21) sampled residents for hospice care. Findings: Review of the facility and hospice agency's contract titled Nursing Facility Services Agreement dated 10/01/2019 read in part: Agreements: (i) Plan of Care means a written care plan established, maintained, reviewed and modified, at intervals identified by the Interdisciplinary Group (IDG). The plan of care must reflect hospice patient and family goals and interventions based on the problems identified in the hospice patient assessments. (d) Coordination of Care. (ii) Design of Plan of Care - In accordance with applicable federal and state laws and regulations, facility shall coordinate with hospice in developing a plan of care for each hospice patient. Hospice retains primary responsibility or development of the plan of care. 6. Records: Creation and Maintenance of Records. Facility shall prepare and maintain complete and detailed records concerning each hospice patient receiving facility services under this agreement in accordance with prudent record-keeping procedures and as required by applicable federal and state laws and regulations and Medicare and Medicaid program guidelines. Review of a document titled Hospice Program read in part . 12. the hospice provider is responsible for the following: d. obtaining the following information from the hospice: (1) the most recent hospice plan of care specific to each resident. (4) Names and contact information for hospice personnel involved in hospice care of each resident. Review of Resident #17's clinical record revealed he was admitted to the facility on [DATE] with diagnoses that included Senile degeneration of brain, Malignant neoplasm of prostate, Acute myeloblastic leukemia, Chronic kidney disease, and Type 2 diabetes mellitus. Further review of the clinical record revealed a physician order dated 06/29/2023 to admit to hospice. On 08/22/2023 at 7:30 a.m., an interview and record review was conducted with S16LPN (Licensed Practical Nurse). S16LPN was asked to provide Resident #17's hospice binder with the plan of care. S16LPN stated that the resident did not have a hospice binder or plan of care. An review of the resident's hard chart was conducted with S16LPN, which failed to reveal any information related to his hospice care. S16LPN stated that the resident was admitted into the facility on hospice care. She confirmed that a binder was never completed for Resident #17, and a plan of care should have been completed.

Based on observations and interviews, the facility failed to maintain an effective pest control program by failing to ensure to facility was free from cockroaches. The deficient practice had the potential to affect 83 residents who resided in the facility. Findings: Review of the facility's policy Pest Control, read in part our facility shall maintain an effective pest control program .1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. On 08/21/2023 at 8:36 a.m., an observation in the beauty shop revealed a live cockroach by the soap dispenser. S14MAINT verified there was a cockroach. On 08/21/2023 at 8:46 a.m., a second observation of a live cockroach was visualized by the bathroom door in the beauty shop. S12ADMIN and S13MAINTSUP were present and confirmed the cockroach. S13MAINSUP stated the trees were recently cut and they are having a Cockroach problem. On 08/21/2023 at 9:00 a.m., a third observation of a live cockroach was observed on the wall of the beauty shop. S13MAINTSUP confirmed the third cockroach.

Based on observations and interviews, the facility failed to maintain a clean and sanitary environment as evidenced by: 1. multiple cockroaches in the facility; 2. multiple pads, fitted sheets, flat sheets, and pillow cases were stained or torn. This deficient practice had the potential to affect all 80 Residents residing in the facility. On [DATE] at 8:44 a.m., an initial walkthrough of the kitchen was conducted with S6DM. The refrigerator and freezer that are both located outside of the kitchen under an awning. Two large deceased cockroaches were found by the refrigerator and two more deceased roaches were found by the door. Further observation of the dry storage room revealed one deceased cockroach on the floor. Another deceased cockroach was observed in the kitchen under the metal sink. S6DM confirmed cockroaches should not be in the kitchen and food storage areas. On [DATE] at 11:26 a.m., one large brown cockroach was observed running under the surveyor's chair. S2AA witnessed it, grabbed it with a tissue paper and discarded it. S2AA stated the facility should not have cockroaches On [DATE] at 9:07 a.m., an observation of .and interview was conducted with S7HLS. A stack of linen was observed in the clean linen bin. Closer observations of the linen inside the clean linen bin revealed stained, and ripped fitted sheets, along with stained pads, and stained pillow cases. S7HLS then went through the entire bin. Multiple stained pads and torn fitted sheets were observed. A total of 35 pads, 32 flats, 25 fitted and 10 pillow cases were observed with stains or tears. S7HLS stated the linen should not have tears or stains in them, and that it should have been discarded.

