Every finding on record at Summerhill Elderliving Home & Care

Based on observation, staff interview, record review, and policy review, the facility failed to ensure equipment, floors, walls and ceiling surfaces were clean and in good repair, beard guards were worn while serving food, and hands were washed between touching soiled and clean dishes when operating the dish machine. These failures had the potential to cause food-borne illnesses for 136 of 136 residents who received meals prepared in the facility's kitchen.Findings include: 1. On 01/20/26 at 8:45 AM and 01/21/26 at 2:00 PM the kitchen was toured with the Dietary Supervisor (DS) and sanitation issues found included:The floor in the walk-in refrigerator had dried spillage and trash debris along the walls behind shelves and a long crack across the concrete floor.The walk-in freezer was full of numerous stacks of boxes of food. Some boxes were crushed with the weight of other boxes, causing the food product to be exposed. The floor contained food debris throughout the freezer.The interiors of the two convection ovens were soiled with baked-on grease and charred food debris. The exterior contained a greasy residue and a thick coating of grease next to the fryer.The stove top and burners were soiled with baked on spillage. During an interview on 01/21/26 at 2:10 PM, the DS stated the ovens, fryers, and stove top were cleaned every other week.The two fryer wells contained food debris. Inside of the fryer cabinets there were heavy layers of grease along the tops of the doors and thick layers of grease spillage. A thick accumulation of grease residue was noted along the exterior oven against the fryers and dried spillage on the backs of the fryers.The walls in and around the dish machine contained numerous small holes, stains, and old glue. During an interview on 01/21/26 at 2:15 PM, the DS stated the holes were from the removal of old equipment. The walls and base boards behind the beverage station and the back wall where a large trash barrel was contained a collection of dried splatters.The ceiling throughout the kitchen contained dried splatters.Door frames were noted to have worn paint and scraped, exposing the wood.During an interview on 01/23/26 at 9:43 AM, the Certified Dietary Manager (CDM) was asked if the Registered Dietitian (RD) conducted kitchen inspection. CDM stated, Yes, but she doesn't leave a report but just talks about what she found. CDM stated she also conducted inspection and she writes a report. Review CDM's Kitchen/Food Service Observation, dated 12/04/25, provided by the facility revealed oven dirty and stove, Fryer, stove areas greasy, Fryer not clean, convection oven dirty, Floor bin dirty, walk-in in total disarray, Stove oven dirty, cracked floor, and Whether the facility has and follows, a cleaning schedule for the kitchen and food service equipment; - No.During an interview on 01/23/26 at 10:00 AM, the Administrator was asked if there were any plans for the kitchen walls as there were dried splatters, holes, and old glue. The Administrator stated he was not aware of any, but he would ask the corporate maintenance person. The Administrator stated the holes in the walls were due to the recent removal of old equipment. The Administrator was asked if he was aware of the kitchen sanitation issues in the kitchen, such as heavily soiled convection ovens, fryers, and floors in the walk-in coolers. The Administrator stated, No. The Administrator then toured the kitchen and observed the above conditions.Review of the daily cleaning assignments provided by the facility revealed the floors were cleaned on 01/21/26 and 01/22/26. No initials were documented for 01/18/26, 01/19/26, and 01/20/26 to indicate cleaning had been performed. The fryer and area, stove, cooler were cleaned 01/18/26, 01/19/26, 01/20/26, and 01/21/26.Review of the five weeks of the weekly cleaning assignments, dated January 2026, provided by the facility revealed the convection ovens, baseboards, walls, fryers, and stove oven had no initials were documented to indicate cleaning had been performed.2. On 01/21/26 at 2:05 PM, Dietary Aide (DA)1 was observed touching clean dishes without washing his hands after touching dirty dishes while operating the dish machine. DS was asked if DA1 should have washed his hands before touching the clean hands, DS stated, Yes, and then spoke with DA1.3. On 01/22/26 at 12:30 pm, DA2 and Cook1 were serving lunch from the main kitchen tray line had beards and were not wearing beard guards.During an interview on 01/23/26 at 9:50 AM, DS was asked should the men in dietary with beards wear beard guards and DS stated, Yes. DS was asked why Cook1 and DA2 had beards and were not wearing beard guards 01/22/26 at lunch while serving on the tray line. DS stated he was out of beard guard but would be getting some on Monday, 01/26/26.Review of the facility policy titled Sanitation, dated 01/08/15, provided by the facility, revealed The food service area shall be maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion. open seams, cracks, and chipped areas.Review of the facility policy titled Handwashing/Hand Hygiene, revised 11/02/22, provided by the facility, revealed This facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.

Based on observation, staff interview, and document review, the facility failed to have an effective pest control program to prevent an infestation in the kitchen and in resident rooms. This failure could cause a decrease in quality of life, contamination of food, and transmission of disease for all residents in the facility.Findings include: Review of the facility's grievance log involving pests included: On 05/27/25, Resident rooms have Water Bugs and roachesOn 06/25/25, There are roaches and ants in [resident's] roomOn 07/29/25, having issues with roaches, silverfish, and fliesOn 08/26/25, found a roach in a resident's food, roaches in a resident's room, found a roach in a resident's bed.On 09/21/25, resident is still having issues with roaches.On 12/30/25, room has roachesReview of the facility's pest control receipts revealed:On 08/14/25, cockroach treatment was applied to the exterior area [of the building] and near entry- introduction point [of the building]On 09/09/25, cockroach treatment was applied to the exterior areaOn 10/10/25, cockroach treatment was applied to the exterior area and near entry- introduction [NAME] 10/30/25, cockroach treatment was applied to the patient/guest room- interior.On 11/04/25, cockroach treatment was applied to the exterior area and near entry- introduction [NAME] 12/04/25, cockroach treatment was applied to the kitchen area- interior, exterior area, near entry- introduction [NAME] 12/15/25, cockroach treatment was applied to the kitchenOn 01/12/26, cockroach treatment was applied to the exterior area, near entry- introduction [NAME] 01/22/26, cockroach treatment was applied to the kitchenReview of the Certified Dietary Manager (CDM)'s Kitchen/Food Service Observation, dated 12/04/25, provided by the facility, revealed Is there documentation of pest control services that have been provided? - No, Is the facility aware of the current problem? - Yes, If the facility is aware of the current problem, what steps have been taken to eradicate the problem? Contact [name of pest control company] to come out.On 01/20/26 at 8:45 AM and on 01/21/26 at 2:00 PM, the top of the column at the entrance door contained a collection of small dark specks resembling a pepper appearance as a sign of a roach infestation.On 01/20/26 at 9:05 AM, a large collection of small cockroaches scattered in all directions after the Dietary Supervisor (DS) moved a bucket on wheels of sanitizer located next to the three-compartment sink. DS stated they recently had the kitchen bombed with roach treatment.On 01/22/26 at 7:20 AM, the same chemical bucket from 01/20/26 was slightly moved and more small cockroaches scattered. The DS stated, the kitchen was treated again the other day. The DS stated the pest control company comes monthly and treats the kitchen.During an interview on 01/22/26 at 11:57 AM, the CDM stated the kitchen was treated with a roach bomb sometime in late December 2025.During an interview on 01/23/26 at 10:00 AM, the Administrator was asked if he was aware of the large number of roaches that scattered after the sanitizer container on wheels under the three-compartment sink was moved on 01/20/26 and 01/21/26. The Administrator stated he thought it was only one roach, not a large number. The Administrator then toured the kitchen and observed several dead roaches in and around the chemical bucket and the top of the column at the entrance door containing a collection of small dark specks resembling a pepper appearance. Review of the facility policy titled Pest Control, dated 01/11/09, provided by the facility, revealed, 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

