Every finding on record at West Carroll Care Center, Inc

Based on record reviews, interviews, and observations, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 1 (#22) of 1 resident sampled for urinary catheter. The facility failed to document intake and output records, document character and consistency of urine daily, and report unusual appearance of urine/signs and symptoms of a urinary tract infection to the Director of Nursing (DON) and physician immediately for Resident #22.Findings:Review of the facility's undated Catheter Care, Urinary policy and procedure revealed the following, in part:PurposeThe purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.Complications1. Observe the resident for complications associated with urinary catheters. Report unusual findings to the physician or supervisor immediately:b. if urine has unusual appearance (example color, blood),e. if signs and symptoms of urinary tract infection or urinary retention occur. Review of Resident #22's record revealed an admission date of 03/31/2022 with diagnoses including urinary tract infection, obstructive and reflux uropathy, unspecified disorder of prostate, and chronic kidney disease stage 3.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 6 indicating severe cognitive impairment. Further review of the MDS revealed obstructive uropathy, renal insufficiency, and indwelling urinary catheter were marked, and resident required setup or clean up assistance with toileting.An observation on 08/12/2025 at 10:03 a.m. of Resident #22 revealed the urine in the resident's urinary catheter tubing was cloudy with sediment present.An observation on 08/13/2025 at 8:30 a.m. of Resident #22 revealed the urine in the resident's urinary catheter tubing was blood tinged and cloudy with sediment present.An interview on 08/13/2025 at 8:20 a.m. with S4Certified Nursing Assistant (CNA) revealed she provided catheter care to Resident #22 every shift. S4CNA reported she emptied the resident's catheter every shift but only documented his output sometimes.An interview on 08/13/2025 at 8:25 a.m. with S4Licensed Practical Nurse (LPN) revealed Resident #22 had a urinary catheter. S4LPN reported she has not documented the color, clarity, and consistency of Resident #22's urine. An observation with S4LPN on 08/13/2025 at 8:35 a.m. of Resident #22's catheter tubing revealed his urine was blood-tinged and cloudy with sediment present. S4LPN confirmed that the resident's urine was blood-tinged and cloudy with sediment present. Review of the August 2025 Physician's Orders revealed an order dated 09/27/2024 for intake every shift, serve estimated fluid needs every day (1919 cubic centimeters). Further review of the physician's orders revealed no order for monitoring of urine every shift. Review of the record for Resident #22 revealed no documented evidence of monitoring for consistency, color, clarity of urine on the July or August 2025 Medication Administration Records (MAR) or Treatment Administration Records (TAR).Review of Resident #22's current care plan revealed the resident had an indwelling catheter related to obstructive and reflux uropathy and an unspecified disorder of prostate. The interventions included: check tubing for kinks each shift, monitor and document intake and output as per facility policy, monitor for signs and symptoms of discomfort on urination and frequency.Review of Resident #22's nurses notes for July and August 2025 revealed the staff failed to document the quality and character of resident's urine daily.Review of Resident #22's record revealed no documentation in the electronic health record notifying the Director of Nursing (DON) or physician regarding the unusual appearance of urine for Resident #22 on 08/12/2025 and 08/13/2025 after observations on 08/12/2025 and 08/13/2025 revealed Resident #22's urine had an unusual appearance. Further review of the record revealed the nurses failed to notify the DON and physician immediately with unusual appearance of urine as per policy.An interview on 08/13/2025 at 10:40 a.m. with S2DON revealed Resident #22 had a urinary catheter on admission. S2DON reported that Resident #22 has had abnormal urine such as blood-tinged and cloudy with sediment present frequently and the nurse practitioner was aware of this. S2DON reported the nurse documents on the character of Resident #22's urine weekly, not daily. An interview on 08/13/2025 at 2:00 p.m. with S2DON confirmed that the facility documents on Resident #22's urine weekly and failed to notify the physician or supervisor immediately of unusual appearance of urine and signs and symptoms of urinary tract infections for Resident #22 as per the facility's policy. S2DON further confirmed the facility failed to document Resident #22's intake and output as per the physician's order.

Based on record reviews, interviews, and observations, the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible for 1 (#47) of 4 (#3, #6, #35, and #47) residents sampled for nutrition. The facility failed to document meal intake for each meal and update care plan with a significant weight loss for Resident #47. Findings:Review of facility's Weighing and Measuring the Resident policy and procedure, revised March 2011, revealed the following, in part:Reporting1.) Report significant weight loss/weight gain to the nurse supervisor.2.) The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria (where percentage of body weight loss = (usual weight-actual weight) divided by the usual weight and multiply by 100):a. 1 month-5% weight loss is significant; greater than 5% is severe.b. 3 months- 7.5% weight loss is significant; greater than 7.5% is severe.c. 6 months- 10% weight loss is significant; greater than 10% is severe. Review of Resident #47's record revealed an admission date of 08/02/2024 with diagnoses including unspecified dementia unspecified severity with other behavioral disturbance, urinary tract infection, anorexia, hypertensive heart disease without heart failure, hyperlipidemia, major depressive disorder, and gastro-esophageal reflux disease without esophagitis.Review of Resident #47's Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 1 indicating severe cognitive impairment. Further review of the MDS revealed resident required substantial/maximal assistance with eating and weight loss was marked.Review of Resident #22's August 2025 Physician's Orders revealed an order dated 10/01/2024 for a regular diet, regular texture, with regular/thin consistency. Further review of the physician's order revealed no orders for supplements or appetite stimulants ordered for this resident.Review of Resident #47's weights revealed a weight of 119.1 pounds on 01/06/2025, a weight of 107.0 pounds for 06/2025 and a weight of 107 for 7/08/2025, indicating a weight loss of 10.16% in a 6-month period.Review of Resident #47's current care plan revealed the resident had the potential for a nutritional problem related to vitamin deficiency. Further review of the care plan revealed interventions included: administer medications as ordered, monitor/document for side effects and effectiveness, allow me ample time to consume food, provide assistance as needed, cueing, and/or feeding assist, ask family/significant other about my food preferences, dietary noted weight loss, Director of Nursing (DON) noted the family happy with the resident's weight and physician aware, dietician to evaluate and follow up annually and as needed, encourage me to dine in dining room for meals to encourage socialization, monitor food intake at each meal and record and report any decline to physician and dietician, observe and document my nutritional status every month and report any negative trends to physician, obtain lab work as ordered by physician. Report results to physician when available, promptly offer me food alternatives when appropriate for any meal served, provide, and serve diet as ordered, monitor intake and record every meal.An observation of Resident #47 on 08/11/2025 at 11:40 a.m. revealed the resident was being fed lunch by S5CNA in the dining room. The lunch meal included fried pork chop, pinto beans, greens, cornbread, chocolate pie, and tea, and her meal card revealed resident was on a regular diet. S5CNA confirmed that Resident #47 does not eat at times.Observation on 08/12/2025 at 11:45 a.m. revealed Resident #47 was being fed lunch in the dining room by S5CNA. Resident's meal consisted of meatloaf, mashed potatoes, roll, peas, tea, water and lemon pie, Resident #47 ate about 50-75% of her lunch meal. Interview on 08/12/2025 at 1:30 p.m. with S2DON revealed Resident #47 had a history of weight loss, but resident's daughter refused an appetite stimulant back in January 2025. S2DON reported resident's daughter has been pleased with resident's weight loss and does not want the resident on an appetite stimulant or supplement. S2DON confirmed Resident #47's care plan was not updated for the resident's significant weight loss in July 2025. S2DON confirmed resident #47 did not have any supplements or appetite stimulants ordered.Review of Resident #47's record revealed no documented evidence of meal intake documented with each meal for July and August 2025.An interview on 08/13/2025 at 8:35 a.m. with S3Licensed Practical Nurse (LPN)/MDS Coordinator revealed she was unable to provide surveyor with the individual meal intake of each meal for Resident #47 for July and August 2025.An interview on 08/13/2025 at 2:00 p.m. with S2DON confirmed the facility failed to document meal intake for each meal for Resident #47 for July and August 2025 and failed to update Resident #47's care plan with weight loss for July 2025.

Based on record reviews, interviews, and observations, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (#6) of 1 resident sampled for dialysis. The facility failed to document intake and output records as specified in plan of care for Resident #6.Findings:Review of the record for Resident #6 revealed an admission date of 06/16/2025 with diagnoses that included end stage renal disease, edema, hypertensive heart disease with heart failure, and type 2 diabetes mellitus with chronic kidney disease.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 which indicated the resident is cognitively intact for daily decision making. The MDS also documented that the resident required dialysis.Review of the August 2025 Physician's Orders revealed an order to document intake every shift and serve estimated fluid needs daily. There was no order noted to document output. The active plan of care that addressed Resident #6's end stage renal disease and need for dialysis included interventions for nursing staff to monitor intake and output. Review of the intake and output record revealed that no intakes were documented for 14 days from 07/01/2025-08/11/2025. There were no outputs documented from 07/01/2025-08/11/2025.On 08/12/2025 at 9:55 a.m., an interview was conducted with S6Certified Nursing Assistant (CNA) who voiced that CNA staff were responsible for documenting intake and output. S6CNA also confirmed that Resident #6 produced a small amount of urine outputs and the outputs were to be documented in the resident's record.On 08/13/2025 at 12:49 p.m., an interview was conducted with S4Licensed Practical Nurse (LPN) who voiced that CNA staff were responsible for documenting intake and output. S4LPN also confirmed that Resident #6 produced a small amount of urine. On 08/13/2025 at 1:59 p.m., an interview was conducted with S2Director of Nursing (DON) related to the documentation of intake and output. S2DON confirmed that the intake and output had not been documented as specified in the plan of care and provided no other documentation for review.

Based on interview and record review, the facility failed to ensure there was sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services. The facility had excessively low weekend staff during Fiscal Year Quarter 2 2025 dated 01/01/2025 to 03/31/2025. Findings:Review of the facility's Payroll-Based Journal (PB&J) Staffing Report revealed the facility triggered excessively low weekend staff for Fiscal Year Quarter 2 2025 dated 01/01/2025 to 03/31/2025. Review of the facility's February 2025 weekend personnel staffing pattern revealed insufficient staff for the following date: 02/16/2025.Review of the facility's March 2025 weekend personnel staffing pattern revealed insufficient staff for the following dates: 03/08/2025 and 03/23/2025. An interview on 08/12/2025 at 11:25 a.m. with S1Administrator confirmed the facility had low staffing for the dates listed above and did not meet the required hours.