Based on record review, interview and observation, the facility failed to ensure that two (#29 and #137) of seven residents (#1, #25, #29, #37, #55, #57and #137) received adequate supervision and assistance to prevent accidents by failing to: 1. ensure transportation staff was trained and competent on the facility's transportation policy/procedure, 2. ensure all transportation drivers had current and valid driver's licenses, 3. ensure staff licensure was submitted to the facility's contract insurance agent, 4. obtain a motor vehicle report as per facility policy prior to staff being allowed to provide transportation to residents and, 5. ensure resident #29 was provided adequate supervision, staff assistance, an appropriate assistive device, and coffee at an appropriate temperature as to prevent 2nd degree burns. This deficient practice resulted in an Immediate Jeopardy situation on 7/5/19 at 1643 hours (4:43 PM) for Resident #137 when the resident was transported in the facility's transportation van by S3CNA who was untrained and did not have a current/valid driver's license. Resident #137's seatbelt was not secured during transport which resulted in the resident being ejected from her wheelchair to the floor of the van during a motor vehicle accident. The resident was transported to a local hospital and admitted with a non-displaced distal left radius fracture. The facility implemented corrective actions on 7/5/19 prior to the resident's admission to the facility on [DATE]. In-service training, policy implementation and monitoring occurred prior to State Agency's investigation, thus the Immediate Jeopardy was determined to be Past Noncompliance. This deficient practice resulted in an Immediate Jeopardy situation on 7/30/2019 at 5:00 a.m., for Resident #29 when the resident was given a water pitcher containing hot coffee, with a facility reported temperature of 150 degrees, and was left alone with no staff supervision or assistance. The resident, whose [DIAGNOSES REDACTED]. The facility implemented corrective actions which included the immediate removal of the coffee pot and in-servicing of the staff prior to the State Agency's investigation, thus the Immediate Jeopardy was determined to be Past noncompliance. On 8/8/19 at 11:05 AM, S1AAdm was notified of the Past Noncompliance IJs for Residents #29 and #137. Findings: Resident #137: Review of facility policy and procedure revealed: Policy: Transportation Drivers must meet all of the facility mandated qualification, verification checks, and training prior to transporting resident in order to maintain highest level of safety. Additional training should be provided as needed but must be conducted annually .Procedures: 1. Transportation drivers must meet staff qualification including a criminal history check. 2. Transportation drivers must be legally licensed. Administrator or designee will submit a copy of driver's license to their (insurance company) who will obtain a Motor Vehicle Report from insurance company. 4. Administrator will conduct competency skills check list with transportation driver prior to any resident transports . 6. Transportation Drivers must visually inspect van for serviceability prior to driving and maintain routine service as needed. Immediately report any van parts needing servicing or repair to the Administrator. Drivers must inspection tags . Review of hospital records revealed Resident #137 was seen at _____ hospital on [DATE] at 6:28 PM. The hospital's emergency department records revealed the following in part, .Motor Vehicle Crash .bilateral knee pain from MVC, was in transport van and fell out of wheelchair due to single vehicle crash XXX[AGE] year-old .female with history of [MEDICAL CONDITION] hypertension presents to ER for evaluation after a MVC just prior to arrival. Patient was discharged from (rehab hospital) and was being transferred to (facility). Patient was in a wheelchair that was secured in the transport van however the patient was not secured into the wheelchair. Patient reports that the van went off the road and struck a fence. She was ejected from the wheelchair and landed onto her knees. She denies striking her head or loss of consciousness. She complains of right shoulder, left wrist, bilateral hip, bilateral knee, and bilateral foot/ankle pain. Scattered bruises and abrasions noted .History provided by: Patient x-ray of the left wrist shows a non-displaced distal radius fracture .Diagnosis: [REDACTED]. Motor vehicle collision, initial encounter 3. Contusion of left knee and lower leg, initial encounter . During an interview with S1AAdm on 8/6/19 at 1:25 PM, she reported that Resident #137 was in transit in to the nursing home in the facility's transportation van on 7/5/19 when the facility van was involved in a motor vehicle accident. S1AAdm stated that Resident #137 was picked up by the facility's staff, S3CNA, from a rehab hospital, and was coming to the facility to be admitted for further rehab services. Review of the facility's investigative report completed by S2DON revealed that Resident #137 reported to S2DON that .she was unbuckled . Further review of this report confirmed that Resident #137 sustained a wrist fracture. Review of the police report revealed the following in part, .On (MONTH) 5, 2019 at 1643 hrs., I, PO was in the Eastbound left turning lane near Road waiting to make a left hand turn onto ___ Street when I observed a vehicle behind me suddenly veer off the roadway next to my left and impact a fence and metal pole at___ Street causing damage to the fence and pole. Upon making contact with the vehicle, I observed the air bags deployed and the passenger had been ejected from her wheelchair she was being transported in and asked if everyone was ok. Both the driver of vehicle 1 and the passenger advised of being shaken up and the passenger stated she had knee and leg pain. I also observed the passenger to be bleeding from her nose where it appeared she impacted the dash board. Driver and passenger of vehicle 1 both stated the brakes failed when the driver attempted to slow down for the traffic light at the intersection. The driver stated her brake light on her driving console had come on earlier in the day and when she attempted to brake at the intersection the brake did not work. Due to the condition of the vehicle, I was unable to test the brake system to ensure the brakes did fail. The passenger of vehicle 1 was transported to ____ Hospital. Driver of vehicle 1 was cited for driving with a suspended license. Record review revealed a vehicle inspection conducted by a transmission service on 8/1/2019 which indicated in part, Dodge [MEDICATION NAME] .Facility's Name .Vehicle was inspected by ASE Certified Mechanic. It was determined that the vehicles brakes are working properly . During further interview with S1AAdm on 8/6/19 beginning at 2:30 PM, S1AAdm stated that S3CNA had not received training in transporting residents, and had not officially been assigned as a van driver. S1AAdm reported it was unknown who instructed S3CNA to pick up Resident #137 and transport her to the facility in the facility's transportation van. S1AAdm stated S3CNA was initially hired for activities and later received her CNA certification and had been working the floor as a CNA since her certification. S1AADM confirmed that the facility only had copy of a Louisiana Identification Card issued 