Based on resident and staff interviews, record review, and policy review, the facility failed to provide residents and their Resident Representatives (RR) with the required written transfer and bed-hold notices following emergent hospital transfers for four of four residents (Resident (R) 4, R3, R11, and R141) reviewed for hospitalization out of 32 sampled residents. The facility also failed to ensure the required information was communicated to the hospital at the time of the transfer. These failures created a risk that residents and their RRs would be uninformed about the reason and location of the transfer, their right to appeal, and the bed-hold process, increasing the potential for denial of readmission and loss of the resident's home following hospitalization.Findings include: 1. Review of R4's admission Record located under the Profile tab of the electronic medical record (EMR) revealed R4 was admitted on [DATE]. Review of R4's Progress Notes located under the Prog (Progress) Note tab of the EMR dated 01/06/26 at 2:30 PM revealed the resident was transported to the hospital for evaluation by two-person Emergency Medical Transportation (EMT). Progress Note dated 01/08/26 at 2:44 PM communication with physician confirmed the resident readmitted back to the facility from the hospital. Review of R4's Minimum Data Set (MDS) located under the MDS tab in the EMR confirmed the resident had a discharge return anticipated MDS dated [DATE] and an entry MDS dated [DATE]. Review of R4's Evaluation tab of the EMR revealed no eInteract Transfer Form was completed for R4's hospital transfer on 01/06/26. Review of R4's EMR revealed no documentation that R4 or the RR was provided with the transfer notice or bed hold policy for the hospital transfer dated 01/06/26. Further review revealed no documentation that the information was conveyed to the hospital at the time of the transfer on 01/06/26. During an interview on 01/21/26 at 9:09 AM, R4 confirmed he was recently in the hospital and was admitted for two days. During an interview on 01/22/26 at 1:28 PM, Financial Coordinator (FC) confirmed he did not send the notice of transfer form or bed hold policy to the hospital for the resident or out to the responsible party. During an interview on 01/22/26 at 2:02 PM, the Director of Nursing (DON) said the nurse that sent R4 out to the hospital did not complete an E-Interact Transfer Form to send with R4 to the hospital on [DATE], did not send the form with EMS, and did not call report to the hospital. The DON confirmed the Financial Coordinator did not send the transfer or bed hold notices to R4's representative or give the notices to the resident. 2. Review of R3's admission Record, located under the Profile tab in the EMR indicated R13 was admitted to the facility on [DATE] with the diagnosis of diabetes mellitus, end stage renal disease, heart failure, anxiety disorder, chronic obstructive pulmonary disease (COPD), bipolar disorder, and dependence on renal dialysis. Review of R3's five-day MDS located under the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/23/25 indicated R3 was coded as having a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R3's cognition was moderately impaired. Review of R3's Progress Notes located under the Prog Notes tab in the EMR reflected R3 had been transferred to the emergency room (ER) on 11/14/25 at 1:40 PM for pain and returned to the facility from the hospital on [DATE]. Review of R3's EMR revealed there was no documentation regarding the bed hold policy being provided to the RR at the time of transfer. Review of R3's Progress Notes located under the Prog Notes tab in the EMR reflected R3 was transferred to the emergency room (ER) on 11/26/25 at 3:51 AM for severe headache without relief. Review of R3's Evaluation tab of the EMR revealed no eInteract Transfer Form was completed for the hospital transfer on 11/26/25. During an interview on 01/23/26 at 12:45 PM, the Administrator confirmed that an eInteract transfer form could not be found for R3 on 11/26/25. The Administrator stated the FC had not been sending bed hold notifications for Medicaid residents. During an interview on 01/23/26 1:02 PM, the DON reviewed R3's EMR and confirmed there was no written notice of transfer form completed for the transfer to the hospital on [DATE]. The DON stated The expectation for transfers to the hospital included an eInteract packet, transfer form, advanced directives, and bed hold policy. The facility should send a bed hold policy to the family after 24 hours. During an interview on 01/23/26 at 2:49 PM, the FC stated, I would be responsible to send bed hold notifications to the representative. I didn't know I needed to send notification for those on Medicaid since they are held for seven days with no fees due. The representative would not have been aware of this since notification was not sent. A bed hold was not sent to the representative for [R3] on 11/14/25. 3. Review of R11's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, COPD, (congestive) heart failure, diabetes mellitus, dependence on renal dialysis, anxiety disorder, end stage renal disease, and dementia. Review of R11's annual MDS located under the MDS tab in the EMR with an ARD of 11/19/25 indicated R11 had a staff assessment for mental status coded as severely cognitively impaired. Review of R11's Progress Notes located under the Prog Notes tab in the EMR indicated R11 had been transferred to the ER on [DATE] at 3:59 PM from dialysis for shortness of breath and returned to the facility from the hospital on [DATE]. Review of R11's Progress Notes located under the Prog Notes tab in the EMR indicated R11 had been transferred to the ER on [DATE] at 3:45 PM from dialysis for shortness of breath. Review of R11's EMR revealed there was no documentation that a written notice of transfer or information regarding the bed hold policy were provided to the RR at the time of transfer on 12/08/25 and 12/27/25. During an interview on 01/23/26 at 12:50 PM, the Administrator confirmed written notice of transfer could not be found. During an interview on 01/23/26 at 2:49 PM, the FC stated bed hold notifications had not been sent. 4. Review of R141's admission Record, located under the Profile tab of the EMR, revealed she was admitted to the facility on [DATE] with diagnoses including dementia, influenza, and repeated falls. Review of R141's Discharge – Return Not Anticipated MDS, with an ARD of 11/12/25 and located under the MDS tab of the EMR, documented R141 was transferred to the hospital on [DATE]. Review of R141's Incident Progress Note Follow Up, dated 11/13/25 and located under the Progress Notes tab of the EMR, documented she was becoming aggressive with other residents and staff and was transferred to the emergency room for management of behaviors and possible infection. Review of R141's Hospital Transfer note, dated 11/12/25 and located under the MDS tab of the EMR, revealed, Resident transferred to [Emergency Room] via stretcher with EMS [emergency medical services]. Resident voiced no pain or discomfort at this time. RP [responsible party] notified that resident has left the building. Review of R141's EMR revealed there was no documentation regarding a written notice of transfer or information regarding the bed hold policy were provided to the RP at the time of transfer. During an interview on 01/23/25 at 2:06 PM, the Administrator stated there was no documentation to indicate a written notice of transfer and the bed hold notice were provided. Review of the facility's policy titled, Notice of Transfer/Discharge, dated 03/2017, indicated Immediate Transfer/Discharge. Notice of Transfer and Discharge will be made as soon as practicable when: . an immediate transfer or discharge is required by the resident's urgent medical needs . The Notice will include the following: The reason for the transfer or discharge; the effective date of the transfer or discharge; the location to which the resident is to be transferred or discharged ; an explanation of the resident's right to appeal the transfer or discharge to the State; and the name, address, and telephone number of the state long-term care ombudsman; and bed hold information for Medicaid and other payers if transfer/discharge to hospital. Review of the facility's policy titled, Bed Hold Policy, dated March 2017, indicated, Policy Statement: Our facility informs residents of our bed-hold notice policy upon admission and prior to a transfer for hospitalization or therapeutic leave. Policy Interpretation and Implementation: . 2. At the time a resident is transferred to the hospital or going out on therapeutic leave, the facility will provide the resident with information regarding holding bed space. 3. When emergency transfers are necessary, the facility will provide the resident or representative [sponsor] with information concerning our bed-hold policy within twenty-four hours of such transfer via telephone or mail . 12. A copy of the Transfer/ Discharge Notice will be sent with the resident to the hospital. A copy will be sent to the Business office. The Business office/ designee will contact the resident and/ or responsible party by mail or by phone in order to ascertain the resident/ responsible party's wishes regarding holding the bed privately.

Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to encode and transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) system for two residents (Resident (R) 42 and R124) out of 32 sampled residents. This failure prevented the transmission of resident-specific information used for payment, quality measures, and ongoing clinical data analysis.Findings include:1. Review of R42's Prog (Progress) Notes tab located in the electronic medical record (EMR) revealed R42 discharged from the facility on 08/18/25.Review of the MDS tab of the EMR revealed no discharge MDS assessment was entered, completed, or transmitted to CMS.2. Review of the MDS tab of the EMR revealed Resident R124 had a Death in Facility assessment with an Assessment Reference Date (ARD) of 08/25 entered and completed but not transmitted to the CMS site.During an interview on 1/23/26 at 2:47 PM, Corporate Clinical Reimbursement Coordinator (CCRC) acknowledged R42 did not have a Discharge MDS entered, completed, or transmitted. CCRC also acknowledged R124 had a death in facility MDS assessment completed, but it was never transmitted.During an interview on 01/23/26 at 3:40 PM, Administrator stated the facility follows the Resident Assessment Instrument (RAI) manual for completion and transmission timing of Minimum Data Set (MDS) assessments.Review of the RAI Manual, dated 10/25 and located at https://www.cms.gov/files/document/final-mds-3-0-rai-manual-v1-20-1-october-2025.pdf, revealed that a discharge MDS Must be completed within 14 days after the discharge date and Must be submitted within 14 days after the completion date. A death in facility tracking record Must be completed when the resident dies in the facility or when on LOA [leave of absence]. It Must be completed within 7 days after the resident's death and Must be submitted within 14 days after the resident's death.

Based on record review, staff interviews, policy review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure an accurate Minimum Data Set (MDS) was submitted to include the correct Preadmission Screening and Resident Review (PASSAR) II status for one of three residents (Resident (R) 5) reviewed for PASARR out of 32 sampled residents. This deficient practice had the potential to place R5 at risk of inaccurate assessments and care planning. Findings include:Review of R5's admission Record located under the Profile tab of the electronic medical record (EMR) indicated the resident was admitted to the facility on [DATE] with diagnoses ofmajor depressive disorder, anxiety disorder, and bipolar disorder.Review of R5's Treatment Service: PASRR Level II located under the Misc tab of the EMR, dated 12/20/22, revealed R5 had Serious Mental Illness (SMI) with diagnoses of bipolar disorder, generalized anxiety disorder, and major depressive disorder.Review of R5's annual MDS located under the MDS tab with an Assessment Reference Date of 06/25/25 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 that indicated R5 was cognitively intact. The assessment revealed the response to: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? was marked No.During an interview on 01/21/26 at 2:04 PM, the Social Services Director (SSD) reviewed R5's EMR and stated R5 did have a PASSR II. The SSD reviewed R5's annual MDS dated [DATE] and confirmed it was marked No for PASSR Level II serious MI. The SSD stated It should have been marked Yes. It is not accurate. Section A is completed by the MDS Coordinator.During an interview on 01/21/26 at 2:17 PM, the MDS Coordinator (MDSC) 1 reviewed R5's annual MDS dated [DATE] and confirmed she had completed Section A which included PASRR Level II status. The MDSC1 stated PASRR Level II status is usually already filled out. If not, I call social services. I wouldn't know where to look for it in the computer. MDSC1 contacted social services and confirmed R5 had a PASRR Level II and the MDS should have been marked Yes for PASRR Level II.Review of the facility's policy titled, Admissions, PASARR Levels I & II, dated 06/16/25, indicated, The Level II evaluation report must be used by the facility when conducting assessments of the resident, developing the care plan, and when transitions of care occur. Incorporating the Level II information in these processes promotes comprehensive assessment and provision of care for residents with MD [serious mental disorder] or ID [intellectual disability].Review of the RAI manual, dated 10/25 and located athttps://www.cms.gov/files/document/final-mds-3-0-rai-manual-v1-20-1-october-2025.pdf,revealed, . It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment, and should be validated for accuracy [what the resident's actual status was during that observation period] by the IDT [Interdisciplinary] completing the assessment .

