Every finding on record at Smithfield Manor Rehabilitation and Healthcare Cen

Based on record review and interviews with resident, staff, and pharmacist the facility failed to ensure communication between the pharmacy, facility staff, and provider occurred in order that a prescription be obtained for a controlled medication so that a new supply of the medication could be filled and dispensed, which in turn resulted in a resident missing 12 consecutive doses of an ordered medication. This was for one (Resident # 1) of one resident reviewed for pharmacy services.The findings included:Record review revealed Resident # 1 was admitted to the facility on [DATE]. One of the resident's diagnoses included chronic pain.Review of Resident # 1's physician orders revealed an order, dated 5/15/26, for pregabalin 150 mg (milligrams) three times per day. (Pregabalin is a medication used for neuropathic pain and is a controlled medication which requires nurses to sign out on a controlled drug record for each dose removed from a supply of the medication before administering the medication.)Review of Resident # 1's June 2026 MAR (Medication Administration Record) and controlled drug records revealed the following information.On 6/20/26 at 9:30 PM Resident # 1's last dose of pregabalin, which had been received by the facility on 5/22/26, was signed out and which therefore left no doses of pregabalin available for administration. Five days later, on 6/25/26 a new controlled drug record included documentation the facility had received 30 more doses of Resident # 1s pregabalin from the pharmacy. There were no controlled drug records noting that there was a supply of Resident # 1's pregabalin for doses which were scheduled to be administered from 6/21/26 through the 6/24/26.Resident # 1's June MAR included the scheduled administration times of 9:00 AM, 2:00 PM, and 9:00 PM for Resident # 1's pregabalin. On 6/21/26 MA # 1 (Medication Aide # 1) documented a 9 by the 9:00 AM dose on the MAR rather than a check mark. This indicated the pregabalin was not administered, and a progress note had been made. On 6/21/26 at 9:49 AM MA # 1 documented Resident # 1's pregabalin was on order.On 6/21/26 MA # 1 documented a 9 by the 2:00 PM dose on the MAR rather than a check mark. This indicated the pregabalin was not administered, and a progress note had been made. On 6/21/26 at 1:02 PM MA # 1 documented Resident # 1's pregabalin was on order.On 6/21/26 MA # 2 documented a 9 by the 9:00 PM dose on the MAR rather than a check mark. This indicated the pregabalin was not administered, and a progress note had been made. On 6/21/26 at 10:12 PM MA # 2 documented waiting on pharmacy.On 6/22/26 MA # 1 documented a 9 by the 9:00 AM dose on the MAR rather than a check mark. This indicated the pregabalin was not administered, and a progress note had been made. On 6/22/26 at 9:37 AM MA # 1 documented Resident # 1's pregabalin was on order.On 6/22/26 MA # 1 documented a 9 by the 2:00 PM dose on the MAR rather than a check mark. This indicated the pregabalin was not administered, and a progress note had been made. On 6/22/26 at 1:51 PM MA # 1 documented Resident # 1's pregabalin was on order.On 6/22/26 Nurse # 1 documented a 9 by the 9:00 PM dose on the MAR rather than a check mark. This indicated the pregabalin was not administered, and a progress note had been made. On 6/22/26 at 10:08 PM Nurse # 1 documented waiting from pharmacy.On 6/23/26 Nurse # 2 documented a 9 by the 9:00 AM dose on the MAR rather than a check mark. This indicated the pregabalin was not administered, and a progress note had been made. On 6/23/26 at 11:31 AM Nurse # 2 documented the pregabalin was not available.On 6/23/26 Nurse # 2 documented a 9 by the 2:00 PM dose on the MAR rather than a check mark. This indicated the pregabalin was not administered, and a progress note had been made. On 6/23/26 at 2:41 PM Nurse # 2 documented the pregabalin was not available.On 6/23/26 MA # 1 documented a 9 by the 9:00 PM dose on the MAR rather than a check mark. This indicated the pregabalin was not administered, and a progress note had been made. On 6/23/26 at 9:04 PM MA # 1 documented Resident # 1's pregabalin was on order.On 6/24/26 Nurse # 3 documented a 5 by the 9:00 AM dose on the MAR rather than a check mark. This indicated the pregabalin was held and not administered.On 6/24/26 there was a blank by the 2:00 PM dose of pregabalin. Nurse # 3 noted on 6/24/26 at 2:13 PM that the pregabalin was held.On 6/24/26 MA # 2 documented a 9 by the 9:00 PM dose on the MAR rather than a check mark. This indicated the pregabalin was not administered, and a progress note had been made. On 6/24/26 at 9:49 PM MA # 2 documented waiting pharmacy.MA # 1 was interviewed on 7/29/26 at 3:20 PM and reported the following information. She had not been able to administer Resident # 1's pregabalin when she worked on 6/21/26, 6/22/26, and 6/23/26 because it was not available. She did not recall which supervisor she had told, but it had been reported and the pharmacy needed a prescription to fill the medication. The supervisor called and talked to the pharmacy.MA # 2 was interviewed on 7/29/26 at 3:15 PM and reported the following information. She had not been able to administer the medication on 6/21/26 and 6/24/26 because they were waiting on the pharmacy to deliver the medication. She thought the nurse had called to check on the medication, but it was not sent.Nurse # 2 was interviewed on 7/29/26 at 3:39 PM and reported the following information. She only filled in at the facility on occasion. If a medication was not available, then she had been told to try to reorder the medication by clicking on an option in the electronic MAR. She always did that, but there were times when the option was grayed out and it would not allow a reorder. There would be no explanation other than awaiting pharmacy if that happened. The system did not flag if a prescription needed to be obtained when she looked at it. Nurse # 3 was interviewed on 7/29/26 at 3:31 PM and reported the following information. She filled in at the facility and did not work full time. She could not recall the specific details of what had occurred with Resident # 1's pregabalin. Routinely if a resident was out of medication, she would try to call the pharmacy and check on it. At times, if it was after hours, she would not be able to speak to someone. If she had not charted the administration of the pregabalin on 6/24/26 then she would not have given it because it was not available, but she would have tried to obtain it.An attempt was made to interview Nurse # 1 on 7/29/26 at 3:44 PM but she was not available for interview.A pharmacist from the facility's contracted pharmacy was interviewed on 7/29/26 at 3:05 PM and reported the following information. The pharmacy did not generally make and keep records of phone calls from the facility if staff called about a certain medication. The pharmacy's records showed the pharmacy first received a reorder request on 6/23/26. They sent a fax to the facility which alerted the facility that a prescription was needed. The pharmacy's records showed that the fax failed to transmit, but it was not clear if that was due to the pharmacy's transmission or the facility's receipt of the fax. On 6/24/26 the facility sent another request for a refill. The pharmacy again faxed the facility that a prescription was needed. A prescription was sent to the pharmacy on 6/24/26. It was not clear if the prescription was obtained by the pharmacy reaching out to the provider or if it had been obtained because the facility had reached out to the provider. The new prescription was filled on 6/24/26 by the pharmacy and placed in the delivery which left the pharmacy at 9:30 PM on 6/24/26. The facility would have received Resident # 1's pregabalin sometime between 10:00 PM on 6/24/26 and 2:00 AM on 6/25/26.Resident # 1 was interviewed on 7/28/26 at 11:45 AM and again on 7/29/26 at 8:50 AM and reported the following information. She had chronic pain for which she received more than one type of medication. In recent weeks, the facility was out of her nerve pill for several days and she did not receive it. The staff would tell her they were waiting for the pharmacy to deliver it. The resident indicated she could tell a difference when she did not receive it, but did not indicate that the difference was significantly more limiting or extreme.During the survey, the Director of Nursing was on leave and was not present during the survey. The Administrator and Assistant Director of Nursing (ADON) were interviewed on 7/30/26 at 4:05 PM. Both the ADON and the Administrator reported they had not been aware prior to 7/29/26 of a concern about the pharmacy not delivering medication. The ADON reported the following information. The facility did not have pregabalin in their back up supply and therefore Resident # 1's pregabalin would have needed to be delivered from the pharmacy for it to be administered. The pregabalin was supplied in a bubble pack card and each card denoted when the medication should be reordered. Within the electronic MAR, there was an electronic means to reorder the medication when a nurse or medication aide saw that the supply on the bubble card was getting low. If the reorder button was grayed out, then the pharmacy was working on the order. The pharmacy notified the provider when a prescription was needed and then filled and dispensed the medication.

Based on record review and staff interview the facility failed to ensure a resident's record was complete regarding measures taken when a change of status was initially noted. This was for one (Resident # 2) of three residents whose medical records were reviewed for change of status.The findings included:Resident # 2 was admitted to the facility on [DATE].Review of orders revealed Resident # 2 had an order, dated 3/27/25, for acetaminophen 325 mg (milligrams) two tablets every four hours as needed for general discomfort.On 5/29/26 at 10:00 PM Resident # 2's temperature registered 97.0 in the vital sign record portion of Resident # 2's medical record.The following day, on 5/30/26 at 4:54 PM, Nurse # 4 documented in the vital sign portion of Resident # 2's medical record that Resident # 2's temperature was 103.1 via way of a tympanic reading (measured near the eardrum using an infrared thermometer.) There was no corresponding nursing note of an assessment or actions taken.There was no indication on the MAR (Medication Administration Record) that Resident # 2 received acetaminophen at anytime on the date of 5/30/26.On 5/30/26 at 9:57 PM Nurse # 4 documented in the vital sign portion of the record that Resident # 2's temperature was 103.2 and the reading had been taken on the resident's forehead. On 5/30/26 Nurse # 4 documented at 10:32 PM in a nursing note that Resident # 2 had a fever of 103.2 after the nurse had been asked by the resident's daughter to check on the resident. The resident was alert but reported she felt confused. The provider was notified and orders obtained for labs, acetaminophen, and vitals every four hours for 24 hours.Nurse # 1 was interviewed on 7/29/26 at 11:00 AM and reported the following information. She had cared for Resident # 2 on the 3:00 PM to 11:00 PM shift on 5/30/26 and Nurse # 4 was the supervisor. In general Resident # 2 had complaints of knee pain and she tended to get upper respiratory symptoms. She did not recall specific complaints for the date of 5/30/26 or symptoms which might have triggered the fever. The resident did not appear confused to her. She (Nurse # 1) had administered acetaminophen two times during the eight-hour evening shift on 5/30/26. She (Nurse # 1) might have forgotten to document the administration and the response. Resident # 2 tended to easily become emotional and would cry. Therefore, when the resident got like that, she (Nurse # 1) tended to stay with the resident and try to calm her down. In doing so, she probably forgot to go back and chart the administration and response to the acetaminophen.Nurse # 4 was interviewed on 7/29/26 at 12:02 PM and reported the following information. As supervisor he helped the nurses. Given the amount of time that had lapsed since 5/30/26, he could not recall the specific details of 5/30/26. Generally, if a resident had a high fever to the degree that Resident # 1 was documented to have had at 4:54 PM on 5/30/26, he would have made some sort of assessment and documented any symptoms she was having. He was not sure why the resident's record did not show what actions had been taken.Interview with the Administrator on 7/29/26 at 11:30 PM revealed the following information. She would have expected the medical record to be complete by showing the administration of the acetaminophen both times Nurse # 1 administered it and evaluation of whether it was effective or not. Nurse # 1 was a very caring nurse and Resident # 2 could be emotional. She (the Administrator) did feel the resident was cared for and assessed, and that Nurse # 1 did probably sit with Resident # 2 for a while which possibly resulted in her forgetting to document.

Based on observation, record review, and resident and staff interviews, the facility failed to provide staff and residents with washcloths and towels to complete Activities of Daily Living (ADL) care. This occurred for 5 of 5 residents residing on 2 of 4 halls reviewed for linens (East and [NAME] Halls). The findings included:Review of the facility's census dated 4/22/2026 revealed the East Hall census was 56 residents and the [NAME] Hall census was 53 residents.a. Resident #134 was admitted to the facility on [DATE] and was housed on the [NAME] Hall. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #134 was cognitively intact and had no rejection of care documented. The MDS documented Resident #134 required substantial/maximal assistance with bathing and toileting. Resident #134 was frequently incontinent of urine and always incontinent of bowel.Review of the facility's ADL documentation sheet showed Resident #134's shower days were Wednesday and Saturday.Review of Resident #134's ADL documentation from 2/1/2026 to 4/21/2026 revealed Resident #134 had 2 showers and 7 bed baths.Observation of the linen room on [NAME] Hall occurred on 4/20/2026 at 10:47AM. The observation revealed there were no towels and washcloths available. Resident #134 was interviewed on 4/20/2026 at 11:06AM. Resident #134 stated the facility was unable to provide her with towels and washcloths for ADL care. Resident #134 discussed being unable to shower or bathe daily due to lack of washcloths and towels. She also stated she had to purchase her own washcloths for use not too long ago. Resident #134 discussed reporting to nursing staff (was unable to recall the specific staff member) and the Administrator the inability to shower or bathe due to the lack of washcloths and towels. Resident #134 did not remember when she reported the lack of washcloths and towels to nursing staff or the Administrator.An interview with Nurse Aide (NA) #3 occurred on 4/22/2026 at 9:50AM. NA#3 discussed working on [NAME] Hall during first shift (7:00AM to 3:00PM) and revealed that there was a problem with having enough washcloths and towels to provide a shower or bed bath to residents. She explained she would use disposable wipes for incontinence care, however, would need a washcloth and towel for care that required more cleaning. NA #3 stated she tried to get her assigned residents washed up and ready for the day early in the shift. NA #3 stated if there were no washcloths or towels available, she would tell the nurse, and the nurse would go and get some washcloths and towels from the laundry room. NA #3 indicated there were times that she had to use a sheet or clothing protector for ADL care. NA #3 stated there were problems with not having washcloths and towels available for use since May 2025. b. Resident #78 was admitted to the facility on [DATE] and resided on the [NAME] Hall. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #78 was cognitively intact. The MDS documented Resident #78 required set-up or clean up assistance with bathing and toileting. Resident #78 was also documented as being occasionally incontinent of urine and bowel.Observation of the linen room on [NAME] Hall occurred on 4/22/2026 at 6:05AM. The observation revealed 13 towels and no washcloths. During an interview with Resident #78 on 4/22/2026 at 10:43AM, she reported that she did have trouble getting washcloths. Resident #78 stated that she was independent with her ADL care and that if there was a shortage of washcloths and towels, she would make do with either disposable wipes and/or paper towels for any type of ADL care she would need to do. She indicated that she had bought her own washcloths. Resident #78 stated that she had informed nursing staff (was unable to recall a specific staff member) that she was not able to obtain washcloths and towels from the facility daily so, that was why she bought her own. Resident #78 did not provide a timeframe of when she purchased her own washcloths.Interview with NA #9 occurred on 4/20/2026 at 10:48AM. NA #9 stated she was assigned to the [NAME] Hall and on first shift (7:00AM to 3:00PM) there were hardly any washcloths or towels for staff to use for residents. She explained she used disposable wipes for incontinence care unless the care required a washcloth and towel. NA #9 stated she would have to cut blankets to use as towels and washcloths. NA #9 indicated even when they immediately reported to a supervisor that they needed washcloths and towels, they sometimes got what they needed and sometimes they did not. NA #9 indicated the issue began around March 2025. During an interview with NA #7 on 4/22/2026 at 6:11AM, the NA stated she worked the 11:00PM to 7:00AM shift on [NAME] Hall. NA #7 discussed not having enough towels and washcloths, she reported this immediately to her supervisor. She stated she would use one end of the towel as a washcloth and the other end of the towel to dry. NA #7 also indicated that she would use disposable wipes when available to provide a bed bath and/or incontinence care. NA #7 indicated the issue began around March 2025. NA #4 was interviewed on 4/23/2026 at 9:31AM. NA #4 discussed working on [NAME] Hall during second shift (3:00PM to 11:00PM). NA #4 stated that the facility was short on washcloths and towels. NA #4 indicated a normal assignment would include 12 residents, and she would usually get 2 washcloths and 1 towel for each resident to use for a shower/bed bath. If the washcloths and towels were in short supply, NA #4 would only do showers/bed baths based on resident's scheduled shower days. NA #4 stated she would use sheets or pillowcases to shower/bathe residents if there were no washcloths and towels available. The interview further revealed NA #4 would let a laundry staff member know if there were no clean washcloths and towels; laundry staff member's response to staff was that they could not do anything. NA #4 indicated the issue began around March 2025.c. Resident #143 was admitted to the facility on [DATE] and resided on the East Hall.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #143 was cognitively intact. The MDS documented Resident #143 required partial/moderate assistance with bathing and substantial/maximal assistance with toileting. Resident #143 was also documented as being always incontinent of urine and frequently incontinent of bowel.An interview occurred with Resident #143 on 4/22/2026 at 10:50AM. Resident #143 stated that she had trouble getting washcloths and towels as recently as last week and she had missed a bath last week. Resident #143 stated that staff were aware of the lack of washcloths and towels for residents to use because the NAs were the ones telling her there were no washcloths and towels available. She explained the issue with obtaining towels and washcloths had been an issue since her admission.Interview with NA #6 who worked on the East Hall, occurred on 4/22/2026 at 5:45AM. The NA stated there were currently no washcloths or towels available and that she was using disposable wipes to provide incontinence care. NA #6 also stated that a bath or shower would not be provided for her assigned Residents who were scheduled for a bath or shower because there were no washcloths and towels available.d. Resident #87 was admitted to the facility on [DATE] and resided on the East Hall.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #87 was cognitively intact. The MDS documented Resident #87 required partial/moderate assistance with bathing and dependent with toileting. Resident #87 was also documented with frequent urine incontinence and occasional bowel incontinence.Resident #87 was interviewed on 4/22/2026 at 10:55AM. She reported that she had problems with getting washcloths and towels. Resident #87 indicated today (4/22/2026) she was only provided one washcloth and no towel by staff to perform ADL care. Resident #87 explained the NA told her there were no other towels and washcloths available. She stated she could perform her own bath with assistance. Resident #87 stated she could not have a full bath and was only able to wash her face today. Resident #87 indicated the issue had been going on for a while.An interview with NA #8 who worked on East Hall occurred on 4/22/2026 at 6:20AM. The NA stated she worked from 11:00PM to 7:00AM. NA #8 discussed not having enough towels and washcloths and instead would use a pillowcase to provide ADL care. She stated the issue began around March 2025.e. Resident #122 was admitted to the facility on [DATE] and resided on the East Hall.The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #122 was cognitively intact. The MDS documented Resident #122 required substantial/maximal assistance with bathing and toileting. Resident #122 was also documented with frequent urine and bowel incontinence.During an interview with Resident #122 on 4/22/2026 at 10:57AM, she reported that she had problems with getting washcloths and towels since her admission. Resident #122 indicated she could not clean up when she wanted and was so tired of not having any washcloths available that she purchased her own washcloths and had her name put on them. An interview occurred with Nurse #7 on 4/21/2026 at 10:21AM. Nurse #7 usually worked on the East Hall. She stated that the facility was short on washcloths and towels, so they were unable to clean Residents; staff were told to use paper towels. Nurse #7 would not state who gave the directive to use paper towels and she stated she had heard NAs discussing this. She stated the issue began around March 2025 and Nurse #7 discussed reporting the issue to her supervisor each time there were not enough towels and washcloths available. Observation of the linen room on East Hall occurred on 4/20/2026 at 10:54AM. The observation revealed there were no towels and washcloths available. Observation of the linen room on East Hall occurred on 4/22/2026 at 5:43AM. The observation revealed there were no towels and washcloths available. The Environmental Services Director and a Laundry Staff Member were interviewed on 4/21/2026 at 3:30PM. The Environmental Services Director stated that his staff came in at 6:30AM to start laundry and then his staff took the main linen cart out to start stocking the three linen rooms. The Laundry Staff Member confirmed when she arrived at work at 6:30AM, she would begin gathering the soiled towels and washcloths from the soiled linen rooms and begin washing and drying the washcloths and towels for the 3:00PM to 11:00PM shift. She stated she did not count the returned washcloths and towels prior to washing them. The Environmental Services Director provided the following times the three linen rooms were stocked: (7:00AM, 3:00PM, and10:00PM). The Environmental Services Director also provided the record keeping of the linens, washcloths, towels, and clothing protectors being placed in each linen room. The document provided showed the East and [NAME] Halls received on average 30 washcloths and 16 towels each with approximately 56 Residents on each hall. The Environmental Services Director stated the number of washcloths and towels provided was based on Resident scheduled shower days which he received each morning by the Director of Nursing. He stated that he was instructed by Administration to provide enough washcloths and towels for each shift for the Residents who were scheduled for a shower that day. The Environmental Services Director stated there was no system in place for counting returned soiled washcloths and towels and that the count of the linens was completed after the laundry was done, so he was unaware of the number of towels and washcloths being returned to laundry. The Environmental Services Director stated he and his staff would go look for washcloths and towels in resident rooms that allegedly nursing staff did not place in the dirty linen room or stockpile (clean washcloths and towels) in resident rooms to be able to use later. The Environmental Services Director stated that staff would throw washcloths and towels away and that was why the number of available washcloths and towels was dwindling. The Environmental Services Director and the Laundry Staff Member reported they had seen soiled towels and washcloths in residents trash cans after the NAs had provided ADL care. He indicated that he would inform the Administrator of the need for more towels and washcloths, and she would place the order. The Environmental Services Director stated he did not have a total count of washcloths and towels available and discussed being aware staff were cutting up blankets to use as washcloths. He stated he did not understand why staff would cut up blankets to use as washcloths when all staff had to do was wait for laundry to be completed. The Environmental Services Director explained he had heard staff were using pillowcases to provide care but was unaware of staff using paper towels. He again stated he did not understand why staff were doing this. An observation was made of the Maintenance staff rolling a full linen cart down East Hall on 4/22/2026 at 7:05AM. An interview with the Maintenance staff on 4/22/2026 at 7:20AM revealed that he was providing linens (Washcloths, towels, sheets, and blankets) to all three linen rooms. Observation of [NAME] Hall linen room after linen was delivered by Maintenance staff, on 4/22/2026 at 7:20AM revealed there were no washcloths or towels available. Observation of East Hall linen room after linen was delivered by Maintenance staff, on 4/22/2026 at 7:29AM revealed there were no washcloths or towels available. A follow-up interview with the Environmental Services Director on 4/22/2026 at 9:00AM, revealed the evening shift (3:00PM to 10:00PM) laundry staff did not complete washing and drying of the washcloths and towels because the evening shift laundry staff informed him there were no dirty washcloths and towels in the soiled linen room for her to wash and have ready for this morning (4/22/2026). The Environmental Services Director stated once the laundry was completed sometime this morning he would provide the rest of the washcloths and towels. The Environmental Services Director stated there was not any emergency stock for washcloths and towels and was unable to provide a current total count of washcloths and towels. He explained an order was placed on 4/13/2026 for more washcloths and towels. The Environmental Services Director stated he was following the guidance provided to him by Administration on the number of towels and washcloths needed per shift for the NAs to provide ADL care to all residents.Interview with NA #5 who was assigned to the East Hall, occurred on 4/23/2026 at 9:42AM. NA #5 discussed working on first shift (7:00AM to 3:00PM). NA #5 stated that the facility was short on washcloths and towels. A normal assignment would include 12 residents, and she would usually get one washcloth and one towel from the linen room for each resident to use for shower/bed bath. NA #5 indicated if there was a shortage of washcloths and towels, she would use one part of the towel to wash the resident and the other part to dry. NA #5 would use wipes or paper towels to get the shower/bed bath completed. NA #5 stated that any resident that was assigned to her always received a shower/bed bath. NA #5 later stated she did not feel there were any issues with not having washcloths or towels. When there were no washcloths and towels available, NA #5 would not report it to her supervisor or ask laundry for more washcloths and towels. An interview with Nurse #2 occurred on 4/22/2026 at 10:06AM. Nurse #2 stated she was assigned to East Hall and it was a daily or every other day occurrence that staff had to tell residents that they must wait for the laundry to be done to get some clean washcloths and towels. Nurse #2 stated some residents would react with anger and some families have purchased washcloths and towels for their family members. Nurse #2 explained that even nurses and NAs have purchased washcloths to have at the facility. Nurse #2 stated that some staff have cut up blankets, sheets, and clothing protectors to use as washcloths. Nurse #2 stated that first shift staff would report to her that there were no washcloths and towels, and she would instruct staff to go to laundry and ask for washcloths and towels. Staff would then report back to her that laundry told them they did not have any clean washcloths and towels available for use. Nurse #2 stated that she had reported this issue every time it happened to her Supervisor and Administration, but nothing changed. Staff have reported to Nurse #2 that they were not able to give their residents a shower because there were no clean washcloths and towels available. Nurse #2 indicated the issue began around May 2025.Nurse Supervisor #1 and Nurse Supervisor #3 were interviewed together on 4/22/2026 at 10:25AM. Nurse Supervisor #1 stated that usually at the beginning of first shift there were no clean washcloths and towels available. Nurse Supervisor #3 stated that laundry sometimes had some clean washcloths and towels available for use but most of the time staff must wait for laundry staff to come and collect the dirty washcloths and towels off the hall and start the laundry. Staff reported daily that there were no clean washcloths and towels available, Nurse Supervisor #1 and Nurse Supervisor #3 stated that they would notify the Administrator, and the Administrator had some extra washcloths and towels in her office and would give those to the staff that needed them. Nurse Supervisor #1 stated some residents have gone without a shower/bed bath due to no availability of clean washcloths and towels. Nurse Supervisor #3 stated that she heard about staff cutting up blankets to use as washcloths or purchasing washcloths.An interview with Director of Nursing (DON) occurred on 4/23/2026 at 12:59PM. She stated that she started working for the facility in August 2025. When the DON was asked about the laundry process at the facility for washcloths and towels, she stated she did not know what time the carts go out to the linen rooms to be stocked but the timing needed to be tweaked. She stated that when she first started working at the facility there used to be individual linen carts on the hallways and two to three months ago, she converted certain storage rooms into clean linen rooms. The DON indicated that no concerns were brought to her about staff not having any washcloths and towels to do residents showers/bed baths. The DON stated residents should receive a shower or bed bath every day. The DON was not aware of any residents not receiving a shower/bed bath because of washcloths and towels not being available. The DON further stated she would need to know the number of washcloths and towels and the census to fix the issue.During an interview with the Administrator on 4/23/2026 at 1:10PM, she stated that she started working for the facility in June 2025. The Administrator stated she first heard the concern about the washcloth and towel shortage from staff in July 2025. The Administrator found out through nursing staff that staff threw washcloths and towels away after one use; in response the Administrator placed a directive out around July 2025 for facility staff that all washcloths and towels go to laundry and if stained, washcloths and towels were thrown out by the laundry staff. The Administrator stated she started utilizing the minimum number of washcloths and towels needed for everyday showers, the use of disposable wipes for incontinence care, and a monthly linen (clothing protectors, washcloths, towels, fitted sheets) order. The Administrator stated no residents should go without a shower/bed bath. The Administrator further stated she was aware that staff and residents currently had concerns of no towels or washcloths available for daily showers/bed baths. The Administrator discussed keeping towels and washcloths in her office and stated staff knew to come to her for more towels and washcloths. She discussed the towels and washcloths that were in her office, were only available when she was at the facility. When the Administrator was not at the facility her office remained locked. She stated the number of towels and washcloths being delivered each shift should be approximately 116 but did not specify how many of each. The Administrator was shown the document provided by the Environmental Services Director as to how many towels and washcloths were being provided and the Administrator stated well, that is not enough. She then stated that depending on how many showers were scheduled that day, each scheduled resident would receive 3 washcloths and 2 towels each, this was her expectation.

