Every finding on record at The Springs Searcy

Number of residents sampled: Number of residents cited: Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure one (Resident #5) of four residents reviewed for accidents received adequate supervision and assistive devices to prevent accidents. Specifically, the facility failed to ensure the resident was transferred with the proper equipment, and the number of staff members required, according to the resident's assessed needs, which resulted in a fractured hip. The findings include: Review of the admission Record indicated the facility admitted Resident #5 with diagnoses that included senile degeneration of brain, dementia, polyosteoarthritis, disorders of bone density and structure, chronic pain syndrome and anxiety. Review of a five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/19/2025, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. The MDS also revealed Resident #5 was dependent for chair/bed transfers, toileting transfers, sit to lying, and rolling from left to right. Review of Resident #5's Care plan, initiated on 04/09/2025, and revised on 04/11/2025 revealed Resident #5 had an Activities of Daily Living (ADL) self-care performance deficit related to decreased cognition and mobility. Care Plan interventions included that [Resident #5 was] dependent on two staff members with [name brand mechanical lift] for transfers. Review of an Order Summary revealed Resident #5 had an x-ray of both hips, pelvis, and right leg dated 04/11/2025. The Order Summary also revealed Resident #5 had an order to transfer to the local emergency room (ER) the next morning for further evaluation and possible treatment. Review of an X-Ray Evaluation dated 04/11/2025, revealed Resident #5 had an acute distal femur (hip) fracture. Review of Progress Notes revealed that Resident #5 was being moved to wheelchair from bed by Certified Nursing Assistant (CNA) #8 with no help and had to lay Resident #5 to the floor causing the resident's leg to become twisted under the resident. Review of a Nursing Assistant Clinical Skills Checklist and Competency Evaluation dated 04/11/2025 revealed CNA #8's signature and an instructor's signature indicating re-education and competency of lifts and transfers. Review of an undated Employee Memorandum, revealed that CNA#8 was terminated on 04/21/2025 after investigation and suspension on 04/12/2025 for failure to follow facility policy, and did not confirm transfer status before performing a transfer after educated to do so. This surveyor attempted to contact CNA #8 for a telephone interview but was unsuccessful. During an interview on 03/25/2026 at 2:46 PM, CNA #9 stated a resident's Care Plan on the computer system was to be reviewed daily before seeing a resident. During an interview on 03/25/2026 at 2:34 PM, the Director of Nursing (DON) stated staff were made aware of changes to a resident's Care Plan by stand-up meetings with the department heads, in-services as needed, the electronic computer system and word of mouth with each other. The DON stated, CNAs were to look at the electronic computer system a minimum of daily. During a second interview on 03/26/2026 at 12:44 PM, the DON stated Resident #5 was transferred without using a lift and without assistance of two staff, by CNA #8. The DON was asked what her expectations of staff were regarding knowing how to take care of a resident. The DON stated that staff were to look at Care Plans on the computer system at least once before going in to see a resident. During an interview on 03/26/2026 at 1:16 PM, the Administrator stated that her expectation was for the staff to look at the Care Plan of a resident at least daily to see what transfer assistance the resident required. The Administrator stated, Staff need to look at the computer system several times a day because things can change. The Administrator also stated she expected staff to know the policy and procedure for transfers and lifts. Review of a facility in-service education report dated 04/12/2025 revealed, Please ensure before attempting to transfer a resident you are confirming transfer status, with the resident's [electronic care plan] and following the transfer guidelines that should be followed according to their transfer status. Review of a facility policy titled, Safe Lifting and Movement of Residents, revised on 07/01/2017, revealed that Manual lifting of residents shall be eliminated when feasible. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Staff responsible for direct care will be trained in the use of manual and mechanical lifting devices. Review of a facility policy titled, Lifting machine, using a mechanical, revised on 07/01/2017, revealed that At least two nursing assistants are needed to safely move a resident with a mechanical lift. The facility re-educated all staff on 04/12/2025 following the incident, on ensuring that transfer status of a residents is confirmed by the resident's electronic care plan prior to the transfer and that all transfer guidelines are followed according to their transfer status. Per a competency evaluation for CNA #8, the CNA was re-educated and evaluated on for competency regarding transfers and lifts after the 04/11/2025 incident. In addition, CNA #8 was suspended pending investigation on 04/12/2025 and later terminated on 04/21/2025. These actions were performed before the survey team entered the facility, resulting in this finding being cited at past non-compliance.

Based on observation, record review and interview, the facility failed to store medications at proper temperatures to preserve their integrity.The findings are:Based on observation, interview, record review and facility policy review, the facility failed to store medications at proper temperatures to preserve the integrity of the medications for one of two medication refrigerators observed. The findings include: During an observation of Medication room [ROOM NUMBER], near Hall 8 on 03/24/2026 at 12:40 PM, Unit Manager/Licensed Practical Nurse (LPN) #2 opened the narcotic fridge door and stated the temperature of the interior of the refrigerator was 32 degrees Fahrenheit according to visual observation of a thermometer secured to the inside of the refrigerator door. This surveyor observed a buildup of ice approximately three inches tall by six inches wide by seven inches deep in the freezer compartment of the dorm sized refrigerator. The refrigerator contained insulins and other medications. During an interview on 03/24/2026 at 12:40 PM, Unit Manager LPN #2 indicated she was unsure of the proper temperature for the refrigerator. A Pharmacist walked into Medication room [ROOM NUMBER] during the interview and stated the temperature of the refrigerator should be between 36 and 46 degrees. Unit Manager LPN #2 indicated nurses should log the temperature of the refrigerator daily. Review of a March Daily Refridge Temp Log on 03/23/2026, revealed the temperature was 36 degrees on March 18, March 19, and March 20, all other days were outside of range at 32-34 degrees. Review of a document which listed residents with medications in the fridge revealed on 03/24/2026, 16 residents had medications stored in the fridge located in Medication room [ROOM NUMBER] by Hall 8. During an interview on 03/26/2026 at 1:52 PM, the Director of Nursing indicated it was important for the medication refrigerator to be kept between 36 to 46 degrees to maintain the quality of the medications. She reported the result of medications not kept at temperatures between 36 to 46 degrees could cause the medication to be ruined. She reported the medications that were stored at inappropriate temperatures were disposed of and replaced. During an interview on 03/25/2026 at 8:11 AM, the Administrator reported nurses were responsible for logging the medication refrigerator temperatures and referred to the two signatures at the bottom of the log sheets that were nurse signatures. Review of an undated facility document titled Medication Storage Information revealed best practice guidelines for a refrigerator were a refrigerator temperature log must be posted on the outside of refrigerator and logged daily; temperature must be 36 to 46 degrees Review of a facility policy titled Storage of Medications with a revised date of November 2020, revealed The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner. Review of an article titled Safe Storage of Insulin from the American Diabetes Association revealed It's important to store insulin as directed so that it remains usable by those who need it. Specifically, under section keep it cool, According to the product labels from all three United States (U.S.) insulin manufactures, it is recommended that insulin be stored in a refrigerator at approximately 36 degrees Fahrenheit (F) to 46 degrees F. Do not use insulin that has been frozen.

Number of residents sampled: Number of residents cited: Based on record reviews and interviews, the facility failed to ensure dialysis was coded on the Minimum Data Set (MDS) for the last two quarters for one (Resident #8) of two residents reviewed for accuracy of assessments. The findings include: Review of Resident #8's Medical Diagnosis revealed Resident #8 had diagnoses which included stroke, multiple sclerosis (an autoimmune disease where the immune system attacks the protective covering surrounding nerve cells in the brain and spinal cord), and end stage renal disease (ESRD) stage 5 (the kidneys have lost nearly all ability to work resulting in dialysis or kidney transplant to live). Review of a quarterly MDS with an Assessment Reference Date (ARD) of 01/19/2026, revealed Resident #8 had a Brief Interview of Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS also revealed Resident #8 was not on dialysis. Review of a quarterly MDS with an ARD of 10/24/2025, also revealed Resident #8 was not on dialysis. Review of Order Summary revealed an active order, order date of 04/29/2019 and a start date of 05/01/2019, to take Resident #8 to dialysis on Monday, Wednesday and Friday at 4:30 PM, and as needed. Review of a Care Plan with a revised date of 08/19/2025, revealed Resident #8 was at risk for complications related to hemodialysis at [local Dialysis Center] secondary to end stage renal disease [ESRD] due to diabetic neuropathy. Care Plan interventions included to administer medications as ordered, change dressing at the access site, monitor left forearm shunt for infection, redness, bleeding and thrill. The Care Plan also revealed Resident #8 had an Activities of Daily Living (ADL) self-care deficit related to multiple comorbidities, including dialysis, and the resident required maximum assistance with upper body dressing, two-person assistance with lower body dressing, one person assistance when in wheelchair, the resident self-propelled small distances, and was maximum to dependent with locomotion. Review of a list of Residents on Dialysis on 03/25/2026 at 11:03 AM, revealed Resident #8 was on dialysis. During an interview on 03/25/2026 at 8:51 AM, the Treatment Nurse stated Resident #8 was at dialysis and she would provide wound care when Resident #8 returned to the facility. During an interview on 03/25/2026 at 12:48 PM, this surveyor asked the MDS Nurse to review the most recent MDS with an ARD of 01/19/2025 for Resident #8. The MDS Nurse stated she forgot to check hemodialysis for Resident #8. The MDS Nurse was asked to review the quarterly MDS with an ARD of 10/24/2025. The MDS Nurse stated, It was an oversight data entry error and confirmed the MDS was not coded for dialysis the last two quarters and stated, it should have been coded because it is necessary care. The MDS Nurse revealed Resident #8 had been at the facility for many years and had been on hemodialysis since shortly after admission for ESRD. The MDS Nurse stated the Resident Assessment Instrument (RAI) manual was used when coding the MDS and provided a copy of instructions used. During an interview on 03/25/2026 at 2:53 PM, the Administrator stated, My expectation is that the MDS will be coded correctly, so that the MDS will be as accurate as possible.

Number of residents sampled: Number of residents cited: Based on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure staff changed gloves when contaminated during wound care for one (Resident #10) of two residents reviewed for wound care. Additionally, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) while providing wound care to Resident #10 who was on Enhance Barrier Precaution (EBP). The findings include: Review of an admission Record indicated the facility admitted Resident #10 with diagnoses that included blastomycosis (lung infection) and pressure ulcer of sacral (base of spine) region, stage 4. Review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/09/2025, revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of Resident #10's Care Plan revised on 03/11/2026, revealed the resident required EBP related to a chronic wound (stage 4 Pressure Ulcer to Sacrum). Care planned interventions included for staff to wear gown and gloves during high contact resident care activities. Review of an Order Summary revealed Resident #10 had an active order dated 03/11/2026 for EBP every shift related to a Stage 4 pressure ulcer of sacral region. Review of a Treatment Administration Record (TAR) revealed Resident #10 had wound care ordered as follows: stage 4 pressure ulcer to sacrum to be cleansed with [name brand] solution, patted dry with gauze, collogen particles applied, hydrophilic gel applied, covered with super absorbent gauze every day and as needed (PRN). On 03/25/2026 at 9:01 AM, this surveyor observed EBP signage posted outside of Resident #10's room. Before performing wound care to Resident #10 Treatment Licensed Practical Nurse (LPN) #7 did not put on the appropriate PPE to include a gown required for EBP. Treatment LPN #7 removed the old wound dressing from the sacral area and did not change the contaminated gloves or perform hand hygiene before she continued to perform wound care to Resident #10. During an interview on 03/26/2026 at 2:15 PM, Treatment LPN #7 stated she did not put on a gown before she performed wound care to Resident #10 and did not change contaminated gloves during wound care. When she was asked what the importance of wearing PPE and changing contaminated gloves, Treatment LPN #7 stated wearing PPE and changing contaminated gloves were important to prevent the spread of infection and prevent cross contamination to residents. During an interview on 03/26/2026 at 12:42 PM, the Director of Nursing (DON) stated the expectation of staff regarding infection control was for staff to wear PPE when it was ordered, wear gloves during resident care, maintain cleanliness, wash hands, utilize hand sanitizer and call in if ill. In response to when should staff change gloves during wound care, the DON stated, after prepping supplies and going from dirty to clean. The DON stated the importance of staff following infection control was to ensure their own safety and safety of other residents. Review of a facility policy titled Wound Care, with a revision date of 10/01/2010, revealed Wash and dry hands thoroughly. Put on exam gloves. Loosen tape and remove dressing. Pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves. Review of a facility policy titled Enhanced Barrier Precautions (EBP) revealed, Initiation of EBP will be obtained for residents with the following: Wounds, and/or indwelling medical devices even if the resident is not known to be infected or colonized with multidrug-resistant organism (MRDO). PPE for EBP is only necessary when performing high-contact care activities. High contact resident care activities include Dressing, Bathing, Transferring, providing hygiene, wound care, changing briefs or assisting with toileting, changing linen.

Based on interview, and facility document review, the facility failed to update the facility assessment to include staffing levels needed for specific shifts such as days, evenings, weekends, and memory care units. The findings include: A review of the Facility Assessment Tool indicated that it was last updated on 07/04/2024, with a staffing table that stated Licensed Practical Nurses (LPN), with 6 to 9 daily average of full time employees (FTEs), Certified Nursing Assistants (CNA) (including restorative) with 22-30 daily average of FTEs, Nursing Administration (Director of Nursing and Assistant Director of Nursing) 4 to 5 daily average of FTEs, Social Services with 1 to 2 daily average of FTEs, Dietary Manager with a daily average of 1 FTE, food and nutrition services staff with a daily average of 6 to 8 FTEs, Administration with a daily average of 2 FTEs, Activities with a daily average of 3 FTEs, Environmental services/Maintenance with a daily average of 1 to 2 FTEs, Therapy Staff with a daily average of 2 to 5 FTEs, Infection Preventionist with a daily average of 1 FTE, 24/7 Registered Nurse coverage with a daily average of 4 FTEs. On 3/12/2025 at 11:30 AM, during an interview, the Administrator stated that the facility assessment was part of her job, and that it was last updated in July of last year. The Administrator stated that it was set up for total average of employees needed in the building. The Administrator stated it was not divided by shifts, weekends, or by memory care units. The Administrator stated the facility updated the facility assessment as needed or annually and was not aware of the changes made in the requirements for the facility assessment.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure dishware were not exposed to dust, or other contamination; kitchen equipment was maintained in a clean and sanitary condition; dietary employees washed their hands or changed gloves before handling food items and clean equipment when contaminated; expired food products were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria, and ice machine and ice scoop holder were maintained in clean and sanitary condition. The findings are: 1. On The following observations were made in the kitchen: a. On [DATE] at 10:18 AM, 24 small plates, located on the bottom storage shelf in the kitchen, had food serving side uncovered. b. On [DATE] at 10:21AM, the can opener had an orangish-brown and a white fuzzy unknown substance adhered to the blade. c. On [DATE] at 10:26AM, a trash can was located next to the microwave used to heat residents' food. d. On [DATE] at 10:27AM, 12 drinking cups had brown stains on the inside. 2. On [DATE] at 12:18 PM, the Assistant Dietary Manager took out trays that contained glasses and placed them on the counter, then opened the refrigerator and removed 2 boxes of nutritional drinks and placed them on the counter. Without washing her hands, she picked up glasses by the rims and poured beverages in them to be served to the residents for lunch. 3. On [DATE] at 12:23 PM, Assistant Dietary Manager, who was on the tray line assisting with lunch meal, picked up cartons of nutritional drinks and placed them on the trays. Without washing her hands, Assistant Dietary Manager picked up glasses of beverages and placed them on the trays to be served to the residents for lunch. Assistant Dietary Manager confirmed, she should have washed her hands. 4. On [DATE] at 1:45 PM, Two boxes of hash browns were on a shelf in the refrigerator with an expiration date of [DATE] 5. On [DATE] at 2:17 PM, A section above the ice machine top panel in the break room on 100 Hall had wet, black/brownish residue on it. Dietary Manager wiped the area where the wet, black/brownish residues were observed, and the residues easily transferred to the paper towel. She stated, CNAs use it to fill the water pitchers for the residents' rooms, and the maintenance man cleans it every month. The Dietary Manager stated the area had wet, black /brownish residue on it. 6. On [DATE] at 2:19 PM, the ice scoop holder on the wall, by the ice machine in the break room on 100 hall, had buildup of wet, black residue in it. The ice scoop was in direct contact with the buildup of wet, black residue. Dietary Manager confirmed, the scoop holder had buildup of wet, black residue in it. 7. On [DATE] at 10:42 AM, Dietary [NAME] (DC) #13 was observed wearing gloves on his hands when he picked up a paper listing the names of residents who requested salad and sandwiches with their lunch meal. After reviewing the list, he placed it back on the counter, without changing gloves and washing his hands he picked up clean plates from the plate warmer and placed them on the counter, touching inside of the plates with his contaminated gloved fingers. DC #1 removed slices of bread from the bag and placed them on individual plates. DC#1 then removed slices of cheese from a container and placed them on top of the bread slices to be used in preparing ham and cheese sandwiches that would be served to the residents who asked for them. DC #1 confirmed she should have washed her hands. 8. A review of facility policy titled, Preventing Foodborne Illness -Employee Hygiene and Sanitary Practices, revised October2017, provided by the Dietary Manager on [DATE] indicated, employees must wash their hands after engaging in other activities that contaminate the hand.

Based on observation, interviews, record review, facility document review, it was determined that the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 01 (Resident #101) of 2 (Resident #101, #9) sample mix residents reviewed for care plan; and to ensure care plan interventions were implemented for 1 (Resident #9) of 2 (Resident #101, #9) sample mix residents reviewed for care plan. The findings include: On 10/1/24 at 9:43 AM, the Surveyor interviewed Resident #101 and they revealed they are a smoker and that they have a smoking apron offered to them during smoke break, but they don't wear it. Review of Resident #101's Care Plan with an initiated date of 2/7/2024 did not note the resident is wear a smoking apron. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/10/2024 revealed Resident #101 scored a 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). The MDS also revealed Resident #101 has a diagnosis of Alzheimer's disease. Review of Resident #101's Smoking Safety Screening completed on 9/18/2024 noted the resident is to wear a smoking apron with supervision while smoking. On 10/2/2024 at 11:20 AM, the Surveyor observed Resident #101 on smoke break with seven (7) other residents present. Certified Nurse Aid (CNA) #12 was present to supervise the smoke break. CNA #12 was observed asking the residents if anyone needed a smoking apron and all residents responded no. Resident #101 was observed sitting in wheelchair with no smoking apron. On 10/2/2024 at 11:20 AM, the Surveyor interviewed CNA #12 and she revealed the residents were evaluated for smoking aprons but that only one (1) resident was assessed to wear an apron and that was Resident #45. CNA #12 confirmed that the residents were assessed for wearing a smoking apron for safety and that none of the residents present were wearing a smoking apron. On 10/3/2024 at 11:29 AM, the Surveyor interviewed the Assistant Director of Nursing (ADON) and she confirmed that residents are assessed to wear smoking aprons during smoke breaks for safety reasons and that should explain why it should be worn. The ADON confirmed that Resident #101 is a smoker and assessed to wear a smoking apron but was not care planned to wear a smoking apron and that the care plan is how staff know how to properly care for the residents. On 10/3/2024 at 11:50 AM, the Surveyor interviewed the Director of Nursing (DON) and she confirmed that residents are assessed to wear smoking aprons during smoke breaks for safety reasons, and that staff observing the smoke break should not be asking residents assessed to wear a smoking apron if they want to wear it based on their assessment they are to have one on. The DON confirmed that Resident #101 is a smoker and assessed to wear a smoking apron but was not care planned to wear a smoking apron and that the care plan is how staff are aware of how to care for the resident. 49413 Based on observation, interviews, record review, facility policy review, it was determined that the facility failed to ensure the comprehensive care plan addressed and individualized appropriate care and services for 1 (Resident #101) of 2 sample mix residents reviewed for care plan; and to ensure care plan interventions were implemented for 1 (Resident #9) of 2 sample mix residents reviewed for care plan. The findings include: 1. On 10/01/2024 at 9:43 AM, Surveyor interviewed Resident #101, who revealed they were a smoker and that they had a smoking apron offered to them during smoke break, but they do not wear it. Review of Resident #101's Care Plan with an initiated date of 02/07/2024 did not note the resident was to wear a smoking apron. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/10/2024 revealed Resident #101 scored a 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). The MDS also revealed Resident #101 had a diagnosis of Alzheimer's disease. Review of Resident #101's Smoking Safety Screening completed on 09/18/2024 noted the resident was to wear a smoking apron with supervision while smoking. On 10/02/2024 at 11:20 AM, Surveyor observed Resident #101 on smoke break with seven (7) other residents present. Certified Nurse Aid (CNA) #12 was present to supervise the smoke break. CNA #12 was observed asking the residents if anyone needed a smoking apron and all residents responded no. Resident #101 was observed sitting in wheelchair with no smoking apron. On 10/2/2024 at 11:20 AM, Surveyor interviewed CNA #12, and she revealed the residents were evaluated for smoking aprons but that only one (1) resident was assessed to wear an apron and that was not Resident #101. CNA #12 stated residents were assessed for wearing a smoking apron for safety and none of the residents present were wearing a smoking apron. On 10/03/2024 at 11:29 AM, Surveyor interviewed the Assistant Director of Nursing (ADON) who stated residents were assessed to wear smoking aprons during smoke breaks for safety reasons and staff should explain why it should be worn. The ADON confirmed that Resident #101was a smoker and assessed to wear a smoking apron but was not care planned to wear a smoking apron and t the care plan was how staff knew how to properly care for the residents. On 10/03/2024 at 11:50 AM, Surveyor interviewed the Director of Nursing (DON) who stated residents are assessed to wear smoking aprons during smoke breaks for safety reasons, and staff observing the smoke break should not be asking residents assessed to wear a smoking apron if they want to wear it. Based on their assessment the residents are to have a smoking apron on. DON indicated Resident #101 was a smoker and assessed to wear a smoking apron but was not care planned to wear a smoking apron and the care plan was how staff were aware of how to care for the resident. 2. Review of a facility policy titled Residents Rights 2001 MED-PASS, Inc. (Revised February 2021) indicated federal, and state laws guarantee certain basic rights to all residents of the facility, including resident's right to be treated with respect, kindness, dignity, and self-determination. Review of facility policy titled Activity Programs 2001 MED-PASS, Inc. (Revised February 2021) indicated activity programs support the well-being of residents and encouraged independence and community interaction. Activities were based on comprehensive resident centered assessment and preferences of each resident that promote or enhance physical, cognitive or emotional health. Activities were not limited to those only provided by activities staff. Other staff members may also provide activities. Adequate equipment would be provided to ensure needed services in the resident's care plan are met. Review of facility policy Care Plans, Comprehensive Person-Centered 2001 MED-PASS, Inc. (Revised December 20l6) indicated care plan would be consistent with the resident's rights to receive the services and/or items included in the care plan. Review of a Medical Diagnosis report indicated the facility admitted Resident #9 on 07/28/2021 with diagnoses of senile degeneration of the brain and sever dementia with other behavioral disturbance. Resident #9 has a cognitive ability of 0 which indicates a severe cognitive impairment. Resident #9's care plan indicated the following behaviors of combative with care, yells, curses, throws objects, disruptive, and bites. Likes to have a baby doll and will take other resident's (doll) and has impaired communication. Resident #9 resides on secure unit hall 8. On 09/30/2024 at 11:17 AM, Resident #9 was at the dining room table in a wheelchair. Resident #9 self-propelled into the hallway. Certified Nursing Assistant (CNA) #11 returned Resident #9 to the dining room table without explaining what was being done or asked if Resident #9 needed anything. Resident #9 was placed at a dining room table without any interaction or anything to do. On 09/30/2024 at 11:26 AM, Resident #9 self-propelled from the dining room for a second time. Resident #9 sat in the hallway in the wheelchair quietly. 11:28PM, CNA #11 returned Resident #9 to the dining room table without an explanation of what was being done or asking if Resident #9 needed anything. Resident #9 was placed at the dining room table without any interaction or anything to do. CNA #11 told Resident #9 they would eat real soon. Lunch meal was brought to Hall 9 between 12:45PM and 1:00PM. On 09/30/2024 at 12:10 PM, Resident #9 sat next to another Resident's walker. The Resident became agitated with Resident #9, told Training Nursing Assistant (TNA) #8 to move Resident #9. TNA #8 pushes Resident #9 to a dining room table away from the other resident. TNA #8 did not inform Resident #9 she was going to be moved. Resident #9 had no interaction from staff, other residents nor was provided any activity. On 09/30/2024 at 12:13 PM, a resident yelled out here [Resident # 9] comes. TNA #8 wheeled Resident #9 to the back dining room table. TNA #8 did not inform Resident #9 they would be moved prior. Resident #9 sat by themself without any interaction. Resident #9 became agitated after continuously being moved from one area to another. Resident #9 told TNA #8 to get out of here. On 09/30/2024 at 12:16 PM, another resident was upset that Resident #9 was coming back in their area. The resident was coloring and stated Resident #9 will take the color pencils. At 12:19 PM, another resident was agitated with Resident #9. CNA #11 moved Resident #9 to face the back wall dining room table. At 12:23 PM, Resident #9 tried to leave dining room for a third time in 17 minutes. CNA #11 returned Resident #9 to the back dining table and told Resident #9 to stay in dining room. After asking another resident if anything was needed CNA #11then pulled Resident #9 (who was in a wheelchair) to the dining room table. Resident #9 asked what the [expletive] did I do [to be kept at the table]. At 12:27 PM, Resident #9 left the dining room table, CNA #11 then pushed Resident #9 back to the dining room table while Resident #9 said [expletive] don't push me this way. At 12:29 PM, Resident #9 self-propelled from the dining room again, asked which way to go, then rolled down the hallway, TNA #8 returned Resident #9 to the dining room table and stated, lunch is almost here. At 12:35 PM, Resident #9 left the dining room table. Both CNA #11 and TNA #8 attempted to push resident #9's wheelchair back to the dining room table. Resident #9 told the CNAs to get the [expletive] away from them. CNA #11 and TNA #8 told Resident #9 lunch would be there soon. At 12:38 PM, Lunch meal was brought to Hall 9 dining room. TNA #8 pushed Resident #9 to table without explaining lunch had arrived. Resident #9 pushed away from table. At 12:44 PM, Resident #9 went to other side of dining room as they continued to wait for meal tray. Resident #9's care plan shows to provide resident with baby doll, sensory activities, assess and anticipate needs for food, thirst, toileting needs, redirect with conversation or other activity. At 1:04 PM, Resident #9 finished eating and self-propelled out of the dining room. Certified Nursing Assistant Supervisor pushed Resident #9 back to the dining room table. Resident #9 was not provided any type of activity or interaction. At 1:41 PM, Resident #9 remained in dining room without any activity or interaction from staff. On 9/30/2024 at 2:00 PM, 10/01/2024 at 8:35 AM, and 2:30 PM, Resident #9 did not have a baby doll with them or in their room as care plan showed. On 10/02/2024 at 11:08 AM, during an interview, CNA #9 stated, a resident should not be placed at a dining room table by themself unless they choose to. Staff needs to watch Resident # 9 to keep them from entering other resident's rooms which had caused other residents to become upset and angry. There is not a reason Resident # 9 should be at a table with nothing to do. On 10/02/2024 at 11:37 AM, during an interview LPN #10 stated a resident should not be placed at a table with nothing to do. They may get lonely which could cause them to get upset or angry. There is not a reason Resident # 9 was to be kept in the dining room. On 10/02/2024 at 3:12 PM, during an interview the ADON stated a resident should not be placed at a table alone. Staff can always get something for them to do. There was not a reason Resident # 9 was to remain in the dining room all the time. On 10/02/2024 at 3:40 pm, Activity Assistant stated Halls 9 and 10 have baby dolls and pop-it fidgets in cabinet for residents to use. On 10/02/2024 at 3:42 PM, Activities Director was unaware of the baby doll in Resident #9's care plan until Activities Director reviewed the care plan at this time. On 10/03/2024 at 11:00 AM, during an interview, MDS/Care Planner stated, the care plan goes to the task list. For example, activities interventions would show on activities tasks. Activities would let Hall 9 CNA staff know how to redirect or other interventions for the resident. Sensory redirect was for when activity department was with Resident #9. Resident #9's day to day activity without Activity Department involvement would be television and music usually played on Hall 9. Resident #9 did not have alternate activities documented.