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that a resident's fingernails were kept clean and properly trimmed for one of one resident (Resident (R) 12) reviewed for activities of daily living (ADLs) out of 32 sampled residents. This failure created a potential risk of infection, injury, and compromised personal hygiene.Findings include:Review of R12's admission Record located under the Profile tab of the electronic medical record (EMR) indicated R12 was admitted on [DATE].Review of R12's Care Plan located under the Care Plan tab of the EMR revealed, observe for need to trim fingernails, toenails during bath/ shower time. Let nurse know if these items need to be completed during the bath/shower, with a start date of 04/21/22.Review of R12's quarterly Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date ARD of 11/12/25 revealed a Staff Interview for Mental Status (SAMS) score of three indicating moderately impaired for decision making. Functional limitation impairment on one side of upper extremity was marked, rejection of care behavior not exhibited was marked, and personal hygiene was marked as dependent (helper did all the effort).During an observation on 01/20/26 at 11:35 AM, R12 was observed with her fingernails approximately half an inch long on the right hand with a thick brown substance underneath them and were over one inch long on her left hand with a brown substance underneath them. During an observation on 01/22/26 at 10:04 AM, R12 was observed with her fingernails approximately half an inch long on the right hand with a thick brown substance underneath them and over one inch long on her left hand with a brown substance underneath them.During an interview on 01/22/26 at 10:07 AM, Certified Nurse Assistant (CNA) 1, at R12's bedside, confirmed R12's right hand fingernails were at least half an inch long and confirmed brown flakes under the middle finger of the right hand and a brown substance under the ring finger of the right hand. CNA1 confirmed fingernails on the left hand were over one inch long with a brown substance underneath them. CNA1 confirmed R12's fingernails should be trimmed for general hygiene. During an interview on 01/22/26 at 10:28 AM, Licensed Practical Nurse (LPN) 2, at R12's bedside, confirmed R12's right hand fingernails were at least half an inch long and confirmed a brown substance underneath the fingernails of the right hand. LPN2 confirmed R12's fingernails on the left hand were over one inch long with brown substance underneath them and confirmed R12's fingernails should be trimmed to prevent scratching self and for sanitation purposes.During an interview on 01/22/26 at 5:26 PM, the Director of Nursing (DON) confirmed R12's fingernails should be trimmed and that R12 should be care planned for refusing if she refuses. The DON confirmed R12's fingernails should be cleaned daily when activity of daily living (ADL) care was performed. The DON confirmed fingernails should be trimmed to prevent infection, scratching, or tearing skin.Review of the facility's policy titled, Care of Fingernails/ Toenails, dated 12/11/17, revealed 1. Review the resident's care plan to assess for any special needs of the resident . 3. Nail care includes daily cleaning and regular trimming. 4. Proper nail care can aid in the prevention of skin problems around the nail bed . 6. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on interviews, record reviews, and a review of the policy titled Adverse Consequences and Medication Errors, the facility failed to ensure that the physician or nurse practitioner was notified of a significant medication error in a timely manner for one resident (R) (R2), from a total sample of 11 residents. Actual harm was identified to have occurred on 12/19/2024 when a Licensed Practical Nurse (LPN) CC administered the wrong resident's medications to R2. R2 was sent to the hospital and admitted for monitoring of potential side effects. Findings include: The facility also had an Adverse Consequences and Medication Errors policy, dated 3/22/2017. The policy documented in the event of a significant medication-related error or adverse consequence, immediate action is taken, as necessary, to protect the resident's safety and welfare. Significant was defined to include, but not limited to, requiring hospitalization . The policy also documented that the Attending Physician is notified promptly of any significant medication error or adverse consequence. Review of the 9/19/2024 Annual Minimum Data Set (MDS) assessment revealed that R2 was assessed as being cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15. A review of facility investigation information including a 12/19/2024 Facility Incident Report Form, staff written statements, and a 12/23/24 conclusion summary revealed that R2 received oral medications that were ordered for R6 on 12/19/2024 around 9:03 am. LPN CC identified her error around 10:15 am and notified the Registered Nurse (RN) Supervisor EE around 11:00 am and the Nurse Practitioner (who was onsite). There was no evidence that LPN CC notified R2's physician or Nurse Practitioner of the medication error when she identified it at 10:15 am. Review of R2's physician ordered medications and review of R6's physician ordered medications, and December 2024 Medication Administration Record (MAR) revealed that on 12/19/2024, medications were signed out by LPN CC and administered in error to R2 at 9:02 am - 9:03 am to include a total of 14 medications. During an interview on 1/9/2025 at 4:05 pm, which included RN Supervisor EE and the Director of Nursing (DON), RN Supervisor EE stated that she would have expected LPN CC to report the medication error right away to nursing management, even if unable to locate RN Supervisor EE, the DON responded that LPN CC should have found the RN Supervisor and called the physician right away. During an interview on 1/16/2025 at 2:44 pm, the Medical Director confirmed that LPN CC should have notified him or the Nurse Practitioner of the medication error right away. When questioned if 45 minutes (from 10:15 am when the medication error was identified to 11:00 am when RN Supervisor EE was notified and subsequently the Nurse Practitioner) was considered prompt notification, the physician said no, he considered five to ten minutes prompt. He was in agreement with LPN CC to check on R2 and obtain vital signs, but she should have called him or the nurse practitioner. Cross reference to F760

Based on observation, staff and resident interviews, record reviews, and a review of the policy titled Abuse Prohibition Policy and Procedures, the facility failed to protect the resident's right to be free from physical abuse by Certified Nursing Assistant (CNA) FF for one of 11 residents (R) (R3), from a total sample. Actual harm was identified to have occurred on 12/17/2024, (CNA FF) grabbed R3's hand tight and took her call light out of her hand resulting in bruises and discoloration on the first three fingers on the right hand of R3. Findings include: The facility had an Abuse Prohibition Policy and Procedures, dated January 2017. The policy's statement documented that it was the intent of the facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse or misappropriation of resident property. The policy included definitions of abuse and physical abuse. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. Physical abuse was defined as including hitting, slapping, pinching, and kicking. It also included controlling behavior through corporal punishment. Review of R3's clinical record revealed a diagnosis that included, but were not limited to, Parkinson's disease, polyneuropathy, adjustment disorder with mixed anxiety and depression, and dementia. Review of the 11/12/2024 Quarterly Minimum Data Set (MDS) assessment revealed that R3 was assessed as needing assistance from staff for Activities of Daily Living (ADL) care. Review of the 1/11/2025 Brief Interview for Mental Status (BIMS) form revealed that R3 was assessed as being cognitively intact with a score of 15 out of 15. A review of facility reported incidents revealed a Facility Incident Report Form, dated 12/18/2024, that documented an allegation of staff to resident abuse that had occurred on 12/17/2024 around 1:00 am. The form included that R3 reported to Registered Nurse (RN) LL on 12/18/2024 at 12:30 pm that she had bruises on her right hand because the CNA from the previous night (CNA FF) grabbed her hand tight and took her call light out of her hand. The form included that R3 had bruises on the first three fingers on the right hand. Further review of the form revealed that CNA FF had been removed from the schedule until an investigation was complete. The physician, responsible party, and ombudsman were notified. Review of the accompanying investigation information that included clinical record information, personnel file information, an assessment of the injury, and a follow-up summary revealed evidence that the allegation had occurred. The investigation revealed that CNA FF grabbed R3's hand on 12/17/2024 while in her room. CNA FF was terminated from employment. Review of CNA documentation on R3, dated 12/18/2024, revealed a new discoloration to the right hand was noted. Review of an incident report for R3, dated 12/18/2024, revealed that bruises were noted to the right hand, three middle fingers, towards the base of each finger. The bruises were dark purple and blue in color. Review of the facility's follow-up summary revealed that R3 was interviewed by different staff members, three separate times, on 12/18/2024 by RN Supervisor LL, the Assistant Director of Nursing (ADON), and the Social Services Director and again on 12/19/2024 by the Social Services Director. R3's statements remained consistent. R3 reported during the interviews that CNA FF had come into her room to answer the call light, grabbed her right hand and squeezed it tight, and took her call light, telling her she did not need the call light. R3 was asking for water, which she did not receive. Review of CNA FF's written statement, dated 12/18/2024, revealed she did not recall seeing any bruising and denied squeezing R3's hand. During an observation and interview on 1/13/2024 at 2:48 pm, when R3 was asked about bruising to her hand, she responded by pointing (with her left hand) to the base of the first three fingers on her right hand (to indicate where the bruises had been). During an interview on 1/14/2025 at 2:00 pm, the Director of Nursing (DON) confirmed that CNA FF was taken off the schedule during the investigation and then terminated. Review of the Employee Consultation form, dated 12/23/2024, and the Payroll Change Form, dated 12/23/2024, revealed that CNA FF was terminated on 12/23/2024. The Employee Consultation form included the nature of the incident as mistreating/abuse/neglect of a resident. The Payroll Change form included CNA FF, which was terminated for resident neglect. Following the incident, in-service education on abuse was provided to facility staff on 12/20/2024.

Based on observation, staff and resident interviews, record reviews, and review of the policy titled Abuse Prohibition Policy and Procedures, the facility failed to ensure that an allegation of abuse was reported to law enforcement for one of 11 residents (R) (R3), from a total sampled. Findings include: The facility had an Abuse Prohibition Policy and Procedures, dated January 2017. The policy included a section titled Reporting. The reporting section included that regarding reasonable suspicion of a crime, it would be reported to the State Agency and one or more law enforcement entities for the location in which the facility is located. Review of R3's clinical record revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Parkinson's disease, polyneuropathy, adjustment disorder with mixed anxiety and depression, and dementia. A review of facility reported incidents revealed a Facility Incident Report Form, dated 12/18/2024, that documented an allegation of staff to resident abuse that had occurred on 12/17/2024 around 1:00 am. The physician, responsible party, and ombudsman were notified. Review of an incident report for R3, dated 12/18/2024, revealed that bruises were noted to the right hand, three middle fingers, towards the base of each finger. The bruises were dark purple and blue in color. Although the facility's investigation information revealed that the physician, responsible party, and ombudsman were notified, there was no evidence that law enforcement was notified of the allegation of abuse with bruising. During an interview on 1/14/2025 at 2:40 pm, the Director of Nursing (DON) confirmed that law enforcement was not notified. During an interview on 1/24/2025 at 3:35 pm with the Administrator, when questioned why law enforcement was not notified, the Administrator responded that the situation was, and the police were not notified because the resident R3 did not sustain serious bodily injury. The Administrator also stated that the facility had reported allegations in the past but did not feel this incident warranted notifying the police. R3 said the CNA grabbed her hand, and the CNA denied it, and the resident did not sustain serious bodily injury. After surveyor inquiry, the facility contacted law enforcement. A review of the local police department's Incident/Investigation Report, dated 1/14/2025, revealed that the allegation of abuse of R3 by CNA FF was reported. The crime incident was listed as Abuse of Elderly. Cross reference to F600