Based on observations, and staff interviews, the facility failed to maintain kitchen equipment clean and in a sanitary condition to prevent the potential for cross contamination of food by failing to clean the shelf under the steam table for 2 of 2 steam tables observed. In addition, failed to clean the door handles for 2 of 2 reach-in refrigerators and 1 of 1 hot box/warmer and to clean 1 of 1 pellet plate warmer observed. These practices had the potential to affect food served to residents. T The findings included:Review of the undated AM (morning) [NAME] Cleaning Schedule revealed: Monday: Clean under both steamtables thoroughly including the legs.Review of the undated Dietary Aide #2 Daily Cleaning Schedule revealed: Monday: Clean pellet warmer and polish.During the tour of the kitchen with the Clinical Registered Dietitian on 4/20/26 (Monday) at 10:23 AM the following were observed:The two 5-foot shelves under the steam tables were observed covered with dark dried food particles and were sticky to touch.The two reach-in refrigerators door handles were noted with dried food particles and the hot box/warmers door handles had dried food particles on the door handles.The three-cylinder pellet plate warmer dispenser was observed with dried food particles in the bottom of all three cylinders.Observations of the kitchen on 4/22/26 at 9:59 AM revealed the two 5-foot shelves under the steam tables were observed to be in the same condition. The two reach-in-refrigerators and the hot box/warmers door handles had dried food particles on the door handles. The three-cylinder pellet plate warmer dispenser was observed with dried food particles in the bottom of all three cylinders.In an interview on 4/23/26 at 10:45 AM (Thursday) the morning [NAME] revealed they were training new staff and he didn't get to clean the steam table.In an interview on 4/23/26 at 10:23AM the Certified Dietary Manager (CDM) stated that the [NAME] should have wiped down the steam tables after every meal and staff should wipe down the reach in refrigerator, hot box/warmer door handles each shift. She indicated she would follow up more closely on staff completion of the cleaning schedules.In an interview on 4/23/26 at 10:31 AM the Administrator stated the kitchen staff should clean the steam tables, plate warmer and all door handles daily.

Based on record review and staff interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic pain medication (Oxycodone) for 1 of 1 resident reviewed for misappropriation of property (Resident #60).The findings included: Resident #60 was admitted to the facility on [DATE] with diagnoses which included chronic pain. A physician's order dated 12/30/24 documented Oxycodone HCL oral tablet 5 milligrams (mg) one tablet by mouth every 6 hours as needed (PRN) for ankle pain. Resident #60's annual Minimum Data Set assessment (MDS) dated [DATE] revealed he was cognitively intact and had not received opioid (narcotic) pain medication. The pharmacy packing slips #1 and #2 dated 8/25/25 revealed 2 medication cards of Oxycodone (44 tablets on each medication card) were accepted and signed by Nurse Supervisor #2. A review of the narcotic countdown sheets (an inventory log used to record a running total for each controlled medication card) for Resident #60's PRN Oxycodone 5 mg revealed the narcotic countdown sheet labeled #2 of 2 revealed 44 tablets of Oxycodone 5 mg was received on 8/25/25 and verified by Nurse Supervisor #2 and Nurse #3. The narcotic countdown sheet #1 of 2 for 44 tablets of Oxycodone 5 mg which was also received on 8/25/25 was missing. The facility's investigation report dated 8/28/25 completed by the Administrator documented the pharmacy delivered two (2) Oxycodone 5 mg medication cards (44 tablets per medication card for a total of 88 tablets) with narcotic countdown sheets to the facility during the second shift (3:00 pm - 11:00 pm) on 8/25/25 for Resident #60. Nurse Supervisor #2 and Nurse #3 verified the Oxycodone count (88 tablets) and added the Oxycodone (2 medication cards) to the medication cart utilized for Resident #60's medications and the two narcotic countdown sheets were added to the narcotic book (a book used in healthcare facilities to track the administration, wasting, and inventory of controlled substances). On 8/27/25 during the change of shift narcotic count between on-coming Nurse #3 and off-going Nurse #2, Nurse #3 discovered that one (1) medication card (44 tablets) of Resident #60's Oxycodone 5 mg was missing. Nurse #3 and Nurse #2 notified Nurse Supervisor #2 and then notified the Director of Nursing (DON) and the Administrator of the missing narcotics. The Administrator and DON began an immediate investigation. The discrepancies noted were one medication card of Oxycodone 5 mg (44 tablets) was missing and the shift change count sheet (a sheet utilized by nurses to add new narcotic medications or subtract completed or discontinued narcotic medications) was missing for medication card #1 of 2, and the narcotic countdown sheet was also missing. The facility was unable to locate the narcotic medication. Statements were obtained from all the nurses with access to the Oxycodone for Resident #60 and drug testing was conducted with no positive results for Oxycodone. The local police department was notified on 8/28/25. During a phone interview on 4/23/26 at 5:15 pm, Nurse #3 stated he received two medication cards of Oxycodone 5 mg (44 tablets per medication card, totaling 88 tablets) on 8/25/25 and placed them in the medication cart during the second shift (3:00 pm to 11:00 pm). Nurse #3 indicated the narcotic count was correct at the end of his shift on 8/25/25.During a phone interview on 4/22/26 at 4:46 pm, Nurse #6 stated she worked the night shift (11:00 pm - 7:00 am) beginning on 8/25/25 and ending on 8/26/25. She reported her narcotic count was correct at the end of her shift. Nurse #6 stated she did not recall how many medication cards of Oxycodone 5 mg were present in the medication cart at that time for Resident #60. Nurse #6 indicated she maintained possession of the medication cart keys at all times while on duty.During an interview conducted on 4/22/26 at 1:15 pm, Nurse #2 reported that on 8/26/25 during the first shift (7:00 am to 3:00 pm), she remembered only one medication card of Resident #60's Oxycodone 5 mg. Nurse #2 revealed there would have been nothing to alert her that there should have been two medication cards of Oxycodone 5 mg for Resident #60 if the narcotic countdown sheet was not on the cart. Nurse #2 stated that during shift change between the first shift and the second shift on 8/27/25, while conducting a narcotic count with Nurse #3, Nurse #3 identified that one medication card of Resident #60's Oxycodone 5 mg (44 tablets) was missing. Nurse #2 reported that the count was immediately stopped, and Nurse Supervisor #2 was notified of the discrepancy. According to Nurse #2, Nurse Supervisor #2 instructed them to notify the DON and the Administrator. Nurse #2 confirmed that both she and Nurse #3 reported the missing medication to the DON and Administrator. Nurse #2 also stated that she maintained possession of the medication cart keys at all times while on duty.Attempts to interview Nurse Supervisor #2 via phone on 4/22/26 were unsuccessful and no written statement was obtained by the facility. During a phone interview on 4/23/26 at 5:15 pm, Nurse #3 stated he did not work on 8/26/25 but returned to work on 8/27/25 for the second shift. During the narcotic count with Nurse #2 on 8/27/25, Nurse #3 identified that one (1) medication card of Oxycodone 5 mg (44 tablets) was missing. Nurse #3 stated he recognized the discrepancy because he had personally added the two Oxycodone 5 mg medication cards (44 tablets each medication card totaling 88 tablets) to the medication cart on 8/25/25. He further indicated that in addition to the missing medication, the corresponding shift change count sheet and the narcotic countdown sheet were also missing. Nurse #3 stated that had he not received and placed the Oxycodone on 8/25/25, he would not have known the medication was missing when the count was conducted on 8/27/25. Nurse #3 indicated he maintained possession of the medication cart keys at all times while on duty. Nurse #4 was on the schedule on 8/26/25 on second shift. Attempts to interview Nurse #4 via phone on 4/22/26 were unsuccessful. Nurse #4's written statement dated 8/27/25 indicated Nurse #4 counted the narcotic medications on the second shift and signed the shift change count sheet. Nurse #4's written statement also indicated the shift change count sheet, narcotic countdown sheet and narcotic medication cards were present.Nurse #5 was interviewed via phone on 4/22/26 at 4:52 pm and stated she worked the night shift on 8/26/25 beginning at 11:00 pm and ending on 8/27/26 at 7:00 am. Nurse #5 indicated she did not recall missing narcotics during her reconciliation count with Nurse #4. Nurse #5 stated she maintained possession of the medication cart keys at all times while on duty. During an interview on 4/23/26 at 11:45 am, the DON stated she was notified on 8/27/25 of the missing Oxycodone 5 mg (44 tablets), as well as the missing shift change count sheet and narcotic countdown sheet for Resident #60. The DON stated that she and the Administrator immediately initiated an investigation. She reported that all nurses who had access to the medications and were responsible for the medication cart during the relevant time frame were drug tested; there were no positive results for Oxycodone for any of the nurses tested. The DON further stated that a search of all medication carts and medication storage rooms were conducted; however, the missing narcotic was not located.During an interview on 4/23/26 at 11:45 am, the Administrator confirmed she was notified of the narcotic discrepancy on 8/27/25 and initiated an investigation with the DON; however, the missing Oxycodone 5 mg (44 tablets) for Resident #60 were not found. The Administrator stated she notified the local police department on 8/28/25. When asked if the Drug Enforcement Administration (DEA) was notified, she stated she made two (2) attempts to contact the DEA (email and phone) but did not receive a response and did not provide documentation of the attempts. The facility provided a corrective action plan that was not acceptable to the State Agency.

Based on record review and staff interviews, the facility failed to accurately code the physician's documented clinical contraindication of a gradual dose reduction (GDR) of psychotropic medications (Resident #2) and appliances in the bowel and bladder section for 2 of 27 residents reviewed for Minimum Data Set (MDS) assessment accuracy (Resident #91).The findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included dementia and schizoaffective disorder. A review of the psychiatric provider note dated 3/11/26 revealed an attempted dosage reduction to the psychotropic regimen was likely to impair the resident's function and exacerbate underlying psychiatric conditions. The quarterly MDS dated [DATE] for Resident #2 indicated a GDR had not been documented by the physician as clinically contraindicated. An interview was conducted with MDS Nurse #1 on 4/22/26 at 11:55 AM who stated the physician documented GDR as clinically contraindicated was marked no on the quarterly MDS dated [DATE] which was an error on his part and should have been marked yes. He stated it was an oversight and he would do a modification. An interview with Administrator was held on 4/22/25 at 2:30 PM. She stated her expectation was for MDS assessments to be accurate. 2. Resident #91 was admitted to the facility on [DATE] with diagnoses which included obstructive uropathy (a condition by a blockage in the urinary tract that prevents urine from flowing normally). Review of Resident #9's physician order dated 9/29/22 revealed a urostomy (surgical procedure that creates an opening in the abdomen to allow urine to exit the body when the blader is not functional or has been removed) due to obstructive uropathy. Review of Resident #91's care plan dated 1/26/26 revealed a focus for an urostomy due to obstructive uropathy. Review of Resident #91's admission MDS assessment dated [DATE] revealed he was coded for both an indwelling catheter and an ostomy. Nurse #2 was interviewed on 4/21/26 at 12:30 pm. Nurse #2 stated Resident #91 has had an urostomy since his admission to the facility. Nurse #2 further stated Resident #91 has never had an indwelling catheter. During an interview with MDS Nurse on 4/21/26 at 12:46 pm, he stated he completed Resident #91's admission MDS assessment and the indwelling catheter was coded in error. During an interview with the Administrator on 4/23/26 at 11:45 am, she stated the MDS assessment should have been coded accurately for Resident #91.

Based on observations, and staff and Medical Director interviews, the facility failed to observe a resident to ensure they had taken their medications during medication administration which resulted in a cup of pills being found on the resident's bed for 1 of 1 resident observed with medications at the bedside (Resident #83).Findings included:Resident #83 was admitted to facility on 2/2/2024 with diagnoses that included peripheral vascular disease, atrial fibrillation, hypertension, chronic pain syndrome, hypothyroidism, hyperlipidemia, generalized anxiety disorder, and bipolar disorder with a history of depression.Based on record review, Resident #83 was prescribed a medication regimen that included anticoagulant (Apixaban), beta blocker (Metoprolol), diuretic (Furosemide), thyroid replacement (Levothyroxine), psychotropic medications (Sertraline, Aripiprazole, Alprazolam), and opioid pain management (Oxycodone), as well as additional medications for constipation, electrolyte balance, and nutritional supplementation.The care plan initiated on 07/09/2024 and revised through 02/18/2026 addressed multiple areas of risk and care needs. The plan included interventions for medication management and psychotropic use, requiring medications to be administered as ordered with monitoring for effectiveness and adverse side effects, along with routine pharmacy review.A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #83 as cognitively intact.On 4/20/2026 at 10:42 AM, a medicine cup containing approximately twelve (12) pills was observed sitting unattended on Resident #83's bed. The medications were not secured, and no staff member was present at the bedside at the time of observation. During an interview at the time of the observation, Resident #83 stated that she did not know the medication was there on her bed. Resident #83 explained she was blind and slept in the recliner next to her bed. She stated that she must have been asleep or in the bathroom, so the nurse left her medication.An interview with Nurse #10 in Resident #83's room on 4/20/2026 at 10:48 AM revealed that the medications observed to be sitting on resident's were not Resident #83's morning medications. Nurse #10 stated that she was just coming to check Resident #83 blood pressure before administering morning medications. She stated that she did not know where the medications came from but believed them to be from the night before. She stated that she would not leave any medication in a resident room. Nurse #10 then handed the medications off to Nurse Supervisor #5 who was coming down the hall and Nurse Supervisor #5 entered the room. Nurse Supervisor #5 asked Resident #83 when she last took medication and resident stated she took medication at dinner time the day before. Nurse Supervisor #5 then asked Resident #83 if she took her nighttime medications and resident stated she could not remember.On 4/20/2026 at 10:49 AM Nurse Supervisor #5 stated that nursing staff should not leave medication unattended in a resident's room. She stated that both Resident #83 and her roommate were blind so they would not have seen the medication. She believed that the medication was from the previous shift. Nurse Supervisor #5 stated she would take pills to identify and discard.At an interview on 4/20/2026 at 12:29 pm the Director of Nursing (DON) stated that Nurse Supervisor #5 discarded the medication without identifying any of them. The DON indicated they believed the medication was left in the room by the third shift nurse (Nurse #9). She stated that Resident #83 had not been coded for self-administration of medication. The DON stated that it was facility policy for nurses to pull medications one at a time, enter resident's room to administer the medication, the nurse should stand there and observe the resident take the medication and then chart. She further stated that the medication from the night before was all charted as administered. She acknowledged there was no way to tell when or who left the cup of medication on Resident #83's bed or even if it was her medication.During an interview with Medical Director on 4/22/2026 at 12:55 pm, he stated that it could be unsafe to leave medications at a patient's bedside, but he would have to look into this situation to understand it better. He stated that he would not expect that staff would leave any medication in the patient room but there were a lot of possibilities.

Based on record review and staff interviews, the facility failed to provide care in a safe manner when the resident rolled off of the bed and onto the floor during incontinence care. This deficient practice affected 1 of 4 residents reviewed for accidents (Resident #121).Findings included:Resident #121 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), heart failure, atherosclerotic heart disease, and dementia.A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #121 had moderate cognitively impairment and no behaviors or rejection of care. Resident #121 had functional limitations in range of motion to both lower extremities. She was dependent on staff assistance for toileting and required substantial/maximum assistance for rolling left to right on the bed.A Fall Risk Evaluation dated 02/26/2025 identified the resident as high risk for falls indicating the need for ongoing fall prevention interventions and monitoring. Items checked that contributed to the resident's fall risk included cognitive status, history of falls, ambulation/elimination status, vision status, gait and balance, medication use and predisposing diseases.An active care plan as of 4/20/2026 (initiated on 7/7/2024) indicated Resident #121 required staff assistance with activities of daily living, including repositioning and incontinence care. The interventions included assisting Resident #121 with repositioning frequently and assisting with toileting and/or incontinent care needs promptly.A nurse progress note dated 4/20/2026 at 1:30 am completed by Nurse #9 indicated Resident #121 was found lying on the floor beside the bed after a fall during care. The resident was assessed as alert, she denied pain, and no visible injury was noted. Vital signs were obtained, and the resident was returned to bed using a mechanical lift. A phone interview was conducted on 4/21/2026 at 1:10 pm with Nursing Assistant (NA) #9, an agency NA. NA #9 reported that she worked a double shift, 3:00 pm to 11:00 pm and 11:00 pm to 7:00 am beginning on 4/19/2026 and ending on 4/20/2026. NA #9 stated she was not familiar with Resident #121 care needs and had not provided care to this resident before. NA #9 indicated on 4/20/2026 around 1:30 am she entered Resident #121's room to provide incontinence care. She stated the bed had been raised to about three feet from the floor to provide care. She indicated that she had already unfastened the resident's brief and partially cleaned the resident when she retrieved the clean brief that she had obtained prior to beginning incontinence care. NA #9 indicated the clean brief was within her reach. She reported that the resident was on her back in the center of the bed at that time. She stated that as she was getting the clean brief, she observed the resident hold onto her trapeze bar (an overhead assistive device utilized to assist with changing positions on bed) and began to turn from her back to her right side by lifting her left leg. She explained that at that time, she (NA #9) was near the head of the bed, on the left side of the bed and she took her hands and eyes off of the resident to prepare the clean brief (opening the brief so it could be placed on the resident). She revealed that as she was preparing the brief, the resident rolled off the side of the bed. NA #9 explained that since she was standing on the opposite side of the bed, she was unable to prevent the resident from rolling off of the bed. NA #9 stated she did not know how or why the resident rolled off the bed since she was looking down at the clean brief she was preparing to put on the resident. She indicated she observed the resident on the floor, the resident was talking, did not appear to have visible bleeding, and she denied hitting her head. NA #9 indicated she pressed the resident's call light for staff assistance then went to room door to get assistance because she did not want to leave resident alone in the room. She explained that she saw NA #10 coming down the hall, and she (NA #9) asked NA #10 to get Nurse #9 because Resident #121 fell. On 4/21/2026 at 4:17 pm during a phone interview, NA #10 stated that on 4/20/2022 around 1:30 am she saw the call light on outside the door of Resident #121's room and began walking towards the room. She reported that as she arrived at the room, NA #9 was at the doorway and stated that Resident #121 had fallen. NA #10 further stated that NA #9 stayed with the resident while she (NA #10) got Nurse #9. NA #10 stated that she worked with Resident #121 on a regular basis. She further stated that Resident #121 had a trapeze bar over her bed that the resident used to help her turn over for incontinence care.All attempted phone interviews with Nurse #9 were unsuccessful.Resident #121 was not available for interview.An interview was conducted with Director of Nursing (DON) in the presence of the Administrator on 4/22/2026 at 3:03 pm. The DON indicated that nursing staff were expected to provide care in such a way that residents did not roll off of the bed during care and were not injured during care. The DON indicated that NA #9 took her eyes off the resident during care and was not observing the resident when Resident #121 was using the trapeze bar to ensure the resident did not roll too far. The DON explained that NA #9 stated she had not been looking at the resident and had no hands on the resident at the time the resident utilized the trapeze bar and rolled off of the bed. She added that Resident #121 was not injured from the fall.

Based on record review, observations, and staff interviews, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 1 of 2 residents reviewed with urinary catheters (Resident #123).The findings included: Resident #123 was admitted to the facility on [DATE] with diagnoses which included retention of urine and obstructive uropathy (a condition by a blockage in the urinary tract that prevents urine from flowing normally). Review of Resident #123's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. Resident #123 was coded for an indwelling urinary catheter. An initial observation was conducted on 4/22/26 at 5:40 am of Resident #123 as he was lying in his bed. A urinary catheter drainage bag was observed to be hanging off the bed frame on the resident's right side of the bed (with a solid, blue-colored side of the bag facing the door). The entire bottom of the urinary catheter drainage bag was resting on the floor. Additional observations were conducted on 4/22/26 at 6:07 am and 6:23 am of Resident #123's urinary catheter drainage bag that was observed to be hanging off the bedframe on the resident's left side of the bed (with a solid, blue-colored side of the bag facing the door). The entire bottom of the urinary catheter drainage bag was resting on the floor. During an interview and observation in Resident #123's room on 4/22/26 at 7:00 am with Nurse Aide (NA) #1, she stated she did not know the urinary catheter bags were not supposed to be touching the floor and did not know why. NA# 1 stated Resident #123's bed needed to be in the lowest position for safety and did not know where to place the catheter bag so that it was not touching the floor. NA #1 repositioned the urinary catheter drainage bag on the end foot board so that it was not resting on the floor, and it was observed with no tension or pulling of the catheter tubing. In an interview with Nurse #2 on 4/22/26 at 7:15 am, she stated she was the hall nurse assigned to care for Resident #123. Nurse #2 was made aware of the observation of Resident #123's urinary catheter drainage bag on the floor and stated it should not touch the floor. Nurse #2 stated she thought the urinary catheter drainage bag ended up touching the floor due to the low position of Resident # 123's bed During a subsequent observation on 4/22/26 at 9:35 am, Resident #123's urinary catheter drainage bag was observed to be hanging on the bedframe on the resident's right side of the bed (with a solid, blue-colored side of the bag facing the window). The entire bottom of the urinary catheter drainage bag was resting on the floor. On 04/22/2026 at 10:05 am, an interview was conducted with NA #2. NA #2 stated she was unaware that the resident's urinary catheter drainage bag was positioned on the floor. NA #2 acknowledged that the catheter bag should not be placed on the floor due to infection control concerns. NA #2 further stated she was in the process of transferring Resident #123 into his wheelchair and indicated she would ensure the urinary catheter bag was properly positioned off the floor. On 4/23/26 at 11:45 am in an interview with the Director of Nursing, she stated to prevent contamination urinary drainage bags were not to be touching or placed on the floor. She stated her expectation was that urinary catheter bags were kept off the floor to prevent infection.

