Every finding on record at Riverpoint Crest Nursing and Rehabilitation Center

Based on observation, record review, and staff interviews, the facility failed to follow their infection control policy and procedures for Enhanced Barrier Precautions (EHB) during high contact care for a resident with an indwelling urinary catheter, when a nurse aide and a nurse were providing catheter care without wearing personal protective equipment (PPE) to include a gown for 2 of 6 staff observed for infection control practices (Nurse Aide #1 and Nurse #2). Findings included: The facility policy titled, Enhanced Barrier Precautions dated 06/13/2024 stated in part: EBP are used in conjunction with standard precautions to reduce the risk for multi drug resistant organism transmission during high contact resident care activities. Includes the use of both gowns and gloves. High contact resident care activities were listed as: dressing, bathing, showering, transferring, changing linens, providing hygiene, changing briefs and assisting with toileting, device care or use, central lines, urinary catheter, feeding tube, tracheostomy and wound care, any skin opening requiring a dressing. An observation of catheter care was conducted with Nurse Aide (NA) #1 on 09/17/25 at 10:20 AM. Nurse Aide #1 entered Resident #1's room, closed the door, washed her hands and applied gloves that were on the wall located near the door. The PPE to include gowns was noted hanging on the back of the door. Nurse Aide #1 did not apply a gown. Nurse Aide #1 proceeded to lift Resident #1's gown and lowered his brief to access the indwelling urinary catheter. Nurse Aide #1 provided care to catheter but never applied a gown. Nurse Aide #1 noted there was bloody urine in the tubing of the catheter and in the catheter bag and stated she would notify Nurse #2. Nurse Aide #1 secured the brief back on the resident and lowered his gown. She removed her gloves and washed her hands. An interview was conducted with Nurse Aide #1 on 09/17/25 at 10:30 AM. Nurse Aide #1 stated when asked why she did not apply a gown during the catheter care; she stated she was just focusing on getting the care done and forgot to put the gown on. Nurse Aide #1 reviewed the signage on the door for Enhanced Barrier Precautions and stated she should have put a gown on while providing catheter care. An observation was conducted of Nurse #2 assessing Resident #1's indwelling urinary catheter on 09/17/25 at 10:35 AM. Nurse #2 entered Resident #1's room, washed her hands, and applied gloves. Nurse #2 did not apply a gown. Nurse #2 was observed lifting Resident #1's gown and lowering his brief to assess the insertion site of the indwelling catheter. Once she was finished assessing the site, she secured the brief, lowered the gown, and disposed of her gloves and washed her hands. An interview was conducted with Nurse #2 on 09/17/25 at 10:40 AM. Nurse #2 reported she was flustered and forgot to apply a gown. Nurse #2 stated she should have applied a gown since she was assessing the indwelling urinary catheter. An interview with the Staff Development Coordinator (SDC) on 09/17/25 at 10:50 AM. The SDC stated both staff members should have applied a gown while providing care to Resident #1's urinary catheter. The SDC stated both staff members have been educated on the importance and adherence of the Enhanced Barrier Precautions, but she would reinforce the education. An interview with the Director of Nursing (DON) on 09/17/25 at 3:30 PM revealed she would have expected both staff members to apply the appropriate PPE to include gowns whenever providing care to an indwelling urinary catheter. She stated the Enhanced Barrier Precaution policy was in place to protect other residents and staff members from infection.

Based on observation, record review and staff interviews, the facility failed to secure medications used in the treatment of wounds in an unattended and unlocked treatment cart for 1 of 1 treatment cart observed. The facility further failed to store a medication according to the manufacturers' guidelines for 2 of 3 medication carts observed (400 hall and 200 hall). Findings included: 1. A continuous observation was conducted of the facility treatment cart on 9/16/25 from 8:10 AM to 8:35 AM. The cart was observed to be parked next to the door of the Wound Care Nurse’s office, facing out to the hallway at the end of 200 hall. The treatment cart was observed to be unlocked as evidenced by the push lock not being flush with the cart face as it would have been had it been locked. There was no staff member with the treatment cart, no staff in the Wound Care Nurse's office or in the offices across the hall from the cart. During the observation, two visitors, the Director of Nursing (DON), kitchen manager, nurse supervisor, two staff nurses and two Nurse Aides (NA) walked by the unlocked treatment cart. At 8:15 AM a resident was approximately 3 feet away in her wheelchair. At 8:35 AM the Wound Care Nurse approached the treatment cart and locked it. The Wound Care Nurse was asked what was kept in the treatment cart and she stated it held bandages. During an observation of the contents of the treatment cart with the Wound Care Nurse it was discovered the bottom drawer held several topical medications used to clean and treat wounds including antiseptic solution for skin wounds, medical grade honey, hydrocortisone cream, corticosteroid cream and a cream used to treat skin conditions. The Wound Care Nurse indicated these medications could possibly be dangerous if a cognitively impaired resident were to have access to them. The Wound Care Nurse revealed she had forgotten to lock the treatment cart this morning, and she knew she was to have kept the cart locked at all times when she wasn’t using it. In an interview with the DON on 9/16/25 at 8:44 AM she stated the treatment cart should be locked at all times when not directly in use. The DON indicated the medications kept in the treatment cart could pose a possible danger for a resident were they to ingest them. In an interview with the Administrator on 9/16/25 at 8:50 AM she indicated the treatment cart should have been locked since the Wound Care Nurse was not using the cart. The Administrator stated various topical medications are kept in the treatment cart that could be harmful if ingested by a cognitively impaired resident. 2. Review of the manufacturers’ instructions on the bottle indicated the nasal spray must be stored in an upright position. Storing the bottle in an upright position prevents leaking and ensures the pump mechanism works correctly. a. An observation of the 400-hall medication cart on 09/17/25 at 8:50 AM with Nurse #3 revealed a medication called Astelin nasal spray (a prescription nasal spray used to relieve symptoms of seasonal allergies), was noted to be stored horizontally, not in an upright position, in the medication cart. An interview with Nurse #3 revealed she did not read the manufacturers’ instructions and did not know the medication should be stored in the upright position. b. An observation of the 200-hall medication cart on 09/17/25 with Nurse #4 revealed the Astelin nasal spray was noted to be stored horizontally, not in an upright position, in the medication cart. An interview with Nurse #4 revealed she did not read the manufacturers’ instructions and did not know the medication should be stored in the upright position. An interview with the Director of Nursing (DON) on 09/17/25 at 3:30 PM revealed she would expect her nursing staff to be checking the carts and reading all manufactures’ guidelines for proper medication storage. The DON stated if the bottle indicated the nasal spray needed to be stored upright, then the bottle should be stored upright.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan within 7 days of the completion of the comprehensive assessment to include the use of psychotropic medications for 2 of 2 residents reviewed for care planning (Resident #21 and Resident #66). Findings included: 1. Resident #21 was admitted to the facility on [DATE] with diagnoses that included non-Alzheimer's dementia, anxiety and major depressive disorder. Review of Resident #21's admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was taking antianxiety and antidepressant medications. The MDS assessment revealed psychotropic medication use and care planning decision was triggered in Care Area Assessment (CAA) section of the MDS. Review of Resident #21's physician orders revealed an order for Fluoxetine hydrochloride (HCL) 40 mg (an antidepressant) give one capsule by mouth in the morning related to major depressive disorder with a start date of 8/22/25. Review of Resident #21's comprehensive care plan created 8/28/25 revealed no care plan regarding psychotropic medication. In an interview with MDS Nurse #1 on 9/16/25 at 10:10 AM she stated Resident #21's care plan should have been created with psychotropic medication use when the admission MDS was coded for antianxiety and antidepressant medication use. MDS Nurse #1 further stated the CAA had been triggered for psychotropic medication use and the care plan was not created at that time due to human error. In an interview with the Director of Nursing (DON) on 9/17/25 at 1:53 PM, she indicated the MDS nurse, or floor nurse were responsible for generating the initial care plan. The DON stated staff discussed new medication orders in morning meeting each day and the MDS nurse or Unit Manager were responsible for updating care plans. She further stated there was not a single person identified as being responsible and that was probably why Resident #21 did not have a care plan for psychotropic medications. In an interview with the Administrator on 9/17/25 at 1:50 PM she stated she thought MDS Nurses were responsible for creating the initial care plan. The Administrator further stated psychotropic medication use should have been care planned for Resident #21. 2. Resident #66 was admitted to the facility on [DATE] with diagnoses that included anxiety, depression and Alzheimer's dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #66 took antianxiety medication. The MDS assessment revealed psychotropic medication use and care planning decision was triggered in Care Area Assessment (CAA) section of the MDS. Review of Resident #66's physician orders revealed and order for Ativan oral tablet 1 milligram (mg) (Lorazepam) (an antianxiety medication) give one tablet by mouth every eight hours as needed for anxiety, agitation for 14 days with a start date of 8/28/25 and an end date of 9/9/25. Review of Resident #66's care plan last revised on 9/2/25 revealed there was no care plan regarding psychotropic medication. In an interview with MDS Nurse #1 on 9/16/25 at 10:10 AM she stated Resident #66's care plan should have been created with psychotropic medication use when the admission MDS was coded for antianxiety medication use. MDS Nurse #1 further stated the CAA was triggered for psychotropic medication use and the care plan was not created at that time due to human error. In an interview with the Director of Nursing (DON) on 9/17/25 at 1:53 PM, she indicated the admitting nurse, MDS nurse, or floor nurse were responsible for updating care plans. The DON stated staff discussed new medication orders in morning meeting each day and the MDS nurse or Unit Manager were responsible for updating care plans. She further stated there was not a single person identified as being responsible for updating care plans after morning meeting, and that was probably why Resident #66 did not have a care plan for psychotropic medications. In an interview with the Administrator on 9/17/25 at 1:50 PM she stated she thought MDS Nurses were responsible for updating care plans. The Administrator further stated psychotropic medication use should have been care planned for Resident #66.

