Every finding on record at Valley Vista Care Center of Sandpoint

2. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses including intrahepatic (within the liver) bile duct (small tubes that transport bile to the small intestine) cancer. Resident #27's record documented a PASRR Level II was completed on 4/18/24. Resident #27's admission MDS assessment section A1500 dated 4/24/24, documented she did not have a PASRR Level II evaluation. Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 6 of 6 residents (#27, #35, #37, #38, #47, and #57) whose MDS records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The RAI Manual, revised 10/1/2024, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determined a resident had a serious mental illness and/or intellectual disability, or related condition. 1. Resident #35 was admitted to the facility on [DATE] with multiple diagnoses including senile degeneration of the brain, PTSD, and an unspecified personality disorder. Resident #35's PASRR Level I, dated 6/9/22, documented he had a major mental illness diagnosis of anxiety disorder. Resident #35's PASRR Level II, dated 7/5/22, documented he had a current diagnosis of severe mental illness per PASRR criteria of anxiety disorder. Resident #35's Significant Change in Status MDS Assessment, dated 4/27/25, at A1500, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?, documented the answer no. 3. Resident #37 was admitted to the facility on [DATE] with multiple diagnoses including dementia, PTSD, and depression. Resident #37's updated PASRR level II, dated 4/30/24, documented he had a primary diagnosis of dementia with PTSD and depression. Resident #37's Annual MDS assessment, dated 9/23/24, documented under question A1500 he was not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. 4. Resident #38 was admitted to the facility on [DATE] with multiple diagnoses including dementia, hallucinations, and depression. Resident #38's PASRR level II, dated 3/24/23, documented he had a primary diagnosis of dementia. Resident #38's Annual MDS assessment, dated 4/14/25, did not document at A1500 a PASRR Level II was completed. 5. Resident #47 was admitted to the facility on [DATE] with multiple diagnoses including neurocognitive disorder with Lewy Bodies (a progressive brain disorder characterized by dementia with fluctuating cognitive abilities, hallucinations, and parkinsonian motor symptoms), dementia with psychotic disturbance, PTSD, and depression. Resident #47's PASRR Level II, dated 1/15/25, documented he had a primary diagnosis of dementia and a secondary diagnosis of PTSD. Resident #47's Annual MDS assessment, dated 1/21/25, documented Resident #47 did not have a PASRR level II at A1500. On 6/25/25 at 10:12 AM, the MDS Coordinator stated, I interpreted the question incorrectly and marked no when it should have marked yes, at A1500 a PASRR level II was completed, for Resident #27, #35, #37, #38, and #47. 6. Resident #57 was admitted to the facility on [DATE], with multiple diagnoses including hypertension and chronic obstructive pulmonary disease. Resident #57's admission MDS assessment, Section P, dated 4/21/25, documented she was not using a wanderguard (a sensor for an alarm when a resident nears a building exit). On 6/24/25 at 9:44 AM, Resident #57 was observed to have a wanderguard attached to her left ankle. On 6/25/25 at 12:09 PM, the MDS Coordinator reviewed Resident #57's record and stated the MDS should have been coded yes.

Based on observation, interview, and policy review, it was determined the facility failed to ensure residents were routinely provided nourishing evening snacks. This was true for 5 of 7 resident's (#5, #26, #31, #56, and #115) who attended the resident council discussion with surveyors. This failure created the potential for residents to experience hunger between meals, increased fatigue, weight loss, and poor quality of sleep. Findings include: The CMS SOM, Appendix PP, updated 4/25/25, documented no more than 14 hours between a substantial evening meal and breakfast the following day should elapse, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span. The SOM defines a nourishing snack as items from the basic food groups (protein, grain, dairy, fruit, and vegetables), either singly or in combination with each other. On 6/25/25 at 10:33 AM, Resident #5, #26, #31, and #115 stated they were provided snacks when asked, but the snacks were not very big or filling. Resident #56 stated he was unaware he could ask for snacks after dinner. The residents added they were unaware they could ask for more than one snack. A review of the facility meal hours documented there were 15 hours between dinner and breakfast. On 6/26/25 at 2:55 PM, the CDM stated she was aware there were more than 14 hours between dinner and breakfast, and it was determined the snacks available were considered nourishing and appropriate for the residents. She was unaware of any resident group agreement to the meal hours as they were changed in 2020. The CDM stated the nursing staff should offer snacks to the residents between meals. On 6/27/25 at 10:50 AM, the DON stated nursing staff offered snacks available from the snack cart and whenever a resident asked for one. She was unaware if they were routinely offered between dinner and breakfast. On 6/27/25 at 11:15 AM, LPN #4 stated residents are always offered snacks between meals if they are care planned for staff to do so, or if a resident asks for a snack, but he was unaware if staff routinely offered snacks between dinner and breakfast for all residents.

Based on observation and staff interview, it was determined the facility failed to ensure the resident's refrigerators were cleaned, and expired spices were discarded. These deficiencies had the potential to affect the 59 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, documented marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded. The FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions, documented cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared. On 6/26/25 at 2:25 PM, it was observed the following spices were expired in the spice rack next to the cook preparation area: Fajita (expired 12/24), Chili Powder (expired 6/24), and Onion Powder (expired 4/24). On 6/26/25 at 2:30 PM, the CDM stated she was unaware the spices were expired and they should have been thrown out. On 6/24/25 at 1:45 PM, and on 6/26/25 at 2:45 PM, it was observed the resident's refrigerators located in the Lodge, the Village, and the Kitchen were not clean, with food residue located on the interior shelves. On 6/26/25 at 3:50 PM, the CDM stated there is a cleaning schedule documenting what is cleaned and when; however, she was unable to find documentation a cleaning schedule had been followed in June 2025.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained when the facility failed to offer hand hygiene to residents before their meals were served. This was true for 7 of 9 residents (#6, #9, #36, #37, #46, #47, and #50) eating in the Lodge dining room and 3 of 6 resident's (#12, #38, and #39) observed eating in their rooms. This failed practice had the potential for negative outcomes by exposing residents to the risk of infection and cross-contamination. Findings include: The CMS SOM, Appendix PP, revised 4/25/25, documented hand hygiene should be offered to residents before meals. The facility's Hand Hygiene Policy, revised October 2023, documented hand hygiene should be practiced helping to prevent the spread of infections, and offered to residents, family members, and/or visitors. On 6/23/25 at 12:04 PM, the following was observed in the Lodge dining room: 1. Residents #6, #9, #37, #46, #47, and #50 were not offered hand hygiene before being provided their beverages and meals. 2. Resident #36 was observed sitting at the dining table coughing into his hands and then rubbed his face after sneezing. Staff did not offer hand hygiene before serving his meal or after he sneezed into his hands. 3. Residents #12, #38, and #39 were not offered hand hygiene before being offered their meal trays. On 6/23/25 at 12:35 PM, LPN #2 stated she had not offered hand hygiene to residents #12, #38, and #39, and she should have. On 6/23/25 at 12:40 PM, LPN #3 stated we should be offering hand hygiene before their meals and after a resident sneezes.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents' right to be treated with respect and dignity was upheld for 1 of 4 resident (Resident #1) who required assistance with their meals. This deficient practice resulted in a resident not being fed in a dignified manner. Findings include: The facility's Assistance with Meals policy, revised July 2017, documented residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example not standing over residents while assisting them with meals. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including intracranial (brain) injury with loss of consciousness of unspecified duration. On 6/23/25 from 12:38 PM to 12:56 PM, LPN #4 was observed standing while feeding Resident #1 his meal. On 6/23/25 at 2:25 PM, LPN #4 stated he was standing when he assisted Resident #1 with his meal. LPN #4 stated he should have been sitting down while assisting Resident #1 with his meals.

Based on record review and staff interview it was determined the facility failed to ensure residents exercised their right to formulate an Advance Directive. This was true for 2 of 15 residents (#37 and #38) whose records were reviewed. This failed practice created the potential for an adverse outcome if the resident's wishes were not followed. Findings include: The State Operation Manual (SOM), Appendix PP, defined an Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST paradigm form is not an advance directive. 1. Resident #37 was admitted to the facility on [DATE] with multiple diagnoses including dementia, post-traumatic stress disorder (PTSD), and depression. Resident #37's record did not include an advance directive for healthcare. Resident #37's record did not include documentation of resources offered for assistance with executing a healthcare advance directive. On 6/26/25 at 9:54 AM, the CCU Coordinator stated Resident #37 had a BIMS of 15 on admission in 2022. His sister facilitated admission and signed the financial power of attorney, but Resident #37 did not sign the power of attorney form. There was no documentation the facility followed up with Resident #37 about his healthcare advance directive options. The CCU Coordinator stated the facility focused on the POLST form during discussions at care conferences and did not discuss advance directives. 2. Resident #38 was admitted to the facility on [DATE] with multiple diagnoses including dementia, hallucinations, and depression. Resident #38's record did not include an advance directive for healthcare. Resident #38's record did not include documentation of resources offered for assistance with executing a healthcare advance directive. On 6/26/25 at 9:57 AM, the CCU Coordinator stated there was no documentation information or assistance executing an advance directive was offered to Resident #38's legal guardian.