Based on record review and interview the pharmacist failed to identify and report irregularities to the physician and DON (Director of Nursing) for 1(#39) of 5 (#1, #2, #38, #39, #47) residents reviewed for unnecessary medications. The pharmacist failed identify irregularities for Resident #39. Resident #39 was not being monitored for signs and symptoms of bleeding while receiving an anticoagulant medication.Findings: Record review revealed Resident # 39 was admitted to the facility on [DATE]. Resident #39's diagnoses included the following: hypertensive heart disease without heart failure, abnormal findings on diagnostic imaging of heart and coronary circulation, long term use of anticoagulants, type 2 diabetes mellitus unspecified dementia, unspecified severity, with other behavioral disturbance, chronic kidney disease stage 3, and hypothyroidism. Review of active August 2025 Physician Orders revealed Coumadin 4 milligrams (mg) tablet give1 tablet by mouth (po) at bedtime every Monday, Wednesday, and Friday. Coumadin 5 mg tablet give 1 tablet po every Tuesday, Thursday, Saturday, and Sunday. Coumadin is an anticoagulant medication. Review of the Electronic Medication Administration Record (EMAR) August 2024 through August 2025 revealed documentation Resident #39 received Coumadin as ordered by the physician. Further review of the EMARs revealed there was no documentation Resident #39 was monitored daily for signs and symptoms of bleeding while receiving Coumadin. Review of the current care plans revealed Resident #39 received anticoagulant therapy (Coumadin). Goal: The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date.Interventions included the following:Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift.Bleeding precautions every shift.Monitor/document/report as needed (PRN) adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of the Monthly Medication Regimen Reviews from August 2024 through August 2025 for Resident #39 revealed the consultant pharmacist failed to identify the facility was not monitoring Resident #39 for signs and symptoms of bleeding while receiving Coumadin. Further review revealed the consultant pharmacist did not make any recommendations to the Physician and Director of Nursing (DON) that Resident #39 needed to be monitored for signs and symptoms of bleeding while receiving Coumadin. On 08/13/2025 at 1:30 p.m., an interview with S2DON revealed Resident #39 has been receiving Coumadin since being admitted to the facility in August 2024. S2DON confirmed there was no documentation Resident #39 was being monitored for signs and symptoms of bleeding while receiving Coumadin. S2DON further confirmed Resident #39 should have been monitored for signs and symptoms of bleeding every shift while receiving Coumadin. 08/13/2025 1:32 PM an interview with S2DON confirmed the consultant pharmacist failed to identify that the facility was not monitoring Resident #39 for bruising or bleeding while receiving Coumadin.

Based on record review and interview, the facility failed to ensure that each resident was free from unnecessary medication use for 1 (#39) of 5 (#1, #2, #38, #39, #47) residents reviewed for unnecessary medications. The facility failed to monitor Resident #39 for signs and symptoms of bleeding while receiving an anticoagulant medication.Findings:Record review revealed Resident # 39 was admitted to the facility on [DATE]. Resident #39's diagnoses included the following: hypertensive heart disease without heart failure, abnormal findings on diagnostic imaging of heart and coronary circulation, long term use of anticoagulants, type 2 diabetes mellitus unspecified dementia, unspecified severity, with other behavioral disturbance, chronic kidney disease stage 3, and hypothyroidism. Review of active August 2025 Physician Orders revealed Coumadin 4 milligrams (mg) tablet give1 tablet by mouth (po) at bedtime every Monday, Wednesday, and Friday. Coumadin 5 mg tablet give 1 tablet po every Tuesday, Thursday, Saturday, and Sunday. Coumadin is an anticoagulant medication. Review of the Electronic Medication Administration Record (EMAR) August 2024 through August 2025 revealed documentation Resident #39 received Coumadin as ordered by the physician. Further review of the EMARs revealed there was no documentation Resident #39 was monitored daily for signs and symptoms of bleeding while receiving Coumadin. Review of the current care plans revealed Resident #39 received anticoagulant therapy (Coumadin). Goal: The resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date.Interventions included the following:Administer anticoagulant medications as ordered by physician. Monitor for side effects and effectiveness every shift.Bleeding precautions every shift.Monitor/document/report as needed (PRN) adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising , blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. On 08/13/2025 at 1:30 p.m., an interview with S2Director of Nursing (DON) revealed Resident #39 has been receiving Coumadin since being admitted to the facility in August 2024. S2DON confirmed there was no documentation Resident #39 was being monitored for signs and symptoms of bleeding while receiving Coumadin. S2DON further confirmed Resident #39 should have been monitored for signs and symptoms of bleeding every shift while receiving Coumadin.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 1 (# 45) of 1 sampled residents reviewed for environmental concerns. The facility failed to ensure that the resident's air conditioning vent remained clean and free of mold like substance.Findings:Review of Resident #45's record revealed an admit date of 09/30/2021 with diagnoses including cerebral infarction, unspecified; allergic rhinitis, unspecified; shortness of breath; and hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.On 08/11/2025 at 9:45 a.m. and 08/12/2025 at 8:25 a.m., observations of Resident #45's air conditioner revealed a mold like substance on the surface of the vent.On 08/12/2025 at 8:50 a.m., an observation made with S1Administrator confirmed the presence of a mold like substance on Resident #45's air conditioner vent.

Based on record review and interview the facility failed to electronically transmit encoded, accurate and complete Minimum Data Set (MDS) data to Centers for Medicare and Medicaid (CMS) in a timely manner for 1 (#43) of 2 (#11, #43) residents reviewed for the completion of a seven day discharge assessment. Findings:Record review revealed Resident #43 was admitted to the facility on [DATE] and discharged on [DATE]. The last transmitted MDS assessment in the electronic health record was a Quarterly and State Optional-Other assessment completed on [DATE] in the batch accepted on [DATE].On [DATE] at 12:55 p.m. an interview with S3Licensed Practical Nurse (LPN)/MDS nurse revealed she failed to complete and transmit the discharge MDS assessment for Resident #43. S3LPN/MDS nurse reported Resident #43 expired at facility on [DATE] and should have submitted the MDS discharge assessment to the state by [DATE] within 7 days of discharge.

Based on observations, record review and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 1 (#71) of 1 (#71) resident reviewed for respiratory care. The facility failed to ensure Resident #71's nebulizer tubing and t-piece was properly stored in a plastic bag.Findings:Review of the facility's Administering Medications through a Small Volume (Handheld) Nebulizer policy dated August 2025 revealed in-part: 18. When the treatment is complete, turn off nebulizer and store in a plastic bag with the resident's name and date on it. On 08/11/2025 at 9:50 a.m. and 08/12/2025 at 8:20 a.m., observations of Resident #71's room revealed the nebulizer tubing and t-piece was dated 08/10/2025 and secured to a nebulizer machine sitting on dresser. The nebulizer tubing and t-piece was not stored in a plastic bag. Resident #71 reported she received breathing treatments several times daily. Record review revealed Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #71's diagnoses included chronic obstructive pulmonary disease, shortness of breath, cough, wheezing, generalized epilepsy, anemia, chronic pain. Review of the active August 2025 Physician Orders revealed the following: Albuterol Sulfate inhalation nebulization solution (2.5 milligrams (mg)/3 milliliters (ml) 0.083% inhale 1 vial orally via nebulizer every 4 hours as needed for cough. May leave neb at bedside (order date 07/29/2025).Monitor Nebulizer (Neb) tubing and setup every (q) shift for proper storage q shift (order date 07/30/2025). Review of the August 2025 Electronic Medication Administration Record (EMAR) revealed documentation Resident #71 received Albuterol sulfate 2.5 mg/3ml 1 vial per nebulizer on 08/04/2025 at 8:52 a.m. and 6:52 p.m. and on 08/09/2025 at 6:35 p.m.Further review of the August 2025 EMAR revealed documentation of the monitoring Neb tubing and setup q shift for proper storage every shift was signed off by the nurses 08/01/2025 through the day shift on 08/12/2025. On 08/12/2025 at 11:15 a.m. an observation of Resident #71's room with S2Director of Nursing (DON) revealed the nebulizer tubing and t-piece was secured to the nebulizer machine that was sitting on the dresser. The nebulizer tubing and t-piece was not stored in a plastic bag. S2DON confirmed the nebulizer tubing and t-piece should be stored in a plastic bag.