Based on record review and staff interviews, the facility failed to develop and implement a person-centered care plan for a resident who had a diagnosis of Post Traumatic Stress Disorder for 1 of 1 record reviewed for Post Traumatic Stress Disorder (Resident #5). The findings included: Resident #5 was admitted to the facility on [DATE]. Diagnoses included Post Traumatic Stress Disorder (PTSD), delusional disorders, mood disorder, and major depressive disorder. A Trauma Informed Assessment was completed and dated 09/11/24 for Resident #5. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #5 was cognitively intact and demonstrated no behavior during this assessment period. Review of Resident #5's current care plan revealed there was no plan of care in place for Post Traumatic Stress Disorder. An interview was conducted with Nurse #2 on 09/18/25 at 10:10 AM. Nurse #2 stated she was not aware of any specific triggers Resident #5 had as a result of her PTSD. She stated Resident #5 had some behaviors such as refusal of care, and paranoid behavior and was care planned for those behaviors. Nurse #2 stated if she wanted to know what interventions were in place she would refer to the care plan. An interview with the MDS Nurse on 09/18/25 at 9:50 AM revealed Resident #5 should have had a person-centered care plan for her diagnosis of PTSD. She stated the care plan should identify triggers that would precipitate negative responses or outcomes. She stated Resident #5's post-traumatic stress trigger included loud noises. The MDS Nurse stated she did not put a care plan in place because Resident #5 has not had any problems with her PTSD since admission. An interview with the Director of Nursing on 09/18/25 at 10:15 AM revealed she would have expected a person-centered plan of care be developed for Resident #5 due to her diagnosis of PTSD. The DON stated Resident #5 has not had any identifying triggers or concerns in the time she had been at the facility, but should she have a Post Traumatic Stress episode, staff should be aware of what to do.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of hypoglycemic medication use for 1 of 18 residents reviewed for accuracy of assessments (Resident #72).Findings included: Resident #72 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus II with long term current use of insulin. Review of Resident #72's physician orders revealed an order dated 8/11/25 for Tresiba flex touch subcutaneous solution 100 unit/millileters (ml) (insulin). Inject 24 units subcutaneously in the morning related to type II Diabetes Mellitus. A second order dated 8/11/25 read: Insulin Aspart injection solution 100 units/ml to be injected per sliding scale subcutaneously three times a day related to type II Diabetes Mellitus. Review of Resident #72's Medication Administration Record (MAR) for August 2025 revealed both orders for insulin were administered daily. Review of Resident #72's admission MDS assessment dated [DATE] indicated the resident received insulin injections 7 of 7 days during the lookback period of 7 days. The MDS assessment was not coded for hypoglycemic (including insulin) medication use in the previous 7 days. In an interview with MDS Nurse #1 on 9/16/25 at 10:10 AM she stated Resident #72's MDS should have been coded for use of hypoglycemic medication during the lookback period. MDS Nurse #1 revealed the error was made due to human oversight. In an interview with the Administrator on 9/16/25 at 10:10 AM, she stated Resident #72's MDS should have been coded correctly, showing the resident received hypoglycemic medication (including insulin).

Based on observation, record review and staff interview, the facility failed to provide personal privacy when Nurse #2 left the door to the resident's room open when assessing Resident #1's indwelling urinary catheter. Nurse #2 did not close the curtain when she pulled the resident's gown up and his brief down resulting in the resident being visible from the hallway while he was exposed. This was for 1 of 1 resident observed for privacy (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE]. Diagnoses included obstructive reflux uropathy (a condition where urine flow is blocked in any part of the urinary tract), benign prostate hypertrophy (enlarged prostate) with urinary complications. A physician's order written on 08/26/25 revealed Resident #1 had an order for indwelling urinary catheter and to provide catheter care each shift for urinary retention. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and was coded as having an indwelling urinary catheter. An observation of urinary catheter care was conducted with Nurse Aide (NA) #1 on 09/17/25 at 10:20 AM. NA #1 closed Resident #1's door but did not pull the privacy curtain. Resident #1 resided in the bed closest to the door, he had a roommate who was in the room, and the roommate's privacy curtain was pulled closed. Once the catheter care was completed, NA #1 noticed Resident #1's catheter tubing to have bloody urine. NA #1 stated she would let Nurse #2 know. NA #1 left the room and left the door open. An observation was conducted from the hallway outside of Resident #1's room on 09/17/25 at 10:35 AM. Nurse #2 entered the resident's room, applied gloves and proceeded to pull Resident #1's gown up and take down his brief to assess the catheter insertion cite. Nurse #2 did not close the door or pull Resident #1's curtain for privacy. The door was fully opened door and Resident #1 was observed from the hall outside his door exposing Resident #1's bare stomach and penis. Staff were noted to be passing by Resident #1's room while Nurse #2 assessed his indwelling catheter. An interview was conducted with Nurse #2 on 09/17/25 at 10:40 AM. Nurse #2 stated she should have provided the resident privacy before she removed his gown and pulled his brief down. She stated she should have closed the door and pulled the privacy curtain. She stated she was flustered and forgot. An interview was conducted with the Director of Nursing (DON) on 09/17/25 at 3:00 PM. The DON revealed she would have expected the nurse to provide privacy for the resident and not let him be exposed to passersby in the hallway or to his roommate. She stated this was an issue and she would make sure further education was done.

Based on record review, staff and Resident Representative (RR) interviews, the facility failed to facilitate the inclusion of the RR of a severely cognitively impaired resident in the care planning process for 1 of 2 residents reviewed for the care planning process (Resident #71). Findings included: Resident #71 was admitted to the facility on [DATE]. The most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 was severely cognitively impaired. The medical record indicated Resident #71's family member was her Resident Representative (RR). A review of the care plan for Resident #71 indicated it was last revised on 8/18/25. Record review for Resident #71 revealed there were no care plan meetings documented nor was there documentation of attempts to contact or conversations with the RR since admission. On 9/17/25 at 9:50 AM a telephone interview with Resident #71's RR revealed he did not recall being invited to a care plan meeting. Resident #71's RR stated he would like to be invited to attend care plan meetings. In an interview with the Administrator on 9/17/25 at 9:50 AM she stated the facility had last employed a Social Worker (SW) from January to June of 2025 and she was responsible for invitations to care plan meetings during that time. The Administrator indicated she had been responsible for sending care plan meeting invitations to residents or their RR's since June 2025 but could not locate documentation regarding sending an invitation to Resident #71's RR. The previous SW was unavailable for interview.

Based on observations, record review and staff interviews the facility failed to treat 1 of 3 residents in a respectful and dignified manner when Resident #66 was seated in his geriatric wheelchair (a special medical recliner with a wheeled base designed for older adults and individuals with mobility issues) as Occupational Therapist #1 pulled the wheelchair down the hall with the resident positioned behind her resulting in the resident being unable to see where he was being taken to. A reasonable person has the expectation of being treated with dignity and would not want to be moved via wheelchair in a backwards motion with no ability to view where they are traveling. Findings included: Resident #66 was admitted to the facility on [DATE]. A physician's order written on 08/28/25 revealed an order for Occupational Therapy (OT) to evaluate and treat as indicated. Resident #66's Minimum Data Set 5-day assessment dated [DATE] revealed he was severely cognitively impaired. An observation of Resident #66 on 09/15/25 at 11:10 AM revealed the resident was seated in his geriatric wheelchair while Occupational Therapist #1 (OT) pulled the wheelchair down the hall with the resident positioned behind her resulting in the resident being unable to see where he was being taken to by OT #1. An interview was conducted with OT #1 on 09/15/25 at 11:10 AM. OT #1 stated she was not aware that pulling a resident behind her was a dignity issue and that she was pulling the chair because it was difficult to push. OT #1 turned Resident #66's chair around and proceeded down the hall while she pushed the resident in front of her. An interview was conducted with the Rehabilitation Manager on 09/17/25 at 2:45 PM. The Rehabilitation Manager stated that OT #1 was an agency therapist, and that all staff including agency staff had been in-serviced according to the training for this facility to include treating residents with dignity and respect. She stated just recently the therapy staff were all sub-contracted, but now there was new therapy staff, and they were employed by the facility and the training that was required for this facility was given to the therapists. The Rehabilitation Manager stated OT #1 should have known that pulling a resident from behind while the resident was sitting in a mobility device was a dignity issue. She stated she would make sure further education was provided. An interview was conducted with the Director of Nursing (DON) on 09/17/25 at 3:00 PM. The DON stated she had some new staff in the therapy department, but that she would have expected for the therapy staff to know that pulling a resident behind them as they walked down a hall was a dignity concern and she would be sure education was done to reinforce this dignity issue.

Based on observations, record review, and staff and resident interviews, the facility failed to assess the ability of a resident to self-administer medications (chewable antacid tablets, cough drops, topical arthritis cream with 25% capsaicin and topical arthritis pain relief gel with 2% menthol) that were kept at the bedside for 1 of 1 resident reviewed for self-administration of medications (Resident #19). Findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses that included non-Alzheimer's dementia and chronic pain syndrome. Review of Resident #19's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was moderately cognitively impaired. Review of Resident #19's physician orders revealed no order to self-administer medications, no order for arthritis pain relief cream with capsaicin, arthritis pain relief gel with menthol, cough drops or chewable antacid tablets were noted. Review of Resident #19's medical record revealed no documentation Resident #19 was assessed for self-administration of medications. Review of Resident #19's care plan last revised 9/15/25 did not reveal a care plan related to self-administration of medications. In an observation and interview with Resident #19 on 9/15/25 at 1:24 PM the resident stated she had chronic pain and had a Nurse or Nurse Aide (NA) put arthritis cream on her knees that morning. Resident #19 proceeded to open the second drawer of her bedside table to show that she kept arthritis cream with 25% capsaicin and arthritis pain relief gel with 2% menthol in the drawer for ease of use throughout the day. Resident #19 further stated she applied the arthritis cream or gel herself throughout the day. A 12-ounce paper cup was observed in the drawer that held what appeared to be loose chewable antacid tablets and individually wrapped cough drops. Resident #19 indicated she used chewable antacid tablets when she had an upset stomach and the cough drops were used for an occasional scratchy throat. A second observation and interview were conducted on 9/16/25 at 8:06 AM with Resident #19. A tube of arthritis cream with 25% capsaicin was sitting on top of the bedside table. Resident #19 indicated she still had the arthritis gel, chewable antacid tablets and cough drops in her bedside table. Resident #19 opened the second drawer of the bedside table where the items were observed to still be there. In an interview with Nurse #1 on 9/16/25 at 10:25 AM she stated she was unaware Resident #19 kept any medications at her bedside and was unsure if the resident had been assessed for self-administration of medications. Nurse #1 further stated she had applied arthritis cream to Resident #19's knees but the cream had come from the medication cart. In an interview with the Unit Manager (UM) on 9/16/25 at 10:36 AM she stated she was unaware Resident #19 had medications at the bedside. She further stated she was unaware of how a resident would have been assessed for self-administration of medications. An interview was conducted with NA #6 on 9/16/25 at 10:40 AM. NA #6 stated had not put arthritis cream or gel on Resident #19 at any time. An interview was conducted with the Director of Nursing (DON) on 9/16/25 at 10:48 AM she indicated she was unaware Resident #19 kept medications in her bedside table. The DON stated Resident #19 had not been assessed for self-administration of medications. An interview was conducted with the Administrator on 9/15/25 at 2:40 PM. She stated she was unaware Resident #19 kept medications at the bedside and was unsure how the facility would have known that Resident #19 had them. The Administrator indicated Resident #19 had not been assessed for self-administration of medications.