Based on record review and staff interviews, the facility failed to ensure agency personnel was adequately trained and competent before providing care of residents for 1 of 8 agency personnel reviewed for training requirements (Nursing Assistant #9).Findings included:This tag was cross referenced to:F689 Based on record review and staff interviews, the facility failed to provide care in a safe manner when the resident rolled off of the bed and onto the floor during incontinence care. This deficient practice affected 1 of 4 residents reviewed for accidents (Resident #121).A phone interview with Nursing Assistant (NA) #9 on 4/21/2026 at 1:10 pm NA #9 stated that she worked for an agency and this was her first time working with Resident #121. NA #9 further stated that she was not aware that Resident #121 was not on her assignment until NA #10 told her. NA #9 stated that she had not received any training from facility regarding fall prevention or what to do after a fall.A interview with Director of Nursing (DON) on 4/22/2026 at 3:03 pm revealed that nursing staff were expected to provide care in such a way that residents were not injured. The DON stated that the NA and Nurse working the hall that night were agency nurses and had not received any training or in-service about facility policies or procedures.A joint interview conducted on 04/23/2026 at 9:10 am with the Director of Nursing and Administrator revealed that the facility did not provide training or verify competencies for agency nurses and nurse aides and did not have a system in place at the time of the incident to ensure staff were competent in required post-fall procedures. The Administrator further stated that staff should receive in-service training regarding fall prevention, accidents and abuse upon hire and then annually. They both acknowledged that this training was not completed by NA #9.

Based on observations, manufacturer's instructions, and staff and Pharmacist interviews, the facility failed to remove one (1) open bottle of zinc sulfate, (1) multi-dose lispro insulin injector pen, and one (1) multi-dose glargine insulin injector pen that were expired in 1 of 4 medication carts reviewed for medication storage and labeling (Upper East Medication Cart).The findings included: An observation of the Upper East medication cart on 4/3/26 at 7:50 am with Nurse #1 revealed one (1) open bottle of floor stock zinc sulfate (a supplement) 50 milligrams (mg) tablets with a manufacturer's expiration date of 2/2026 circled in red and an illegible handwritten open date on the side of the bottle, one (1) open insulin lispro injector pen with a handwritten open date of 3/8/26 with no handwritten expiration date, and the manufacturer's expiration date of 4/10/27, and one (1) open insulin glargine injector pen with a handwritten open date of 3/5/26 with no handwritten expiration date, and the manufacturer's expiration date of 3/18/27. The lispro injector and insulin glargine pens were located in a clear plastic bag with a pharmacy label on the outside of the clear plastic bag with an expiration date of 4/10/27. An interview with Nurse #1 during the medication cart observation on 4/23/26 at 7:50 am revealed Nurse #1 checked the expiration dates of the floor stock medications as she pulled them to administer. Nurse #1 further stated she did not check all the floor stock medications for expiration dates and did not know the zinc sulfate was expired. Nurse #1 indicated she went by the expiration date on the outside of the pharmacy bag and should have followed the handwritten opened date of 3/8/26 on the lispro injector pen and the handwritten opened date of 3/5/26 on the glargine injector pen and discarded the insulin pens after 28 days. During an interview with the Pharmacist on 4/23/26 at 12:18 pm, he stated the insulin pens should have been discarded 28 days after opening and the zinc sulfate floor stock should have been discarded after 2/2026. During an interview with the Director of Nursing (DON) and Administrator on 4/23/26 at 11:45 am, the DON stated the nurses were responsible for checking the medication carts daily for expired medications and discarding any expired medications identified. The DON further stated her expectation was that the nursing staff, including medication aides, check the medication carts daily and remove any expired medications. The Administrator stated her expectation was the nursing staff would check the medication carts daily and have no expired medications in the medication carts.

Based on record review and staff interviews, the facility failed to ensure daily nurse staffing sheets were accurate for 33 of 33 days reviewed for posted staffing.Findings included: Review of the facility's daily nurse staffing sheets dated 3/20/26 through 4/21/26 posted for resident and visitor view, revealed that the total number and the actual hours worked by registered nurses (RNs) and licensed practical nurses (LPNs) directly responsible for resident care per shift, were not categorized separately. There was one column labeled Licensed Nursing Staff and it was not delineated for RNs and LPNs separately.An interview was conducted on 4/22/26 at 1:07 PM with the Staffing Coordinator. She stated the process she used for filling out the nurse staffing sheets included confirming the census, reviewing the staffing for the day, completing the sheet, and then the nurse staffing sheet was posted in the front lobby. The Staffing Coordinator stated she was trained on how to complete the nurse staffing sheets by a nursing supervisor when she took over the role. The Staffing Coordinator stated she was unaware of the regulatory requirement that LPNs and RNs needed to be totaled separately on the nurse staffing sheets.An interview was conducted on 4/23/26 at 11:52 AM with the Nurse Supervisor who trained the Staffing Coordinator on how to complete the nurse staffing sheets. She stated when completing the nurse staffing sheets, the number of licensed nurses was written in one section, and the number of nurse aides was written in another section on the sheet. She explained the nurse staffing sheets also included the total number of hours worked for nurse aides, as well as the census. The Nurse Supervisor stated she did not recall who trained her on the completion of the nurse staffing sheets. She further stated she was unaware of the regulatory requirement that LPNs and RNs needed to be totaled separately when completing the nurse staffing sheets. In an interview with the Director of Nursing (DON) on 4/22/26 at 1:44 PM she stated the nurse staffing sheets were completed by obtaining the census, allocating how many nurses and nurse aides were needed based on the census, and ensuring the facility had adequate Registered Nurse (RN) coverage. The DON stated she had not been formally trained on completing nurse staffing sheets at the facility, however she had experience completing them at other facilities. She stated she was aware that the regulation required that the nurse staffing sheets included licensed personnel, nurse aides, and 8 hours of RN coverage daily. The DON further stated she knew the licensed nurses needed to be separated out by license type, and she should have been reviewing the nurse staffing sheets to ensure all categories were included and correct. An interview was conducted with the Administrator on 4/22/26 at 1:56 PM. She stated the nurse staffing sheets were competed based on the staff schedule and census by the Staffing Coordinator Monday through Friday and by a Nurse Supervisor on Saturdays and Sundays. The Administrator stated she was aware the regulation required that a nurse staffing sheet included the number of nurses, number of nurse aides, the total number of hours, the census, and that staffing needed to be adjusted if the census changed. She further stated the nurse staffing sheets were reviewed by the Administrator, supervisors, and the Staffing Coordinator, and the form that was in use was the form used when she came onboard at the facility.

Based on observations, record review, and resident, staff and physician interviews, the facility failed to provide care in a safe manner on 10/26/25 when Resident #1 rolled out of bed while a nurse aide was providing care sustaining a left distal tibia and fibula fracture (two main bones in the lower leg). Resident #1 required surgical intervention to repair the fractures and was discharged back to the facility on [DATE] with a splint applied to her left leg. This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included osteoporosis (a disease that makes bones weak and brittle increasing the risk of fractures from falls), vitamin D deficiency, atrial fibrillation (an irregular heartbeat), and dementia. A review of Resident #1's Physician's orders revealed an order dated 7/6/2024 for Apixaban (anticoagulant medication) 5 milligrams (mg) by mouth twice daily for atrial fibrillation. An ADL care plan last revised on 5/19/2025 included the following intervention: the Resident required 2 staff members to assist with ADL. An at risk for falls care plan due to impaired mobility, poor safety awareness, and impulsiveness last revised on 5/19/2025 included the following interventions: ensure the bed is in the lowest position and place frequently used items by the resident within easy reach.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was coded as having memory problems, no alteration in mood or behaviors, required partial to moderate assistance from staff for toileting hygiene, and supervision/touching assistance from staff with rolling from her left to right side in the bed, was coded as receiving physical therapy and occupational therapy services during the assessment period, and receiving a blood thinner. A Physical Therapy discharge summary note dated 10/22/2025 stated Resident #1's discharge functional status for bed mobility was supervision/touch assistance from 1 staff member. A review of Resident #1's undated Care Guide (a guide that explained the level of care a resident required) revealed Resident #1 required assistance from 2 staff members to complete activities of daily living (ADL). An interview was completed on 11/4/2025 at 3:05pm with the Administrator. The Administrator stated at the time of the incident Resident #1's assessed level of bed mobility per Physical Therapy was 1 person supervision/touch. The Administrator stated the therapy department had notified nursing of the change upon Resident #1's discharge from therapy services on 10/22/2025, but her care plan and Care Guide had not been updated yet at the time of the 10/25/25 fall.A telephone interview was completed on 11/4/2025 at 1:12pm with NA #1. The NA stated she was completing incontinence care for Resident #1 on 10/26/2025. NA #1 revealed she raised Resident #1's bed to her waist height and positioned Resident #1 towards the middle of the bed on her back prior to her beginning care. The NA stated she informed Resident #1 she was going to turn her to her left side to clean her. NA #1 stated as she was having Resident #1 turn on her left side away from her, the resident swung her right leg over her left leg and slid off the bed to the floor. NA #1 revealed Resident #1's Care Guide stated she was a 2 person assist with ADL. The NA stated was unable to say why she did not request assistance from another staff member. NA #1 further stated she should have rolled Resident #1 towards her when repositioning her. An Incident Report dated 10/26/25 at 5:40am was completed by Nurse #1 regarding a fall for Resident #1. The nursing description portion of the incident report stated Resident #1 rolled to her left side for Nursing Assistant (NA) #1 to provide ADL care, kept going and rolled off the bed to the floor onto her left side. Resident #1 revealed to Nurse #1 she believed she hit her head during the fall. The resident description portion of the incident report stated she fell off the bed while NA #1 was changing the bed. Nurse #1 assessed Resident #1, and no injuries were observed at the time of the incident. The Resident's Representative was notified on 10/26/2025 at 5:50am and the Physician was notified on 10/26/2025 at 6:11am. A telephone interview was completed on 11/4/2025 at 12:45pm with Nurse #1. The Nurse stated he was the 11:00pm to 7:00am nursing supervisor on the morning of 10/26/25 when Resident #1 fell. Nurse #1 stated he was called to the Resident's room by NA #1 stating Resident #1 had fallen. Nurse #1 stated when he arrived at the room Resident #1's bed raised to his waist height (unable to state how many feet) and Resident #1 was lying on her left side on the floor between the bed and the wall. Nurse #1 revealed the resident stated to him she hit her head as she was falling, but he did not observe any redness, bruising, or swelling. Nurse #1 stated during the assessment of Resident #1, the Resident did not have any complaints of pain or discomfort. The Nurse stated Resident #1 revealed to him she fell from bed as the NA was rolling her to provide care. Nurse #1 stated he notified the Physician of the fall and the resident being prescribed an anticoagulant and was given a verbal order to send Resident #1 to the hospital for evaluation and treatment. Nurse #1 stated the resident was able to assist staff with turning and repositioning using her right side. A progress note dated 10/26/25 Nurse #2 stated Resident #1 left the facility for the emergency department (ED) at 6:32am via emergency services for further evaluation status post fall. The hospital record for Resident #1 included a hospital history and physical note dated 10/26/2025 which indicated while in the ED a computed tomography (CT) scan (a noninvasive imagining procedure that uses x-rays to create detailed images of the body) of Resident #1's cervical (neck) area and head revealed no abnormal findings. An x-ray completed on Resident #1's left leg revealed a fracture of her tibia and fibula. The record indicated on 10/29/2025 Resident #1 had a surgical procedure to repair the left leg fractures. A hospital discharge summary note dated 10/31/2025 for Resident #1 stated she was discharged back to the facility with a splint applied to her left leg, was to be non-weight bearing status, and follow up with the Orthopedic Physician in 10 to14 days. An interview was completed on 11/4/2025 at 2:30pm with the Physical Therapist. The Physical Therapist stated Resident #1 was discharged from therapy services on 10/22/2025 having met her goal of requiring supervision/touch assistance from 1 staff member with bed mobility. The Physical Therapist stated she notified nursing of the change in assistance required by Resident #1. An interview was completed on 11/4/2025 at 1:30pm with Resident #1. The Resident stated she did not recall falling and hurting her leg. During the interview, no observation of bruising, redness, or swelling was noted to Resident #1's face. An interview was completed on 11/4/2025 at 2:40pm with the Physician. The Physician stated Resident #1 had a diagnosis of osteoporosis putting her at greater risk for fractures. The Physician stated Resident #1 should not have experienced a fall during care. An interview was completed on 11/4/2025 at 2:50pm with the Director of Nursing (DON). The DON revealed during the investigation NA #1 demonstrated prior to beginning to reposition Resident #1 onto her left side the bed was raised to approximately her waist level, Resident #1 was laying on her back positioned towards the middle of the bed. The DON stated she believed Resident #1 was attempting to assist NA #1 with repositioning causing Resident #1 to roll too far to the edge of the bed causing her to fall to the floor. The DON stated NA #1 should have rolled Resident #1 towards her when repositioning her but did not. The DON stated NA #1 was immediately reeducated on turning and repositioning related to rolling the Resident towards staff to maintain safety of Resident during ADL care. NA #1 was also suspended pending completion of the facility's investigation. During an interview on 11/4/2025 at 3:05pm the Administrator stated Resident #1 should not have experienced a fall during care.The facility provided the following corrective action plan with a completion date of 10/28/2025: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 was noted to have received Activities of Daily Living (ADL) care by Nursing Assistant (NA) #1 on 10/26/25. While receiving care, NA #1 was noted to be providing care independently with Resident #1 on her left side with the bed positioned at waist height. During incontinent care, NA #1 rolled Resident #1 away from her onto left side with Resident #1's right ankle crossed over her left ankle. The draw sheet was positioned under Resident #1. NA #1 began to tuck the clean linen under the resident and Resident #1 lifted her right leg as if she were attempting to assist NA #1 with repositioning, and this movement caused the Resident #1 to roll onto the floor landing on her left side. The root cause was determined during the return demonstration to be that resident was not properly positioned in the center of the bed while replacing and/or tucking clean linens with 2 person assist. Resident #1 was sent to the hospital for evaluation. Resident had an open reduction internal fixation of her left distal tibia fibula. Resident readmitted to Smithfield Manor 10/31/25.On 10/26/25, NA #1 was suspended pending investigation. On 10/26/25 through 10/27/25 the Administrator audited the employee file of NA #1 with no concerns identified. On 10/27/25, NA #1 was brought back into the facility for a return demonstration with the Director of Nursing, Assistant Director of Nursing and the Administrator. The Director of Nursing re-educated NA #1 after the return demonstration on the proper technique of turning and repositioning residents during ADL care. Upon the resident's return to the facility from the hospital, the care guide and care plan remained the same to reflect 2 person assistance with ADLs per family request. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 10/26/25 the Quality Assurance Nurse conducted a 100% audit of all residents' falls utilizing incident reports to ensure there were no further concerns with falls during ADL care for the past 30 days. No concerns were identified. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 10/26/25 the Quality Assurance Nurse initiated an in-service for all nursing staff on Turning and Repositioning related to rolling patient towards staff to maintain safety of resident during activities of daily living care. Resident Care Safe Handling Questionnaires were completed by NAs, Medication Aides, and Nurses to include questions on how to access the Kardex (care guide) to determine the level of care for transfers and ADLs. There were no concerns identified. After 10/27/25, any nursing staff that have not worked and received the in-service and questionnaire will complete upon their next scheduled shift. All newly hired NAs, Medication Aides, and Nurses will be in-serviced on the proper technique of turning and repositioning during ADL care. The Quality Assurance Nurse and/or Assistant Director of Nursing are responsible for ensuring no staff work prior to completing the in-service and questionnaire. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.Include dates when corrective action will be completed. The decision to monitor the turning and repositioning of a resident during activities of daily living was made on 10/26/25 by the Administrator and Director of Nursing and presented to the Quality Assurance Committee on 10/27/25.On 10/26/25 the Quality Assurance Nurse initiated an observational audit on turning and repositioning to include rolling the residents towards staff during activities of daily living care. The Unit Managers, Quality Assurance Nurse, and Assistant Director of Nursing will utilize the Turning and Repositioning Audit Tool to ensure proper turning and repositioning. All areas of concern will be addressed by the Director of Nursing and/or Administrator. Audits will include 10 residents x 4 weeks then, 5 residents x 4 weeks, then 1 resident x 4 weeks.The Administrator will forward the results of the Turning and Repositioning Audit Tool to the Executive QA Committee monthly for 3 months for review to determine trends and/or issues that may need further intervention put into place and to determine the need for further and/or frequency of monitoring. Alleged Completion Date: 10/28/2025 The facility's corrective action plan was validated on 11/4/2025 through staff interviews, observations, and record reviews. The initial audit results were reviewed with no concerns noted. The in-service records and questionnaires completed on 10/26/2025 were reviewed. Interviews with nurses and nursing assistants were completed to validate the in-service Turning and Repositioning relating to rolling patient towards staff to maintain safety of residents during ADL care was completed. An observation of turning and repositioning during incontinence care for Resident #1 performed by NA #2 was completed with no concerns noted. The weekly audit with an ending date of 11/1/2025 was reviewed with no concerns noted. The facility's corrective action plan completion date of 10/28/2025 was validated.