10/21/15 for S3CNA. She confirmed the facility did not have a copy of a current valid driver's license for S3CNA on file. She reported that their contracted insurance agent runs driver's license checks and driving histories on staff that are assigned to drive the provider's transportation van. S1AAdm confirmed that through the provider's investigation, it was determined that the seatbelt that attached to Resident #137's wheelchair was secured, but the second seatbelt which was to be secured around Resident #137's shoulder and waist had not been secured at the time of the MVA. When asked if this seat belt should have been secured around Resident #137, she stated, Yes. When asked if S3CNA should have been driving the facility's transportation van, S1AAdm stated, No. She stated that S3CNA reported that the brakes on the van were not working at the time of the incident. S1AAdm reported and presented a statement by one of the facility drivers, S6CNA, who reported driving the vehicle earlier on 7/5/19 with no incident. Review of a written statement by S7Maint (no date) revealed the following in part, On the day of the accident, I was contacted by (S3CNA) on the facility phone. She stated that BRAKE light was ON on the dashboard. She then stated that she wasn't in the van. I told her that when she got back in, to check the emergency brake to see if that was the cause for the light, and if the light did not turn off, to call me back. I never received a call or text from her after this conversation . During interview with S2DON on 8/7/19 at 1:40 PM, S2DON confirmed that the type of seat belt that was attached to the facility's transportation van at the time of the 7/5/19 incident with Resident #137, was a shoulder/lap belt. S2DON confirmed that the second belt in the facility's transportation van attached to secure the wheelchair. S2DON stated Resident #137's shoulder/lap belt was not secured while being transferred via the facility van. During interview with S1AAdm, S2DON, and S5RN on 8/7/19 starting at 2:00 PM, S1AAdm reported the provider did not keep transportation logs at the time of the incident, but have implemented one since. She stated that she would not have record of S3CNA ever providing transportation, because S3CNA had not been assigned as one of the official transportation drivers. She reported S3CNA's driving and transporting Resident #137 was an isolated incident; that S3CNA was not an official van driver; that the provider did not know who asked S3CNA to transport Resident #137. S1AAdm stated that the facility was responsible to ensure the safe transport of Resident #137 on 7/5/19. S5RN confirmed she assessed the resident to ensure the facility was able to meet her needs and determined she could be safely transported in the facility van. Interview on 8/8/19 at 11:05 AM with S1AAdm, S1AAdm stated the following interventions were put into place for their transportation services: 1. The facility's transportation services was suspended pending training and verification of valid and current licensure, driving records, and that each driver was covered and approved by the facility's insurance; that all 5 identified facility drivers had documented skills competency in transportation policy, loading/unloading, securing, transporting, and had in-services with documented evidence of such. She confirmed the following were the 5 identified facility drivers: S6Driver/CNA, S11 Driver/CNA, S12 Driver/CNA, S13 Driver/CNA, and S14Driver/CNA. 2. S3CNA did not report back for work with the facility. 3. In-service training was conducted. 4. Verified that Resident #137 was appropriate for transfer in the facility transportation van as previously assessed by S5RN. 5. The facility had the accident van brakes checked and the brakes at the time of the check were working per mechanic service (van no longer in use as of the date of the incident); maintenance had documentation of check of facility vans, inspections, and license up to date on the accident van and current other facility vans in use. 6. The facility implemented record keeping of their transportation services and drivers. 7. The facility implemented a policy change that only trained, competent, and approved drivers were allowed to transport residents. 8. The facility implemented a quality assurance plan related to the incident which ensured the monitoring of staff compliance with facility policy, staff qualifications, training, and competency to ensure this type of incident did not recur. The facility had implemented the following immediately post incident and prior to State Agency entrance on 8/5/19 and subsequent investigation: 1. Resident #137 was immediately brought via ambulance post incident. There were no other incidents related to resident injury while being transported by the facility's transportation service. The facility identified all residents who could or could likely be affected by this deficient practice. 2. S3CNA did not return to work post incident. 3. The facility immediately suspended transportation services, and ensured training and verification that all 5 identified facility drivers had evidence of documented in-services and skills competency in transportation policy, loading/unloading, securing, and transporting for S6Driver/CNA, S11 Driver/CNA, S12 Driver/CNA, S13 Driver/CNA, and S14Driver/CNA. 4. The facility ensured current and valid driver's licenses for all facility drivers, and ensured a driving history was conducted on each of the 5 identified, trained, and deemed competent drivers. The facility had documented evidence of driving records run and approved on 7/5/19 by the provider's insurance agent who reported S6Driver/CNA, S11 Driver/CNA, S12 Driver/CNA, S13 Driver/CNA, and S14Driver/CNA all had drivers' records deemed acceptable, and have been added to the policy. An addendum to the facility Transportation Driver Policy was made to include licensing information. 5. The facility ensured verification of that the 5 identified CNA/Drivers were covered and met the requirements with the provider's contracted insurance agent. S6Driver/CNA, S11 Driver/CNA, S12 Driver/CNA, S13 Driver/CNA, and S14Driver/CNA. 6. The facility in-services all nursing staff in their new process regarding the transportation of residents or potential residents in the facility's transportation van. Only licensed, approved, insured, trained, and skills competent drivers were currently allowed to be given the keys to the transportation van for resident transport. 7. The facility ensured their procedure for assessment and identification of residents appropriate for transfer. 8. Maintenance had documentation of checks of facility vans, including inspections and licensure. 9. The facility implemented record keeping of their transportation services and drivers. 