Based on observations, staff interviews, and record review the facility failed to attempt alternatives prior to installing siderails for 2 of 2 residents (Resident #27, Resident #56) reviewed for accidents. Findings included: 1. Resident #27 was admitted to the facility on [DATE] with a diagnosis of vascular dementia and chronic obstructive pulmonary disease (COPD). A review of Resident #27's record revealed an assessment titled physical device use evaluation dated 7/23/24 and completed by Unit Manager (UM) #1 indicated no alternatives to one quarter siderails were attempted before use. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #27 was severely cognitively impaired. The MDS indicated Resident #27 required partial to moderate assistance with bed mobility, transfers, and was non-ambulatory. The MDS revealed Resident #27 had an impairment of both upper and lower extremities. The MDS indicated Resident #27's siderails were not used as a restraint. A care plan with the latest review date of 8/14/24 revealed a problem of use of siderails for increasing or maintaining current bed mobility. The goal was Resident #27 would continue to use siderails safely for facilitating bed mobility and transfers through next review. Interventions included: use of siderails to assist resident to enter and exit the bed independently and use of siderails to assist resident to turn and reposition when in bed. An observation on 9/24/24 at 2:35 pm revealed Resident #27 lying in bed with bilateral one-quarter length siderails in the up position on the bed. An observation 9/25/2024 at 2:04 PM revealed Resident #27 sitting in her wheelchair next to her bed. The siderails were observed to be in the raised position. An interview with Nurse #2 on 9/25/24 at 9:25 AM revealed the Nurses completed the physical device use evaluation on admission and quarterly. Nurse #2 stated this form was used for siderail screening. She further stated she always answered no to the question Of these alternatives, which have been attempted (i.e. rehab screening, restorative nursing program, toileting schedule, activity programming, assistive devices, medication review, pain management, room change, etc.)? Nurse #2 indicated siderails were on the beds on admission. Newly admitted residents began using the siderails immediately. She further indicated Nursing did not try alternatives to siderails before they were used. In an interview with UM #1 she stated she recalled completing the physical device use evaluation for Resident #27. She further stated she was not aware of a time the facility tried alternatives to siderails. UM #1 revealed siderails were always on the beds unless they were removed by request of the resident, the residents responsible party or physical therapy. She was not aware alternatives to side rails needed to be attempted before using them. In an interview with the Director of Nursing (DON) on 9/25/24 at 12:55 PM she stated Nursing completed the physical device use evaluation on admission and quarterly. She further stated they did not try interventions before using siderails as she was not aware this was a requirement. The DON indicated that siderails were only taken off the beds if found to be contraindicated for a resident or if a resident or resident representative declined them. In an interview with the Administrator on 9/25/24 at 8:45 AM she stated siderails were not removed from the beds unless the resident or their representative declined them, or if they were found to be a danger to the resident. She further stated alternative interventions to the siderails were not tried first. 2. Resident #56 was admitted to the facility on [DATE] end stage renal disease with dependence on renal dialysis, Chronic Obstructive Pulmonary Disease (COPD) and fracture of the right femur (upper leg bone). A review of Resident #56's record revealed an assessment titled physical device use evaluation dated 8/23/24 and completed by Nurse #3 indicated no alternatives to one quarter siderails were attempted before use and a medical symptom for use of siderails was not found. A 5-day Minimum Data Set (MDS) dated [DATE] revealed Resident #56 was moderately cognitively impaired and had no impairment of upper extremities and did have impairment in lower extremities. The Resident required substantial assistance with rolling in bed, sitting to lying and sit to stand. The MDS indicated Resident #56's siderails were not used as a restraint. A care plan with the latest review date of 8/23/24 revealed a problem of use of siderails for increasing or maintaining current bed mobility. The goal was Resident #56 would continue to use siderails safely for facilitating bed mobility and transfers through next review. Interventions included: Use of siderails to assist resident to increase ability to enter and exit the bed at highest practical mobility level and use of siderails to assist resident to turn and reposition when in bed. An observation on 9/23/24 at 9:38 AM revealed Resident #56 in bed with the one-quarter length siderails in the raised position. An observation 9/25/2024 at 2:28 PM revealed Resident #56 in bed with bilateral one-quarter length siderails in the up position on the bed. Nurse #3 could not be reached for an interview. An interview with Nurse #2 on 9/25/24 at 9:25 AM revealed the Nurses completed the physical device use evaluation on admission and quarterly. Nurse #2 stated this form was used for siderail screening. She further stated she always answered no to the question Of these alternatives, which have been attempted (i.e. rehab screening, restorative nursing program, toileting schedule, activity programming, assistive devices, medication review, pain management, room change, etc.)? Nurse #2 indicated siderails were on the beds on admission. Newly admitted residents began using the siderails immediately. She further indicated Nursing did not try alternatives to siderails before they were used. In an interview with the Director of Nursing (DON) on 9/25/24 at 12:55 PM she stated Nursing completed the physical device use evaluation on admission and quarterly. She further stated they did not try interventions before using siderails. The DON indicated that siderails were only taken off the beds if found to be contraindicated for a resident or if a resident or resident representative declines them. She was not aware alternative interventions to siderails needed to be tried before implementation of siderails. In an interview with the Administrator on 9/25/24 at 8:45 AM she stated siderails were not removed from the beds unless the resident or their representative declines them, or if they were found to be a danger to the resident. She further stated alternative interventions to the siderails were not tried first. The Administrator was not aware alternatives to siderails needed to be attempted before siderail use.

Based on observations, record review, and resident and staff interviews the facility failed to provide incontinence care to a severely cognitively impaired dependent resident. This was for 1 of 3 residents (Resident #45) reviewed for activities of daily living. This placed Resident #45 at risk for skin integrity impairment. Findings included: Resident #45 was admitted to the facility on [DATE] with a diagnosis of cerebral infarction (disrupted blood supply to the brain). A review of Resident #45's care plan last updated 5/30/24 revealed a focus area for activities of daily living. The goal was for Resident #45's activities of daily living to be completed with staff support. An intervention was dependence for toileting hygiene and incontinence of bladder. A review of Resident #45's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired. He had functional impairment in range of motion on both sides of his upper and power extremities. He was dependent for toileting hygiene. He was always incontinent of bowel and bladder. He had no pressure ulcers, skin conditions, or moisture associated skin damage. A review of Resident #45's full body skin assessment dated [DATE] completed by Nurse #5 did not indicate any skin redness, irritation, or breakdown. On 9/25/24 at 2:02 PM Resident #45 was observed lying in his bed. A portion of the bottom of his blanket was pulled back and the edge of his incontinence pad visible. This pad was observed to have a yellowish wet ring. There was the slight odor of urine. An interview with Resident #45 at that time indicated he was doing fine. He stated he had already had his bath that morning and he did not need anything. On 9/25/24 at 2:12 PM an interview with Nurse Aide (NA) #1 indicated she was assigned to care for Resident #45 on the 7AM-3PM shift that day. She stated she was familiar with Resident #45. She reported Resident #45 did not use his call bell for assistance, and he was always incontinent of bowel and bladder. NA #1 went on to say Resident #45 had not had his bath yet, and she had not been in his room to check him for incontinence or provide him with any incontinence care since she began her shift at 7:00 AM that morning. She stated she had a really demanding resident who had taken up a lot of her time that day, and she had not had a chance to get to Resident #45. She reported she had not asked anyone to help her, or let the nurse know she had not been able to get to Resident #45. NA #1 reported she felt if she had asked the nurse for help, the nurse would have helped her. She went on to say Resident #45 should have been checked for incontinence at least every 2 hours and incontinence care provided to him if he needed this. On 9/25/24 at 2:18 PM an observation of Resident #45's incontinence care was conducted with the Director of Nursing (DON) and NA #1. The DON stated Resident #45's incontinence pad was wet, and his incontinence brief was saturated with urine and the odor of urine was present. No redness, irritation, or skin breakdown was observed to Resident #45's perineal area or buttocks. During the observation, NA #1 confirmed to the DON that she had not checked Resident #45 for incontinence since she started her shift at 7 AM that morning or provided him with incontinence care yet that day. The DON stated she was very upset and disappointed and could not understand why NA #1 had not provided Resident #45 this care. The DON reported Resident #45 was always incontinent and didn't use his call bell. She went on to say NA #1 should have checked Resident #45 for incontinence at least every 2 hours and provided him with incontinence care if he needed it. She stated going 7 hours without this care put Resident #45 at risk for skin breakdown. The DON reported if NA #1 had not been able to provide Resident #45 with care for whatever reason, NA #1 should have asked a nurse, a unit manager, or herself and someone would have gladly assisted. On 9/25/24 at 2:23 PM an interview with Nurse #4 indicated she was assigned to care for Resident #45 on the 7AM-3PM shift that day. She stated she was not aware that Resident #45 had not received any incontinence care yet that day, and NA #1 had not asked her for any help providing this or she would have gladly assisted. Nurse #4 did not indicate she checked Resident #45 for incontinence or provided any incontinence care to Resident #45 that day. On 9/25/24 at 3:26 PM an interview with Unit Manager #2 indicated she was the Unit Manager for the hall where Resident #45 resided. She stated she had been on Resident #45's hall at both the breakfast and lunch meals that day, and NA #1 had not asked her for any assistance with providing incontinence care to Resident #45. On 9/26/24 at 9:58 AM, a follow-up interview with Unit Manager #2 indicated she had been in Resident #45's room on 9/25/24 to deliver his breakfast and lunch meals. She stated she had not checked him for incontinence or provided him with any incontinence care. She went on to say she had not noticed any urine odor, and Resident #45 had not requested any care. On 9/25/24 at 3:41 PM an interview with Nurse #5 indicated she conducted Resident #45's full body skin assessment dated [DATE]. She stated Resident #45 had no skin redness, irritation or breakdown observed during this assessment. On 9/26/24 at 7:55 AM a telephone interview with NA #2 indicated she had been assigned to care for Resident #45 on 9/24/24 at 11:00 PM until 9/25/24 at 7:00 AM. She stated she had last provided Resident #45 with incontinence care at 5:00 AM on 9/25/24 before she finished her shift at 7:00 AM that morning. On 9/26/24 at 9:50 AM an interview with the Administrator indicated she would have expected Resident #45 to be provided with incontinence care in a timely manner. She stated although Nurse #4 had been in Resident #45's room to administer his morning and lunch time medications, and Unit Manager #2 had been in his room during his breakfast and lunch meals, and he had not indicated he needed anything; he should have received incontinence care every 2 hours as needed