Based on observation, record review, and interviews with the resident, staff, and the Medical Director, the facility failed to follow the manufacturer's instructions for wheelchair securement in a transportation van. On August 26, 2025, the Transport Driver incorrectly anchored all four securement straps to the rear wheels of the wheelchair, leaving the front of the wheelchair unsecured. As the vehicle accelerated, the unsecured wheelchair tipped backward, causing Resident #1 to fall and strike her head and back on the floor of the van. She was transported to the hospital, where she was diagnosed with posterior (back) neck and upper back pain, a superficial laceration on the tip of her tongue, paraspinal (muscles located along the spine) tenderness in the upper thoracic (part of the body between the neck and the abdomen) region, and a superficial abrasion on her right hand. A computed tomography (CT) (non-invasive imaging test that uses x-rays and computer technology to create detailed images of the body's internal structures) scan revealed no evidence of hemorrhage (bleeding) or acute fracture. Resident #1 was discharged back to the facility later that evening. The noncompliance had the high likelihood to cause serious injury, harm, impairment or death. The deficient practice affected 1 of 3 residents reviewed for accident-related incidents (Resident #1).The findings included:The undated manufacturer's instructions for wheelchair tie-downs used by the facility revealed it read in part, Attach the four tie-down hooks to solid frame members or weldments (parts joined by [NAME]), near seat level [of the wheelchair]. Ensure tie-downs are fixed at approximately 45 degrees. Do not attach hooks to wheels, plastic, or removable parts of wheelchair.Resident #1 was admitted to the facility on [DATE]. Her active diagnoses included neuropathy, chronic ischemic heart disease osteomyelitis, atherosclerotic heart disease, diabetes, amputation of the right toes and left leg above the knee, and generalized anxiety disorder.Resident #1's Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. She had range of motion impairment on both sides of her lower extremities. She was dependent on staff for transfers and required setup assistance with wheelchair mobility. She was also assessed to receive scheduled and as needed pain medication. She had pain or hurting during the 5 days prior to the assessment and was documented as having pain occur rarely or not at all and described the pain as mild. She received an opioid for her pain control during the lookback period. Resident #1's orders revealed on 7/18/25 she was ordered oxycodone 5 milligram tablet every 8 hours as needed for pain. On 7/19/25 she had orders for chewable aspirin 81 milligrams one time a day related to chronic ischemic heart disease as well as clopidogrel bisulfate oral tablet 75 milligrams, an anti-platelet medication, in the morning related to atherosclerotic heart disease. During an interview on 9/10/25 at 10:33 AM Resident #1 stated the Transport Driver came to her room on 8/26/25 and rolled her out to the transport van for a dentist appointment. This van was the facility's transport van that opened in the back and had a ramp on which the Transport Driver pushed her up. The Transport Driver would always do something with the floor that would lock her wheelchair in place and to the best of her memory, the Transport Driver did something, and it seemed like she had locked the wheelchair in the van as she normally did, and Resident #1 did not know what failed this time. She confirmed her seatbelt was also in place. During transport, everything seemed normal until they had stopped at a red light. When the light turned green, the Transport Driver pressed the gas to go straight, and as the van accelerated at a normal pace, her wheelchair came loose. The chair flipped backwards resulting in her landing on her back still seated in the wheelchair. The ramp had been pulled up in the back and stored, and she hit her head on the steel ramp as she fell backwards. She bit her tongue, causing some bleeding but she could not remember how bad it bled. She stated the Transport Driver parked the van, but she could not say how long it took to come to a stop. Her back was in pain due to the sudden jerk of the wheelchair flipping over and the doctors at the hospital said she probably had some whiplash from the incident once she had made it to the emergency department. Resident #1 stated her pain was a 9 out of 10 (0 being no pain and 10 being the worst pain imaginable). The Transport Driver came into the back of the van after parking and called Emergency Medical Services (EMS) as well as the facility. Three people came from the facility to where they were parked, arriving before EMS as the van had not made it far from the facility. The three staff members who arrived at the van were the Director of Nursing, the Administrator, and the Maintenance Director. It did not take them long to get there but she was unsure of the length of time. She was still lying on her back, seated in the flipped wheelchair when the three staff members arrived. The Administrator began taking pictures of the van and the things on the floor of the van that anchored the chair to the van, and the Maintenance Director was inspecting the van. The Director of Nursing assessed her and explained they would need to wait for EMS to ensure Resident #1 was moved safely. During an interview on 9/10/25 at 12:36 PM the Transport Driver stated Resident #1 had a dental appointment on 8/26/25 at 2:30 PM. At around 2:00 PM to 2:15 PM she went to Resident #1's room to take her to the van and get her set up for transport. Once Resident #1 was in the van, she locked the wheels on the wheelchair and then secured the two front straps and two back straps from the floor of the van to the large, back wheels of the wheelchair, one front and one back strap per wheel. She then did a pull test to make sure the wheelchair did not move by pulling back on the chair handles to ensure it was securely in place and allow the automatic tension to tighten. She stated she heard the clicking of the locking mechanisms which indicated the wheelchair was securely in place. She then put on Resident #1's seatbelt. One belt went around the resident's waist and locked into the floor on the right and left side of the resident. Then another belt attached to the side wall of the van is pulled over the resident's right shoulder and locked into the waist belt. She then completed another pull test by pulling back on the wheelchair by its handles and asked Resident #1 if she was comfortable or if the seat belt was too tight. Resident #1 indicated she was comfortable. The ramp was folded and stored by folding it to sit upright in the back of the van and then the doors of the van were closed. Everything continued without incident, and they stopped at a stop light. When the light turned green, she pressed the gas, and as she accelerated through the light, Resident #1 shouted, and she heard a noise from the back. She asked Resident #1 what happened, and the resident responded she had come out of the chair. The Transport Driver told Resident #1 to just hold on as she was trying to get out of the road and park. She pulled to the shoulder of the road and parked the van. The Transport Driver told Resident #1 to keep talking to her to keep her conscious and told Resident #1 she could not move her before a medical professional assessed her. The Transport Driver then called the EMS as well as the Administrator. She stated by then she had moved to the back of the van with Resident #1. The wheelchair had tipped over backwards with Resident #1 in it, resulting in her lying on the floor of the van on her back, halfway in the wheelchair with her buttock having shifted up to the middle of the back rest of the wheelchair. She stated Resident #1 asked if she could get her up and the Transport Driver told her she could not move her due to the increased risk of injury. Resident #1 told the Transport Driver she thought she had hit her head. The top of Resident #1's head was up against the ramp which was folded and stored behind Resident #1. At no point did she move the resident or move any items including the ramp due to the risk of moving the resident, causing more injury. The only thing she moved was to unlock the right front anchor strap which was still secured on the wheel and the van floor when she first entered the back of the van. She did this to get back to Resident #1 without having to step over the anchors. The Director of Nursing and Administrator arrived 7 to 10 minutes prior to EMS arriving. The Transport Driver stated she demonstrated how she had anchored Resident #1's wheelchair in the van for the Maintenance Director, Director of Nursing, and Administrator. This was completed while still pulled over to the side of the road. After the demonstration, she was informed she could not drive the van again until the investigation was completed and she had been reeducated on how to secure resident wheelchairs in the van. The Maintenance Director drove the van back to the facility. The Transport Driver indicated she attended training, watched instructional videos, and took tests during the investigation which she completed on 9/2/25 and she was now currently monitored with a monitoring tool by the Maintenance Director. The Transport Driver stated she was educated that by attaching both the front and rear anchors to the same rear wheel on each side, the frame of the wheelchair was still free to rotate and flip over. She stated she had done it correctly in the past as far as she could recall and did not know why she attached it this way on 8/26/25.During an interview on 9/10/25 at 2:23 PM the Maintenance Director stated he was in the building when the incident happened on 8/26/25, and he got a call from the Administrator to come to the location of the incident. The Administrator informed him an incident had occurred during transport of Resident #1 in the facility van. When he arrived, EMS was already there on the scene, and the side door was open and through the side door he noted Resident #1 lying on her back. The Director of Nursing and Administrator were already on there as well. EMS was in the process of getting Resident #1 out of the van, and once the resident was safely removed from the van and on the way to the hospital, he was then able to examine the van, and they could start their investigation. The Transport Driver explained what happened and he asked her how she had attached the anchor straps to the chair and floor of the van. She demonstrated how she attached the anchors to the wheelchair, and it was done incorrectly. He stated when a wheelchair was anchored in a transport van, it must be anchored by the front and back frame of the wheelchair. Wheels should never be used to anchor a wheelchair down. Also, she had anchored the left front and back anchors to the same larger back left wheel and anchored the right front and back anchors to the same larger back right wheel. Because she anchored both the back and front anchors to the same wheel on either side, the frame was still free to rotate while the back wheels stayed stationary. When the van had accelerated, the wheelchair was free to rotate backwards, causing the incident. He stated they inspected the van and found all parts were functioning correctly.The EMS narrative dated 8/26/25 revealed EMS documented that upon arrival, Resident #1 was found laying on her back in a transport van. The resident was partially in her wheelchair and partially on the floor of the van. Resident #1 indicated she tipped over during transport and now her neck and upper back were hurting. No deformities were noted with assessment. Resident #1 was lifted from the floor and placed back in her wheelchair. The facility staff present informed EMS she did take blood thinners, and she had hit her head. Resident #1 was transferred to the ambulance and was complaining of 8 out of 10 pain in her neck and back. Resident #1 was transported to the hospital. Resident #1's hospital record dated 8/26/25 revealed Resident #1 was in a vehicle transport going to an appointment when her wheelchair flipped backwards resulting in her striking her head on the floor of the van. Resident #1 indicated she saw stars but did not lose consciousness. She suffered back and neck pain as well. She was transported to the emergency department for further evaluation. Resident #1 indicated she had posterior neck pain and upper back pain but was otherwise at her baseline. She denied any other symptoms. She was documented to take clopidogrel bisulfate and aspirin but denied any other anticoagulant medication. CT scans demonstrated no evidence of hemorrhage or acute fracture. Blood work was unremarkable for acute issues and Resident #1 was discharged back to the facility on 8/26/25.A nursing note dated 8/26/25 revealed Resident #1 was documented to have returned to the facility via transport Med-X/stretcher from hospital where she had been evaluated for possible head injury from a fall. The nurse documented the hospital found negative findings from CT scans and lab work up.A provider note dated 8/27/25 revealed the Nurse Practitioner saw Resident #1 and documented Resident #1 was in a transport van headed to a dental appointment when the van accelerated, causing her wheelchair to tip over. She struck her head, neck, and back on the floor of the van. She also bit her tongue and sustained scrapes. She was taken to the emergency department where CT scans of the head and cervical spine were performed, all of which were negative for acute findings. She was discharged back to the facility with instructions to rest in bed for a few days. Resident #1 reported persistent pain, particularly in the shoulders and neck, and was ordered oxycodone 5 mg every 8 hours as needed for pain. Resident #1's diagnoses were acute whiplash injury, contusion of tongue, and pain. During an interview on 9/11/25 at 10:05 AM the Medical Director stated she was notified of the incident on 8/26/25, the day it happened. She further stated the main concern with an accident of this type would be internal bleeding because of the fall which thankfully did not occur. Another concern would be fractures because of the impact of the fall. She stated they had been seeing her regularly due to her medical condition and the incident to monitor Resident #1's status. The Medical Director stated the resident had not mentioned any fear of transportation or increase in her pain since the initial acute pain from the fall. During an interview on 9/11/25 at 10:54 AM the Director of Nursing (DON) stated on 8/26/25 she was informed by the Administrator they had to go because there had been a van incident. They got in the Administrator's car and arrived in less than 5 minutes. The van was parked on the shoulder of the road, and the Director of Nursing heard the Transport Driver saying, I'm in here as she opened the passenger front door. At that point she saw the Driver in the back of the van with Resident #1. The resident was in the wheelchair, on her back, with the front wheels in the air. Resident #1 told the Director of Nursing she bit her tongue and there was some bleeding but there was no pooling of blood as well as no indication or observed risk of choking on blood by Resident #1. EMS arrived shortly after the DON assessed Resident #1. EMS got in the van, assessed the resident and asked her questions. EMS transferred Resident #1 to a stretcher, placed her in the ambulance, and took her to the hospital. The Director of Nursing, Transport Driver, Administrator, and Maintenance Director examined the van. They had the Transport Driver demonstrate how she had anchored the wheelchair in the van. The Transport Driver had anchored both left and right front and rear straps to the rear wheels. At that point they determined the wheelchair had been anchored incorrectly by the Transport Driver.During an interview on 9/11/25 at 12:10 PM the Administrator stated she received a call from the Transport Driver on 8/26/25 and she told her there had been an incident with the van. The Administrator found out where the transport van was parked and then instructed the Transport Driver to call 911 if she had not done so. The Administrator then got the Director of Nursing and told her what she knew, and they got in her car and drove to the transport van. She stated Resident #1 was alert and oriented and talking with her and the other staff members. While the Director of Nursing assessed the resident, she called the Maintenance Director and asked him to come to the location as well so that he could examine the transport van after Resident #1 was taken care of. She stated shortly after this, EMS arrived and worked with the Director of Nursing to safely transfer Resident #1 to the ambulance and take her to the hospital. While this was happening, the Maintenance Director arrived. After Resident #1 had been transferred to the ambulance, she requested the Transport Driver demonstrate to her, the Director of Nursing, and Maintenance Director, how she had anchored the wheelchair to the van. Following her demonstration, they understood she had attached the anchors incorrectly to the rear wheels on both sides. The Transport Driver was suspended from transportation, and the Maintenance Director drove the van back to the facility. The Administrator was notified of the immediate jeopardy on 9/10/25 at 4:12 PM.The facility provided the following corrective action plan:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 8/26/25 Resident #1's wheelchair tipped backwards in the facility transportation van due to the transportation driver failing to follow manufacturer's instructions for wheelchair securement. The driver had improperly anchored both left and right front and rear straps to the rear wheels, leaving the front of the wheelchair unsecured. When the vehicle accelerated, the wheelchair tipped backwards, causing Resident #1's head and back to strike the floor of the van. Emergency services were called, and Resident #1 was transported to the hospital where she was treated for posterior neck pain, upper back pain, a superficial tongue laceration, paraspinal tenderness, and a superficial abrasion to her right hand. A CT scan revealed no evidence of hemorrhage or acute fracture, and the resident was discharged back to the facility the evening of 8/26/25.On 8/26/25, the transportation driver was removed from driving duties pending retraining and competency validation. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 8/26/25 the facility conducted a 100% audit of progress notes, transport log and interview with the Transportation Driver of in-house facility residents' transports for the past 90 days by the Assistant Director of Nursing (ADON) that was completed on 8/27/25, with no concerns identified. The Assistant Director of Nursing reviewed the transport log to identify any resident that would potentially be transported with facility van. No residents were to be transported until investigation and retraining completed. All scheduled appointments were scheduled by the Transportation Driver with a contracted outside transportation company beginning 8/27/25. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.The facility has two employees who drive the transportation van. The Transportation Driver is the primary driver and the Maintenance Director is the back up driver. The Administrator audited on 8/26/25 the transport employee files: audit to include training, valid driver's license, van maintenance checklist to include proper alignment of the wheelchair between the tie down straps, attaching the rear tie down straps to the rear frame, front tie down straps to the front frame, ensuring tightness on both the front and rear tie downs, and securing seatbelt around resident, and employee vehicle policy to include but not limited to vehicle purpose, driver licensing, maintenance of company van, proof of insurance on company van, traffic violations, usage of cellular phone, accidents involving company vehicle, theft of company vehicle and driver responsibilities in regards to operation of vehicle, use of seatbelts and securement devices and reporting requirements with no concerns identified. The Maintenance Director did the initial education for the Transportation Driver on site of incident and return demonstration on 8/26/25. The Administrator reviewed the manufacturer's video and training documents provided by the facility and re-educated post incident on 8/27/25. The Maintenance Director conducted education and an initial return demonstration with the Transportation Driver, Director of Nursing and Administrator on 8/26/25 that included proper securement of the wheelchair and van anchors per manufacturer's instructions. Outside Maintenance Director from a sister facility provided additional education to the Administrator, Maintenance Director and Transportation Driver regarding proper securement of the wheelchair and van anchors per manufacturer's instructions on 9/2/25. On 8/27/25 the Administrator initiated 100% in-service with the Maintenance Director and Transportation Driver about proper securement of wheelchairs during transport per manufacturer's instructions. The in-service was completed by 8/28/2025. All newly hired Transport Drivers will be in-serviced by the Maintenance Director during orientation to include the skills check list. The skills check list includes but is not limited to a competency validation of loading, securing and unloading a resident and a return demonstration. The Maintenance Director sent the van out for inspection that included checking functional status of the wheelchair anchors that was completed on 8/27/25 with no concerns identified. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. On 8/26/25 the facility initiated 10% audit of all residents being transported by the facility to be completed by the Maintenance Director weekly x 4 weeks then monthly x 2 months utilizing the Van Transport Audit Tool to ensure proper securing of the resident before leaving the facility and this was taken to Quality Assurance committee meeting on 8/26/25. This audit is an observational audit to determine proper securement of the resident, wheelchair, and van anchors. The results will be documented on the Van Transport Audit Tool. All areas of concern will be addressed by the Administrator and/or Maintenance Director immediately.The Administrator will forward the results of the Van Transport Audit Tool to the Executive Quality Assurance Committee to include Administrator, Director of Nursing, Assistant Director of Nursing, Quality Assurance Nurse, Infection Control Preventionist/Staff Development Nurse, Activities Director, social workers, unit managers and unit coordinators, Maintenance Director, Minimum Data Set nurse, Dietary Manager, Medical Director and additional staff representatives monthly x 3 months for review to determine trends and / or issues that may need further interventions put into place and to determine the need for further and / or frequency of monitoring. Completion date 9/3/25Onsite validation of the facility's corrective action plan was completed on 9/11/25. The initial audit results were reviewed. The in-service education records completed 9/2/25 were reviewed. Interviews with the Transport Driver and Maintenance Director as well as observations of a demonstration of anchoring a wheelchair to a transport van by both staff members were completed. The monitoring results were reviewed, and the Quality Assurance meeting minutes were reviewed. The facility's immediate jeopardy removal date of 9/3/25 was validated.

Based on record review and staff interviews, the facility failed to have a process that provided an opportunity to formulate an advance directive (Resident's #'s 292, 73, 287, 54) and have accurate advance directive documentation throughout the medical record (Resident #54) for 5 of 15 residents reviewed for advance directives. Findings included: 1a. Resident #292 was admitted to the facility on [DATE] with diagnoses including spinal cord disease and chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #292 was cognitively intact. Physician orders dated [DATE] included an order for cardiopulmonary resuscitation (CPR). There was no documentation in Resident #292's medical record that education regarding the formulation of advance directives and/or an opportunity to formulate an advance directive was offered. b. Resident #73 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #73 was cognitively intact. Physician orders dated [DATE] included an order for cardiopulmonary resuscitation (CPR). There was no documentation in Resident #73's medical record that education regarding the formulation of advance directives and/or an opportunity to formulate an advance directive was offered. c. Resident #287 was admitted to the facility on [DATE] with diagnoses including pyothorax (a condition where pus builds up around the lungs). The admission/5-day Minimum data Set (MDS) assessment dated [DATE] indicated Resident #287 was moderately cognitively impaired. Physician orders dated [DATE] included an order for cardiopulmonary resuscitation (CPR). There was no documentation in Resident #287's medical record that education regarding the formulation of advance directives and/or an opportunity to formulate an advance directive was offered. d. Resident #54 was admitted to the facility on [DATE] with diagnoses including chronic ischemic heart disease (heart weakening caused by reduced blood flow to the heart), type 2 diabetes mellitus (a chronic disease that occurs when the body doesn't produce enough insulin or doesn't use it properly), and generalized muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #54 was cognitively intact. Physician orders dated [DATE] for Resident #54 included an order for cardiopulmonary resuscitation (CPR). There was no documentation in Resident #54's medical record that education regarding formulation of advance directives and/or an opportunity to formulate an advance directive was offered. An interview was conducted on [DATE] at 10:23 AM with the Admissions Coordinator. She stated she does not discuss advanced directives with residents. She further stated the Assessment/Admissions Nurse talks about code status/advanced directives with residents. An interview was conducted on [DATE] at 10:26 AM with the Assessment/Admission Nurse. She stated she reviews information regarding code status provided by the sending facility. She further stated if a resident is admitted to the facility from home, a verbal explanation of the difference between full code status and do not resuscitate (DNR) status is provided to the resident, however that discussion itself is not documented. An interview was conducted on [DATE] at 12:07 PM with the Director of Clinical Operations (former Director of Nursing). He stated code status was verified with the order from the hospital. There is no other written information that advance directives were discussed with residents. An interview was conducted on [DATE] at 2:54 PM with the Medical Director. She stated advance directives were discussed during the initial assessment, at least once per year, as well as with a resident's change in condition and/or recurrent hospitalization s. She further stated there was no specific statement that is documented regarding discussion of advance directives with the residents. An interview was conducted on [DATE] at 3:03 PM with the Administrator. She stated she assumed advance directives were discussed and documented with the residents by Admissions Coordinator. The Assessment/Admission Nurse should also be documenting the discussion of advanced directives; however, it was discovered that neither of these staff members were doing so. 49502 2.Resident #25 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, dementia, and cognitive communication deficit. Review of Resident #25's hard chart located at the nurse's station revealed a form dated [DATE] indicating the preference of Do Not Resuscitate (DNR) and was visually identified as a DNR. Resident #25's hard chart further revealed a physician's order dated [DATE] which indicated a DNR code status. Resident #25's care plan dated [DATE] revealed a focus for her code status with the intervention listed as if resident's heart stops beating, their wishes of being a full code status will be adhered to, and Cardiopulmonary Resuscitation (CPR) will be administered. Review of Resident #25's annual Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was severely cognitively impaired. During an interview with the MDS Coordinator on [DATE] at 4:53 pm, she explained the MDS nurses were responsible for updating the care plans and they should the reflect the code status for Resident #25. Resident code status was discussed during the morning meetings with the different department heads. During an interview with MDS Nurse #1 on [DATE] at 4:10 pm, she indicated code status was discussed in morning meetings as well as care plan meetings. MDS Nurse #1 confirmed she was responsible for updating Resident #25's care plan and explained she was aware Resident #25's code status was DNR. The MDS Nurse #1 stated she entered the care plan intervention of full code status in error for Resident #25. In an interview with the Director of Nursing (DON) on [DATE] at 5:00 pm, she stated her expectations were the care plans reflect the accurate code status of the resident's wishes. Resident code status was discussed during the morning meetings as well as care plan meetings. The DON indicated the MDS nurses were responsible for updating the care plans.

Based on record review, observations and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of skin conditions (Resident #129), bowel and bladder (Resident #31), nutritional status (Resident #5) and discharge (Resident #134) for 4 of 36 residents whose MDS assessments were reviewed. Findings included: 1. Resident #129 was readmitted to the facility on [DATE] and diagnoses included the absence of right toes. The hospital discharge summary dated 12/30/2024 recorded on 12/26/2024 Resident #129 had a transmetatarsal amputation (surgery to remove part of the foot that included the metatarsals (bones between ankle and toes). The discharge summary further recorded Resident #129's surgical wound was being treated with a wound vacuum (type of treatment that uses a device to decrease air pressure of the wound to help it heal). Nursing documentation dated 12/30/2024 at 8:39 pm by the Admission Nurse reported Resident #129 was readmitted to the facility and had surgery to remove gangrenous toes from the right foot. Physician orders dated 12/30/2024 included an order to clean the right foot wound with Dakin's solution, apply black foam with wound vacuum at 125 millimeters of mercury continuous suction and change three times a week on Monday, Wednesday, Friday and as needed. Resident #129's January 2025 Treatment Administration Record recorded wound care to the right foot was administered as ordered from 1/1/2025 to 1/23/2025. The admission MDS assessment dated [DATE] indicated the resident was coded for no pressure ulcer, no venous or arterial ulcer and no surgical wound. The MDS further indicated Resident #129 was receiving no surgical wound treatments. An interview conducted with the MDS Coordinator on 1/23/2025 at 4:32 pm, after reviewing Resident #129's MDS dated [DATE] for skin conditions, she stated the MDS assessment was inaccurate because a surgical wound had not been coded for Resident #129. She stated the MDS data entered for Resident #129 was not reviewed prior to transmitting and her signature on the MDS only represented completion of data collection on the MDS assessment and not accuracy of the MDS. In a follow up interview on 1/24/2024 at 10:27 am with the MDS Coordinator, she stated Resident #129's MDS assessment dated [DATE] should have also been coded for receiving wound care. In an interview with the Administrator on 1/24/2025 at 10:28 am, she stated the MDS assessment for Resident #129 should be coded accurately. 2. Resident #31 was admitted to the facility on [DATE] with diagnoses including cancer. Nursing documentation dated 7/19/2024 reported Resident #31's urostomy bag was drained several times during the shift by the nurse. Resident #31's care plan last reviewed on 7/22/2024 included Resident #31 having an urostomy (a surgery that creates a stoma, a small opening in the abdomen used to remove body waste like urine, in the abdomen to collect urine outside of the body). Interventions included to empty the urostomy bag every shift and as needed, expel gas from urostomy bag as needed and notify physician of any changes in the appearance of the urostomy's stoma. Physician orders dated 10/21/2024 included an order to change urostomy bag as needed. There were no orders for an internal or external urinary catheter. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #31's assessment for bowel and bladder was coded for an indwelling urinary catheter, external urinary catheter, ostomy and incontinence in urine occasionally. On 1/21/2025 at 12:32 pm, Resident #31 was observed with a urostomy bag with amber urine on the left lower quadrant of the abdomen. In an interview with Nurse #5 on 1/23/2025 at 11:47 am, she stated Resident #31 had a urostomy due to bladder cancer and had never had an internal or external urinary catheter. In an interview with the MDS Coordinator on 1/24/2025 at 10:27am, she stated Resident #31's MDS assessment for bowel and bladder was inaccurately coded. She explained Resident #31 had a urostomy and stated Resident #31 should not have been coded for an internal or external urinary catheter. In an interview with the Administrator on 1/24/2025 at 10:28 am, she stated Resident #31's MDS assessment should have been coded accurately. 49502 3. Resident #5 was admitted to the facility on [DATE] with diagnoses which included coronary artery disease, hypertension, diabetes mellitus, and dementia. A physician's order dated 9/20/24 revealed an order for tube feeding four times a day. Review of Resident #5's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was severely cognitively impaired. The MDS dated [DATE] did not have Resident #5 coded as having a gastrostomy tube. During an interview with Nurse #1 on 1/23/25 at 1:55 p.m., she explained she had just finished giving Resident #5's tube feeding. During an interview with the MDS Coordinator on 1/23/25 at 4:47 p.m., she explained the dietary department coded the nutrition section of the MDS for all of the residents. She further explained that it was coded in error. During an interview with the Food Service Director on 1/24/25 at 2:12 p.m. she explained she was responsible for coding the nutrition section of the MDS for Resident #5. She further explained it was an oversight and an error on her part. During an interview with the Director of Nursing (DON) on 1/23/25 at 5:00 p.m., she stated Resident #5's MDS should be accurately coded. During an interview with the Administrator on 1/24/25 at 3:15 pm she indicated the MDS should be completed accurately. 4. Resident #134 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, hypertension, and atrial fibrillation. Review of Resident #134's discharge Minimum Data Set (MDS) dated [DATE] revealed he was cognitively impaired and was discharged to an acute hospital. Review of a progress note dated 12/4/24 noted Resident #134 had been discharged to an assisted living facility. During an interview with the MDS Coordinator on 1/23/25 at 4:37 p.m., she explained the MDS discharge for Resident #134 dated 11/28/24 was coded incorrectly and should have been coded as discharged to an assisted living facility. During an interview with the Director of Nursing (DON) on 1/23/25 at 5:00 p.m., she stated the resident's discharge MDS should accurately reflect their discharge status. During an interview with the Administrator on 1/24/25 at 3:15 p.m. she indicated the MDS should be completed accurately.

Based on record review and staff interviews, the facility failed to develop and implement an individualized care person centered care plan in the area of nutrition for 3 of 36 residents reviewed for comprehensive care plans (Resident #67, Resident #122 and Resident #19). Findings included: 1 a. Resident #67 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. A record of Resident #67's weights indicated on - 6/6/2024 Resident #67 weight was 144 pounds (lbs). - 8/7/2024 Resident #67 weight was 133 lbs. Physician orders included an order on 9/6/2024 for speech therapy evaluation for weight loss. Registered Dietician consult dated 9/9/2024 reported a weight loss of ten pounds in one month and recommended monitoring weights and adding sugar free shakes with all meals for nutritional support. A record of Resident #67's weights indicated on - 11/7/2024 Resident #67 weight was 134.6 lbs. - 12/4/2024 Resident #67 weight was 128.4 lbs. Physician orders included orders on 12/6/2024 for a carbohydrate controlled diet and sugar free shakes (meal replacement options for residents with diabetes) with all meals. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #67 was cognitively intact and required only assisting with setting up meal tray for eating. The MDS coded Resident #67's nutritional status with a weight of 128 pounds, on a therapeutic diet and with a weight loss more than 5% in the last month or 10% in more than six months and not on a physician prescribed weight loss regimen. Resident #67's care plan did not include a plan of care that addressed Resident #67's risk for a decrease in the nutritional status and/or weight loss. Resident #67's care plan was last reviewed on 12/10/2024. Dietary notes dated 12/11/2024 indicated Resident #67 was receiving supplemental sugar free protein and calorie dense shakes with meals due to weight loss and Resident #67's weight at 128.4 was a 5% weight loss over the past 30 days and 10% weight loss over the last 180 days. b. Resident #122 was admitted to the facility on [DATE] with diagnoses including depression. Dietary notes dated 10/14/2024 indicated Resident #122 weighed 170.9 pounds with a an eleven pound weight loss in last 90 days. The report included Resident #122 was receiving a no added sugar protein and calorie dense frozen supplement with lunch and dinner meals for nutritional support and recommended monitoring Resident #122's weights and oral intake. Additional dietary notes on 11/25/2024 recorded Resident #122 weight as stable at 170.1 pounds. Nursing documentation dated 11/22/2024 reported a change in diet to pureed due to dysphagia. Speech therapy note dated 11/24/2024 indicated Resident #122 presented with oropharyngeal dysphagia and receiving a pureed and thin liquid diet. Resident #122's care plan did not include a plan of care that addressed Resident #67's risk for a decrease in the nutritional status and/or weight loss. Resident #67's care plan was last reviewed on 12/5/2024. Physician orders dated 12/6/2024 included an order for a fortified nutritional supplement shake for weight loss and malnutrition, 120 milliliters three times a day for weight loss and poor appetite. On 12/12/2024, Resident #122 diet was changed to a no added salt mechanical soft diet and thin liquids. The quarterly Minimal Data Set (MDS) assessment dated [DATE] indicated Resident #122 was cognitively intact and required assistance in setting up meal trays only for eating. The MDS coded Resident #122's nutritional status as receiving a therapeutic diet, weighing 170 pounds (lbs) with no weight loss. c. Resident #19 was admitted on [DATE] to the facility with diagnoses including diabetes mellitus, dementia and depression. Resident #19's weights indicated a weight loss in the last six months: - 7/8/2024 127.0 pounds (lbs). - 7/17/2024 124.0 lbs. - 7/24/2024 121.0 lbs. - 7/31/2024 119.0 lbs. - 8/7/2024 119.0 lbs. - 9/10/2024 114.0 lbs. - 9/11/2024 113.0 lbs. - 9/18/2024 113.0 lbs. - 9/25/2024 117.0 lbs. - 10/2/2024 112.0 lbs. -12/4/2024 107.9 lbs. -1/1/2025 103.2 lbs. Physician orders dated 7/8/2024 included an order for a regular diet and a protein and calorie dense frozen supplement for weight loss, with lunch and dinner. Dietary notes dated 9/9/2024 reported a 10% weight loss in 180 days. The note included the fortified nutritional supplement shake for weight loss and malnutrition was increased from 30 milliliters to 60 milliliters three times a day and continued to monitor weights. Physician notes dated 9/16/2024 reported a six pounds (5%) weight loss in one month and the weight loss team addressed with the addition of the fortified nutritional supplement shake three times a day for nutritional support. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 was severely cognitively impaired and coded Resident #19's nutritional status receiving a therapeutic diet. A weight of 112 pounds and with weight loss more than 5% in the last month or 10% in more than six months and not on a physician prescribed weight loss regimen. The annual MDS triggered a concern for nutritional status for Resident #19's care plan. Resident #19's care plan did not include a plan of care that addressed Resident # 67's risk for a decrease in the nutritional status and/or weight loss. Resident #67's care plan was last reviewed on 12/3/2024. In an interview on 1/24/2025 at 3:18 pm with the MDS Coordinator, she stated the Dietary Manager was responsible for creating a care plan for residents who were at risk for a decrease in their nutritional status. She explained meetings were held to discuss residents with weight loss and the Dietary Manager was responsible for updating the residents' care plan after weight loss meetings. In an interview on 1/24/2025 at 3:26 pm with the Dietary Manager, she stated she was responsible for entering the initial care plans for residents when there was a risk for a change in their nutritional status and updating residents' care plans for weight loss discussed in the monthly weight loss meeting. She explained she been trained on the new electronic medical record system in July 2024 and had access to the information to create care plans for Resident #67, Resident #122 and Resident #19 and had not entered or updated the care plans for the residents. She stated she knew she was responsible for entering the nutrition information into the care plans and had not been able to complete the tasks and was working on entering the information into the care plans. In an interview with the Administrator on 1/24/2025 at 3:48 pm, she stated she was unaware that Resident #67, Resident #122 and Resident #19 care plans did not include a nutritional risk care plan. She stated the Dietary Manager should have been updating the residents' care plan due to weight loss and included interventions.