10. The facility had evidence of implementing a quality assurance plan related to the incident which ensured the monitoring of staff compliance with facility policy, staff qualifications, training, and competency to ensure this type of incident did not recur. The facility monitoring on 7/8/19 to include observations of driver qualification, loading the resident, securing the wheelchair and securing the passenger. Monitor was done 5 x per week x one week, 2 times a week times 1 week and weekly times two by S5RN. A log was given to S2DON for review. Preliminary monitoring completed 7/31/19. Monitoring to continue monthly by S5RN. Resident #29 Review of the policy and procedure labeled as Assistance with Meals revealed that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Review of Resident #29's record revealed an admitted [DATE] and [DIAGNOSES REDACTED]. Review of Resident #29's Quarterly MDS dated [DATE] revealed the following: The resident was coded to have a BIMS score of 10, which indicated moderately impaired cognition. Review of the resident's Functional Status revealed the following: Section G0110 ADL assistance- Functional Status: H. Eating - How Resident eats and drinks, regardless of skill. The Self Performance Section Coded the Resident as 4 = Total dependence - full staff performance every time during entire 7-day period. The Support section coded the Resident as a 2 = one-person physical assist. Section G0400: Functional Limitation in Range of Motion Upper extremity (shoulder, elbow, wrist, hand) coded the Resident with a 2 = Impairment on both sides. Review of Resident #29's Comprehensive Plan of Care revealed: Focus area: Dependent for eating/drinking due to [MEDICAL CONDITION]. Interventions/tasks included: 2 handled covered mug for fluids with meals, Feed Resident #29. Focus area: Requires assistance device to enable resident to drink fluids with meals per self: Goal: Resident #29 will drink fluids per self during meals. Interventions/Tasks included: Teach/Assist Resident #29 on how to use device, evaluate effectiveness. Focus area: Resident #29 is totally dependent for all ADL's .Intervention/Tasks included: Feed all meals and offer fluids between meals. Initial observation and interview with Resident #29 on 8/05/19 at 11:30 AM revealed the Resident was seated at a table being fed by facility staff. She was noted with a large bandage on her right arm. Resident #29 said she had burned herself with hot coffee a couple of days ago. A follow up interview with Resident #29 at 1:20 PM that same day revealed she had spilled hot coffee on herself and sustained a burn to her right forearm and right chest. During an interview with S2DON on 8/06/19 at 9:00 AM, she verified Resident #29 had [MEDICAL CONDITION] a result of spilling hot coffee on herself. S2DON said the facility immediately addressed the issue by discontinuing the coffee access to residents and said the coffee machine will be changed. During an interview with S19MD on 8/06/19 at 9:20 AM, S19MD stated Resident #29 had [MEDICAL CONDITION] her body by spilling hot coffee on herself. He said the facility had reported and addressed the incident. S19MD said the incident was reported to him when it occurred, the resident was seen by a doctor and a physician's assistant, received treatment, and a wound specialist was consulted. S19MD said Resident #29 drinks coffee daily and after the incident, the facility noted the temperature of the coffee was 150 degrees and the temperature was addressed. Review of the facility's nurse investigative report revealed in-part: Incident occurred on 07/30/2019 at 05:15 AM while in dining room on (Hall 1). Burn to chest Location: (Hall 1) dining room, while sitting up in Geri chair with other residents Resident assessed, V/S, assist back to room to change clothes, site cleansed with normal saline and left OTA (open to air) Pain Level: 5 Why does the Resident think the Incident occurred? - Weakness Last person to see Resident before incident: S20CNA Date and Time of the last person to see the Resident before Incident: 7/30/19 at 05:00 AM Who was the first responder to the incident: S23CNA/Supervisor Review of the facility's pain assessment log on the Weights and Vitals Summary for Resident #29 revealed a pain level of a #5 on 7/30/2019 at 5:15 AM. The facility continued assessing and documenting the Resident's pain level. Review of the follow up Investigative Report dated 7/30/2019 at 10:00 AM revealed in-part: Resident stated mug got too heavy in her hand and she dropped it on her chest. The coffee spilled from the openings of the cup, the top didn't come off. Resident has used this cup multiple times before for beverages. Consulted wound care, assessed by doctor, referred to OT, removed 32-ounce cup and replaced with 10-ounce that is spill proof and with built in straw. 7/1/19 at 9:00 AM = Resident continues to use sippy cup with no complications or spills. S1AAdm reported the date of 7/1/19 was an error, and the correct date was 7/31/19. Review of the facility's Investigative Questionnaire: via S20CNA dated 7/30/19 revealed: Describe interaction with the resident: gave resident coffee, went to get rest of residents up before I got off (Hall 1) heard screams realize coffee had spilled on resident. Actions Taken: went to see what was wrong, told supervisor, then told nurse. (SIC) Review of the Physicians Progress Notes for Resident #29 dated 7/30/19 revealed: Patient seen and examined .she had coffee spill this morning that got onto her chest with some scalding. She admits to having some pain at burn site. Skin: right chest wall extending to lateral wall with some [DIAGNOSES REDACTED] and blistering. Burn to right chest wall - keep open for now, consult wound care, approximately 3% surface area. Review of the consulting agency's Surgical & Wound Care notes signed and dated 7/30/19 by S24NP revealed: Wound to chest mid and right upper: Measurements L x W x D (cm) = 17 x 19 x 0 with and area of 323 sq. cm. second degree Initial Exam Wound to right, posterior lower arm/elbow: Measurements L x W x D (cm) = 16 x 16.5 x 0 with and area of 264 sq. cm. second degree Initial Exam Scant Sero-sanguineous Exudate (documented same to both wound areas). Peri-Wound color: [DIAGNOSES REDACTED] (documented same to both wounds). Signs/Symptoms of infection: No (documented same to both wounds). Assessment notes: light [DIAGNOSES REDACTED] present with sporadic superficial blisters noted. Depth of affected area is < 0.1 (documented same to both wounds). An interview and review of Resident #29's current CP[NAME] with S21LPN/MDS on 8/07/19 at 9:30 AM revealed the resident was assessed as dependent for eating/drinking due to [MEDICAL CONDITION] and required one person physical assist for this task. An interview with S13CNA on 8/07/19 at 9:38 AM revealed she worked with Resident #29 and gave her coffee on a regular basis, coffee every day. S13CNA said she had never served the resident coffee in a pitcher. An interview with S23CNA/Sup on 8/7/2019 at 9:48 AM revealed she was working as CNA Supervisor and training another CNA on (Hall2) at the time of Resident #29's incident on the morning of 7/30/2019. She said she was on Hall 2 and heard Resident #29 scream. S23CNA/Sup stated that as she responded to Resident #29's scream, S20CNA was already with the resident in the Hall 1 dining room. A phone interview was conducted with S20CNA on 8/7/2019 at 10:30 AM. S20CNA said he had been working at this facility for 4 months and was trained on patient care before he started working with residents. He verified he was working with Resident #29 on 7/30/19 when she received the burn from the hot coffee. S20CNA explained that on the morning of 7/30/19, he got Resident #29 up in her Geri-chair. He said the resident wanted her coffee as she always drinks coffee. He said he pushed Resident #29 to the main dining room where the coffee dispenser was, and there were no regular glasses available. He said he always gives