Based on record review and staff interviews the facility failed to develop a comprehensive care plan that included the diagnosis of diabetes mellitus and the use of hypoglycemic medication for 1 of 5 residents (Resident #61) reviewed for unnecessary medication. Findings included: Resident #61 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. A review of his quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was taking hypoglycemic medication. A physician's order dated 1/25/24 indicated to give Resident #61 one 500 milligram tablet of metformin extended release (a hypoglycemic medication) once daily in the morning related diabetes mellitus. A review of his comprehensive care plan dated last reviewed on 7/26/24 did not reveal any focus area, goals, or interventions related to Resident #61's diagnosis of diabetes mellitus or his use of hypoglycemic medication. On 9/25/24 at 8:11 AM an interview with MDS Nurse #1 indicated she was the MDS Coordinator. She stated Resident #61's comprehensive care plan was last reviewed by the interdisciplinary team from 7/2/24 through 7/9/24. She stated she did not see Resident #61's diabetes mellitus or his use of hypoglycemic medication addressed in his current comprehensive care plan. She reported it would have been her responsibility to include this, she should have caught it on his last care plan review, and she had missed it. MDS Nurse #1 stated this was a human error. On 9/25/24 at 4:05 PM an interview with the Director of Nursing indicated Resident #61's diabetes mellitus and his use of hypoglycemic medication were things that should be included in his comprehensive care plan. On 9/26/24 at 9:50 AM an interview with the Administrator indicated Resident #61's diabetes mellitus and use of hypoglycemic medication should have been reflected in his comprehensive care plan.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of falls (Resident #17), oxygen (Resident #56), and discharge status (Resident #93). This was for 3 of 3 residents reviewed for Minimum Data Set assessments. The findings included: a. Resident #17 was admitted to the facility on [DATE] with diagnoses that included diabetes, chronic kidney disease, and hypertension. A review of a nurse progress note written by Nurse #1 dated 4/2/24 revealed Resident #17 had a fall. A review of Resident #17's Quarterly Minimum Data Set assessment dated [DATE] did not indicate she had a fall. In an interview with MDS Nurse #1 on 9/24/24 at 11:17 AM she stated changes in resident conditions were discussed with the interdisciplinary team (IDT) (a group of healthcare professionals who work together to treat a resident) each morning. MDS Nurse #1 stated the MDS assessment completed on 6/20/24 should have indicated Resident #17 had a fall. She stated she was not sure how the error occurred. In an interview with MDS Nurse #2 on 9/24/24 at 11:18 AM she stated the MDS assessment completed on 6/20/24 should have indicated Resident #17 had a fall. She stated she failed to code the fall related to human error. In an interview with the DON on 9/24/24 at 11:24 AM she stated all falls were reviewed with IDT team each morning and when the MDS Nurse's received the information, they should have coded it in the MDS. In an interview with the Administrator on 9/25/24 at 4:08 PM she stated the MDS assessment should accurately reflect resident falls. 48230 b. Resident #56 was admitted to the facility on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD). A review of Resident #56's medical record revealed a Physician's order dated 8/23/24 for oxygen to be delivered at 2 liters per minute via nasal cannula continuously. A review of the admission Minimum Data Set (MDS) dated [DATE] did not indicate Resident #56 used oxygen. A review of Resident #56's Medication Administration Record revealed she had been receiving oxygen at 2 liters per minute continuously since admission. An interview with MDS Nurse #1 on 9/24/24 at 2:52 PM revealed changes in resident conditions were discussed with the interdisciplinary team (IDT) (a group of healthcare professionals who work together to treat a resident) each morning. MDS Nurse #1 stated the MDS assessment completed on 8/29/24 should have indicated Resident #56 used oxygen. She indicated coding for oxygen was missed due to human error. In an interview with the Administrator on 9/24/24 at 2:57 PM she stated the MDS assessment should have accurately reflected Resident #56's oxygen use. In an interview with the Director of Nursing (DON) on 9/25/24 at 12:55 PM she stated Resident #56's MDS should have been coded for oxygen use. 37468 c. Resident #93 was admitted to the facility on [DATE]. Her active diagnoses included chronic obstructive pulmonary disease, atrial fibrillation, and hypertension. Review of Resident #93's progress note dated 9/12/24 revealed she was discharged home. Review of Resident #93's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed she was coded as discharged to a short-term general hospital. During an interview on 9/24/24 at 2:38 PM MDS Nurse #2 stated Resident #93 was discharged home and the discharge MDS dated [DATE] was marked in error. During an interview on 9/24/24 at 2:57 PM the Administrator stated MDS assessments should accurately reflect residents' discharge status.

Based on observations, record review and staff interviews, the facility failed to handle soiled linen in a manner to prevent the spread of infection. This was for 1 of 2 staff members observed for infection control practices during activities of daily living care (Nurse Aide #1). Findings included: A review of the facility's policy titled: Linen Handling dated 4/2023 revealed in part: All soiled linen should be considered as contaminated. The risk of actual disease transmission from soiled linen with pathogenic microorganisms is insignificant if handled, transported, and laundered in a way that avoids the transfer of microorganisms. Soiled linen should be bagged or placed in containers at the location where it is used. Wet and/or soiled linens should be placed and transported in leak proof bags. On 9/25/24 at 10:29 AM an continuous observation of bathing activity was conducted for Resident #1 with Nurse Aide (NA #1). At the conclusion of the activity at 11:25 AM NA #1 removed her soiled gloves, performed hand hygiene and applied clean gloves. NA #1 was observed to pick the soiled linen up from the floor while wearing her gloves, open Resident #1's room door, transport the linen out into the hallway, and place it into the soiled laundry hamper which was positioned outside the door to Resident #1's room. NA #1 then removed her gloves and performed hand hygiene. An interview with NA #1 at that time, after leaving Resident #1's presence, indicated the linen on the floor of Resident #1's room was the soiled linen from Resident #1's bath. NA #1 stated sometimes she placed resident's soiled linen into a bag after their bath if she needed to transport the soiled linen down the hallway, but if the linen hamper was outside the room like it was today, she would pick the linen up from the floor and place into the laundry hamper without putting it into a bag first. On 9/25/24 at 4:05 PM an interview with the Director of Nursing (DON) indicated she was also serving as the facility's Infection Preventionist. She stated NA #1 should not be placing soiled linen directly on the floor in resident's rooms. She went on to say this was an infection control issue because it could result in the cross contamination of microorganisms. The DON reported NA #1 should be placing soiled linen directly into a bag for transport. On 9/26/24 at 9:50 AM an interview with the Administrator indicated soiled linen should be bagged for transportation unless it could be placed directly into the soiled linen hamper and should not be placed on the floor in resident's rooms.

Based on record review and staff interviews the facility failed to have quarterly care plan meetings for 2 of 4 residents reviewed for care planning (Resident #23, Resident #11). Findings included: 1. Resident #23 was admitted to the facility on [DATE]. His active diagnoses included chorea, psychomotor deficit following cerebral infarction, type 2 diabetes, and psychophysiological insomnia. Review of a social narrative progress note dated 6/17/22 revealed the social worker spoke with Resident #23's case worker. The Case Worker asked the social worker to send over the care plan as well as medical records for her status report. The Case Worker indicated she had not had the chance to schedule a care plan meeting. Once the Case Worker had finished all status reports, the Case Worker would call the social worker to schedule a proper care plan meeting. There was no further documentation of a care plan meeting in Resident #23's facility records. During an interview on 07/24/23 10:11 AM Resident #23 stated he had not been invited to care plan meetings. During an interview on 7/25/23 at 10:01 AM the Social Worker stated care plan meetings were held quarterly. The social worker looked in the medical record and found in Resident #23's medical record that on 6/17/22 the previous social worker noted having a care plan meeting with the case worker. She stated she did not have any documentation of a care plan meeting for Resident #23 since that date. She concluded she did not know how he was missed and had not had a care plan meeting since 6/17/22. During an interview on 7/26/23 at 8:23 AM Case Manager #1 stated she was Resident #23's Case Worker. She further stated she had attended care plan meetings in the past but had not attended a care plan meeting in a long time. She concluded she could not remember the last time she had been invited to a care plan meeting. During an interview on 7/26/23 at 9:11 AM the Administrator stated care plan meetings should be conducted quarterly. 41009 2. Resident #11 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus. A review of Resident #11's medical record revealed her last documented care plan meeting was on 3/2/23. A review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. A review of Resident #11's current comprehensive care plan revealed it was last reviewed on 5/23/23. In a telephone interview on 7/24/23 at 2:03 PM Resident #11's Representative (RP) stated she liked to be very involved in Resident #11's care. She went on to say she used to receive invitations to attend Resident #11's care plan meetings every 3 months. She further indicated she had not gotten an invitation to attend Resident #11's care plan meeting in several months. In an interview on 7/25/23 at 3:52 PM the Social Worker (SW) stated she was responsible for scheduling care plan meetings with resident's and their RPs. She stated care plan meetings were conducted at least every 3 months in conjunction with a resident's MDS assessment and more frequently as needed. She went on to say she had been mailing out invitations to RPs to schedule care plan meetings but had not been getting consistent responses, so she had begun calling to schedule them. The SW stated Resident #11's last documented care plan meeting was 3/2/23. She went on to say if she had called Resident #11's RP to schedule a care plan meeting since then, it would have been documented in Resident #11's medical record. She further indicated she used the dashboard on her computer to create the care plan meeting schedule. The SW stated according to this dashboard, Resident #11's next scheduled care plan meeting would be in August 2023. She went on to say Resident #11 should have had a care plan meeting between the 3/2/23 meeting and the next care plan meeting in August but Resident #11 had not. She further indicated she could not explain why this had not occurred. In an interview on 7/27/23 at 8:30 AM the Director of Nursing (DON) stated Resident #11's RP was very involved in Resident #11's care. She went on to say care plan meetings with residents and their RPs normally occurred at least every 3 months and more frequently as needed.