Based on interviews and record reviews, the facility failed to ensure that Activities of Daily Living (ADL) care was provided by the appropriate number of staff as care planned for one resident (R1), and medications were administered as care planned and ordered for one resident (R2), from a total sample of 11 residents. Actual harm was identified to have occurred on 12/21/2024, when Certified Nursing Assistant (CNA) AA provided ADL care to R1 by herself, instead of with the required two-person assistance. R1 fell from the bed and sustained a laceration to the right side of the forehead. Actual harm was also identified to have occurred on 12/19/2024 when Licensed Practical Nurse (LPN) CC administered the wrong resident's medications to R2. R2 was sent to the hospital and admitted for monitoring for potential side effects. Findings include: 1. Review of the care plan revealed that R1 had impaired cognition, a self-care deficit, was at risk for falls, and received hospice services. The fall risk care plan problem included an intervention, dated 1/22/2024, for padded bolsters to bilateral sides of the bed to define the bed parameters and bring a sense of security related to fear of falling from the bed. The ADL self-care performance deficit care plan problem included an intervention, dated 1/25/2022, that documented R1 required total assistance from two staff persons to turn and reposition in bed. There was also an intervention, dated 1/25/2022, that indicated R1 was not toileted. She was incontinent of bowel and bladder, wore adult briefs, and was checked and changed. Review of progress notes revealed a 12/21/2024 6:28 am nurse's note entry that documented Licensed Practical Nurse (LPN) HH was notified by staff that R1 was observed on the floor. R1 was observed to be on the floor beside the bed with blood on the floor. R1 was responding normally to verbal and physical stimuli. The nurse's note documented that R1 had a cut above the right eyebrow and a scrape to the right knee with noticeable bleeding in both areas. Hospice services, R1's family, and the physician were notified, and R1 was sent to the hospital emergency room for evaluation. A review of the 12/21/2024 hospital emergency department physician documentation revealed that R1 sustained a 3-centimeter (cm) laceration to the right forehead and received three sutures to close the wound. A 12/21/2024 nurse's note at 2:47 pm documented that R1 had returned to the facility. The resident had three sutures to the right side of the forehead and a dressing wrapped around her head. A review of facility investigation information including a 12/21/2024 Facility Incident Report Form, staff written statements from 12/21/2024, and a 12/23/2024 conclusion summary revealed that R1 fell out of bed during the provision of ADL care by one staff person, CNA AA. During an interview on 1/6/2025 at 2:00 pm, the Director of Nursing (DON) confirmed that CNA AA did not follow R1's care plan. During the interview, a detailed view of R1's ADL self-care performance deficit care plan problem was reviewed. The care plan problem specified the interventions that were included on the Kardex, which was for the CNAs to reference for resident care needs. The interventions included that R1 required total assistance from two staff persons to turn and reposition in bed. The DON stated that the information on the Kardex was generated directly from the care plan. During an interview on 1/7/2025 at 2:16 pm, CNA AA stated that on 12/21/2024, she was in R1's room providing care by herself. When questioned how she knows what to do for a resident and how to care for them, CNA AA stated she gets a report from the previous shift CNA and goes on the (electronic) chart system and clicks on the Kardex to see what they need. She did not recall how many people were required to provide bed mobility for R1. Cross reference to F689 2. Review of clinical record for R2 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction, aphasia, dysphagia, cerebral atherosclerosis, atherosclerotic heart disease, hypertension, hyperlipidemia, major depressive disorder, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, and vitamin D deficiency. A review of the care plan dated 10/30/2020 revealed that R2 had a communication problem related to aphasia following cerebral infarction. Further review of the care plan dated 1/16/2020 revealed interventions in place for licensed nursing staff to administer medications as ordered for cardiac prophylaxis, altered cardiovascular status, gastro-esophageal reflux disease, hyperlipidemia, depression, history of cerebral vascular accident and vitamin D deficiency. However, on 12/19/2024, Licensed Practical Nurse (LPN) CC failed to administer the correct medications to R2 as care planned and ordered. A review of facility investigation information including a 12/19/2024 Facility Incident Report Form, staff written statements, and a 12/23/2024 conclusion summary, revealed that R2 received oral medications that were ordered for R6 on 12/19/2024 around 9:03 am. R2 was subsequently admitted for observation due to polypharmacy and a syncopial episode. LPN CC documented in a written statement that on 12/19/2024, R2 was pushed (in his wheelchair) to the medication cart. LPN CC asked R2 if his name was R2 or R6's last name. R2 incorrectly stated R6's last name. LPN CC looked at the picture on the Medication Administration Record (MAR) (for R6), which she documented resembled R2. Her statement included that she administered R6's oral medications (to R2). During an interview on 1/9/2025 at 4:05 pm, which included RN Supervisor EE and the Director of Nursing (DON), RN Supervisor EE stated that she was coming out of a meeting (on 12/19/2024) when LPN CC told her about the medication error. RN EE went to put her paperwork down on her desk and said she was going to call the Nurse Practitioner and check on R2. As RN EE rounded the corner to go that way, the CNA called out about R2 being on the floor. When questioned why LPN CC asked R2 if his name was the last name of R2 or R6 (instead of just asking him what his name was), the DON stated that she did not know why LPN CC asked the question that way. The DON stated that R2 jokes and can be silly. RN Supervisor EE stated that R2 was probably joking when he told LPN CC his name was R6. Review of the 12/19/2024 hospital Emergency Department (ED) Physician Documentation revealed that it was determined that R2 had a vasovagal syncope (fainting) episode while having a bowel movement. Additional differential diagnoses included medication error, polypharmacy, and chronic obstructive pulmonary disease exacerbation. Poison control was contacted about the medication error and recommended baseline laboratory tests, an electrocardiogram (EKG), monitoring vital signs and 24-hour observation. R2 was subsequently admitted to the hospital. Cross reference to F760

Based on observation, interviews, record reviews, and a review of the policy titled Care Plans - Comprehensive, the facility failed to revise the care plan to include actual skin impairment (bruising) for one resident (R) (R3), from a total sample of 11 residents. Findings include: The facility had a policy titled Care Plans - Comprehensive. The policy documented that assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's condition change. Review of the care plan revealed that R3 was at risk for impairment to skin integrity. However, further review of the care plan revealed no evidence that the care plan had been revised to include actual skin impairment of bruising to the right hand, which was identified on 12/18/2024. A review of facility reported incidents revealed a Facility Incident Report Form, dated 12/18/2024, that documented an allegation of staff to resident abuse that had occurred on 12/17/2024 around 1:00 am. The form included that R3 had bruises to the first three fingers on the right hand. During an observation and interview on 1/13/2024 at 2:48 pm, when R3 was asked about bruising to her hand, she responded by pointing (with her left hand) to the base of the first three fingers on her right hand (to indicate where the bruises had been). During an interview on 1/9/2025 at 4:05 pm, when the MDS Coordinator was questioned if the bruising to R3 hand that was identified on 12/18/2024 would be information included on the care plan, she responded yes. The MDS Coordinator stated that the treatment nurse or RN supervisor would be responsible for adding the bruising information to the care plan. Cross reference to F600

Based on interviews, record review, review of the facility's policy titled Documentation of Medication Administration, and review of the Licensed Practical Nurse (LPN) job description, the facility failed to ensure that services being provided by a licensed nurse met professional standards of quality including inaccurate documentation of medication administration for one resident (R2), from a total sample of 11 residents. Actual harm was identified to have occurred on 12/19/2024 when a Licensed Practical Nurse (LPN) CC administered the wrong resident's medications to R2. R2 was sent to the hospital and admitted for monitoring of potential side effects. Findings include: The facility had a Documentation of Medication Administration policy, dated 3/22/2017. The policy documented that the nurse shall document all medications administered to each resident on the resident's electronic Medication Administration Record (eMAR). The policy included that administration of medication must be documented immediately as medications administration is being done per individual resident. Review of LPN CC's personnel file revealed a Licensed Practical Nurse Job Description. The job description documented a position summary of an LPN which included that the LPN provides direct patient care under the supervision of a registered nurse. The LPN contributes to patient care, provides a therapeutic environment, and is expected to abide by the standards, the job description, policies and procedures of the nursing department and hospital. The job description also documented that one of the principle duties and responsibilities included administering medications and treatments utilizing the five Rights of Medication Administration and two patient identifiers. Further review of LPN CC's personnel file revealed a Clinical Competency Testing evaluation. The evaluation included that LPN CC had between mid-level and advanced-level experience with medication administration and advanced-level experience in a nursing home setting. On 12/19/2024, a significant medication error occurred when LPN CC incorrectly administered another resident's medications to R2. Further review revealed R2 was sent to the hospital emergency room for evaluation and admitted for observation due to polypharmacy and syncopial episode. LPN CC documented in a written statement that on 12/19/2024, that she asked R2 if his name was R2 or R6's last name. R2 incorrectly stated R6's last name. LPN CC looked at the picture on the Medication Administration Record (MAR) (for R6), which she documented resembled R2. Her statement included that she administered R6's oral medications (to R2). When she arrived at R6's room to administer medication to his roommate, she realized her error when R6 was lying in his bed and was wearing different clothing. Further review of the facility's conclusion summary revealed that following the medication error on 12/19/2024, LPN CC was relieved of her medication cart at 11:50 am and subsequently sent home. However, after being relieved of her medication cart on 12/19/2024 at 11:50 am, LPN CC then documented administering medications to R2, who was no longer in the facility. Review of R2's MAR revealed that LPN CC signed off administering 10 medications at 12:44 pm- 12:45 pm, that were scheduled for 9:00 am. The medications signed off as administered included docusate sodium 100 milligrams (mg), GlycoLax powder, Linzess 72 micrograms (mcg), probiotic oral capsule, Zetia 10 mg, Klor-Con 20 milliequivalents (mEq), Lasix 40 mg, metoprolol succinate extended release 25 mg, amlodipine besylate 2.5 mg, and a chewable aspirin 81 mg. However, review of the hospital Emergency Department (ED) Physician Documentation revealed that R2 was seen by the physician at the hospital on 12/19/2024 at 12:15 pm. During an interview on 1/9/2025 at 4:05 pm, that included RN Supervisor EE and the Director of Nursing (DON), RN Supervisor EE stated that the Education Nurse took the keys to the medication cart before 11:30 am (on 12/19/2024) and LPN CC was off of the hall but could still document. The DON stated that when she spoke with LPN CC (over the phone, after the medication error), LPN CC did not indicate she gave R2 his own medications. The DON stated that she thought LPN CC signed items off on the MAR before she left the facility because the items were signed off after 12:00 pm. During an interview on 1/13/2025 at 11:05 am, the Education Nurse confirmed she took over the medication cart for LPN CC on 12/19/2024. Cross reference to F760