Based on observation, record review, and Medical Director, Pharmacist Consultant, Sales Representative and staff interviews, the facility failed to protect the resident from a potential flammable hazard for 1 of 3 residents reviewed for accidents. (Resident #16) The findings included: The National Institute of Health's website included an article dated October 2016 titled Safety in the use of [name brand of petroleum jelly] during oxygen therapy: the pharmacist's perspective indicated the following: The justification of the combination of [name brand of petroleum jelly] and oxygen has been subject for discussion in many hospitals. Due to the lack of evidence-based data in literature, we have provided recommendations from a pharmacist's perspective. The use of petroleum-based products should be avoided when handling patients under oxygen therapy. Whenever a skin moisturizer is needed for lubrication or rehydration of dry nasal passages, the lips or nose when breathing oxygen, consider the use of oil-in water creams or water-based products. Resident #16 was readmitted to the facility on [DATE] with diagnoses which included hypoxia (a condition that occurs when the body or a part of the body doesn't receive enough oxygen), and cognitive communication deficit. A physician's order dated 12/23/24 revealed an order for oxygen at 1 liter per minute (LPM) via nasal cannula (NC) to maintain oxygen saturation rates greater than 94% every shift for hypoxia. A physician's order written by the Medical Director dated 12/24/24 revealed an order for white petroleum jelly to be applied to Resident #16's lips every day and every evening for dry lips. Review of Resident #16's annual Minimum Data Set (MDS) dated [DATE] revealed Resident #16 to be severely cognitively impaired. Resident #16 was dependent on staff for all activities of daily living (ADL) and transfers. Resident #16 was coded for continuous oxygen therapy. Resident #16's January 2025 Treatment Administration Record (TAR) revealed the white petroleum jelly had been initialed as administered every day twice a day. An observation made on 1/21/25 at 1:05 pm revealed Resident #16 laying in bed with the NC in her nares (the openings of the nose, or nostrils). Resident #16's lips were not visually dry. A phone interview was conducted on 1/24/25 at 12:56 pm with the Sales Representative from an oxygen concentrator repair company. The Sales Representative explained the petroleum jelly was safe to use with residents who received oxygen therapy. When asked about the petroleum jelly being inflammable, the Sales Representative stated the petroleum jelly was heavily processed and the risk would be small. During an interview with Nurse #2 on 1/24/25 at 9:58 am, she indicated she was applying petroleum jelly but was unaware of the potential hazard of petroleum jelly when used on residents with oxygen. Nurse #2 further indicated if the white petroleum jelly was flammable then it should not be used. Nurse #2 was assigned the day shift (7:00 am until 3:00 pm) for Resident #16 and was familiar with Resident #16. In an interview with the Director of Nursing (DON) on 1/24/25 at 3:15 pm, she stated the facility should not be using petroleum jelly on residents who received oxygen therapy. The risk was small, but the petroleum jelly should not be used. During a phone interview with the Pharmacist Consultant on 1/24/25 at 8:52 am, she indicated petroleum jelly was not good to use with residents on oxygen therapy because it was considered flammable. She further indicated the risk was small; however, she would not want to take the chance of using petroleum jelly. In a phone interview with the Medical Director on 1/24/25 at 2:45 pm, she stated petroleum was flammable and there was a small risk for an adverse reaction for residents who were receiving both oxygen therapy and petroleum jelly. She further stated she was unaware of the petroleum jelly being used for Resident #16 and when it was brought to her attention, changes were made for Resident #16.

Based on observations, record review, interviews with the Medical Director and staff, the facility failed to provide supplemental oxygen as ordered by the physician for 1 of 1 resident reviewed for respiratory care (Resident #16). The findings included: Resident #16 was readmitted to the facility on [DATE] with diagnoses which included hypoxia, (a condition that occurs when the body or a part of the body doesn't receive enough oxygen). Resident #16's care plan dated 12/23/24 revealed a focus for oxygen therapy at 1 liter (L) via nasal cannula (NC) for hypoxia. Intervention included oxygen saturations to be monitored as ordered and as needed. A physician's order dated 12/23/24 revealed an order for oxygen at 1 L via NC to maintain oxygen saturation rates greater than 94% every shift for hypoxia. Review of Resident #16's annual Minimum Data Set (MDS) dated [DATE] revealed Resident #16 was severely cognitively impaired. Resident #16 was dependent on staff for all activities of daily living (ADL's) and transfers. Resident #16 was coded for continuous oxygen therapy. An observation made on 1/21/25 at 1:05 pm revealed Resident #16 laying in bed with the NC in her nares (the openings of the nose, or nostrils). An observation of the in-room oxygen concentrator revealed the oxygen setting at 2 L. Resident #16 had no signs or symptoms of respiratory distress. A follow up observation was made on 1/21/25 at 2:56 pm which revealed Resident #16's in-room oxygen concentrator setting remained at 2 L. Resident #16 had no signs or symptoms of respiratory distress. Resident #16 was observed at lunch on 1/23/25 at 12:15 pm which revealed Resident #16's in-room oxygen concentrator setting remained at 2 L. No signs or symptoms of distress were observed. During an interview at the medication cart on 1/23/25 at 5:11 pm with Nurse #1, she stated Resident #16's order was for 1L of oxygen via NC. Nurse #1 verified the physician order in the electronic medication administration record (eMAR) which revealed Resident #16 was ordered continuous oxygen at 1 L via NC. An observation with Nurse #1 was completed on 1/23/25 at 5:13 pm in Resident #16's room. Nurse #1 observed the in-room oxygen concentrator setting at 2 L. Nurse #1 alerted her supervisor and asked him if she needed to change the oxygen setting to 1 L. Nurse #1 indicated nurses should be checking the in-room oxygen concentrators every shift to make sure the correct ordered liter was still in place for their residents on supplemental oxygen. In an interview with the Quality Coordinator (QA) on 1/23/25 at 5:15 pm, he explained the knob could have been accidentally bumped when performing care. He stated he did not know why the oxygen setting was at 2 L, but it should have been on 1 L as ordered by the physician. Nurses should be checking the in-room oxygen concentrators every shift to make sure the correct ordered liter was still in place for their residents on supplemental oxygen. An interview with the Director of Nursing (DON) on 1/23/25 at 5:17 pm, she stated nurses should be checking supplemental oxygen settings daily to ensure residents were on the correct ordered liter. An interview with the Medical Director was completed on 1/24/25 at 2:45 pm. The Medical Director explained Resident #16's in-room oxygen concentrator should have been set at the correct ordered liter. She further explained there was no harm to Resident #16 for being on 2 L instead of 1 L of oxygen.

Based on observations and staff interviews, the facility failed to secure residents' medications in a locked medication cart for 1 of 6 medication carts observed (200-hall upper west medication cart). Findings included: On 1/24/2025 at 6:14 am, the 200-hall upper west medication cart was observed unlocked and located outside the nurse's station in the hallway approximately 15 feet from an unlocked entrance to the facility where staff were observed exiting as the surveyor entered the facility. There were no staff observed at the 200-hall upper west medication cart or in the nursing station. There were also no residents and/or staff observed on the 200-hall upper west. On 1/24/2025 at 6:15 am, Nurse #3 was observed exiting a resident's room that was located 30 feet away from the 200-hall upper west medication cart into the 200-hall and walking toward the unlocked 200-hall upper west medication cart. On 1/24/2025 at 6:16 am during an interview with Nurse #3, Nurse #3 was observed locking the 200-hall upper west medication cart. She stated she was in a resident's room administering medications and explained the 200-hall upper west medication cart was to be locked before leaving the medication cart unattended. When asked why the 200-hall upper west medication cart was observed unattended and unlocked upon entering the facility, Nurse #3 did not provide a reason. In an interview with the Director of Nursing on 1/24/2025 at 4:02 pm, she stated the 200-hall upper west medication cart was to be locked at all times when Nurse #3 was not present at the medication cart.

Based on observation, record review and interviews with staff, Nurse Practitioner, Medical Examiner and Physician, the facility failed to protect a resident's right to be free from neglect for 1 of 3 sampled residents reviewed for neglect (Resident #1). On 3/4/24, Nursing Assistant (NA) #1 disregarded Resident #1's physician orders and plan of care for the assessed need of 2 person assistance with Activities of Daily Living (ADL) care and provided care to the resident without assistance. During care, NA # left the resident positioned on his right side with the bed at waist height and turned his back to get a washcloth. Resident #1 rolled off the bed, landing face down on the tile floor. Resident #1 was transferred to the emergency room where a Computerized Tomography (CT) scan revealed a closed fracture of the left distal femur (a break of the thigh bone just above the knee) and a small skin tear to the left elbow. Resident #1 was on a blood thinning medication and he had multiple medical comorbidities making him vulnerable and at high risk for injury. The death certificate dated 3/31/24 listed the cause of death as complications of a left femur fracture. Immediate jeopardy began on 3/4/24 when NA #1 neglected to provide Resident #1 with the necessary care and services required to provide care safely. The immediate jeopardy was removed on 4/19/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower level and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place were effective. The findings included: This tag is cross-referenced to: F689: Based on observation, record review, staff, Nurse Practitioner, Medical Examiner and Physician interviews, the facility failed to provide Activities of Daily Living (ADL) care safely to a dependent resident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On 3/4/24 Nursing Assistant (NA #1) began providing care to Resident #1 when he left the resident positioned on his right side with the bed at waist height and turned his back to get a washcloth. Resident #1 rolled off the bed, landing face down on the tile floor. Resident #1 was transferred to the emergency room where a Computerized Tomography (CT) scan revealed a closed fracture of the left distal femur (a break of the thigh bone just above the knee) and a small skin tear to the left elbow. Resident #1 was on a blood thinning medication and he had multiple medical comorbidities making him vulnerable and at high risk for injury. The death certificate dated 3/31/24 listed the cause of death as complications of a left femur fracture. Review of the Initial Allegation Report dated 4/18/24 revealed the facility's Director of Nursing (DON) became aware of Resident #1's allegation of resident neglect from the State Survey Agency. The alleged incident occurred on 3/04/24 at 2:50 PM. The resident received a bath and the aide turned away from the bed to retrieve cloth and resident rolled from bed resulting in fall. The Investigation Report dated 4/19/24 completed by the DON for the neglect allegation related to Resident #1 documented the accused staff member (NA #1) was noted to be aware of 2 person ADL care requirement, however, the NA felt he could provide care independently because he had worked with the resident for over a year. A fall occurred during care as a result of care plan not being followed. The report indicated Resident #1 sustained serious bodily injury and the allegation was substantiated. The Administrator and Director of Nursing (DON) were notified of Immediate Jeopardy on 4/17/24 at 5:51 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to surer, a serious adverse outcome as a result of the noncompliance Resident # 1 noted to have received activities of daily living (ADL) care by NA #1 on 3-4-24. While receiving care, NA#1 noted to be providing care independently with Resident # 1 on his right side with bed at waist height. During care, it is noted that resident had a fall from the bed while NA#1 turned from care to retrieve bath cloth. Resident noted to have 2 person ADL (activities of daily living) ordered. Resident was noted to be sent to ER and returned with left leg injury. Resident remained in facility until new onset of facial drooping noted and was sent to ER 3/18/24 where he was discovered to have renal stones leading to sepsis whereupon resident aspirated and became unresponsive leading to a hospice admission at a local Hospice House instead of returning to facility for hospice care. NA #1 noted to be out of work indefinitely since 3/8/2024 with no expected return to work date. All residents receiving ADL care with concentration on residents with orders and care plans for 2 person assist with ADLs (Activities of Daily Living) identified as Recipients at Risk for neglect. Residents with orders and care plans for 2 person assist with ADLs shall be identified through audit entitled 2 person ADL care order Audit completed by Director of Nursing no later than 4/17/2024. Audit shall be completed by reviewing all active residents' current orders and care plans to ascertain all Recipients at Risk for neglect. Entity shall complete facility wide audit of Residents at Risk, no later than 4/17/2024. Results of audit identifying residents with 2 person assist with ADL care, shall be reviewed by facility Quality Assurance Committee (Physician services, Administrator, Director of Nursing, Quality Assurance Coordinator, Rehab Manager, Staff Development Coordinator, Social Worker, Environmental Services Director) on 4/18/2024 and results ensured to be communicated clearly in facility software to all nursing staff (Nurses and Nurse Aide 1). Software communication noted to populate in ADL documentation grid for all nurses and nurse aides and is populated through the ADL care plan once any orders are received and is documented by care planning nurse. Current care plan and communication shall be validated by Quality Assurance Committee by 4/18/24. Resident #1 shall have neglect reported via Initial Allegation Report by Director of Nursing to Health Care Personnel Investigation 4/18/2024. Director of Nursing shall also notify neglect to adult protective services on 4/18/24. Audits entitled 2 Person ADL Care Audit to include physician orders, care planning and staff observation shall be completed by Quality Assurance Coordinator on 4/18/2024. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring, and when the action will be complete: The Quality Assurance Committee shall also adopt new 2 Person assist with ADL Care Icon to be placed at foot of bed for any Residents at Risk as to improve process, in order to more clearly identify Residents at Risk with 2 person ADL care ordered. Once Committee has ensured accuracy of audit, as well as communication through facility software and new icon, all nursing staff shall receive education by Staff Development Coordinator or their designee, regarding all residents currently at risk. Education to encompass all residents receiving ADL care will include instruction on safety with ADL care to include gathering supplies and equipment, ensuring proper positioning in bed to provide safety, awareness of bed height and leaving residents in a safe position with call light in place. Education shall also include current list of all Residents at Risk, with 2 person ADL care and where their orders and care plan, may be identified in facility software, care plan awareness through new Icon and expectations regarding 2 person assist with ADL care. Residents / responsible party shall also be contacted by Resident Services Coordinator by 4/18/2024 to ensure permission to place Icon as to avoid any dignity issues and documented acceptance. Additionally, all staff shall receive education on facility policy for Resident Abuse and Neglect to include policy entitled Resident Abuse Prohibition Policy and Procedures with concentration on residents at higher risk for falls during ADL care requiring 2 people and to report to the Administrator / Director of Nursing, any witnessed abuse or neglect of care for these residents not meeting facility expectations. Education shall be completed and all efforts to encompass entire staff present 4/18/2024. Any staff not present 4/18/2024 shall have attempts made to complete education by phone no later than 4/18/2024 with messages left for any not spoken to, to contact facility as soon as possible for education, as to prevent future serious adverse outcomes from occurring. Education shall be documented on In-service Training Report. Staff Development Coordinator shall notify nursing supervisor of any nursing staff on the schedule who have not received in-servicing so that education may be delegated and completed for any nursing staff that may enter facility after 4/18/24. 2 Person assist with ADL Icon shall be placed at foot of bed for all Residents at Risk by Quality Assurance Coordinator by 4/18/2024. Audits entitled 2 Person ADL Care Audit shall be completed by Quality Assurance Coordinator 4/18/2024 monitoring for compliance of education completed as to ensure prevention on possible neglect. Alleged Immediate Jeopardy Removal Date: 4/19/24 Onsite validation of the immediate jeopardy removal plan was conducted on 4/19/24. The validation included staff interviews, observation, and record review. Inservice sign in sheets and staff interviews verified in-services were completed on the Abuse and Neglect Policy and Procedure with a concentration on residents at higher risk for falls during ADL care. Staff verified their understanding of neglect and the importance of providing residents with their assessed level of assistance. Additionally, staff revealed during education they had the opportunity to ask questions on resident Abuse and Neglect. Evidence of audits were reviewed for Abuse and Neglect and identifying Residents at Risk. Resident interviews were conducted with no issues identified. Observation of ADL care revealed staff provided the necessary assistance to meet the resident's assessed needs. The immediate jeopardy removal date of 4/19/24 was validated.

Based on observation, record review, staff, Nurse Practitioner, Medical Examiner and Physician interviews, the facility failed to provide Activities of Daily Living (ADL) care safely to a dependent resident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On 3/4/24 Nursing Assistant (NA #1) began providing care to Resident #1 when he left the resident positioned on his right side with the bed at waist height and turned his back to get a washcloth. Resident #1 rolled off the bed, landing face down on the tile floor. Resident #1 was transferred to the emergency room where a Computerized Tomography (CT) scan revealed a closed fracture of the left distal femur (a break of the thigh bone just above the knee) and a small skin tear to the left elbow. Resident #1 was on a blood thinning medication and he had multiple medical comorbidities making him vulnerable and at high risk for injury. The death certificate dated 3/31/24 listed the cause of death as complications of a left femur fracture. Immediate jeopardy began on 3/4/24 when NA #1 failed to provide care safely to Resident #1. The immediate jeopardy was removed on 4/19/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower level and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place were effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included, chronic atrial fibrillation (a type of irregular heartbeat that causes the heart to beat too quickly), heart failure, diabetes mellitus, peripheral artery disease (a condition in which narrowed arteries reduce blood flow to the arms or legs), and obesity. Resident #1's quarterly Minimum Data Set, dated dated dated [DATE] revealed he was cognitively intact. He was assessed as dependent with bed mobility, incontinence care and bathing. Resident #1 was not coded for any falls since the prior assessment. The MDS indicated the resident's weight as 325 pounds and he was coded for receiving an anticoagulant. A review of the active physician orders for March 2024 included the following orders: - Two person assist with ADL care (order start date 11/01/22). - Eliquis (anticoagulant) 5 milligrams twice daily Resident #1's care plan initiated on 10/24/22 and reviewed on 12/20/23 revealed he was at risk for falls related to impaired mobility, multiple comorbidities, and continuous oxygen (02). Interventions initiated on 11/01/22 included two people assisting with care. An interview was conducted with NA #2 on 4/16/24 at 2:29 PM. She indicated Resident #1 was a two person assist as he was a heavy-set man, and she always had another NA to help her provide his care. NA #2 revealed she would check in the FYI (for your information) section of the computer to see what care a resident needed. An interview on 4/17/24 at 1:09 PM was conducted with NA #3. She revealed Resident #1 was a 2 person assist with ADL care. NA #3 indicated she looked in the computer to see what type of care a resident needed. On 4/17/24 at 1:25 PM the Director of Nursing (DON) stated Resident #1 had extension bars on his bed that extended the bed frame out 8 inches on either side of the bed and a larger mattress to fit the bed frame. The Nurse note dated 3/4/24 completed by Nurse #1 revealed NA# 1 called nursing staff to Resident #1's room at 2:50 PM. Resident #1 was noted laying on his side undressed on the floor with the bed in the high position. NA #1 stated he was turning Resident #1, and he kept on rolling off the bed onto the floor. The Supervisor was notified and on assessment Resident #1 was noted to have blood upon inspection but could not locate the source due to his positioning. The note documented Resident #1 was on a blood thinner. EMS (Emergency Medical Service) were notified, and Medical Doctor notified. Order was obtained to send Resident #1 to (name of hospital) for evaluation. The Fall Incident/Accident Report initiated on 3/4/24 and signed completed on 3/4/24 by Unit Manager Nurse was reviewed. The report revealed while care was being provided Resident #1 was turned to face the door, the NA turned his back to get a cloth and Resident #1 landed face down on the floor. NA #1 was interviewed by phone on 4/16/24 at 5:29 PM. NA #1 indicated on 3/4/24 he positioned Resident #1 on his right side in the middle of bed. He indicated he (NA #1) turned to the tray table to grab a washcloth. He indicated while he was turned away from the bed he looked in the mirror in the room and saw the resident move his leg and he roll off the bed face first onto the floor. NA #1 indicated he was aware Resident #1 was a two person assist according to the care plan. When asked why he provided care without another staff member's assistance on 3/4/24 he indicated there was a lot going on that day, it was close to shift change, he worked with Resident #1 daily, and thought he could provide incontinence care alone. NA #1 indicated Resident #1 was able to assist with his turning and repositioning in bed. A follow up interview with NA #1 was conducted by phone on 4/17/24 at 4:10 PM. He revealed on 3/4/24 the bed was at waist height when the resident rolled onto the floor. NA #1 stated Resident #1 did not hit his head when he fell . In a phone interview on 4/16/24 at 1:12 PM Nurse #1 stated that when she arrived in Resident #1's room on 3/4/24, she found Resident #1 on the floor lying between Bed A and Bed B. He was on his side and she observed some blood but she could not tell where it was coming from, and she wanted to send Resident #1 out for evaluation in case of head injury as he was receiving a blood thinner. She revealed Resident #1 was a larger man and required two persons for assistance with his ADL care. The Unit Manager Nurse was interviewed on 4/17/23 at 9:31 AM. The Unit Manager Nurse revealed when she arrived at Resident #1's room on 3/4/24, the resident was on the floor face down with slight weight on his left side. She indicated NA #1 worked with the resident daily and the resident was a two person assist as he was a heavy man. She reported Resident #1 fell on to the tile floor. The Unit Manager Nurse called 911, the hospital to notify them they had a fall resident and the RP (responsible person). She stated that EMS arrived at the facility within 5 minutes of her call. Review of the emergency room (ER) report dated 3/4/24 revealed upon arrival at 4:09 PM EMS reported an obese, chronically ill-appearing, but awake, alert, Glasgow Coma Scale (a scale used to objectively describe the extent of impaired consciousness) of 15 (a score of 15 means you are fully awake, responsive and have no problems with thinking ability or memory). A Computerized Tomography (CT) scan was conducted in the ER of Resident #1's left lower extremity and revealed a comminuted non-displaced fracture of distal femoral meta-epiphysis (rounded long end portion of the bone) with fracture line extending to the lateral femoral condyle (a break in the lower part of a bone) with extension to posterior lateral femoral condyle. The resident was assessed by orthopedics and the fracture was non-operative. He was splinted at bedside and returned to the facility on [DATE]. Review of the physician progress note dated 3/11/24 documented Resident #1 was sent out to theER on [DATE] following a fall from bed while being adjusted in bed. He was noted with some bleeding and concerned for a head injury as on Eliquis. CT scan revealed a closed fracture of the left distal femur. The orthopedist was consulted, determined the fracture was nonoperative and the resident was splinted at bedside. Post splint x-ray showed stable positioning and the resident was cleared to discharge to the facility. Review of the nurse notes dated 3/17/24 documented the resident was complaining of chest pain at 10:30 AM. The Supervisor was notified of the resident's cardiac history (chronic atrial fibrillation), 911 was called, and the resident was transported to the ER by EMS for evaluation and treatment. Review of the physician progress note dated 3/18/24 documented Resident #1 was sent out to theER on [DATE] for concern of acute chest pain. A complete blood count showed no leukocytosis (high white blood cell count may indicate an infection or inflammation in the body). Cardiac tests were unremarkable, (for heart proteins leaking into the blood) and the resident was discharged back to the facility. Review of the nurse note dated 3/18/24 at 11:46 AM indicated the resident was seen by Nurse Practitioner #1 for follow up of chest pain. Resident #1 was noted to have right sided facial droop, a fixed pupil and acute disorientation. Resident #1 was sent to the ER for evaluation and treatment. Review of the emergency room report dated 3/18/24 at 12:44 PM revealed Resident #1 presented as a prehospital code stroke due to a change in mental status. The resident was afebrile, chronically ill-appearing and had a left lower extremity in a splint due to recent fracture. An EKG (electrocardiogram) revealed atrial fibrillation with premature atrial contraction (PVC is associated with an increased risk of atrial fibrillation) and a chest x-ray revealed pulmonary venous congestion with hypoventilatory changes (breathing that is too shallow or slow to meet the needs of the body). Review of the Discharge Summary dated 3/29/24 revealed Resident #1 was reviewed by the Tele-neurologist for suspected stroke. The stroke was ruled out and suggested probable acute metabolic encephalopathy (metabolic encephalopathy occurs when problems with your metabolism cause brain dysfunction). He was treated with antibiotics for a complicated UTI (urinary tract infection that carries a higher risk of treatment failure and typically require longer antibiotic courses) and aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs instead of being swallowed). The Discharge Summary documented that due to Resident #1's age related debility and poor improvement the family decided on comfort measures. Resident #1 was discharged from the hospital on 3/29/24 to an inpatient hospice facility. Review of Resident #1's death certificate dated 3/31/24 listed the cause of death as complications of a left femur fracture. An interview was conducted with the Medical Examiner (ME) on 4/17/24 at 12:39 PM. She indicated she had reviewed Resident #1's medical history after she received the body for autopsy which revealed he fractured his ankle 3 years prior. The Medical Examiner indicated after a fall or broken bone patients were never the same and the femur fracture precipitated a decline in the body. The ME indicated Resident #1 was not a young man, had many comorbidities and determined the cause of death was due to blunt force trauma to the femur. The Nurse Practitioner was interviewed by phone on 4/16/24 at 3:24 PM. He revealed Resident #1 had a history of atrial fibrillation, was on a blood thinner, and after his fall on 3/4/24 the facility sent Resident #1 out immediately to evaluate for head injury (individuals taking a blood thinner are at higher risk of brain bleeding, following a head injury). The Nurse Practitioner indicated the resident was diagnosed with a femur fracture, received a soft cast in the ER and returned to the facility that same day. He indicated on 3/17/24 Resident #1, was sent to the ER for a complaint of chest pains, where a cardiac evaluation was unremarkable for heart proteins leaking into the blood, and the resident returned to the facility. The Nurse Practitioner revealed he followed up with Resident #1 on 3/18/24 and sent him back to the ER for a facial droop and slurred speech. He stated within a two-week period, Resident #1 had no further falls, had two hospital visits and with his contributing comorbidities he did not see how the fracture could have contributed to his death. A phone interview was conducted with the Medical Doctor on 4/17/24 at 2:47 PM. He indicated during Resident #1's hospital stay on 3/18/24, he was diagnosed with an UTI (urinary tract infection), an acute kidney injury, renal stones, and during that hospital stay he had an infection that overwhelmed his system and had an acute aspiration event. The MD indicated Resident #1's infection, UTI, and renal stones would have occurred regardless of the fall, and the hospital record highlighted the aspiration pneumonia as a contributing factor. The Medical Doctor indicated he saw no connection between his fall/fracture and expiration. The Director of Nursing (DON) was interviewed on 4/17/24 at 5:00 PM. The DON revealed staff were trained to look in the computer for resident care needs and NA #1 should have followed their policies and procedures. He indicated Resident #1 was care planned and documented in the computer for a two person assist with ADL care and any residents requiring extensive assistance with ADL's staff should use 2-person assistance with care. The Administrator and DON were notified of Immediate Jeopardy on 4/17/24 at 5:51 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident # 1 noted to have received Activities of Daily Living (ADL) care by NA #1 on 3-4-24. While receiving care, NA #1 noted to be providing care independently with Resident #1 on his right side with bed at waist height. During care, it is noted that resident had a fall from the bed while NA #1 turned from care to retrieve bath cloth. Resident noted to have 2 person ADL (activities of daily living) ordered. Resident was noted to be sent to emergency room (ER) and returned with left leg injury. Resident remained in facility until new onset of facial drooping noted and was sent to ER 3/18/24 where he was discovered to have renal stones leading to sepsis whereupon resident aspirated and became unresponsive leading to a hospice admission at a local Hospice House instead of returning to facility for hospice care. NA #1 noted to be out of work indefinitely since 3/8/2024 with no expected return to work date. All residents receiving ADL care with concentration on residents with orders and care plans for 2 person assist with ADLs (Activities of Daily Living) identified as Recipients at Risk for accidents and failure to provide safe care. Residents with orders and care plans for 2 person assist with ADLs shall be identified through audit entitled 2 person ADL care order Audit completed by Director of Nursing no later than 4/17/2024. Audit shall be completed by reviewing all active residents' current orders and care plans to ascertain all Recipients at Risk for accidents and failure to provide safe care. Entity shall complete facility wide audit of Residents at Risk, no later than 4/17/2024. Results of audit identifying residents with 2 person assist with ADL care, shall be reviewed by facility Quality Assurance Committee (Physician services, Administrator, Director of Nursing, Quality Assurance Coordinator, Rehab Manager, Staff Development Coordinator, Social Worker, Environmental Services Director) on 4/18/2024 and results ensured to be communicated clearly in facility software to all nursing staff (Nurses and Nurse Aide 1). Software communication noted to populate in ADL documentation grid for all nurses and nurse aides and is populated through the ADL care plan once any orders are received and is documented by care planning nurse. Current care plan and communication shall be validated by Quality Assurance Committee by 4/18/24. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Quality Assurance Committee shall also adopt new 2 Person assist with ADL Care Icon to be placed at foot of bed for any Residents at Risk as to improve process, in order to more clearly identify Residents at Risk with 2 person ADL care ordered. Once Committee has ensured accuracy of audit, as well as communication through facility software and new icon, all nursing staff shall receive education by Staff Development Coordinator or their designee, regarding all residents currently at risk. Education to encompass all residents receiving ADL care will include instruction on safety with ADL care to include gathering supplies and equipment, ensuring proper positioning in bed to provide safety, awareness of bed height and leaving residents in a safe position with call light in place. Education shall also include current list of all Residents at Risk, with 2 person ADL care and where their orders and care plan may be identified in facility software, care plan awareness through new Icon and expectations regarding 2 person assist with ADL care. Residents / responsible party shall also be contacted by Resident Services Coordinator by 4/18/2024, to ensure permission to place Icon as to avoid any dignity issues and documented acceptance. Education shall be completed and all efforts to encompass entire staff present 4/18/2024. Any staff not present 4/18/2024 shall have attempts made to complete education by phone no later than 4/18/2024 with messages left for any not spoken to, to contact facility as soon as possible for education, as to prevent future serious adverse outcomes from occurring. Education shall be documented on In-service Training Report. Staff Development Coordinator shall notify nursing supervisor of any nursing staff on the schedule who have not received in-servicing so that education may be delegated and completed for any nursing staff that may enter facility after 4/18/24. Staff Development Coordinator shall additionally add lesson plan to Orientation packet to encompass all new hires as well. 2 Person assist with ADL Icon shall be placed at foot of bed for all Residents at Risk by Quality Assurance Coordinator by 4/18/2024. Alleged Immediate Jeopardy Removal Date: 4/19/24. Onsite validation of the immediate jeopardy removal plan was conducted on 4/19/24. The validation included staff interviews, observation, and record review. Inservice sign in sheets and staff interviews verified in-services were completed on 2- person assist with ADL care. Education was confirmed for facility nursing staff. Observation of staff providing 2-person assistance with ADL care revealed no issues. Evidence of audits were reviewed for 2 person ADL care and the current list of identified Residents at Risk. Resident interviews were conducted with no issues identified. The immediate jeopardy removal date of 4/19/24 was validated.