Based on observation and interviews with resident, vendor company, and staff, the facility failed to clean a black substance on and around the ceiling vents (diffusers) for 3 of 4 resident rooms (Rooms #501, #505 & #508) and 1 of 4 nursing station areas (500 hall nursing station) observed for environment. In addition, the facility failed to initiate testing of the black substance to ensure it was not hazardous to residents. Findings included: Observation on 7/24/23 at 11:23 AM, during the initial tour revealed room [ROOM NUMBER]'s ceiling vent had a dark substance on the vent and on the ceiling around the vent. An interview on 7/26/23 at 9:54 AM with a resident who resided in room [ROOM NUMBER]. The resident was alert and oriented to person, place, time, and situation. He stated he had noticed the black area on and around the ceiling vent but had not reported it to anyone. He also stated he thought it was dirty and needed to be cleaned. Observation on 7/24/23 at 11:31 AM, during the initial tour revealed the occupied resident room, room [ROOM NUMBER], had a ceiling vent with a dark substance on the vent and on the ceiling around the vent. An interview and observation on 7/25/23 at 1:21 PM with Nurse #1 revealed she had noticed the black substance on the ceiling vents in a few areas and verbally notified the Maintenance Director. She did not remember when she had first noticed the black substance or when she had notified him. She stated that there was a black substance on the ceiling diffuser at the nurses' station on the 500 hall and that she had seen it in other areas of the building but did not remember specifically locations. During this interview at the nurses' station on the 500 hall a black substance was observed on the ceiling diffuser. An interview on 7/26/23 at 9:33 AM with Nurse Aide (NA) #2 revealed she reported any maintenance concerns she observed to the unit nurse. She stated she had noticed some of the ceiling vents and had reported the black substance on the ceiling vents to the nurse a couple of months ago. She stated she did not remember specifically which ceiling vents on which hall she had observed or which nurse she informed. An observation and interview on 7/25/23 at 10:46 AM with the Housekeeping Director revealed she checked the resident rooms daily for cleanliness. She stated the ceiling vents in Rooms #501 and #505 needed to be cleaned and repaired due to the black substance on and around the vent. An additional interview on 7/26/23 at 9:23 AM with the Housekeeping Director revealed they inspected and cleaned the ceiling vents if necessary, during their monthly room deep cleaning. An additional interview on 7/26/23 at 8:37 AM with the Maintenance Director revealed that he was expecting a private vendor company to examine the building and potentially add more exhaust fans to the ventilation system. He also stated that the 100 hall and 500 hall rooms and areas had the worse black substance on the ceiling diffusers. He stated that they had taken most of the diffusers down on the 100 hall where they cleaned, painted and replaced them since 6/28/23. An observation and interview were conducted on 7/25/23 at 10:13 AM with the Maintenance Director and the Administrator in Rooms #501 and #505. The Maintenance Director confirmed that the ceiling vents, which were called diffusers, had a dark substance on and around them which he believed was caused by condensation due to the hot weather temperatures. He stated he first became aware of the extent of the black substance on 6/28/23 and he contacted the corporate office on 6/28/23. He also stated that he was unaware the black substance on the ceiling diffuser was that bad in Rooms #501 and #505. The Maintenance Director stated the black substance had not been tested and he could not specifically state what it was. The Administrator stated she was aware of the dark substance on the ceiling vents but was not specifically aware of the vents in Rooms #501 and #505. An additional observation and interview on 7/25/23 at 10:30 AM with the Maintenance Director he revealed the ceiling diffusers throughout the facility were 16 inches by 16 inches. He stated the dark area around the ceiling diffuser in room [ROOM NUMBER] measured about 6 inches by 8 inches. The observation continued in room [ROOM NUMBER] where the black substance around that ceiling diffuser measured 3 inches by 5 inches. A further observation continued in room [ROOM NUMBER] where the ceiling diffuser had a brown substance located at all four corners of the diffuser. There was no brown or black substance located on the ceiling around the diffuser in room [ROOM NUMBER]. room [ROOM NUMBER] was occupied by a resident. An interview was conducted on 7/25/23 at 10:30 AM with the resident who resided in room [ROOM NUMBER]. He was alert and oriented to person, place, time, and situation. He indicated he had not noticed the brown substance located at all four corners of the diffuser in his room. A phone interview was conducted on 8/03/23 at 11:44 AM with the Maintenance Director. The Regional [NAME] President of Operations, Nursing Consultant, and Administrator were present on the phone call during the interview. The Maintenance Director revealed he first became aware of the black substance on the ceiling diffusers on 6/28/23 when a nursing staff member informed him of a room on the 400 hall. He stated he did not remember the exact room number. He then contacted the Administrator, the Senior Regional Maintenance Director, and the facility management company through the electronic maintenance system. He stated the vendor came the same day (6/28/23) and assessed the problem and made a recommendation to clean the hot water coil on one of the air conditioning systems in an attempt to improve air flow and improve the condensation in the ceiling diffusers. The Maintenance Director stated the coil cleaning was approved and completed within a few days but did not resolve the condensation in the ceiling diffusers. The vendor returned to the facility on [DATE] and recommended a larger heating and air conditioning system be installed which was ordered and installation was completed on 8/1/23. He clarified the condensation was on the exterior of the vents and was not inside of the duct work. He stated the black substance was not tested and he believed that it was not in the facility management company's protocol to do testing. He stated that he cleaned the ceiling diffusers with the cleaning product recommended by the facility management company. A phone interview was conducted on 8/03/23 at 12:46 PM with the [NAME] President (VP) of the facility management company. The Senior Regional Maintenance Director, Nursing Consultant, Maintenance Director, Administrator, and Regional [NAME] President of Operations were also present on the phone call during the interview. The VP of the facility management company revealed she became aware of the ceiling vent condensation and black substance at the facility on 6/28/23. She stated she contacted a vendor the same day for a service call. She stated the vendor completed the service call on 6/28/23 and made a recommendation to clean the hot water coil on the heating and air conditioning unit. They later recommended that the heating and air conditioning unit be upsized to a larger unit which was completed on 8/01/23. The VP of the facility management company stated the black substance was not tested and that out of an abundance of caution, they recommended the facility use a cleaning product for mold control to clean regardless of what the substance was to remove and remedy any potential problems. She stated that the facility management company did not have a protocol for testing. A phone interview was conducted on 8/03/23 at 1:19 PM with the Vendor Company President. The [NAME] President (VP) of the facility management company, Maintenance Director, Senior Regional Maintenance Director, Administrator, Nursing Consultant, and Regional [NAME] President of Operations were present on the phone call during the interview. The Vendor Company President revealed he had gone to the facility for the first service call on 6/28/23. He had recommended the hot water coil be cleaned which was completed on 7/07/23. Another service call on 7/19/23 revealed no real improvement in the air flow and the technician recommended a larger heating and air conditioning unit be installed. The Vendor Company President stated this was completed on 8/01/23. He stated that condensation can occur without proper air flow. He also stated he had not observed the black substance and he was not a mold specialist and would not have made any recommendations. A phone interview was conducted on 8/03/23 at 2:38 PM with the corporate Regional [NAME] President. The Administrator, Nursing Consultant, and [NAME] President of the facility management company were present on the phone call during the interview. He revealed that they did not have a testing policy or procedure on when to test or not test black substances. He stated they did not automatically assume it was mold and were using the same chemicals to clean as if it had been tested and determined to be mold. He also stated there were filters in place to ensure clean air was recirculated in the duct work.

Based on staff interviews and record review the facility failed to accurately code a fall on a Minimum Data Set (MDS) Assessment and failed to accurately code the Preadmission Screening and Resident Review (PASARR) on a MDS assessment for 2 of 22 resident MDS assessments reviewed (Resident #26). Findings included: 1. Resident #61 was admitted to the facility on [DATE]. Her active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #61 ' s progress note dated 3/4/22 revealed Resident #61 was sitting in chair in dining room. The resident went to get up and became dizzy and slid to floor with no injuries found. Resident #61 ' s MDS dated [DATE] revealed she was assessed as severely cognitively impaired. She was assessed to have no falls since admission/entry or reentry or prior assessment. During an interview on 5/5/22 at 10:32 AM the MDS Coordinator stated Resident #61 ' s fall on 3/4/22 should have been captured on the 4/8/22 MDS and it was not. During an interview on 5/5/22 at 10:37 AM the Administrator stated falls should be accurately captured on MDS assessments. 2. Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's medical record contained a Preadmission Screening and Resident Review (PASARR) Level II Determination Notification dated 7/27/15 with no end date. The annual Minimum Data Set (MDS) dated [DATE] indicated Resident #26 was not coded for Level II PASARR. An interview on 5/04/22 at 1:24 PM with MDS Nurse #1 revealed she was responsible for coding the PASARR on Resident #26's MDS. She stated it should have been coded on the annual MDS and she just missed it. An interview on 5/04/22 at 1:36 PM with the Administrator revealed she expected the MDS to be coded correctly.