Based on observation, resident representative, and staff interview, it was determined the facility failed to ensure residents had a homelike environment. This was true for 1 of 1 resident's (Resident #16) whose room was observed to have a wall in disrepair. This deficient practice created the potential for psychosocial harm if Resident #16 was not provided a homelike environment. Findings include: The facility's Homelike Environment policy, revised February 2020, documented the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized and homelike setting. Resident #16 was admitted to the facility on [DATE] with multiple diagnoses including aphasia (inability to communicate verbally) after a stroke, right side weakness and paralysis, and dementia. On 6/24/25 at 9:39 AM, Resident #16's Representative stated she was concerned the baseboard area of his wall had exposed wood. On 6/25/25 at 3:19 PM, the base of the wall near the headboard of the resident's bed was observed with a long section of coving peeling away from the wall. Additionally, there were multiple long scratches on the board panel placed to protect the wall. On 6/25/25 at 3:25 PM, CNA #1 stated the coving and board on the wall near the resident's headboard needed to be repaired. On 6/26/25 at 10:50 AM, the Maintenance Assistant stated he was not aware Resident #16's room needed repairs to the wall until the previous evening. He added the wall had been repaired that morning.

Based on record review and staff interview it was determined the facility failed to provide hospital transfer paperwork for 1 of 3 residents (Resident #18) when they were discharged to the hospital. This deficient practice created the potential for Resident #18 to experience harm if the receiving hospital was not provided current medical documentation when he was transferred for emergency medical care. Findings include: The CMS SOM Appendix PP, revised 4/25/25, documented when a facility transfers or discharges a resident the facility must ensure the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. Additionally, the facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility in a form and manner the resident can understand. Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including stroke and left-side paralysis. Review of Resident #18's record documented he was transferred to the hospital on 4/19/25. Review of Resident #18's record did not document the hospital was provided his current medical documentation when he was transferred. On 6/25/25 at 2:50 PM, the DON stated she could not provide documentation the transferring hospital was provided Resident #18's current medical documentation when he was transferred.

Based on record review and staff interview, it was determined the facility failed to ensure residents were provided notice of bed-hold and return policy and the Ombudsman advocate for residents was not informed of their transfer. This was true for 2 of 4 residents (#18, and #54) whose records were reviewed for discharge documentation. This failure placed the residents at risk for unnecessary psychosocial distress if they were unaware they could return to the facility following a hospitalization or therapeutic leave and the Ombudsman was not made aware a resident may require an advocate while out of the facility. Findings include: 1. Resident #54 was admitted to the facility on [DATE] with multiple diagnoses including a history of blood clots and kidney and bladder cancer. Resident #54's medical record documented he went to the hospital on 6/14/25 when his nephrostomy tube (a thin surgically placed tube from the kidney to a collection bag outside the body for urine) fell out. Resident #54's medical record did not include documentation a written bed-hold policy notification was provided to the resident or the Ombudsman was notified of his transfer to the hospital. 2. Resident #18 was admitted to the facility on [DATE] with multiple diagnoses including stroke and left-side paralysis. Review of Resident #18's record documented he was admitted to the hospital on [DATE] for lethargy, confusion, low blood oxygen levels on room air, and for refusing supplemental oxygen. Review of Resident #18's record did not document a written bed-hold policy notification was provided to him and did not document the Ombudsman was notified of Resident #18's transfer to the hospital. On 6/25/25 at 2:45 PM, the DON stated they had not provided bed-hold policy notification. She added on admission, resident's sign they understand the facility did not hold a bed for residents if they were discharged from the facility. On 6/25/25 at 3:05 PM, the CCU Coordinator stated, I notify the Ombudsman if I need her help, but I have not notified her when we have transfers or discharges.

Based on policy review, record review, and resident and staff interviews, it was determined the facility failed to provide a copy or summary of the baseline care plan to residents and/or their representative. This was true for 1 of 1 residents (Resident #115) reviewed for baseline care plan. This failure placed Resident #115 and/or his representative at risk of not being informed and having input in his care plan. Findings include: The facility's Care Plans - Baseline policy, revised December 2016 stated the resident and/or their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility, and d. Any updated information based on the details of the comprehensive care plan, as necessary. Resident #115 was admitted to the facility on [DATE], with multiple diagnoses including fracture of T(thoracic) 11 - T12 vertebra, ankylosing hyperostosis [NAME] (a non-inflammatory disorder characterized by calcifications and ossification (turns to bone) of spinal ligaments and entheses - places where tendons and ligaments connect to bones) and diabetes. An admission MDS assessment dated [DATE], documented Resident #115 was cognitively intact. On 6/24/25 at 9:58 AM, Resident #115 was in his room watching the television. When asked if he received a copy of his care plan, Resident #115 stated he was not sure if he had received a copy of his care plan or had a meeting with the staff about his care. Resident #115 stated he came from the hospital and there was no family member with him when he was admitted to the facility. A review of Resident #115's Baseline Care Plan did not include documentation a copy of his baseline care plan was provided to him and/or to his representative. On 6/25/25 at 9:43 AM, the DON stated she was unable to find documentation of Resident #115's Baseline Care Plan was provided to him and/or to his representative.