Based on record review, observation, resident interviews, staff interview, and physician interview, the facility failed to prevent residents from rolling out of the bed during care for 2 of 3 sampled residents who had a history of [REDACTED].# 3) resulting in a [MEDICAL CONDITION] for Resident #1 and Resident #3's toe nail coming off. The findings included: 1. Record review Resident # 1 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. The resident received anticoagulation therapy for her [DIAGNOSES REDACTED]. Review of Resident # 1's quarterly Minimum Data Set (MDS) assessment, dated 12/20/18, revealed the resident was severely cognitively impaired. The resident was assessed to need extensive assistance by two people with bed mobility. The resident was assessed to need total assistance of 1 staff member with hygiene and toileting. The resident was coded as having a history of one fall without injury since the last assessment. Review of Resident # 1's care plan, last revised on 2/26/19, revealed the facility had identified the following problem. Resident is at risk for falls due to use of psych meds, [MEDICAL CONDITION], dementia, incontinence, anticoagulant therapy. This problem had been originally added to the care plan on 6/19/18 and remained as an active part of the resident's 2/26/19 care plan. Bed in lowest position had been added as an intervention on 6/19/18 and remained an active intervention. Impact mat to front side of bed, had been added to the care plan on 10/26/18, and remained an active intervention. There had been no added interventions to address falls for the resident since 10/26/18. The care plan also noted the resident needed assistance with activities of daily living. This had been added to the care plan on 6/19/18, and continued to be a part of the resident's 2/26/19 care plan. There was no notation on the care plan regarding the number of staff members needed to provide assistance for Resident # 1's activities of daily Living. Review of nursing notes revealed an entry dated 12/10/18 at 10:57 AM by Nurse # 1 with the following information. The resident had been observed on the floor at 9:45 AM on the right side of the bed. The NA (nurse aide) had reported she was giving AM care went to wardrobe to get a brief and resident rolled out of bed. The resident sustained [REDACTED]. The physician and family were notified, and the resident was transferred to the hospital. Review of the facility's investigative report for this fall, dated 12/10/18, revealed the following description of the incident was noted. Resident observed lying on R (right) side beside bed. Per CNA (nurse aide) was giving resident AM care. Went to wardrobe to get a brief and resident rolled OOB (out of bed). Skin tear to R elbow-ROM (range of motion) to all extremities c (with) staff assist (assistance)-Resident placed back in bed c (with) sheet underneath her. While dsg (dressing) skin tear to R elbow resident with c/o (complaints) R leg pain. Call placed to triage. Order received to send resident to ED (Emergency Department). According to the investigative report, the bed had been in the elevated position at the time of the incident. There was no statement from the nurse aide who had been involved in the incident. There was no notation that the resident's position in bed, prior to the nurse aide leaving the bedside and the resident falling, was investigated. Review of the falls committee follow up report, dated 12/13/18, revealed the fall had been discussed. Under the section entitled comments a note had been added which read, two person assist (assistance) with ADL (activities of daily living) care when increased restlessness is observed. The facility's QA (quality assurance) nurse was interviewed on 3/14/19 at 11:50 AM. The QA nurse reported the following. The 12/10/18 incident was discussed in the facility's weekly falls committee meeting on 12/13/18. The QA nurse verified the bed had been in the elevated care position when the resident fell on [DATE]. The QA nurse stated the NA had not said how the resident was positioned in the bed at the time of the fall. According to the QA nurse, the resident was very small and only needed one person's assistance to turn and position her prior to 12/10/18. The falls committee discussed if two people should be required for assistance if the resident was restless, but this intervention was not initiated. The QA nurse stated the comment found on the falls committee follow up note which read, two person assist (assistance) with ADL (activities of daily living) care when increased restlessness is observed, did not mean that this was initiated. It only meant that the intervention was discussed as a possibility at the meeting. After the 12/10/18 incident was discussed, it was determined that it was an isolated incident by the falls committee, and that the resident's current care plan would be continued without any needed modifications. The QA nurse was interviewed regarding safety practices the facility followed. According to the QA nurse, facility safety practices were determined by the DON and he would need to speak regarding that. An observation of the semiprivate room, in which Resident # 1 resided until 3/4/19, was made with the DON (Director of Nursing) on 3/14/19 at 12:40 PM. According to the DON, the layout of the room was the same on 3/14/19 as when Resident # 1 had resided in it. According to the DON, Resident # 1 had resided in the first bed as you enter the room. The head of the bed was observed to be against the right wall as you entered the room from the doorway. On either side of the bed, there was open space which allowed for resident care. Another wall was approximately four feet away from the foot of the bed. On this wall were located the residents' sink and wardrobe. It was approximately six feet to the wardrobe/sink area from the bedside. Nurse # 1 was interviewed on 3/14/19 at 2:00 PM and reported the following regarding the incident of 12/10/18. She had been the Nurse Team Leader on 12/10/18, and either NA # 1 or Nurse # 3 had called her to Resident # 1's room. When she entered the room, Resident # 1 was lying on the floor to the right of the bed (if facing the head of the bed from the foot of the bed). NA # 1 had reported to Nurse # 1 she had been giving Resident # 1 morning care. The NA had further reported she went to the wardrobe, and when she turned back around the resident was on the floor. At the time of the incident, the bed was in the elevated care position. Nurse # 1 did not recall if the resident was on the mat or not. The resident was assessed on the floor, and found to have a skin tear and no other obvious injury. They used a sheet to lift the resident into the bed, and Nurse # 3 (the floor nurse) immediately started dressing the resident's skin tear. During the care, the resident complained of pain in her hip. The physician was notified and the resident was sent to the hospital. Nurse # 1 reported Resident # 1 had generally not moved too much and pretty much was total care. Nurse # 1 also reported that NAs had an information sheet (FYI sheet) that had the resident's care plan information and which the NAs accessed so that they were aware of care needs for residents. Nurse # 3 was interviewed on 3/14/19 at 2:30 PM, and reported the following. Nurse # 3 was the floor nurse on 12/10/18. She had worked with Resident # 1 for two years, and had not personally seen her have the physical strength to independently turn herself over. Nurse # 3 reported Resident # 1 was stiff from her [MEDICAL CONDITION], and had both physical and cognitive limitations. On 12/10/18 Resident # 1's assigned NA # 1 alerted her that the resident was on the floor. Nurse # 3 recalled NA # 1 had reported to her that she (the NA) had turned around for something, and when she turned back around the resident was on the floor. Nurse # 3 stated the NA did not say how the resident was lying in the bed before she fell . Nurse # 3 entered the room and found the resident lying on the floor as if she had rolled out of bed. Nurse # 3 obtained the supervisor (Nurse # 1), and the resident was assessed before getting her back to bed. Once in bed, the resident patted her hip as if it hurt. The physician was called and the resident was transferred to the hospital. According to an interview with the DON (Director of Nursing) on 3/14/19 at 12:40 PM, NA # 1 had been assigned to care for Resident # 1 on 12/10/18 and was with her when she fell . The DON stated NA # 1 was no longer employed at the facility. According to the DON, following the incident of 12/10/18, he had viewed it as an isolated incident. The DON felt that staff should be in attendance when a resident was in an elevated bed for care. The DON stated NA # 1 was in attendance, and she had stepped to the wardrobe. The DON stated the distance between the foot of the bed and the wardrobe was similar to the distance between the bedside and the foot of the bed. The DON stated on older beds, there used to be a crank to lower the bed, and staff would have to step to the foot of the bed to lower the bed. Therefore directly following the incident, he had not viewed the NA stepping to the wardrobe as different from a staff member going to the foot of the bed when crank beds were utilized. The DON acknowledged that at the time of the 12/10/18 incident, the bed had a remote control to lower and elevate its height. An attempt was made to call NA #1 on 3/14/19 at 12:55 PM, and she could not be reached. Review of Resident # 1's hospital discharge summary, dated 12/13/18, revealed Resident # 1 had been identified to have a right [MEDICAL CONDITION] upon her hospital admission. The hospital discharge summary also noted fractures of the right superior and inferior pubic ramus (pelvis) are also suspected. There was documentation by the radiologist which noted the resident had severe osteopenia and this limited the diagnostic evaluation of the pelvis. Resident # 1 was hospitalized from [DATE] to 12/13/18, and underwent surgical repair of the [MEDICAL CONDITION]. Review of facility records revealed Resident # 1 was readmitted to the facility on [DATE] for care. Review of physical therapy documentation revealed Resident # 1 received physical therapy services from 12/14/18 to 12/24/18. Review of the physical therapist's initial evaluation, dated 12/14/18, revealed the resident had required total assistance with bed mobility prior to her surgery, and continued to do so. The physical therapist (PT) was interviewed on 3/14/19 at 11:30 AM, and reported the following. The resident had cognitive and physical limitations which limited her ability to move and participate in therapy. While he worked with the resident, he had never witnessed the resident to turn herself independently in bed. While working with the resident he would tell her he was going to help her turn over. The resident would initiate some movement by reaching her hand or turning her head towards him, but then never carried through with actually turning. She had always required his assistance to completely turn in bed, and he was able to safely turn her himself while working with her. Review of hospital records revealed the resident was hospitalized again from 1/21/19 to 1/25/19 secondary to displacement of her right hip hardware due to [MEDICAL CONDITION]. The resident underwent [REDACTED]. According to facility records the resident returned on 1/25/19 for care at the facility. Review of the resident's care plan revealed no updates to her care plan in regards to falls and safety while in bed. Review of nursing notes revealed an entry on 3/4/19 at 11:06 PM noting Resident # 1 had sustained a second fall from the bed while a staff member was caring for the resident. Nurse # 2 documented at this time, Pt. noted to be on floor beside bed, after rolling off bed during change. Has small skin tear on right arm. Cleansed and covered. Pt alert and talking. T (temperature) 97.8, P (pulse) 88, R (Respirations) 20, B/P 100/62. Pt assisted back to bed with dependent lift. Nurse # 2 did not document the time the resident rolled out of bed in the medical record. According to a facility investigative report, the incident occurred on 3/4/19 at 8:00 PM. Nurse # 2 documented under the section entitled description of what happened the following. Pt (Patient) noted to be on floor beside bed on side-alert-responsive-Skin tear R (right) lower elbow area. No other bleeding-No C/O (complaint of) pain. There was no notation in regards to how the resident was positioned before the fall. The investigative report had the bed was in the low position. In an interview with the DON on 3/14/19 at 11:10 AM, the DON validated the bed had been in the elevated waist level care position when the resident rolled out of the bed on 3/4/19, and the fall at occurred at 8:00 PM. NA # 2 was interviewed on 3/14/19 at 3:10 PM. NA # 2 had been assigned to care for Resident # 1 on the evening shift of 3/4/19. NA # 2 reported she had worked at the facility since September, (YEAR) and prior to 3/4/19, she had not cared for Resident # 1 since her (MONTH) orientation. She therefore was not very familiar with her when she was assigned to care for her on 3/4/19. She knew there was a FYI (For Your Information) sheet that described resident's care needs, but had not looked at it that evening before caring for Resident # 1. The other NAs had told her that the resident was a one person assist. The resident had appeared okay at the beginning of the evening. Later in the shift she was giving Resident # 1 incontinent care. She had the resident turned on her left side, and the NA validated the bed was elevated to her (the NA's) waist level for care. She realized she had forgotten her washcloths, and she went to the sink to get them. While her back was to the resident, she heard the resident fall from the bed which was still at the elevated care position level. She turned, and saw that the resident was on the floor mat beside of the bed. She called for help. Another NA, Nurse # 2, and Nurse # 4 all came. The resident was talking in her confused manner and looking around. After the nurses checked the resident, she and the other NA assisted the resident back to bed with the lift and got her changed. When she left the resident, the resident was looking around and had her eyes open. The NA was interviewed regarding whether she had been aware on 3/4/19 that Resident # 1 had fallen in December, (YEAR) and sustained a [MEDICAL CONDITION] when another NA had left the bedside. The NA replied she had not known this on 3/4/19, and if she had, she would have gotten help before caring for Resident # 1 on 3/4/19. Nurse # 2 was interviewed on 3/14/19 at 4:50 PM, and reported she was the supervisor for the evening of 3/4/19. She stated she had been called to Resident # 1's room at 8:00 PM by the floor nurse (Nurse # 4). The resident was lying on the floor mat facing the door. NA # 2 had reported that she had turned the resident, and for a few seconds there had been a time when her eyes were not on the resident, and the resident had fallen. She checked her head, and did not find any evidence of head trauma. She checked her entire body for injuries, and other than a skin tear to the arm did not find any. The resident's pupils were normal and her vital signs were checked. After she thoroughly made sure the resident was okay, she instructed the NAs they could get the resident back to bed with the lift. She then went to complete paperwork related to the fall. She returned to the room around 8:30 PM. She looked at the resident's pupils, and they appeared to be normal. She again checked the resident's body, and did not see any evidence of problems. Nurse # 4 was interviewed on 3/14/19 at 4:20 PM and reported usually Resident #1 would lay straight in the bed unless you moved her, and she had never seen her move herself in bed. On 3/4/19, Resident # 1 appeared her normal self at the beginning of the shift. NA # 2 had come to get her help later in the evening, and told her the resident had rolled off the bed. She obtained the help of Nurse # 3, and when she entered they found the resident lying on the floor on her left side facing the door. The resident had a skinned area on her hand but otherwise appeared okay upon assessment. Later she (Nurse # 4) checked the resident around 8:30 PM, and her eyes were open. She did not speak, but that was not unusual for the resident. The physician, who also served as the facility's medical director, was also interviewed on 3/15/19 at 1:12 PM regarding safety and the resident's falls. The Physician stated when Resident # 1 initially fell on [DATE] she had struggled to understand how this could have occurred. The Physician stated the resident was pretty much immobile because of her [MEDICAL CONDITION]. The Physician stated that after the resident fell a second time, she felt the facility staff needed to really review and change the way they were doing things. She stated the staff needed to be prepared with things they needed for care, and have them in reach before beginning care. Interview with the facility DON on 3/15/19 at 3:00 PM revealed during the resident's multiple years of residency she had sustained only one other fall other than the ones sustained on 12/10/18 and 3/4/19. The DON stated that prior to 12/10/18, there had been an incident on which the resident was found half on and half off the bed on 10/19/18, and therefore she could move her body some. The DON felt the 12/10/18 incident was very isolated, and he had not conducted widespread in-service training with all of his staff at that point. After the 3-4-19 incident he evaluated the need to in-service his staff in the following areas and developed a plan of correction in regards to making sure the following measures were followed: If a resident sustained [REDACTED]. to pull a resident close to them before turning a resident; Staff were trained to have all their supplies with them before starting care. According to the DON, he had not completely finished his in-service training of all his staff and he had not yet begun any audits. 2. Record review revealed Resident # 3 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of Resident # 3's quarterly MDS (Minimum Data Set) assessment, dated 1/2/19, revealed the resident was coded as cognitively intact, incontinent of bowel and bladder, and needed extensive assistance by two staff members with her bed mobility. The resident was assessed to need extensive assistance of one staff member with hygiene needs. Review of Resident # 3's care plan, last revised on 2/12/19, revealed the resident was identified to be at risk for falls due to a history of fall. According to the 2/12/19 care plan, this problem had been added to the care plan on 8/3/18. One of the interventions on the care plan which had been initiated on 8/20/18 and remained in effect through 2/12/19 was to provide two person assistance with all activities of daily living. Review of nursing notes revealed an entry by Nurse # 2 on 1/23/19 at 9:38 PM noting the following. The resident's brief was being changed, and when she was turned over, she had involuntary jumping movements and slid off the bed landing on buttocks. Her left great toenail was bleeding and loose up to the nailbed. The toe was wrapped. Resident # 3 was interviewed on 3/15/19 at 9:03 AM and reported the following. There was only one Nurse Aide (NA) who was assisting her on 1/23/19 when the incident occurred. The resident stated she needed two people to assist her. The resident stated she told the NA, Don't push too hard because I'm going to roll out of the bed while the NA was changing her brief. The resident stated the NA replied to her that she was not going to roll off the bed because she had her. The resident stated while the care was being provided, she then rolled out of the bed and onto the floor. The resident stated her big toenail came off because of the fall. NA # 3 was interviewed on 3/15/19 at 11:40 AM and reported the following. NA # 3 was Resident # 3's NA on the evening of 1/23/19. She was aware the resident needed two people to turn and reposition, but at the time of the incident the resident was soiled. NA # 3 reported she could not find another staff member at the time, and therefore she thought it was more important to make sure the resident was not lying soiled in bed. She therefore did the care alone. NA # 3 reported the resident always stated she was going to fall when she was turned, and this was a routine statement for her. When she turned her for the care, the resident's legs jerked and NA # 3 reported she could just not grab her in time to stop her from rolling out of the bed. Nurse # 2 was interviewed on 3/15/19 at 12:46 PM. Nurse # 2 reported she was the nursing supervisor on the evening of 1/23/19, and had been called into Resident # 3's room where she found her on the floor. She had talked to NA # 3 who had informed her that one part of the resident's body jerked and came off the bed, and then the rest of her body started rolling. The nurse stated the resident's toenail was lifted up, but otherwise the resident was without injury. Interview with the DON (Director of Nursing) revealed NA # 3 was a newer NA at the time, and she had not followed the resident's plan of care on 1/23/19 when she did not get help to turn Resident # 3. The DON stated he had taken measures for individualized counseling and follow up with her regarding safety at the time, but had not implemented full in-services with all of his staff following the incident until another resident rolled out of bed while a staff member was in attendance on 3/4/19. According to the DON, in-service training began on 3/4/19 regarding safety measures and was on-going.