Based on interviews and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice when the nursing staff failed to recognize, assess, intervene, and document a resident's condition after a fall to avoid delayed treatment for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for falls. This deficient practice resulted in an Immediate Jeopardy situation on 01/24/2025 at approximately 3:15 p.m., when resident #1 had a fall in his room. The resident's nurse failed to assess the resident after the fall, document the incident, and report the incident to the resident's physician and the director of nursing. On 01/28/2025, it was determined that the resident had obtained a left displaced femoral neck fracture, which required surgical repair on 01/29/2025. This deficient practice resulted in a delay of treatment for resident #1. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 02/11/2025. It was determined to be a Past Noncompliance Citation. Findings: Review of the facility policy, Falls-Clinical Protocol (no date noted), revealed in part: Assessment and Recognition: 2. The nurse shall assess and document/report the following: recent injury, especially fracture or head injury; musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; pain; precipitating factors, and details on how fall occurred. 4. The staff will evaluate and document falls that occur while the individual is in the facility. 6. Falls should also be identified as witnessed or unwitnessed events. Monitoring and Follow-up: 1. The staff will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture have been ruled out or resolved. Delayed complications such as late fracture and major bruising may occur hours or several days after a fall. Review of the facility policy, Accidents and Incidents-Investigating and Reporting (no date noted), revealed in part: All accidents or incidents involving residents occurring on the premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation: 1. The nurse supervisor and/or nurse shall promptly initiate and document an investigation of the accident or incident. 2. The following data shall be included on the Report of Incident/Accident form in part: date and time of incident; nature of the injury/illness; notification of attending physician and family; the condition of the injured person; any corrective action taken; follow-up information; and the signature and title of the person completing the report. 6. Incident/Accident reports will be reviewed for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review of the record for resident #1 revealed a [AGE] year old with an admitted [DATE]. Diagnoses included but not limited to the following: unspecified dementia with other behavioral disturbance, major depressive disorder, coronary atherosclerosis, atrial fibrillation, weakness, and left displaced femoral neck fracture. Further review revealed resident #1 was unable to verbally communicate his needs effectively. He also had behaviors (i.e. yelling out, resisting care, combative with staff) and he had increased muscle tone which cause his legs to be stiff. Review of resident #1's quarterly Minimal Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated severely impaired cognitive skills for daily decision making. Resident #1 was unable to walk and used a wheel chair for locomotion. He also required substantial/maximal assistance for toileting, personal hygiene, chair to bed transfer, and lying to sitting on the side of the bed. Review of the Fall Risk assessment dated [DATE] revealed resident #1 had a score of 10 which indicated he was at a high risk for falls. Review of resident #1's current care plan revealed on 05/24/2024 he was totally dependent on 1 staff for assistance with toileting, personal hygiene, and for transfers. Further review revealed he was at risk for falls. Review of the Electronic Health Record (EHR) Progress Notes dated 01/28/2025 at 6:40 a.m. revealed Certified Nursing Assistants (CNAs) informed this nurse (S5Licensed Practical Nurse [LPN]) that resident #1 had a bruise to left hip and was complaining of pain. When S5LPN assessed resident, there was a small purple bruise noted to his left hip. Resident #1 complained of pain even when not being touched, and kept his left hand at side. S5LPN notified S2Director of Nursing (DON) and the resident's physician assistant. Further review of the resident #1's EHR Progress Notes dated 01/28/2025 at 9:40 a.m. revealed the facility received the resident's left hip x-ray results and he had a displaced femoral neck fracture. The resident's physician was notified and at 10:40 a.m., the resident was transferred to the emergency room . On 01/29/2024 at 11:30 a.m., S2DON was informed by hospital nurse that the resident was supposed to have surgery for his hip today. Review of the S2DON's investigation summary for the resident's incident of unknown injury revealed after interviews were conducted with staff regarding the resident's left hip bruise, initially there was no known incident or cause of the bruise. However, on 01/30/2025, S2DON conducted an interview with S4CNA and she informed S2DON that she was providing care for the resident when he had a fall from his bed on 01/24/2025. S4CNA reported she had asked S6CNA to assist her with transferring the resident. After that, resident #1 was aggravated and he had unplugged the bed, attempting to poke her with the plug. The resident jumped at her and fell out of the bed hitting the floor. Further review of S2DON's notes revealed camera footage was reviewed from 01/24/2025 and the footage supported S4CNA's statement. S4CNA was observed leaving to go to the nurses' station and then she and S3LPN went back into the resident's room. After S2DON further interviewed S4CNA and S6CNA they revealed resident #1 had no apparent injuries and no complaint of pain with transfer or during care. Immediate action taken by facility on 01/28/2025: -A body audit of resident #1 was completed by the S2DON with no other significant findings discovered. -Resident #1 was placed in the dayroom so he could be observed by nursing staff and when the CNA's provided personal care, a management nurse was in attendance. -An investigation regarding the injury of unknown origin was initiated. -Initially, staff interviews initiated with no significant findings noted. -Interviews with residents that resided on resident #1's hall were initiated with no significant findings noted. -Left hip x-ray results received and indicated a displaced femoral neck fracture and resident #1 was transferred to the emergency room for evaluation and transfer for orthopedic care. Review of resident #1's medical record revealed there was no documentation of resident #1's fall on 01/24/2025. Further review revealed there was no documentation the resident was assessed after the 01/24/2025 fall, and the fall was not reported to the resident's physician nor the director of nursing. On 02/12/2025 at 12:15 p.m., an interview with S2DON revealed she interviewed S3LPN regarding the above incident and S3LPN told her she could not remember S4CNA reporting to her that resident #1 had a fall on 01/24/2025. She confirmed S3LPN viewed video footage from 01/24/2025 with her. They watched as she entered resident #1's room with S4CNA, but S3LPN still could not recall that the resident had a fall on 01/24/2025 or if she had assessed him after the fall. S2DON confirmed S3LPN failed to report the resident's fall to her and there was no documentation in the nurse's notes and no incident report was completed regarding resident #1's fall. S2DON revealed the last day that S3LPN worked at the facility was on 01/30/2025 and after the investigation into the incident, she was terminated on 02/07/2025. On 02/12/2025 at 2:12 p.m., a phone interview was conducted with S3LPN and she was unable to recall S4CNA reporting to her that the resident had a fall on the evening on 01/24/2025. She confirmed she worked on 01/24/25 but could not remember any details regarding resident # 1's fall or if she had assessed him after the fall. On 02/12/2025 at 3:58 pm, a phone interview with S4CNA revealed she was trying to change resident #1 and he unplugged the bed and he was trying to poke her or hit her with the plug. He lunged at her with the plug and this caused him to fall out of his bed (that was in low position) onto his left side on the floor. She yelled for S6CNA to come stay with the resident while she went to get his nurse. S4CNA revealed she informed the nurse at the nurse's station that she needed the resident's nurse. She reported that S3LPN came quickly to the room and instructed S4CNA and S6CNA to transfer resident #1 back to bed. S4CNA reported she did not observe S3LPN assess the resident but she had left the room soon after the resident was transferred back to bed. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. On 01/28/2025, the facility implemented the following actions to correct the deficient practice with a completion date of 01/31/2025: 01/28/2025 - Weekly body audits reviewed for 01/27/2025 to determine if there were any unknown injuries or significant findings. Body audits will continue until full facility body audits are completed. Statewide Incident Management System (SIMS) report opened. 01/28/2025- Staff education initiated: Abuse and neglect, staff rounding requirements: CNA even hours/nurses odd hours, ensure staff using proper transfer techniques, report changes in condition, change in behavior, change in skin condition to the nurse in a timely manner and any issues identified with a resident should be assessed immediately and addressed in a timely manner. 01/29/2025- Investigation continues regarding resident #1's injury of unknown origin, and full facility body audits continued. 01/30/2025- Video footage was reviewed by S1Administrator and S2DON. The video footage supported S4 CNA's statement. S3LPN was witnessed entering the resident's room after being notified of the incident. There were no issues identified with review of the footage and routine care rounds were being provided. 01/30/2025- S3LPN was suspended pending investigation. 01/30/2025- Incidents and accidents for resident #1's hall reviewed, no injuries of unknown origin noted; no additional incidents/accidents were noted. 01/30/2025- QA started on reviewing nurse's notes and 24-hr report to ensure that incidents/accidents are reported, processed, and completed. QA will be done 5x a week x 8 weeks then 3x a week x 4 weeks then as needed. 01/30/2025- Residents that resided on resident #1's hall were assessed to identify any potential significant changes, any recent hospitalization s, or other abnormal findings and there were no concerns noted. 01/30/2025 - Staff members who worked with resident #1 through the weekend were re-interviewed in order to gain more details regarding his care, complaints, and activity level. No signs or report of distress or pain was noted. Resident appeared to continue normal activities, including being out of bed, in day room watching television, interacting with others and meal intake was normal. 01/30/2025 - Safety measures were assessed and found to be functioning properly. Included in these were the following: 1) Resident #1's call light was activated, the light lit up in the hall and at the switchboard (the clerk at the desk and nurse in the room could clearly hear each other speaking). 2) Wedge cushion was in place and properly fit the resident's wheelchair. 3) Assist bar was properly attached to resident #1's bed and raised/lowered correctly. 4) Functions of the bed were checked. The head and foot of the bed raised and lowered properly. The bed raised and lowered also with no issues. 5) The mattress fit was checked and was correct. There was no physical damage noted to the exterior of the mattress (no rips, tears or sunken spots). 01/30/2025- Resident #1's incidents were reviewed for the last six months and all prior interventions were assessed and found to be in place. 01/31/2025- Staff in-service for CNAs: Reporting any incident or accidents that occur with a resident. If unsure if something is new or if you should report, always report to the nurse or supervisor. If you feel like an additional assessment may need to be done then report to a management nurse. 01/31/2025- Staff in-service for nurses: An incident report should be done for any of the following (bruises, skin tears, falls, unintentional change in plane, setting a resident in the floor from getting weak, sliding out of bed or wheelchair, etc). Physician, responsible party, and DON should all be made aware. Proper documentation should be done and include any new orders or treatment. If any immediate actions should be put into place, then make sure those are done (increase supervision, increase monitoring, etc.). 01/31/2025- Staff in-service: Abuse & Neglect, reporting any change in condition or change in status to nurse/nurses station. 01/31/2025- QA initiated to ensure nurse competency and return demonstration for incident/accident reporting and completion of appropriate documentation. 01/31/2025- Resident #1 returned to the facility with orders for non-weight bearing status and hip rehab exercises. He is a two person assist with lift transfer. Nursing assessment completed. 01/31/2025- As an immediate protective action, S6CNA sat near the resident's door providing additional supervision due to him having had a fall and behaviors. On 01/30/2025, once the facility was aware of resident #1's fall, corrective action was initiated immediately, staff was suspended with subsequent termination, and all staff education and QA was initiated. Compliance was met on 01/31/2025 after the determination was made that no other residents were affected and the QA process was in place. Date facility asserts the likelihood for serious harm to any recipient no longer exists: 01/31/2025.

Based on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 (#5) of 3 (#5, #6, and #61) residents reviewed for nutrition. The facility failed to document the supper meal intake percentages daily for resident #5. Findings: Review of the medical record for resident #5 revealed an admitted [DATE] with diagnoses including hypertension, diabetes mellitus, hypokalemia, insomnia, gout, polyneuropathy, reflux, dementia, anorexia, hyperlipidemia, and vitamin deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment with daily decision making skills and required assistance with activities of daily living. Review of the current care plan revealed resident #5 had a potential for weight loss related to leaving 25% or more of food uneaten at most meals. Further review of the care plan revealed an intervention to document the resident's food intake with each meal. Review of the Meal Roster form for July 2024 and August 2024 revealed no documented evidence of the supper meal intake percentage daily for resident #5. On 08/14/2024 at 9:15 a.m., an interview with S2Director of Nursing (DON) confirmed the supper meal intake percentages were not documented on the Meal Roster form.

Based on record review, and interview, the facility failed to ensure that nursing staff are able to demonstrate competency in skills necessary to care for resident needs for 1 (#5) of 5 (#3, #5, #15, #40 and #62) residents records reviewed. The facility failed by not having documentation of sites for administration of insulin. Findings: Review of the medical record for resident #5 revealed an admitted [DATE] with diagnoses including hypertension, diabetes mellitus, hypokalemia, insomnia, gout, polyneuropathy, reflux, dementia, anorexia, hyperlipidemia, and vitamin deficiency. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment with daily decision making skills and required assistance with activities of daily living. Review of the current care plan dated 03/14/2024 revealed resident #5 had labile blood sugars related to diabetes. Further review of the care plan revealed an intervention to obtain finger stick blood sugars as ordered before meals and at bedtime. Review of the August 2024 physician orders revealed an order dated 05/22/2024 for finger stick blood sugars before meals and at bedtime and give sliding scale insulin with Novolog sliding scale 0-200 give 0 units, 201-250 give 4 units, 251-300 give 6 units, 301-350 give 8 units, 351-400 give 10 units, and if blood sugar level is greater than 401 call the physician. Review of the Medication Administration Record (MAR) revealed no documented evidence of the sites of administration for sliding scale insulin injections 47 times during the month of July 2024 and 6 times during the month of August 2024. On 08/14/2024 at 9:15 a.m., an interview with S2Director of Nursing (DON) confirmed the nurses failed to document the sites of administration for sliding scale insulin injections for July 2024 and August 2024.