her coffee in a regular glass. S20CNA stated there were a bunch of water pitchers available and he used a regular pink water pitcher with the handle and said I did not fill it up, I put a top and a straw on the pitcher and then I brought her to the Hall 1 dining room. As I was returning back to Hall 2 to get my other residents, I heard Resident #29 scream, I had just turned the corner of the dining room and was still on Hall 1 when I heard her. I turned back around. He stated Resident #29 and another resident were the only ones in the dining room, no other staff were present in the dining room. He said as I turned the corner, I saw she had spilled her coffee. My supervisor, (S23CNA/Sup), also responded to the scream. I brought her back to her room, changed her clothes and the nurse came in. S20CNA said, In training, the DON told me she (Resident #29) was supposed to use a cup, a special cup and I never saw a special cup. I was never shown a special cup. S20CNA confirmed he was re-trained by the DON and was told she had ordered a special sippy cup for the resident. During an interview with S1AAdm conducted on 8/07/19 at 1:45 PM. The interview revealed the facility's process for residents who are dependent on staff with eating and drinking was to not serve the residents food or beverage until a staff member was with the residents. S1AAdm said the staff usually transported the residents who required assistance with eating to the dining areas and said residents were not to be served until staff were available and present with the residents. S1AAdm confirmed Resident #29 should not have been served her coffee until her staff finished bringing their residents to the dining room and the staff were present with the Resident. Interview on 8/7/19 at 8:45 AM with S1AAdm revealed that the following interventions were put into place after Resident #29's burn incident to ensure another incident would not occur for this resident or any other residents in the facility: 1. Resident #29's wounds were immediately addressed. A wound care consult was conducted on 7/30/19 with follow up noting improvement of Resident #29's wounds. Occupational therapy was consulted for strengthening of upper extremity and determined that the resident would benefit from therapy services, but refuses therapy at this time. Proper cup and weight determined by OT and available for staff, and monitoring to ensure staff use and resident not left alone while eating or drinking. 2. S1AAdm confirmed all staff were in-serviced with ongoing monitoring to ensure procedure of not leaving residents who are dependent or requiring staff assistance for eating/drinking unattended. She confirmed that ensuring proper utensils, cups, adaptive equipment and staff knowledge of such was addressed with monitoring to ensure compliance. She stated in-services included training on assisting residents with drinking, providing hot liquids and assisting residents with eating and drinking. S1AAdm said the facility staff are not to leave any resident alone with food or beverages if that resident requires staff supervision and assistance with eating. She stated the facility immediately unplugged the coffee pot on 7/30/19 and ordered a safer coffee pot for resident use when it was determined that the temperature of the pot could not be maintained at ranges acceptable to the facility. She stated currently coffee is not available in the resident area. In-services and temperature monitoring of the new coffee pot will begin as soon as it is delivered. 3. During further interview with S1AAdm on 08/08/19 at 9:45 AM, she confirmed that facility staff are present in each dining area and the monitoring of CNA staff includes ensuring they are assisting the residents, identified as dependent on staff for eating and drinking, and these residents are not left unattended. The facility implemented the following immediately post incident and prior to State Agency entrance on 8/5/19 and subsequent investigation for Resident #29: 7/30/19 - All CNAs were in-serviced by S2DON- to include: when providing hot liquids to any resident, assure that the beverage is served in a cup that can be appropriately handled by the individual safely. If there is any chance the resident may spill the beverage due to not being able to handle the cup or container, assist the resident with drinking. S20CNA also received additional individualized counseling and was in-serviced on resident-specific needs. Effective 7/30/19, immediately after the accident, there has been a nurse or direct care staff member providing supervision in both cafes during meals with the residents being assisted as needs dictate during eating and drinking. Nurses monitor proper positioning, assistive eating/drinking devices utilized for resident safety. Residents were not left alone during meal time. 7/30/19 2 PM the vendor adjusted the self-dispensing coffee machine temperature, but the dispenser would not work at such a low temperature. The coffee machine continued to be out of service. New coffee system ordered. The facility will in-service dietary staff on proper method of checking coffee temperatures and documenting on temperature logs. When new coffee system arrives, designated coffee passes will be set. Dietary will monitor the temperature of the coffee to ensure it is between 110-115 degrees Fahrenheit. They will monitor temperatures every coffee pass. Monitoring will be indefinite. The facility identified all other residents who require assistance/supervision by staff or likely to experience the same incident or outcome as a result of the noncompliance. The provided list of residents that that the facility identified as requiring staff assistance with eating/drinking included: Residents #20, #79, #3, #29, #43, #86, #77, #82, #187, #71, #26, #1, and #65. All meal are being monitored by an assigned nurse in each café to assure there is direct staff supervision of all residents that require feeding/drinking assistance/supervision during meals. No food or liquid will be served to these residents until a staff member assisting resident is present. Monitoring is being done for all meals x1 week, then one meal per day x 1 week, then 3 meals per week 2 x weeks, then prn. QA monitoring of supervision log for meals will be monitored by S5RN and turned into S2DON. On 8/08/2019 at 9:45 AM, S1AAdm confirmed all staff were in-serviced with ongoing monitoring to ensure procedure of not leaving residents who are dependent or requiring staff assistance for eating/drinking unattended. She confirmed that ensuring proper utensils, cups, adaptive equipment and staff knowledge of such was addressed with monitoring to ensure compliance. She stated in-services included training on assisting residents with drinking, providing hot liquids and assisting residents with eating and drinking. S1AAdm said the facility staff are not to leave any resident alone with food or beverages if that resident requires staff supervision and assistance with eating. She stated the facility immediately unplugged the coffee pot on 7/30/19 and ordered a safer coffee pot for resident use when it was determined that the temperature of the pot could not be maintained at ranges acceptable to the facility. She stated currently coffee is not available in the resident area. In-services and temperature monitoring of the new coffee pot will begin as soon as it is delivered.