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance of cold and hot foods at temperatures that were acceptable to residents to improve palatability and encourage good nutritional intake during 2 of 2 meals observed on the following halls: 8, 10, 11, 200, 300 and 500. The findings are: 1. A Grievance Form dated 7/3/2024, was reviewed and indicated cold food as a concern at the supper meal. 2. On 10/01/24 at 12:46 PM, an unheated food cart that contained 17 lunch trays was delivered to the Hall 8 dining room by the Certified Nursing Assistant #3. At 12:52 PM, immediately after the last resident tray was served in the dining room, the temperatures of the food items on the test tray from the cart were checked by the Dietary Manager with the following results: a. Milk, 48 Degrees Fahrenheit. b. Vegetable blend 114 .6 Degrees Fahrenheit. c. Pureed vegetable 108 Degrees Fahrenheit. d. Pureed carrots 112.9 Degrees Fahrenheit. e. Pureed potatoes 105.5 Degrees Fahrenheit. f. Vegetable blend106.9 Degrees Fahrenheit. 3. On 10/01/24 at 1:02 PM, an unheated food cart that contained 15 lunch trays was delivered to hall 10 dining room by the Certified Nursing Assistant #3. At 1:15 PM, immediately after the last resident tray was served in the dining room, the temperatures of the food items on the test tray from the cart were checked by the Dietary Manager with the following results: a. Pureed potatoes 113 Degrees Fahrenheit. b. Pureed carrots 91.4 Degrees Fahrenheit. c. Pureed bread 110 Degrees Fahrenheit. d. Vegetable blend 112 Degrees Fahrenheit. e. Pureed carrots 110 Degrees Fahrenheit. 4. On 10/01/24 at 1:19 PM, Restorative Certified Nursing Assistant #7 began loading breakfast meal tray for hall 11 into the unheated food cart by the kitchen window in the dining room. She left the food cart door open while loading, finishing at 1:27 PM. After closing the food cart door. The unheated food cart that contained 9 lunch trays was delivered to hall 11 by the Certified Nursing Assistant #4. At 1:37 PM, immediately after the last resident tray was served in the dining room, the temperatures of the food items on the test tray from the cart were checked by the Dietary Manager with the following results: a. Milk 48 Degrees Fahrenheit. b. Vegetable blend 100 Degrees Fahrenheit. c. Pureed carrots 106. Degrees Fahrenheit. d. Pureed pot pie 102 Degrees Fahrenheit. e. Pureed carrots 106.9 Degrees Fahrenheit. 5. On 10/02/24 at 11:32 AM, Restorative Certified Nursing Assistant #7 was interviewed and asked what would happen when an unheated food cart was left open from the time you began loading the food trays into it, until the time you finished and close the door to it? She stated, it will get cold. 6. On 10/02/24 at 7:40 AM, an unheated food cart that contained 6 breakfast trays was delivered to the 300 Hall by Certified Nursing Assistant #5. At 7:50 AM, immediately after the last resident tray was served in their room, the temperatures of the food items on the test tray from the cart were checked by the Dietary Manager with the following results: a. Milk 48 Degrees Fahrenheit. b. Sausage links 105.5 Degrees Fahrenheit. c. Scrambled eggs 99.5 Degrees Fahrenheit. 7. On 10/02/24 at 7:51 AM, an unheated food cart that contained 15 breakfast trays was delivered to the 500 Hall by Certified Nursing Assistant #6. At 8:07 AM, immediately after the last resident tray was served in their room, the temperatures of the food items on the test tray from the cart were checked by the Dietary Manager with the following results: a. Milk 48.7 Degrees Fahrenheit. b. Pureed eggs 103 Degrees Fahrenheit. c. Pureed sausage 95 Degrees Fahrenheit. d. Scrambled eggs 97.6 Degrees Fahrenheit. e. Pureed French toast with milk 89 Degrees Fahrenheit.

Based on observation, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure residents who were assessed to wear a smoking apron wore one during the facility allotted smoke break time, and to ensure residents were not in possession of a lighter for 1 (Resident #101) of 1 sample mix residents reviewed for smoking. The findings include: On 10/1/24 at 9:43 AM, Surveyor interviewed Resident #101 who revealed they are a smoker and that they have a smoking apron offered to them during smoke break, but they don't wear it. Review of Resident #101's Care Plan with an initiated date of 2/7/2024 revealed Resident #101 was a smoker, facility was to store all smoking materials and the resident was to be supervised while smoking. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/10/2024 revealed Resident #101 scored a 15 (13-15 indicates cognitively intact) on the Brief Interview for Mental Status (BIMS). The MDS also revealed Resident #101 has a diagnosis of Alzheimer's disease Review of Resident #101's Smoking Safety Screening completed on 09/18/2024 noted the resident was to wear a smoking apron with supervision while smoking, and the facility was to store the resident ' s lighter. On 10/02/2024 at 11:20 AM, Surveyor observed Resident #101 on smoke break with seven (7) other residents present. Certified Nurse Aid (CNA) #12 was present to supervise the smoke break. CNA #12 asked the residents if anyone needed a smoking apron, and all residents responded no. Resident #101 was observed sitting in wheelchair with no smoking apron. Resident #101 was observed pulling a blue lighter out of their left shirt pocket and using it to light two cigarettes during the smoking break. The resident placed the lighter back in their shirt pocket and was allowed to re-enter the facility and go to their assigned room with the lighter. On 10/02/2024 at 11:20 AM, Surveyor interviewed CNA #12 who revealed the residents were evaluated for smoking aprons but that only one (1) resident was assessed to wear an apron and that was not Resident 101. CNA #12 stated residents were assessed for wearing a smoking apron for safety and none of the residents present were wearing a smoking apron. CNA #12 confirmed residents should not have possession of their own lighter for safety reasons, and Resident #101 was not permitted to keep their own lighter. On 10/02/2024 at 11:47 AM, Surveyor went to Resident #101's room and asked resident #101 if they still had their lighter they used to light the two cigarettes they smoked during smoke break. Resident #101 pulled out a blue lighter from their left shirt pocket, showed it to the surveyor and stated, I'm not supposed to have it. On 10/03/2024 at 11:29 AM, Surveyor interviewed the Assistant Director of Nursing (ADON) who stated, residents are assessed to wear smoking aprons during smoke breaks for safety reasons and staff should explain why it should be worn. ADON confirmed residents are not permitted to keep their own lighters for safety reasons and the facility stores them. ADON confirmed Resident #101 was not permitted to keep their own lighter. On 10/03/2024 at 11:50 AM, Surveyor interviewed the Director of Nursing (DON) who confirmed residents are assessed to wear smoking aprons during smoke breaks for safety reasons, and that staff observing the smoke break should not be asking residents assessed to wear a smoking apron if they want to wear it based on their assessment they are to have one on. DON stated residents are not permitted to keep their own lighters due to the potential danger to the whole facility and that Resident #101was not permitted to keep their own lighter. Review of a facility policy titled Smoking Policy- Residents with a revision date of July 2017 revealed in the 'Policy Statement' that the facility will establish and maintain safe resident smoking practices. 'Policy Interpretation and Implementation' noted 7. The staff shall consult with the attending physician and the DON to determine if safety restrictions are needed for a resident's smoking privileges based on their safe smoking evaluation.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore gloves while obtaining a blood sample from a fingerstick for 1 (Resident #1) of 3 residents reviewed for infection control. The findings include: The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2024, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact, and had a diagnosis which included diabetes mellitus during the 7 day look back period. A review of the Care Plan indicated the facility admitted Resident #1 with diagnoses that included diabetes mellitus without complications, acquired absence of right leg below knee, and epilepsy. A review of Resident #1's Care Plan, revised 04/18/2023, revealed the resident had Diabetes Mellitus. Interventions included diabetes medication as ordered by the doctor, observe for side effects and effectiveness of insulin, and fasting blood sugar as ordered by doctor. A review of the Physician's Orders, for May 2024 revealed Resident #1 had an order for a fast acting insulin per sliding scale .subcutaneously per Accuchecks (a device to measure the amount of glucose in the blood) before meals and bedtime related to Type 2 Diabetes mellitus. During an observation on 05/02/2024 at 12:18 pm, Licensed Practical Nurse (LPN) #1 obtained a blood sample with a finger stick on Resident #1 in the hallway at the medication cart. LPN #1 did not have on gloves during the sampling. LPN #1 placed a cotton ball with blood on it in the trash bin without gloves on. During an interview on 05/02/2024 at 12:24 pm, the LPN #1 confirmed she should have gloves on due to infection control. During an interview on 05/02/2024 at 1:11 pm, the Director of Nursing (DON) confirmed LPN #1 should have gloves on to perform a blood sampling by fingerstick due to infection control and should not have completed the sampling in the hallway due to dignity. During an interview on 05/03/2024 at 10:01 am, the Assistant Director of Nursing (ADON) confirmed LPN #1 should have gloves on to perform a blood sampling by fingerstick due to infection control. During an interview on 05/03/24 at 12:28 pm, Resident #1 confirmed he asked the nurse to check his blood sugar in the hallways and he does not mind having it checked in the hallways. A review of a facility policy titled, Blood Sampling-Capillary (Finger Stick), dated 09/30/2014, indicated, Purpose The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne disease to residents and employees .Equipment and Supplies .4. Personal Protective equipment (e.g., gloves) . Steps in Procedure .2. Don gloves .9. Remove gloves, and discard into appropriate receptacle . A review of a facility policy titled, Personal Protective Equipment - Using Gloves, dated 09/01/2010, indicated, Purpose: To guide the use of gloves . When to Use Gloves 1. When touching excretions, secretions, blood, body fluids, mucous membranes, or non-intact skin . A review of a facility policy titled, Standard Precautions, dated 10/01/2018, indicated, Policy Statement: Standard precautions are used in the care of all residents regardless of their diagnosis, or suspected or confirmed infection status. Standard precautions presume that all blood body fluids, secretion, and excretion (except sweat0, non-intact skin and mucous membranes may contain transmissible infectious agents . 1. Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease .2. Gloves: a. Gloves (clean, non-sterile) are worn when in direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material .

39316 Based on observation and interview, the facility failed to ensure foods stored in the refrigerator and freezer were covered and sealed to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; 1 of 2 ice machines and 1 of 2 ice scoop holders were maintained in clean and sanitary condition; floors, ceiling tiles, equipment were free of stain, debris, dirt, rust chipped; tiles were replaced, expired dairy products were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, failed to ensure residents were offered hand sanitation before lunch, and staff performed hand hygiene before handling resident's food without gloves for 1 of 1 (Resident #1). The failed practices had the potential to 100 affect residents who received meals from the kitchen. The findings are. On [DATE] at 9:06 AM, an opened, unsealed bag of hot dog buns was on the bread rack. On [DATE] at 9:17 AM, the following observations were made on the shelf in the freezer. a. An opened box that contained an uncovered and unsealed bag of dinner rolls. b. An opened box that contained an unsealed and uncovered bag of sweet rolls. On [DATE] at 9:36 AM, the ice machine panel in the break room for 100 to 600 halls had an accumulation of wet black residue on it. The Surveyor asked the Dietary Supervisor to wipe the area and wet black residue easily transferred to the paper towel. The Surveyor asked the Dietary Supervisor to describe what was in the ice scoop holder. She said there is black residue on the ice scoop holder. The Surveyor asked the Dietary Supervisor how often is the ice machine cleaned and who uses the ice from the machine? She stated, The (Certified Nursing Assistant) CNAs used it to fill the water pitchers in the residents' rooms. The maintenance man cleans it once a month. On [DATE] at 9:39 AM, the ice scoop holder on the wall by the ice machine had standing water in it. There were gray particle substances in the water. The Surveyor asked the Dietary Supervisor how often is the ice scoop holder cleaned and who uses the ice from the machine? She stated, The CNAs used it to fill the water pitchers in the residents' rooms. On [DATE] at 9:46 AM, the following observations were made on a shelf in the refrigerator in the medication room for 8 to 11 halls. a. An opened, uncovered, undated, and unlabeled cup of chocolate shake with a straw. b. Fourteen of 14 cartons of nutrition drink on a shelf in the refrigerator with an expiration date of [DATE]. On [DATE] at 9:47 AM, an opened and unlabeled box of ice cream was inside the freezer in the medication room on 8 to 11 halls. The ice cream was discolored and had ice cycles on it. The Surveyor asked the Dietary Supervisor to describe the appearance of the ice cream. She stated, It has freezer burn. On [DATE] at 9:50 AM, an opened box with an unsealed bag of cheese taquitos was on a shelf in the refrigerator in the medication room on 1 to 6 halls. On [DATE] at 10:16 AM, the following observations were made in the kitchen. a. Two loose ceiling tiles next to the steam table. b. The ceiling tile above the deep fryer had grease stains on it. c. The metal tracks around the tiles had rust on them, and some of the tracks had rust and were peeling. d. The ceiling tiles above the stove, oven, tea, and coffee maker had dirty lint hanging down from them. e. The ceiling tiles throughout the kitchen had stains. f. The formic to the window where meal trays are being sent out to the dining was chipped. g. The floor throughout the kitchen had stains and wax build up. h. The floor around the hand washing sink and the 3-compartment sinks had food and liquid spilled on it. i. The ceiling tiles in the storage room had a yellow and sage color on them. j. One ceiling tile was loose in the food preparation area. k. The ceiling tiles in the food preparation room were peeling exposing the fiber. l. There were loose food crumbs on the shelf below the food preparation counter where a meat slicer was kept and a rack where clean spatulas and spoons were kept. m. The facing of the freezer was removed, exposing the metal frames and air vent. The areas that were exposed had dust and lint hanging from them. On [DATE] at 10:29 AM, Dietary Employee #1 removed a box of bread sticks from the freezer and placed it on the counter. Without washing her hands, she removed gloves from the glove box and placed them on her hands. She then used her contaminated gloved hands to remove bread sticks from the box and placed them on the pans to be baked and served to the residents for lunch meal. [DATE] at 10:47 AM, Dietary Employee #1 opened the refrigerator, removed a bag of shredded lettuce, a bag of shredded cheese, and a plastic bag that contained half cut tomatoes and placed them on the counter. Without washing her hands, removed gloves from the glove box and placed them on her hands. She unzipped a plastic bag that contained shredded cheese and a bag of lettuce. Without removing her gloves and washing her hands, she removed lettuce from the bag and placed it in two to go containers. With the same gloves, she removed shredded cheese from the bag and placed them on top of the lettuce. Removed a half-cut tomato from a plastic bag and placed it on the cutting board. She sliced half cut tomatoes and placed them on top of the lettuce and cheese to be served to residents. On [DATE] at 10:56 AM, Dietary Employee #2 opened the refrigerator door and removed a container of slices of cheese and placed it on the counter. Without washing her hands, she removed 2 slices of cheese and bagged them to give them to the resident who requested cheese and crackers. During interview on [DATE] at 2:00 PM, the Surveyor asked Dietary Employee #2 what should you have done after touching dirty objects and before handling food items? She stated, Washed my hands. On [DATE] at 11:59 AM, Dietary Employee #1 scratched her face. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. The Surveyor asked Dietary Employee #1 immediately what should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. During observation on [DATE] at 1:27 PM, Certified Nursing Assistant (CNA) #4 set-up Resident #1's meal tray on the Resident#1's bedside table. CNA #4 began to assist Resident #1 with the meal and did not offer to wash the Resident's hands. At 1:28 PM, CNA #4 picked up a ,d+[DATE] grilled cheese sandwich with bare hands and handed it to Resident #1 During interview on [DATE] at 1:43 PM, CNA #4 said she should not have handed Resident #1 her sandwich with her bare hands. During interview on [DATE] at 2:07 PM, The Director of Nursing (DON) said staff should not touch residents' food with bare hands, and staff should provide or offer hand hygiene before meals. Review on [DATE] at 12:57 PM of facility policy titled Handwashing/Hand Hygiene showed, the staff will follow the handwashing/hand hygiene procedures to help prevent the spread of infections.

Based on observation, record review and interview, the facility failed to ensure a resident with an indwelling foley catheter received the appropriate care and services to prevent further complications and possible infections for 1 (Resident #210) resident with an indwelling foley catheter . The findings are: Review of Resident #210's Order Summary Report as of 10/23/23 showed an admitted [DATE] and no physician order for an indwelling foley catheter. Review of Resident #210's care plan showed an admitted [DATE] and no documentation regarding an indwelling foley catheter. During observation on 10/24/23 9:55 AM, Resident #210 was in bed with an indwelling foley catheter bag observed attached to the bed frame. Resident #210's family member was asked, why does Resident #210 have an indwelling foley catheter? Resident's family member stated, because Resident #210 can't walk or get up to the bathroom, and because of the sores on the Resident's bottom. During observation on 10/25/23 at 8:15 AM and 9:55 AM, Resident #210 was in bed with an indwelling foley catheter bag attached to the bed frame. During interview on 10/25/23 at 12:26 PM, Certified Nursing Assistant (CNA) #5 was asked, why does Resident #210 have a foley catheter? CNA #5 stated, I don't know. CNA #5 was asked, how is Resident's foley catheter being monitored? CNA #5 stated, I assume I would empty every shift. CNA #5 was asked; how do you know how to take care of Resident's foley catheter? CNA #5 stated, I can't see anything on the computer because I can't log onto it yet. On 10/25/23 at 12:35 PM, Licensed Practical Nurse (LPN) #2 was asked, why does Resident #210 have a foley catheter? LPN #2 stated, I don't know. LPN #2 was asked, how is Resident #210's foley catheter being monitored? LPN #2 stated, they report every shift output-it should be on the medication administration record [MAR]. LPN #2 was asked, is the Resident's output documented on the MAR? LPN #2 stated, it is not. LPN #2 was asked, how do you know how to take care of the Resident ' s foley catheter? LPN #2 stated, it should be care planned. LPN #2 was asked, is there a physician order for Resident #210's foley catheter? LPN #2 stated, no, there is no order, there should be an order. During interview on 10/26/23 at 9:21 AM, the Director of Nursing (DON) was asked, why should there be an order for a resident with an indwelling foley catheter? The DON stated, so we know why it's there, when it was put in, so we can relay to CNA's and make it a task for them to ensure care. It helps us if a resident gets a urinary tract infection, and to keep an eye on infection risks. Review on 10/26/23 at 9:27 AM, of facility policy titled Catheter Care, Urinary showed, the the purpose is to prevent catheter-associated urinary tract infections. Review the resident's care plan to assess for any special needs of the resident.