Based on record review and staff interviews the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for 1 of 1 resident (Resident #1) reviewed for resident assessment. Findings included: Resident #1 was admitted to the facility on [DATE]. A nursing note dated 12-21-21 at 11:22 was reviewed. The note revealed Resident #1 was discharged to an assisted living facility and was transported by her daughter. Review of the Minimum Data Set (MDS) assessments revealed no discharge MDS had been completed. An interview occurred with the MDS Coordinator on 5-5-22 at 8:57am. The MDS Coordinator confirmed there had not been a discharge MDS completed for Resident #1. She explained the discharge MDS had been overlooked. The Administrator was interviewed on 5-5-22at 11:58am. The Administrator stated there should be a discharge MDS in place for all residents who are discharged from the facility.

Based on observation, record review, and staff interviews the facility failed to accurately document advanced directives (code status) throughout the medical record for 1 of 1 resident reviewed for hospice care (Resident #7). Findings included: Resident #7 was admitted to the facility on [DATE]. A review of Resident #7 ' s order dated [DATE] revealed she was ordered to be a DNR. Resident #7 ' s minimum data set assessment dated [DATE] revealed the resident was assessed as severely cognitively impaired. She was documented as being on hospice care. Resident #7 ' s care plan dated [DATE] revealed she was care planned for end-of-life advance directives. The interventions included that the resident was a full code and to receive cardio-pulmonary resuscitation (CPR). During an interview on [DATE] at 8:43 AM the MDS Coordinator stated the resident was ordered a DNR for advanced directives and should not be care planned as a full code. She concluded the social worker was responsible for updating advanced directives in the resident ' s care plans. During an interview on [DATE] at 9:55 AM the Social Worker stated she was responsible for updating advanced directives in the resident ' s care plans. She further stated when Resident #7 requested a DNR instead of being a full code, she was not working at the facility, and she started work a couple of weeks after the request for the DNR. She stated she was not aware she was supposed to go through the orders and miscellaneous documents every three months to update the care plans for residents. She concluded that was why the update to the care plan was missed. During an interview on [DATE] at 8:50 AM the Director of Nursing stated advanced directives code status should be accurately reflected in resident care plans and it was not correct for Resident #7.

Based on observation, record review, and staff interviews the facility failed to treat a resident with dignity and respect by referring to the resident who required assistance with meals as a feeder for 1 of 1 resident reviewed for dignity (Resident #7). Findings included: Resident #7 was admitted to the facility on [DATE]. Resident #7 ' s minimum data set assessment dated [DATE] revealed the resident was assessed as severely cognitively impaired. She had no moods or behaviors and was totally dependent on staff for eating. Resident #7 ' s care plan dated 2/16/22 revealed she was care planned for hospice care related to progressive and declining disease process. The interventions included to encourage and assist with meals. During observation on 5/2/22 at 12:44 PM Nurse Aide #1 was observed standing next to Resident #7 in the 300-hall dining room and stated to another nurse aide that Resident #7 was a feeder. There were approximately 10 other residents in the dining room at that time. This statement was able to be heard at the entrance to the dining room approximately 20 feet away. During an interview on 5/2/22 at 12:46 PM Nurse Aide #1 stated she used the term feeders for residents who needed assistance with meals and to her knowledge that was just what staff called those residents. During an interview on 5/2/22 at 9:57 AM the Director of Nursing stated the term feeder should not be used by staff due to dignity concerns and she began in servicing staff when she was made aware of the concern.