Based on record review and interview, the facility failed to ensure that each resident receive the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care as evidenced by the facility nurse administering the incorrect medications to resident #3. As a result, resident #3 was admitted to the hospital and treated for [REDACTED]. (#3) Findings: 1. Resident #3. Review of resident #3 ' s admission orders [REDACTED]. Review of resident #3 ' s Statement of Medical Status dated 5/16/14, which was faxed to the facility on [DATE] at 09:19 am revealed that the resident was diagnosed with [REDACTED]. The resident ' s Statement of Medical Status did not include a [DIAGNOSES REDACTED]. Review of resident #3 ' s Admit assessment dated [DATE] at 11:50 revealed that the resident was oriented to person, place, and time. Also, it revealed that the resident was alert. Review of resident #3 ' s Interim Care Plan dated 5/16/14 at 3:06 revealed that the resident was not cognitively impaired. Also, the care plan revealed that the resident could communicate easily with staff and that the resident could understand the staff. Further review of the care plan revealed that the resident was currently taking diuretics, insulin, and pain medications. Also, the care plan revealed that the resident was diagnosed with [REDACTED]. Review of resident #3 ' s Nurse ' s Notes dated 5/17/14 at 0843 revealed, " (S3LPN) reported to this nurse that when she attempted to adm. Insulin to resident, res daughter stopped her and stated res is (not) on insulin. Nurse reports she adm meds according to MAR. This nurse went to med room to retrieve and review res chart. Upon review of res chart, noted that incorrect med list was filled in res chart, therefore causing res to receive incorrect meds last night and this am. @ 0853 this nurse notified DON of med error upon discovery. Instructed to assess res and notify MD immediately ... .... Notified res daughter who was seated @ nurse ' s station that a med error had occurred and that res needed to be assessed ... ... .... Asked daughter if she felt res needed to go to hospital and if any adverse effects noted by fly. Daughter c/o res appears drowsy ... ... ... Informed that d/t drowsiness it is best to send to ER for eval ... ..... Paged Dr. ____ answer service @ 0920. While awaiting MD return call, daughter states she wants resident sent to hospital. Informed daughter that res will be sent to hospital. (Ambulance) called @ 0923 and emergency transport requested. Dr. _____ returned page @ 0933. Informed of med error, res v/s, c/o feeling cold & tired. States send res to ER for eval ... ... ..... " Review of the medication list that was in resident #3 ' s chart that was faxed to the facility on [DATE] at 09:08 revealed that resident #2 ' s name was on the medication list. Review of resident #2 ' s medication list that was faxed from the hospital on [DATE] at 08:32 revealed that resident 2 ' s name was on the bottom of the page. The medication list for resident #2 was the same list that was found on resident #3 ' s chart. Review of the medication list that was faxed from the hospital on [DATE] at 9:30 am revealed that resident #3 was on [MEDICATION NAME] 100 mg oral daily, Potassium Chloride 20 meq oral, and [MEDICATION NAME] 10 mg oral daily, which were only 3 medications. Review of resident #3 ' s Medication Error Report dated 5/17/14 revealed that the date of the incident occurred on 5/16/14 and on 5/17/14. The report revealed that the incorrect medication list was placed in resident #3 ' s chart ... .... " Review of documents for investigation conducted by S1DON dated 5/17/14 revealed that (S3LPN) returned call @ 853 and discussion was as follows: " She started explaining that the new resident was saying that she does not get the medications that was on the MAR. Explained res had some confusion. Talk to her daughter that was in the room, ... ... .... I told her to check the medication reconciliation sheet from the hospital to verify meds. (S2RN) did that and discovered that the medication reconciliation was for another resident. I instructed her to take resident ' s vital signs and blood sugar and notify MD on call immediately that the facility wants to send to emergency room for evaluation ... ... ... ... ... ....1900 entered (facility) to continue investigation. Reviewed resident ' s medications from admission. Another resident ' s medication reconciliation sheet was placed in resident ' s chart and those meds were carried out as (resident #3 ' s) admit orders. The two new admissions were coming from the same hospital at the same time to the same hall. The paperwork was coming off of the same fax machine in close sequence. Two different nurses did the admissions and did not compare meds ... ..... " . Review of resident #3 ' s Significant Change Documentation note dated 5/17/14 at 0843 revealed that the resident ' s chart was reviewed and that the resident ' s medications were removed from the cart and that the resident was assessed and then sent to the emergency room for evaluation and treatment. Review of the report given by the emergency room staff on 5/17/14 at 1220 revealed, " Phoned ER for res status update. Informed by receptionist res has been admitted ... .... dx: [MEDICAL CONDITION] & drug induced [DIAGNOSES REDACTED]. " On 5/27/14 at 12:10 pm, S1DON stated that on 5/16/14 resident #3 and resident #2 were both admitted from the hospital and resident #6 was a readmit from the hospital at that time. S1DON stated that the three residents were transferred from the hospital by the facility staff. S1DON stated that the three resident ' s were picked up from the hospital without the admission and physician's order [REDACTED]. [REDACTED]. S1DON stated that resident #3 ' s physician's order [REDACTED]. S1DON stated that she text the discharge planner at the hospital to inform her that they did not receive the list of medications that was ordered for resident #3. S1DON stated that a list of medications that was ordered by the physician was faxed to the facility and that she placed the medication list that was ordered on resident #3 ' s chart. S1DON stated that she did not check for the resident ' s name on the medication list because she assumed that since she text the discharge planner for resident #3 ' s medication list that it was for resident #3. S1DON stated that she was not aware that the medication list was not for resident #3 until