Based on observations, record review and staff interviews, the facility utilized a device without considering it to be a restraint and without a medical symptom for 2 of 4 residents (Resident #167 and Resident #19) when Resident #167 was observed by staff with his legs between the side rail bars and required staff assistance to remove his legs from the side rail and for Resident #19 who was observed with both legs between the side rail bars which required staff assistance to remove her legs and sustained a skin tear. Immediate Jeopardy began on 6/27/2017 when Resident #167 was observed by staff with his legs between the side rail bars. Immediate Jeopardy began on 10/2/2017 for Resident #19 both of the resident's legs were between the side rail bars and required staff assistance to remove. The Immediate Jeopardy was removed on 10/6/2017 when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education to ensure monitoring systems are in place that are effective. Findings included: 1-Record review revealed resident #167 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the Care Plan initiated 4/25/2017 included a problem of the risk for falls due to impaired mobility and severely impaired cognition. Interventions included the bed in low position, dependent lift for transfers, mat at bedside, and give resident verbal reminders not to transfer without assistance. The last comprehensive (Admission) Minimum Data Set ((MDS) dated [DATE] and the most recent quarterly assessment dated [DATE] indicated the Resident #167 was rarely/never understood, had short and long term memory problems, and was severely impaired for daily decision making. The MDS indicated the resident required extensive to total assistance of 1 to 2 persons with all activities of daily living (ADLs) and bed mobility, required total assistance for transfers and had no impairment to upper or lower extremities and had no impairment to upper or lower extremities. The MDS indicated physical restraints which included bed rails, trunk restraints or limb restraints were not used for the resident. The Care Area Assessment (CAA) dated 4/28/2017 indicated the Resident #167 was at a risk for falls and was significantly and severely cognitively impaired. The CAA indicated falls and cognition would trigger to the care plan. Record review of nursing notes revealed a note dated 6/27/2017 at 11:15 PM which reported the Resident #167 was awake the entire shift, was agitated and restless and was observed with his legs between the side rail bars frequently during the shift. The note indicated the resident was repositioned numerous times. The note further indicated the nurse would request an order for [REDACTED]. Record review revealed a Side Rail Rationale Screen assessment dated [DATE] for Resident #167. The resident was assessed as non-ambulatory with an alteration in safety awareness due to cognition. The assessment screen indicated the resident demonstrated difficulty moving to a sitting position, difficulty with balance and poor trunk control, and was on medications which required increased safety precautions. The assessment screen indicated the side rail was used for positioning and back support, and was indicated for the resident as an enabler which promoted independence. An observation was conducted of the Resident #167 on 10/05/2017 8:53 AM. The resident was observed in bed sleeping. The head of the bed was raised approximately 35 degrees. A full side rail was on the right side of the bed in a raised position. There was grey colored foam- like thin covering wrapped around the bar at the top of the rail, the center bar and the bottom rail. The resident's right leg was observed to be leaning against the right side rail. An interview was conducted on 10/05/2017 at 11:53 AM with the Resident #167's family member. The family member was in the resident's room during the interview. The family member indicated she visited the resident daily. Resident #167's family member indicated the right full side rail was on the resident's bed upon admission to the facility. The family member stated the resident was usually very busy and moved around in the bed. The family member indicated the resident often put his feet, legs and sometimes his arms through the spaces in the side rail. The family member indicated the resident had some bruises in the past which she and the staff felt were from the rail. The family member stated the resident did not use the rails to position himself. The family member stated the rail was probably there to keep him from falling out of the bed. During the interview the resident started moving his legs toward the rail and wedged his right knee in the space between the center and lower bar. The resident's family member walked to the right side of the bed and told the resident he needed to be still. The family member moved his knee out of the rail space. An interview was conducted with Nurse #2 on 10/5/2017 at 2:46 PM. Nurse #2 was the nurse on duty the evening of 6/27/2017 and verified she was the nurse who wrote the note on 6/27/2017. Nurse #2 stated she worked with the Resident #167 five days a week on the evening shift. Nurse #2 reported the resident is very agitated at times and will flail his limbs in the air at times when he is agitated. Nurse #2 indicated since the resident was capable of moving his extremities, he was physically capable of getting his limbs caught in the spaces between the bars of the side rail. Nurse #2 indicated the resident continued to require frequent monitoring due to his severe cognition impairment and the inability to follow/understand directions. Nurse #2 also indicated since there was only 1 full side rail, it was not considered a restraint. An interview was conducted with Nursing Assistant (NA) #2 on 10/5/2017 at 2:58 PM. NA #2 indicated she worked with Resident #167 often and was familiar with his care. NA #2 indicated the resident would often get his feet through the spaces in the side rail and she would have to remove them. NA #2 stated he would also position his right knee in the space on the bottom of the rail and she would have to get it out. NA#2 indicated usually when his right knee was caught in the space he would yell because he would be unable to shift in bed and that agitated him. NA #2 indicated the resident was severely cognitively impaired and was unable to follow directions. An interview was conducted with MDS Nurse #3 on 10/05/2017 at 3:11 PM. MDS Nurse # 3 indicated she completed the last assessment on Resident # 167 on 8/2/2017. MDS Nurse #3 said she assessed the rail to be safe for the resident and promoted independence, even though he was severely cognitively impaired. MDS Nurse #3 indicated the full rail was not a restraint because it was an enabler and the resident used it for positioning. MDS Nurse #3 further indicated the rail was not coded on the MDS because it was not considered a restraint. An interview was conducted with the Assistant Director of Nursing (ADON) on 10/5/2017 at 3:20 PM. The ADON indicated he was familiar with Resident #167 and recalled instances when the resident would have new bruised areas. The ADON indicated investigations were conducted, and the facility and the resident's family member concluded the bruises were from the resident hitting his limbs on the bars of the side rail. The ADON stated he was familiar with the resident, and the resident would flail around in bed when he was agitated. The ADON indicated since there was only 1 full rail on the bed, it was not considered a restraint. 2-Record review revealed resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a Side Rail Rationale Screen assessment dated [DATE] for Resident #19. The resident was assessed as non-ambulatory with an alteration in safety awareness due to cognition. The assessment screen indicated the resident demonstrated difficulty moving to a sitting position, difficulty with balance and poor trunk control, had a history of [REDACTED]. The assessment screen indicated the resident could not voluntarily get out of bed due to physical limitations, and the side rail was used for positioning and back support. The assessment form indicated side rails were indicated and served as an enabler which promoted independence. The form further indicated the resident expressed a desire to have side rails used while in bed. Record review revealed the last comprehensive (Significant Change) Minimum Data Set ((MDS) dated [DATE] and the most recent quarterly MDS dated [DATE] indicated the resident was significantly cognitively impaired, rarely/never understood, and severely impaired for decision making. The MDS indicated the resident required total assistance for all activities of daily living (ADLs), and restraints were not used. The Care Area Assessment (CAA) dated 12/15/2016 indicated the resident was at a risk for falls and was significantly and severely cognitively impaired. The CAA indicated falls and cognition would trigger to the care plan. Record review revealed the Care Plan updated 7/17/2017 included problems of the risk for falls due to no personal safety recognition and, the resident's confusion and disorientation with significant compromise to functional abilities and understanding. Interventions included the bed in low position, dependent lift for transfers, mat at bedside, and make frequent positioning checks when resident in bed and noted with agitation. An Incident/Accident Report dated 10/2/2017 was reviewed and revealed Resident #19 was found by Nursing Assistant (NA) #5 at 9:40 PM with both of her legs caught between the side rails. The report indicated the resident sustained [REDACTED].#5 removed the resident's legs from the rail, and treatment was initiated. The report listed the resident's condition before the incident as confused and indicated no restraint was in use. There was no nursing note in the medical record on 10/2/2017 and no note regarding the incident. A review of the physician's orders [REDACTED]. An observation was made of the Resident #19 on 10/5/2017 at 8:10 AM. The resident was observed lying in a low bed with her eyes closed. A full side rail was on the left side of the bed in a raised position. There were 3 horizontal bars on the side rail. The resident was observed lying on her left side facing the full rail. An interview was conducted with NA #2 on 10/05/2017 at 3:03 PM. NA #2 indicated she worked with Resident #19 regularly. NA #2 revealed the resident would put her feet and legs through the spaces in the rail and between the mattress and the rail when she was agitated. The NA indicated the resident would wiggle all around in the bed. The NA further indicated she removed the resident's feet and legs from the side rail spaces several times and would tell the nurse the resident was agitated. An interview was conducted with MDS Nurse #1 on 10/05/2017 at 3:10 PM. MDS Nurse #1 verified she completed the Side Rail Rationale Screen assessment dated [DATE] for Resident #19. MDS Nurse #1 indicated the screens were usually updated every quarter and did not know why there was not an updated screen for the resident. MDS Nurse #1 also indicated she did not know why she indicated the resident expressed a desire to have the side rails up because the resident was not capable of expressing that desire, due to her significant decreased cognition. MDS Nurse #1 further indicated the side rail did not promote independence for the resident, but she did not consider the rail a restraint. An interview was conducted with the Assistant Director of Nursing (ADON) on 10/5/2017 at 3:20 PM. The ADON indicated the facility Incident/Accident Reports are reviewed daily to evaluate the need for follow up actions. The ADON reported if there were issues with the bed rails, the clinical team would indicate the rails needed to be padded to reduce further risk of injury. The ADON stated the facility looked at each incident on an individual basis. The ADON indicated since there was only 1 full rail on the bed, it was not considered a restraint. An interview was conducted on 10/5/2017 at 4:07 PM with NA #5. NA #5 stated she went into Resident #19's room after dinner on 10/2/2017 and found the resident turned sideways in bed with her legs criss- crossed and completely through the bottom rail space on the bed rail. NA #5 indicated the resident's legs were stuck and the resident was trying to get them out but could not. The NA stated the right leg was over the top of the left leg, so she pulled the right leg out first, and the resident's right heel scraped over the left lower leg and caused a skin tear. NA #5 stated she immediately notified the nurse after she got the resident out of the rail and situated back in bed. An interview was conducted with Nurse #4 on 10/5/2017 at 4:15 PM. Nurse #4 indicated she was the nurse on duty for Resident #19 on the evening of 10/2/2017. Nurse #4 revealed NA #5 came to her during the shift and reported the resident's legs were in the rail and when the NA got them out the resident sustained [REDACTED].#4 indicated she immediately assessed the resident. Nurse #4 reported the resident was in bed when she entered the room and was in no distress. The resident was noted with a skin tear to her left shin and treatment was initiated. Nurse #4 indicated the resident did not have any other injuries observed. Nurse #4 stated she was unsure why she did not document the incident in the nurse's notes but she did fill out an Incident/Accident report. Nurse #4 indicated the resident did not have any other issues during the shift. The Administer and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/5/2017 at 6:12 PM. The facility provided a credible allegation of compliance on 10/6/2017. The Allegation of Compliance indicated: The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; The process leading to cited deficiency was 1. Resident #167 was diagnosed as having cerebral infarction, dementia and cognitively impaired. He was extensive assist with two person assist, required in bed mobility. He was noted by facility state surveyor during the week of 10-2-17 to have been observed with an uncoded physical restraint/bed rail in place with potential risk for injury at time of observations. Resident #167 noted to be confused and unable to request need or expressed desire for side rail or its intended usage at that time. 2. Resident #19 was diagnosed has having functional [MEDICAL CONDITION], dementia and [MEDICAL CONDITION]. The resident was cognitively impaired. The resident was assessed as being total care, two person assist in bed mobility. She was noted during the week of 10-2-17 to have been observed with an uncoded physical restraint/bed rail in place with the potential risk for injury at time of observations. Resident #19 noted to be confused and unable to request need or expressed desire for side rail or its intended usage at that time. On October 5th, 2017 the Assistant Director of Nursing and Staff Development Coordinator re-assessed Resident #167 and #19 using the Side Rail Rationale Screen assessment tool. The side rails were discontinued and removed by Environmental Services for both Resident #167 and Resident #19's beds. Resident #167 and Resident #19's care plans were reviewed by the Resident Care Coordinator to ensure safety measures and the level of assistance required for activities of daily living (emphasis on bed mobility and transfer) accurately reflected the resident(s) status. There were no changes made to the resident care plans updated October 5th, 2017 since safety measures and fall prevention interventions were already in place and remained applicable. There were also no changes in the level of assistance needed as documented in the residents plan of care. The side rails were removed on 10/5/17 The procedure for implementing the acceptable plan of correction for the specific deficiency cited; Based on the root cause analysis findings, we determined a more comprehensive side rail-screening process was needed to assist the interdisciplinary team in deciding when side rails would be utilized. This process helped to assure through assessment the purpose of the side rails so that they did not pose safety risks such as entrapment for the resident(s). The process also helped to identify bed rails as physical restraints, particularly in cognitively impaired residents as they were not utilized to treat medical symptoms for these two residents. Individual interventions were implemented based on the reassessment of the two residents. Staff were re-educated on all shifts for the two residents. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; On October 6th, 2017, the Director of Compliance amended the policy entitled Proper Use of Side Rails to require completion of the Side Rail Rationale Screen upon admission, quarterly, annually and with significant change as it relates to the assurance of effective ongoing assessment of the need for side rails for resident #167 and resident #19. The title of the person responsible for implementing the acceptable plan of correction. The Administrator shall be responsible for implementing all above actions to include an acceptable plan of correction. The facility provided a credible allegation of compliance on 10/6/2017 at 6:48 PM. The Allegation of Compliance indicated: The Credible Allegation was verified by: 1-On 10/5/2017 Resident #167 and Resident #19 were reassessed by the ADON and the Staff Development Coordinator using the Side Rail Rationale Assessment Screens and the side rails were removed for both residents. Both residents were observed on 10/6/2017 at 8:01 AM in bed without side rails. 2-Documentation of the reassessments for every resident in the facility using the Side Rail Rationale Screen was reviewed by the survey team on 10/6/2017. The assessments were completed by the clinical management team. Side rails which were assessed as a safety hazard were documented as removed. Observations of the residents who were assessed as not appropriate for the side rails per the screening form were observed to have their side rails removed. 3-Documentation of Side Rail Safety Inservicing was reviewed on 10/26/2017 and the inservicing included the safe use of side rails and side rails as restraints when not treating a medical symptom. The inservicing was completed by the facility Staff Development Coordinators. Interviews were conducted with staff present in the facility on 10/6/2017. The staff interviewed confirmed the recent inservice regarding said rails/restraints/safety/entrapment.

Based on observations, record review and staff interviews, the facility failed to accurately assess the use of a full side rail as a physical restraint for 2 of 4 residents (Resident #167 and Resident #19). Immediate Jeopardy began on 6/27/2017 when Resident #167 was observed by staff with his legs between the side rail bars. Immediate Jeopardy began on 10/2/2017 for Resident #19 both of the resident's legs were between the side rail bars and required staff assistance to remove. The Immediate Jeopardy was removed on 10/6/2017 at 6:54 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education to ensure monitoring systems are in place that are effective. Findings included: 1-Record review revealed Resident #167 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed Resident #167's Care Plan initiated 4/25/2017 and last updated 9/8/2017 included a problem of the risk for falls due to impaired mobility and severely impaired cognition. Interventions included the bed in low position, dependent lift for transfers, mat at bedside, and give resident verbal reminders not to transfer without assistance. The last comprehensive (Admission) Minimum Data Set ((MDS) dated [DATE] and the most recent quarterly assessment dated [DATE] indicated Resident #167 was rarely/never understood, had short and long term memory problems, and was severely impaired for daily decision making. The MDS indicated the resident required extensive to total assistance of 1 to 2 persons with all activities of daily living (ADLs), and had no impairment to upper or lower extremities. The MDS indicated bed rails were not used for the resident. The Care Area Assessment (CAA) dated 4/28/2017 indicated Resident #167 was at a risk for falls and was significantly and severely cognitively impaired. The CAA indicated falls and cognition would trigger to the care plan. Record review of nursing notes revealed a note dated 6/27/2017 at 11:15 PM which reported Resident #167 was awake the entire shift, was agitated and restless and was observed with his legs between the side rail bars frequently during the shift. The note indicated the resident was repositioned numerous times. The note further indicated the nurse would request an order for [REDACTED]. Record review revealed a Side Rail Rationale Screen assessment dated [DATE] for Resident #167. The resident was assessed as non-ambulatory with an alteration in safety awareness due to cognition. The assessment screen indicated the resident demonstrated difficulty moving to a sitting position, difficulty with balance and poor trunk control, and was on medications which required increased safety precautions. The assessment screen indicated the side rail was used for positioning and back support, and was indicated for the resident as an enabler which promoted independence. An observation was conducted of the Resident #167 on 10/05/2017 8:53 AM. The resident was observed in bed sleeping. The resident's right leg was observed to be leaning against the right side rail. There was grey colored foam- like thin covering wrapped around the bar at the top of the rail, the center bar and the bottom rail. An interview was conducted on 10/05/2017 at 11:53 AM with Resident #167's family member. The family member was in the resident's room during the interview. The family member indicated she visited the resident daily. The family member stated the resident was usually very busy and moved around in the bed. The family member indicated the resident often put his feet, legs and sometimes his arms through the spaces in the side rail. The family member stated the resident did not use the rails to position himself. The family member stated the rail was probably there to keep him from falling out of the bed. During the interview the resident started moving his legs toward the rail and wedged his right knee in the space between the center and lower bar. The resident's family member walked to the right side of the bed and told the resident he needed to be still. The family member moved his knee out of the rail space. An interview was conducted with Nurse #2 on 10/5/2017 at 2:46 PM. Nurse #2 was the nurse on duty the evening of 6/27/2017 and verified she was the nurse who wrote the note on 6/27/2017. Nurse #2 stated she worked with the Resident #167 five days a week on the evening shift. Nurse #2 reported the resident is very agitated at times and will flail his limbs in the air at times when he is agitated. Nurse #2 indicated the right side rail was up at all times while the resident was in bed. Nurse #2 indicated she was unsure of the exact reason the rail was utilized for the resident, but she thought it was probably to keep him from rolling off of the bed. Nurse #2 indicated the resident continued to require frequent monitoring due to his severe cognition impairment and the inability to follow/understand directions. An interview was conducted with Nursing Assistant (NA) #2 on 10/5/2017 at 2:58 PM. NA #2 indicated she worked with Resident #167 often and was familiar with his care. NA #2 indicated the resident would often get his feet through the spaces in the side rail and she would have to remove them. NA #2 stated he would also position his right knee in the space on the bottom of the rail and she would have to get it out. NA#2 indicated usually when his right knee was caught in the space he would yell because he would be unable to shift in bed and that agitated him. NA #2 indicated the resident was severely cognitively impaired and was unable to follow directions. An interview was conducted with MDS Nurse #3 on 10/05/2017 at 3:11 PM. MDS Nurse # 3 indicated she completed the last assessment on Resident # 167 on 8/2/2017. MDS Nurse #3 said she assessed the rail to be safe for the resident and promoted independence, even though he was severely cognitively impaired. MDS Nurse #3 indicated the full rail was not a restraint because it was used as an enabler and for positioning. MDS Nurse #3 further indicated the rail was not coded on the MDS because it was not considered or assessed as a restraint. An interview was conducted with the Assistant Director of Nursing (ADON) on 10/5/2017 at 3:20 PM. The ADON stated he was familiar with the resident, and the resident would flail around in bed when he was agitated and the side rail was on the bed as an enabler. The ADON indicated since there was only 1 full rail on the bed, it was not considered a restraint. 2-Record review revealed resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a Side Rail Rationale Screen assessment dated [DATE] for Resident #19. The resident was assessed as non-ambulatory with an alteration in safety awareness due to cognition. The assessment screen indicated the resident demonstrated difficulty moving to a sitting position, difficulty with balance and poor trunk control, had a history of [REDACTED]. The assessment screen indicated the resident could not voluntarily get out of bed due to physical limitations, and the side rail was used for positioning and back support. The assessment form indicated side rails were indicated and served as an enabler which promoted independence. The form further indicated the resident expressed a desire to have side rails used while in bed. Record review revealed the last comprehensive (Significant Change) Minimum Data Set ((MDS) dated [DATE] and the most recent quarterly MDS dated [DATE] indicated the resident was significantly cognitively impaired, rarely/never understood, and severely impaired for decision making. The MDS indicated the resident required total assistance for all activities of daily living (ADLs), and restraints were not used. The Care Area Assessment (CAA) dated 12/15/2016 indicated the resident was at a risk for falls and was significantly and severely cognitively impaired. The CAA indicated falls and cognition would trigger to the care plan. Record review revealed the Care Plan updated 7/17/2017 included problems of the risk for falls due to no personal safety recognition and, the resident's confusion and disorientation with significant compromise to functional abilities and understanding. Interventions included the bed in low position, dependent lift for transfers, mat at bedside, and make frequent positioning checks when resident in bed and noted with agitation. An Incident/Accident Report dated 10/2/2017 was reviewed and revealed the resident was found by Nursing Assistant (NA) #5 at 9:40 PM with both of her legs caught between the side rails. The report indicated the resident sustained [REDACTED].#5 removed the resident's legs from the rail, and treatment was initiated. The report listed the resident's condition before the incident as confused and indicated no restraint was in use. There was no nursing note in the medical record on 10/2/2017 and no note regarding the incident. A review of the physician's orders [REDACTED]. An observation was made of the resident on 10/5/2017 at 8:10 AM. The resident was observed lying in a low bed with her eyes closed. A full side rail was on the left side of the bed in a raised position. There were 3 horizontal bars on the side rail. There was grey colored foam- like thin covering wrapped around the bar at the top of the rail, the center bar and the bottom rail. The resident was observed lying on her left side facing the full rail. An interview was conducted with NA #2 on 10/05/2017 at 3:03 PM. NA #2 indicated she worked with Resident #19 regularly. NA #2 revealed the resident would put her feet and legs through the spaces in the rail and between the mattress and the rail when she was agitated. The NA indicated the resident would wiggle all around in the bed. The NA further indicated she removed the resident's feet and legs from the side rail spaces several times and would tell the nurse the resident was agitated. An interview was conducted with MDS Nurse #1 on 10/05/2017 at 3:10 PM. MDS Nurse #1 verified she completed the Side Rail Rationale Screen assessment dated [DATE] for Resident #19. MDS Nurse #1 indicated the screens were usually updated every quarter and did not know why there was not an updated screen for the resident. MDS Nurse #1 also indicated she did not know why she indicated the resident expressed a desire to have the side rails up because the resident was not capable of expressing that desire, due to her significant decreased cognition. MDS Nurse #1 further indicated the side rail did not promote independence for the resident, but she did not consider the rail a safety hazard. The MDS Nurse #1 further indicated the side rail did not meet the definition of a restraint for the resident so therefore was not assessed as a restraint. An interview was conducted with the Assistant Director of Nursing (ADON) on 10/5/2017 at 3:20 PM. The ADON indicated the facility Incident/Accident Reports are reviewed daily to evaluate the need for follow up actions. The ADON stated the facility looked at each incident on an individual basis. The ADON indicated since there was only 1 full rail on the bed, it was not assessed as a restraint. An interview was conducted on 10/5/2017 at 4:07 PM with NA #5. NA #5 stated she went into Resident #19's room after dinner on 10/2/2017 and found the resident turned sideways in bed with her legs criss- crossed and completely through the bottom rail space on the bed rail. NA #5 indicated the resident's legs were stuck and the resident was trying to get them out but could not. The NA stated the right leg was over the top of the left leg, so she pulled the right leg out first, and the resident's right heel scraped over the left lower leg and caused a skin tear. NA #5 stated she immediately notified the nurse after she got the resident out of the rail and situated back in bed. An interview was conducted with Nurse #4 on 10/5/2017 at 4:15 PM. Nurse #4 indicated she was the nurse on duty for Resident #19 on the evening of 10/2/2017. Nurse #4 revealed NA #5 came to her during the shift and reported the resident's legs were in the rail and when the NA got them out the resident sustained [REDACTED].#4 indicated she immediately assessed the resident. Nurse #4 reported the resident was in bed when she entered the room and was in no distress. The resident was noted with a skin tear to her left shin and treatment was initiated. Nurse #4 indicated the resident did not have any other injuries observed. Nurse #4 stated she was unsure why she did not document the incident in the nurse's notes but she did fill out an Incident/Accident report. Nurse #4 indicated the resident did not have any other issues during the shift. The Administer and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/5/2017 at 6:12 PM. The facility provided a credible allegation of compliance on 10/6/2017 at 6:48 PM. The Allegation of Compliance indicated: The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; The process leading to cited deficiency was 1. Resident #167 was diagnosed as having cerebral infarction, dementia and cognitively impaired. He was extensive assist with two person assist, required in bed mobility. He had 14 day MDS assessment completed by MDS staff member, dated 5-30-17 which failed to code resident with presence of physical restraints/bed rails. Resident also had side rail assessment screen completed by MDS staff member, dated 8-4-17 which failed to accurately assess facility usage of single full side rail. 2. Resident #19 was diagnosed has having functional [MEDICAL CONDITION], dementia and [MEDICAL CONDITION]. The resident was cognitively impaired. The resident was assessed as being total care, two person assist in bed mobility. She had a quarterly MDS assessment completed by MDS staff member dated 7-14-17 which failed to accurately code resident with presence of physical restraints/bed rails. Resident also had side rail assessment screen completed by MDS staff member, dated 7-11-16 which failed to accurately assess facility usage of single full side rail and residents ability to indicate expressed desire to have side rails while in bed. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; On October 5th, 2017 the Assistant Director of Nursing and Staff Development Coordinator re-assessed Resident #167 and #19 using the Side Rail Rationale Screen assessment tool. The side rails were discontinued and removed by Environmental Services for both Resident #167 and Resident #19's beds. Resident #167 and #19's current MDS assessment and Side Rail Rationale Screen were reviewed by Resident Care Coordinator to ensure accuracy of resident assessment with emphasis on section P of the MDS assessment. This review and utilization of the MDS assessment with emphasis on resident #167 and resident #19's CAA's helped to accurately assess for the need for physical restraints/bed rails for these residents. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements On 10-6-17 The Nurse Consultant educated the Resident Care Coordinator and MDS staff nurses on the definition of restraints and coding guidelines for P0100 using the RAI Manual and education tool Myths and Facts about Side Rails. MDS staff shall utilize education to monitor and complete ongoing MDS assessments and Side Rail Rationale Screen of Resident #167 and #19 so as to ensure continued accuracy of completed assessments as it relates to regulatory requirements. The title of the person responsible for implementing the acceptable plan of correction. The Administrator shall be responsible for implementing all above actions to include an acceptable plan of correction. The Credible Allegation was verified by: 1-On 10/5/2017 Resident #167 and Resident #19 were reassessed by the ADON and the Staff Development Coordinator using the Side Rail Rationale Assessment Screens and the side rails were removed for both residents. Both residents were observed on 10/6/2017 at 8:01 AM in bed without side rails. 2-Documentation of the reassessments for every resident in the facility using the Side Rail Rationale Screen was reviewed by the survey team on 10/6/2017. Side rails which were assessed as a safety hazard were documented as removed. Observations of the residents who were assessed as not appropriate for the side rails per the screening form were observed to have their side rails removed. 3-Documentation of Side Rail Safety Inservicing was reviewed on 10/6/2017 and the inservicing included the risk of entrapment for residents with unsafe side rails. Documentation of the Nurse Consultant education for the Resident Care Coordinator and MDS staff nurses was reviewed on the definition of restraints and coding guidelines for P0100 using the RAI Manual and education tool Myths and Facts about Side Rails. Interviews were conducted with staff present in the facility on 10/6/2017. The staff interviewed confirmed the recent inservice regarding said rail safety/entrapment.