Based on interviews and record reviews, the facility failed to ensure that bed bolsters were secured, and that Activities of Daily Living (ADL) care was provided by the appropriate number of staff, to prevent accidents for one of 11 residents (R) (R1) sampled for ADL care. Actual harm was identified to have occurred on 12/21/2024, when a Certified Nursing Assistant (CNA) AA provided ADL care to R1 by herself, instead of with the required two-person assistance. R1 fell from the bed and sustained a laceration to the right side of the forehead. Findings include: Review of the clinical record for R1 revealed that she was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Alzheimer's disease, fibromyalgia, dementia, and adult failure to thrive. Review of the 10/11/2024 Quarterly Minimum Data Set (MDS) assessment revealed that R1 was cognitively impaired and dependent on staff for ADL, including bed mobility. Review of physician's orders revealed a corresponding physician's order, dated 1/22/2024, for padded bolsters to bilateral sides of the bed to define the bed parameters and bring a sense of security related to fear of falling from the bed. The ADL self-care performance deficit care plan problem included an intervention, dated 1/25/2022, that documented R1 required total assistance from two staff to turn and reposition in bed. There was also an intervention, dated 1/25/2022, that indicated R1 was not toileted. She was incontinent of bowel and bladder, wore adult briefs, and was checked and changed. Review of the Fall Risk Evaluation form, dated 10/9/2024, revealed that R1 was assessed as being at moderate risk for falls. Review of progress notes revealed a 12/21/2024 6:28 am nurse's note entry that documented Licensed Practical Nurse (LPN) HH was notified by staff that R1 was observed on the floor. R1 was observed to be on the floor beside the bed with blood on the floor. R1 was responding normally to verbal and physical stimuli. The nurse's note documented that R1 had a cut above the right eyebrow and a scrape to the right knee with noticeable bleeding in both areas. Hospice services, R1's family, and the physician were notified, and R1 was sent to the hospital emergency room for evaluation. Review of the 12/21/2024 hospital emergency department physician documentation revealed that R1 sustained a 3-centimeter (cm) laceration to the right forehead and received three sutures to close the wound. A 12/21/2024 nurse's note at 2:47 pm documented that R1 had returned to the facility. The resident had three sutures to the right side of the forehead and a dressing wrapped around her head. A review of facility investigation information, including a 12/21/2024 Facility Incident Report Form, staff written statements from 12/21/2024, and a 12/23/2024 conclusion summary, revealed that R1 fell out of bed during the provision of ADL care by one staff person, CNA AA. CNA AA documented in a 12/21/2024 statement that she went to R1's room on her rounds to perform care. As she had the resident turned on her right side (in bed) to get changed, the sheet and the bolster started sliding off, causing the resident to fall off the bed. During an interview on 1/6/2025 at 2:00 pm, the Director of Nursing (DON) stated that from what she determined, the bolsters were not secured to the bed, and R1 rolled off onto the floor. The DON also confirmed that CNA AA did not follow R1's care plan. During an interview on 1/7/2025 at 2:16 pm, CNA AA stated that on 12/21/2024, she had positioned R1 on her side (in the bed) to change her because she had a bowel movement. CNA AA stated that the bolster slid off really fast, and R1 fell (on the floor) and hurt herself. CNA AA confirmed that she was alone in R1's room providing care. After R1's fall out of bed with head injury sustained on 12/21/2024, in-service education was provided to nursing staff on following the care plan and Kardex and checking bolsters on the bed on 12/21/2024. CNA AA was also removed from the schedule and then terminated on 12/23/2024. Review of the Payroll Change Form, dated 12/23/2024, revealed that CNA AA was terminated. In addition, a 30 Day Resolution plan was developed on 12/23/2024 to address the CNA's failure to follow the care plan.

Based on interviews, record reviews, and review of the facility policies titled Administering Medications and Adverse Consequences and Medication Errors, the facility failed to ensure that one resident (R2) was free from significant medication errors, from a total sample of 11 residents. Actual harm was identified to have occurred on 12/19/2024 when a Licensed Practical Nurse (LPN) CC administered the wrong resident's medications to R2. R2 was sent to the hospital and admitted for monitoring of potential side effects. Findings include: The facility had an Administering Medications policy, dated 4/7/2023. The policy statement documented that medications shall be administered in a safe and timely manner, and as prescribed. The policy interpretation and implementation section included that the individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident included verbally asking the resident their name, checking the photograph attached to the medical record, and if necessary, verifying resident identification with other facility personnel. The facility also had an Adverse Consequences and Medication Errors policy, dated 3/22/2017. The policy included a definition of medication error. A medication error was defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional providing services. Examples of medication errors included omission, unauthorized drug, wrong dose, wrong route, wrong dosage form, wrong drug and wrong time and/or failure to follow manufacturer instructions or accepted professional standards. However, LPN CC failed to accurately verify the correct resident prior to administering medications to R2 on 12/19/2024. Review of clinical record for R2 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction, aphasia, dysphagia, cerebral atherosclerosis, atherosclerotic heart disease, hypertension, hyperlipidemia, major depressive disorder, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, and vitamin D deficiency. A review of facility investigation information, including a 12/19/2024 Facility Incident Report Form, staff written statements, and a 12/23/2024 conclusion summary, revealed that R2 received oral medications that were ordered for R6 on 12/19/2024 around 9:03 am. At 11:00 am Registered Nurse (RN) Supervisor EE was notified by Certified Nursing Assistant (CNA) KK that R2 had fallen in the bathroom. R2 was assisted back to bed and assessed. The Nurse Practitioner (NP) (who was onsite) at the same time was notified and evaluated R2, and he was sent to the hospital emergency room for further evaluation. R2 was subsequently admitted for observation due to polypharmacy and a syncopial episode. LPN CC documented in a written statement that on 12/19/2024, R2 was pushed (in his wheelchair) to the medication cart. LPN CC asked R2 if his name was R2 or R6's last name. R2 incorrectly stated R6's last name. LPN CC looked at the picture on the Medication Administration Record (MAR) (for R6), which she documented resembled R2. Her statement included that she administered R6's oral medications (to R2). LPN CC continued to administer medications to other residents. When she arrived at R6's room to administer medication to his roommate, she realized her error when R6 was lying in his bed and was wearing clothing different from the resident who had identified himself as R6 earlier at the medication cart. She documented that she immediately located R2 and took his vital signs, which were within normal limits. LPN CC included in her statement that she proceeded to look for the Nurse Manager, but was unable to locate her, so she continued to check on R2 until she was able to speak to the Nurse Manager. Minutes later, a CNA reported that R2 fell . LPN CC documented that she, several CNA's, the Nurse Manager, and the NP went to R2's room. During an interview on 1/9/2025 at 4:05 pm, which included RN Supervisor EE and the Director of Nursing (DON), RN Supervisor EE stated that she was coming out of a meeting (on 12/19/2024) when LPN CC told her about the medication error. RN EE went to put her paperwork down on her desk and said she was going to call the Nurse Practitioner and check on R2. As RN EE rounded the corner to go that way, the CNA called out about R2 being on the floor. When questioned why LPN CC asked R2 if his name was the last name of R2 or R6 (instead of just asking him what his name was), the DON stated that she did not know why LPN CC asked the question that way. The DON stated that R2 jokes and can be silly. RN Supervisor EE stated that R2 was probably joking when he told LPN CC his name was R6. Review of R2's physician ordered medications and review of R6's physician ordered medications and December 2024 Medication Administration Record (MAR) revealed that on 12/19/2024 the medications signed out by LPN CC and administered in error to R2 at 9:02 am - 9:03 am included allopurinol 300 milligrams (mg), amiodarone 200 mg, aspirin 325 mg, escitalopram 20 mg, Flomax 0.4 mg, Integra supplement, Linzess 145 micrograms (mcg), Potassium Chloride extended release 10 milliequivalents (mEq), carvedilol 3.125 mg, Eliquis 2.5 mg, hydralazine 50 mg, Magox 400 mg, dicyclomine 10 mg, and gabapentin 300 mg. Review of the 12/19/2024 hospital Emergency Department (ED) Physician Documentation revealed that it was determined that R2 had a vasovagal syncope (fainting) episode while having a bowel movement. Additional differential diagnoses included medication error, polypharmacy, and chronic obstructive pulmonary disease exacerbation. Poison control was contacted about the medication error and recommended baseline laboratory tests, an electrocardiogram (EKG), monitoring vital signs and 24-hour observation. R2 was subsequently admitted to the hospital. Review of additional hospital documentation including the History and Physical and Discharge Instructions and Summary revealed that while hospitalized , R2 tested positive for influenza and remained hospitalized until 12/24/2024, at which time he was discharged back to the facility. During an interview on 1/16/2025 at 2:44 pm, the Medical Director confirmed that the medication error was significant, and could be for someone else, but not harmful or life threatening for R2. When questioned if the vasovagal syncope episode was caused by the medication error, the physician responded no, that they were separate issues. The Medical Director stated that R2 had a remote history of having a vasovagal episode.

Based on observations, staff interviews, record review, and review of the facility policy titled, Drugs Brought to the Facility by the Resident/Family, the facility failed to ensure one of 39 sampled residents (R) (R7) was assessed for self-administration of medication prior to leaving medications at the bedside. This deficient practice had the potential to allow unauthorized access to unsecured medications to residents and visitors in the facility. Findings include: A review of the facility policy titled, Drugs Brought to the Facility by the Resident/Family, dated 2008, revealed the Policy Statement was, Drugs brought into the facility by the resident or family shall be verified before use. The Policy Interpretation and Implementation section included 1. Drugs brought into the facility may not be administered until the following conditions have been met: 1. State law and regulations allow such use; 2. Drugs must have been ordered by the resident's admitting/attending physician; 3. Drugs must have been entered on the admitting physician's drug order form; 4. The contents of each container must be labeled in accordance with established policies; 5. The contents of each container must have been positively identified by a licensed physician or pharmacist. Review of R7's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 12 (indicating little to no cognitive impairment), section GG (Functional Abilities and Goals) documented R7 required set-up to maximal assistance with activities of daily living (ADLs). Review of R7's current Physician's Orders orders revealed no orders for self-administration of medication. Observations on 9/3/2024 at 12:12 pm and 9/4/2024 at 10:44 am revealed one container of topical pain relief medication and one container of Capzasin (a topical medication used to treat muscle and joint pain) at the bedside. In an interview on 9/4/2024 at 11:03 am, Licensed Practical (LPN) FF reviewed R7's physician orders and confirmed there were no orders for self-administration of medications. Observation of R7's room with LPN FF confirmed there was one container of Capzasin, one container of Voltaren Gel (a topical medication used to treat joint pain), and one container of topical pain relief cream at the bedside. LPN FF removed the items from the room. In an interview on 9/5/2024 at 1:02 pm, LPN EE stated residents should not have medications at the bedside without an assessment and physician orders for self-administration. LPN EE further stated if medications were found in a resident's room, she would talk with the resident, report to the supervisor, and contact the responsible party and physician. In an interview on 9/5/2024 at 1:10 pm, Registered Nurse (RN) DD confirmed that residents should not have medication at their bedside unless they have orders for medication self-administration. RN DD stated rounds were completed daily and periodically during the day, and medications at the bedside should have been noticed.