Based on observation, record review, and staff interviews, it was determined the facility failed to ensure medications were administered according to physician's order and professional standards of practice. This was true for 2 of 5 residents (#23 and #41) whose medications administration were observed. This deficient practice created the potential for Resident #41 to develop a yeast infection when he did not rinse his mouth after using his inhaler. Resident #23 had the potential of not receiving the full benefit of his medication from incorrect dosage administration. Findings include: 1. The Wixela Inhub website: www.wixelahcp.com, accessed on 7/1/25, documented Candida albicans [a fungus] has occurred in patients treated with fluticasone propionate and salmeterol inhalation powder. Advise patients to rinse the mouth with water without swallowing following inhalations to help reduce the risk of oropharyngeal candidiasis [mouth and throat yeast infection]. Resident #41 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a progressive lung disease characterized by increasing breathlessness) and dementia. A physician's order, dated 2/18/25 documented Resident #41 was to receive Advair Diskus inhalation (fluticasone-salmeterol) one inhalation orally two times a day for COPD, rinse mouth with water after each use. On 6/26/25 at 8:16 AM, LPN #1 handed the Wixela inhaler to Resident #41. Resident #41 took one inhalation of the Wixela and gave back the inhaler to LPN #1. LPN #1 did not instruct Resident #41 to rinse his mouth after taking one inhalation of the Wixela. On 6/26/25 at 8:40 AM, LPN #1 stated she did not offer Resident #41 to rinse his mouth after taking one inhalation of the Wixela. On 6/26/25 at 11:06 AM, the DON stated Advair Diskus and Wixela are two different names for the same fluticasone-salmeterol inhaled medication. The DON stated LPN #1 should have instructed Resident #41 to rinse his mouth after using the inhaler. 2. The WebMD website: www.webmd.com, accessed on 7/1/25, stated the seven rights of medication administration which included Right Dose. Along with giving the right medications comes giving the right dose. Resident #23 was admitted to the facility on [DATE], with multiple diagnoses including traumatic brain injury with loss of consciousness and quadriplegia (paralysis of both arms and legs). A physician's order dated 11/13/23, documented Resident #23 was to receive Vitamin B-12 oral tablet 1000 mcg, three tablets by mouth one time a day for vitamin deficiency. On 6/26/25 at 7:58 AM, LPN #1 was preparing Resident #23's oral medications to include Vitamin B-12. LPN #1 was observed to put one tablet of Vitamin B-12 to the medication cup. On 6/26/25 at 8:09 AM, LPN #1 administered Resident #23's medications. On 6/26/25 at 8:16 AM, LPN #1 reviewed Resident #23's physician's order and stated she gave Resident #23 one tablet of Vitamin B-12. LPN #1 stated she should have administered Resident #23 three tablets of Vitamin B-12.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure physician's order to provide non-pharmacological intervention were offered to residents prior to administration of their as needed narcotic pain medications. This was true for 3 of 3 residents ( #22, #54 and #115) reviewed for pain medications. This deficient practice created the potential for harm if the residents were overmedicated when their pain may have responded to nonpharmacological interventions. Findings include: The CDC website, www.cdc.gov, article titled, Overdose Prevention: Guideline Recommendations and Guiding Principles, accessed on 7/2/25, recommended clinicians should maximize use of nonpharmacological and nonopioid pharmacological therapies as appropriate for the specific condition and patient, and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. 1. Resident #22 was admitted to the facility on [DATE], with multiple diagnoses including low back pain and dementia. A physician's order, documented Resident #22 was to receive the following medications: - oxycodone (narcotic pain medication) hcl oral tablet, 2.5 mg every eight hours as needed for pain. - acetaminophen oral tablet 500 mg, one tablet every four hours as needed for pain. The physician's order also directed staff to offer Resident #22 non-pharmacological interventions for pain: rest, positioning, distractions, application of cold and heat packs as needed prior to administration of PRN pain medication. Resident #22's June 2025 MAR documented the following: - She was not administered the acetaminophen 500 mg every four hours PRN for pain. - She received oxycodone 2.5 mg on 6/6/25, 6/7/25, 6/9/25, 6/10/25, 6/13/25, 6/14/25, 6/15/25, 6/18/25, 6/22/25, 6/23/25 and 6/24/25. There was no documentation in Resident #22's record she was offered non-pharmacological interventions prior to administration of her pain medications. 2. Resident #115 was admitted to the facility on [DATE], with multiple diagnoses including fracture of T(thoracic) 11 - T12 vertebra, ankylosing hyperostosis [NAME] (a non-inflammatory disorder characterized by calcifications and ossification (turns to bone) of spinal ligaments and entheses - places where tendons and ligaments connect to bones) and diabetes. A physician's order, dated 6/5/25 documented Resident #115 was to receive the following medications: - acetaminophen 500 mg, give one tablet by mouth every four hours as needed for pain level 1-5. - acetaminophen 500 mg, give two tablets by mouth every four hours as needed for pain level 6-10, not to exceed 3,000 mg per day. -oxycodone hcl 5 mg, give one tablet by mouth every six hours as needed for pain. The physician's order also directed staff to offer Resident #22 non-pharmacological interventions for pain: rest, positioning, distractions, application of cold and heat packs as needed prior to administration of PRN pain medication. Resident #115's June 2025 MAR documented the following: - He was not administered acetaminophen 500 mg every four hours as needed for pain - He received oxycodone 5 mg on 6/13/25, 6/14/25 and 6/18/25. There was no documentation in Resident #115's record he was offered non-pharmacological interventions prior to administration of his pain medications. 3. Resident #54 was admitted to the facility on [DATE] with multiple diagnoses including a history of blood clots, a history of substance use disorder, arthritis, and kidney and bladder cancer. Resident #54's physician orders documented the following: -Hydrocodone-Acetaminophen (a narcotic pain medication) tablet 7.5-325 mg, give 1 tablet by mouth every 6 hours as needed for severe pain, dated 3/24/25. -Prior to PRN medication offer nonpharmacological interventions for pain - rest, positioning, distractions, application of cold and heat packs, as needed. Resident #54's medication administration record for June 2025 documented he received the narcotic pain medication 69 times from June 1-24, 2025. The June 2025 medication administration record included documentation he had been offered nonpharmacological pain interventions 0 of the 69 times he received the narcotic pain medication. On 6/25/25 at 1:53 PM, the DON stated she was unable to find documentation Resident #22, #54, and #115 were offered non-pharmacological interventions prior to administration of their PRN narcotic pain medications. The DON stated Resident #22, #54, and #115 should have been offered the non-pharmacological interventions before giving their PRN narcotic pain medications.

Based on record review and staff interview, it was determined the facility failed to ensure a resident was free from unnecessary medications. This was true for 1 of 5 residents (Resident #22) reviewed for unnecessary medications. Resident #22 was continually prescribed of cough medication without clear indication and in excessive duration. This deficient practice had the potential for harm if Resident #22 received medications that may result in negative outcomes without clear indication of need. Findings include: 1. Resident #22 was admitted to the facility on [DATE], with multiple diagnoses including chronic bronchitis, low back pain, and dementia. A physician's order, dated 1/30/25, documented Resident #22 was to receive guaifenesin ER (an expectorant-extended release) oral tablet 600 mg every 12 hours for congestion. Resident #22's March 2025, April 2025, May 2025, and June 1-26, 2025, documented Resident #22 was administered guaifenesin ER oral tablet 600 mg every 12 hours for congestion. A Nurse Practitioner's progress note dated 3/20/25, documented Resident #22 did not have cough or congestion and no shortness of breath. A Nurse Practitioner's progress note dated 4/25/25, documented Resident #22's lungs were clear on auscultation (listening with a stethoscope), no wheezing or rales (abnormal lung sounds) noted. A Nurse Practitioner's progress note dated 5/19/25, documented Resident #22 had no nasal congestion or nasal discharge, no dyspnea (difficulty of breathing), cough, congestion or wheezing. The note documented Resident #22's lungs were bilaterally clear to auscultation, no coughing, wheezing or rales. Resident #22 was observed on the following days with no cough or signs and symptoms of congestion or difficulty of breathing as follows: - 6/23/25 at 1:13 PM, she was sitting quietly on the couch by the nurse station. - 6/25/25 at 1:14 PM, she was lying in bed, eyes were closed. On 6/25/25 at 2:02 PM, when asked why Resident #22 was still taking guaifenesin when the Nurse Practitioner's progress dated 3/20/25, 4/25/25, and 5/19/25 documented she did not have congestion, the DON stated she was not sure why Resident #22 was taking guaifenesin. The DON stated it could be for prophylaxis (preventative), and added the order for guaifenesin needed to be clarified.

Based on license and certification review and staff interview, it was determined the facility failed to ensure nursing staff were licensed/certified within the state where they provided care. This was true for 1 of 3 nursing staff (Staff #1) whose licenses/certification were reviewed and had the potential to affect all 61 residents in the facility. This failure created the potential for harm if residents received inappropriate care due to a nursing staff lacking the credentials to provide nursing care. Findings include: On 6/25/25 at 3:18 PM, licenses and certification of three nursing staff were reviewed with the HR personnel. Staff #1 who was hired as a CNA on 3/26/25 did not have a certification to work as a CNA in this state. The HR personnel stated she was recently hired in the facility as the HR when Staff #1 was hired, and would look further for the certification of the Staff #1. On 6/26/25 at 2:01 PM, the HR personnel stated she reached out with the previous HR personnel and was told Staff #1 had certification as a nursing assistant when she was hired in the facility. The HR personnel also stated she called Staff #1 and asked her to provide a copy of her certification, but Staff #1 stated she did not have a copy of her certification. The HR personnel stated she was unable to find Staff #1 certificate. The HR personnel stated Staff #1 would not be allowed to work in the facility if she could not provide proof of her certification and her employment was immediately terminated.