S3LPN called to inform her that medication errors had occurred on the resident. S1DON stated that she informed S3LPN to check the medication list from the hospital to verify the medications that were ordered. S1DON stated that S2RN checked the medication list and discovered that the medication list was for resident #2 because resident #2 ' s name was at the bottom of the medication list that was faxed from the hospital. S1DON stated that as a result of not ensuring that the medication list was for resident #3 that the resident received 10 medications that were not ordered for her, which were [MEDICATION NAME] 25 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 600 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 5mg, MVI, Rantidine 150 mg, and [MEDICATION NAME] 50 mg. S1DON stated that as a result of the medication errors that resident #3 was admitted to the hospital and treated for [REDACTED]. On 5/27/14 at 3:00 pm, S2RN stated that on 5/16/14 the facility received two new admits and 1 readmit at the same time. S2RN stated that resident #3 and resident #2 were the two new admits and that resident #6 was the readmit. S2RN stated that she took care of resident #6 ' s readmission and that S1DON took care of resident #3 ' s admission, and that the ADON took care of resident #2 ' s admission. S2RN stated that the faxes were coming from the hospital all at the same time. S2RN stated that she was not aware of resident #3 ' s medication errors until 5/17/14 when she was informed by S3LPN. S2RN stated that S3LPN told her that resident #3 may have received the wrong medications. S2RN stated that she then checked resident #3 ' s medication list that was on the chart and noticed that resident #2 ' s name was on the medication list and that was when it was discovered that resident #3 was administered the wrong medications. S2RN stated that S1DON was notified and that the resident ' s daughter was present and stated that the resident was drowsy and not herself so the resident was sent to the emergency room for an evaluation. S2RN stated that the resident was admitted to the hospital and was diagnosed with [REDACTED]. S2RN stated that S1DON told her that the resident was in ICU(Intensive Care Unit). On 5/28/14 at 9:35 am a telephone interview was conducted with S3LPN. S3LPN stated that she discovered that there was a problem with resident #3 ' s medications when the family told her that the resident was not on insulin when she went to administer it to the resident. S3LPN stated that she informed S2RN, who was the RN on duty on 5/17/14. S3LPN stated that S2RN checked the medication list that was on resident #3 ' s chart and she discovered that the medication list had resident #2 ' s name on the list. S3LPN called S1DON to inform her that resident #3 was administered the wrong medications. S3LPN stated that resident #3 was assessed and sent to the hospital. S3LPN stated that S2RN took over the resident after that and that she does not know what the admitting [DIAGNOSES REDACTED]. On 5/28/14 at 10:20 am, S1DON stated that when she called the hospital to check on resident #3 that the person she spoke to informed her that the resident was in ICU.

Based on record review and interview, the facility failed to ensure that residents are free of significant medication errors as evidenced by the facility nurse administering the incorrect medications to resident #3. As a result of the significant medication errors, resident #3 was admitted to the hospital and treated for [REDACTED]. (#3) Findings: 1. Resident #3. Review of resident #3 ' s admission orders [REDACTED]. Review of resident #3 ' s Statement of Medical Status dated 5/16/14, which was faxed to the facility on [DATE] at 09:19 am revealed that the resident was diagnosed with [REDACTED]. The resident ' s Statement of Medical Status did not include a [DIAGNOSES REDACTED]. Review of resident #3 ' s Admit assessment dated [DATE] at 11:50 revealed that the resident was oriented to person, place, and time. Also, it revealed that the resident was alert. Review of resident #3 ' s Interim Care Plan dated 5/16/14 at 3:06 revealed that the resident was not cognitively impaired. Also, the care plan revealed that the resident could communicate easily with staff and that the resident could understand the staff. Further review of the care plan revealed that the resident was currently taking diuretics, insulin, and pain medications. Also, the care plan revealed that the resident was diagnosed with [REDACTED]. Review of resident #3 ' s Nurse ' s Notes dated 5/17/14 at 0843 revealed, " (S3LPN) reported to this nurse that when she attempted to adm. Insulin to resident, res daughter stopped her and stated res is (not) on insulin. Nurse reports she adm meds according to MAR. This nurse went to med room to retrieve and review res chart. Upon review of res chart, noted that incorrect med list was filled in res chart, therefore causing res to receive incorrect meds last night and this am. @ 0853 this nurse notified DON of med error upon discovery. Instructed to assess res and notify MD immediately ... .... Notified res daughter who was seated @ nurse ' s station that a med error had occurred and that res needed to be assessed ... ... .... Asked daughter if she felt res needed to go to hospital and if any adverse effects noted by fly. Daughter c/o res appears drowsy ... ... ... Informed that d/t drowsiness it is best to send to ER for eval ... ..... Paged Dr. ____ answer service @ 0920. While awaiting MD return call, daughter states she wants resident sent to hospital. Informed daughter that res will be sent to hospital. (Ambulance) called @ 0923 and emergency transport requested. Dr. _____ returned page @ 0933. Informed of med error, res v/s, c/o feeling cold & tired. States send res to ER for eval ... ... ..... " Review of the medication list that was in resident #3 ' s chart that was faxed to the facility on [DATE] at 09:08 revealed that resident #2 ' s name was on the medication list. Review of resident #2 ' s medication list that was faxed from the hospital on [DATE] at 08:32 revealed that resident 2 ' s name was on the bottom of the page. The medication list for resident #2 was the same list that was found on resident #3 ' s chart. Review of the medication list that was faxed from the hospital on [DATE] at 9:30 am revealed that resident #3 was on [MEDICATION NAME] 100 mg oral daily, Potassium Chloride 20 meq