Based on observations, record review, and interviews, the facility failed to provide necessary services to maintain diabetic nail care to promote good hygiene and prevent the possible spread of infection for 1 (Resident #1) of 1 sample mix residents who were dependent on staff for nail care. The findings are: Review of Resident#1's Order Summary Report showed a physician order with a start date of 7/26/2022 to perform diabetic nail care on Tuesdays every two weeks on the day shift. Review of Resident #1's care plan with a revision date of 6/8/23 showed an activities of daily living self-care performance deficit, and inform nurse when nails need to be trimmed. During observation on 10/23/23 at 12:04 PM and 1:30 PM, Resident #1's fingernails on the left hand are half inch in length with black/brown dried substance under them. During interview on 10/23/23 at 1:43 PM, Certified Nursing Assistant (CNA) #4 was asked to describe Resident #1's nails. CNA #4 stated, They need to be clipped, cleaned, and filed. During interview on 10/23/23 at 2:07 PM, the Director of Nursing (DON) was asked to describe Resident #1's fingernails. The DON stated, They need to be cleaned and they are sharp. The DON measured Resident #1's nails on the left hand, and the nails were 1 centimeter and two-tenths in length. Review on 10/26/23 at 9:27 AM of facility policy titled Fingernails/Toenails, Care of showed clean the nail bed and keep nails trimmed prevent infection. Nail care includes regular trimming and daily cleaning.

Based on observations, record review, and interviews, the facility failed to ensure skin tears/wounds of unknown origin were recognized and physician orders were obtained for treatment, and family notified for 2 (Resident #1 and #36) of 2 sample mix residents. The findings are: On 10/23/23 at 12:02 PM, 10/23/23 at 1:42 PM, and 10/24/23 at 12:35 PM Resident #1 had a red area approximately 2 centimeters in diameter with a skin tear in the middle to the left wrist with no dressing. Resident #1 did know how it happened. Review of the skin assessment for Resident #1 dated 10/18/23 showed the resident had edema to the lower extremities with ace wraps and heel boots in place, edema in the right elbow and no other skin issues noted. Review of Resident #1's electronic health record revealed no physician orders for treatment to the left wrist and no incident or accident reports related to the skin tear. Review of Resident #1's care plan with a revision date of 9/8/23 showed the resident at risk for impaired skin integrity, with interventions to include full skin audit per facility schedule, observe skin for redness and breakdown. On 10/24/23 at 2:46 PM, Licensed Practical Nurse (LPN) #1 confirmed there was no treatment order for Resident #1's left wrist and said she was not aware of how the injury happened. During an interview on 10/26/23 at 9:21 AM, the Director of Nursing (DON) said if a resident gets a skin tear the nurses should notify the wound nurse, if the wound nurse can't get to it, they should use the standing orders, call the family and physician and do an incident report for any injury. Review on 10/26/23 at 9:27 AM of facility policy titled Skin Tears showed obtain a physician's order, review the resident's care plan, current orders, and diagnoses and treatment orders. On 10/23/24 at 10:13 AM, 10/24/23 at 8:28 AM and 10/24 at 12:36 PM, observed Resident #36 lying in bed with a band aid observed to the right upper arm with no date and dark dried substance under it. The care plan with a revision date of 8/30/2023 showed Resident #36 is at risk for impaired skin integrity. The Medication Administration Record (MAR) dated October 2023 did not document a treatment order for Resident #36's right arm. The Treatment Administration Record (TAR) dated October 2023 did not document a treatment order for Resident #36's right arm. A skin check assessment dated [DATE] showed Resident #36 continues with scattered bruising and old scars to extremities and torso, right side flaccidity, no open areas or skin breakdown at this time, buttocks slightly red but blanchable. On 10/24/23 at 2:42 PM, Certified Nursing Assistant (CNA) #2 said the resident transferred from the other hall with the band aid. During interview on 10/24/23 at 2:46 PM, Licensed Practical Nurse (LPN) #1 confirmed there were no treatment orders, and no documentation related to the wound on Resident #36 right upper arm.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The findings are: On 10/23/23 11:27 AM, Dietary Employee (DE) #1 placed 10 servings of bread sticks into a blender. She added whole milk and pureed it. At 11:31 AM, DE #1 transferred pureed bread into a pan and covered it with foil, and placed it in the oven. The consistency of pureed bread was thick, not smooth, and had lumps. On 10/23/23 at 11:36 AM, DE #1 used a 6-ounce spoon to place 13 servings of spaghetti with sauce into a blender and pureed. At 11:43 AM, she poured the pureed spaghetti with meat sauce into a pan. She covered the pan with foil and placed it in the oven. The consistency was lumpy, not smooth, with pieces of pasta and meat visible in the mixture. On 10/23/23 at 11:49 AM, DE #1 used a 4-ounce spoon to place 13 servings of vegetable blend into a blender and pureed. At 11:53 AM, she poured the pureed vegetable blend into a pan. She covered the pan with foil and placed it in the oven. The consistency was lumpy, runny, not formed and not smooth. There were pieces of carrots visible in the mixture. On 10/23/23 at 12:53 PM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed foods served to the residents who have physician's orders for pureed diets. She stated, Pureed spaghetti has lumps. I can see pasta in it. The pure vegetables were thinner, runny. Too much juice was added from the vegetable. The pureed bread has lumps in it. On 10/24/23 at 7:30 AM, the pureed sausage served to the residents on pureed diets was gritty and not smooth. The pureed bread was thick and had lumps in it. On 10/24/23 at 7:51 AM, the Surveyor asked the Dietary Supervisor to describe the consistency of the pureed food items served to the residents who required pureed diets. She stated, Pureed bread is too thick and pureed sausage was gritty. On 10/24/23 at 7:56 AM, the Surveyor asked the lead Certified Nursing Assistant #1, who was assisting residents in the dining room, to describe the consistency of the pureed food items served to the residents on pureed diets. She stated, Pureed bread was gummy, and pureed sausage was gritty.

Based on observation and interview, the facility failed to ensure trash was properly contained within 1 of 2 dumpsters to minimize the presence of foul odors and decrease the potential for pest infestation. The failed practice had the potential to affect all 101 residents who resided in the facility. The findings are: On 10/23/2023 at 10:04 AM, two dumpsters were located outside of the facility. One dumpster was almost full, and the lid was not closed with flies flying around the dumpster. There were 11 loose gloves, cups, plates straws and other debris lying on the ground around the opened dumpster, and between the first and second dumpster was a clear trash bag with trash. On 10/23/23 at 10:06 AM, there were cups, straws, gloves, cereal bowls on the ground around the second dumpster. During interview on 10/23/23 at 10:06 AM, the Surveyor asked the Dietary Supervisor how often is trash pick-up? She stated, At least once a week. There shouldn't be anything on the ground.

Based on observation and interview, the facility failed to ensure the kitchen was free of pests and failed to ensure the dining room was free of pests for 5 Residents who received meals from the dining room. The failed practice had the potential to affect 100 residents who received food from the kitchen. The findings are. On 10/23/23 at 9:05 AM, multiple flies and gnats were observed on the floor of the washing machine room. During interview on 10/23/23 at 9:05 AM, the Dietary Supervisor confirmed the findings above. On 10/23/23 at 10:37 AM, the following observations were made during the food noon meal preparation. a. A fly was on the leg of a food cart where 2 pans that contained bread sticks to be baked were kept. b. One fly was on the leg of the food preparation counter where a can opener was attached. c. There were 4 flies on the leg of the food preparation counter where the blender machine was kept. d. One fly was on the cod attached to the blender machine. e. One fly was resting on a rag on the counter by the food preparation sink. The Dietary Supervisor confirmed there were 8 flies total resting on the leg, cod, and on a rag. On 10/23/23 at 10:39 AM, one fly was at the edge of a pan that contained bread sticks, and the Dietary Supervisor waved it away. On 10/24/23 at 7:37 AM, a fly was crawling on the floor in the dining room close to the dirty dish window, and a fly at the edge of a pan on a cart close to the dirty dish window. On 10/24/23 at 7:43 AM, a fly was on a clean rack on a cart by the 3- compartment sink that contained a clean lid on it. On 10/24/23 at 7:44 AM, there were 13 flies crawling on the floor in the dish washing machine room and multiple gnats crawling on the floor in and around the hand washing sink. The Dietary Supervisor confirmed there were 13 flies and several gnats crawling on the floor in the dish machine room.

Based on observations, record review and interviews, the facility failed to ensure the baseline care plan addressed the use of an indwelling foley catheter to prevent possible injury and or infections for 1 (Resident #210) of 1 sample mix residents who admitted with an indwelling foley catheter. The findings are: Review of Resident #210's care plan with an initiated date of 10/23/23 showed no documentation regarding an indwelling foley catheter. Review of Resident #210's Order Summary Report showed no documentation no documentation concerning an indwelling foley catheter. On 10/24/23 9:55 AM Resident #210 was observed with an indwelling foley catheter. Resident's family member was asked, why does Resident #210 have an indwelling foley catheter? The Resident's family member stated, because Resident #210 can't walk or get up to the bathroom, and because of the sores on Resident's bottom. On 10/25/23 8:15 AM Resident #210 was observed with an indwelling foley catheter. The Resident's family member said Resident #210 has a catheter because the Redisdnet cant walk or get up to the bathroom and because of the sores on Resident's bottom. On 10/25/23 12:43 PM LPN #3 said, it should be care planned.

Based on observation, record review, and interview the facility failed to ensure the meatloaf portion size met the nutritional needs of residents. This had the potential to affect 107 residents receiving a regular diet and a mechanical soft diet as documented on the list provided by the Administrator on 10/24/22 at 2:39 p.m. The findings are: a. On 10/24/22 at 11:56 a.m. Dietary Service Manager (DSM) #1 hand sliced the meatloaf using a kitchen knife, with random weights from meatloaf size's varying 4.5 oz (ounces), 3.5 oz., and 3 oz. from 3 pans of meatloaf. b. On 10/24/22 at 1:30 p.m. a review of the All-Beef Meatloaf recipe provided by DSM #1 on 10/24/22 at 1:30 p.m. documented, portion Regular 1 4 oz slice. c. On 10/24/22 at 1:40 p.m. The Surveyor asked DSM #1 did you serve the meatloaf at 4.5 oz., 3.5 oz, and 3 oz? DMS #1 replied, yes, it is. The Surveyor asked DSM #1, Can you identify the portion size the recipe called for? DSM #1 replied, 3 to 4 oz. The Surveyor informed DSM #1 the recipe portion size documented 1 4 oz slice. DSM #1 replied, I looked at it wrong then, it said 4 oz. slices equal 3 oz. of protein. That's where I got the 3 oz. from. d. On 10/25/22 at 12:20 p.m. The Surveyor asked the Administrator, Should the recipe be followed regarding portion sizes? The Administrator replied, yes.

Based on observation, interview, and record review, the facility failed to ensure residents received care and treatment in accordance with professional standards of practice as evidenced by failure to ensure indwelling foley catheter drainage bags were changed to prevent infections and the spread of other diseases for 1 (Resident #3) of 2 (Resident #9) sampled residents who had Physician Orders for indwelling/suprapubic foley catheters according to a list provided by the Director of Nursing (DON) on 10/25/2022 at 3:31 pm.; the facility failed to ensure residents with a [CONDITION(S)] had clean dry dressings to prevent skin irritation and possible infection for 1 (Resident #1) of 2 (Resident #7) sampled residents who had tracheostomies according to the Roster Matrix provided by the Administrator on 10/24/2022 at 10:16 am; the facility failed to ensure residents with pressure/venous ulcers were consistently monitored, assessed and dressings were changed to promote healing and to prevent possible infection, for 1 (Resident #2) of 1 sampled resident who had pressure/venous ulcers according to a list provided by the DON on 10/25/2022 at 3:31 p.m. The findings are: 1. Resident #3 (R#3) had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. A Physician Order with a start date of 7/15/2022 documented, .foley catheter 18 French with 10 cc (cubic centimeter) bulb .change PRN (as needed) for removal for occlusion/leaking every night shift starting on the 15th and ending on the 15th every month . b. A Physician Order with an order date of 6/16/2022 documented, .foley catheter care q (every) shift and prn (as needed) with soap and water or wipes . c. A Physician Order with a start date of 6/16/2022 documented, .foley catheter output q (every) shift every shift for output .record foley catheter output q shift . d. The Care Plan with a revision date of 6/22/2022 documented .has a urinary catheter (#18 fr (French) 10 ml (millimeter) bulb) r/t (related to) anal fistula .Cath care q shift .check placement of stat lock/leg band placement . e. On 10/24/2022 at 10:03 a.m., R#3 was lying in bed with an indwelling foley catheter bag and tubing containing a thick brownish/reddish in color liquid and sediment. f. On 10/25/2022 at 2:38 p.m., The Surveyor asked Licensed Practical Nurse (LPN) #1, When are residents indwelling foley catheters changed? LPN #1 replied, they have prn orders whenever they need it, and some have specific orders. The Surveyor asked LPN #1, Why should residents indwelling foley catheter bags and tubing be free from thick brown/reddish sediment? LPN #1 replied, so it doesn't back up in their bladder and cause infection. The Surveyor asked LPN #1, Who is responsible for ensuring residents indwelling foley catheter bags and tubing are changed and free from thick brown/reddish sediment. LPN #1 replied, the primary nurse taking care of the resident? g. On 10/25/2022 at 3:02 p.m., The Surveyor asked the DON, when are residents indwelling foley catheters changed? The DON replied, PRN, unless there's an order. The Surveyor asked the DON, Why should residents indwelling foley catheter bags and tubing be free from thick brown/reddish sediment? The DON replied, It would be an infection risk. The Surveyor asked the DON, Who is responsible for ensuring residents indwelling foley catheter bags and tubing are changed and free from thick brown/reddish sediment. The DON replied, nursing. h. A policy provided by the Administrator on 10/25/2022 at 11:56 a.m., documented .Catheter Care, Urinary .the purpose of this procedure is to prevent Catheter-Associated Urinary Tract Infections .is suggested to change catheters and drainage bags based on clinical indications such as infections, obstruction, or when the closed system is compromised . 2. Resident #1 had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/20/2022 documented the resident scored 11 (8-12 moderately impaired) on the Brief Interview for Mental Status (BIMS), required extensive assist for bed mobility, transfer, toilet use, and personal hygiene, had no behaviors and no rejection of care. a. A Physician Order with an order date of 7/19/2022 documented, .[CONDITION(S)] type: shiley [MEDICATION(S)] .size 6.5 . b. A Physician Order with a start date of 7/19/2022 documented, .[CONDITION(S)] care every shift as needed for prophylaxis . c. A care plan with a revision date of 9/21/2022 documented .at risk for impaired Skin integrity .cancer .malnutrition .[CONDITION(S)] .[CONDITION(S)] .care q (every) shift . R #1 was not care planned for removing the [CONDITION(S)] dressing. d. On 10/24/2022 at 10:19 a.m., R#1 was in bed in her room. There is no dressing around the stoma/insertion site of R #1 [CONDITION(S)] exposing greenish/whiteish thick [MEDICATION(S)] on R #1 skin. There was no [CONDITION(S)] dressing on or around R #1. There was no [CONDITION(S)] dressing in the trash can at R#1 bedside. e. On 10/24/2022 at 10:25 a.m., The Surveyor asked Licensed Practical Nurse (LPN) #2, Is R #1 supposed to have a dressing under her [CONDITION(S)] collar? LPN #1 replied, she does, unless she takes it off. The Surveyor asked LPN #1, When was the last time you were in here? LPN #1 replied, around 8:00 a.m., when I gave her medicine, I make rounds when I can, I've been on the other hall passing medicine. The Surveyor asked LPN #1, Are you trained in [CONDITION(S)] care/suctioning? LPN #1 replied, yes. The Surveyor asked LPN #1, is R #1 care planned for pulling her [CONDITION(S)] dressing off? LPN #1 replied, I know it's documented. f. On 10/25/2022 at 2:38 p.m., The Surveyor asked LPN #1, Why should a resident with a [CONDITION(S)] have a clean dressing around the insertion site/stoma? LPN #1 replied, to keep skin dry and keep moisture off their skin. The Surveyor asked LPN #1, Who is responsible for ensuring residents with tracheostomies have a clean dressing around the insertion site/stoma. LPN #1 replied, the nurse taking care of them. g. On 10/25/2022 at 3:03 p.m., The Surveyor asked the Director of Nursing (DON), Why should a resident with a [CONDITION(S)] have a clean dressing around the insertion site/stoma? The DON replied, to prevent infection. The Surveyor asked the DON, Who is responsible for ensuring residents with tracheostomies have a clean dressing around the insertion site/stoma? The DON replied, nursing. h. A policy provided by the Administrator on 10/25/2022 at 11:56 a.m., documented, .[CONDITION(S)] Care .the purpose of this procedure is to guide [CONDITION(S)] care and the cleaning of reusable [CONDITION(S)] cannulas .remove old dressings .apply a fenestrated gauze pad around the insertion site .replace supplemental oxygen mask over [CONDITION(S)] . 3. Resident #2 (R#2) had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/15/2022 documented the resident scored 15 (13-15 Cognitively Intact) on the Brief Interview for Mental Status (BIMS), required extensive assist for transfers and toilet use, and required limited assist for bed mobility, dressing, and personal hygiene, had no behaviors or rejection of care, was always incontinent of bladder and had a [CONDITION(S)]. a. On 10/24/2022 at 9:45 am, The Surveyor entered R #1's room. There was a strong, pungent odor of infection. R #1 was laying on the bed. The left lower leg was wrapped in loose, soiled, kerlix, with a date of 10/19/2022. The Surveyor asked R #1, how often do they change it? R #1 replied, every other day. The Surveyor asked R #1, Is there infection in it? R #1 replied, the doctor thinks so. The Surveyor asked, R #1, does it hurt? R #1 replied, yes. b. On 10/24/2022 at 10:59 a.m., a review of R #1 October 2022 Treatment Administration Record (TAR) documented, .Monitor Stage 3 pressure ulcer to left heel for dressing intactness and s/s (signs and symptoms) of infection QS (every shift) related to pressure ulcer of left heel stage 3 . There was no monitoring documentation on 7A-7P shift for 10/2/2022. There is no monitoring documentation for 7P-7A shift for 10/1, 10/2, 10/7, 10/8, 10/9, 10/14, 10/15, 10/16, 10/21, 10/22, and 10/23/2022. c. On 10/24/2022 at 10:59 a.m., a review of R#1 October 2022 TAR documented, .Monitor venous ulcer to left lateral calf for dressing intactness and s/s [signs/symptoms] of infection QS every shift related to [CONDITION(S)] . There was no monitoring documentation on and A [and]-7P shift for 10/2/2022. There is no monitoring documentation for 7P-7A shift for 10/1, 10/2, 10/7, 10/8, 10/9, 10/14, 10/15, 10/16, 10/21, 10/22, and 10/23/2022. d. On 10/24/2022 at 11:00 a.m., a review of R #1's Physician Orders showed no treatment orders. e. On 10/24/2022 at 11:15 a.m., a review of R #'1's Care Plan with a revision date of 10/17/2022 documented, .at risk for impaired skin integrity .left lateral calf .left lateral ankle .now stage 3 .stage 3 to left heel .treatment to stage 3 PU (pressure ulcer) lt (left heel) as ordered . f. On 10/24/2022 at 11:23 a.m., a review of the Progress Notes dated 10/13/2022 documented, .Treatment changed from collagen gel to hydrometra blue d/t (due to) deterioration in wound size this week .Cleanse Stage 3 pressure ulcer to left lateral ankle with wc (wound cleaner), pat dry with gauze, apply [MEDICATION(S)] blue and cover with ABD (abdominal) pad, wrap with kerlix and secure with tape, change Q (every) M,W, and F (Monday, Wednesday, Friday) and PRN (as needed) till healed every day shift every Mon, Wed, Fri related to pressure ulcer of left ankle, stage 3 and as needed related to pressure ulcer of left ankle stage 3 . Treatment changed from calcium alginate AG to Medi honey d/t increase in eschar tissue and decrease in drainage .treatment cleanse stage 3 pressure ulcer to left heel with wc, pat dry with gauze, apply Medi honey and cover with ABD pad, wrap with kerlix and secure with tape, change Q M,W and F and PRN till healed every day shift every Mon, Wed, Fri related to pressure ulcer of left heel, stage 3 and as needed related to pressure ulcer of left heel stage 3 . g. On 10/24/2022 at 12:02 p.m., R #1 was lying in bed with a dressing to the left lower leg with a date of 10/19/2022 and initials of AC. The dressing was loose and soiled. The room smells of infection. The Surveyor asked R #1, has anyone been in today to change the dressing to your leg? R #1 replied, no they haven't been in here to change it. h. On 10/24/2022 at 12:11 p.m., The Surveyor asked Licensed Practical Nurse (LPN) #3, how often is the dressing on R #1 left heel changed? LPN #3 replied, on Monday, Wednesday, and Friday. The Surveyor asked LPN #3, When was the last time it was changed? LPN #3 replied, it says it was done on 10/19/2022. The Surveyor asked LPN #3, why wasn't it changed on 10/21/2022? LPN #3 replied, because she was at a doctor's appointment all day. The Surveyor asked LPN #3, is there a PRN order for dressing changes. LPN #3 replied, yes, change day or night. The Surveyor asked LPN #3, do you have an order to monitor the wounds. LPN #3 replied, yes, it's on the Treatment Authorization Request (TAR) for every shift. The Surveyor asked LPN #3, how often are wounds measured. LPN #3 replied, once a week. The Surveyor asked LPN #3, why would you use a PRN order. LPN #3 replied, if soiled, or wet, if it hasn't been done, I could use the PRN order if it's out of range, and if it's not intact. The Surveyor asked LPN #3, who can monitor the wounds and dressings. LPN #3 replied, all nurses can do monitoring. i. On 10/25/2022 at 2:38 p.m., The Surveyor asked LPN #1, Why should wounds/pressure ulcer dressings be changed on a regular basis? LPN #1 replied, to keep the wound clean and dry, and keep bacteria from getting in, and keep infection from getting in. The Surveyor asked LPN #1, Why should wounds/pressure ulcers be monitored and assessed? LPN #1 replied, to check for changes and report to the doctor. The Surveyor asked LPN #1, Why should this be documented? LPN #1 replied, so each nurse knows what's going on. The Surveyor asked LPN #1, Who is responsible for ensuring wounds/pressure ulcer dressings are changed, monitored, and assessed? LPN #1 replied, during the week, the wound nurse, Monday through Friday, and there are PRN orders, so the floor nurses can change it if its soiled. j. On 10/25/2022 at 3:02 p.m., The Surveyor asked the Director of Nursing (DON), why should wounds/pressure ulcer dressings be changed on a regular basis. The DON replied, to prevent the wound from getting worse and prevent infection. The Surveyor asked the DON, Why should wounds/pressure ulcers be monitored and assessed? The DON replied, to check to see if wound is worsening or if there is infection or see if we need to change the orders. The Surveyor asked the DON, Why should this be documented? The DON replied, To prove we completed it and to document if it's getting better or worse and monitor for infection, if it's not documented, it didn't happen. The Surveyor asked the DON, Who is responsible for ensuring wounds/pressure ulcer dressings are changed, monitored, and assessed? The DON replied, the treatment nurse, then I would follow up. The Surveyor asked the DON, What are your expectations from your staff regarding following the facility policy and procedures and the CMS (Centers for Medicare and Medicaid Services) Guidelines. The DON replied, I expect for them to follow them. k. On 10/25/2022 at 3:23 p.m., The Surveyor asked the Administrator, who is responsible for ensuring wounds/pressure ulcer dressings are changed, monitored, and assessed The Administrator replied, nursing. The Surveyor asked the Administrator, What are your expectations from your staff regarding following the facility policy and procedures and the CMS Guidelines? The Administrator replied, they are to be followed. l. A policy provided by the Administrator on 10/25/2022 at 11:56 a.m. documented, .Wound Care .the purpose of this procedure is to provide guidelines for the care of wounds to promote healing .verify that there is a physician's order .review the resident's care plan .remove dressing .apply treatments as indicated .dress wound .mark tape with initials, time, and date and apply to dressing .the following information should be recorded in the resident's medical record .the type of wound care given .the date and time the wound care was given .the name and title of the individual performing the wound care .all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound .report other information in accordance with facility policy and professional standards of practice .