Based on observations, record reviews and staff interviews, the facility failed to follow manufacturer ' s instructions to prevent accidents/hazards for 1 of 7 cognitively impaired residents (Resident #2) reviewed with mesh side rails. The Immediate Jeopardy began on 10/22/10 at 10:00PM and was identified on 2/24/11 at 5:00PM. The Immediate Jeopardy was removed on 2/25/11 at 2:05PM, when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of D (with more than minimal potential for harm that is not immediate jeopardy). The findings are: Resident #2 was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of an undated manufacturer ' s instructions for, " The First Years, Secure Comfort Fold Down Bedrails, " (mesh rails) under warning, read in part, " Make sure there are no gaps or voids between the side of the mattress and bedrail. Never use on a: Non-standard sized mattress and box spring. Use only on an adult bed with mattress and box spring. Use only for children who can get in and out of an adult bed unassisted. " According to the manufacturer ' s instructions for the, " The First Years, Secure Comfort Fold Down Bedrails, " the mesh panel side rails fit into metal brackets (sockets) on both sides of the bed. When the mesh panel side rails are locked into place, the mesh panels can be wiggled back and forth slightly but will not swing down and out of position. In order for the mesh panels to break away or fall, the top rail has to be lifted straight up on both ends of the mesh panel until the locking disks come out of the brackets. Review of the Resident Assessment Protocol Summary (RAPS) dated 7/29/10, revealed that Resident #2 triggered for falls. The Resident Assessment Protocol Summary (RAPS) for Falls, dated 7/26/10, under, Narrative Note, read, in part, " At risk for falls characterized by hx. (history) of falls, safety awareness, and unsteady gait. " Review of the Nursing Notes dated 10/13/10 at 10:00PM revealed that Resident #2 returned from the hospital, an admission assessment was completed and she was comfort measures only. According to the admission assessment dated [DATE], in the area of bed mobility, Resident #2 was totally dependent on staff for turning and repositioning and was bedfast. The resident was transferred by a mechanical lift. Review of facility Nurses Notes dated 10/14/10, read in part, " Mesh siderail applied to r (right) side of bed. " Comfort measures continued and the resident was turned every 2 hours and as needed. Review of facility Nurses Notes dated 10/15/10, read in part, " Moving around in bed more today, had legs on side of bed, re-positioned. " Comfort measures continued and resident was turned and repositioned every two hours and as needed. Review of facility Nursing Notes dated 10/20/10 at 2:00AM, read in part, " Side rails up. Safety measures in place. " Review of a facility document dated, 10/22/10 and titled, " Resident Incident Witness Statement " under, " Describe the incident in detail (What, where, how it happened) read, " I walk into Resident Room to do my 10:00 (PM) round (s) found Resident hanging half of upper body on the floor resident climb between the opening on the bed. " During a telephone interview on 2/25/11 at 9:45AM, NA#3 gave a different version of the statement she wrote regarding Resident #22 ' s fall on 10/22/10. She stated that she was doing her 10:00PM rounds, which was her last round for the night. NA#3 revealed that she found Resident #2 leaning between the mesh rails and the mat, toward the head of the bed. She stated that the resident was basically trying to get out of bed. NA#3 indicated that Resident #2 was trying to push the mesh rail off of the bed. She stated that the mesh rails were up and Resident #2 was not entangled in the rails. She stated that the lower part of the resident ' s body was on the mat. NA #3 revealed that Resident #2 ' s leg was hanging between the mat and the bed. She stated that the resident ' s head was facing the head board of the bed. NA#3 indicated that the resident ' s head was not hanging. She stated that hanging was a poor choice of words. She indicated that the Resident ' s chest area was up on the bed and her legs and knees were on the mat. NA#3 revealed that the resident was kneeling facing the bed, like she was praying. She indicated that the resident ' s lower body had gone between the gap in the mesh side rail and the half side rail. NA#3 explained that the Resident ' s head was on the bed facing the head of the bed and her legs were on the mat in a kneeling position. She stated that the resident was not hanging or leaning. NA#3 stated that she worded it wrong. She stated that the resident ' s lower body was on the mat and she was not entangled in the mesh rail at all. NA #3 stated that she went to get the nurse and the nurse checked the resident and the resident was fine. Review of facility Nursing Notes dated, 10/22/10 at 10:20PM, read, " at 10:10PM, CNA (Nursing Assistant) found resident on the floor between siderails. Alert, non-verbal. (symbol for no), s/sx (signs/symptoms) (of) pain (symbol for no) apparent injury. I assisted in transfer back to bed. " During a telephone interview on 2/24/11 at 12:25PM, Staff Nurse#5 explained how she found Resident #2 after she was called by NA#3 to assess the resident after the resident ' s fall on 10/22/10. She stated that Resident #2 had a four inch thick mat on the floor beside her bed. She stated that Resident #2 had a cradle mattress, mesh rails and the side rails attached to an electric bed. Staff Nurse #5 revealed that the cradle mattress and mesh side rails did not cover the eight inch opening. She indicated that the mesh rails were for the bottom of the bed and did not cover the mid section of the bed. Staff Nurse #5 stated that the cradle mattress had high sides on upper and lower parts of the bed. She stated that there was a scoop in the middle half way down the bed. Staff Nurse #5 revealed that Resident #2 moved down to the opening where she was found hanging out of the opening on the floor. She stated that Resident #2 ' s head and shoulders were on the mat. Staff Nurse #5 revealed that the resident ' s head was face up as she recalled. She stated that she knew that the mesh rails would break away. Staff Nurse #5 further indicated that the reason the mesh rails did not break away was probably the way Resident #2 turned in bed and did not knock them over. She stated that there was no mat on the floor anymore. During a second interview and observation on 2/24/11 at 3:50PM, Staff Nurse #5 began to describe how Resident #2 was found when she was called to the resident ' s room after the resident ' s fall on 10/22/10. The Director of Nursing (DON) was in the room during the observation and interview. Staff Nurse #5 pointed to the mat and stated that she found Resident #2 face up and her back part touching the mat. Staff Nurse #5 stated that she did not remember if the resident had the mesh rails on her bed. Documentation revealed that the mesh side rails were on Resident #2 bed when she fell on [DATE]. She revealed that she did not remember what kind of mattress the resident had. Staff Nurse #5 became very emotional and the interview was stopped. Review of a facility document, written to the Physician, from Staff Nurse #5, " Date/Time: 10/22/10 " under, " Concern: FYI " read, " at 10:10PM resident found on floor next to bed. No apparent injury. Will be placed on 30-day incident monitoring. " During an interview on 2/25/11 at 9:25AM, the Vice President of Operations stated that Resident #2 ' s kick was strong, but she was not strong enough to do things on her own. She discussed Resident #2 ' s fall on 10/22/10. The Vice President of Operations stated that the resident was not hanging off the bed, she was not injured and she did not fall off the bed or anything as a result. She indicated that NA#3, who found the resident after the fall used the wrong words. The Vice President of Operations explained that whenever anyone was off the bed staff considered it as hanging and it was a poor choice of words. She stated that Resident #2 was reaching her hand out as if she was reaching for something on the dresser. On 2/25/11 at 9:50AM a written statement received from the Vice President of Operations was written by Staff Nurse #5 on 2/24/11, and read, " Concerning Resident #2 ' s fall of October, 2010. As best as I can recall: CNA (Nursing Assistant) called me to resident ' s room. Resident found sideways in bed with her head and arms on mat next to bed, apparently she had slid through the gap in the bed ' s siderails. Her right arm was raised above her head and she was looking towards the ceiling. Bed was in low position. " On 2/25/11 at 10:20AM, the Vice President of Operations reenacted how Resident #2 was found after she had fallen from the bed on 10/22/10. According to the Vice President, the bed used during the reenactment (hospital standard electric bed) was the one in use when Resident #2 fell from bed. The bed was in low position, with half side rails up (toward the head of bed) on both sides of the bed. The mesh side rails were up (lower end of the bed), on both sides of the bed. There was about an eight inch gap between the half side rails and the mesh side rails on both sides of the bed. The Vice President initially laid down on her back and scooted toward the end of the bed to position her body toward the opening of the two side rails. She turned from her back to her right side (looking toward the head of bed) and maneuvered her body between the two side rails with her right hand stretched out as she moved her body from the low bed onto the four inch thick mattress. While she moved between the two side rails, the mesh side rail bent slightly at an angle on one side as her legs went through the opening, but the mesh side rail did not fall down. The Vice President ' s right hand touched the night stand, which was about four to five feet from the bed and she turned from her right side onto her back, with her head on the mat, close to the night stand with her face looking up at the ceiling. Most of her torso was on the mat and her legs were half on the bed and half on the mattress. After the Vice President finished the reenactment, she indicated that the mattress had springs under the mattress. Review of Nursing Notes dated " 10/23/10 at 3:15AM, read in part, " mesh siderails in place, mat beside bed. Personal alarm on. No acute episodes. " Review of Nursing Notes dated 10/23/10 at 11:20AM, read in part, " Moving all over bed. Kicking feet over bedrail Ativan IM 0.5mg given @ 9:00AM in L (left) thigh, tolerated well. " Review of Nursing Notes dated 10/23/10 at 9:28PM, read in part, " Bed in (low) position. Mesh rails in place. Mat on floor next to bed. " Review of Nursing Notes dated 10/24/10 at 2:30PM, read in part, " Trying to get out of bed freq. (frequently) sitting on side of bed looking in drawer. " Review of a Rehabilitation Services Referral/Screen dated 10/25/10, read, in part, " Change in Condition, " " The above named patient is referred to Physical or Occupational Therapy, due to: " " Sits on side of bed, opens drawer & gets things out. Moves all over the bed. More active than on re-admit. " A note written by the Physical Therapist read, " PT (patient) not able to follow commands & movements are spontaneous- not functional for skilled PT (Physical Therapy) Services. Unable to perform motor sequencing or task sequencing. " Review of a doctor ' s order dated 10/25/10, read in part, " May discontinue comfort measures. " Review of Nursing Notes dated 10/25/10 at 9:05PM read in part, " Mattress chg ' d (changed) on bed to cradle type mattress. " (Deep winged mattress). Review of the facility ' s " Interdisciplinary Care Plan Progress Notes, " dated 10/25/10, read in part, " Fall noted 10/22/10. No injury. Deep winged mattress used for intervention. " Review of Resident #2 ' s Care Plan, which was updated on 10/26/10, under, " Problem " read, " Risk for Falls characterized by history of falls r/t (related to) decreased cognition. " Under " Goal, " read, " Res. (resident) will remain free of injury as evidenced by no falls or accidents. " Under " Approach " read, " Low bed (with) Deep Winged Mattress (with) mesh rails to both sides while in bed. " Review of an undated Resident Care Guide on the inside of Resident #2 ' s closet door, under, " Special Precautions (continued), Falls, " read in part, " Deep winged mattress with mesh rails both sides when in bed. " Bed alarm was crossed out on the Resident Care Guide. A facility report dated 10/26/10 and titled, " Resident QI (Quality Improvement) Reporting, " was reviewed. The description of the incident and interventions taken afterward are: The Event/Incident, which was documented as an unobserved fall from a low bed occurred on 10/22/10 at 10:00PM. The factor that contributed to the incident was Alzheimer ' s disease. The resident was noted to be totally dependent. There was no injury as a result of the fall. The interventions taken were a mattress replacement (Deep winged mattress) and Nursing observation and neuro checks. The incident occurred in the resident ' s room. Review of a facility document, titled, " Investigation Follow-up " dated 10/26/10 described the event/incident that occurred on 10/22/10, as an unobserved fall, with no injury, from a low bed. The investigation documented that the resident ' s bed was in the low position and the mesh rails were up. The contributing factor was Alzheimer ' s disease and interventions taken to prevent reoccurrence were mattress replacement (Deep winged). The investigation did not recommend referral to the appropriate QI (Quality Improvement) Committee. Description of Deep Winged Mattress and Mesh side rails used by the facility for Resident #2: A Deep Winged Mattress is a mattress with high thick padded vinyl sides on the upper and lower portion of the mattress on all four sides of the mattress. The winged mattress was on the frame of a standard hospital electric bed. The length of the wings on the four sides of the mattress are estimated to be about two inches longer than half side rails. The head board and foot board of the mattress was also covered with thick padded vinyl. The depth of the winged mattress was an estimated 24 inches deep at the upper and lower portions of the mattress. In addition to the winged mattress, half rails were attached to the frame of the bed at the upper portion of the bed on both sides. The half rails were on the outside of the padded wings on both sides of the upper portion of the mattress. The mesh (net like material) side rails cover the lower portion of the bed on both sides. The mesh side rails are flexible. Review of the facility ' s " Interdisciplinary Care Plan Progress Notes, " dated 10/29/10, read in part, " Mesh rails added today to deep winged mattress. " Review of Nursing Notes dated 10/30/10 at 10:35PM, read in part, " Very active-moving around in bed (with) high sides. " Review of facility Nurses Notes dated 10/31/10 at 10:30PM, read in part, " Alert, non-verbal. Cont. (continued) movement in bed. Throws feet over side of mattress. Safety measures in place. " A doctor ' s order dated 11/3/10 read, " Xanax 0.5mgs. (milligrams) one tablet by mouth every evening at 8:00PM. Ativan 0.5mgs. by mouth twice daily as needed for anxiety. Remeron 30mgs. one tablet by mouth at bedtime. " Review of the most recent Quarterly Minimum Data Set ((MDS) dated [DATE], revealed that Resident #2 had both long and short term memory deficits and severely impaired decision making. Resident #2 required extensive to total assistance in all areas of activities of daily living. The resident was 5 feet tall and weighed 113 pounds. In the area of bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep), Resident #2 was totally dependent (required full staff performance every day during the entire 7-day period) with one person physical assistance. In the area of transfers (how resident moves between