Based on record review and staff interview, the facility failed to ensure staff followed care plan interventions to ensure that a two-person assist was provided for one resident (R) (R#1) during a bed bath which resulted in actual harm when the resident fell out of the bed and sustained a fracture of the right femur. The sample size was six residents. Findings include: R#1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: Alzheimer's disease, low back pain, age related osteoporosis and vitamin D deficiency. Review of the 9/1/22 Admission Minimum Data Set revealed the resident was assessed as requiring a two-person physical assist with bed mobility and bathing. The resident had a care plan since 9/14/22 for activities of daily living self-care performance deficit related to impaired balance with the following interventions: resident is totally dependent on two staff to provide a shower three times a week and totally dependent on two staff for repositioning and turning in bed. The resident also had a Kardex Report with interventions for assist x 2 during bed baths. Review of the 12/1/22 Nurse's Notes revealed at 9:40 p.m. the nurse was summoned to the resident's room and noted resident on the floor on the left side. The staff member stated that she was bathing the resident and as she turned the resident towards the door, she was coming around the side of the bed, heard a bang and resident fell on the floor. The resident was transferred to the emergency room (ER) for evaluation. Review of the 12/3/22 hospital History and Physical revealed the resident had an intra-articular, comminuted fracture extending from the distal femoral metadiaphysis into the femoral component of the knee arthroplasty. During an interview with the Director of Nursing and the Assistant Director of Nursing on 8/24/23 at 11:50 a.m., they confirmed the agency Certified Nursing Assistant (CNA AA) was providing care alone and should have had another staff person to assist her with the bed bath for R#1, as care planned. They stated the resident has always been a two person assist. Cross refer to F689.

Based on record review and staff interviews, the facility failed to provide adequate supervision during a bed bath to prevent an avoidable fall for one of six sampled residents (R) (#1). Actual harm occurred on 12/1/22 when R#1 fell from her bed during care and sustained a right femur fracture. Findings include: Review of the policy titled, Fall Management dated 5/17/17 indicated it is the policy of this facility that the administration and staff provide a safe environment for all residents. The facility will assess residents for fall risk, will evaluate each resident individually and provide, to the best of the facility's ability, interventions to decrease the likelihood of falls. R#1 was admitted to the facility on [DATE] with the following but not limited to diagnoses: Alzheimer's disease, low back pain, age related osteoporosis and vitamin D deficiency. Review of the 9/1/22 Admission Minimum Data Set revealed the resident was assessed as requiring a two-person physical assist with bed mobility and bathing. Review of the 12/1/22 Nurse's Notes revealed at 9:40 p.m. the nurse was summoned to the resident's room and noted resident on the floor on the left side. The staff member stated that she was bathing the resident and as she turned the resident towards the door, she was coming around the side of the bed, heard a bang and resident fell on the floor. The resident was transferred to the emergency room (ER) for evaluation. On 12/2/22 at 5:04 a.m. the resident returned from the ER with no new orders. Review of the 12/2/22 Fall Follow Up Note indicated the resident's right knee was swollen with no pain. The writer was concerned about swelling in the knee and investigated if there were any diagnostic observations completed. X-Rays were completed at the ER, but the resident was discharged back to the facility before the results were read. The X-Ray results showed a right femur fracture. The physician ordered for the resident to be sent back to the ER. Review of the 12/3/22 hospital History and Physical revealed the resident had an intra-articular, comminuted fracture extending from the distal femoral metadiaphysis into the femoral component of the knee arthroplasty. The 12/6/22 hospital Discharge Summary indicated the resident was Status Post right open reduction internal fixation surgery to the right hip. In review of the facility's investigation and five-day follow-up report sent to the State Survey Agency on 12/7/22, indicated in the resident's care plan she was to be a two person assist to the shower three times a week, she was a Hoyer lift which also requires a two person assist. It also indicated she was totally dependent and was a two person assist with bed mobility as well. It further documented the CNA (CNA AA) was neglectful in providing care to the resident as evidenced by the fact that the CNA did not follow the resident's care plan and she caused harm to her. She was an agency CNA and will no longer be allowed to return to the facility and the agency has been made aware of this. Review of the staffing agency's Complaint Report that was completed by the facility revealed the CNA (CNA AA) was bathing the resident and when she completed the bath and was changing the linen, she rolled the resident to the right side away from her toward the door. The CNA made her way to the foot of the bed and the resident fell out of the bed to the floor. The resident was sent to the ER and had a contusion to her right knee, right femur fracture. The resident was care planned to have a shower, not a bed bath, she is also care planned as a two person assist for transfers, showers and bed mobility. The CNA did not have anyone assisting her with the bath or turning the resident. During an interview with the Director of Nursing and the Assistant Director of Nursing on 8/24/23 at 11:50 a.m., they confirmed the agency Certified Nursing Assistant (CNA AA) should have another staff person to assist her with the bed bath. They stated the resident has always been a two person assist. They stated that the staffing agency was notified of the incident and told the agency that CNA is not to return to the facility.

Based on record review and staff interview, the facility failed to notify the physician timely of one resident (R) (#2) ingesting skin and hair cleanser from a sample of six residents. Findings include: R#2 was admitted to the facility on [DATE] with the following but not limited to diagnoses: moderate dementia with mood disturbance, unspecified mood disorder, and altered mental status. The resident was assessed and coded on the 6/17/23 Quarterly Minimum Data Set as having severely impaired cognition, inattention, and disorganized thinking. Review of the 6/1/23 Incident Progress Note revealed that at 11:45 p.m. the nurse was informed that the resident possibly ingested skin and hair cleanser. The Certified Nursing Assistant (CNA) stated she saw the resident in the dining room with a skin and hair cleanser bottle with no top in her hand with most of the cleanser gone out of the bottle. Per the CNA, the resident vomited about eight times and the vomit appeared soapy. The resident's vitals were stable, and Poison Control was contacted at 11:56 p.m. The Registered Nurse (RN) informed the cleanser does not contain any harmful ingredients and instructed to make sure the resident stays hydrated. Review of the Safety Data Sheet (SDS) for Derma Vera Skin and Hair Cleanser indicated the cleanser had no hazardous components. The toxicological information indicated if ingested drink large amounts of water and call physician. Review of the 6/2/23 Incident Progress Note revealed the Nurse Practitioner was not notified until 6/2/23 at 8:50 a.m. During an interview with the Administrator and the Director of Nursing on 8/24/23 at 12:30 p.m., they stated the Nurse Practitioner was not immediately notified because the staff called and spoke to the RN at poison control.

Based on record review and staff interviews, the facility failed to obtain a Urinalysis with a Culture and Sensitivity and failed to change an indwelling catheter as ordered by the physician for one resident (R) (#4) from a sample of six residents. Findings include: Review of the facility policy titled, Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing dated 8/30/22 indicated the following CAUTI prevention strategies have been adopted and are to be followed by clinical staff: After aseptic insertion, maintain a sterile closed drainage system. b) Follow physician orders for changing catheters. Report signs and symptoms of urinary tract infection to the Infection Preventionist and to the physician. Follow orders given after reporting and document those orders. R#4 was admitted to the facility on [DATE] with the following but not limited to diagnoses: [NAME] syndrome, chronic ulcerative proctitis, hydronephrosis, unspecified dementia without behavioral disturbance, cognitive communication deficit and COVID-19. The resident was also admitted to the facility with an indwelling catheter with a 4/25/22 Physician's Order to change the catheter every month. However, review of the May 2022 Treatment Administration Record revealed the indwelling catheter was scheduled to be changed on 5/22/22 but there was no documentation it had been done as ordered by the physician. Review of the 6/19/23 Nurse's Notes revealed the resident was lethargic but arousal with calling his name, his vital signs were normal, and the urine was thick and cloudy. The Nurse Practitioner was notified. The 6/21/22 Patient at Risk Note documented the resident tested positive for COVID-19 on 6/10/22 and has had an increase in weakness. Has been more lethargic but arousable when name stated. Antibiotic Stewardship started 6/20/22 by Nurse Practitioner (NP) related to writer notifying NP of cloudy thick urine in Foley catheter. Fluids are being encouraged and resident being observed for signs and symptoms of urinary tract infection (UTI). The resident had an appointment with urologist on 6/13/22 but appointment had to be canceled due to positive status. The resident will continue to be observed on PAR and started on antibiotics if necessary. Review of the 6/21/22 NP Progress Note revealed the resident was seen for discolored urine and lethargic. The NP documented the staff stated the resident had been more withdrawn and lethargic at times and noticed his urine had a lot of sediment in it. The NP noted would obtain urine sample for urinalysis and culture. Review of the 6/24/22 NP Progress Note revealed the resident was seen for discolored urine and altered mental status. The NP noted the staff stated the resident is lethargic and having trouble taking food and medicine by mouth. He has a Foley catheter that has urine with sediment. Twenty-four hour UTI screen was initiated at last visit but no urine collected to be analyzed. Will send to ED for evaluation. Review of the 6/24/22 Nurse's Note documented the resident was admitted to the hospital with a diagnosis of UTI, acute kidney injury and dehydration. Review of the 6/24/22 ED Physician Documentation revealed the resident was admitted with diagnoses of UTI and acute kidney injury. Review of the 6/28/22 Hospital Discharge Summary indicated the resident was discharged to Hospice care with discharge diagnosis of sepsis, acute kidney injury, COVID-19, catheter associated urinary tract infection. During an interview with the Nurse Practitioner on 2/24/23 at 1:00 p.m. she stated staff notified her on 6/19/22 of the resident having thick and cloudy urine and she instructed them to start the infection screen. When she saw the resident on 6/21/22 he was lethargic and had discolored urine and sediment. She gave an order to the nurse to do a UA with a culture. She stated when she visited on 6/24/22 he was lethargic with worsening mental status, got worse and they sent the resident out because she was suspicious of sepsis. She confirmed the UA had not been done as ordered. She also stated they send the urine samples to a local hospital and results can take up to two days before they are available. Therefore, the resident was already in the hospital by the time the facility would have received the results. She also stated the resident's indwelling catheter not being changed in May 2022 most likely did not contribute to the resident's UTI.