Based on record review, and interview, the facility failed to ensure an assessment was completed to determine wounds on the abdomen so treatment could be promptly initiated to prevent further decline for 1 (Residents #1) of 6 (Resident #1 - #6) sampled residents who had wounds. This failed practice resulted in harm to Resident #1 who was diagnosed with multiple wounds to the abdomen during an emergency room evaluation and had the potential to affect 18 residents with wound treatment orders as documented on order listing report provided by the Administrator on 8/30/21. The findings are: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/21/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); required extensive two-plus person assistance for bed mobility, transfer and toilet use; was occasionally incontinent of bladder; weighed 389 pounds; was at risk for developing pressure ulcers; and had an unstageable pressure ulcer with suspected deep tissue injury (DTI) in evolution. The discharged Return Not Anticipated was dated 8/5/2021. a. The care plan documented, Focus [Resident #1] is at risk for impaired skin integrity r/t decreased mobility, episodes of incontinence, Lymphodema, and present of skin concerns and [CONDITION(S)] on admission. admitted with stasis ulcer to left calf and pressure ulcer to (DT) to back of right thigh, 5/27/21 - Rash noted to body r/t allergic reaction to IV [intravenous] antibiotics. Date Initiated: 5/17/21 . Interventions .Conduct body audits weekly . Date Initiated: 5/28/21 . Tx [treatment] as ordered to existing skin concerns. Observe weekly for improvement. Report worsening to MD [Medical Doctor] . Date Initiated 5/28/21. b. A weekly skin check dated 7/26/21 documented, Does the resident have a loss of skin integrity? Yes . Existing update skin and wound evaluation for each existing area of loss. Does the resident have a new loss of skin integrity? No There was no documentation of any wounds to the abdomen. c. A note completed by the Registered Nurse Practitioner documented, .Date of Visit 8/5/2021 . Shearing to buttocks was called yesterday when I was off due to bleeding to patient's buttocks. Nursing reported there was a lot of bleeding coming from open sheared areas. I told nursing to hold until bleeding stopped. Hold her blood thinners and get labs in the am [morning] . Called back to resident's room at 1730 [5:30 p.m.] due to change in condition. Patient was alert . but appeared more pale than previous to upper body. Her legs exhibited modeling [sic mottling] to bilateral inner thighs which extended to mid-thigh. She denied any pain or discomfort but appeared to not feel well. Labs were significant for WBC [white blood count] 26.68, Hbg [hemoglobin] 10.1, HCT [hematocrit] 33.1, Platelets 555. I called and discussed with [physician] who agreed with my plan of sending patient to ED [emergency department] for further evaluation and treatment. d. Hospital emergency room records dated 8/5/21 documented, .Patient presents for evaluation of abnormal CBC [complete blood count] or hematology results, decreased platelet count . Physical Exam . Abdomen Female: .Chronic appearing wound to the right inferior pannus [abdominal fold] with serous drainage . e. On 8/31/21 at 9:01 a.m., the ER physician was asked if Resident #1 had abdominal wounds. He stated, Yes, she had a large necrotic area below the belly button in the fold. He was asked, Can you estimate the size? He stated, Approximately 5 areas all about 1 centimeter by 1 centimeter overall it was about 8 centimeter by 8 centimeter. f. On 8/31/21 at 9:06 a.m., the Director of Nursing and the Assistant Director of Nursing were both asked about the wound on the abdomen and both of them stated, We didn't know about any wounds on her abdomen. g. On 8/31/21 at 9:30 a.m., the Dedicated Treatment Nurse was asked, Where are the weekly skin assessments documented? The nurse stated, On the Weekly Skin Check form in [facility software]. The nurse was asked, Were you aware of any wounds on [Resident #1's] abdomen? The nurse stated, No, I wasn't. h. On 8/31/21 the following interviews were conducted: 1) At 12:44 p.m., Certified Nursing Assistant (CNA) #1 was asked, Can you tell me where [Resident #1's] wounds were? The CNA stated, On her foot, leg, in the folds of her back. The CNA was asked, Did she have anything on her abdomen below the belly button? The CNA stated, No. 2) At 12:46 p.m., CNA #2 was asked, Can you tell me where [Resident #1] wounds were? The CNA stated, On her foot, leg, in the folds of her back. The CNA was asked, Did she receive baths? The CNA stated, She couldn't stand for water to hit her. She was bathed sitting in a chair in her room and we just patted the areas. The CNA was asked, Did she have anything on her abdomen below the belly button? The CNA stated, No. 3) At 12:50 p.m., CNA #3 was asked, Can you tell me where [Resident #1] wounds were? The CNA stated, On her foot, leg, in the folds of her back. The CNA was asked, Did she have anything on her abdomen below the belly button? The CNA stated, No. 4) At 12:55 p.m., CNA #4 was asked, Can you tell me where [Resident #1] wounds were? The CNA stated, On her foot, leg, in the folds of her back. The CNA was asked, Did she receive baths? The CNA stated, She couldn't stand for water to hit her. she was bathed sitting in a chair in her room and we just patted the areas. The CNA was asked, Did she have anything on her abdomen below the belly button? The CNA stated, No. i. On 9/1/21 at 8:37 a.m., the APN was asked, When you saw her on 8/5/21 did you look at her skin? The APN stated, Yes, I did. The APN was asked, Did you lift her abdomen and look at the skin? The APN stated, No, but I palpated her abdomen and I would have expected her to identify pain if she'd had any skin issues under there. j. On 9/1/21 at 9:24 a.m., the Treatment Nurse was asked, Did you ever lift the abdomen to view the skin? The nurse stated, No, ma'am. k. On 9/1/21 at 9:37 a.m., CNA #4 was asked, Did you ever lift up the abdomen to look at the skin? The CNA stated, No. l. On 9/1/21 at 9:39 a.m., Licensed Practical Nurse (LPN) #1 was asked, Did you perform weekly skin audits on [Resident #1]? The LPN stated, From time to time. The LPN was asked, Did you ever lift up her abdomen to look at the skin under there? Stated, Yes, but I can't tell you the last time I did. I know she had several wounds on her bottom and legs though. The LPN was asked, What was the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] ? The LPN stated, All they ordered was powder.

Complaint # (AR 073) was substantiated, all, or in part, with these findings. Based on observation, record review, and interview, the facility failed to ensure the resident environment was as free of accident hazards as possible, as evidenced by failure to immediately remove, repair or replace a raised metal threshold at 1 (Hall 4) of 1 exit door to minimize the risk of falls for residents who smoked and utilized the affected exit to access the smoking area. The facility also failed to ensure all staff were trained and compliant with the necessary safety precautions for transporting residents in wheelchairs across the raised threshold, which resulted in a fall with injury for 1 (Resident #5) of 3 (Residents #5, #2 and #4) who required a wheelchair for mobility and utilized the exit door to access the smoking area. The failed practices resulted in past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #5, who was pushed forward over the raised threshold in a wheelchair and was thrown from the wheelchair to the ground, resulting in injury, had the potential to cause more than minimal harm to 8 residents who utilized the smoking area, according to a list provided by the Administrator on 2/20/18. The Administrator was informed of the past immediate jeopardy condition on 2/20/18 at 3:49 p.m. The findings are: 1. Resident #5 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. a. Nurses' Notes dated 2/12/18 at 19:44 (7:44 p.m.) documented, .Resident was being taken out to smoke by CNAs (Certified Nursing Assistants). Resident pushed over uneven surface by CNA in WC (wheelchair) forward, instead of backward, and resident fell forward out of wheelchair, fell on L (left) side (is paralyzed on the L side r/t (related to) stroke two weeks ago). Resident vomited. This nurse, assisted by a CNA assisted resident from ground to sitting position where this nurse cleaned resident face with a towel and water brought by a CNA and then assisted resident from ground to WC. This nurse brought resident from the ground by the kitchen where she fell , into the kitchen and called (Medical Director) from there 1923 (7:23 p.m.) on 2nd nurse's phone, called ADON (Assistant Director of Nursing) and DON (Director of Nursing) 1922 (7:22 p.m.) on this nurse's phone. ADON and (Medical Director) ordered to send resident to (Hospital) ER (emergency room ). Called (Emergency Service) at 1925 (7:25 p.m.) Called resident daughter at 1930 (7:30 p.m.). This nurse brought resident in WC back to station two by exit doors to await (Emergency Service). (Emergency Service) arrived 1945 (7:45 p.m.) and assisted resident from WC to stretcher and left with resident after given a copy of face sheet and two copies of MAR (Medication Administration Record) . b. The Incident and Accident Report dated 2/12/18 at 7:44 p.m. documented, .Nursing Description: Resident was being taken out to smoke by CNAs. Resident Description: Resident pushed over uneven surface by CNA in WC forward instead of backward and resident fell forward out of wheelchair . 'I don't know what happened, I just fell forward and threw up. I'm all right but my face is hurting; please call my daughter'. Immediate Action Taken Description: See above. Water and towels, held pressure to resident face to stop bleeding, sent to ER . Face Description r/t (related to) bruised eyebrow and abrasion to face . c. The hospital records dated 2/12/18 documented, .Triage Time: Mon (Monday) Feb (February) 12, (YEAR) 19:54 (7:54 p.m.) . CT (Computerized Tomography) Brain without contrast . Impression: 1. No acute intracranial findings. 2. Appropriate interval evolution of right MCA (Middle Cerebral Artery) territory infarct. 3. [MEDICAL CONDITION] bones . Patient Plan: The patient will be admitted to the hospital, Discussed with the family. They are uncomfortable taking the patient back to (Facility) . d. On 2/20/18 at 10:47 a.m., Licensed Practical Nurse (LPN) #1 was asked about Resident #5's fall on 2/12/18. LPN #1 stated, All the CNAs were in-serviced. We were working on finding a better place to take the smokers. The CNA wasn't very careful. She hit that bump and the resident fell forward out of her wheelchair. She didn't mean to do it, she should've pushed her backwards out of the door. She was laying (sic) there, had just thrown up. She was talking immediately, saying she was not hurt or injured. The CNA should've been more careful, should've backed her up. She had thrown up on the left side of her face, around her eyebrow area. I didn't want to leave her in her vomit. I called the Doctor, the family. I dried up her face. I had the daughter talk to her Mom on the phone. Her Mom was still talking she said, 'I'm okay.' .I lifted her face out of the vomit. My goal was to get her ready to go to the hospital . We sat her up in her wheelchair, two of us put her in her wheelchair . e. On 2/20/18 at 3:36 p.m., CNA #1 was asked about Resident #5's fall on 2/12/18. CNA #1 stated, She was in a standard-sized wheelchair; it did have foot pedals. She was alert and oriented. I was not there when she fell . I took her to the cafeteria in a wheelchair. She had told me that she wanted to go smoke. She was back on the Medicare unit. The nurse asked me to go check on her . The CNA was asked if staff had been in-serviced prior to the incident regarding the need to pull residents in wheelchairs backward over the raised threshold and stated, It might've been mentioned; I don't remember being formally trained on pulling a resident backwards through that door. I know that foot pedals would catch that threshold. I don't want to say it is common sense to pull someone through that doorway. I know your momentum would carry over that threshold. I do know some residents were having problems getting over that threshold; it was a little too high off the ground. f. On 2/20/18 at 1:44 p.m., the Maintenance Manager was asked about the raised threshold where the incident occurred on 2/12/18 and stated, .It is a regular exit door . They should've been pulling (wheelchairs across the threshold) instead of pushing . When asked if efforts had been made to repair the threshold prior to the incident on 2/12/18, he stated, .I gave a bid about a year and a half ago . to replace the door; I don't know who did that mess (installed the door / threshold originally). You would have to re-pour the concrete anyway you go . It was hard for the residents to pull themselves out of the door . I never heard back about the bid . It was like that long before I came here. g. On 2/20/18 at 10:18 a.m., the Assistant Director of Nursing (ADON) was asked about any incidents related to the exit door / threshold to the smoking area and stated, .There was an incident . Only 1 resident fell , that I know of. It had to do with the bottom lip of the door . h. On 2/20/18 at 8:14 a.m., the resident's daughter was contacted via phone and asked about the incident on 2/12/18. She stated, .She was thrown about 8 feet and landed on her left eye. She has blood behind her eye and has been having vision problems. They pushed her forward through the door instead of pulling her . She (resident) was only at the facility for 3 hours . 2. Resident #2 had [DIAGNOSES REDACTED]. The Re-Admission Minimum Data Set with an Assessment Reference Date of 12/22/17 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status and required one-person assistance with transfers. On 2/21/18 at 9:47 a.m., Resident #2 was asked about the exit door to the former smoking area where Resident #5 fell on [DATE]. Resident #2 stated, I started out the door in my wheelchair and scraped my skin on those hand rails trying to pull myself out. It was worse coming back in. I was bleeding real bad. They should've put a ramp there. I know (Resident #5) fell over the side . Someone said she fell off the sidewalk. I seen (sic) her laying (sic) there; she had just gotten here. I just got to the smoke area. The girl that pushed her was really new. I don't know if she had taken anyone out to smoke before. The lady (Resident #5) was holding a blanket over her and her cigarettes in one hand .The resident was asked if staff ever pulled wheelchairs through the door backward and stated, .They did sometimes pull you backwards . 3. On 2/21/18 at 10:50 a.m., the sliding glass door in the main dining area was observed and measurements obtained with the ADON present. The door was completely covered with plywood. The threshold protruded upward from floor level approximately 1/8 of an inch when exiting to the outside, and protruded upward from the ground 1/4 of an inch when entering from outside. On the outside of the threshold was a stamped or indented piece of tin bolted with pop rivets into the concrete. The piece of tin had two rivets or bolts that were not flush and protruded upward above the tin. This door was no longer in use for residents to access the former smoking area at the time of the survey. 4. The facility removed the immediate jeopardy and corrected the failed practices on 2/12/18 at 7:44 p.m., as evidenced by the following: a. Nurses' Notes dated 2/12/18 documented, .CNAs in-serviced on pushing wheelchairs backward, not forward over uneven surfaces . b. The Incident and Accident Report dated 2/12/18 at 7:44 p.m. documented, .Immediate Action Taken Description: Area where residents smoke changed . c. The Performance Improvement Project (PIP) Guide documented, .One-on-one Inservice . Start Date 2/13/18 . Inservice CNAs . Start Date 2/12/18 . Move Smoke break area . Start Date 2/12/18 . Brainstorm: R (resident) was pushed forward over lip of door r/t (related to) rails surrounding sidewalk and unable to push out backwards . Gazebo not conducive to smoke breaks. Railings surrounding sidewalks, lip of door . d. On 2/20/18 at 10:47 a.m., LPN #1 stated that after the incident on 2/12/18, .All the CNAs were in-serviced, and, .We were working on finding a better place to take the smokers . e. On 2/20/18 at 1:44 p.m., the Maintenance Manager was asked about corrective actions after the 2/12/18 incident and stated, They (CNAs) were in-serviced to pull over instead of push over any uneven surface. f. On 2/20/18 at 10:18 a.m., the Assistant Director of Nursing (ADON) was asked about corrective actions taken after Resident #5's fall on 2/12/18 and stated, We have a new smoke area, the front entrance, which is covered . There is plywood that covers the door (to the former smoking area), and it is a locked entrance. We had issues and we corrected it immediately. We did in-services and changed the smoking area .

Complaint # was substantiated (all or in part) with these findings. Based on observation, record review and interview, the facility failed to ensure a system was in place to assure thorough skin assessments and prompt identification of new areas of skin breakdown for residents at risk for the development of pressure sores to prevent delays in treatment and failed to ensure pressure relieving devices were used to prevent further skin breakdown for 1 (Resident #1) of 3 (Residents #1, #2 and #4) case mix residents who were at risk for the development of pressure sores. This failed practice resulted in a pattern of actual harm for Resident #1 who experienced deterioration of his right heel resulting in infection and hospitalization and had the potential to cause more than minimal harm for 20 residents who were at risk for skin breakdown according to a list provided by the Administrator on 1/22/14. The findings are: 1. A "Wound Prevention and Treatment" Policy provided by the Administrator on 1/8/14 documented, "...Procedure- 1. Assess all residents...Assessments may include, but are not limited to: -Skin Assessment upon admission daily times three days, weekly thereafter and prior to discharge (exception is a 911 discharge)...6. Develop and implement individualized preventive and/or treatment interventions..." 2. Resident #1 had [DIAGNOSES REDACTED]. a. A Braden Risk Assessment Report dated 8/13/13 documented, " ...Friction (and) Shear: Potential Problem- Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. ..." b. The October 2013 Physician order [REDACTED]. Check daily for s/s (signs and symptoms) of infection...9/26/13- Cleanse (unstageable) PU (pressure ulcer) to (right) lat (lateral) ankle (with) (wound) cleanser, apply [MEDICATION NAME] and wrap (with) Kling daily...10/28/13-...Cleanse PU to (left) heel (with) (wound) cl (cleanser), apply [MEDICATION NAME], cover (with) 4x4's and wrap (with) Kling daily..." There were no orders documented for a pressure ulcer to the right heel. c. As of 1/9/14, there was no documentation of a weekly skin assessment/body audit completed by the Nurse in the clinical record for the months of September and October 2013 for this resident. On 1/9/14 at 4:20 p.m., the Director of Nursing (DON) was asked, " Are body audits done weekly? " The DON stated, "Yes." When asked who does those, he stated, "CNA's (Certified Nurse Aides) do them in the shower and the nurses check them off." When asked what does check off mean, he stated, "If they give the nurse a body audit sheet that says clear, they don't go check it. If it identifies something, then the nurse goes and checks it." When asked does a professional do a body audit weekly, he stated, "No." d. A Nurse's Note dated 10/29/13 at 10:35 a.m. documented, "Late Entry for 10/28/13 at (4:15 p.m.). Order received to transfer resident to (Geropsych Hospital). Order noted and processed. Wife ...aware of need for transfer for medication adjustment related to recent escalation of behaviors and physical violence toward staff ... Resident willing and voluntarily leaving facility..." There was no documentation of a skin assessment prior to discharge. On 1/10/14 at 11:20 a.m., the DON was asked, was a body audit done on discharge (10/28/13), and he stated, "No..." e. A "(Hospital) Shift Assessment" documented, "...admitted : 10/28/13 at (8:58 p.m.)..." 1) A (Hospital) Nursing Notes dated 10/29/13 at (12:15 a.m.) documented, "...Assessed feet of (patient). Both feet ever swollen. (Left) heel has a large decubitis and some portion of it draining yellow. Some portion has eschar. (Right) heel has eschar on it (approximately) 2 inches. (Right) great toe swollen, reddened with some purulent draining on top..." 2) A (Hospital) "Report of Consultation" dated 10/29/13 documented, "...Chief Complaint: Foot Ulcerations. History of Present Illness/Examination:...ulceration to the right lateral ankle...He has bilateral heel ulcerations that are necrotic with eschar formation that are secondary to pressure. The right heel ulceration measures approximately 3.0 x 4.0 x 0.1 cm (centimeters)...He has a left heel pressure ulceration that measures approximately 5.5 x 5.0 x 0.1 cm..." 3) A (Hospital) "Laboratory Results" documented, "...Coll: (Collected) 10/29/13- 1340 (1:40 p.m.)...Right Heel...Wound Culture- Final...Organism 1-[MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus)...Growth- Abundant...(Right) Great Toe...Wound Culture- Final...Organism 1-[MEDICAL CONDITION]- Abundant...Left Heel...Wound Culture- Final...Organism 1-[MEDICAL CONDITION]- Abundant..." f. A Skilled Documentation Note dated 12/18/13 documented, " ...Summary ...Resident readmitted to facility today. Arrived via facility van accompanied by one staff member. Resident continues to have open areas to right lateral malleus and left lateral leg, as well as right great toe. Pressure ulcer noted to both right and left heels. Treatment on admit. Will not remove ..." g. A handwritten note dated 12/19/13 on the Care Plan signature page (unsigned) documented, "Readm (readmitted ) to facility 12/18 excoriated area on coccyx, healing US (unstagable) PU (Pressure Ulcer) to L (left) lat (lateral) heel, healing PU to R (right) lat ankle, Tx (Treatment per MD (Medical Doctor) orders. Also healed US PU to R heel (with) soft tissue present." h. A Body Audit dated 12/19/13 and signed by Certified Nurse Assistant documented, "Right and Left heels calluses, Right lateral ankle sore." i. A Wound Assessment Report dated 12/23/13 and signed by Licensed Practical Nurse (LPN) #2 documented, "Notes: Area was a healed US pu from recent hospital stay but on readmit area was very thin and fragile, now has superficial open wound with serous drainage, no odor, tx (treatment) initiated with [MEDICATION NAME] Extra Ag and [MEDICATION NAME] dsg (dressing) q (every) m,w, f & prn (Monday, Wednesday, and Friday and as needed) res (resident) encouraged to keep feet elevated on pillows when in bed, but res not always compliant, res also prefers to sit up in w/c (wheelchair) majority of day." j. The Quarterly Minimum Data Set with an assessment reference date of 12/25/13 documented the resident scored 7 (0-7 indicates severe impairment) on a Brief Interview for Mental Status, had impairment to a lower extremity on one side, was at risk for developing pressure ulcers and had pressure ulcers. k. The Care Plan updated 12/26/13 documented, "Problem Onset: 5/28/13- I am at risk for skin breakdown r/t (related to) lack of mobility...I currently have US (unstageable) PU (pressure ulcer) to right lateral ankle...Approaches...Body Audit weekly and PRN (as needed) by nurse. Document any new or worsening of skin condition and report promptly..." The Care Plan did not address any other skin concerns prior to the October discharge. l. A Wound Assessment Report dated 12/23/13 and signed LPN #2 documented, "Notes: Area same with current tx of [MEDICATION NAME] extra ag and kling dsg daily, less drainage noted, res non-amb (ambulatory) at this time, prefers to stay up in w/c most of day, allowing feet and legs to dangle, cont (continue) to have [MEDICAL CONDITION] to BLE (bilateral extremities), encouraged to elevate when in bed, res not always compliant, ..." m. On 1/8/14 at 11:16 a.m., the resident was up in a wheelchair, propelling himself in the hallway with socks on his feet bilaterally. There was no pressure relieving device in place on his feet. At 1:25 p.m., the resident was in a wheelchair with wound dressings and socks in place on both feet. Both feet resting on pedals of wheel chair. There was no pressure relieving device to the feet. n. On 1/9/14 at 8:53 a.m., 12:45 p.m., and 1:55 p.m., the resident was in a wheel chair and had on his feet non-skid socks over the wound dressings on both feet. There was no pressure relieving device in place on his feet. o. On 1/9/14 at 1:55 p.m., LPN #2 provided wound care. Observation of the residents wounds to heels and ankles were as follows: Left heel with eschar in center with granulation tissue covering the outer area of wound bed measuring approximately 2.5 centimeter (cm) x 2cm; Right heel with small area of eschar covering wound bed to upper area of heel measuring approximately 2 cm x 2 cm; and right great toe, open abrasion measuring approximately .5 cm, with red tissue, and right ankle has open area tissue pink measuring approximately 1 cm x 1 cm. p. On 1/9/14 at 4:20 p.m., the DON was asked why an intervention was not implemented for this resident's feet and the DON stated, "He's not going to leave a boot on." q. On 1/9/14 at 4:50 p.m., Licensed Practical Nurse (LPN) #1 applied bilateral Prevalon boots to the resident ' s lower extremities. r. On 1/10/14 at 8:45 a.m., the resident was up in a wheelchair propelling himself in the hallway with the blue Prevalon boots in place to both lower extremities. At 12:05 p.m., the resident was in a wheel chair. The blue Prevalon boots remained in place to the lower extremity of both feet.