surfaces including to or from bed, chair, wheelchair, standing position), Resident #2 required extensive assistance (resident involved in activity, staff provide weight bearing support) with one person physical assistance. In the area of ambulation (walking between locations in her room), Resident #2 required extensive assistance with one person physical assistance. Resident #2 was coded for a trunk restraint on the MDS. Siderails was not coded as a restraint. Review of the facility ' s " Interdisciplinary Care Plan Progress Notes, " dated 1/26/11, read, " Clinical Review today - Mats to floor removed at this time. Res. (resident) cont. (continues) to have x 2 mesh rails & deep winged mattress. " During an interview on 2/23/11 at 5:30PM, Staff Nurse#6 stated that Resident #2 turned herself in bed and she occasionally needed some help. He revealed that the side rails were kept up so that the resident would not injure herself. Staff Nurse #6 stated that the side rails were kept up at all times while the resident was in bed. He indicated that if Resident #2 wanted to get out of bed, she turned a lot and she would probably try to swing her leg or arm over the side rail. Staff Nurse#6 revealed that Resident #2 tried to get out of bed a month ago. During a telephone interview on 2/24/11 at 3:55PM, Staff Nurse #6 stated that he did not remember the date that Resident #2 tried to get out of bed a month ago, but he revealed that the time was around 6:00PM. Staff Nurse #6 indicated that Resident #2 put her legs over the side of the bed and climbed out of bed. He stated that he placed her back in bed and monitored her. When asked if Resident #2 climbed over the side rails, Staff Nurse #6 stated that the resident attempted to go over the side rails, but she did not go all the way over the side rails. He stated that Resident #2 did not touch the floor. Staff Nurse #6 revealed that the resident ' s leg was over the side rail. He revealed that the side rails were up on both sides of the bed. Staff Nurse #6 revealed that he did not report the incident because the resident did not get out of bed or hit the floor. He stated that there was nothing for him to report. During an observation on 2/23/11 at 7:50AM, Resident #2 was asleep on a winged mattress. Both half side rails were up on the upper portion of the winged mattress and both mesh side rails were up on the lower portion of the winged mattress. Further observation revealed that the winged mattress had about an eight inch gap between the upper portion of the wings and the lower portion of the mesh side rails on both sides of the mattress. There were also gaps between the sides of the mattress and mesh side rails on both sides of the mattress. There were gaps between the sides of the outer wing portion of the mattress and the inner portion of the mesh side rails on both sides. During an observation on 2/23/11 at 8:25AM, Resident #2 was awake in bed picking at the linen on her bed. Both half side rails were up on the upper portion of the winged mattress and both mesh side rails were up on the lower portion of the winged mattress. The head of the winged mattress was elevated to almost sitting position. The winged mattress had a gap between the upper portion of the wings and the lower portion of the mesh side rails on both sides of the mattress. There were gaps between the sides of the mattress and mesh side rails on both sides of the mattress. There were gaps between the sides of the outer wing portion of the mattress and the inner portion of the mesh side rails on both sides. During an interview on 2/23/11 at 11:00AM, NA#2 stated that Resident #2 required total care and she took her for walks daily. She stated that Resident #2 required one person to transfer her and sometimes two persons if she was combative. Na#2 indicated that Resident #2 had a winged mattress with half side rails and mesh side rails. She indicated that the resident ' s bed was kept in the low position. NA#2 stated that Resident #2 moved around in her bed and that the mesh rails were up anytime the resident was in bed. She revealed that the bed alarm was discontinued when Resident #2 no longer tried to climb out of bed. There was no documentation of when the bed alarm was removed. NA#2 stated that she had not seen Resident #2 try to get out of bed and that if Resident #2 wanted to get out of bed, she would throw her feet over (pointed to the mesh rail) and climb over it, or she would kick it. NA#2 shook the mesh rail attached to the winged mattress and said, " Both sides are secure. " During an interview on 2/24/11 at 8:45AM, Staff Nurse #2 indicated that when Resident #2 returned from the hospital, she was falling out of bed. She stated that she would find the resident sitting on the blue mat on the floor beside her bed. Staff Nurse #2 stated that the resident would move all over the bed. She indicated that when Resident #2 had the regular mattress she would try to get things off of the dresser, which was within her reach. She revealed that the regular mattress did not keep the resident safe. Staff Nurse #2 stated that she had not seen Resident #2 try to climb out of bed or fall since the bed was changed to the winged mattress. She revealed that she had not seen Resident #2 try to climb over the bed rails. Staff Nurse #2 indicated that the winged mattress and bed rails were for her safety and that Resident #2 usually stayed in the middle of the bed. She stated that if Resident #2 tried to get out of bed they would get her up out of bed. Staff Nurse #2 revealed that they did not think it was necessary for Resident #2 to have a bed alarm because she slept through the night. She revealed that the resident had improved a lot. During an interview on 2/24/11 at 9:05AM, the Minimum Data Set (MDS) Coordinator revealed that the mesh side rails attached to Resident #2 ' s winged mattress were used to prevent falls. She revealed that both mesh side rails had to be up at all times. The MDS Coordinator explained that the mesh side rails were not considered a restraint, because if Resident #2 attempted to get out of bed the mesh side rails would break away. The MDS Coordinator could not explain how the mesh side rails would break away. She stated that the mesh side rails did not prevent Resident #2 from getting out of bed. The MDS Coordinator revealed that she had not known Resident #2 to try to crawl out of bed. She stated that if Resident #2 tried to get up on her own, then the mesh side rails would be considered a restraint. The MDS Coordinator revealed that she could not remember Resident #2 falling out of bed. She stated that she did not know if Resident #2 would try to climb out of bed. The MDS Coordinator indicated that when staff put Resident #2 in bed, she stayed there. During an interview on 2/24/11 at 9:30AM, the Physical Therapist stated that it had been a few months since she had worked with Resident #2. She stated that the resident went to the hospital and when she returned she was comfort care measures only. The Physical Therapist revealed that the resident started moving around a lot in her bed, but the movement was not functional. She stated that within minutes Resident #2 was sideways when she was put in bed. The Physical Therapist indicated that when the resident was agitated she moved around in the bed. She stated that Resident #2 started falling out of bed and they put things into place because they thought she might hurt herself. The Physical Therapist revealed that the resident would twist around in bed and the winged mattress was used to keep her safe. She revealed that the bed alarm was removed from her bed. The Physical Therapist indicated that she did not assess Resident #2 for the bed or bed rails and she did not have anything to do with recommending the winged mattress. She stated that she did not think Resident #2 could manually put down the mesh side rails or climb over the bed rails. The Physical Therapist stated that in theory the resident could climb over the mesh side rails, but she did not think that she would. She revealed that the mesh side rails prevented Resident #2 from falling out of bed. The Physical Therapist explained that the resident ' s cognition had declined and she could not get out of bed safely. She stated that the only way the resident could try to get out of bed was to throw her feet over the top of the bed rail. The Physical Therapist revealed that the mesh side rails were a restraint since it restricted the resident from getting out of bed. She stated that the mesh side rails were necessary to keep the resident safe. During an interview on 2/24/11 at 10:20AM, the Director of Nursing (DON) stated that when Resident #2 returned from the hospital, she was comfort measures. She stated that mesh side rails were placed at the bottom of Resident #2 ' s bed because she had a fall. The DON revealed that they tried the mesh rails first and then the deep winged mattress. She stated that the mesh rails would break away, and they were not considered a restraint. The DON revealed that she did not know why staff did not know that the mesh side rails would break away (fall down). She stated that her expectation would be for staff to know that the mesh side rails would break away. During an interview on 2/24/11 at 10:50AM, the QI (Quality Improvement) Nurse indicated that at one time Resident #2 had a regular mattress with both mesh side rails up. She stated that Resident #2 was found with her legs hanging off of the bed. She stated that Resident #2 would do circles in bed and she moved her legs constantly. The QI Nurse indicated that the resident could get through the hole between the half side rails and the mesh side rails on her bed. She revealed that Resident #2 could kick the mesh side rails down. The QI Nurse indicated that if the resident kicked the mesh side rail just right it would fall down. She explained that the bed had to be flat (not elevated) for the mesh side rail to fall down, otherwise it would not work. The QI Nurse stated that the mesh side rails were placed on Resident #2 ' s bed when the resident kept falling over in the bed. She stated that the mesh side rails did not go all the way down to the foot of the resident ' s bed. The QI Nurse revealed that all falls were reviewed. She indicated that she did not know that staff that worked with Resident #2 was not aware that the mesh side rails would break away (fall down). She stated that she had not inserviced staff on the mesh side rails for them to know that they (mesh side rails) would break away. The QI Nurse stated that she would inservice staff on the mesh side rails today. During an observation on 2/24/11 at 11:00AM, the Vice President of Operations demonstrated how Resident #2 moved around in bed and how the mesh rails would break away or fall down. Resident #2 had a deep winged mattress on her bed with mesh side rails on both sides of the bed. There was about an eight inch gap between the winged mattress which covered both sides of the upper portion of the bed and the mesh side rails which covered the lower portion of the winged mattress on both sides. The Vice President of Operations scooted down a little, while still lying flat on the bed, between the upper portion (wing and half side rail) of the winged mattress and mesh side rails on the lower portion of the mattress. She moved her hands, arms and legs vigorously on the mattress. When she pushed her leg against the mesh side rail on the right side of the bed, the mesh side rail did not fall down. Each time the Vice President pulled up on the mesh side rail, either with her hand or foot, the mesh side rail fell down. When she tried to go over the mesh rail, the mesh side rail would bend at an angle, but it did not fall. The Vice President stated that Resident #2 would not put her legs over the mesh side rails. She indicated that the resident would move around in the bed. During an observation of the winged mattress and interview on 2/24/11 at 12:50PM, the Vice President of Operations indicated that after Resident #2 ' s fall on 10/22/10, the regular mattress was changed to a winged mattress and side rails were put up. She stated that there was still a space between the mesh rails and the winged mattress. The Administrator was notified of the Immediate Jeopardy on 2/24/11 at 5:00PM. The Immediate Jeopardy was removed on 2/25/11 at 2:05PM, when the facility provided a credible allegation of compliance. The allegation of compliance indicated: 1. Resident #1965 had mattress replaced with High winged mattress with mat to floor and mesh rails due to involuntary movement. No other incidents related to falls from bed since interventions put in place. Resident condition has improved since re-admission on 10/13/10. Mesh rails have been removed and High winged mattress remains in place with mats to floor on both sides of bed and bed remains in low position as of 2/24/11. 2. 100% audit has been completed on all residents who currently have mesh rails were completed on 2/24/11 by DON and administrative nurses. No other resident incidents or areas of concerns were identified as a result of the audit. Care plans have been updated to reflect current interventions. All Care plans have been reviewed and updated as needed on all residents that had mesh rails in place on 2/24/11. DON, RN supervisor and administrative nurses audited residents with mesh rails using an audit tool/census and upon review it was decided to remove all mesh rails on 2/24/11. All residents have been re-evaluated for appropriate use of mesh rails. Changes will be made as indicated. There were 7 residents. Mesh rails were removed, floor mats placed on floor beside beds, all low beds in lowest position, Care Plans will be updated to reflect changes along with Resident Care Guides on 2/24/11 and all available staff has been inserviced on the removal of mesh rails and to follow the Resident Care Guide to ensure interventions are in place as of 2/25/11. Any staff that has not been in-serviced, due to unavailability, will be inserviced before being allowed to return to work. All mattress ' and beds are all according to manufacture ' s instructions as of 2/24/11. All available staff has been in-serviced on the removal of the mesh rails and to follow the Resident Care Guide to ensure interventions are in place as of 2/25/11. 3. The DON, RN supervisor and administrative nurses will monitor residents through a random audit tool weekly x4 weeks, then every 2 weeks x4 weeks, and then monthly. Any areas of concerns identified will be corrected. In-servicing in progress by administrative nurses for nursing staff, to ensure that the Resident Care Guides are being followed to properly care for the resident and to make sure that the appropriate interventions are in use. Audit tool will be used by the DON and administrative nurse if future situation becomes appropriate. Facility will contact any staff that has not been in-serviced by phone, if unable to come to the facility, or in person at facility as of 2/25/11. The audit tools will be reviewed weekly per QI/QA meetings for identified areas of concern and interventions updated as indicated. Will also determine need and frequency of continuation of monitoring through the QI process. These results will be presented for review during Quarterly Executive QI/QA meetings to ensure interventions continue to be appropriate. On 2/25/11 at 2:30PM the credible allegation was validated by reviewing all 7 residents identified as having mesh side rails and verifying that all Care Plans and Resident Care Guides were updated. All 7 of the resident ' s records were reviewed and documentation revealed that all Care Plans and Resident Care Guides had been updated. During review of the records and observations it was determined that one of the seven residents did not have mesh side rails and should not have been included for review. Observations revealed that all mesh side rails had been removed and replaced with less restrictive alternatives, such as