Based on observations, staff interviews, and record review, the facility failed to notify the physician or nurse practitioner of abnormal toenails for one of 53 sampled residents (R) (R#91). This failure had the potential to delay or prevent treatment for one resident in the facility. Findings include: Record review of the physician's Order for R#91 located in the electronic medical record (EMR) under the Orders tab included an order dated 9/14/2021 for Podiatry Care consults as needed. An interview with R#91 on 11/30/2022 at 10:38 a.m. revealed that she would like for her toenails to be trimmed, but no one has been in to trim them for a long time. The resident further stated that she does not recall ever seeing a physician or podiatrist regarding the condition of her feet/toenails. Interview on 11/30/2022 at 12:48 p.m. with Restorative Nursing Assistant (RNA) AA the podiatrist comes out every few months to clip residents' toenails. RNA AA further stated that the nurses and CNAs inform the social worker of residents who need to be seen by the podiatrist, and the social worker is responsible for arranging this service for the residents. Interview on 12/01/2022 at 9:27 a.m. with Social Worker (SW) CC revealed the facility offers Podiatry services quarterly. The SW CC further stated that the podiatry schedule has not been consistent, but they still do come into the facility. The SW CC stated that a resident or family can request Podiatry services, and they are signed up/added on the next scheduled visit and go onto a rotation. The SW CC further revealed that the nursing staff informs them of residents needing podiatry services. The SW CC further stated that all residents in the facility can receive podiatry services if needed, regardless of the payor source. An interview on 12/01/2022 at 10:16 a.m. with Licensed Practical Nurse (LPN) DD revealed that if a resident needs foot care/ podiatry care, the nurses are responsible for informing the RN Supervisor, who in turn informs the social worker of the needed service. LPN DD further revealed that the CNAs also inform the social worker of the need for residents to be seen by the podiatrist. An interview and observation on 12/01/2022 at 10:27 a.m. with Registered Nurse (RN) EE revealed that the facility does offer podiatry care for the residents in the facility, and sometimes residents or their families request for the resident to be seen by an outside foot care provider. The RN EE further revealed that the social worker is responsible for ensuring the residents names are added to the list to be seen by the podiatrist at the facility. RN EE observed and verified that the toenails for R#91 were (long, thick, and yellow) and agreed that the resident needs podiatry care. She further stated that the nurse or CNA had not informed her that the resident's toenails were in that condition. An interview and observation on 12/01/2022 at 10:35 a.m. with the Nurse Practitioner revealed that she believed R#91 was being seen by the podiatrist for foot care. The nurse practitioner stated that she is at the facility every day, Monday through Friday, and no one had informed her of the condition of the resident's feet. An interview with the Director of Nursing (DON) on 12/01/2022 at 11:02 a.m. revealed she was unaware that R#91 needed treatment for her feet. The DON stated that it is her expectation that the nurses address areas of concern, including foot care, with the weekly skin assessments and the identified issues than should be communicated with the RN Supervisor or DON. Record review of the document listing the residents seen by the podiatrist during their last visit to the facility on [DATE] and 9/9/2022. The record revealed that R#91 was not seen by the podiatrist. Cross refer 687

Based on observations, interviews, record review and review of facility policies, the facility failed to review and revise the comprehensive care plan for three residents, (Resident (R) #98, R#68, R#202) related to the use of side rails. Actual harm was identified to have occurred on 3/2/18, when R#98's arm was found to be stuck in the side rails and an x-ray revealed that she had sustained a fracture to her humerus. The sample size was 55 residents. Findings include: 1. Review of the clinical record for R#98 revealed the following [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 99 out of 15 which indicates that the resident was severely cognitively impaired. Further review of Section G revealed total dependent for bed mobility with full staff performance at one time, one staff assist, bed transfer two person assist. Review of Resident(R) #98's medical record revealed on 3/2/18 R#98 had an x-ray that revealed an acute left humeral neck fracture without displacement. An Order Note dated 3/2/18 at 11:52 a.m. revealed an order to send resident to the hospital for direct admission. Further record review revealed that R#98 was readmitted to facility on 3/6/18, and the resident's care plan was not revised to address the residents fracture and that there were not any new interventions put in place after the resident returned to the facility. During an observation on 4/9/18 at 11:30 a.m., R#98 was observed lying in bed with bilateral side rails raised. During an observation on 4/10/18 at 9:07 a.m., R#98 was observed lying in bed with bilateral side rails raised. During an observation on 4/10/18 at 12:00 p.m., R#98 was observed lying in bed with bilateral side rails raised. During an interview on 4/11/18 at 12:00 p.m. with the Social Worker (SW) and Director of Nursing(DON), the SW revealed that usually the nurse has a discussion with the family 1:1 regarding side rails. The DON confirmed that she was not aware that the residents care plan had not been updated regarding her fracture. She stated the MDS Coordinator is responsible for updating the care plans. 2. Record review revealed that R#68 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment tool dated 2/22/18 indicates R#68 does not transfer from the bed and requires the extensive assistance of two persons for bed mobility. Observation on 4/11/18 at 2:00 p.m. and 5:30 p.m. revealed that R#68 was lying in the bed with bilateral one-half length side rails in the raised position. Observation on 4/13/18 at 8:33 a.m. revealed R#68 was observed lying in bed with bilateral one-half length side rails in the raised position. The care plan for R#68 reflects the use of one half side rails for safety and mobility on 4/14/14 as an intervention for the prevention of falls. The care plan does not include the use of one-half side rails for mobility under the problem of activities of daily living (ADL) self-care performance deficit. The care plan does not include the use of side rails under any other problem areas. 3. Record review revealed that R#202 had [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] revealed that R#202 is dependent in bathing, dressing, personal hygiene, requiring the physical assistance of one person; she is non-ambulatory, and requires extensive physical assistance of one person for bed mobility. Observation on 4/11/18 at 8:55 a.m. revealed that R#202 was observed lying in bed with bilateral side rails raised. Review of care plan for R#202 reveals a problem for activities of daily living (ADL) self-performance deficit. There were no interventions related to the use of side rails when reviewed on 4/10/18. Interview on 4/13/18 at 1:28 p.m. with Resident Assessment Coordinator-certified (RAC-CT) AA, LPN, MDS Coordinator BB and LPN, MDS nurse CC revealed that the updating of care plans was the responsibility of the MDS nurses and the RN that was over the unit. RN, RAC-CT AA stated that they simply missed revising the interventions on the care plan. Review of policy titled Care Planning-Interdisciplinary Team Section Quarterly Review revealed 2. The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans; a. When there has been a significant change in the resident 's condition; b. When the resident has been readmitted to the facility from a hospital stay; and c. at least quarterly. Review of Section Change in a Resident 's Condition or Status Cross refer F689