Based on observations, record reviews and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 1 (#3) of 4 (#3, #37, #62, #68) residents on Enhanced Barrier Precautions (EBP). The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing incontinent care to Resident #3 who was on Enhanced Barrier Precautions. Findings: On 08/13/2024 at 11:19 a.m., record review for Resident #3 revealed an admitted [DATE]. Further review of the record revealed Resident #3 had diagnoses of hypertension, urinary tract infection, herpes viral vesicular dermatitis (fever blister), anorexia, anxiety disorder, disorder of urinary system, type 2 diabetes, chronic kidney disease (stage 3), depressive episodes, urgency of urination, Alzheimer's disease, and herpes zoster. Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 99 (unable to assess). Review of the plan of care in part revealed: Chronic kidney disease- monitor for declining urine output, assess peripheral edema, Placed on contact precautions due to Multi Drug Resistant Organisms (MDRO), Chronic urinary tract infections (UTI) - will be free of negative effects of incomplete bladder emptying. Review of the record revealed on 07/27/2024 an order for a urinalysis with culture and sensitivity was ordered. The culture and sensitivity results showed Methicillin Resistant Staphylococcus Aureus (MRSA) and was susceptible to Vancomycin. On 08/14/2024 at 9:59 a.m., observation of resident #3's door revealed a sign was posted that the resident was on Enhanced Barrier Precautions (EBP). The EBP sign read: Everyone must: Cleanse their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and gown for the following High-Contact Resident Care Activities. Dressing Bathing/Showering Transferring Changing Linens Providing Hygiene Changing briefs or assisting with toileting Device Care or use: Central line, urinary catheter, feeding tube, tracheostomy Wound Care: any skin opening requiring a dressing. Do not wear the same gown and gloves for the care of more than one person. Further observation of the hallway revealed there was PPE such as gown and gloves on the hallway in close proximity to Resident #3's room. On 08/14/2024 at 10:00 a.m., observation of incontinent care to resident #3 performed by S4Certified Nurses Assistant (CNA) revealed she was already in resident #3's room. Further observation revealed S4CNA was not wearing any PPE. Observation of S4CNA revealed she transferred resident #3 from the geri chair to bed without wearing PPE. Further observation revealed S4CNA then donned gloves without washing her hands, opened resident #3's brief, and touched the container of wipes with same gloves. S4CNA proceeded to wipe resident #3 front to back, turn resident #3 on the right side, retrieve more wipes from the package, wipe the resident's buttocks and then apply a new brief all with the same gloves. Further observation of S4CNA revealed she proceeded to move the geri chair with the same gloves (that were worn to clean the resident with), transfer the resident into the chair, put the soft neck pillow behind the resident's neck, place pillows on the right and left side of resident #3 and place a blanket over resident #3 without ever changing the gloves she used to clean resident #3 with. Further observation revealed S4CNA then picked up the trash bag that contained the dirty brief and the container of wipes with the dirty gloves and proceeded to open the door. S4CNA placed the wipes on the hall cart with the same gloves. S4CNA confirmed at that time the wipes would be used on another resident. Interview with S4CNA at the end of the care confirmed the sign on the door said resident #3 was on EBP and she should have cleaned her hands before and after the procedure. She further confirmed she was supposed to wear gloves and a gown for the incontinent care. On 08/14/2024 at 10:20 a.m., review of the EBH policy and procedure dated March 2024 revealed in part: EBP are utilized to prevent the spread of multi-drug resistant organisms (MDROs). 1. EBP are used as an infection prevention and control intervention to reduce the spread of MDROs to residents. 2. EBP employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact care activity. b. PPE is changed before caring for another resident. 3. Examples of high contact resident care activities requiring the use of gown and gloves for EBP include: a. dressing b. bathing/showering c. transferring d. providing hygiene e. changing linens f. changing briefs or assisting with toileting 4. EBP are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with the following: f. MRSA 6. EBP remain in place for the duration of the residents' stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at risk. 9. Staff are trained prior to caring for residents on EBP. 10. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required. 11. PPE is available outside of the resident rooms. 12. Resident, families and visitors are notified of the implementation of EBP throughout the facility. Review of the EBP tracking revealed resident #3 was placed on EBP on 08/13/2024 related to MRSA of the urine. On 08/14/2024 at 10:17 a.m., an interview with S3 Infection Control Nurse confirmed resident #3 had been on contact isolation due to a UTI, came off of contact isolation on 08/13/2024 and was immediately placed on EBP. S3 Infection Control Nurse further confirmed S4CNA should have worn a gown while performing incontinent care and she should have washed her hands and changed her gloves after providing the care. S3Infection Control Nurse further confirmed the wipes should not have been taken into the resident's room to provide the care and should have stayed on the hall cart.

Based on record reviews and interviews, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 (#1) of 5 (#1, 2, 3, 4, 5) sampled residents by failing to ensure resident #1 was safely secured in a lift chair while bathing in the whirlpool room. This deficient practice resulted in an Immediate Jeopardy situation that began on 04/30/2024 at 9:15 a.m., when resident #1 was not properly secured with the seat belt in a lift chair while receiving a whirlpool bath. The resident fell from the chair to the floor and sustained a fractured skull, fractured left arm, laceration to the left side of the head and a brain bleed. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 05/06/2024. It was determined to be a Past Noncompliance Citation. Findings: Review of the facility's current Bath, Shower/Tub policy, which was last revised February 2018 revealed When using the lift system, be sure whirlpool lift is firmly positioned and locked. Assist the resident into the whirlpool chair lift. Secure the safety belts. Review of the resident #1's medical record revealed she was admitted to the facility on [DATE] and had diagnoses which included chronic obstructive pulmonary disease, hypothyroidism, hypertensive heart disease and hyperlipidemia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1's Brief Interview for Mental Status (BIMS) score was 11. A score of 11 indicated moderate cognitive impairment. The MDS also indicated the resident required partial to moderate assistance with bathing. Review of the care plan for resident #1 revealed she had impaired mobility and required 1 person assistance with bathing. The resident's care plan also indicated she was at high risk for falls. Review of the nurse's notes dated 04/30/2024 indicated resident #1 fell and was lying face down on the floor with blood around her head when the nurse entered the WP (whirlpool) room. The resident's respirations were shallow at 6-8 beats per minute and her heart rate was slow at 10 beats per minute. She did not respond verbally and S2DON (Director of Nurses) initiated deep sternal stimulation. After being stimulated her respirations and heart rate increased. The resident had a 5-6 centimeter laceration to her left forehead. The resident was placed on a stretcher and taken to the emergency room , which was connected to the facility. Review of the facility's incident report revealed on 04/30/2024 at 9:15 a.m., S3CNA (Certified Nurse Aid) was assisting resident #1 with a whirlpool bath which included using the lift chair attached to the bath. S3CNA failed to properly secure the seat belt and the resident fell to the floor. Nursing staff were called to the whirlpool room. They found the resident was unresponsive. S2DON opened resident #1's airway and applied oxygen. The resident was placed on a stretcher and taken to the local hospital's emergency room . Review of the facility's investigation which began on 04/30/2024 revealed S3CNA failed to use the lift seat belt and while she was looking down to lock the lifts wheels the resident fell to the floor. The investigation also indicated S3CNA was suspended while the investigation was ongoing. On 05/06/2024 at 9:10 a.m., an interview with S2DON revealed S3CNA failed to use the seat belt on the lift chair that was attached to the whirlpool bath, to properly secure resident #1 while bathing. S2DON reported the resident fell from the whirlpool lift chair on 04/30/2024 and sustained a laceration to the left side of the head. S2DON stated she was contacted on 04/30/2024 by the emergency room nurse at the local hospital with an update on the resident's status which included a brain bleed, a fractured skull, and a fractured arm. S2DON reported resident #1 was airlifted to another hospital from the local hospital's emergency room . On 05/06/24 at 10:00a.m., an interview with resident #1 revealed that she thought she passed out. Resident #1 reported the last thing she remembered was seeing the last of the water drain from the tub. The next thing she remembered she was on a stretcher on her way to the emergency room . Resident #1 reported her arm was broken and she had been experiencing pain. Observations at this time revealed resident #1 had a heavily bruised face and she was wearing a cervical neck collar. On 05/07/2024 at 10:25 a.m., an interview with S3CNA was conducted via telephone. S3CNA was upset that she forgot to apply the seat belt. S3CNA reported that resident #1 had been wheeled out of the whirlpool. S3CNA was talking to the resident and she walked to the back of the lift to lock the wheels. As she was looking down to lock the wheels resident #1 fell from the chair landing on the floor. S3CNA reported she immediately called for help. On 05/06/2024 at 11:30 a.m., an observation was made of resident #2 receiving a whirlpool bath using the lift. S5CNA and S6CNA were observed properly applying the seat belt of the lift. Interviews with the CNAs revealed whirlpool baths had recently been suspended. The CNAs reported only after they were retrained and performed competency demonstrations, were they able to resume using the lift to give whirlpool baths. The CNAs also reported a nurse has been supervising seat belt use during whirlpools. On 04/30/2024 the facility implemented the following actions to correct the deficient practice. 1. The facility immediately suspended use of the lifts used for whirlpools. 2. Signage was placed at the whirlpool instructing staff not to use it until they had received additional training. 3. A whirlpool safety assessment was completed for every resident in the facility, even if they did not require a lift or use the whirlpool. The assessments were completed on 05/01/2024. 4. All CNAs were trained on: belt safety when using the whirlpool lift chair, locking the lift wheels, keep lift chair in lowest position, proper disinfecting, do not exceed 105 degrees and making sure lift seat is locked when the resident is placed back on the lift. The final in-service was completed on 05/02/2024. 5. The CNAs were retrained and performed a demonstration of the proper use of the whirlpool lift chair x 3. Only after each CNA was reeducated and successfully completed the demonstrations were they allowed to resume use of the lift. The first in-service was conducted on 05/01/2024 and the final in-service was completed. 6. As part of the facility QA (Quality Assurance), S4RN (Registered Nurse), the person responsible for staff development, monitored for proper lift use by the CNAs when they were using the lift in the whirlpool. Review of the QA checkoff sheet developed to review CNAs' compliance to proper lift use showed there had been no issues found. The facility began using the Safety Belt Usage Log on 05/01/2024. 7. Review of the Quality Assurance monitoring logs revealed the monitoring was ongoing and will continue at present time. 8. The above actions were all completed as of 05/02/2024.