Based on record review, policy review, review of the State Agency's Long-Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to protect the residents' right to be free from physical and verbal abuse by staff. This was true for 2 of 3 residents (#3 and #37) who were reviewed for abuse. These deficient practices placed the safety of Resident #3 and Resident #37 and all other residents residing in the facility at risk for immediate jeopardy of serious harm, impairment or death. Findings include: The faclity's Abuse policy, dated December 2023, defined verbal abuse as the use of oral, written, or gestured language that willfully included disparaging derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The policy stated when an incident of resident abuse was suspected staff were to ensure the resident was safe by stopping the abuse and/or removing the resident from the situation. If the accused individual was an employee, the alleged perpetrator was removed from resident care areas immediately and placed on suspension pending results of the investigation. 1. Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including heart disease, high blood pressure, arthritis, and depression. An admission MDS assessment, dated 3/18/24 documented Resident #37 was cognitively intact. During an interview on 4/30/24 at 12:00 PM, Resident #37 stated LPN #1 on the night shift was confrontational. Resident #37 stated that LPN #1 hollered and screamed at her, leaned her body in toward her and stated she never liked Resident #37 and never would. LPN #1 continued to scream she wanted Resident #37 out of the facility because Resident #37 had turned everyone against her. Resident #37 stated she could not remember the date of the incident approximately two weeks ago, but knew it was around 8:00 or 8:30 PM. During the same interview, Resident #37 stated she was very afraid of LPN #1 and she was afraid when LPN #1 was in the building she may do something to her. Resident #37 stated after LPN #1 left her room she immediately called the Administrator and the Administrator planned to send LPN #2 to come to her room and sit with her. Resident #37 stated LPN #1 came back by herself a second time and they again had a verbal encounter. LPN #2 asked LPN #1 to leave Resident #37's room. Resident #37 stated she had not seen LPN #1 since the incident but knew she was in the building. On 4/30/24 at 1:16 PM, LPN #2 stated while on duty (she worked 2:00 PM to 10:00 PM on 4/7/24) the Administrator called her and instructed her to go to Resident #37's room and sit with her. The Administrator told LPN #2 Resident #37 called him and stated LPN #1 was yelling at her. LPN #2 stated the Administrator gave her no additional instructions regarding Resident #37. LPN #2 stated when she checked on Resident #37 she was upset, tearful, and stated she wanted to leave the facility. On 4/30/24 at 2:19 PM, the Administrator and the DON were asked if a resident had reported an allegation of verbal abuse in the last month. The DON stated no and the Administrator stated, nothing comes to mind. When asked if Resident #37 had made an allegation of verbal abuse against LPN #1, the DON stated the incident was investigated and unsubstantiated. On 4/30/24 at 3:15 PM, the DON confirmed the incident occurred on the evening shift of 4/7/24. The nursing schedule, provided by the DON, dated 4/7/24, documented LPN #1 was the only licensed nurse on duty on 4/7/24 and 4/8/24 during the night shift from 10:00 PM to 6:00 AM. The DON stated LPN #1 returned to work the following day on the night shift of 4/8/24. During an interview on 5/2/24 at 8:22 AM, LPN #1 stated her shift assignment was night shift from 6:00 PM to 6:00 AM. When asked what type of contact she had with Resident #37 on 4/7/24, LPN #1 stated she provided Resident #37 medication administration but did not answer Resident #37's call light. LPN #1 denied yelling or screaming at Resident #37 on the evening of the alleged incident on 4/7/24. When asked if she had spoken to the Administrator or the DON during her shift on 4/7/24 - 4/8/24 about the incident, LPN #1 stated no. The facility's failure to ensure residents were protected from alleged verbal abuse placed the health and safety of all residents residing in the facility at risk for immediate jeopardy of serious harm, impairment, or death. On 4/30/24 at 5:05 PM, the Administrator and DON were informed verbally and in writing of an Immediate Jeopardy (IJ) determination at F600 related to the facility's failure to protect residents from alleged verbal abuse. This failure resulted in a serious adverse outcome for Resident #37 who verbalized she was fearful LPN #1 would do something to her when LPN #1 continued working in the facility and placed other residents residing in the facility in immediate jeopardy of serious harm, impairment, or death. On 5/1/24 at 5:51 PM, the facility provided a plan to remove the immediacy which was accepted. The facility's IJ removal plan included: - All residents were safe by having the accused leave the building immediately and placed on administrative leave. LPN #1 was placed on administrative leave on 4/30/24. - The facility will re-educate all staff members to Valley Vista Care Corporation Abuse Policy and Procedures and the Federal and State requirements for reporting prior to their next shift following Train the Trainer in-service by 4 PM on 5/1/24. - The CEO, Director of Corporate Compliance, and/or Director of Administrative Services will be alerted of any allegation(s) of abuse immediately to ensure Federal and State law has been followed. - Residents were interviewed on 4/30/24 to ensure they felt safe in the building, if they were abused (verbal, physical, and/or neglect), and if they knew who they could report abuse allegations. On 5/3/24 at 1:00 PM, the Administrator was verbally notified the immediacy was removed based on onsite verification the IJ removal plan was implemented. Following the immediacy, noncompliance remained at actual harm. 36193 2. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including traumatic brain injury with loss of consciousness, dementia, and epilepsy (seizure). An annual MDS assessment, dated 1/11/24, documented Resident #3 was moderately cognitively intact. An Abuse Investigation report, dated 10/24/23, documented CNA #14 reported to Human Resources (HR) that on 10/20/23, she observed CNA #15 and CNA #16 flick Resident #3's ear and start laughing. CNA #15 and CNA #16 continued to tease Resident #3 which made Resident #3 swear, causing other residents to also swear. CNA #14 asked CNA #15 and CNA #16 to stop, at which time CNA #14 and CNA #15 started to mock her. CNA #14 reported to LPN #5 about the incident, however LPN #5 thought it was funny and did nothing to stop the situation. The report also documented Housekeeper #1 reported to the Human Resources Coordinator that on 10/24/23, she saw a CNA pulling Resident #3's hair as she was pushing him in his wheelchair toward the nurses' station from the Day Room. This caused Resident #3 to yell out cuss words. Another CNA then yelled at Resident #3 for cussing. The same CNA pulled Resident #3's hair again which caused Resident #3 to yell out again. Housekeeper #1 was unable to identify the two CNAs' names. However, on 10/25/23, Housekeeper #1 was able to identify to the Human Resources Coordinator that it was CNA #15 and CNA #16 making fun of Resident #3. The report also included a statement made by CNA #17. CNA #17 reported on 10/24/23, she heard CNA #15 and CNA #16 getting Resident #3 all worked up using bad language. CNA #14 and CNA #15 were laughing at Resident #3 and CNA #17 felt they were antagonizing Resident #3. LPN #5, CNA #15, and CNA #16 all made statements and denied the abuse allegations regarding Resident #3. The Abuse Investigation report substantiated the abuse allegation based on the three separate witness statements, which two were observed and one heard on three separate occasions. LPN #5, CNA #15, and CNA #16 were terminated from employment at the facility. On 10/31/23, the facility provided abuse training titled Abuse - What it is and How to Report it to all staff. On 5/3/24 at 12:39 PM, CNA #17 stated she reported to the Human Resources Coordinator an incident wherein she heard a CNA making fun of a resident. CNA #17 stated the incident was investigated and the CNAs involved were no longer in the facility. On 5/2/24 at 2:49 PM, the DON stated staff involved in Resident #3's abuse allegation were removed from their schedule while it was being investigated. The DON stated the CNAs and the LPN were no longer in the facility.

Based record review, review of the State Survey Agency's Long-Term Care Reporting Portal, I&A reports, and staff interview, it was determined the facility failed to ensure residents' care plans were followed to prevent falls. This was true for 1 of 5 residents (Resident #16) reviewed for falls. This resulted in harm to Resident #16 when he fell and sustained a calcaneal (heel) fracture while being assisted by one staff during his pericare. Findings include: Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE], with multiple diagnoses including viral infection of the brain, dementia, epilepsy (seizure), and abnormal posture. An annual MDS assessment, dated 9/27/23, documented Resident #16 was rarely/never understood. A care plan, revised 2/18/21, documented Resident #16 had an ADL self-care performance deficit related to his alteration in cognition, behaviors, weakness, and decreased mobility secondary to Human Prion (group of disorders that damage brain and nervous system tissues and function) disease. The care plan directed staff to provide him 2-person total assist in all his ADLs. An I&A report, dated 12/21/23 at 1:45 PM, documented Resident #16 had a witnessed non-injury fall. He was transferred to his bed by CNA #13 and RN #1 using a Hoyer lift. RN #1 left the room and CNA #13 proceeded to perform pericare to Resident #16. CNA #13 pulled Resident #16's pants down, turned him to his right side, and cleaned him. CNA #13 then turned Resident #16 towards her. While CNA #1 was turning Resident #16 towards her, Resident #16 threw his left arm to his right side and rolled off his bed onto the floor. The I&A report documented possible muscle spasm or seizure activity as the root cause of Resident #16's fall and to provide him with 2 staff for all his cares. A nurse's progress note, dated 12/22/23 at 10:10 PM, documented Resident #16 had a bruise to his right heel. A nurse's progress note, dated 12/23/23 at 12:01 PM, documented Resident #16 had no apparent signs of pain or other latent injuries. A nurse's progress note, dated 12/24/23 at 1:42 PM, documented Resident #16's right foot was swollen and bruised. He had no signs and symptoms of pain. A nurse's progress note, dated 12/28/23 at 1:27 PM, documented Resident #16's right foot was yellow and swollen. A physician's progress note, dated 1/4/24 at 10:15 AM, documented It was unclear if there was any injury. I do not appreciate any ecchymosis (bruise) but it is definitely painful to palpate. The physician ordered for Resident #16 to have an x-ray of his foot. An x-ray report, dated 1/5/24, documented Resident #16 had a nondisplaced superior calcaneal fracture. On 5/2/24 at 2:49 PM, the DON stated there was only one staff assisting Resident #16 during his pericare and he might have a seizure. The DON stated Resident #16's care plan was not followed, he needed two staff assistance during his cares because he could be combative and became rigid during his cares. She stated CNA #13 should have known Resident #16 needed two persons during cares by checking their Kardex (a desktop file system that gives a brief overview of each patient and is updated every shift). The DON stated CNA #13 was in-serviced after Resident #16's fall.