Based on observation, staff interview, facility and hospital clinical record review, review of the Food and Drug Administration (FDA) Guidance on reducing entrapment in hospital beds, facility policies titled Side Rails Policy and Guidelines and Bed Safety, the facility failed to provide an environment that was free from accidents. Actual harm was identified to have occurred on 3/2/18, when R#98's arm was found to be stuck in the side rails and an x-ray revealed that she had sustained a fracture to her humerus. In addition, the facility failed to obtain Physician orders [REDACTED].#98, R#17, R#118, R#68, R#202, R#20, R#150, R#82, R#83) for the use of side rails. The sample size was 44 residents. Findings include: 1.Review of the clinical record for R#98 revealed the following [DIAGNOSES REDACTED]. Record review revealed a Health Status Note dated 3/2/18 at 6:34 a.m., that documented that R#98 was noted by CNA (Certified Nursing Assistant) during rounds, with her left arm stuck in the side rail. Writer assessed left arm and resident c/o (complained of) pain to her left shoulder 8/10. [MEDICATION NAME] (pain medication) was given as ordered. MD (Medical Doctor) called and received N.O. (new order) for x-ray of left shoulder/arm. RP (Responsible Party) notified. Further record review revealed a Health Status Note dated 3/2/18 at 11:28 a.m. revealed that x-ray results received per fax. An Order Note dated 3/2/18 at 11:52 a.m. revealed an order to send resident to the hospital for direct admission. Further review revealed a Communication Note dated 3/2/18 at 12:15 p.m. RP (Responsible Party) was notified of order to send resident to the hospital due to x-ray results to left humerus. Record review of Radiology results dated 3/2/18 at 9:55 a.m. revealed the following x-ray results: Humerus: There is an acute left humeral neck fracture without displacement. The shoulder is grossly intact. Review of Nurse Note titled Communication with Family dated 3/2/18 at 1:03 p.m. documented Responsible party, here in the facility waiting on for transport to the hospital. Informed RP that facility may decide to remove side rails from resident bed. RP stated he had rather R#98 kept side rails to hold onto during bed repositioning. Further review of clinical record revealed that R#98 did not have a Physician order [REDACTED]. Review of the Quarterly Side Rail assessment dated [DATE] and 3/7/18 revealed that R#98 was assessed for side rails, side rails in use, continue side rails, and with no indication to discontinue side rails. Review of care plan dated 9/16/16 revealed no revision to the care plan to address safety prevention measures to prevent the resident from getting her arm stuck in the side rails again. The goal of care for the resident was to maintain the current level of function in activities of daily living through the review date. During an interview on 4/10/18 at 4:11 p.m., the Director of Nursing (DON) revealed that R#98's side rail assessment was completed on 3/6/18 when R#98 returned to the facility from the hospital. She further stated that the side rail assessment was based on the resident's responsible party's decision to keep the side rails on the bed for safety purposes. The DON further revealed that no new interventions were put in place at the time and verified that the residents side rails had been care planned to be used only during patient care. The DON further revealed that on 3/6/18, the Licensed Practical Nurse (LPN) PP who received R#98 back from the hospital completed a side rail assessment (Side Rail Assessment Initial, V.1). Register Nurse (RN) AA completed the shorter version, Quarterly Side Rail Assessment, on 3/7/18. The form includes a note stating: 1/2 side rails in use per RP, to assist with bed positioning. return from hospital w/ fx (fracture) of the left humeral head. The DON further revealed that the Responsible party does not want to remove side rails and that the RP had been informed regarding side rail risks and he verbalized understanding. The DON further revealed that assessments are usually completed along with the care plans and that the nurses are responsible for getting an order from the Physician for the use of side rails. The DON further revealed that the facility did educate the residents RP regarding side rails. During an interview on 04/11/18 at 10:05 a.m., with the R#98's Physician revealed that he was not particularly aware of the cause of the injury for R#98. He was contacted by the facility nurse about the resident's injury and that he gave orders for the resident to receive a mobile x-ray and then later he sent R#98 to the emergency room (ER). The Physician revealed that he was not aware that the side rails could had caused the fracture until today. Further interview revealed that with the Physician is the Medical Director and that he is also the Physician for R#98. He revealed that his expectations are that the facility have orders for side rails and that the families sometimes want side rails. He felt that due to the resident's [DIAGNOSES REDACTED]. During an interview on 04/11/18 at 11:49 a.m., with the Maintenance Director revealed that he had receiving training on side rail entrapment. He reported that all side rails were removed previously from all beds and that later some were re-installed per resident/family request. The facility now has newer beds and that the side rails are built to industry standards. Assist bars were implemented previously and this seemed to work very well. He further revealed that the maintenance department conducts monthly rounds and looks at side rails and bed remotes. A log is kept on each check and that a quarterly inspection is completed of beds and furnishes and that this includes side rails. He revealed that he was not aware of R#98's arm being stuck in the side rail until yesterday. During an interview on 4/11/18 4:46 p.m., Licensed Practical Nurse (LPN) EE revealed that R#98's arm was stuck in the side rails on 3/2/18 during her shift. LPN EE revealed that Certified Nursing Assistant (CNA) FF approached her (LPN EE) at the nursing station saying that R#98 was complaining that her left shoulder was hurting. LPN EE further revealed that CNA FF stated that when she walked into R#98's room she observed the resident's arm in the side rail and that CNA FF lowered the head of the bed and removed the resident 's arm out of the side rail. LPN EE revealed that she did not observe R#98's arm in the side rail. LPN EE revealed that when she assessed R#98 the resident was lying flat on the bed and the resident confirmed that her arm was hurting. LPN EE revealed that she examined the residents shoulder and didn't see any bruising and that the bone was not sticking out. LPN EE revealed that she called the Physician and the residents son and that she had received orders for the resident to have x-rays. LPN EE revealed that she called a portable x-ray company to come in to obtain the x-ray and that they (the mobile x-ray company) came during the next shift which was the 7a.m. to 3 p.m. shift. LPN EE further revealed that she administered pain medication to R#98. LPN EE revealed that she had told the Physician that the residents arm was caught in the side rails when she called the Physician and that she had also informed the DON as well. LPN EE doesn't recall any of any other residents being stuck in the side rails. During an observation on 4/9/18 at 11:30 a.m., R#98 was observed lying in bed with both side rails raised with a sling in place on the residents left arm. During an observation on 4/10/18 at 9:07 a.m., R#98 was observed lying in bed with both side rails raised with a sling in place on the residents left arm. During an interview on 4/13/18 at 1:43 p.m., with the Family of R#98 (RP) revealed that the reason he requested side rails was for safety precautions for R#98 because of the residents' history of falling, being weak from a stroke and becoming very confused and agitated at times, and the resident often thinking she was going to fall over onto the floor. He stated that the residents poor vision contributes a lot to her problem. He revealed that he was not aware that he needed to sign a consent form until yesterday, 4/12/18. 2. Record review revealed that R#17 had [DIAGNOSES REDACTED]. Further review revealed that R #17 had Brief Interview Mental Status (BIMS) 00 which indicates resident was severely cognitively impaired. Continued record review revealed that the resident does not have a Physician order [REDACTED]. Observation on 4/11/18 at 9:30 a.m. revealed that R#17 was observed in the bed asleep with bilateral side rails raised. Observation on 4/11/19 at 2:00 p.m. revealed that R#17 was observed in the bed asleep with bilateral side rails raised. Observation on 4/12/18 at 1:30 p.m. revealed that R#17 was observed in the bed asleep with bilateral side rails raised. An interview was conducted on 4/11/18 at 4:37 p.m. with the Director of Nursing (DON) who confirmed that R#17 did not have a Physician order [REDACTED]. 3. Record review revealed that R#118 had the following [DIAGNOSES REDACTED]. A Brief Interview Mental Status (BIMS) revealed a score of 7 which indicates that the resident has severe cognitive impairment. Further review revealed that the resident does not have a Physician order [REDACTED]. Observation on 4/11/18 at 8:30 a.m. revealed that R #118 was observed in the bed with bilateral half side rails raised. Observation on 4/12/18 at 3:30 p.m. revealed that R# 118 was observed in the bed with bilateral half side rails raised. 4. Record review R#68 [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment tool dated 2/22/18 indicates R#68 does not transfer from the bed and requires the extensive assistance of two persons for bed mobility. Further record review revealed that the resident did not have a Physician order [REDACTED]. Observation of R#68 on 4/11/18 at 2:00 p.m. and 4/11/18 at 5:30 p.m. revealed that R#68 was lying in the bed with bilateral one-half length side rails in the raised position. Observation on 4/13/18 at 8:33 a.m. revealed that R#68 was lying in bed with bilateral one-half length side rails in the raised position. A review of R#68's physician's orders [REDACTED]. However, a new physician's orders [REDACTED]. Review of a quarterly Side Rail Assessment, for R#68, dated 2/22/18 includes the following: side rails are in use, there is no change in condition since last assessment, continue use of side rails. The form has a space for comments and nothing else has been documented; the space is blank. The form is signed by a staff member but there is no resident or family signature noted. The document does not indicate that the facility reviewed the risks and benefits of side rails with R#68 or her responsible party; it also does not indicate that that facility obtained the informed consent of either R#68 or her responsible party prior to using the one-half length side rails. There is no evidence documented that the facility attempted to use other appropriate alternatives prior to installing and using the side rails. A Side Rail Assessment, Initial, V.1. dated 12/15/15 documents the resident is able to state side rail preference and she or her RP requested side rails; half rails are noted; rails for bed mobility, positioning, and/or transfers is marked yes. The form has a place (Section H.) for the resident or responsible party to sign - it is not signed. 5. Record review revealed that R#202 had [DIAGNOSES REDACTED]. Review of the most recent MDS dated [DATE] revealed that R#202 is dependent in bathing, dressing, personal hygiene, requiring the physical assistance of one person; she is non-ambulatory, and requires extensive physical assistance of one person for bed mobility. Further record review revealed that the resident did not have a Physician order [REDACTED].>Observation on 4/11/18 at 8:55 a.m. revealed that R#202 was lying in the bed with bilateral side rails raised. 6. Record review revealed that R# 20 had [DIAGNOSES REDACTED]. R# 20 had a Brief Interview of Mental Status (BIMS) score of 4 which indicated that the resident had severe cognitive impairment. Further record review revealed that R#20 did not have a Physician order [REDACTED]. Observation on 4/11/18 at 8:54 a.m. revealed that R# 20 was in bed with side rails in the raised position. Observation on 4/13/18 at 7:18 a.m. revealed that R# 20 was in a low bed with side rails in the raised position and the resident had a fall mat on the floor. 7. Record review revealed that R#150 had [DIAGNOSES REDACTED]. R#150 had a BIMS of 8 which indicated cognitive impairment. Further review revealed that R#150 had a Physician order [REDACTED].>Observation on 4/11/18 at 8:46 a.m. revealed that R#150 was in bed with side rails in the raised position. Observation on 4/12/18 at 7:10 a.m. revealed that R# 150 was observed in the bed asleep with the bed in low position and that the side rails were in the raised position. An interview on 4/11/18 at 4:37 p.m. with the Director of Nursing (DON) revealed that prior to today's date that R#150 did not have a Physician order [REDACTED]. The DON then provided copies of a phone order dated 4/11/18 for R#150 to have 1/4 side rails x 2 to assist with bed mobility, transfers, and/or define bed parameters at all times when resident is in bed per family request. The DON also provided copy of education titled Benefits and Risks of side rails that was provided to the family of R# 15 and an updated side rail assessment and a signed consent for use of side rails that was signed by the family for R#150 on 4/11/18. 8. Record review revealed that R#82 had [DIAGNOSES REDACTED]. The MDS documented that the resident was totally dependent for all activities of daily living. Review of Quarterly Minimum Data Sets ((MDS) dated [DATE] for R#82 revealed a Brief Interview for Mental Status score of 02 which was indicative of severe cognitive loss. Review of side rail assessments dated 12/8/17 and 3/5/18 revealed that side rails were in use and were to continue being used. Further record review revealed that the resident does not have a Physician order [REDACTED]. Review of side rail assessments, for R#82, dated 12/8/17 and 3/5/18 revealed that side rails were in use and were to continue being used. Observation on 4/11/18 at 8:46 a.m. revealed that R#82 was lying in bed with the side rails raised. Observation on 4/11/18 at 3:45 p.m. revealed R#82 was lying quietly in bed bilateral side rails raised. 9. Record review revealed that R#83 had [DIAGNOSES REDACTED]. Record review of the Quarterly Minimum Data Sets (MDS), for R#83, dated 3/2/18 revealed a Brief Interview of Mental Status (BIMS) score of 00 indicating severe cognitive loss. The MDS documented that the resident required extensive assistance to being totally dependent with most activities of daily living. Review of the side rail assessment dated [DATE] revealed that side rails were in use and were to continue being used. Further record review revealed that the resident does not have a Physician order [REDACTED]. Review of the side rail assessment, for R#83, dated 3/2/18 revealed that side rails were in use and were to continue being used. Observation on 4/11/18 at 8:50 a.m. revealed R#83 lying in bed with side rails up in the raised position. Observation on 4/11/18 at 3:30 p.m. revealed that R#83 was lying quietly in bed with bilateral side rails raised. Observation on 4/12/18 at 10:15 a.m. revealed that R#83 was lying in the bed with bilateral side rails raised. An interview on 4/12/18 at 3:40 p.m. with Licensed Practical Nurse (LPN) BB the MDS Coordinator and Registered Nurse (RN) AA an RN Supervisor revealed that the rehab unit beds all have one-quarter side rails on both sides of the beds and that the rest of the facility uses one-half length side rails. The reason provided for the difference in side rails is that the beds in the rehab unit were purchased more recently and came equipped with the one-quarter length side rails. RN AA and LPN BB revealed that their understanding was that the older beds in the rest of the facility would not accommodate the shorter length side rails. Further interview revealed that the facility conducts quarterly reviews of side rails and that they look at those residents who may be weaker or have had a decline in bed mobility or transfers. Residents with a decline in health status may need a side rail to help them stay mobile in the bed or assist in transfers. RN AA and LPN BB verbalized that some residents want side rails because it helps them to define the perimeter of the bed and makes them feel more secure. They also stated that they (facility staff) are currently working on obtaining consents for side rail use from residents or their responsible parties and they will have the admitting nurses complete the consents in the future. Review of the document titled Guidance for Industry and FDA Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued by the FDA division of the U.S. Department of Health and Human Services on 03/10/06, revealed the following: The term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame Patient entrapments may result in deaths and serious injuries Patient entrapments may result in deaths and serious injuries. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement Review policy titled Side Rail Policy and Guidelines revealed side rails will be utilized based on individual resident assessment. The side rail assessment will include assessing the resident 's mental status, physical status including bed mobility and ability to transfer, need for side rail usage and resident 's and /or responsible party's desire for side rail(s). 1) Resident s will be assessed for side rail usage on admission, quarterly, and with any significant change in status. 2. Side rails will be used a. to prove a sense of security b. to assist with transferring in and /or out of the bed c. to increase participation in ADL care. Review of policy titled Bed Safety revealed our facility shall strive to provide a safe sleeping environment for the resident. 2) To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches. e) identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapments (e.g. altered mental status, restlessness, etc ), the staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use.8) after appropriate review and consent as specified above, side rails may be used at the resident 's request to increase the resident 's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised , or he/she is used to sleeping in a large bed). 9) before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails and obtain informed consent.