oral, and [MEDICATION NAME] 10 mg oral daily, which were only 3 medications. Review of resident #3 ' s Medication Error Report dated 5/17/14 revealed that the date of the incident occurred on 5/16/14 and on 5/17/14. The report revealed that the incorrect medication list was placed in resident #3 ' s chart ... .... " Review of documents for investigation conducted by S1DON dated 5/17/14 revealed that (S3LPN) returned call @ 853 and discussion was as follows: " She started explaining that the new resident was saying that she does not get the medications that was on the MAR. Explained res had some confusion. Talk to her daughter that was in the room, ... ... .... I told her to check the medication reconciliation sheet from the hospital to verify meds. (S2RN) did that and discovered that the medication reconciliation was for another resident. I instructed her to take resident ' s vital signs and blood sugar and notify MD on call immediately that the facility wants to send to emergency room for evaluation ... ... ... ... ... ....1900 entered (facility) to continue investigation. Reviewed resident ' s medications from admission. Another resident ' s medication reconciliation sheet was placed in resident ' s chart and those meds were carried out as (resident #3 ' s) admit orders. The two new admissions were coming from the same hospital at the same time to the same hall. The paperwork was coming off of the same fax machine in close sequence. Two different nurses did the admissions and did not compare meds ... ..... " . Review of resident #3 ' s Significant Change Documentation note dated 5/17/14 at 0843 revealed that the resident ' s chart was reviewed and that the resident ' s medications were removed from the cart and that the resident was assessed and then sent to the emergency room for evaluation and treatment. Review of the report given by the emergency room staff on 5/17/14 at 1220 revealed, " Phoned ER for res status update. Informed by receptionist res has been admitted ... .... dx: [MEDICAL CONDITION] & drug induced [DIAGNOSES REDACTED]. " On 5/27/14 at 12:10 pm, S1DON stated that on 5/16/14 resident #3 and resident #2 were both admitted from the hospital and resident #6 was a readmit from the hospital at that time. S1DON stated that the three residents were transferred from the hospital by the facility staff. S1DON stated that the three resident ' s were picked up from the hospital without the admission and physician's order [REDACTED]. [REDACTED]. S1DON stated that resident #3 ' s physician's order [REDACTED]. S1DON stated that she text the discharge planner at the hospital to inform her that they did not receive the list of medications that was ordered for resident #3. S1DON stated that a list of medications that was ordered by the physician was faxed to the facility and that she placed the medication list that was ordered on resident #3 ' s chart. S1DON stated that she did not check for the resident ' s name on the medication list because she assumed that since she text the discharge planner for resident #3 ' s medication list that it was for resident #3. S1DON stated that she was not aware that the medication list was not for resident #3 until S3LPN called to inform her that medication errors had occurred on the resident. S1DON stated that she informed S3LPN to check the medication list from the hospital to verify the medications that were ordered. S1DON stated that S2RN checked the medication list and discovered that the medication list was for resident #2 because resident #2 ' s name was at the bottom of the medication list that was faxed from the hospital. S1DON stated that as a result of not ensuring that the medication list was for resident #3 that the resident received 10 medications that were not ordered for her, which were [MEDICATION NAME] 25 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 600 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] 20 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] 5mg, MVI, Rantidine 150 mg, and [MEDICATION NAME] 50 mg. S1DON stated that as a result of the medication errors that resident #3 was admitted to the hospital and treated for [REDACTED]. On 5/27/14 at 3:00 pm, S2RN stated that on 5/16/14 the facility received two new admits and 1 readmit at the same time. S2RN stated that resident #3 and resident #2 were the two new admits and that resident #6 was the readmit. S2RN stated that she took care of resident #6 ' s readmission and that S1DON took care of resident #3 ' s admission, and that the ADON took care of resident #2 ' s admission. S2RN stated that the faxes were coming from the hospital all at the same time. S2RN stated that she was not aware of resident #3 ' s medication errors until 5/17/14 when she was informed by S3LPN. S2RN stated that S3LPN told her that resident #3 may have received the wrong medications. S2RN stated that she then checked resident #3 ' s medication list that was on the chart and noticed that resident #2 ' s name was on the medication list and that was when it was discovered that resident #3 was administered the wrong medications. S2RN stated that S1DON was notified and that the resident ' s daughter was present and stated that the resident was drowsy and not herself so the resident was sent to the emergency room for an evaluation. S2RN stated that the resident was admitted to the hospital and was diagnosed with [REDACTED]. S2RN stated that S1DON told her that the resident was in ICU(Intensive Care Unit). On 5/28/14 at 9:35 am a telephone interview was conducted with S3LPN. S3LPN stated that she discovered that there was a problem with resident #3 ' s medications when the family told her that the resident was not on insulin when she went to administer it to the resident. S3LPN stated that she informed S2RN, who was the RN on duty on 5/17/14. S3LPN stated that S2RN checked the medication list that was on resident #3 ' s chart and she discovered that the medication list had resident #2 ' s name on the list. S3LPN called S1DON to inform her that resident #3 was administered the wrong medications. S3LPN stated that resident #3 was assessed and sent to the hospital. S3LPN stated that S2RN took over the resident after that and that she does not know what the admitting [DIAGNOSES REDACTED]. On 5/28/14 at 10:20 am, S1DON stated that when she called the hospital to check on resident #3 that the person she spoke to informed her that the resident was in ICU.