Based on record review and staff interview, it was determined the facility failed to meet the regulation requirements for frequency of QA meetings. This has the potential to negatively affect all residents in the facility if quality deficiencies throughout the facility were not identified and responded timely and appropriately. Findings include: The facility's Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020, stated the committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan. On 5/3/24 at 1:02 PM, the Administrator stated the facility held their QAPI meetings monthly. The surveyor then asked for the attendance sheet of QAPI meetings from April 2023 to April 2024. The QAPI attendance sheet was reviewed with the Administrator. Upon review of the sign-in sheets, it was determined there was no QAPI meetings held between April 2023 and June 2023. When asked why there was no meetings held between April 2023 and June 2023, the Administrator stated he could not find the sign-in sheets of QAPI meetings held between April and June 2023.

Based on record review, policy review, and staff interview, the facility failed to provide a minimum of 12 hours of in-service education per year for 3 of 25 CNAs (CNA #7, CNA #8, and CNA #9) reviewed for sufficient and competent CNA staffing. This failure placed residents at risk of receiving care from staff who are not adequately trained in competencies to meet residents' needs. Findings include: The facility's policy, In-Service Training Program, dated 12/1/23, stated, .All nursing home direct care personnel (CNAs) are required to complete twenty-four (24) hours of in-service per year .Attendance at all mandatory in-service is incorporated as a part of the annual performance evaluation. Lack of completion of mandatory in-service hours or required in-services may impact any pay raise normally given at the time of the annual evaluation and will result in termination if the training is required for the position . An untitled document provided by the Human Resources Coordinator (HRC) documented CNA #7 was hired as a CNA in 2/2022. Review of CNA #7's training log documented 2.75 hours of training between 2/2023 through 2/2024. An untitled document provided by the HRC documented CNA #8 was hired as a CNA in 1/2023. Review of CNA #8's training log documented 6.75 hours of training between 1/2023 through 1/2024. An untitled document provided by the HRC documented CNA #9 was hired as a CNA in 4/2006. Review of CNA #9's training log documented 7.75 hours of training between 4/2023 through 4/2024. During an interview on 5/3/24 at 9:15 AM, the HRC stated the facility used the employee anniversary date for the training hours needed to meet the CNA education requirement. When asked how often the training hours were reviewed, the HRC stated, I review them [training hours] monthly. The HRC stated she was aware the CNAs were short on getting their 12 hours of training annually. During an interview on 5/3/24 at 11:35 AM, HR confirmed the training hours for CNA #7, CNA #8, CNA #9 did not meet the criteria for 12 hours of annual training.

Based on observation, policy review, and staff interview, it was determined the facility failed to ensure to respect and maintain a residents' dignity. This was true for 1 of 1 resident (Resident #12) reviewed for respect and dignity. This deficient practice created the potential for psychosocial harm if Resident #12 experienced embarrassment or lack of self-esteem. Findings include: The facility's Resident Rights policy, dated 12/26/22, stated residents are to be treated with respect, kindness, and dignity. Resident #12 was admitted to the facility on [DATE], with multiple diagnoses including intracranial (brain) injury with loss of consciousness and epilepsy (seizure disorder), and aphasia (an impairment of language due to brain injury, affecting the production or comprehension of speech and the ability to read or write). An annual MDS assessment, dated 9/20/23, documented Resident #12 was rarely/never understood. On 4/29/24 at 1:11 PM and 5/2/24 at 7:36 AM, Resident #12 could be seen from outside his room with no sheet to cover his lower body. He was wearing an adult diaper and his legs were exposed. Resident #12's shirt was rolled up exposing his PEG (percutaneous endoscopic gastrostomy - a surgically placed tube inserted through the abdomen into the stomach to administer liquid feedings) tube. Resident #12's door was all the way open, and he was in full view of anyone passing by his room. On 5/2/24 at 7:47 AM, the DON entered Resident #12's room and stated he would always uncover himself. The DON then took the sheets to cover Resident #12 and stated she would remind the staff to always check on Resident #12 and make sure he had a sheet covering his body.

Based on record review, policy review, observation, and resident and staff interview, the facility failed to ensure the interdisciplinary team had determined it was appropriate for a resident to self-administer medications for 2 of 6 residents (#39 and #52) reviewed for self-administration of medications. Findings include: The facility's policy Self-Administration of Medications dated December 2016, documented Residents had the right to self-administer medications if the interdisciplinary team clinically determined it was appropriate and safe for the resident to do so. 1. Resident #39 was admitted to the facility on [DATE], with multiple diagnoses including chronic obstructive pulmonary disease (COPD - group of diseases that cause airflow blockage and breathing-related problems). A quarterly MDS assessment, dated 3/25/24, documented Resident #39 was cognitively intact. A physician order, dated 4/4/24, documented Resident #39 was to start a Ventolin inhaler, two puffs every 4 hours as needed for bronchospasms and that she may keep the inhaler in her room. On 4/30/24 at 9:56 AM, and 5/1/24 at 4:57 PM, a Ventolin inhaler was observed on Resident #39's overbed table in her room. On 4/30/24 at 9:56 AM, Resident #39 stated, They let me have that [Ventolin inhaler] in case I get short of breath. On 5/1/24 at 5:03 PM, the DON accompanied the surveyor to Resident #39's room and stated there was an albuterol (Ventolin) inhaler with Resident #39's name on it lying on her overbed table. On 5/2/24 at 11:00 AM, the DON stated there was no checklist completed indicating Resident #39 knew and understood how to use the inhaler. On 5/2/24 at 2:30 PM, the RCS was asked if Resident #39 was able to self-administer medications. The RCS stated, I am not aware Resident #39 can. The RCS was notified of the 4/4/24 order which stated Resident #39 could have a Ventolin inhaler at the bedside. The RCS stated, I was not aware of that order. The RCS also confirmed the interdisciplinary team had not determined Resident #39 was appropriate for self-administering medications. 2. Resident #52 was admitted to the facility on [DATE], with multiple diagnoses including type 2 diabetes mellitus, heart disease, and dementia. A quarterly MDS assessment, dated 4/12/24 documented Resident #52 was moderately cognitively impaired. On 4/30/24 at 9:21 AM, LPN #3 was observed taking a cup containing Resident #52's pills and placed the cup on the dining room table where Resident #52 was sitting. LPN #3 walked out of the dining room to the hallway to obtain a glucometer strip from the medication cart before returning to Resident #52 in the dining room. On 4/30/24 at 9:24 AM, when asked if Resident #52 could self-administer medications, LPN #3 stated, No, I don't believe so. LPN #3 stated she could not visualize the medication cup she left on the table when she left the dining room and went into the hallway. On 5/3/24 at 2:00 PM, the DON stated Resident #52 was not assessed or determined by the interdisciplinary team to be appropriate to self-administer medications.