Complaint # and were substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure a patent airway was established prior to or during cardiopulmonary resuscitation (CPR) for 1 of 1 case mix resident (Resident #3) who had a documented swallowing problem and was identified without vital signs, post-ingestion of a peanut butter and jelly sandwich. This failed practice resulted in Immediate Jeopardy which caused or was likely to cause serious injury, harm or death for Resident #3 who expired due to asphyxiation post the incident. The Administrator was notified of the Immediate Jeopardy on [DATE] at 5:20 p.m. This failed practice had the potential to affect 75 residents who had full code status as documented on a Physician order [REDACTED]. The facility failed to ensure that an established emergency crash cart available for CPR (cardiopulmonary resuscitation) was maintained in such a manner as to have adequate supplies for the initiation of CPR. Additionally, the facility failed to ensure professional nursing staff were familiar with policies and procedures for cardiopulmonary resuscitation, an emergency crash cart supplies check list and assignment of responsibility for crash cart inventory on a daily basis. This failed practice had the potential to affect 75 residents who had full code status as documented on a Physician order [REDACTED]. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 4 (,[DATE] indicates severe impairment) on a Brief Interview for Mental Status, required extensive assistance of one person for eating, total dependence with two person physical assist for locomotion, mobility device was a wheelchair, no swallowing disorders and received a mechanically altered therapeutic diet. a. The Resuscitation Designation Order dated [DATE] and signed by Resident #3 documented, "I do desire cardiopulmonary resuscitation to be performed at this facility if I suffer cardiac or respiratory arrest." The Physician order [REDACTED]." b. The Modified [MEDICATION NAME] Swallow dated [DATE] documented an assessment of "Patient exhibited the following dysphagia symptoms of reduced tongue elevation anteriorly and posteriorly, delayed onset of the swallow, delayed swallow reflex and reduced tongue base retraction." The plan was documented as "Recommend patient continue with current diet as ordered, recommend patient complete safe swallow technique of alternate liquids and solids and patient educated on the results of this evaluation--patient needs reinforcement." c. The Physician order [REDACTED]. d. The Nurse's Notes dated [DATE] at 5:30 p.m., signed as authored by Licensed Practical Nurse (LPN) #5 documented, "Res (resident) c/o (complained) nausea at dinner, said 'I don't feel like eating right now.' Res propelled up to nurse's station and was asking for a dip (snuff). VS (vital signs) ,[DATE], 78, 20, 98.1 Will cont (continue) to monitor." e. On [DATE] at 2:26 p.m., Certified Nursing Assistant (CNA) #3 stated sometime around 8:00 p.m. on [DATE] "Two CNA's and I helped to pull (Resident #3) up because she was sliding down (in her wheelchair). She had a peanut butter and jelly sandwich in her hand, one half eaten. I didn't know what kind of diet she was on. (LPN #5) was at the nurse's station charting." On [DATE] at 2:55 p.m., CNA #4 stated "At 8:00 p.m. (on [DATE]) I came up front and saw (Resident #3) was sliding out of the wheelchair. I asked two people to help me. There was one of the women nurse LPN at the nurse's station. (Resident #3) was eating a peanut butter and jelly sandwich. She had one half sandwich left of a full sandwich that had been eaten to one half." f. The Witness Statement Form dated [DATE] at 8:30 p.m. and signed as authored by CNA #2 documented, "I was walking up hall 2 and I seen (Resident #3) sitting by the nurse's station with her head down. She looked like she was sleeping. As I got closer to her she was not breathing. I lifted her head up and told (LPN #5) that (Resident #3's) gone and we put her in the floor and the nurses took over. She was not blue, she just looked like she was asleep." On [DATE] at 2:00 p.m., CNA #2 stated "(Resident #3) was sitting at the desk in front of the nurse's station at 8 o'clock (8:00 p.m. on [DATE]). I did not see her again until 8:30 p.m. I was down the hall putting residents to bed. I was walking down hall 3. She was sitting there with her head down. Her head was yellow, not a normal color. I walked over to her. I raised her head up. I noticed her lips were blue, purple, like she was gone. She wasn't breathing. Her lips were blue, purple, her hands on her lap were yellow and blue-her fingernail beds. I looked at (LPN #5), the nurse. I said 'She's gone'. (LPN #5) was in shock because she had just talked to her. (LPN #5) called 911. Me, (LPN #6) and two other aides got her out of the chair and put her on the floor. I went and got the crash cart. (LPN #5) swiped her mouth. She didn't have anything in her mouth while I got the crash cart. (LPN #5) was already checking her mouth before I got the crash cart. She assessed her, checked her mouth then I went and got the crash cart. I stood there for a second, (LPN #5) was feeling around in her mouth as far back as she could go. Then she said to go in the med room. They had the door wide open to the med room. One of the nurses had just came out. I got the crash cart. I was running with it. They took that breather round black/green thing. They put it over her face and (LPN #6) was pumping and (LPN #5) was doing chest compressions. The suction apparatus was never hooked up. I never saw an airway put in her mouth. Another LPN went and got an oxygen tank and hooked it up. They had no wrench to turn the oxygen tank on that was on the cart." g. The witness statement dated [DATE] at no time noted and signed as authored by LPN #5 documented, "It had not even been five minutes, I had went back to charting, when (CNA #2) walked up and said '(LPN #5) (Resident #3) is dead.' I said 'don't say that'. I then noted resident with her head down, she appeared asleep. I ran around the nurse's station, assessment, no resp (respirations), no carotid pulse, called 911, noted res to be full code. At that time (LPN #6) had brought the crash cart out and I started compressions. (LPN #6) acquired ambu bag and as we were trying to get an airway, it was noted that she had peanut butter on the roof of her mouth and a half of a peanut butter sandwich in the floor beside her. Res was warm and lips were cyanotic, continued compressions and bagging until (Emergency Medical Services) arrived and they took over. I then notified ER (emergency room ) and sister. At 2125 (9:25 p.m.) (sister) called and stated 'She died , choked on her sandwich.' Res made no sound or noise or struggle as to note that she was in any distress or choking, I was only 3 ft (feet) away from her. I heard nothing, her airway was clear, nothing noted in the back of her throat, chest was rising upon each breath we gave her with ambu bag. Never once did the res turned blue, remained acyanotic during CPR--noted chest rising and falling, never met any resistance when bagging res." On [DATE] at 2:35 p.m., LPN #5 stated that she had seen Resident #3 "about 3 minutes " before she was found without vital signs. LPN #5 stated, "She had just asked for a dip of snuff. (Resident #3) is dead stated (CNA #2). She had her chin on her chest. I called 911. (LPN #6) was coming down hall 3. I said 'Help me (LPN #6), get the crash cart.' When I lifted her head her lips were cyanotic, face was swollen, no breathing and no carotid pulse. I watched and I felt and there was nothing. (LPN #6), (CNA #3) and (CNA #2) put her in the floor. Then I began compressions. (LPN #6) was doing the airway, applying an airway, putting her head back, looked in her mouth. I said '(LPN #6) there is peanut butter in the roof of her mouth. (LPN #6) did a finger sweep to the roof of her mouth and removed peanut butter from the roof of her mouth, a teaspoon full. We both checked the back of her mouth by looking in her mouth while still doing chest compressions. (LPN #6) did use the ambu bag. There was no airway utilized. The oxygen tank did not work. It was empty. We had to switch the tanks out." LPN #5 was asked if Resident #3 was suctioned. LPN #5 stated, "I saw no reason." LPN #5 was asked about the ratio of breaths to compressions. LPN #5 stated, "100 compression to two breaths. EMT's (emergency medical technicians) got there and as I was doing compressions, they lifted her up and they left." h. The Witness Statement Form dated [DATE] at 8:30 p.m. and signed as authored by LPN #6 documented, "Moments before R (resident) found unresponsive, R had just asked this nurse for some snuff. I was walking past R towards med room when (CNA #2) said 'I think (Resident #3) is dead.' CPR initiated. R was not cyanotic. No resistance noted when ambu bag was placed and oxygen was given. Noted rise and fall of chest. Finger sweep done. No food noted only peanut butter film on roof of mouth." On [DATE] at 3:16 p.m., LPN #6 was asked to tell the surveyor about the events of [DATE] regarding Resident #3. LPN #6 stated, "I was coming out of the med (medication) room. (CNA #2) said 'I think (Resident #3) is dead.' I went to (Resident #3). Her lips were blue, eyes were closed, no carotid pulse and she wasn't breathing. (LPN #5) looked at her chart and she was a full code. (LPN #5) told someone to get the crash cart, called 911, then she came around. Resident was on the floor, crash cart not yet there. I started chest compressions, I think I did. After the crash cart came, no one was breathing her yet. I tilted her head back, swiped for food, got a thin film of peanut butter." LPN #6 was asked if she suctioned the resident. LPN #6 stated, "I felt no resistance." LPN #6 was asked why she did not use an airway. LPN #6 stated "I don't know, I am CPR certified. I was not thinking properly. We attached the oxygen tank to the ambu bag and found it empty. We got another tank." On [DATE] at 10:40 a.m., LPN #6 stated "I did not see any more bread or peanut butter after I swiped the roof of her mouth. I did not suction her because I did not see any obstruction to the back of her mouth. I was taught in CPR class to use an airway if available. I did not know there was one available. I did not do the [MEDICATION NAME] or abdominal thrust when she was on the floor." i. The Nurse's Notes dated [DATE] at 8:30 p.m. signed as authored by LPN #5 documented, "Res at nurse's station watching TV (television), asking me for snuff. This nurse had just spoke with res about smoke time. Aide was walking by and alerted this nurse to res in chair nonresponsive. This nurse noted res to be full code; called 911; called for crash cart; assisted by another nurse compressions began; acquired an airway, chest rising, noted peanut butter sandwich half eaten in floor beside res; noted the smell of peanut butter on res breath and a film of peanut butter on the roof of res mouth; no peanut butter or bread noted to be blocking airway; (EMS (Emergency Medical Services)) arrived and took over compressions. No b/p (blood pressure) or hr (heart rate) noted at that time less than 10 secs (seconds) began compressions again on the way to ambulance; Sister called and notified of code; res transferred to ER." j. The Emergency Medical Services Report's narrative authored by Paramedic #1 on [DATE] documented, "Upon our arrival found 72 yo (year old) wf (white female) [MEDICAL CONDITION] CPR in progress. Pt (patient) had been down approx (approximately) 5 min (minutes) prior to our arrival. Continued CPR. Moved pt to unit. Placed pt on cm (cardiac monitor) asystole x 3 leads. Est (established) IV (intravenous) 18 g (gauge) l (left) wrist NS (normal saline) wide open. Administer EPI ([MEDICATION NAME]) ,[DATE] at 2038 (8:38 p.m.). CPR. Suction pt to remove peanut butter sandwich from airway. Intubated pt 8.0 et (endotracheal tube) 26 at lip. Secured tube ET passed through cords breath sounds positive. Fogging in tube. Resume CPR. Second epi at 2034 (8:34 p.m.). Resume CPR. Still asystole on monitor. Administer third epi at 2049 (8:49 p.m.) Resume CPR. Pt transported code 3." On [DATE] at 12:30 p.m., Paramedic #1 stated, "On [DATE] we went to (facility) for an emergency transport (for Resident #3). We tried to ventilate, it did not go in very well. So, I attempted to intubate. I found peanut butter and bread just above the epiglottis. I suctioned it out and intubated her and continued (ventilation). Her airway was partially occluded when we started intubation." r. The (Hospital) Admission Summary documented a final primary [DIAGNOSES REDACTED]. The disposition was documented as "expired 21:38 (9:38 p.m.)." s. On [DATE] at 2:35 p.m., the crash cart for the front hall housed in the medication room was checked with LPN #5. A plastic lock embossed with # 84 was removed from the bottom cabinet. LPN #5 stated that the ambu bag should be housed there. LPN #5 stated "There's no ambu bag." There was no ambu bag on any area of the cart. LPN #5 was asked if there was a crash cart check list. LPN #5 stated, "Not to my knowledge." LPN #5 was asked if she knew what was supposed to be on the cart and how many of each. LPN #5 stated, "No". When asked who was responsible for setting up the cart, LPN #5 stated "LPN's are usually responsible for setting up the crash cart." There were six adult airways on the cart. 2. On [DATE] at 4:25 p.m., the surveyor and Director of Nursing (DON) checked the crash cart on the nurse's station on the back hall adjacent to hall 10. There was a crash cart check sheet on the cart which documented the date checked as [DATE]. There was no suction machine on this cart. The Director of Nursing stated, "I will get one now." On [DATE] at 4:30 p.m., the Crash Cart Inventory Sheet was removed from the back hall and copied by the surveyor. The items listed were: "cart top: suction machine and oxygen bottle; drawer #1: plastic tape, scissors, stethoscope, blood pressure cuff, lubricating jelly, airways, mouth barriers and resuscitator mask; drawer #2: [MEDICATION NAME] suction cath, suction connect tube, suction cath 14 fr (French), Xmas tree connector, oxygen cannula, oxygen mask, oxygen tubing and updraft tubing; drawer #3: humidification bottle, biohazard bag, gauze wrap, 4 x 4 gauze pads, non-sterile gloves and sterile gloves; and bottom/door: ambu bag and backboard." a. On [DATE] at 4:52 p.m., the DON was asked what was the significance of the plastic lock embossed with # 84 on the front hall crash cart. The DON stated, "To see if someone had used it." The DON stated, "Either myself or (ADON (Assistant Director of Nursing)) look at the crash cart everyday to see if someone has used it. I have not looked at it today." The DON was asked if the facility had a crash cart policy. The DON stated, "Not that we could find." The DON was asked if the facility had a crash cart checklist. The DON stated, "No we don't have a checklist." b. On [DATE] at 5:00 p.m., the ADON was asked when she last checked the crash cart. The ADON stated that she last checked the crash cart on [DATE]. The ADON was asked what was the significance of the plastic lock embossed with # 84 on the front hall crash cart. The ADON stated, "The green tags are used to lock the drawers on the cabinet. If the tag is on there and sealed, I didn't break that (plastic lock embossed with # 84) when I checked the cart)." 3. On [DATE] at 5:10 p.m., the DON stated, "We do not have a CPR policy. The nurses are CPR certified." 4. On [DATE] at 5:50 p.m., the surveyor and the Administrator who is also a Registered Nurse checked the crash cart on the 600 hall. The oxygen tank had less than 15 minutes of oxygen availability in the tank. The Administrator had the DON to look at this issue and the DON took the oxygen tank from the cart and went to get a replacement. 5. The Immediate Jeopardy was removed and the scope/severity reduced to "G" on [DATE] at 7:00 p.m. when the facility implemented the following Plan of Removal: a. The Director of Nursing stocked two crash carts for the facility which will be located in the Front Nurse's Station Medication Room and the Back Nurse's Station Medication Room. The crash carts both contain all supplies needed to conduct a proper code according to CPR guidelines including a suction machine, oxygen tank, plastic tape scissors stethoscope, blood pressure cuff, lubricating Jelly, mouth barrier, [MEDICATION NAME] suction catheter, suction connection tube, 14 French suction catheter, Christmas tree connector, 02 cannula, 02 mask, oxygen tubing humidification bottle, biohazard bag, gauze wrap, 4 X 4 gauze pads, non-sterile gloves, sterile gloves, ambu bag and backboard according to the Crash Cart Contents list. This was completed for both carts by the Director of Nursing and Assistant Director of Nursing at 18: 15 p.m. b. At 6:45 p.m. training by the Director of Nursing was implemented for all licensed personnel in the facility. The training included the location of each crash cart, the contents of each crash cart, Basic Life Support guidelines and procedures to follow in the event a resident is found to be unresponsive. Also included in the training was the procedure for daily monitoring of the crash cart by the DON/Designee and documentation of that monitoring. In the event the crash cart is used for any reason, it is the responsibility of the licensed nurse who used the cart to restock the cart and document restocking. This training was completed for the ,[DATE] shift LPN's at 7:30 p.m. The ADON will be in the facility to train ,[DATE] LPN's on [DATE] on these policies and procedures at 10:45 p.m. The DON will be at the facility at 6:45 a.m. [DATE] to train the ,[DATE] LPN's on these policies and procedures. Licensed staff will not be allowed to work until they have received this training. c. The licensed nurse schedule for the next 24 hours was checked and personnel who were certified in CPR were scheduled for each shift and will be trained by the DON/Designee at the beginning of their shifts until all licensed personnel have received the training on Crash Carts, contents, procedures to follow and Basic Life Support guidelines. For those LPN's who need to be recertified in CPR, the facility will have them complete the on-line training and testing and pay for the CPR Certification. Any LPN who needs CPR certification rather than recertification, will be trained by an accredited instructor in the facility on [DATE]. CPR certification will be required of all LPN's working for the facility. New hire LPN's who are not CPR certified, will receive CPR certification or recertification at the expense of the facility within 30 days of hire. The Human Resource Manager will be responsible for maintaining copies of each licensed personnel's CPR certification and dates recertification is due and will insure their CPR certification remains current. d. The DON/Designee will inspect both crash carts at the beginning of their shift daily and document findings of that inspection on the daily monitoring log for each month. The Administrator/Designee will also check each crash cart daily. Any problems noted will be corrected immediately and the Administrator will be notified. Findings will be reported to the QA Committee monthly for additional recommendations if needed.