Based on observations, record review and staff interviews, the facility failed to identify a full side rail as an accident hazard for 2 of 4 residents (Resident #167 and Resident #19) when Resident #167 was observed by staff with his legs entrapped between the side rail bars and required staff assistance to remove his legs from the side rail space and failing to implement interventions to prevent it from happening again and for Resident #19 who was observed with both legs entrapped between the side rail bars which required staff assistance to remove her legs and sustained a skin tear while staff removed her legs and failing to implement interventions to prevent it from happening again. Immediate Jeopardy began on 6/27/2017 when Resident #167 was observed by staff with his legs between the side rail bars. Immediate Jeopardy began on 10/2/2017 for Resident #19 both of the resident's legs were between the side rail bars and required staff assistance to remove. The Immediate Jeopardy was removed on 10/6/2017 at 6:54 PM when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education to ensure monitoring systems are in place that are effective. Findings included: 1. Record review revealed resident #167 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the Care Plan initiated on 4/25/2017 included a problem of the risk for falls due to impaired mobility and severely impaired cognition. Interventions included the bed in low position, dependent lift for transfers, mat at bedside, and give resident verbal reminders not to transfer without assistance. The last comprehensive (Admission) Minimum Data Set ((MDS) dated [DATE] and the most recent quarterly assessment dated [DATE] indicated the Resident #167 was rarely/never understood, had short and long term memory problems, and was severely impaired for daily decision making. The MDS indicated the resident required extensive to total assistance of 1 to 2 persons with all activities of daily living (ADLs) and bed mobility, required total assistance for transfers and had no impairment to upper or lower extremities. The MDS indicated bed rails were not used for the resident. The Care Area Assessment (CAA) dated 4/28/2017 indicated Resident #167 was at a risk for falls and was significantly and severely cognitively impaired. The CAA indicated falls and cognition would trigger to the care plan. Record review of nursing notes revealed a note dated 6/27/2017 at 11:15 PM which reported Resident #167 was awake the entire shift, was agitated and restless and was observed with his legs between the side rail bars frequently during the shift. The note indicated the resident was repositioned numerous times. The note further indicated the nurse would request an order for [REDACTED]. Record review revealed a Side Rail Rationale Screen assessment dated [DATE] for Resident #167. The resident was assessed as non-ambulatory with an alteration in safety awareness due to cognition. The assessment screen indicated the resident demonstrated difficulty moving to a sitting position, difficulty with balance and poor trunk control, and was on medications which required increased safety precautions. The assessment screen indicated the side rail was used for positioning and back support, and was indicated for the resident as an enabler which promoted independence. An observation was conducted of Resident #167 on 10/05/2017 8:53 AM. The resident was observed in bed sleeping. The head of the bed was raised approximately 35 degrees. A full side rail was on the right side of the bed in a raised position. There were 3 horizontal bars on the side rail. There was a 4 inch space between the between the center bar and the top bar of the rail and same amount of space between the center bar and the lower bar on the side rail. There was grey colored foam-like thin covering wrapped around the bar at the top of the rail, the center bar and the bottom rail. The foam padding did not lessen the amount of space between the horizontal bars on the side rail. The Resident #167's resident's right leg was observed to be leaning against the right side rail. An interview was conducted on 10/05/2017 at 11:53 AM with Resident #167's family member. Resident #167's family member was in the resident's room during the interview. The family member indicated she visited the resident daily and was with Resident #167 when he was admitted to the facility from the hospital. Resident #167's family member indicated the right full side rail was on the resident's bed upon admission to the facility. The family member stated the resident was usually very busy and moved around in the bed. The family member indicated the resident often put his feet, legs and sometimes his arms through the spaces in the side rail. The family member indicated Resident #167 had some bruises in the past which she and the staff felt were from the rail. The family member reported the staff put the covering on the rail bars a few weeks ago to help with the rail being so hard if he hit it, but the covering didn't make the space between the bars any smaller. The family member stated the resident did not use the rails to position himself. The family member further stated the rail was probably there to keep him from falling out of the bed. During the interview the resident started moving his legs toward the rail and wedged his right knee in the space between the center and lower bar. The resident's family member walked to the right side of the bed and told the resident he needed to be still. The family member moved his knee out of the rail space. An interview was conducted with Nurse #2 on 10/5/2017 at 2:46 PM. Nurse #2 was the nurse on duty the evening of 6/27/2017 and verified she was the nurse who wrote the note on 6/27/2017. Nurse #2 stated she worked with Resident #167 five days a week on the evening shift. Nurse #2 reported the resident is very agitated at times and will flail his limbs in the air at times when he is agitated. Nurse #2 indicated she requested an order for [REDACTED]. Nurse #2 indicated padding the bars on the rail did not lessen the risk for entrapment. Nurse #2 indicated since the resident was capable of moving his extremities, he was physically capable of getting his limbs caught in the spaces between the bars of the side rail. Nurse #2 indicated the resident continued to require frequent monitoring due to his severe cognition impairment and the inability to follow/understand directions. An interview was conducted with Nurse Aide (NA) #2 on 10/5/2017 at 2:58 PM. NA #2 indicated she worked with Resident #167 often and was familiar with his care. NA #2 indicated the resident would often get his feet through the spaces in the side rail and she would have to remove them. NA #2 stated he would also position his right knee in the space on the bottom of the rail and she would have to get it out. NA#2 indicated usually when his right knee was caught in the space he would yell because he would be unable to shift in bed and that agitated him. NA #2 indicated the resident was severely cognitively impaired and was unable to follow directions. An interview was conducted with MDS Nurse #3 on 10/05/2017 at 3:11 PM. MDS Nurse # 3 indicated she completed the last assessment on Resident #167 on 8/2/2017. MDS Nurse #3 said the right side rail was on Resident #167's bed upon his admission to the facility and she assessed the rail to be safe for the resident and promoted independence, even though he was severely cognitively impaired. An interview was conducted with the Assistant Director of Nursing (ADON) on 10/5/2017 at 3:20 PM. The ADON indicated he was familiar with Resident #167 and recalled instances when the resident would have new bruised areas. The ADON indicated investigations were conducted, and the facility and the resident's family member concluded the bruises were from the resident hitting his limbs on the bars of the side rail. The ADON stated he was familiar with the resident, and the resident would flail around in bed when he was agitated. The ADON reported if there were issues with the bed rails, the clinical team would indicate the rails needed to be padded to reduce further risk of injury and the rails would be covered on the day the decision was made. The ADON indicated when the rails were padded, a thin foam-like covering was placed on the horizontal bars of the side rails. The ADON further indicated when the bed rails were padded, the spaces between the bars of the rails were not affected. The ADON stated the facility looked at each incident on an individual basis. 2. Record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed a Side Rail Rationale Screen assessment dated [DATE] for Resident #19. The resident was assessed as non-ambulatory with an alteration in safety awareness due to cognition. The assessment screen indicated the resident demonstrated difficulty moving to a sitting position, difficulty with balance and poor trunk control, had a history of [REDACTED]. The assessment screen indicated the resident could not voluntarily get out of bed due to physical limitations, and the side rail was used for positioning and back support. The assessment form indicated side rails were indicated and served as an enabler which promoted independence. The form further indicated the resident expressed a desire to have side rails used while in bed. Record review revealed the last comprehensive (significant change) Minimum Data Set ((MDS) dated [DATE] and the most recent quarterly MDS dated [DATE] indicated the Resident #19 was significantly cognitively impaired, rarely/never understood, and severely impaired for decision making. The MDS indicated the resident required total assistance for all activities of daily living (ADLs), and bed rails were not used. The Care Area Assessment (CAA) dated 12/15/2016 indicated Resident #19 was at a risk for falls and was significantly and severely cognitively impaired. The CAA indicated falls and cognition would trigger to the care plan. Record review revealed the Care Plan updated 7/17/2017 included problems of the risk for falls due to no personal safety recognition and, Resident #19's confusion and disorientation with significant compromise to functional abilities and understanding. Interventions included the bed in low position, dependent lift for transfers, mat at bedside, and make frequent positioning checks when resident in bed and noted with agitation. An Incident/Accident Report dated 10/2/2017 was reviewed and revealed Resident #19 was found by Nurse Aide (NA) #5 at 9:40 PM with both of her legs caught between the side rails. The report indicated the resident sustained [REDACTED].#5 removed the resident's legs from the rail, and treatment was initiated. The report listed the resident's condition before the incident as confused and indicated no restraint was in use. There was no nursing note in the medical record on 10/2/2017 and no note regarding the incident. A review of the physician's orders [REDACTED]. An observation was made of Resident #19 on 10/5/2017 at 8:10 AM. The resident was observed lying in a low bed with her eyes closed. A full side rail was on the left side of the bed in a raised position. There were 3 horizontal bars on the side rail. There was a 4 inch space between the center bar and the top bar of the rail and same amount of space between the center bar and the lower bar on the side rail. There was grey colored foam-like thin covering wrapped around the bar at the top of the rail, the center bar and the bottom rail. The foam padding did not lessen the amount of space between the horizontal bars on the side rail. The resident was observed lying on her left side facing the full rail. An interview was conducted with NA #2 on 10/05/2017 at 3:03 PM. NA #2 indicated she worked with Resident #19 regularly. NA #2 revealed the resident would put her feet and legs through the spaces in the rail and between the mattress and the rail when she was agitated. The NA indicated the resident would wiggle all around in the bed. The NA further indicated she removed the resident's feet and legs from the side rail spaces several times and would tell the nurse the resident was agitated. An interview was conducted with MDS Nurse #1 on 10/05/2017 at 3:10 PM. MDS Nurse #1 verified she completed the Side Rail Rationale Screen assessment dated [DATE] for Resident #19. MDS Nurse #1 indicated the screens were usually updated every quarter and did not know why there was not an updated screen for the resident. MDS Nurse #1 also indicated she did not know why she indicated the resident expressed a desire to have the side rails up because the resident was not capable of expressing that desire, due to her significant decreased cognition. MDS Nurse #1 further indicated the side rail did not promote independence for the resident, but she did not consider the rail a safety hazard. An interview was conducted with the Assistant Director of Nursing (ADON) on 10/5/2017 at 3:20 PM. The ADON indicated the facility Incident/Accident Reports were reviewed daily to evaluate the need for follow up actions. The ADON reported if there were issues with the bed rails, the clinical team would indicate the rails needed to be padded to reduce further risk of injury. The ADON indicated when the rails were padded, a thin foam-like covering was placed on the horizontal bars of the side rails and Resident #19's were padded on 10/3/2017. The ADON further indicated when the bed rails were padded, the spaces between the bars of the rails were not affected. The ADON stated the facility looked at each incident on an individual basis. An interview was conducted on 10/5/2017 at 4:07 PM with NA #5. NA #5 stated she went into Resident #19's room after dinner on 10/2/2017 and found the resident turned sideways in bed with her legs criss-crossed and completely through the bottom rail space on the bed rail. NA #5 indicated the resident's legs were stuck and the resident was trying to get them out but could not. The NA stated the right leg was over the top of the left leg, so she pulled the right leg out first, and the resident's right heel scraped over the left lower leg and caused a skin tear. NA #5 stated she immediately notified the nurse after she got the resident out of the rail and situated back in bed. An interview was conducted with Nurse #4 on 10/5/2017 at 4:15 PM. Nurse #4 indicated she was the nurse on duty for Resident #19 on the evening of 10/2/2017. Nurse #4 revealed NA #5 came to her during the shift and reported the resident's legs were in the rail and when the NA got them out the resident sustained [REDACTED].#4 indicated she immediately assessed the resident. Nurse #4 reported the resident was in bed when she entered the room and was in no distress. The resident was noted with a skin tear to her left shin and treatment was initiated. Nurse #4 indicated the resident did not have any other injuries observed. Nurse #4 stated she was unsure why she did not document the incident in the nurse's notes but she did fill out an Incident/Accident report. Nurse #4 indicated the resident did not have any other issues during the shift. The Administer and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 10/5/2017 at 6:12 PM. The facility provided a credible allegation of compliance on 10/6/2017 at 6:48 PM. The Allegation of Compliance indicated: The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; The process leading to cited deficiency was 1. Resident #167 was diagnosed as a having cerebral infarction, dementia and cognitively impaired. He was extensive assist with two person assist required in bed mobility. He was noted to be anxious and restless moving body/legs across bed. Resident found with both legs in between side rail on numerous occasions on 6-27-17. 2. Resident # 19 was diagnosed has having functional quadriplegia, dementia and depressive disorder. The resident was cognitively impaired. The resident was assessed as being total care two person assist in bed mobility. She was found to have both legs between the side rails on 10-2-17. While repositioning resident to remove legs from side rail by C.N.A., a skin tear to the right lower leg was sustained. On October 5th, 2017 the Assistant Director of Nursing and Staff Development Coordinator re-assessed Resident #167 and #19 using the Side Rail Rationale Screen assessment tool. The side rails were discontinued and removed by Environmental Services for both Resident #167 and Resident #19's beds. Resident #167 and Resident #19's care plans were reviewed by the Resident Care Coordinator to ensure safety measures and the level of assistance required for activities of daily living (emphasis on bed mobility and transfer) accurately reflected the resident(s) status. There were no changes made to the resident care plans since safety measures and fall prevention interventions were already in place and remained applicable. There were also no changes in the level of assistance needed as documented in the residents' plan of care. The side rails were removed on 10/5/17 and the care plan was updated on the same date. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; Based on the root cause analysis findings, we determined a more comprehensive side rail-screening process was needed to assist the interdisciplinary team in deciding when side rails would be utilized. The process helped to assure through assessment the purpose of the side rails so that they did not pose safety risks such as entrapment for the resident(s). Individual interventions were implemented based on the reassessment of the two residents. Staff were re-educated on all shifts for the two identified residents. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; On 10/6/17 the FDA Hospital Bed System Dimensional and Assessment Guide to Reduce Entrapment for bed rail use was completed by Environmental Services for these two residents. The Social Worker notified the facility residents and responsible party/ family as to this process. The title of the person responsible for implementing the acceptable plan of correction. The Administrator shall be responsible for implementing all above actions to include an acceptable plan of correction. The Credible Allegation was verified by: 1-On 10/5/2017 Resident #167 and Resident #19 were reassessed by the ADON and the Staff Development Coordinator using the Side Rail Rationale Assessment Screens and the side rails were removed for both residents. Both residents were observed on 10/6/2017 at 8:01 AM in bed without side rails. 2-Documentation of the reassessments for every resident in the facility using the Side Rail Rationale Screen was reviewed by the survey team on 10/6/2017. Side rails which were assessed as a safety hazard were documented as removed. Observations of the residents who were assessed as not appropriate for the side rails per the screening form were observed to have their side rails removed. 3-Documentation of Side Rail Safety Inservicing was reviewed on 10/6/2017 and the inservicing included the risk of entrapment for residents with unsafe side rails. Interviews were conducted with staff present in the facility on 10/6/2017. The staff interviewed confirmed the recent inservice regarding said rail safety/entrapment.

Based on physician interview, staff interview, and record review the facility failed to transfer 1 of 3 sampled residents (Resident #3), who experienced falls/fractures, as specified in a physician's orders [REDACTED]. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's admission medications included Plavix (for anti-clotting) 75 milligrams (mg) daily (QD). A 02/21/13 falls risk assessment documented Resident #3 was at high risk for falls, scoring 18 (with a score of 10 or higher putting the resident at high risk). The resident was found to be at high risk due to intermittent confusion, experiencing 1 - 2 falls in the past 3 months, having poor vision, being chairbound, not being able to perform gait/balance, having 1 - 2 predisposing diseases/diagnoses, and taking 3 - 4 medications which increased fall risk. On 02/21/2013 the resident was identified as being at risk for falls on her care plan due to her fall history, use of psychotropic medications, osteoarthritis, recent cerebrovascular accident, and fatigue and weakness. Interventions to this problem included transfer with the Golvo lift utilizing two staff members. A 02/22/13 physician order [REDACTED]. Resident #3's 02/27/13 Admission Minimum Data Set (MDS) documented the resident had short and long term memory impairment, was moderately impaired in decision making, required extensive assistance by two staff members for transfers, and was unsteady with surface to surface transfers, only being able to stabilize herself with staff assistance. A 03/05/13 physician's orders [REDACTED]. Resident #3's 03/12/13 hospital Discharge Summary documented the discharge [DIAGNOSES REDACTED]. The family declined invasive procedures, and the resident was discharged back to the nursing home on Lovenox (anticoagulant) therapy. The resident was receiving 60 mg Lovenox twice daily (BID). A 03/12/13 physician's orders [REDACTED].#3's transfers. A 03/19/13 falls risk assessment documented Resident #3 was at high risk for falls, scoring 18. A 03/26/13 physician order [REDACTED]. The order documented the transfers could be completed with one or two staff members. The resident's care plan was also revised to reflect the resident's new transfer status. On 04/18/13 the physician ordered an x-ray of Resident #3's left foot secondary to swelling (4+ edema), pain, and bruising. The x-ray determined the resident had a fracture of her fifth and possibly fourth left distal metatarsals. A 04/20/13 physician's orders [REDACTED]. A 04/22/13 orthopaedic consult documented, "Left (symbol used) foot swelling dorsally, appears secondary to (symbols used) trauma, some [DIAGNOSES REDACTED] & (and) localized collection, suspect hematoma. Echymosis (bruising) of toes & dependent border of foot (much improved per family member)." The orthopaedist placed the resident on Doxycycline (antibiotic) 100 mg BID, and ordered touch down weight bearing (TDWB) only for all transfers. A 04/28/13 physician's orders [REDACTED]. A 06/06/13 orthopaedic consult documented Resident #3's metatarsal fractures were clinically healed. He placed the resident on weigh bearing as tolerated (WBAT) for transfers. The resident's 06/06/13 Quarterly MDS documented her cognition was severely impaired, she required extensive assistance from two staff members for transfers, and when transferring from surface to surface and from a seated position to a standing position the resident was so unsteady that she required staff assistance to stabilize. A 06/06/13 falls risk assessment documented Resident #3 was at high risk for falls, scoring 20. This falls assessment identified the resident as being legally blind. An incident/accident report documented on 06/13/13 at 7:30 PM Resident #3's feet became entangled with her nursing assistant's (NA's) feet when the NA was attempting to transfer the resident alone from the chair to the bed using a gait belt. The resident was sent out to the ER because of complaints of pain (in the left chest and rib area). The resident suffered two one-inch skin tears to the left elbow and a three centimeter (cm) hematoma to the back of her head. A 06/14/13 nurse's note documented the resident returned from the hospital where it was determined she had fractures to her left sixth and seventh ribs. A 06/22/13 nurse's note documented Resident #3 was sent out to the ER due to respiratory problems and poor appetite and fluid intake. A 06/22/13 hospital History and Physical documented, "On visit 06/13 x-ray and CT (computed tomography) scan showed no evidence of pneumothorax or hemothorax. Back toER on ,[DATE] for increased (symbol used) SOB (shortness of breath) and tachypnea. A chest x-ray demonstrated a near total whiteout of her left chest. The CT scan still demonstrated the left sixth and seventh rib fractures, but now shows an organizing left hemothorax....Will be taken to the operating room for a thoracoscopy, drainage, and debridement on 06/24/13." At 2:07 PM on 06/25/13 NA #1, who cared for Resident #3 on first shift, stated the transfer status of the residents was documented in the electronic FYI (for your information) section. She reported Resident #3's FYI section documented she was to be transferred using a Sabina lift or by using two staff members for manual transfers. However, she commented there were family members who did not want the staff to use the lift to transfer the resident. According to this NA, she had seen family members transfer the resident themselves by having the resident stand, hold onto an object, and pivot. She also reported she had seen other staff transferring Resident #3 by using a gait belt. The NA stated the resident was very unsteady and wobbly, and sometimes appeared anxious. At 2:28 PM on 06/25/13 Nurse #1, who cared for Resident #3 on second shift, stated the resident was at risk for falls upon admission due to confusion, unsteady balance, and history of falls and anticoagulant use. The nurse reported the FYI section, to which NAs were to refer for transfer instructions, documented Resident #3 was to be transferred using a Sabina stand up lift. However, she commented some family members wanted the resident transferred without using a lift. According to this nurse, there were times when Resident #3 was very wobbly, and it was better during these times to have two staff members complete transfers. She explained the NA who was assigned to the resident on 06/13/13 had put the resident to bed many times before, and should have known to use the lift to transfer the resident from her chair to the bed. The nurse commented it could have been the NA was rushed because staff were late getting residents to bed on 06/13/13 due to a severe storm, and the NA felt it was quicker to use the gait belt. However, she remarked, "I guess that is how accidents can happen." At 3:18 PM on 06/25/13 NA #2, who cared for Resident #3 on second shift including the night of 06/13/13, stated she had cared for the resident some when she was assigned to float, but had the resident on permanent assignment about two weeks before her 06/13/13 fall. She reported she transferred the resident as her family encouraged, by having the resident hold onto her neck and using the gait belt to lift the resident up out of the bed or chair. According to NA #2, she thought the FYI screen documented the resident was to be transferred using a gait belt. She commented she had not noticed Resident #3 having any balance problems until the evening of 06/13/13. On that night the NA explained she was late getting Resident #3 to bed because of a severe storm, but she stated she had removed the resident's top, slid her night gown over her head, and lifted her up out of a chair using the gait belt. She stated on their way to the bed the resident's feet became entangled with her own, and they both fell to the floor. At 3:42 PM on 06/25/13 the Therapy Manager (TM) stated there was a family member who wanted Resident #3 to be able to return home. Therefore, she explained this family member desired to preserve the resident's independence by having her complete transfers without the use of mechanical assistance. The TM also reported she received a 06/06/13 therapy referral for foot massages as Resident #3 transferred from TDWB to WBAT status. According to the TM, she examined the resident's left foot and interviewed the resident and family, ultimately deciding the massages would not be of benefit. However, the TM stated she did not complete an assessment of the resident's transfer capabilities because the staff reported no difference in her activities of daily living. At 3:56 PM on 06/25/13, during a telephone interview with Nurse #2 who cared for Resident #3 on first shift, she stated she thought the electronic FYI section documented the resident should be transferred using a lift or manually by two staff members. She reported she thought this was because the resident sometimes had balance problems. However, she commented she saw family having the resident stand and pivot during transfers. At 5:02 AM on 06/25/13 the Assistant Director of Nursing (ADON) stated the NA staff were trained to use the electronic FYI system to determine resident needs such as transfers. He reported ideally the staff was supposed to follow physician orders, but the facility was trying to accommodate and work with Resident #3's family to keep her as independent for as long as possible. The ADON commented he did not complete any disciplinary action or write up NA #2 after the 06/13/13 fall because he did not feel that she did anything wrong. According to the ADON, he reminded NA #2 to use the gait belt safely since she was transferring the resident as some of the family desired. Looking back on the care provided Resident #3 before the 06/13/13 fall, the ADON stated he thought the only thing the facility should have done differently was to obtain an open-ended order which allowed for some flexibility in how the resident was to be transferred based on assessment by the staff, family, and physician. He also reported the MDS Coordinator was the person who controlled input into the electronic FYI system. However, he commented the FYI information could not be viewed because the resident was no longer in active status, having been discharged to the hospital. At 8:55 AM on 06/26/13 the MDS Coordinator stated she used physician orders [REDACTED]. She stated although the FYI information for Resident #3 could no longer be viewed, she was absolutely sure the FYI instructions for the transfer of Resident #3 on 06/13/13 were to use the Sabina lift with a 1 - 2 person assist. She explained the 03/26/13 physician order [REDACTED]. At 11:08 AM on 06/26/13, during a telephone interview with Resident #3's primary physician, he stated the resident had a history of [REDACTED]. He reported his expectation was that the facility keep the resident as safe as possible during transfers. He explained this would usually be done by staff working with the physician and therapy to formulate orders for the best care. He stated ideally he would like for a resident whose weight baring status changed to work with the staff and therapy to reassess the resident's transfer capabilities. At 11:32 AM on 06/26/13 the Administrator stated the facility tried to honor family requests/care preferences, but there were times when the best approach was to bring family, facility staff, and the physician together when there were differences in thoughts about what was the safest or most beneficial care for the resident. He reported the goal would be to have some good discussion between all participants, and reach some common ground.