Based on observation, interviews, and record review, it was determined the facility failed to provide an environment as free as possible from accident hazards, and failed to provide adequate supervision for a resident with a history of falls. This was true for 4 of 15 residents (#s 10, 12, 13, and 15) sampled for accident hazards and supervision. Resident #10 was harmed when she became entrapped in the bed rail as she fell from bed, and died as a result of her injuries. Resident #12's seatbelt was not assessed for safety. This practice created the potential for more than minimal harm should Resident #12 become entrapped by the seatbelt. Resident #s 13 and 15 had the potential for more than minimal harm when they were not provided supervision as directed in the care plan, or pertinent medical history was not included in a safety assessment for the use of bed rails. Findings included: The State Operations Manual, Guidance to Long Term Care Surveyors, Appendix PP, under F323, documented: "Regardless of the purpose for use, bed rails...and other bed accessories...while assisting with transfer and positioning, can increase resident safety risk. Bed rails include rails of various sizes (e.g., full length rails, half rails, quarter rails) that may be positioned in various locations on the bed. In 1995, the FDA (Food and Drug Administration) issued a Safety Alert entitled 'Entrapment Hazards with Hospital Bed Side Rails.' Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement...that may cause them to move about the bed or try to exit from the bed. The timeliness of toileting, appropriateness of positioning, and other care-related activities can contribute to the risk of entrapment." The guidance at F323 further documented: "The use of a specialty air-filled mattress or a therapeutic air-filled bed may also present an entrapment risk that is different from rail entrapment with a regular mattress. The high compressibility of an air-filled mattress compared to a regular conventional mattress requires appropriate precautions when used for a resident at risk for entrapment. An air-filled mattress compresses on the side to which a person moves, thus raising the center of the mattress and lowering the side. This may make it easier for a resident to slide off the mattress or against the rail. Mattress compression widens the space between the mattress and rail. When a resident is between the mattress and rail, the mattress can re-expand and press the chest, neck, or head against the rail. While using air therapy to prevent and treat pressure ulcers, facilities should also take precautions to reduce the risk of entrapment. Precautions may include following manufacturer equipment alerts and increasing supervision." The Administrator provided 2 copies of a document entitled, "Proper Use of Side Rails", dated 2001, revised [DATE]. The administrator identified one copy as the facility's policy on siderails use before [DATE] (P1), and the second copy as the policy after [DATE] (P2). Both policies included: *"Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents." *"The use of side rails as an assistive device will be addressed in the resident care plan." *"When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk for entrapment." (NOTE: For this bullet point, P1 and P2 differed slightly after this sentence. P1 documented, "(the amount of safe space may vary, depending on the type of bed and mattress being used.)" P2 documented, "The facility will also assess gaps within the bed system to be sure they are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement, or body position.")) 1. R #10 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #10's admission MDS assessment, dated [DATE], coded: *BIMS of 15, indicating the resident was cognitively intact. *Extensive assistance of two for bed mobility and transfers. *Physical assistance required for moving from a seated to a standing position, moving on and off the toilet, and surface-to-surface transfers. Resident # 10's Quarterly MDS assessment, dated [DATE], coded: *Unable to complete the BIMS, assessed by staff as having long-term and short-term memory loss and moderately impaired decision making skills. *Extensive assistance of two for bed mobility and toilet use. *Totally dependent on two for transfers, locomotion on and off the unit, and personal hygiene. *Extensive assistance of one for dressing and eating. *Did not ambulate. On [DATE], an "Evaluation for Use of Side Rails" form in R #10's record documented: *Side rail use was, "Family requested" to, "help her move." *Identified contributors to the resident's need for side rail use were documented as weakness and pain. There were spaces in this area of the form for cognitive and security considerations, both of which were blank. *The "Recommendations" area of the form offered the options of "Side Rails are recommended at this time...", "Side rails are not indicated at this time...", or "Further evaluation is required by", with boxes to select either PT, OT, or Other. The box next to "OT" had an "X" in it. *The "Recommended Type" of side rail was documented as, "Arco", with the boxes for ",[DATE] partial rails" for both the left and right checked. (NOTE: It was not clear from this assessment what an "Arco" rail was. On [DATE] at 9:00 AM, the Administrator identified it as a side rail which could be used in two different ways, either as a "bed cane" or as a "quarter rail.") *The "Recommended Use" area of the form, which offered options of using the side rails only at night, at all times when the resident is in bed, or only when the resident is ill, was blank. *The area of the form indicating whether side rail precautions had been discussed with either the resident, or the resident's family, was blank. *The area of the form indicating alternatives to side rail use had been discussed with either the resident, or the resident's family, was blank. *The area of the form indicating when the use of side rails should be reevaluated, was blank. *The area of the form indicating whether a physician's order for the side rails had been obtained, was blank. *The area of the form indicating whether the resident's care plan had been updated, was blank. *The "Comments" area of the form documented, "[DATE]. Reassed (sic) for continued use of Arco rails - incontinent of B/B (bowel and bladder) - continues to remain appropriate for ongoing use of bilat(eral) Arco rails (at) this time - Remains safe/appropriate." (NOTE: This was the only reevaluation documented regarding R #10's side rails since her admission in [DATE], even though the resident was documented with an ongoing decline, had been enrolled in hospice services, and had been placed on an air mattress. There was no documentation of how the side rails had been assessed as safe for this resident. Two days after this comment was added to the form, R #10 died when she fell from bed and became entrapped in her side rail.) Resident #10's Interdisciplinary Progress Notes documented: *[DATE], 3:30 PM, from OT, "OT orders to eval(uate) and (treat) (received). Chart reviewed Attempted to initiate eval, (patient) in bed sleeping, opened eyes to command but then closed again; shook head. Will do eval on [DATE]." (NOTE: This note did not include evidence the OT conducted an assessment for the need for side rails.) *[DATE] at 4:20 PM, from the Physical Therapist. "Requested Arco rails for bed to assist rolling and supine to sit." (NOTE: These were the only two progress notes the facility provided from OT or PT discussing the use of side rails. There was no evidence either OT or PT had reevaluated the need for side rails as the resident's health and strength began to decline.) On [DATE], a "Consent for Use of Side Rails" form in R #10's chart documented family consent for the use of "Arco" ,[DATE] partial side rails on the left and right upper portions of her bed. The form was signed by Resident #10's daughter, rather than by Resident #10. (NOTE: At the time, the resident had been assessed as cognitively intact. There was no explanation as to why the resident herself did not sign the consent.) Resident #10's Physician's progress notes documented: *[DATE]. "Cannot speak properly...Aggravating factors include situational stress. Relieving factors include nothing...Positive for fatigue, weight loss, anxiety, dizziness, gait disturbance, dyspnea...patient is oriented to time, place, person, and situation...has normal insight. Exhibits normal judgement, demonstrates appropriate mood and affect..." *[DATE]. "Weight loss...risk factors...include anxiety, history of stroke, [DIAGNOSES REDACTED]...positive for anxiety, depression, extremity weakness, gait disturbance, memory impairment, numbness in extremities...level of distress is lethargic. Nourishment type is thin...the patient is not oriented to time, place, person, or situation...has poor insight...does not demonstrate the appropriate mood or affect...she has become despondent...she has not responded to therapy to recover her lost function. This has prompted a referral to Hospice..." (NOTE: The facility did not reassess the need for side rails for this resident at this time, even though the physician had noted a number of areas of decline for the resident.) *[DATE]. "Failure to thrive...the symptoms began three months ago...reported as being incapacitating...the symptoms are uncontrolled...positive for extremity weakness, gait disturbance, memory impairment, numbness in extremities...her orientation cannot be evaluated due to her expressive aphasia. Today I did not see recognition of me in her eyes..." *[DATE]. "Failure to thrive...reported as being severe...has been unable to speak coherently and has been difficult to feed...now on Hospice care...positive for dizziness, extremity weakness, gait disturbance, memory impairment...level of distress is anxious...not oriented to time, place, person, or situation...poor insight...exhibits poor judgement...does not demonstrate the appropriate mood or affect..." *[DATE]. "Failure to thrive...Aggravating factors include change in routine...the symptoms are uncontrolled...has been admitted to hospice care...swelling...occurred 1 week ago. The severity is moderate and has worsened...The swelling is associated with appetite change, blistering, decreased mobility, generalized weakness and malaise...the left leg has started weeping...the patient is not oriented to time, place, person, or situation...has poor insight. Exhibits poor judgement..." Resident #10's Physician Order Report (Recapitulation Orders) for [DATE] documented, "Monitor air bed for proper inflation every shift." Initiated [DATE]. Resident #10's Monthly Nursing Summary forms documented under the area of, "P. Restraints", the use of bed rails, right side up and left side down, for safety in bed, on [DATE], [DATE], [DATE], and [DATE]. Resident #10's care plan documented, under the problem area, "Potential for Injury: Falls... Related to...narcotic use...CHF...weakness/fatigue...poor safety awareness...