Based on observations, record reviews and interviews, the facility failed to ensure 1 (#1) of 5 (#1, #2, #3, #4 and #5) residents who was assessed at risk for elopement, was adequately supervised to prevent her from eloping from the facility. This deficient practice resulted in an Immediate Jeopardy situation on 04/19/2024 at approximately 6:20 p.m. when resident #1 (a severely cognitively impaired resident identified as an elopement risk) was found approximately 300 yards outside of the facility by a staff member. Resident #1 was located 10 minutes after she eloped on 04/19/2024 through a facility door and was returned to the facility at approximately 6:32 p.m. The facility implemented corrective actions which were completed prior to the State Agency's investigation entry on 04/24/2024. It was determined to be a Past Noncompliance Citation. Findings: Review of the facility's Emergency Procedure for Missing Resident Policy revised August 2018 revealed: Policy Interpretation and Implementation Residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety. Review of the medical record revealed resident #1 was admitted to the facility on [DATE] with diagnoses including depressive disorder, macular degeneration, dementia, and hypothyroidism. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a brief interview for mental status of 3 which indicated that resident #1 had severe cognitive impairment with daily decision making. The assessment also indicated the resident was independent with transfers, and did not require mobility devices. Review of the current care plan revealed resident #1 was at risk for elopement. The interventions for elopement included: determine the resident's walking pattern, encourage the resident to participate in activities, staff should attempt to keep the resident occupied, assess cognitive abilities. The care plan also noted to monitor the resident for possible risk factors such as history of elopement, wandering, and making statements regarding wanting to go home. Additional interventions were to monitor the resident for potential triggers of elopement such as visual/hearing impairment, hunger, pain or thirst, and educate staff on the resident's potential for elopement. Review of the facility's investigation report revealed on 04/19/2024 at approximately 6:32 p.m. resident #1 was brought back to the facility by a staff member. The resident was found walking approximately 300 yards outside of the facility. Further review of the investigation report documented the facility's camera footage revealed on 04/19/2024 at 6:20 p.m. resident #1 exited the building out of the exit door by the activity room. Review of the Elopement Risk assessment dated [DATE] revealed resident #1 had confusion and was disoriented. The resident had diagnoses of dementia and depression. The resident ambulated independently and verbally expressed the desire to go home during the assessment. Further review of the assessment revealed the facility assessed resident #1 to be at high risk for elopement. Review of the nurse notes dated 04/19/2024 at 6:45 p.m. revealed resident #1 was found about two blocks from the facility by an employee of the nursing facility. The employee brought the resident back to the facility, and a body audit revealed no apparent injuries noted. The resident stated, I just went out the back door. When asked if she put a code in to get out the door she replied, If I did I don't remember it. Resident tearful saying I didn't mean to cause all this trouble. If ya'll would have left me alone I'd be home now. Review of the Resident Incident Report dated 04/19/2024 at 6:45 p.m. revealed resident #1 was found outside, about two blocks from the nursing facility. A staff member found resident #1 and brought the resident back to the facility. During the survey observations of resident #1 revealed she ambulated independently in the hallways. On 04/24/2024 at 10:30 a.m. interview with S3Licensed Practical Nurse (LPN) revealed resident #1 walks by herself in the halls. On 04/24/2024 at 11:00 a.m. interview with S4LPN revealed resident #1 ambulates independently. On 04/24/2024 at 12:50 p.m. interview with S5Certified Nursing Assistant (CNA) revealed resident #1 walks by herself in the halls and the resident goes all over the building. On 04/24/2024 at 1:00 p.m. interview with S6CNA revealed resident #1 walks in the halls independently. On 04/24/2024 at 1:10 p.m. interview with S7CNA revealed she has seen resident #1 walk in the halls by herself. On 04/25/2024 at 1:30 p.m. interview with S2Director of Nursing (DON) revealed resident #1 eloped from the building on 04/19/2024. S2DON revealed she assumed resident #1 entered the code to the locked door and exited the building on 04/19/2024 at approximately 6:20 p.m. On 04/25/2024 at 2:07 p.m. interview with S1Administrator confirmed resident #1 was at risk for elopement. On 04/19/2024 resident #1 eloped from the building, and it was assumed she entered the code and exited the building at approximately 6:20 p.m. On 04/19/2024, the facility implemented the following actions to correct the deficient practice with completion on 04/21/2024: 1. Resident #1 was placed on 1:1 supervision until 04/22/2024 at 2:30 p.m. Resident #1 was then monitored every 30 minutes for 24 hours and then placed on hourly monitoring. 2. All other residents were placed on every 30 minute monitoring until 04/21/2024, and then placed on hourly monitoring. 3. A census check for all residents was done immediately. 4. All exit doors were checked immediately for proper functioning. 5. All residents were reassessed for elopement risk on 04/19/2024. 6. All exit door keypad codes were covered with thick paper and tape on 04/19/2024. 7. Extra staff were called to work to monitor the exit doors. 8. On 04/19/2024 the staff were in-serviced regarding: Resident #1 placed on 1:1 monitoring and all other residents were placed on every 30 minute monitoring. The staff were in-serviced on monitoring the exit doors to ensure resident safety and a review of the missing resident protocol was presented. On 04/20/2024 an in-service for missing resident protocol, abuse and neglect policy was presented, and 1:1 care and supervision for the resident who eloped until it is discontinued by the Administrator and/or DON. 9. Staff were educated on residents at risk for elopement. 10. On 04/20/2024 exit doors functioning was checked to ensure proper functioning. 11. An additional camera was installed on the door in which the resident eloped. 12. On 04/22/2024 the plaques above the keypad with the exit code displayed were removed from every exit door and replaced with a small label with the exit code. 13. On 04/22/2024 part of the facility's action list provided by S2DON indicated that the door locks/keypad company would be changing the codes on the exit doors. The door alarm company was in the process of changing all of the door codes upon the surveyor's entrance to the facility on [DATE]. The keypad codes to all exit doors were changed on 04/24/2024. 14.Quality Assurance was conducted with the Administrator, DON and staff immediately following the incident and continues to evolve identifying areas of improvement including but not limited to daily door checks for proper functioning every day for two weeks and then three times a week for two week and then as needed. The hourly monitoring of all residents will continue until further notice.