Based on observation, record review and interview, the facility failed to ensure the comprehensive assessment was accurate regarding the use of restraints and falls; a thorough assessment regarding the necessity and safety in the use of side rails was conducted prior to the use of side rails; and interventions were developed and implemented to ensure that the use of side rails were reassessed if resident attempted to climb over them for 2 of 2 (Resident #14 and #15) case mix residents who repeatedly climbed or attempted to climb over the side rails. This failed practice resulted in Immediate Jeopardy which could have caused harm, serious injury or death for Residents #14 and #15 and 4 other residents identified by the facility on 4/26/12 at 12:10 p.m. The facility was notified of the Immediate Jeopardy on 4/26/12 at 12:00 p.m. The findings are: 1. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Area Assessment for the Problem Area: Falls with ARD 2/6/12 documented, "...History of Falls unchecked...Notes: Resident at risk for falls r/t (related to) use psychotropic medications and decreased mobility. Standard fall precautions in place such as assist provided with all adl's (activities of daily living), call light and other frequently used items kept within reach, and patient teaching to always call for assist when needed. No falls since admit (was attempting to climb out of bed 2/1/2 and found in floor 2/3/12)." There was no Care Area Assessment for Restraints as the MDS documented no restraint (side rails, trunk, limb or chair to prevent rising) in use although bilateral side rails was used since admission. a. A Side Rail Evaluation dated 1/30/12 documented bilateral side rails in use. The Evaluation documented: "...Requested to have them (bilateral side rails)... Is there a risk to the resident if side rails are used? (checked yes)...Do the side rails alternatives/interventions create more risks than side rail use? (checked No)..." The Care Plan documented, "...02/06/2012... Multiple falls ...Approaches... Give verbal reminders not ambulate or transfer without assistance. Ensure that resident has and wears properly-fitting non-skid soled shoes for ambulation. Maintain resident environment free of clutter and safety hazards Provide environment with adequate lighting, free of glare." The care plan did not address the use of bilateral side rails or the fact the resident would attempt to climb over them per the 1/30/12 side rail evaluation. The care plan did not address the use of any type of restraint or alternatives to prevent falls (velcro seat belt, bed/chair alarms, low bed, and floor mat ordered 2/1/12). b. Nurses Notes/Incident Reports regarding attempts to get out of bed and falls as a result of getting out of bed for February 2012 documented the following incidents: 1) Nurses Notes dated 2/1/12 at 7:00 a.m., "R (resident) displaying attempts to get out of bed and out of wc (wheelchair) Received TO (telephone order) from (Physician) to place bed alarm and Velcro seat belt to w/c (wheelchair). Placed both alarms and checked functioning. Low bed with floor mat as well." 2) An Incident/Accident Report (I&A) dated 2/3/12 at 4:30 a.m., "A CNA (Certified Nursing Assistant) reported to this nurse that Resident was sitting up in the floor." The I&A was blank in regards to "Were bed rails present." The Nurses Notes on 2/3/12 at 7:20 a.m. documented the 4:30 a.m. incident but did not indicate that side rails were present. There was no documentation on the I&A or the 2/3/12 Nurses Notes as to whether or not the bed alarm was functioning. There were no new interventions documented on the I&A report. 3) Nurses Notes dated 2/17/12 at 8:30 p.m. documented, "Resident combative (with) staff and attempting to climb over raised bed rail..." 4) Nurses notes dated 2/18/12 at 6:15 p.m., "Resident laid down by CNA. Daughter reports that resident attempting to climb out of bed..." 5) An I&A report dated 2/19/12 at 00:30 a.m. (12:30 a.m.), "Res observed lying in floor @ foot of bed." This report documented that side rails were present and in the up position and bed alarm in use. The interventions to prevent recurrences documented, "Bed alarm switched." The Investigation Follow-Up dated 2/19/12 documented the "Bed alarm on bed yet not functioning properly... Recommendations/New Interventions: psych (psychiatric) consult sched (scheduled) tues (Tuesday) 2/21/12... Bed alarm switched out..." 6) An I&A report dated 2/20/12 at 10:40 p.m. documented, "...Were bed rails present? (yes was checked and up was checked yes)..." The Post Fall Investigation no date documented, "What was the resident doing or attempting to do prior to fall? Get out of bed... Was an alarm or restraint in place? Was it functioning? Yes, No Bed alarm was not going off, turned off..." No recommendations/new interventions were documented. 7) An I&A report dated 2/22/12 at 10:40 p.m., "Resident found in room on floor. Blood and laceration noted to back of head. Alarm sounding. Ambulance called." This report also documented that the side rails were up at the present time and the height of the bed was "down." Nurses Notes dated 2/23/12 at 1:15 a.m. documented the resident received 10 Staples to the back of his head and was returned to the facility. No recommendations/new interventions were documented. 8) Nurses notes dated 2/23/12 at 7:15 p.m., "Resident attempting to climb out of bed. Argumentative and combative with staff when trying to assist resident to bed." 9) Nurses notes dated 2/28/12 (no time documented), "R (resident) cont (continues) to require skilled nursing care r/t (related to) dx. (diagnosis) R requires supervision r/t trying to get out of bed or chair. R is unsteady when attempting to ambulate..." 10) Nurses notes dated 2/29/123 at 5:45 p.m., "Resident climbed out of bed. CNA assisted to w/c (wheelchair). Resident attempting to hit this nurse and CNA..." c. Nurses Notes/Incident Reports regarding attempts to get out of bed and falls as a result of getting out of bed for March 2012 documented the following incidents: 1) Nurses notes dated 3/4/12 at 3:30 a.m., "Summoned to Rm (room). Res sitting on mat beside bed. Alarm sounding. Assisted (up) to w/c." 2) An I&A Report dated 3/9/12 at 2:30 a.m. documented, "Res on floor beside bed alarm sounding...Were bed rails present? (yes was checked and up was checked yes)... Recommendations/New Interventions: cont (continue) to respond ASAP (as soon as possible). " 3) An I&A report dated 3/22/11 at 2:00 a.m., "A CNA reported to this nurse that this resident was on the floor, upon assessment resident was lying on the floor with a skin tear to right elbow." The I&A was blank as to whether or not bed rails were up. The Investigation/Follow-Up dated 3/22/12 documented, "...Resident was trying to get up (and) he fell to the floor... Recommendations/New Interventions: CNA must check on R frequently. CNA must make sure bed alarm is on at all time..." c. Nurses Notes/Incident Reports regarding attempts to get out of bed and falls as a result of getting out of bed April 1st thru April 11th, 2012 documented the following incidents: l) Nurses notes dated 4/2/12 at 1:00 a.m., "Resident observed sitting on floor, @ (at) foot of bed, bed in lowest position & alarm on." 2) An I&A report dated 4/4/12 at 2:45 a.m., "Resident climb to end of bed (and) ended up on the floor @ corner of bed on bottom... Were bed rails present? (checked yes but blank as to whether up or down)... Additional comments and/or steps taken to prevent recurrence: (change) alarm staff training." The Investigation Follow-Up no date documented: "...R climbing out of bed (and) fell in floor... Changed bed alarm out with different alarm, In-service to (check) placement & function of alarm @ beginning of q shift, (Check) resident frequently." 3) An I&A report dated 4/11/12 at 2:20 p.m., "Appears R crawled over end of bed & fell laceration to (right) temple & St (skin tear) to (right) cheek." The nurses notes dated 4/11/12 at 3:00 p.m., documented the family did not want the resident sent to the ER so the LPN cleansed the abrasion and Steri-Stripped the laceration. The Nurses Notes also documented, "Clarification orders rec'd (received) Bed to lowest position Monitor q shift for position. Pressure alarm mat at bedside." d. The use of side rails was not re-evaluated until 4/11/12. The Side Rail Evaluation form documented a reassessment due to significant change dated 4/11/12. The evaluation documented, "Has resident expressed a desire to have side rails raised while in bed for their own safety and/or comfort? (checked yes)...Is the resident able to get in/out of bed? (checked yes)...Is the resident able to get out of bed safely? (checked no) Does the resident have a history of falls? (checked yes)... Does the resident use side rails for positioning or support? (checked no)... Is there a possibility the resident will climb over the side rails? (checked yes)... Is there a risk to the resident if side rails are used? If yes, explain (checked yes) R climbs over side rails..." The Summary of Findings on the back of the evaluation form was blank for 4/11/12. e. The plan of care for the problem of "Falls" was not updated until 4/11/12 with interventions, "Bed in lowest position, check q shift for placement, Pressure alarm mat @ (at) bedside. Check q (every) shift for placement and function." Use of side rails and risk of using side rails was not addressed. f. On 4/26/12 at 3:00 p.m., the resident was in bed. There were no side rails on the bed. The resident's spouse stated she asked them (facility) to take them off after he climbed over them and got 2 head injuries (2/22/12 and 4/11/12 per I&As). g. On 4/26/12 at 8:08 a.m., the Director of Nurses (DON) was asked, "Do you have beds that are low to the floor?" She replied, "Yes." She was then asked, "Do you know why he wasn't placed in one?" She replied, "I don't know." She was then asked, "Do you consider the side rail as a restraint?" She replied, "Yes, if he's climbing over them." She was asked also to furnish documentation of when the side rails were removed from the bed. 1) At 8:35 a.m., the DON stated she could not locate any documentation as to when the side rails were removed. 2) At 10:07 a.m., the Assistant Director of Nurses stated that she worked at the facility for two years. She stated that she does the interventions for all the I&A's. She was asked, "Do you know why he wasn't placed on a bed lower to the floor?" She replied, "No." 2. Resident #15 had [DIAGNOSES REDACTED]. A Side Rail Evaluation dated 2/20/12 documented the resident did not use side rails for positioning, could not get out of bed safely and that the resident may have a reason to get out of bed d/t (due to) cognitive condition, res may attempt climbing OOB (out of bed). This form also documented, "May attempt to climb OOB over rails causing her to fall." The Summary of Findings on the other side of the form was blank and did not indicate whether or not side rails were used. a. Nurses Notes dated 2/22/12 at 4:40 a.m. documented, "...R was put to bed early in shift (and) immediately began climbing out of bed..." At 9 p.m., "Resident on bed @ this (time) (with) SR (side rails) (up) x 2..." b. The Plan of care developed 3/7/12 documented, "Problem Onset: 03/01/12...Falls... with interventions of "Soft lap belt when in w/c (wheelchair), check q (every) minutes, release q 2 hours for ROM (range of motion)." There were no interventions documented regarding the use of side rails or the risk to the resident in the use of the side rails. c. An Incident/Accident report dated 3/14/12 at 2:30 p.m. documented, "Noted Resident lying on floor next to bed with raised area on left upper side of forehead. MD (medical doctor) notified and orders received to transfer to local hospital. A bedside mat was placed beside the bed to prevent recurrence." The I&A was blank as to whether or not bed rails were present or up. d. An Incident/Accident report dated 3/17/12 at 4:00 a.m., documented, "R climb out of bed (and) fell in the floor... Were bed rails present? (checked yes...If yes, up or down not indicated on form)..." e. A Side Rail Evaluation documented a reassessment dated [DATE]. The evaluation documented, the resident did not use side rails for positioning, could not get out of bed safely and that the resident may have a reason to get out of bed d/t (due to) cognitive condition, and no to the possibility resident will climb over the side rails. This form also documented, "Is there a risk to the resident if side rails are used (checked yes) May attempt to climb OOB over rails causing her to fall." The Summary of Findings on the other side of the form was blank and did not indicate whether or not side rails were used. f. The Initial Minimum Data (MDS) with an assessment reference date of 4/6/12 documented the resident had short/long term memory problems, required extensive assist for all activities of daily living, had a fall during the month before admission and a fall 2-6 months before admission, did not have falls since admit/reentry/prior assessment and did not have a restraint (side rails, trunk, limb or chair to prevent rising). The Care Area Assessment for the Problem Area: Falls with ARD 4/6/12 documented, "...History of Falls unchecked... Notes: Resident at risk for falls r/t impaired mobility, incontinence, dementia, hx (history) of falls, and use of antipsychotic medications. Standard fall precautions in place such as call light and other frequently used items kept within reach, as assist provided with all adl's and walkways kept free of clutter, non skid socks or shoes worn when out of bed. No falls since admit (I&A documented falls on 3/14/12 and 3/17/12)." There was no Care Area Assessment for Restraints as the MDS documented no restraint (side rails, trunk, limb or chair to prevent rising) in use although bilateral side rails was noted in Nurses Notes dated 2/22/12 and the 3/17/12 I&A documented use of bed rails. g. On 4/26/12 at 11:00 a.m., the Director of Nursing was asked if this resident had side rails on her bed. She went to the room and stated, "Yes, she does and the tops are padded." h. On 4/26/12 at 11:04 a.m., the resident's bed had full side rails on them. 3. The Immediate Jeopardy was removed on 4/27/12 at 9:00 a.m. and the scope and severity reduced to an "E" when the facility implemented the following plan of removal. a. On 4/26/12 at 12:00 p.m., the Director of Nursing assessed Residents #14 and 15 to determine their current physical status, No injuries or problems to either resident were found at this time due to the deficient practice, Bed rails have already been removed from Resident #14's bed, he was in low bed and a mat was in place on the floor by his bed. His family was already informed on 4/11/12. Resident #15's bed was exchanged for an electric bed which is positioned at the lowest level and has 1/4 rails only that can be raised up to the head of the bed by the Administrator and Housekeeping Supervisor at approximately 12:30 p.m. on 4/26/12. An alarm mat was placed at the side of her bed and a bed alarm was continued on her bed. Her family was notified on 4/26/12 by the Director of Nursing. b. On 4/26/12 the Administrator, Assistant Administrator and Social Services personnel identified every resident/bed in the facility that currently has some type of side rail on the bed and notified the director of nursing of all resident who currently have a bed with side rails. There were 132 beds in the facility with some type of bed rail in place on the bed. The Director of Nursing, Assistant Director of Nursing, MDS Manager and two LPNs assessed every resident who currently has side rails to determine what type of side rail or if any side rail is appropriate for each resident. After the assessments were completed orders were written if the resident was determined to need side rails the type of side rail needed low beds and alarm mats by the side of bed implemented if necessary and physician's and families notified. For those residents assessed to not require the use of side rails, maintenance requests were written to remove the side rails form the resident's bed, the assessments orders and notification was completed on 4/26/12 at 8:45 p.m. Twenty-seven residents were determined not to require bed rails. The bedrails were lowered to the lowest locked position and a maintenance request was submitted to remove the rails. LPN and CNA staff on duty were educated on maintaining these rails in the low position and in use until they could be removed from the bed by maintenance staff. Four residents were identified to be at risk for harm with bed rails on the bed. Those residents had the bedrails removed, were placed in low beds with bed alarms and floor pads with alarm were placed at bedside. Two residents were assessed as being able to utilize low bed and floor pads without rails. These residents do not move independently in bed and will be placed in low beds with alarm mats at bedside on 4/27/12. The Director of Nursing and Administrator will check all residents at the beginning of the shift on 4/27/12 and determine if additional assessments need to be done or if the type of bedrail in use can be reduced, All other residents with bed rails on their beds requested that they remain on the bed for use in positioning and turning in bed, These residents will also be reassessed on 4/27/12 by the Director of Nursing and Administrator to determine if alternate lesser rails might be implemented. c. Side rail assessments will be completed at the time of admission for all residents, quarterly, with any significant change of condition and annually. This assessment will be completed by the LPN admitting the resident at the time of admission, by the LPN or RN conducting the quarterly, significant change of condition or annual assessment. Completion of these assessments and accuracy will be monitored by the DON/Designee at the time admission for new residents and at any significant change of condition by the RN coordinator at all quarterly or annual assessments. The DON/ADON will monitor the use of bed rails daily during daily rounds on all residents. Any problems noted will be reassessed and corrected immediately and the Administrator notified. Additional training will be given to all licensed personnel on the appropriate use and non-use of bed rails by the Administrator beginning 4/27/12 with the day shift and continuing until all licensed personnel have received training on the proper use of side rails for the benefit of the resident. d. The Administrator and Assistant Administrator/Designee will monitor the use of bed rails on all residents during daily rounds and by reviewing incident reports to assist in the identification of residents who might be at risk for harm with the use of bed rails so they may be removed. The Director if nursing will report all findings of side rail use and monitoring to the QA Committee

Based on observation, record review and interview, the facility Administration failed to ensure the comprehensive assessment was accurate regarding the use of restraints and falls; a thorough assessment regarding the necessity and safety in the use of side rails was conducted prior to the use of side rails; and interventions were developed and implemented to ensure that the use of side rails were reassessed if resident attempted to climb over them for 2 of 2 (Resident #14 and #15) case mix residents who repeatedly climbed or attempted to climb over the side rails. This failed practice resulted in Immediate Jeopardy which could have caused harm, serious injury or death for Residents #14 and #15 and 4 other residents identified by the facility on 4/26/12 at 12:10 p.m. The facility was notified of the Immediate Jeopardy on 4/26/12 at 12:00 p.m. The finding are: 1. The Job description for " Executive Director (Administrator)." documented the essential job functions as: a. Implement and evaluate written policies, procedures and standards that govern the operation of the facility. b. Assist department directors in the development, use and implementation of departmental policies and procedures. c. Review the facility's policies and procedures at least annually and adhere to changes as necessary to assure continued compliance with current regulation. d. Consult with department directors concerning the operation of their departments to assist in correcting problem areas, improving services and periodically verifying the competence of the workforce. e. Assist the Medical Director in the development and implementation of medical and nursing services policies and procedures and professional standards, 2. On 4/27/12 at 8:45 a.m., the Administrator was interviewed and asked the following questions: a. "Who is on the QAA committee?" She stated, "All the department heads, Medical Director, Consultant Pharmacist and Registered Dietician." b. "How often do you meet?" She replied, "Monthly and daily standup." c. "What types of things are discussed in the daily stand-up." She stated, "We review Pressure Ulcers, Weight Loss, Restraints and New I&As." d. "Has the committee identified any problems with the use of side rails?" She replied, "Have not in the last 6 months for falls and side rails." e. "Does the committee review all I&A's?" She replied, "Yes." 3. 1. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Area Assessment for the Problem Area: Falls with ARD 2/6/12 documented, "...History of Falls unchecked...Notes: Resident at risk for falls r/t (related to) use [MEDICAL CONDITION] medications and decreased mobility. Standard fall precautions in place such as assist provided with all adl's (activities of daily living), call light and other frequently used items kept within reach, and patient teaching to always call for assist when needed. No falls since admit (was attempting to climb out of bed 2/1/2 and found in floor 2/3/12)." There was no Care Area Assessment for Restraints as the MDS documented no restraint (side rails, trunk, limb or chair to prevent rising) in use although bilateral side rails was used since admission. a. A Side Rail Evaluation dated 1/30/12 documented bilateral side rails in use. The Evaluation documented: "...Requested to have them (bilateral side rails)... Is there a risk to the resident if side rails are used? (checked yes)...Do the side rails alternatives/interventions create more risks than side rail use? (checked No)..." The Care Plan documented, "...02/06/2012... Multiple falls ...Approaches... Give verbal reminders not ambulate or transfer without assistance. Ensure that resident has and wears properly-fitting non-skid soled shoes for ambulation. Maintain resident environment free of clutter and safety hazards Provide environment with adequate lighting, free of glare." The care plan did not address the use of bilateral side rails or the fact the resident would attempt to climb over them per the 1/30/12 side rail evaluation. The care plan did not address the use of any type of restraint or alternatives to prevent falls (velcro seat belt, bed/chair alarms, low bed, and floor mat ordered 2/1/12). b. Nurses Notes/Incident Reports regarding attempts to get out of bed and falls as a result of getting out of bed for February 2012 documented the following incidents: 1) Nurses Notes dated 2/1/12 at 7:00 a.m., "R (resident) displaying attempts to get out of bed and out of wc (wheelchair) Received TO (telephone order) from (Physician) to place bed alarm and Velcro seat belt to w/c (wheelchair). Placed both alarms and checked functioning. Low bed with floor mat as well." 2) An Incident/Accident Report (I&A) dated 2/3/12 at 4:30 a.m., "A CNA (Certified Nursing Assistant) reported to this nurse that Resident was sitting up in the floor." The I&A was blank in regards to "Were bed rails present." The Nurses Notes on 2/3/12 at 7:20 a.m. documented the 4:30 a.m. incident but did not indicate that side rails were present. There was no documentation on the I&A or the 2/3/12 Nurses Notes as to whether or not the bed alarm was functioning. There were no new interventions documented on the I&A report. 3) Nurses Notes dated 2/17/12 at 8:30 p.m. documented, "Resident combative (with) staff and attempting to climb over raised bed rail..." 4) Nurses notes dated 2/18/12 at 6:15 p.m., "Resident laid down by CNA. Daughter reports that resident attempting to climb out of bed..." 5) An I&A report dated 2/19/12 at 00:30 a.m. (12:30 a.m.), "Res observed lying in floor @ foot of bed." This report documented that side rails were present and in the up position and bed alarm in use. The interventions to prevent recurrences documented, "Bed alarm switched." The Investigation Follow-Up dated 2/19/12 documented the "Bed alarm on bed yet not functioning properly... Recommendations/New Interventions: psych (psychiatric) consult sched (scheduled) tues (Tuesday) 2/21/12... Bed alarm switched out..." 6) An I&A report dated 2/20/12 at 10:40 p.m. documented, "...Were bed rails present? (yes was checked and up was checked yes)..." The Post Fall Investigation no date documented, "What was the resident doing or attempting to do prior to fall? Get out of bed... Was an alarm or restraint in place? Was it functioning? Yes, No Bed alarm was not going off, turned off..." No recommendations/new interventions were documented. 7) An I&A report dated 2/22/12 at 10:40 p.m., "Resident found in room on floor. Blood and laceration noted to back of head. Alarm sounding. Ambulance called." This report also documented that the side rails were up at the present time and the height of the bed was "down." Nurses Notes dated 2/23/12 at 1:15 a.m. documented the resident received 10 Staples to the back of his head and was returned to the facility. No recommendations/new interventions were documented. 8) Nurses notes dated 2/23/12 at 7:15 p.m., "Resident attempting to climb out of bed. Argumentative and combative with staff when trying to assist resident to bed." 9) Nurses notes dated 2/28/12 (no time documented), "R (resident) cont (continues) to require skilled nursing care r/t (related to) dx. (diagnosis) R requires supervision r/t trying to get out of bed or chair. R is unsteady when attempting to ambulate..." 10) Nurses notes dated 2/29/123 at 5:45 p.m., "Resident climbed out of bed. CNA assisted to w/c (wheelchair). Resident attempting to hit this nurse and CNA..." c. Nurses Notes/Incident Reports regarding attempts to get out of bed and falls as a result of getting out of bed for March 2012 documented the following incidents: 1) Nurses notes dated 3/4/12 at 3:30 a.m., "Summoned to Rm (room). Res sitting on mat beside bed. Alarm sounding. Assisted (up) to w/c." 2) An I&A Report dated 3/9/12 at 2:30 a.m. documented, "Res on floor beside bed alarm sounding...Were bed rails present? (yes was checked and up was checked yes)... Recommendations/New Interventions: cont (continue) to respond ASAP (as soon as possible). " 3) An I&A report dated 3/22/11 at 2:00 a.m., "A CNA reported to this nurse that this resident was on the floor, upon assessment resident was lying on the floor with a skin tear to right elbow." The I&A was blank as to whether or not bed rails were up. The Investigation/Follow-Up dated 3/22/12 documented, "...Resident was trying to get up (and) he fell to the floor... Recommendations/New Interventions: CNA must check on R frequently. CNA must make sure bed alarm is on at all time..." c. Nurses Notes/Incident Reports regarding attempts to get out of bed and falls as a result of getting out of bed April 1st thru April 11th, 2012 documented the following incidents: l) Nurses notes dated 4/2/12 at 1:00 a.m., "Resident observed sitting on floor, @ (at) foot of bed, bed in lowest position & alarm on." 2) An I&A report dated 4/4/12 at 2:45 a.m., "Resident climb to end of bed (and) ended up on the floor @ corner of bed on bottom... Were bed rails present? (checked yes but blank as to whether up or down)... Additional comments and/or steps taken to prevent recurrence: (change) alarm staff training." The Investigation Follow-Up no date documented: "...R climbing out of bed (and) fell in floor... Changed bed alarm out with different alarm, In-service to (check) placement & function of alarm @ beginning of q shift, (Check) resident frequently." 3) An I&A report dated 4/11/12 at 2:20 p.m., "Appears R crawled over end of bed & fell laceration to (right) temple & St (skin tear) to (right) cheek." The nurses notes dated 4/11/12 at 3:00 p.m., documented the family did not want the resident sent to the ER so the LPN cleansed the abrasion and Steri-Stripped the laceration. The Nurses Notes also documented, "Clarification orders rec'd (received) Bed to lowest position Monitor q shift for position. Pressure alarm mat at bedside." d. The use of side rails was not re-evaluated until 4/11/12. The Side Rail Evaluation form documented a reassessment due to significant change dated 4/11/12. The evaluation documented, "Has resident expressed a desire to have side rails raised while in bed for their own safety and/or comfort? (checked yes)...Is the resident able to get in/out of bed? (checked yes)...Is the resident able to get out of bed safely? (checked no) Does the resident have a history of falls? (checked yes)... Does the resident use side rails for positioning or support? (checked no)... Is there a possibility the resident will climb over the side rails? (checked yes)... Is there a risk to the resident if side rails are used? If yes, explain (checked yes) R climbs over side rails..." The Summary of Findings on the back of the evaluation form was blank for 4/11/12. e. The plan of care for the problem of "Falls" was not updated until 4/11/12 with interventions, "Bed in lowest position, check q shift for placement, Pressure alarm mat @ (at) bedside. Check q (every) shift for placement and function." Use of side rails and risk of using side rails was not addressed. f. On 4/26/12 at 3:00 p.m., the resident was in bed. There were no side rails on the bed. The resident's spouse stated she asked them (facility) to take them off after he climbed over them and got 2 head injuries (2/22/12 and 4/11/12 per I&As). g. On 4/26/12 at 8:08 a.m., the Director of Nurses (DON) was asked, "Do you have beds that are low to the floor?" She replied, "Yes." She was then asked, "Do you know why he wasn't placed in one?" She replied, "I don't know." She was then asked, "Do you consider the side rail as a restraint?" She replied, "Yes, if he's climbing over them." She was asked also to furnish documentation of when the side rails were removed from the bed. 1) At 8:35 a.m., the DON stated she could not locate any documentation as to when the side rails were removed. 2) At 10:07 a.m., the Assistant Director of Nurses stated that she worked at the facility for two years. She stated that she does the interventions for all the I&A's. She was asked, "Do you know why he wasn't placed on a bed lower to the floor?" She replied, "No." 2. Resident #15 had [DIAGNOSES REDACTED]. A Side Rail Evaluation dated 2/20/12 documented the resident did not use side rails for positioning, could not get out of bed safely and that the resident may have a reason to get out of bed d/t (due to) cognitive condition, res may attempt climbing OOB (out of bed). This form also documented, "May attempt to climb OOB over rails causing her to fall." The Summary of Findings on the other side of the form was blank and did not indicate whether or not side rails were used. a. Nurses Notes dated 2/22/12 at 4:40 a.m. documented, "...R was put to bed early in shift (and) immediately began climbing out of bed..." At 9 p.m., "Resident on bed @ this (time) (with) SR (side rails) (up) x 2..." b. The Plan of care developed 3/7/12 documented, "Problem Onset: 03/01/12...Falls... with interventions of "Soft lap belt when in w/c (wheelchair), check q (every) minutes, release q 2 hours for ROM (range of motion)." There were no interventions documented regarding the use of side rails or the risk to the resident in the use of the side rails. c. An Incident/Accident report dated 3/14/12 at 2:30 p.m. documented, "Noted Resident lying on floor next to bed with raised area on left upper side of forehead. MD (medical doctor) notified and orders received to transfer to local hospital. A bedside mat was placed beside the bed to prevent recurrence." The I&A was blank as to whether or not bed rails were present or up. d. An Incident/Accident report dated 3/17/12 at 4:00 a.m., documented, "R climb out of bed (and) fell in the floor... Were bed rails present? (checked yes...If yes, up or down not indicated on form)..." e. A Side Rail Evaluation documented a reassessment dated [DATE]. The evaluation documented, the resident did not use side rails for positioning, could not get out of bed safely and that the resident may have a reason to get out of bed d/t (due to) cognitive condition, and no to the possibility resident will climb over the side rails. This form also documented, "Is there a risk to the resident if side rails are used (checked yes) May attempt to climb OOB over rails causing her to fall." The Summary of Findings on the other side of the form was blank and did not indicate whether or not side rails were used. f. The Initial Minimum Data (MDS) with an assessment reference date of 4/6/12 documented the resident had short/long term memory problems, required extensive assist for all activities of daily living, had a fall during the month before admission and a fall 2-6 months before admission, did not have falls since admit/reentry/prior assessment and did not have a restraint (side rails, trunk, limb or chair to prevent rising). The Care Area Assessment for the Problem Area: Falls with ARD 4/6/12 documented, "...History of Falls unchecked... Notes: Resident at risk for falls r/t impaired mobility, incontinence, dementia, hx (history) of falls, and use of antipsychotic medications. Standard fall precautions in place such as call light and other frequently used items kept within reach, as assist provided with all adl's and walkways kept free of clutter, non skid socks or shoes worn when out of bed. No falls since admit (I&A documented falls on 3/14/12 and 3/17/12)." There was no Care Area Assessment for Restraints as the MDS documented no restraint (side rails, trunk, limb or chair to prevent rising) in use although bilateral side rails was noted in Nurses Notes dated 2/22/12 and the 3/17/12 I&A documented use of bed rails. g. On 4/26/12 at 11:00 a.m., the Director of Nursing was asked if this resident had side rails on her bed. She went to the room and stated, "Yes, she does and the tops are padded." h. On 4/26/12 at 11:04 a.m., the resident's bed had full side rails on them. 3. The Immediate Jeopardy was removed on 4/27/12 at 9:00 a.m. and the scope and severity reduced to an "E" when the facility implemented the following plan of removal. a. On 4/26/12 at 12:00 p.m., the Director of Nursing assessed Residents #14 and 15 to determine their current physical status, No injuries or problems to either resident were found at this time due to the deficient practice, Bed rails have already been removed from Resident #14's bed, he was in low bed and a mat was in place on the floor by his bed. His family was already informed on 4/11/12. Resident #15's bed was exchanged for an electric bed which is positioned at the lowest level and has 1/4 rails only that can be raised up to the head of the bed by the Administrator and Housekeeping Supervisor at approximately 12:30 p.m. on 4/26/12. An alarm mat was placed at the side of her bed and a bed alarm was continued on her bed. Her family was notified on 4/26/12 by the Director of Nursing. b. On 4/26/12 the Administrator, Assistant Administrator and Social Services personnel identified every resident/bed in the facility that currently has some type of side rail on the bed and notified the director of nursing of all resident who currently have a bed with side rails. There were 132 beds in the facility with some type of bed rail in place on the bed. The Director of Nursing, Assistant Director of Nursing, MDS Manager and two LPNs assessed every resident who currently has side rails to determine what type of side rail or if any side rail is appropriate for each resident. After the assessments were completed orders were written if the resident was determined to need side rails the type of side rail needed low beds and alarm mats by the side of bed implemented if necessary and physician's and families notified. For those residents assessed to not require the use of side rails, maintenance requests were written to remove the side rails form the resident's bed, the assessments orders and notification was completed on 4/26/12 at 8:45 p.m. Twenty-seven residents were determined not to require bed rails. The bedrails were lowered to the lowest locked position and a maintenance request was submitted to remove the rails. LPN and CNA staff on duty were educated on maintaining these rails in the low position and in use until they could be removed from the bed by maintenance staff. Four residents were identified to be at risk for harm with bed rails on the bed. Those residents had the bedrails removed, were placed in low beds with bed alarms and floor pads with alarm were placed at bedside. Two residents were assessed as being able to utilize low bed and floor pads without rails. These residents do not move independently in bed and will be placed in low beds with alarm mats at bedside on 4/27/12. The Director of Nursing and Administrator will check all residents at the beginning of the shift on 4/27/12 and determine if additional assessments need to be done or if the type of bedrail in use can be reduced, All other residents with bed rails on their beds requested that they remain on the bed for use in positioning and turning in bed, These residents will also be reassessed on 4/27/12 by the Director of Nursing and Administrator to determine if alternate lesser rails might be implemented. c. Side rail assessments will be completed at the time of admission for all residents, quarterly, with any significant change of condition and annually. This assessment will be completed by the LPN admitting the resident at the time of admission, by the LPN or RN conducting the quarterly, significant change of condition or annual assessment. Completion of these assessments and accuracy will be monitored by the DON/Designee at the time admission for new residents and at any significant change of condition by the RN coordinator at all quarterly or annual assessments. The DON/ADON will monitor the use of bed rails daily during daily rounds on all residents. Any problems noted will be reassessed and corrected immediately and the Administrator notified. Additional training will be given to all licensed personnel on the appropriate use and non-use of bed rails by the Administrator beginning 4/27/12 with the day shift and continuing until all licensed personnel have received training on the proper use of side rails for the benefit of the resident. d. The Administrator and Assistant Administrator/Designee will monitor the use of bed rails on all residents during daily rounds and by reviewing incident reports to assist in the identification of residents who might be at risk for harm with the use of bed rails so they may be removed. The Director if nursing will report all findings of side rail use and monitoring to the QA Committee