(change) in physical condition...impaired communication..." initiated [DATE], the following interventions: *"New fall [DATE] and [DATE]." (NOTE: There was no date documented as to when this intervention was added. The resident was also noted with falls on [DATE], [DATE], and [DATE], which were not mentioned on her care plan.) *"Set up to self propel from nurse station to res room (after) meals as res allows." Initiated [DATE], discontinued [DATE]. *"(Every) 15 minute (checks)." (NOTE: This intervention was highlighted in yellow, indicating it had been discontinued. The date [DATE] was hand-written next to this intervention, with no signature or initials to indicate who had written that date. It was unclear whether [DATE] was the date this intervention was initiated, or the date it was discontinued.) *"Arco rails bilat(erally) while in bed." Date initiated [DATE]. (NOTE: Resident #10's assessment for the use of side rails, and consent to use them, was completed on [DATE]. The monthly nursing summaries referenced above indicated one ,[DATE] side rail up on each summary.) *"High/low bed in low position while in bed." Date initiated [DATE]. On [DATE], the resident's Hospice Recertification form documented, "She is sleeping more with more agitation when awake..." Resident #10's Interdisciplinary Progress Notes (PNs) documented: [DATE] at 11:00 AM. "Care conference held. Daughter present. (Social Services), Activities, Dietary, Hospice Nurse (and Social Services). Daughter voices she does not want discussion of death or hospice." [DATE] at 10:00 PM. "During (bedtime) cares CNA found a skin tear on resident's (right) knee 1.0 cm (centimeter) (long)..." [DATE] at 4:20 PM. "Res found with out signs and symptoms of life per RN." Resident #10's record included documents entitled, "Memorandum for Record." Six of these documents were related to falls for the resident. Documentation on these forms included: *[DATE]. "On..XXX[DATE] at (11:52 PM) (R #10) was found on the floor next to her bed...had been incontinent of BM (bowel movement)...she will attempt to transfer herself if no one is available to assist...(R #10) has a unique condition called Intermittent [DIAGNOSES REDACTED]. This presents with symptoms such as sudden increased energy and activity for on (sic) average of 3 days followed by ,[DATE] days if extreme fatigue with increased weakness." The facility's conclusion was documented as, "Found on floor; likely a fall while trying to respond to bowel urgency." The facility's plan was included, "Provide (every) 15 minute checks to monitor need for toileting assistance following the initiation of bowel protocol", and "Monitor signs and symptoms of Intermittent [DIAGNOSES REDACTED]." *[DATE]. "On Sunday [DATE] (NOTE: The date of the memorandum may have been made in error, as it was two days before the event.) at (3:40 PM) (R #10) was found on the floor perpendicular to her bed, lying on her back...wheelchair was next to the bed where she had been sitting prior to the event...it was noted that since lunch she had refused all cares and assistance with getting into bed...last checked at (3:30 PM)...will attempt to self-transfer if no one is available to assist." The facility's conclusion was, "Found on floor; likely a fall while try (sic) to self-transfer from wheelchair to bed." The facility's plan included, "Provide (every) 15 minute checks while resident is in her room..." *[DATE]. "On [DATE] at 11:10 AM, (R #10) was found sitting on her wheelchair pedals at the North Nurse's station...She is able to self propel her (wheelchair) short distances with cueing. She is most successful in doing this on her way back to her room. However she will attempt to transfer herself if no one is available to assist." The facility's conclusion was, "Found sitting on wheel chair pedals, probably due to attempt to self transfer due to confusion, weakness and poor impulse control." The facility's plan included, "Provide (every) 15 minute checks - one to one (as needed)." *[DATE]. "On [DATE] at 11:55 PM, (Resident #10) was found on her knees on the floor and her upper torso on her bed...prior to the event it was noted that (R #10) was in bed and appeared to be sleeping. On the CNA's last round at (10:20 PM) (R #10) was incontinent of urine and had been changed and repositioned." (NOTE: 1 hour, 35 minutes had elapsed between the time documented by the facility as "last rounds" for R #10, and the time the resident was discovered with her legs out of the bed but her torso in the bed. When R #10 last fell on [DATE], the facility's plan was to implement 15 minute checks.) The facility's conclusion was, "Found with knees on floor and upper torso on her bed, probably due to attempt to self transfer or roll out of bed due to confusion, weakness, and immobility." The facility's plan included, "Provide (every) 15 minute checks - one to one (as needed)." [DATE]. "On [DATE] at (3:05 AM), (R #10) was found on the floor lying next to her lo-bed by (CNA)...On the CNA's last round at (2:00 AM) (R #10) was incontinent of urine and had been changed and repositioned. .." (NOTE: One hour and 5 minutes had elapsed between the last rounds on R #10 and the time of the fall, even though one of the interventions for the 2 previous falls had been every 15 minute checks.) The facility's conclusion was, "Found on floor, probably due to attempt to self transfer or roll out of bed." Again, the facility's plan documented, "Provide (every) 15 minute checks - one to one (as needed)." *[DATE]. "On [DATE], (R # 10) was found partially on the floor by (CNA) as she was passing (R #10's ) room. According to the report, (CNA) was walking past the room and saw that (R 10's) feet were on the floor. Upon further inspection, she noted that (R # 10's) upper body was not on the floor. (NOTE: This describes a similar circumstance as R #10's fall on [DATE].) (R #10's) left arm was between the side rail posts closest to the door, and (R #10's) head was resting on her arm. The right lateral aspect of (R # 10's neck was against the side rail surface of the mattress...she had a pulse but did not appear to be breathing. (R #10) had a nasal cannula on at the time and (LN #6) turned to oxygen flow all the way on the O2 concentrator to provide higher O2 flow. Together with 2 CNA's, she lifted (R #10) back into bed. At that point, she no longer was able to find a pulse or respirations. A purple, approximately 2 cm X 8 cm bruise was noted to be present on the right lateral aspect of (R # 10's) neck where it had made contact with the ,[DATE] rail...CNA reports that she last went into the room and checked on (R # 10) to see if she needed a gown sometime around (3:00 PM). At that time, (CNA #7) observed that (R # 10) was still on her right side and asleep...The alternating air mattress...was operational and appeared to be working effectively...The mattress manufacturer's recommendation advise (sic) that 'It is preferred that the rails be used in the raised position whenever a resident is in bed'...The bed is a standard size with a platform width of 35 inches..." (NOTE: Even though the reports from the three previous falls had documented every 15 minute checks for R #10, there were no staff statements ascertaining her whereabouts or positioning between 3:00 PM, and the time she was observed entrapped in her side rail at 4:05 PM.) The facility's conclusion was documented as, "On [DATE], the county coroner called me (Administrator) and stated that autopsy determined the preliminary cause of death was 'neck compression by bed rail and mattress.' It appears likely that (R #10) rolled over or repositioned herself in bed. At that point, her legs apparently slid off of the bed, her arm threaded between the side rail posts, and her neck became pinned against the side rail." The facility's plan to prevent reoccurrence included: -"Side rail assessments conducted on 100% of facility residents using side rails. -All staff in-serviced on safe side rail usage with air beds. -Bolster mattress overlays were ordered for all air mattresses in use. (NOTE: Bolster overlays are a non-side rail alternative to promote safety with air mattress use.) -Nursing staff in-serviced on proper assessment and use of rails, use and installation of an air mattress, and risk factors for entrapment. (NOTE: Please see example #2 below regarding side rail evaluation completed after this event.) Resident #10's death certificate documented: *"date of death , [DATE]." *"Time of Death, 16:20 (4:20 PM)." *"Cause of Death: Asphyxiation due to neck compression due to hanging." *"Describe how injury occurred..." was documented as, "Found with legs and body out of bed, left arm in siderail, head between mattress and side rail." On [DATE], the Administrator, Corporate Compliance Nurse (CCN), and LN #2 were interviewed regarding Resident #10, and her fatal fall on [DATE]. The Administrator stated on the day Resident #10 expired, he received a phone call from the RN on duty. The Administrator stated once the RN described the circumstance, he immediately came to the facility, and ensured the coroner and police were called, as well as notified the state agency hotline of the event. The Administrator stated the facility launched an investigation to determine what had caused the event, and identify ways such an event could be avoided in the future. Regarding Resident #10, the surveyor's interview on [DATE] revealed: *The facility was unsure if one ,[DATE] side rail was in use, as indicated on the monthly nursing summary forms, or both ,[DATE] side rails, as indicated on the resident's side rail assessment. *It was unknown how or when additional risk factors which developed after the date of the original side rail assessment, such as the failure to thrive diagnosis, weakness, anxiety, and decreased insight and judgement, were reevaluated to determine if ongoing side rail use continued to be appropriate for the resident. (NOTE: The only dates documented