Based on interviews and record reviews, the facility failed to protect the residents' right to be free from neglect by staff failing to provide the care needs every two hours as indicated in the care plan for 3 (#1, #2, and #3) of 3 (#1, #2, and #3) residents reviewed for neglect. This deficient practice resulted in an immediate jeopardy situation on [DATE] at 10:13 p.m. (two hours after resident #1 was last seen) when staff failed to make rounds every two hours on resident #1, who was on oxygen and was dependent on staff for transfers, toileting, and bed mobility. Video surveillance revealed the resident was administered medications on [DATE] at 8:13 p.m. by S3LPN (Licensed Practical Nurse) and no staff rounded on the resident or entered the resident's room until [DATE] at 5:57 a.m. (9 hours and 44 minutes). On [DATE] at 5:57 a.m., resident #1 was found in his room, lying on the floor, and deceased . S3LPN failed to perform rounds every two hours for resident #1 during his shift from 8:13 p.m. on [DATE] to 5:57 a.m. on [DATE]. S4CNA (Certified Nursing Assistant) failed to perform rounds on resident #1 every two hours during her shift from 11:00 p.m. on [DATE] to 7:00 a.m. on [DATE]. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Citation. Findings: Review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting revealed the following: 1. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); and, c. Elimination (toileting). An interview with S2DON (Director of Nursing) on [DATE] at 12:45 p.m. revealed the facility's expectations for nurses and CNAs was to make rounds on each resident residing in the facility at least every two hours and according to the residents' plan of care. Resident #1 Review of the electronic health record revealed resident #1 was admitted to the facility on [DATE]. Further review revealed the date of discharge as [DATE] with a discharge status of death in the facility. The resident's diagnoses included in part, chronic obstructive pulmonary disease with (acute) exacerbation, dependence on supplemental oxygen, epilepsy, dementia, unspecified severity, anxiety disorder, major depressive disorder, viral hepatitis C without hepatic coma, and diverticulitis of large intestine with perforation and abscess without bleeding. Review of the annual minimum data set assessment dated [DATE] revealed in part, that resident #1 had a brief interview for mental status score of 15, indicating that he was cognitively intact with daily decision making. Further review revealed that resident #1 required set up/clean up assistance with toileting, dressing, personal hygiene, roll left to right, sit to lying, lying to sitting up in bed, transfer to toilet, and eating. Review of resident #1's care plan revealed the following: Problem Onset: [DATE]: I am high risk for pressure ulcers/altered skin integrity and impaired mobility. Documented approaches included, in part: assist me turning and repositioning every two hours and as needed. Review of the [DATE] physician's orders for resident #1 revealed an order dated [DATE]; O2 (oxygen) at 3 Liters per minute via nasal cannula to be used continuously. Review of the resident #1's AM/PM Care Roster revealed, in part, that on the date of [DATE] at 11:17 p.m. S4CNA documented that pericare was provided for resident #1, he was continent and had voided two times, resident was continent of stool and had two medium sized soft bowel movements during the shift. Further documentation revealed that S4CNA had performed a skin check on resident #1 with no new skin concerns. Review of the departmental/nursing note dated [DATE] at 6:51 a.m. revealed: Resident found deceased on floor in room next to bed during morning medication pass. Resident was lying face down. Body was lying straight. Slightly cold to touch. Skin color still intact. Bedside table sitting next to bathroom door and it's belonging all over the floor. Urine from urinal and tea spilled all over the floor. The note was signed by S3LPN. Review of the facility's incident report dated [DATE] and completed by S2DON revealed the following: Incident Occurred on [DATE]. Investigation Findings included: On the morning of [DATE], around 6:00 a.m., S3LPN walked into resident #1's room for morning med pass and found him face down on the floor. Further documentation on the incident report revealed that S3LPN stated that resident #1 had been seen last around 2 am and had no complaints during his shift, which had started at 7:00 p.m. on the night of [DATE]. S3LPN further assessed resident #1 and found him to be deceased . Additional documentation from the incident report completed by S2DON revealed that S4CNA was the aide on the hall at the time of resident #1's death and her (S4CNA) witness statement said Around 2 o'clock I proceeded to do my rounds and check on the residents as I should. I entered resident #1's room to check on him and he was sound sleep with his oxygen on. Further review of the facility incident report revealed that a review of the video surveillance from [DATE] had revealed that the last time that staff entered the resident's room was at 8:13 p.m. on the night of [DATE], when S3LPN was in the room during night time medication pass. On [DATE] at 12:40 p.m., an interview with S1Administrator revealed that S3LPN had notified S2DON that he was doing his med pass on Sunday morning ([DATE]) at approximately 5:45 a.m. to 6:00 a.m. and he had found that resident #1 was found on the floor and had passed away. She further reported that S4CNA had wrote (Referring to a witness statement) that she had last been in resident #1's room around 2:00 a.m. S1Administrator further reported that an in-house investigation was conducted. S1Administrator reported that she and S2DON had reviewed the facility's video camera footage and found that both S4CNA and S3LPN had not been in resident #1's room since the nighttime med pass at approximately 8:30 p.m. on [DATE]. On [DATE] at 2:46 p.m. an interview with S2DON revealed that she had received a telephone call from S3LPN on the morning of [DATE], informing her that he had found resident #1 on the floor and deceased around 5:57 a.m. She further reported that S3LPN had told her (S2DON) that resident #1 had been seen at 2:00 a.m. on the morning of [DATE], but he had not said which employee had seen the resident. S2DON revealed that S4CNA had reported that on [DATE] at 2:00 a.m., she had seen resident #1 in his room, in bed, and with his oxygen on. Further interview revealed that upon S2DON's return to work on [DATE], she viewed the facility's video camera footage from the date of [DATE] to [DATE] and confirmed that no staff made rounds or had seen resident #1 from approximately 8:15 to 8:30 p.m. on [DATE], when S3LPN had passed medications to resident #1, until [DATE] at approximately 5:57 a.m. when S3LPN found resident #1 in his room, on the floor, and deceased . During the telephone interview on [DATE] at 8:13 p.m., S4CNA was notified of the findings regarding her documentation on the AM/PM Care Roster of care being provided for resident #1 on [DATE] at 11:17 p.m. S4CNA reported that she had documented the ADLs for resident #1. She stated I was tired, but that is not an excuse, it was a big mistake, and that was dumb on my part. S4CNA confirmed that she had not checked on resident #1 at any time during her shift on [DATE] from 11:00 p.m. to approximately 5:57 a.m. when S3LPN had found resident #1 on the floor, in his room, and deceased . S4CNA confirmed that she had initially lied to S2DON about making rounds on resident #1 on the date of [DATE] at 2:00 a.m. During a telephone interview on [DATE] at 10:59 a.m., S3LPN reported that he had worked on [DATE] from 7:00 p.m. - 7:00 a.m. Further interview revealed that he had administered resident #1's medications during medication pass at approximately 8:50 p.m. to 9:00 p.m. S3LPN confirmed that he had not performed rounds on resident #1 after approximately 9:00 p.m. until he found resident #1 in his room, on the floor, and deceased on [DATE] at approximately 6:00 a.m. Resident #2 Review of the electronic heath record revealed resident #2 was admitted to the facility on [DATE]. Further review revealed the resident's diagnoses included, in part, transient cerebral ischemic attack, dementia, and unspecified severity with behavioral disturbance, weakness, and acute bronchitis. Review of the quarterly minimum data set assessment dated [DATE] revealed resident #2 had a brief interview for mental status of 13 which indicated that resident #2 was cognitively intact with daily decision making. Further review revealed that resident #2 had a function limitation in range of motion to one of her upper extremities with impairment on one side. Review of the [DATE] Physician Orders for resident #2 revealed an order dated [DATE] to assist to turn and reposition every two hours and as needed. Review of resident #2's care plan revealed, in part an onset date of [DATE]: resident #2 required staff assistance with her mobility/ADL's, diagnoses were dementia, TIA (Transient Ischemic Attack), weakness, lower upper extremity weakness, she required staff assistance for all ADLs secondary to weakness due to her diagnoses of cardiovascular accident, and was at risk for contractures. Documented approaches included, in part: Resident #2 required one person extensive assistance with all ambulation, bed mobility, and transfers, her primary mode of locomotion was her wheelchair, and she required assistance to turn and reposition every two hours and as needed. Review of the AM/PM Care Roster dated [DATE] at 11:15 p.m. revealed documentation of resident #2 being provided with pericare and her skin was checked with no new skin conditions. Further review revealed the on [DATE] at 11:16 p.m., resident #2 was continent of urine, had voided two times, had one medium sized soft bowel movement, and was provided pericare. During the telephone interview on [DATE] at 8:13 p.m., S4CNA was notified of the findings regarding her documentation on the AM/PM Care Roster of care being provided for resident #2 on [DATE] at 11:15 p.m. and 11:16 p.m. S4CNA reported that she had documented the ADLs for resident #2. S4CNA confirmed that she had not checked on resident #2 at any time during her shift on [DATE] from 11:00 p.m. - 7:00 a.m. Resident #3 Review of the electronic heath record revealed resident #3 was readmitted to the facility on [DATE]. Further review revealed the resident's diagnoses included, in part: wheezing, unspecified dementia, unspecified severity with other behavioral disturbance, mild, with anxiety, and respiratory syncytial virus causing diseases. Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed resident #3 had a brief interview for mental status of 13 which indicated that resident #3 was cognitively intact with daily decision making. Further review revealed that resident #3 had a function limitation in range of motion. Review of the 5 day minimum data set assessment dated [DATE] revealed resident #3 had a brief interview for mental status score of 10. Further review revealed resident #3 was dependent on staff assistance with toileting, she required partial/moderate assistance with roll left and right, sit to lying, and was dependent with chair-to-bed transfer. Review of the [DATE] physician's orders for resident #3 revealed an order date [DATE]: May assist to turn and reposition every two hours and as needed. Review of resident #3's care plan revealed, in part an onset date of [DATE]: Resident #3 was totally incontinent of bowel and bladder with a history of urinary tract infection, she required one person extensive assistance with bed mobility, she required staff assistance with ADLs, and was at risk for harm due to may require two person assistance with transfers with a two person assistance with turning, repositioning, and transfer. Documented approaches included, in part: provide perineal care after each incontinent episode; require extensive to total dependent with all transfers, she required one person extensive assistance with bed mobility, and may assist to turn and reposition every two hours and as needed. Review of AM/PM Care Roster revealed documentation of resident #3 being incontinent of urine and he had voided three time [DATE] at 11:19 p.m. Further review revealed he was incontinent of bowel, he had two soft consistency medium bowel movements, his skin was checked with no new skin concerns on [DATE]/23 at 11:20 p.m. During the telephone interview on [DATE] at 8:13 p.m., S4CNA was notified of the findings regarding her documentation on the AM/PM Care Roster of care being provided for resident #3 on [DATE] at 11:19 p.m. and 11:20 p.m. S4CNA reported that she had documented the ADLs for resident #3. S4CNA confirmed that she had not checked on resident #3 at any time during her shift on [DATE] from 11:00 p.m. - 7:00 a.m. During an interview on [DATE] at 12:23 p.m., S2DON was notified of the interview with S4CNA confirming that she had documented ADLs tasks as being provided on the AM/PM Care Roster at the beginning of her shift. S2DON was further notified of S4CNA confirming the tasks not been completed, as she had not performed rounds on residents #1, #2 and #3 during her shift on [DATE] from 11:00 p.m. to 7:00 a.m. on [DATE]. S2DON confirmed that S4CNA had not performed the ADL tasks as per a review of the facility's video camera footage and per S4CNA's confirmation interview with S2DON on [DATE]. An interview with S1Administrator on [DATE] at 1:15 p.m. revealed that S3LPN and S4CNA had not rounded on residents #1, #2, and #3 every two hours on [DATE] - [DATE] in accordance with the facility's expectations and in accordance with the residents' plan of care. During the survey, multiple observations were made of staff rounding on residents, resident and staff interviews were conducted, in-service records, and QA (Quality Assurance) monitoring records were reviewed, and it was determined that the facility had implemented the following actions to correct the deficient practice: On [DATE] it was discovered that S3LPN and S4CNA had not been performing routine rounds during the night shift on [DATE] - [DATE]. They were both placed on suspension pending the investigation and later terminated when it was determined by the facility that the two staff members had not performed the necessary every two hour checks on three of their assigned residents (#1, #2, and #3), per the resident's individual plans of care. A state generated report was opened and staff education was initiated on performing routine care rounds for each resident with nurses to complete rounds on odd hours and CNAs on even hours. S1Administrator and S2DON initiated a new QA monitoring plan to ensure that routine care rounds were being provided with focus on nights and weekends via remote access at a minimum of 5 times per week for at least 8 weeks and then as needed. Resident care interviews were reviewed in the morning QA meetings along with the corrective action. The MDS (Minimum Data Set) nurse and ICP (Infection Control Preventionist) nurse were assigned to continue interviews and follow-up; and to provide staff education to the nurses at the beginning of each shift with no concerns reported. The corrective action with documenting and monitoring care rounds (nurse and aides) daily will continue until further notice from S2DON or S1Administrator. The completing, addressing, and documenting resident interviews weekly will continue until further notice and QA for care rounds for all shifts for at least 5 times per week for 8 weeks continued. The MDS and ICP nurses completed resident interviews with all residents who were interviewable in order to continue to identify any care issues. No additional complaints have been noted. Staff education was provided on abuse and neglect, reporting, investigating, immediate action, notification requirements to the state regulatory agency, licensing/Certification boards, and law enforcement per the ICP Nurse. The Louisiana State Board of Nurse Examiners was notified of the findings and the CNA Registry was contacted and stated that the State agency would notify the Registry of any negative findings. Education was provided to the LPNs and CNAs regarding timely, accurate, and complete documentation for resident care including voiding, intake, meal consumption, bowel movements, etc. During an interview on [DATE] at 4:33 p.m., S1 Administrator reported the deficient practice had been corrected with a completion date of [DATE].