Based on observation, record review and interview, the facility QAA committee failed to identify and correct quality deficiencies as evidenced by the failure to ensure the comprehensive assessment was accurate regarding the use of restraints and falls; a thorough assessment regarding the necessity and safety in the use of side rails was conducted prior to the use of side rails; and interventions were developed and implemented to ensure that the use of side rails were reassessed if resident attempted to climb over them for 2 of 2 (Resident #14 and #15) case mix residents who repeatedly climbed or attempted to climb over the side rails. This failed practice resulted in Immediate Jeopardy which could have caused harm, serious injury or death for Residents #14 and #15 and 4 other residents identified by the facility on 4/26/12 at 12:10 p.m. The facility was notified of the Immediate Jeopardy on 4/26/12 at 12:00 p.m. The findings are: 1. On 4/27/12 at 8:45 a.m., the Administrator was interviewed and asked the following questions: a. " Who is on the QAA committee?" She stated, "All the department heads, Medical Director, Consultant Pharmacist and Registered Dietician." b. " How often do you meet?' She replied."Monthly and daily standup." c. "What types of things are discussed in the daily stand-up." She stated, "We review Pressure Ulcers, Weight Loss, Restraints and New I&As." d. "Has the committee identified any problems with the use of side rails?" She replied, "Have not in the last 6 months for falls and side rails." e. "Does the committee review all I&A's?" She replied, "Yes." 1. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Area Assessment for the Problem Area: Falls with ARD 2/6/12 documented, "...History of Falls unchecked...Notes: Resident at risk for falls r/t (related to) use [MEDICAL CONDITION] medications and decreased mobility. Standard fall precautions in place such as assist provided with all adl's (activities of daily living), call light and other frequently used items kept within reach, and patient teaching to always call for assist when needed. No falls since admit (was attempting to climb out of bed 2/1/2 and found in floor 2/3/12)." There was no Care Area Assessment for Restraints as the MDS documented no restraint (side rails, trunk, limb or chair to prevent rising) in use although bilateral side rails was used since admission. a. A Side Rail Evaluation dated 1/30/12 documented bilateral side rails in use. The Evaluation documented: "...Requested to have them (bilateral side rails)... Is there a risk to the resident if side rails are used? (checked yes)...Do the side rails alternatives/interventions create more risks than side rail use? (checked No)..." The Care Plan documented, "...02/06/2012... Multiple falls ...Approaches... Give verbal reminders not ambulate or transfer without assistance. Ensure that resident has and wears properly-fitting non-skid soled shoes for ambulation. Maintain resident environment free of clutter and safety hazards Provide environment with adequate lighting, free of glare." The care plan did not address the use of bilateral side rails or the fact the resident would attempt to climb over them per the 1/30/12 side rail evaluation. The care plan did not address the use of any type of restraint or alternatives to prevent falls (velcro seat belt, bed/chair alarms, low bed, and floor mat ordered 2/1/12). b. Nurses Notes/Incident Reports regarding attempts to get out of bed and falls as a result of getting out of bed for February 2012 documented the following incidents: 1) Nurses Notes dated 2/1/12 at 7:00 a.m., "R (resident) displaying attempts to get out of bed and out of wc (wheelchair) Received TO (telephone order) from (Physician) to place bed alarm and Velcro seat belt to w/c (wheelchair). Placed both alarms and checked functioning. Low bed with floor mat as well." 2) An Incident/Accident Report (I&A) dated 2/3/12 at 4:30 a.m., "A CNA (Certified Nursing Assistant) reported to this nurse that Resident was sitting up in the floor." The I&A was blank in regards to "Were bed rails present." The Nurses Notes on 2/3/12 at 7:20 a.m. documented the 4:30 a.m. incident but did not indicate that side rails were present. There was no documentation on the I&A or the 2/3/12 Nurses Notes as to whether or not the bed alarm was functioning. There were no new interventions documented on the I&A report. 3) Nurses Notes dated 2/17/12 at 8:30 p.m. documented, "Resident combative (with) staff and attempting to climb over raised bed rail..." 4) Nurses notes dated 2/18/12 at 6:15 p.m., "Resident laid down by CNA. Daughter reports that resident attempting to climb out of bed..." 5) An I&A report dated 2/19/12 at 00:30 a.m. (12:30 a.m.), "Res observed lying in floor @ foot of bed." This report documented that side rails were present and in the up position and bed alarm in use. The interventions to prevent recurrences documented, "Bed alarm switched." The Investigation Follow-Up dated 2/19/12 documented the "Bed alarm on bed yet not functioning properly... Recommendations/New Interventions: psych (psychiatric) consult sched (scheduled) tues (Tuesday) 2/21/12... Bed alarm switched out..." 6) An I&A report dated 2/20/12 at 10:40 p.m. documented, "...Were bed rails present? (yes was checked and up was checked yes)..." The Post Fall Investigation no date documented, "What was the resident doing or attempting to do prior to fall? Get out of bed... Was an alarm or restraint in place? Was it functioning? Yes, No Bed alarm was not going off, turned off..." No recommendations/new interventions were documented. 7) An I&A report dated 2/22/12 at 10:40 p.m., "Resident found in room on floor. Blood and laceration noted to back of head. Alarm sounding. Ambulance called." This report also documented that the side rails were up at the present time and the height of the bed was "down." Nurses Notes dated 2/23/12 at 1:15 a.m. documented the resident received 10 Staples to the back of his head and was returned to the facility. No recommendations/new interventions were documented. 8) Nurses notes dated 2/23/12 at 7:15 p.m., "Resident attempting to climb out of bed. Argumentative and combative with staff when trying to assist resident to bed." 9) Nurses notes dated 2/28/12 (no time documented), "R (resident) cont (continues) to require skilled nursing care r/t (related to) dx. (diagnosis) R requires supervision r/t trying to get out of bed or chair. R is unsteady when attempting to ambulate..." 10) Nurses notes dated 2/29/123 at 5:45 p.m., "Resident climbed out of bed. CNA assisted to w/c (wheelchair). Resident attempting to hit this nurse and CNA..." c. Nurses Notes/Incident Reports regarding attempts to get out of bed and falls as a result of getting out of bed for March 2012 documented the following incidents: 1) Nurses notes dated 3/4/12 at 3:30 a.m., "Summoned to Rm (room). Res sitting on mat beside bed. Alarm sounding. Assisted (up) to w/c." 2) An I&A Report dated 3/9/12 at 2:30 a.m. documented, "Res on floor beside bed alarm sounding...Were bed rails present? (yes was checked and up was checked yes)... Recommendations/New Interventions: cont (continue) to respond ASAP (as soon as possible). " 3) An I&A report dated 3/22/11 at 2:00 a.m., "A CNA reported to this nurse that this resident was on the floor, upon assessment resident was lying on the floor with a skin tear to right elbow." The I&A was blank as to whether or not bed rails were up. The Investigation/Follow-Up dated 3/22/12 documented, "...Resident was trying to get up (and) he fell to the floor... Recommendations/New Interventions: CNA must check on R frequently. CNA must make sure bed alarm is on at all time..." c. Nurses Notes/Incident Reports regarding attempts to get out of bed and falls as a result of getting out of bed April 1st thru April 11th, 2012 documented the following incidents: l) Nurses notes dated 4/2/12 at 1:00 a.m., "Resident observed sitting on floor, @ (at) foot of bed, bed in lowest position & alarm on." 2) An I&A report dated 4/4/12 at 2:45 a.m., "Resident climb to end of bed (and) ended up on the floor @ corner of bed on bottom... Were bed rails present? (checked yes but blank as to whether up or down)... Additional comments and/or steps taken to prevent recurrence: (change) alarm staff training." The Investigation Follow-Up no date documented: "...R climbing out of bed (and) fell in floor... Changed bed alarm out with different alarm, In-service to (check) placement & function of alarm @ beginning of q shift, (Check) resident frequently." 3) An I&A report dated 4/11/12 at 2:20 p.m., "Appears R crawled over end of bed & fell laceration to (right) temple & St (skin tear) to (right) cheek." The nurses notes dated 4/11/12 at 3:00 p.m., documented the family did not want the resident sent to the ER so the LPN cleansed the abrasion and Steri-Stripped the laceration. The Nurses Notes also documented, "Clarification orders rec'd (received) Bed to lowest position Monitor q shift for position. Pressure alarm mat at bedside." d. The use of side rails was not re-evaluated until 4/11/12. The Side Rail Evaluation form documented a reassessment due to significant change dated 4/11/12. The evaluation documented, "Has resident expressed a desire to have side rails raised while in bed for their own safety and/or comfort? (checked yes)...Is the resident able to get in/out of bed? (checked yes)...Is the resident able to get out of bed safely? (checked no) Does the resident have a history of falls? (checked yes)... Does the resident use side rails for positioning or support? (checked no)... Is there a possibility the resident will climb over the side rails? (checked yes)... Is there a risk to the resident if side rails are used? If yes, explain (checked yes) R climbs over side rails..." The Summary of Findings on the back of the evaluation form was blank for 4/11/12. e. The plan of care for the problem of "Falls" was not updated until 4/11/12 with interventions, "Bed in lowest position, check q shift for placement, Pressure alarm mat @ (at) bedside. Check q (every) shift for placement and function." Use of side rails and risk of using side rails was not addressed. f. On 4/26/12 at 3:00 p.m., the resident was in bed. There were no side rails on the bed. The resident's spouse stated she asked them (facility) to take them off after he climbed over them and got 2 head injuries (2/22/12 and 4/11/12 per I&As). g. On 4/26/12 at 8:08 a.m., the Director of Nurses (DON) was asked, "Do you have beds that are low to the floor?" She replied, "Yes." She was then asked, "Do you know why he wasn't placed in one?" She replied, "I don't know." She was then asked, "Do you consider the side rail as a restraint?" She replied, "Yes, if he's climbing over them." She was asked also to furnish documentation of when the side rails were removed from the bed. 1) At 8:35 a.m., the DON stated she could not locate any documentation as to when the side rails were removed. 2) At 10:07 a.m., the Assistant Director of Nurses stated that she worked at the facility for two years. She stated that she does the interventions for all the I&A's. She was asked, "Do you know why he wasn't placed on a bed lower to the floor?" She replied, "No." 2. Resident #15 had [DIAGNOSES REDACTED]. A Side Rail Evaluation dated 2/20/12 documented the resident did not use side rails for positioning, could not get out of bed safely and that the resident may have a reason to get out of bed d/t (due to) cognitive condition, res may attempt climbing OOB (out of bed). This form also documented, "May attempt to climb OOB over rails causing her to fall." The Summary of Findings on the other side of the form was blank and did not indicate whether or not side rails were used. a. Nurses Notes dated 2/22/12 at 4:40 a.m. documented, "...R was put to bed early in shift (and) immediately began climbing out of bed..." At 9 p.m., "Resident on bed @ this (time) (with) SR (side rails) (up) x 2..." b. The Plan of care developed 3/7/12 documented, "Problem Onset: 03/01/12...Falls... with interventions of "Soft lap belt when in w/c (wheelchair), check q (every) minutes, release q 2 hours for ROM (range of motion)." There were no interventions documented regarding the use of side rails or the risk to the resident in the use of the side rails. c. An Incident/Accident report dated 3/14/12 at 2:30 p.m. documented, "Noted Resident lying on floor next to bed with raised area on left upper side of forehead. MD (medical doctor) notified and orders received to transfer to local hospital. A bedside mat was placed beside the bed to prevent recurrence." The I&A was blank as to whether or not bed rails were present or up. d. An Incident/Accident report dated 3/17/12 at 4:00 a.m., documented, "R climb out of bed (and) fell in the floor... Were bed rails present? (checked yes...If yes, up or down not indicated on form)..." e. A Side Rail Evaluation documented a reassessment dated [DATE]. The evaluation documented, the resident did not use side rails for positioning, could not get out of bed safely and that the resident may have a reason to get out of bed d/t (due to) cognitive condition, and no to the possibility resident will climb over the side rails. This form also documented, "Is there a risk to the resident if side rails are used (checked yes) May attempt to climb OOB over rails causing her to fall." The Summary of Findings on the other side of the form was blank and did not indicate whether or not side rails were used. f. The Initial Minimum Data (MDS) with an assessment reference date of 4/6/12 documented the resident had short/long term memory problems, required extensive assist for all activities of daily living, had a fall during the month before admission and a fall 2-6 months before admission, did not have falls since admit/reentry/prior assessment and did not have a restraint (side rails, trunk, limb or chair to prevent rising). The Care Area Assessment for the Problem Area: Falls with ARD 4/6/12 documented, "...History of Falls unchecked... Notes: Resident at risk for falls r/t impaired mobility, incontinence, dementia, hx (history) of falls, and use of antipsychotic medications. Standard fall precautions in place such as call light and other frequently used items kept within reach, as assist provided with all adl's and walkways kept free of clutter, non skid socks or shoes worn when out of bed. No falls since admit (I&A documented falls on 3/14/12 and 3/17/12)." There was no Care Area Assessment for Restraints as the MDS documented no restraint (side rails, trunk, limb or chair to prevent rising) in use although bilateral side rails was noted in Nurses Notes dated 2/22/12 and the 3/17/12 I&A documented use of bed rails. g. On 4/26/12 at 11:00 a.m., the Director of Nursing was asked if this resident had side rails on her bed. She went to the room and stated, "Yes, she does and the tops are padded." h. On 4/26/12 at 11:04 a.m., the resident's bed had full side rails on them. 3. The Immediate Jeopardy was removed on 4/27/12 at 9:00 a.m. and the scope and severity reduced to an "E" when the facility implemented the following plan of removal. a. On 4/26/12 at 12:00 p.m., the Director of Nursing assessed Residents #14 and 15 to determine their current physical status, No injuries or problems to either resident were found at this time due to the deficient practice, Bed rails have already been removed from Resident #14's bed, he was in low bed and a mat was in place on the floor by his bed. His family was already informed on 4/11/12. Resident #15's bed was exchanged for an electric bed which is positioned at the lowest level and has 1/4 rails only that can be raised up to the head of the bed by the Administrator and Housekeeping Supervisor at approximately 12:30 p.m. on 4/26/12. An alarm mat was placed at the side of her bed and a bed alarm was continued on her bed. Her family was notified on 4/26/12 by the Director of Nursing. b. On 4/26/12 the Administrator, Assistant Administrator and Social Services personnel identified every resident/bed in the facility that currently has some type of side rail on the bed and notified the director of nursing of all resident who currently have a bed with side rails. There were 132 beds in the facility with some type of bed rail in place on the bed. The Director of Nursing, Assistant Director of Nursing, MDS Manager and two LPNs assessed every resident who currently has side rails to determine what type of side rail or if any side rail is appropriate for each resident. After the assessments were completed orders were written if the resident was determined to need side rails the type of side rail needed low beds and alarm mats by the side of bed implemented if necessary and physician's and families notified. For those residents assessed to not require the use of side rails, maintenance requests were written to remove the side rails form the resident's bed, the assessments orders and notification was completed on 4/26/12 at 8:45 p.m. Twenty-seven residents were determined not to require bed rails. The bedrails were lowered to the lowest locked position and a maintenance request was submitted to remove the rails. LPN and CNA staff on duty were educated on maintaining these rails in the low position and in use until they could be removed from the bed by maintenance staff. Four residents were identified to be at risk for harm with bed rails on the bed. Those residents had the bedrails removed, were placed in low beds with bed alarms and floor pads with alarm were placed at bedside. Two residents were assessed as being able to utilize low bed and floor pads without rails. These residents do not move independently in bed and will be placed in low beds with alarm mats at bedside on 4/27/12. The Director of Nursing and Administrator will check all residents at the beginning of the shift on 4/27/12 and determine if additional assessments need to be done or if the type of bedrail in use can be reduced, All other residents with bed rails on their beds requested that they remain on the bed for use in positioning and turning in bed, These residents will also be reassessed on 4/27/12 by the Director of Nursing and Administrator to determine if alternate lesser rails might be implemented. c. Side rail assessments will be completed at the time of admission for all residents, quarterly, with any significant change of condition and annually. This assessment will be completed by the LPN admitting the resident at the time of admission, by the LPN or RN conducting the quarterly, significant change of condition or annual assessment. Completion of these assessments and accuracy will be monitored by the DON/Designee at the time admission for new residents and at any significant change of condition by the RN coordinator at all quarterly or annual assessments. The DON/ADON will monitor the use of bed rails daily during daily rounds on all residents. Any problems noted will be reassessed and corrected immediately and the Administrator notified. Additional training will be given to all licensed personnel on the appropriate use and non-use of bed rails by the Administrator beginning 4/27/12 with the day shift and continuing until all licensed personnel have received training on the proper use of side rails for the benefit of the resident. d. The Administrator and Assistant Administrator/Designee will monitor the use of bed rails on all residents during daily rounds and by reviewing incident reports to assist in the identification of residents who might be at risk for harm with the use of bed rails so they may be removed. The Director if nursing will report all findings of side rail use and monitoring to the QA Committee