in Resident #10's record for side rail assessments are [DATE] (the date of her admission to the facility), and [DATE] (two days before she died due to a fall and entrapment in her side rail).) *The Administrator agreed the facility had initiated 15 minute checks after one of Resident #10's falls, but he could not recall which fall. He stated as the resident's health declined, the checks were discontinued because she was not attempting to self-transfer, and had been removed from the resident's care plan. The Administrator did not believe the 15 minute checks were in place at the time of Resident #10's final fall. (NOTE: Per the facility's documentation cited above, 15 minute checks were listed as fall interventions following Resident #10's falls on [DATE], [DATE], and [DATE].) *Regarding the 15 minute checks on Resident #10's care plan, the Administrator stated the facility CNAs used "Resident Care Guidelines" more frequently, and if they initialed that document, it meant any item listed on it had been carried out. The Administrator stated he believed the 15 minute checks for Resident #10 were still on her Resident Care Guidelines at the time of her fall. The Administrator did state the resident's care plan and the Resident Care Guide should match one another. *The Administrator could not confirm exactly what time Resident #10 fell , as compared to when she was discovered by staff. (NOTE: Staff statements indicate Resident #10 was seen on rounds at 3:00 PM, then found half on the floor with her arm entrapped in her side rail at 4:05 PM on [DATE]. Therefore, even if 15 minute checks were listed on Resident #10's Resident Care Guidelines, the checks were not carried out.) *The Administrator, CCN, and LN #2 were unable to clearly indicate whether the ,[DATE] side rails for Resident #10 were used for mobility, as documented in her side rail assessment; or for safety, as documented on her monthly nursing summaries. They were unable to report whether lesser restrictive alternatives were considered for Resident #10. The Administrator stated the side rail could have been in place due to the air mattress. The Administrator stated he did not know for sure if the manufacturer's recommendations for side rails up meant a ,[DATE] rail would be sufficient to meet that requirement. The Administrator stated the facility had not questioned that before the fall, because the air mattress had been provided by Hospice and it was up to Hospice to make sure it was safe. Additionally, the Administrator stated the both the air mattress and the side rails were made by the same company, so it could be presumed they were safe to use together. *LN #2 stated initially, the family had requested the use of a side rail for R #10 to help with mobility. *LN #2 stated with the initial assessment of the side rail, the resident would have to show she could use it appropriately to reposition, her head would not fit through it, and it was securely attached to the bed. LN #2 stated from that perspective, the assessment had been accurate because ultimately it was the resident's arm which was trapped in the side rail, not her head. *The Administrator stated the side rail assessment should be repeated at least quarterly, and with any change of condition. The Administrator was unable to explain why the side rail assessment for Resident #10 had not been updated between [DATE] and [DATE]. The Administrator stated following the fatal event for Resident #10 the facility had done extensive education to ensure assessments were being updated regularly. *The Administrator stated he did not believe there would be a physician's order for the use of the side rail, as the facility did not require a physician's order to use such a device. On [DATE] at 1:45 PM, the Administrator provided the following additional documentation for Resident #10: *The manufacturer's recommendations for safe use of the air mattress for Resident #10. Following the statement cited above the facility's report of the event, the recommendations documented, "Health care professionals assigned to each case should make the final determination whether side or assist rails are warranted after assessing patient risks of entrapment and falls..." *A [DATE] order from the hospice agency involved in R #10's care, which documented, "DME (Durable Medical Equipment) as needed", along with a facility care plan for an air bed, initiated [DATE]. (NOTE: The physician's order did not specify an air mattress or side rail should be used for R #10. The care plan for the air mattress pre-dated the physician's order by 82 days.) *R #10's Resident Care Guidelines for [DATE]. The care guidelines included 15 minute checks for the entire month. (NOTE: When R #10 fell on [DATE], staff statements documented a period of an hour and 5 minutes since she was last seen.) The care guidelines also documented the addition of bilateral Arco side rails on [DATE]. Resident #10 was harmed when the facility did not assess the continued use of side rails as her medical condition and equipment in use changed, did not consider lesser restrictive measures which could have been used for safety, and did not monitor the resident per her plan of care. R #10 ultimately became entrapped in her side rail, and died as a result of her injuries. On [DATE] at 5:30 PM, the Administrator, DNS, and CCN were informed of the surveyor's findings. The facility offered no further information to resolve the concern. 2. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. * On [DATE]th, 2010 the Resident completed paperwork assigning her husband as her DPOA (Durable Power of Attorney for Health Care). * Quarterly MDS dated [DATE] documented: -Bed Mobility: Extensive assistance- 1 person physical assist -Functional Limitation in Range of Motion: A. Upper extremity- Impairment on one side B. Lower extremity- Impairment on one side. *Current MD orders dated [DATE] documented that the Resident was receiving a medication for seizures: -"Keppra 500 mg 1 by mouth twice a day (Seizures) Notes: Monitor for seizures and document on seizure log" *Social Services Initial Resident History assessment dated [DATE] documented: "Has had 2 seizures." *Resident's Care Plan dated "Origin [DATE]" documented: -Impaired Physical Mobility -Related To: 1. CVA 2. Hemiparesis/hemiplagia 3. Weakness -Interventions: 5. ",[DATE] side rails ((L/R For)-this area was yellowed out as discontinued) Increased Mobility/Positioning upper, Bilat (bilateral) [DATE]" *Consent for Use of Side Rails dated [DATE] and signed by DPOA documented: -Recommendations-",[DATE] partial rail- Left: Upper- Right: Upper" -Frequency- "Side rail(s) are recommended at all times when resident is in bed." -Purpose- "(Increase) mobility (Increase) repositioning" *Evaluation for Use of Side Rails dated [DATE] documented: -Why is the use of a side rail(s) being considered? Checked was "Resident requested- Other (Increased) mobility" -Identify all that contribute to the resident's need to use side rail(s): Checked was "Physical: Weakness" -Additional Considerations included: Medications that require increased safety measures (diuretics, psychotropic, orthostatic medications) "Yes, list: see MAR(Medication Administration Record)" Will the side rail(s) impede resident's freedom of movement? "Yes" -Recommendations- "Side rail(s) is/are recommended at this time due to: (Increased) mobility -Recommended Type: ",[DATE] partial rail- Left: Upper Right: Upper" (NOTE: DPOA had signed consent for ,[DATE] rails. A new consent explaining to the DPOA why ,[DATE] side rails were being used was not found.) -Recommended Use: "Side rail(s) are recommended at all times when resident is in bed." -"Side rail precautions have been discussed with: "Resident Family/Resident representative" -Alternatives to side rails have been discussed with: "Resident Family/Resident representative" (Note alternatives discussed were not documented on the Evaluation) -Comments section: Dated [DATE] "(Resident) demonstrates safe & appropriate use of ,[DATE] rails for bed mobility and transfers. Then remains safe & appropriate for ongoing use." -Physician order has been obtained, including medical symptom/ condition (NOTE this area was not checked and an order was not found in the record for the use of the side rails.) -Plan of care updated (NOTE this area was not checked and the care plan was noted to have not been updated until [DATE].) *Side Rail Assessment Addendum dated [DATE] documented "Yes" to: 1. Are bars within the bed rails closely spaced to prevent the patient's head from passing through the openings and becoming entrapped? 2. Will the mattress to bed rail interface prevent an individual from falling between the mattress and bed rails and possibly smothering? 5. Is the mattress appropriately sized for the selected bed frame? 6. Is the space between the bed rails and the mattress and the headboard and the mattress filled either with an added firm inlay or mattress that creates an interface with the bed rail that prevents an individual from falling between the mattress and bed rails? 7. Are the latches securing the bed rails stable so that the rails will not fall when shaken? The Assessment documented "No" to: 3. Inspect the mattress to ensure it has not shrunk (related to time and cleaning). Such shrinkage increases the potential space between the rails and the mattress. Any concerns with mattress shrinkage? 4. Check for compression of the mattress outside perimeter since easily compressed perimeters can increase the gaps between the mattress and the bed rail. Any concerns with the outside mattress perimeter? (NOTE: Each section had an area for comments- no comments were found) The Assessment also documented: 9. Type of Mattress: "Therarest" 10. Type, number, and location of side rail(s) assessed: "2 ,[DATE] upper with control (no) entrapment" Summary of Findings: Dated [DATE] "Rails (sic ) snug to mattress (Resident) Demonstrates ability to use them safely. These are safe & appropriate" On [DATE] at 4:40 pm while on the Initial Tour of the facility, the surveyor observed the resident had 2 ,[DATE] upper side rails positioned up on the bed. The resident was not in the room. LN#1 stated the resident used the rails "for positioning." On [DATE] at 4:40 pm both upper half side rails were observed to be up on the resident's bed. There was a bed side table positioned across the foot of the bed. The resident was not in the room. The side rails did not have padding on them. On [DATE]