Based on record reviews and interviews the facility failed to ensure residents' medical records contained accurate documentation of care provided in accordance with accepted professional standards and practices for 3 (#1, #2, and #3) of 3 sampled residents. Findings: Resident #1 Review of the electronic health record revealed resident #1 was admitted to the facility on [DATE]. Further review revealed the date of discharge as [DATE] with a discharge status of death in the facility. The resident's diagnoses included in part, chronic obstructive pulmonary disease with (acute) exacerbation, dependence on supplemental oxygen, epilepsy, dementia, unspecified severity, anxiety disorder, major depressive disorder, viral hepatitis C without hepatic coma, and diverticulitis of large intestine with perforation and abscess without bleeding. Review of the annual minimum data set assessment dated [DATE] revealed in part, that resident #1 had a brief interview for mental status score of 15, indicating that he was cognitively intact with daily decision making. Further review revealed that resident #1 required set up/clean up assistance with toileting, dressing, personal hygiene, roll left to right, sit to lying, lying to sitting up in bed, transfer to toilet, and eating. Review of resident #1's care plan revealed the following: Problem Onset: [DATE]: I am high risk for pressure ulcers/altered skin integrity and impaired mobility. Documented approaches included, in part: assist me turning and repositioning every two hours and as needed. Review of the resident #1's AM/PM Care Roster revealed, in part, that on the date of [DATE] at 11:17 p.m. S4CNA (Certified Nursing Assistant) documented that pericare was provided for resident #1, he was continent and had voided two times, resident was continent of stool and had two medium sized soft bowel movements during the shift. Further documentation revealed that S4CNA had performed a skin check on resident #1 with no new skin concerns. Review of the departmental/nursing note dated [DATE] at 6:51 a.m. revealed: Resident found deceased on floor in room next to bed during morning medication pass. The note was signed by S3LPN (Licensed Practical Nurse). Review of the facility's incident report dated [DATE] and completed by S2DON (Director of Nursing) revealed the following: Incident Occurred on [DATE]. Investigation Findings included: On the morning of [DATE], around 6:00 a.m., S3LPN walked into resident #1's room for morning med pass and found him face down on the floor. Further documentation on the incident report revealed that S3LPN stated that resident #1 had been seen last around 2 am and had no complaints during his shift, which had started at 7:00 p.m. on the night of [DATE]. S3LPN further assessed resident #1 and found him to be deceased . Additional documentation from the incident report completed by S2DON revealed that S4CNA was the aide on the hall at the time of resident #1's death and her (S4CNA) witness statement said Around 2 o'clock I proceeded to do my rounds and check on the residents as I should. I entered resident #1's room to check on him and he was sound sleep with his oxygen on. Further review of the facility incident report revealed that a review of the video surveillance from [DATE] had revealed that the last time that staff entered the resident's room was at 8:13 p.m. on the night of [DATE], when S3LPN was in the room during night time medication pass. On [DATE] at 12:40 p.m., an interview with S1Administrator revealed that S3LPN had notified S2DON that he was doing his med pass on Sunday morning ([DATE]) at approximately 5:45 a.m. to 6:00 a.m. and he had found that resident #1 was found on the floor and had passed away. She further reported that S4CNA had wrote (Referring to a witness statement) that she had last been in resident #1's room around 2:00 a.m. S1Administrator further reported that an in-house investigation was conducted. S1Administrator reported that she and S2DON had reviewed the facility's video camera footage and found that both S4CNA and S3LPN had not been in resident #1's room since the nighttime med pass at approximately 8:30 p.m. on [DATE]. On [DATE] at 2:46 p.m. an interview with S2DON revealed that she had received a telephone call from S3LPN on the morning of [DATE], informing her that he had found resident #1 on the floor and deceased around 5:57 a.m. She further reported that S3LPN had told her (S2DON) that resident #1 had been seen at 2:00 a.m. on the morning of [DATE], but he had not said which employee had seen the resident. S2DON revealed that S4CNA had reported that on [DATE] at 2:00 a.m., she had seen resident #1 in his room, in bed. Further interview revealed that upon S2DON's return to work on [DATE], she viewed the facility's video camera footage from the date of [DATE] to [DATE] and confirmed that no staff made rounds or had seen resident #1 from approximately 8:15 to 8:30 p.m. on [DATE], when S3LPN had passed medications to resident #1, until [DATE] at approximately 5:57 a.m. when S3LPN found resident #1 in his room, on the floor, and deceased . During the telephone interview on [DATE] at 8:13 p.m., S4CNA was notified of the findings regarding her documentation on the AM/PM Care Roster of care being provided for resident #1 on [DATE] at 11:17 p.m. S4CNA reported that she had documented the ADLs (Activities of Daily Living) for resident #1. She stated I was tired, but that is not an excuse, it was a big mistake, and that was dumb on my part. S4CNA confirmed that she had not checked on resident #1 at any time during her shift on [DATE] from 11:00 p.m. to approximately 5:57 a.m. when S3LPN had found resident #1 on the floor, in his room, and deceased . S4CNA confirmed that she had initially lied to S2DON about making rounds on resident #1 on the date of [DATE] at 2:00 a.m. Resident #2 Review of the electronic heath record revealed resident #2 was admitted to the facility on [DATE]. Further review revealed the resident's diagnoses included, in part, transient cerebral ischemic attack, dementia, and unspecified severity with behavioral disturbance, weakness, and acute bronchitis. Review of the quarterly minimum data set assessment dated [DATE] revealed resident #2 had a brief interview for mental status of 13 which indicated that resident #2 was cognitively intact with daily decision making. Further review revealed that resident #2 had a function limitation in range of motion to one of her upper extremities with impairment on one side. Review of the [DATE] Physician Orders for resident #2 revealed an order dated [DATE] to assist to turn and reposition every two hours and as needed. Review of resident #2's care plan revealed, in part an onset date of [DATE]: resident #2 required staff assistance with her mobility/ADL's, diagnoses were dementia, TIA (Transient Ischemic Attack), weakness, lower upper extremity weakness, she required staff assistance for all ADLs secondary to weakness due to her diagnoses of cardiovascular accident, and was at risk for contractures. Documented approaches included, in part: Resident #2 required one person extensive assistance with all ambulation, bed mobility, and transfers, her primary mode of locomotion was her wheelchair, and she required assistance to turn and reposition every two hours and as needed. Review of the AM/PM Care Roster dated [DATE] at 11:15 p.m. revealed S4CNA's documentation of resident #2 being provided with pericare and her skin was checked with no new skin conditions. Further review revealed the on [DATE] at 11:16 p.m., resident #2 was continent of urine, had voided two times, had one medium sized soft bowel movement, and was provided pericare. During the telephone interview on [DATE] at 8:13 p.m., S4CNA was notified of the findings regarding her documentation on the AM/PM Care Roster of care being provided for resident #2 on [DATE] at 11:15 p.m. and 11:16 p.m. S4CNA reported that she had documented the ADLs for resident #2. S4CNA confirmed that she had not checked on resident #2 at any time during her shift on [DATE] from 11:00 p.m. - 7:00 a.m. Resident #3 Review of the electronic heath record revealed resident #3 was readmitted to the facility on [DATE]. Further review revealed the resident's diagnoses included, in part: wheezing, unspecified dementia, unspecified severity with other behavioral disturbance, mild, with anxiety, and respiratory syncytial virus causing diseases. Review of the quarterly Minimum Data Set, dated dated dated [DATE] revealed resident #3 had a brief interview for mental status of 13 which indicated that resident #3 was cognitively intact with daily decision making. Further review revealed that resident #3 had a function limitation in range of motion. Review of the 5 day minimum data set assessment dated [DATE] revealed resident #3 had a brief interview for mental status score of 10. Further review revealed resident #3 was dependent on staff assistance with toileting, she required partial/moderate assistance with roll left and right, sit to lying, and was dependent with chair-to-bed transfer. Review of the [DATE] physician's orders for resident #3 revealed an order date [DATE]: May assist to turn and reposition every two hours and as needed. Review of resident #3's care plan revealed, in part an onset date of [DATE]: Resident #3 was totally incontinent of bowel and bladder with a history of urinary tract infection, she required one person extensive assistance with bed mobility, she required staff assistance with ADLs, and was at risk for harm due to may require two person assistance with transfers with a two person assistance with turning, repositioning, and transfer. Documented approaches included, in part: provide perineal care after each incontinent episode; require extensive to total dependent with all transfers, she required one person extensive assistance with bed mobility, and may assist to turn and reposition every two hours and as needed. Review of AM/PM Care Roster revealed S4CNA's documentation of resident #3 being incontinent of urine and he had voided three time [DATE] at 11:19 p.m. Further review revealed he was incontinent of bowel, he had two soft consistency medium bowel movements, his skin was checked with no new skin concerns on [DATE]/23 at 11:20 p.m. During the telephone interview on [DATE] at 8:13 p.m., S4CNA was notified of the findings regarding her documentation on the AM/PM Care Roster of care being provided for resident #3 on [DATE] at 11:19 p.m. and 11:20 p.m. S4CNA reported that she had documented the ADLs for resident #3. S4CNA confirmed that she had not checked on resident #3 at any time during her shift on [DATE] from 11:00 p.m. - 7:00 a.m. During an interview on [DATE] at 12:23 p.m., S2DON was notified of the interview with S4CNA confirming that she had documented ADLs tasks as being provided on the AM/PM Care Roster at the beginning of her shift. S2DON was further notified of S4CNA confirming the tasks not been completed, as she had not performed rounds on residents #1, #2 and #3 during her shift on [DATE] from 11:00 p.m. to 7:00 a.m. on [DATE]. S2DON confirmed that S4CNA had not performed the documented ADL tasks that were in the residents' medical records noted above.

Based on observations, interviews and record reviews, the facility failed to revise and implement a comprehensive person-centered care plan for 2 (#1 & #52) of 20 sampled residents. The facility failed to revise the plan of care for resident #1 related to edema. The facility failed to provide 2 person assistance with activities of daily living for resident #52. Findings: Resident #1 On 08/07/2023 at 10:43 a.m., Resident #1 was observed in the day area sitting upright in her wheelchair with both feet on the footrests. Resident #1 was observed having a minimum of two+ edema to her left lower leg and at least one+ edema to her right lower leg. On 08/07/2023 at 12:16 p.m., Resident #1 was observed in the dining room with her feet on the footrest of her wheelchair. Nonskid socks were on both feet. Both feet appeared to be swollen based on the tightness of the socks. On 08/08/2023 at 09:44 a.m., Resident #1 was observed in common area sitting in wheelchair with eyes closed. Both feet were on the foot rest of the wheelchair. Both feet were in socks with the top of the socks observed to be sinking into her skin due to the edema. On 08/08/2023 at 12:10 p.m., Resident #1 was observed in the dining room with her feet on the footrest of her wheelchair. Socks were on both of her feet. Both feet appeared to be swollen based on the tightness of the socks. Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnosis that included dementia, muscle weakness, stage 3 kidney disease, coronary artery disease and edema. Review of most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Review of the physician progress notes for the past 6 months revealed documentation of chronic 2+ edema with no new orders written directly related to the edema. Further record review revealed there were no new interventions in the plan of care to elevate lower extremities or attempt the use of compression stockings in order to reduce the edema to the lower extremities in the past 6 months. On 08/09/2023 at 10:11 a.m., an observation was conducted in Resident #1`s room with S3 Licensed Practical Nurse (LPN). Resident #1 was observed sitting up in her wheelchair at the bedside. Both feet were on the footrest with socks on both feet. Both socks were tight and both feet appear to be swollen. S3 Licensed Practical Nurse (LPN) removed the socks and confirmed both feet had edema. Resident #1 acknowledged her feet hurt when S3LPN pressed on her shin to assess the edema. S3LPN agreed other measures, such as elevating her legs, should have been implemented in an attempt to reduce the edema. S3LPN confirmed Resident #1 sat in her wheelchair most days from breakfast until after lunch with her feet resting dependently on the foot rests of the wheelchair without her feet elevated. On 08/09/2023 at 11:11 a.m, an interview with S2 Director of Nursing (DON) was conducted. S2DON agreed Resident #1 needed new interventions in the plan of care to address the edema to her lower extremities. 43405 Resident #52 Review of the record for resident #52 revealed an admitted [DATE] with diagnoses including malignant neoplasm of unspecified kidney except renal pelvis, hypertension, morbid obesity, heart failure, leukemia, type 2 diabetes mellitus, anxiety disorder, major depressive disorder, atrial flutter, secondary malignant neoplasm of other specified sites, and gastrostomy. Review of the current care plan for resident #52 revealed the resident required assistance with all Activities of Daily Living (ADLs). Further review revealed the resident required 2 person physical assist with bed mobility, transfers, and toileting, and 2 person assist with transfers and turning and repositioning in bed. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact. Further review of the MDS revealed resident required 2 person physical assist with bed mobility, transfers, and toileting, and has functional limitation in range of motion to upper and lower extremities on both sides. An interview on 08/07/2023 at 10:50 a.m. with resident #52 revealed he had an incident about a month ago involving S4CNA grabbing his right shoulder while performing pericare. An interview on 08/08/2023 at 2:46 p.m. with S 3Licensed Practical Nurse (LPN) revealed that resident #52 had notified her on 07/22/2023 that S4CNA had forcefully jerked on his right shoulder causing severe pain while performing pericare. An interview on 08/08/2023 at 3:10 p.m. with S2 Director of Nursing (DON) revealed that resident #52 was a 2 person assist with ADLs. S2DON confirmed that S4CNA should not have provided pericare to resident #52 without assistance on 07/22/2023. An interview on 08/09/2023 at 9:47 a.m. with S4CNA revealed that resident #52 was a 2 person assist with all of his ADLs. S4CNA confirmed that she did perform pericare for resident #52 on 07/22/2023 without the assistance of another staff member. An interview on 08/09/2023 at 9:30 a.m. with Administrator confirmed that the facility did not follow the resident's plan of care by not providing 2 person assist with Activities of Daily Living on 07/22/2023.