Complaint # was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure that Resident #2 received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and the physician's plan of care. The facility failed to ensure appropriate identification of residents was made prior to administration of medication; all medications given in error and those already received as prescribed were promptly identified; and staff assessed and continued to monitor for potential adverse side effects in order to ensure treatment without delay in the event of a serious adverse side effect for 1 of 1 (Resident #2) case mix resident who received medications in error. The failed practices resulted in Immediate Jeopardy which caused or was likely to cause serious injury, harm, impairment or death for Resident #2 who became unresponsive and required emergency room interventions to reverse the adverse side effects of the incorrect medications administered. This failed practice had the potential to cause more than minimal harm for 105 residents who received medications from Licensed Practical Nurse (LPN) #1 on Halls 1, 2, 3, 4, 5, and 6 as documented on the Census List provided LPN #4 on 4/10/12 at 12:35 p.m. The Administrator was notified of the Immediate Jeopardy on 4/11/12 at 4:15 p.m. The findings are: 1. The facility's Medication Errors and Drug Reactions general guidelines dated March 2005 documented, "(1.) All medication errors and drug reactions must be promptly reported to the Director of Nursing Services, attending physician and the pharmacist. (2.) A detailed account of the incident must be recorded in the resident's medical record. Such documentation must include, but is not limited to: the time and date of the incident; the name, strength and dosage of medication administered; the resident's reaction to the medication; the condition of the resident; any treatment administered; and the date and time the physician was notified and his/her instructions. (3.) Residents receiving incorrect medication or having a drug reaction must be closely monitored. Any change in the resident's condition must be immediately reported to the Director of Nursing Services and attending physician... The Medication Errors and Drug Reactions documentation section documented, "The following information should be recorded in the resident's medical record: the time and date of the incident; the name, strength and dosage of medication administration; the resident's reaction to the medication; all assessment data obtained during the procedure; any treatment administered; the time the physician was notified and his/her instructions; and the name and title of the individual documenting the incident." 2. Resident #2 had [DIAGNOSES REDACTED]. The MDS with an ARD of 3/4/12 documented the resident had a score of 0 (0-7 indicates severe impairment) on a BIMS. a. The March 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] 1) "[MEDICATION NAME] 125 mg (milligrams) Sprinkle cap (capsule) 2 (250 mg.) PO (by mouth) TID (three times daily) w(with)/food ..." The MAR indicated [REDACTED] "http://www.drugs.com/sfx/[MEDICATION NAME]-side-effects.html: ... COMMON side effects ... dizziness ... tiredness... " 2) "[MEDICATION NAME] 50 mg tab (tablet) 1 PO QAM (every a.m.) w/food ..." The MAR indicated [REDACTED] "http://www.drugs.com/sfx/[MEDICATION NAME]-side-effects.html: ... COMMON side effects... dizziness; drowsiness; dry mouth; ... light-headedness; ... sluggishness; ...weakness... " 3) "[MEDICATION NAME] ER (extended release) 16 mg. cap 1 PO daily ..." The MAR indicated [REDACTED] "http://www.drugs.com/sfx/[MEDICATION NAME]-side-effects.html: ... COMMON side effects... dizziness; ... tiredness... " 4) "[MEDICATION NAME] 6.5 mg 1 BID (twice daily)." The MAR indicated [REDACTED] "http://www.drugs.com/sfx/[MEDICATION NAME]-side-effects.html: ... COMMON side effects ... dizziness;... fatigue; light-headedness; weakness. " 5) "[MEDICATION NAME] 20 mg 1 q (every) a.m." The MAR indicated [REDACTED] "http://www.drugs.com/sfx/[MEDICATION NAME]-side-effects.html: ... COMMON side effects ... Dizziness; lightheadedness. " b. The Medication Error Report completed by LPN #1 on 3/29/12 at 8:30 a.m. documented the explanation/reason med error occurred as "Asked if R (resident's) name was (Resident #1) who was not in her room. R nodded her head yes. Gave R meds then realized R seemed confused. Went to see is R was usually confused. CNA (Certified Nursing Assistant) stated that was not (Resident #1). Reported error to (Director of Nursing) and (LPN #2), 500 hall charge nurse. Notified (niece)." On 4/12/12 at 10:31 a.m. a Physician Assistant stated, "I was notified on 3/29/12 of the error in medication administration. I told the nurse to monitor for any adverse effects of the medications given." c. The Nurse's Notes dated 3/29/12 at 1:30 p.m. and LPN #1 confirmed (4/11/12 at 9:00 a.m.) that Resident #2 received the following medications that belonged to Resident #1: 1) [MEDICATION NAME] 20 mg: "http://www.drugs.com/sfx/[MEDICATION NAME]-side-effects.html--[MEDICATION NAME] may cause the following side effects: ...dizziness; drowsiness; [MEDICAL CONDITION]; fast, slow, or irregular heartbeat; hallucinations; mental or mood changes; [MEDICAL CONDITION]; severe dizziness, drowsiness, or light-headedness;..." 2) [MEDICATION NAME] 150 mg: "http://www.drugs.com/sfx/[MEDICATION NAME]-side-effects.html--[MEDICATION NAME] may cause the following side effects: blurred vision;... dizziness; drowsiness;.. lightheadedness;... fast or irregular heartbeat;... loss of coordination; memory loss;... new or worsening mental or mood changes (eg, anxiety, depression, restlessness, irritability, panic attacks, feeling "high," behavior changes, suicidal thoughts or attempts); new or worsening [MEDICAL CONDITION];..." 3) [MEDICATION NAME] 10 mg: "http://www.drugs.com/sfx/[MEDICATION NAME]-side-effects.html--[MEDICATION NAME] may cause the following side effects: dizziness; drowsiness; fatigue;... weakness;... [MEDICAL CONDITION]; fast, slow, or irregular heartbeat; pounding in the chest; severe or persistent dizziness; shortness of breath;..." 4) Potassium Chloride 10 meq: "http://www.drugs.com/sfx/potassium-chloride-side-effects.html--Potassium Chloride may cause the following side effects:... irregular heartbeat; listlessness; ...unusual confusion or anxiety; unusual muscle weakness or paralysis;... weak or heavy legs." 5) [MEDICATION NAME] 50 mg tab 1/2 (25 mg): "http://www.drugs.com/sfx/[MEDICATION NAME]-side-effects.html--[MEDICATION NAME] may cause the following side effects: anxiety;... dizziness; drowsiness;... decreased coordination; exaggerated reflexes; [MEDICAL CONDITION]; fast or irregular heartbeat;... 6) Fish Oil 1000 mg: "http://www.drugs.com/sfx/fish-oil-side-effects.html--Fish Oil may cause the following side effects: ...General side effects including infection, flu syndrome, back pain, pain, enlarged abdomen, asthenia, body odor, chest pains, chills, suicide, fever, generalized [MEDICAL CONDITION], fungal infection, malaise, neck pain, sudden death, and [MEDICAL CONDITION] infection have been reported... Cardiovascular side effects including [MEDICAL CONDITION] pectoris, arrhythmia, bypass surgery, [MEDICAL CONDITIONS], hypertension, migraine, [MEDICAL CONDITION] infarct, [MEDICAL CONDITION] ischemia, occlusion, peripheral vascular disorder, [MEDICAL CONDITION], and [MEDICAL CONDITION] been reported.... Nervous system side effects including depression, dizziness, emotional lability, facial paralysis, [MEDICAL CONDITION], vasodilation, and [MEDICAL CONDITION] have been reported..." 7) [MEDICATION NAME] ER (extended release) 600 mg. 8) [MEDICATION NAME] Sodium 100 mg. 9) Multivitamin with Minerals d. As of 4/11/12, there was no documentation in Resident #2's clinical record by LPN #1 of the medication belonging to Resident #1 being administered inadvertently to Resident #2 or of any assessment of the resident's condition by LPN #1 prior to the late entry on 3/30/12 at 10:30 a.m. : 1) The Nurse's Notes dated 3/30/12 at 10:30 a.m. documenting a late entry for 3/29/12 and signed by LPN #1 documented, "8:30 a.m.: Attempting to give meds to R on Hall 2. R was not in room, noted a lady in w/c (wheelchair) in front of nurses station that looked similar to picture on MAR. Asked (Resident #2) if she was (Resident #1). Nods head yes. After giving R meds noted she appeared confused. Asked 200 Hall CNA if (Resident #1) was often confused. Stated R was not (Resident #1). Notified DON and Hall 500 Charge Nurse (LPN #2) of error. (LPN #1) continued to check R every 30 minutes. R alert stated she was fine when asked. 10:30 a.m.: checked R B/P 116/76, P 72. R sitting in w/c on hall 500 at 11:15 a.m. R remain alert with eyes open responding to verbal stimulus. Notified (niece) and (Physician Assistant) for (attending Physician) at 10:30 a.m. after vital signs taken. 12:00 noon: Charge nurse reported R lethargic, unable to take noon meds. Assist to bed. 1:30 p.m.: Called to room d/t (due to) unresponsive. Did move but not open eyes when knuckles on sternum. R sent to ER per (LPN #2)." 2) On 4/11/12 at 9:00 a.m., LPN #1 stated, "I started (to work at the facility) on 3/21/12. I was in orientation on 3/21, 3/22 and 3/23. I worked 3/24 on Halls 1 and 6. I was off 3/25/12 and back on 3/29/12. In orientation the first two days I watched the morning meds and gave the 12 o'clock (p.m.) meds. The third day, 3/29/12, I gave meds on halls 1 and 2. I administered (Resident #1's) meds to (Resident #2). I did not document the meds of (Resident #1) that I gave to (Resident #2) on (Resident #2's) MAR. I was not aware that (Resident #2) received [MEDICATION NAME] 50 mg on the 9:00 a.m. med pass from her nurse. I gave (Resident #2) (Resident #1's) 9:00 a.m. meds on 3/29/12 which included [MEDICATION NAME] ER 600 mg, Multiple Vitamins with Minerals, [MEDICATION NAME] 100 mg, Fish Oil 1000 mg, [MEDICATION NAME] 10 mg, [MEDICATION NAME] 20 mg and [MEDICATION NAME] 150 mg. I asked (Resident #2) if she was (Resident #1). She said yes. She took the meds and seemed confused. I asked a CNA and she stated (Resident #2) was not (Resident #1). I did not write any nurse's notes on (Resident #2) on 3/29/12. I filled out a Medication Error Report. I do not know who found her unresponsive at 12:00 noon on 3/29/12. Around 10:30 a.m., I took her vital signs when she was in her wheelchair in the TV area. I did not document. I did not take any other vital signs. I was anticipating a change of condition because of the meds that she received. I told (LPN #2) about the med error. I did not find her unresponsive at noon. I did go to assist her charge nurse (LPN #2). I took her pulse and did a sternal rub. On 3/30/12 someone, I don't know who, told me that I needed to make an entry in the chart as to 3/29/12 on (Resident #2). The nurse's notes are my description of 3/29/12 events. After a little later I gave (Resident #1) her medicine. I anticipated a change of condition and kept watching her in the TV area. The last time I saw her was around 11:15 a.m. She was fine. I never did a full assessment." e. There was no documentation in the Nurses Notes of any assessment of the resident's condition after the administration of multiple medications that were not prescribed for the resident until the DON documented the following untimed Nurses Notes that included a notation that she checked the resident in the dining room at 12:30 p.m. when she noted poor appetite and trying to sleep. There was no documentation that vital signs were obtained: The Nurse's Notes dated 3/29/12, no time noted, and signed by the DON documented "(LPN #1) came to this nurse at approximately 10:30 a.m. stated she had med error on (Resident #2). Inst (instructed) nurse to notify family and MD. Verbal counseled nurse to ask for assist to ID (identify) residents, don't assume they are who they say because majority of R have forgetfulness or dementia or even maybe HOH (hard of hearing), check for pics (pictures) on MAR (Medication Administration Record). At approx (approximately) 12:30 p.m. this nurse checked on R and nurse. Nurse stated no new orders but to observe R. R in DR (dining room). CNA attempting to feed R. She would take bite with a lot of encouragement. This nurse instructed CNA to take R to room due to increased sleepy appearance. Inst CNA to tell nurse R's poor appetite and trying to sleep. R taken to rm (room) and placed in bed." 1) On 4/11/12 at 12:27 p.m., CNA #1 stated, "On 3/29/12 (LPN #2) came up to me and told me to watch (Resident #2). She said she had gotten the wrong medicine. She did not tell me what to look for. That was early that morning. (Resident #2) was the same as always until lunch about noon. She would not eat or swallow. I told (LPN #2). (LPN #2) came in the dining room and looked at her. She did not do vital signs. Then me and my partner laid her down. Twenty minutes later, I came in and shook her. She had no response. I went and got (LPN #3) and told her about (Resident #2). (LPN #3) went to the room. I did not go. (LPN #2) never told me what to look for. She just said watch her, she was given the wrong meds. Se did not tell us to get her vital signs or anything." 2) On 4/11/12 at 2:50 p.m., CNA #1 stated, "The family said after I laid her down and before I got the LPNs that 'She is unconscious because they gave her the wrong medications'. Then I went and got the LPN. I don't know the relationship (of the family members)." 3) On 4/11/12 at 1:27 p.m., LPN #2 stated, "I was the charge nurse for (Resident #2) on 3/29/12. I actually had completed her a.m. ( morning) meds on 3/29/12 when (LPN #1) informed me that she had given (Resident #2) (Resident #1's) meds. She said she had given her [MEDICATION NAME]. I did not check (Resident #1's) chart as to the meds that had been given to (Resident #2). (LPN #1) did not advise me of any other meds. (LPN #1) told me to keep an eye on (Resident #2). I did not assess (Resident #2) until she was unresponsive around 1:00 p.m. I told the aides to keep an eye on (Resident #2). I assumed the CNA would know what to watch for. If I had known what meds she had been given I would have expected a change of condition. I would have gone to a supervisor to find out what to do. I have not had any inservice in the past three weeks regarding medication or change of condition. I did not document an assessment because I did not assess her. I have not had any counseling." 4) On 4/11/12 at 3:00 p.m., the DON stated, "I instructed (LPN #1) to notify the family and physician and to assess (Resident #2) with frequent monitoring. I only knew that [MEDICATION NAME] was given. Around 10:30 a.m., I knew what meds had actually been given. I did not talk to (LPN #2) about the issue. I saw (Resident #2) in the dining room. She appeared sleepy and wasn't eating. I did not complete an assessment. Medication inservice was started on 4/6/12 because more nurses were available. I did not give any inservices relative to adverse reactions related to wrong medication or change of condition. I did not instruct (LPN #2) or (LPN #1) what to assess (Resident #2) for at any time." f. The Nurse's Notes dated 3/29/12 at 1:30 p.m. and signed by LPN #2 documented, "R was given wrong medicine on accident by (LPN #1) [MEDICATION NAME] 20 mg, [MEDICATION NAME] 150 mg, [MEDICATION NAME] 50 mg, Multivitamin, Fish Oil, Potassium 10 meq, [MEDICATION NAME] and [MEDICATION NAME] 10 mg at 8:30 a.m. Monitored for change in mental status. Was alerted at 1:00 p.m. that R was unresponsive. Did not wake up to eat lunch. Ambulance called and R sent out to (hospital). BP (blood pressure) 112/62, P (Pulse) 72, R (respirations) 17." 1) The Resident Transfer Form dated 3/29/12 at 1:30 p.m. and signed by LPN #3 documented a reason for transfer as "severely increased lethargy". The vital signs at the time of the transfer were documented as "P 72, R 17, B/P 112/62." On 4/11/12 at 10:13 a.m. LPN #3 stated, "On 3/29/12 I completed the Resident Transfer Form for (Resident #2) for (LPN #2). I was informed that (Resident #2) was hard to arouse. I went to (Resident #2's) room. She was unresponsive to verbal and tactile stimuli. One of the CNA's had alerted me to her condition. I was the first LPN to arrive. The CNA told me that (LPN #1) had given (Resident #1's) meds to (Resident #2). (Assistant Executive Director) followed me to the room. The CNA went to get equipment to do vital signs. I left the room. I left (Assistant Executive Director) in there and ran to the med room door and got (LPN #2), her charge nurse, and (LPN #1). The vital signs were taken by (LPN #2). The Administrator came in. I called Emergency Medical Services, filled out the transfer form and sent her to the ER (emergency room ). (LPN #4) called the emergency room and gave them a list of the meds of (Resident #1) that (Resident #2) had received and (LPN #4) sent a written list of the meds (with the EMS personnel)." 2) On 4/11/12 at 10:45 a.m., LPN #4 stated, "A CNA stopped me at the front nurse's station saying that she could not get (Resident #2) to wake up. I went to (Resident #2's) room. (LPN #3) was in there. (LPN #1) came in and took the vital signs. (Resident #2) could not be aroused. During the transport process, I called the ER and told them which meds that she had received that were not ordered. I also told them I was sending a list of the meds in writing that she had received." g. The emergency room Record dated 3/29/12 documented, "Patient arrived to ED (Emergency Department) for evaluation of overmedication." The section titled Medication Service documented, "[MEDICATION NAME] ([MEDICATION NAME]) 1.2 mg administered at 2:18 p.m." (http://www.drugs.com/pro/[MEDICATION NAME].html [MEDICATION NAME] prevents or reverses the effects of opioids including respiratory depression, sedation and [MEDICAL CONDITION].) The Physician Notes at 3:15 p.m. documented "Pt (patient) more alert after [MEDICATION NAME] 1.2 mg IV (intravenous)." The assessment documented, "Acute Mental Status Change and Urinary Tract Infection." 3. The Immediate Jeopardy was removed and the scope/severity reduced to "G" on 4/11/12 at 7:15 p.m. when the facility implemented the following Plan of Removal: a. Resident #2 was assessed by the DON at 4:52 p.m. on 4/11/12. Resident was alert, babbling and cooperative. No negative findings were noted in the assessment. b. All residents in the facility who receive medications have the potential to be affected by this deficient practice, which would be 156 residents as listed on the Resident Census Report dated 4/10/12 as determined by the Administrator and Director of Nursing. c. All licensed personnel will be retrained on the proper procedures to follow to identify each resident prior to medication administration, how to observe a resident when a new medication is started or in the event that a resident is given the wrong medication for possible side effects or adverse reactions. Retraining of all licensed personnel on the correct procedure to follow each time any medication is given to any resident was started on 4/11/12 on the 3-11 shift and will continue each shift until all licensed personnel have been retrained. The DON/designee will be responsible for this retraining. Any licensed employee on LOA (leave of absence)/vacation will be retrained prior to returning to work. Initial orientation training for newly hired licensed personnel will include this same training by the DON/designee prior to the new employee administering medications to any resident in the facility. Licensed personnel will also be retrained on the procedures to follow in the event of a medication administration error. These procedures will include identification of each medication that was given in error, identification of the adverse effects potential, immediate assessment of the resident who received the wrong medications, prompt notification of the medication error to the resident's physician, family and Director of Nursing and monitoring of the resident for changes. d. The Medication Error Reports for the past 4 weeks with the exception of (Resident #2) were reviewed by the DON and Administrator and no negative findings were noted. All medication error reports will be reviewed daily by the DON/designee and by the Administrator 5 of 7 days weekly until compliance has been achieved as determined by the regulatory agency. Any problems found will by corrected immediately and the Administrator, DON and consultant pharmacist notified. The DON/designee will monitor a med pass on all licensed personnel weekly until all LPN's demonstrate medication administration competency consistently. After competency has been demonstrated by all licensed personnel, the DON/designee will monitor med pass on all licensed personnel monthly for three months. Any errors found will be corrected immediately and reported to the Administrator and consultant pharmacist. The consultant pharmacist will conduct inservice training monthly on resident identification, medication administration, medication errors and resident monitoring and will observe at least one med pass monthly. Findings of the monitoring will be reported to the QA (Quality Assurance) Committee monthly by the Director of Nursing. The QA Committee will make additional recommendations if needed.

Complaint # was substantiated, all or in part, in these findings. A. Based on record review and interview, the facility failed to ensure the physician was consulted regarding complaints of pain during dressing changes for 1 (Resident #8) of 6 case mix residents (Resident #2, 8, 11, 17, 18 and 31) who received scheduled pain medications. This failed practice resulted in actual harm to Resident #8 who complained of continued pain from a decubitus ulcer on the buttocks and left heel and had the potential to cause more than minimal harm to 54 residents who received scheduled pain medications according to a list dated 11/11/10. The findings are: Resident #8 had [DIAGNOSES REDACTED]. a. A physician order [REDACTED]. Do not exceed 8 tabs in 24 hours. [MEDICATION NAME] 325 mg tablet give 2 tab (650 mg) po Q 6 hrs PRN pain/fever..." A physician orders [REDACTED]." b. The November 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." The administration times were 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. c. The Nursing Home Reporting of Patient Illness and fax verification dated 11/5/10 documented. "Symptoms, R (resident) c/o (complains of) uncontrolled pain during drsg (dressing) (changes). States we're hurting her. Lg (large) PU (Pressure Ulcer) to sacrum and lt (left) heel. Do you think [MEDICATION NAME] would be feasible. On [MEDICATION NAME] 10/500 Q 4 (hrs) while awake. [MEDICATION NAME] 50 mg Q 6 (hours) PRN. Please advise." The fax was signed by Licensed Practical Nurse (LPN) #11. d. A Nurses Note dated 11/10/10 at 11:00 a.m. documented, "...(Resident) also c/o of uncontrolled pain during (dressing) (changes). MD office requested fax (with) current meds (medications). No response from fax on Monday (11/8/10) noted. Nurse (at) MD office states did not receive... Refaxed (resident) meds to MD office. Awaiting reply." This nurses note was signed by LPN #11. e. On 11/10/10 at 11:05 a.m. LPN #10 was asked how long the resident had been experiencing increased pain during dressing changes. The LPN stated, "For over a week. On some days, she has more pain and does yell out. The resident is on scheduled pain medication. I usually try to wait till later to do the dressing when the pain medication had taken effect, but the dressings were off. The LPN was asked, "Do you know the date and time the resident's goes to the wound clinic?" The LPN stated, yes she goes about every 4 weeks. We get a card with the time and date. The LPN was asked if the resident had pain whenever she was moved. The LPN stated, "Yes." The LPN was asked if the physician was notified of the resident's complaints of pain. The LPN stated they had faxed the MD (Medical Doctor) for pain medication. The LPN was asked when was the physician was faxed. The LPN stated, "I don't know. I know they (Resident Care Coordinator) are working on it." f. On 11/10/10 at 11:15 a.m. LPN #11 was asked if the doctor was faxed regarding the resident's pain. The LPN stated, "Yes." The LPN was asked, where was the fax. The LPN looked on the desk and stated, "I don't know, but we have not heard back." g. On 11/11/10 at 3:37 p.m. the Director of Nurses (DON) was asked, when the Nurses fax the Physician, how do they verify the fax was received by the Physician. The DON stated, "They receive a verification after the fax is sent." The DON was asked, if the Nurse does not receive a response what should the Nurse do. The DON stated, "The next shift should follow up on it for continuity of care." B. Based on observation, record review and interview, the facility failed to ensure the resident's family was notified of a change in medication for 1 (Resident #1) of 2 (Residents # 1 and 2) case mix residents who had orders for [MEDICATION NAME]. The facility failed to ensure the family was notified of an admission to the hospital for 1 (Resident #18) of 3 (Residents # 1, 18, 21) case mix residents on Hall 11 who had behaviors. These failed practices had the potential to affect 11 residents who had orders for [MEDICATION NAME] and 4 residents on Hall 11 who had behaviors according to the lists provided by the Administrator on 11/11/10. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an Assessment Reference date of 10/15/10 documented a Staff Assessment for Mental Status as severely impaired in cognitive skills for daily decision making and a Staff Assessment of Resident Mood score of 9 (5-9 indicated mild depression). a. A physician order [REDACTED]. b. A Physician Telephone Order dated 11/2/10 at 2:30 p.m. documented, "1. D/C (discontinue) current [MEDICATION NAME]. 2. [MEDICATION NAME] 9.5 mg (milligrams) patch [MEDICATION NAME] (change) q 24 (hours)." The section of the order for the signature of the nurse receiving the order was blank, and the boxes beside "Resident Notified" and "Family Notified" were empty. c. The Nurse's Notes dated 11/3/10 documented, "R (Resident) new dose [MEDICATION NAME] ordered from (name of pharmacy) this shift. (No) s/s (signs or symptoms) acute distress." d. The Nurse's Notes dated 11/4/10 documented, "R started new (increased) dose [MEDICATION NAME] this shift (without) s/s adv. (adverse) reaction. (No) c/o pain or s/s acute distress." There was no documentation in the nurses notes that the family was notified of the resident's change in medication dosage. e. On 11/10/10 at 11:00 a.m., LPN #1 was shown the nurse's notes documented on 11/3/10 and 11/4/10 and asked, "Did you write these notes?' LPN #1 stated, "Yes." LPN #1 was asked, "Is there any reason the family wasn't notified?" LPN #1 stated, "Whoever wrote the order should have done that." LPN #1 was shown the order and asked, "Who wrote the order?" LPN #1 stated, "I don't know, it's not signed." LPN #1 was asked, "The Telephone Order has boxes to indicate whether the Resident and/or Family were notified. Has that been done?" LPN #1 stated, "Well, it's not checked." 2. Resident #18 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment with the assessment reference date of 7/29/10 documented the resident had moderately impaired cognitive skills for daily decision making. a. The Nurse's Notes dated 9/22/10 documented, "13:00 p.m., recd (received) orders as follows: direct admit to (hospital)." There was no documentation in the nurses notes that the family was notified of the resident being admitted to the hospital. b. On 11/10/10 at 3:10 p.m., the Director of Nursing (DON) was asked, "The nurses notes documented on 9/22/10 that the resident was a direct admit to (hospital). There was no documentation that the family was notified. Is there any reason the family was not notified?" The DON stated, "No. They should be notified."