Based on observations, interviews and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (#32) of 1 (#32) sampled resident reviewed for positioning and mobility. The facility failed to provide maintenance or restorative therapy for Resident #32's left hand contracture. Findings: Resident #32 On 08/07/2023 at 1:09 p.m., an observation of Resident #32 was conducted in her room. Observation revealed her left hand was contracted and she was unable to open her left hand. No brace or corrective device was applied to the left hand. On 08/08/2023 at 1:35 p.m., an observation of Resident #32 was conducted in her room with S4 Licensed Practical Nurse (LPN). S4LPN confirmed Resident #32`s left hand was contracted and there was no order for a splint or corrective device to be placed on the contracted left hand. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnosis that included bipolar disorder, multiple sclerosis, dementia, and major depressive disorder. The most recent quarterly minimum data set (MDS) dated [DATE] revealed a brief interview of mental status (BIMS) score of 10 which indicated moderate cognitive impairment. The MDS also revealed therapy had not provided services for Resident #32. Further record review revealed there was no physician orders or plan of care intervention to provide a splint, brace or corrective device to the contracture of Resident #32`s left hand. Review of the medical record also revealed no documentation of a therapy consultation or therapy services being rendered for Resident #32 in the past year. On 08/08/23 at 3:10 p.m., an interview with S6 Occupational Therapist (OT) confirmed Resident #32 had not received services from the therapy department in the last year. S6 OT revealed the last therapy evaluation was completed in 2021. On 08/08/23 at 3:27 p.m., an interview with S2 Director of Nursing (DON) confirmed there had not been a revision in the plan of care related to Resident #32` s left hand contracture in the past year. S2 DON also confirmed revisions to the plan of care should have been made to address the contracture to Resident #32`s left hand.

Based on record review and interview, the facility failed to implement the facility's abuse policy by not suspending S4 Certified Nurse Assistant (CNA) immediately following an allegation of physical abuse for 1 (#52) of 4 (#7, #43, #52, and #54) sampled residents reviewed for abuse. Findings: Review of the facility's current Abuse Investigation and Reporting Policy and Procedure revealed the following: - Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. Review of the record revealed resident #52 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of unspecified kidney except renal pelvis, hypertension, morbid obesity, polyneuropathy, heart failure, leukemia, acute kidney failure, type 2 diabetes mellitus, anxiety disorder, major depressive disorder, atrial flutter, and secondary malignant neoplasm of other specified sites. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 indicating cognitively intact. Further review of the MDS revealed resident required 2 person physical assist with bed mobility, transfers, and toileting and the resident had functional limitation in range of motion to upper and lower extremities on both sides. An interview on 08/07/2023 at 10:50 a.m. with resident #52 revealed that S4CNA was rough with him about a month ago. Resident #52 reported that S4CNA was changing his brief and he reported that he asked S4CNA to remove a pillow under his left shoulder while she was performing pericare. He reported S4CNA cussed at him and said she would not remove the pillow, then the CNA grabbed his right arm forcefully causing severe pain to his right shoulder. He reported that he had bone cancer in his right shoulder and had to have surgery on his arm years ago due to the bone shattering. He reported he had frequent pain in that right shoulder. He reported that he notified S3 Licensed Practical Nurse (LPN) a short time after it happened. Resident #52 reported that S4CNA has not worked with him since this incident occurred. Review of the Incident Report for resident #52 dated 07/22/2023 at 2:30 p.m. revealed the resident stated the CNA was providing pericare and he asked her to move the pillow under his left arm, the CNA stated I don't have to move the damn pillow. CNA then jerked on the resident's right shoulder forcefully causing severe pain to the resident's right shoulder. Resident was provided pain medication and had portable x-ray of right shoulder. An interview on 08/08/2023 at 2:46 p.m. with S3LPN revealed that on 07/22/2023 at 3:05 p.m., resident #52 reported that S4CNA was changing his brief and when he asked her to remove the pillow from under his left shoulder, she stated she didn't have to move the damn pillow. Resident reported that S4CNA then jerked on his right shoulder forcefully causing severe pain to the resident's right shoulder. S3LPN reported that she immediately notified S2 Director of Nursing (DON) regarding the incident. S3LPN was told by S2DON that S4CNA would be removed from providing care to the resident. An interview on 08/08/2023 at 3:10 p.m. with S2DON revealed she was notified by S3LPN on 07/22/2023 regarding incident involving resident #52 accusing S4CNA of cussing at resident and grabbing his right shoulder causing pain. She instructed S3LPN that S4CNA would be removed from providing care to resident #52. S2DON reported she notified S1Administrator immediately regarding incident and both decided to allow S4CNA to continue working but would not provide care to resident #52. S2DON notified S4CNA that she would not be allowed to work with this resident and that the incident would be investigated. S2DON reported that S4CNA worked at the facility on 07/22/2023 and 07/23/2023 on the 11PM-7AM shift. S2DON confirmed that the facility did not follow their abuse investigation and reporting policy and procedure by not immediately suspending S4CNA immediately on 07/22/2023 when an allegation of physical abuse was reported by resident #52. An interview on 08/09/2023 at 9:47 a.m. with S4CNA revealed that she did work the 11PM-7AM shifts on 07/22/2023 and 07/23/2023 and then she was suspended on 07/24/2023. S4CNA reported she has not worked with resident #52 since this incident occurred on 07/22/2023. An interview on 08/09/2023 at 9:30 a.m. with S1Administrator confirmed that the facility did not follow their abuse investigation and reporting policy and procedure by failing to immediately suspend S4CNA on 07/22/2023 when the allegation of abuse was reported.

Based on observation, interview, and record review the facility failed to 1) assess residents with side rails for the for risk of entrapment, 2) attempt to use alternate measures prior to using side rails, 3) review the risks and benefits of side rails with residents or the residents' representative, and 4) failure to obtain an informed consent from the resident or residents' representative prior to the use of side rails. The deficient practice was identified for 5 (Resident #1, #2, #3, #4, and #5) of 5 (Resident #1, #2, #3, #4, and #5) sampled residents reviewed for side rails. This deficient practice resulted in an Immediate Jeopardy for Resident #1 on 03/20/2022 at 1:29AM when S5LPN (Licensed Practical Nurse) was called to resident #1's room and the resident's right leg was caught in the side rail where he sustained an approximate 8 inch red mark on his right leg. Also, on 05/01/2022 at 5:50AM resident #1 was trapped between the upper and lower side rails on the right side of the bed. Resident #1 was found with his bottom half of his body on the floor and his top half of his body was on the bed. When the side rail was released, the resident went limp. The resident was rushed to the emergency department for evaluation and treatment. Resident #1 was noted to have a six inch long red area at the bottom of his sternum. The Immediate Jeopardy ended for Resident #1 on May 02, 2022 at 4:00PM when the facility implemented a low bed without side rails. However, the Immediate Jeopardy continued for the cognitively impaired residents with side rails in use without assessing for the risk of entrapment, attempting alternate measures, reviewing the risks and benefits with residents or the residents' representative, and failed to obtain a consent for the use of side rails. S6Assistant Administrator was notified of an Immediate Jeopardy situation on 05/13/2022 at 9:20PM. The Immediate Jeopardy situation was removed on 05/17/2022 at 3:15PM when the facility submitted and implemented a plan of removal that included the following: 1. Sunday, May 1, 2022 we immediately began implementing interventions to prevent this type incident from occurring again. 2. Sunday, May 1, 2022 at 6:30 am Nursing staff and CNA's who were in the building were in-serviced not to raise any lower quarter siderails in the facility on any resident bed. Staff in-service continued until all staff had been in-serviced and was completed on May 3, 2022 at 3:00 pm. In-Service included: Side rails cannot be used by staff to keep residents in bed because they are considered a restraint. Residents who have behaviors need to be reported to the DON or designee so that a new side rail assessment can be done in an attempt to determine if side rails can be discontinued. Examples of behavior that must be reported are agitation, squirming, positioning problems, (for example: arms or legs through the rail). Weekend RN's need to look at side rails when doing hall rounds (for cleanliness, proper functioning, and proper use of the rails). We are starting SR Utilization assessments to determine the need for rails on each resident (assessments will be done upon admit, quarterly and with any significant change). Explained that all lower side rails have been taken off beds and that we are beginning reduction of upper rails. 3. Sunday, May 1, 2022 at approximately 6:15 am prior to target resident #1 return from ER both lower quarter rails were lowered and bed was placed in lowest possible position. Staff was immediately notified not to raise rails. 4. Sunday, May 1, 2022 at 9:30 am upon arrival to facility DON went room to room and visually inspected all beds to ensure no other residents had four rails in the raised position and all beds were in the lowest position. 5. Side rail utilization assessments on all residents were initiated on Sunday, May 1, 2022 and completed on Wednesday, May 4, 2022. Side rail utilization assessments will be done upon admit, quarterly, or with any significant change. List of residents with siderails discontinued was placed at nurses' station. 6. Sunday, May 1, 2022 at 8:30 am Maintenance was called to come to the building and arrived at 8:45 am to begin removal of all lower quarter bedrails on all beds throughout the building. Safety checks initiated following FDA guidelines. DON also made rounds room to room to visually inspect beds again on Sunday, May 1, 2022 at 11:00 am and again Sunday, May 1, 2022 at 2:30 pm to ensure lower rails had been removed and remain in proper position. Maintenance and administrator performed safety checks: Sunday, May 1, 2022 at approximately 9:30 am Monday, May 2, 2022 at approximately 7:30 am Tuesday, May 3, 2022 at approximately 9:00 am Wednesday, May 4, 2022 at approximately 9:00 am Monitoring shall continue once per month by maintenance department or administrator x 3 months and if compliance achieved will review quarterly thereafter. Monitoring compliance shall be performed by maintenance, administrator, assistant administrator, or designee. QA team and Medical Director shall review documentation. 7. Sunday, May 1, 2022 at 9:00am Q 30-minute monitoring checks were initiated for target resident #1 to ensure resident safety continuing until Thursday, May 5, 2022 at 4:30 pm. Monitoring checks were performed and documented by LPN charge nurse. 8. Sunday, May 1, 2022 at approximately 10:30 am the bed the resident was in when incident occurred was switched out with a low bed with no lower quarter side rails on bed. Fall mat placed by bed. Sunday, May 1, 2022 at approximately 10:30 am target resident #1 started getting legs out of bed. Added mattress beside bed with fall mat by mattress for additional safety and protection. 9. Sunday, May 1, 2022 at 11:00 am CNA was placed with resident one on one for continuous observation and to ensure resident safety. Observation continued until Monday, May 2, 2022 until 4:00 pm. 10. Monday, May 2, 2022 at 8:00 am Administrator made room to room rounds to ensure that all lower rails had been removed, mattress properly fit beds, and beds were maintained in lower position. 11. CNA one on one observation was continued until Monday, May 2, 2022 at 4:00 pm at which time the facility received a new high/low bed which could be lowered to a lower position than the current low bed resident was on. 12. Monday, May 2, 2022 at 4:00 pm target resident #1 was placed on high/low bed which had no rails on bed and fall mat remained in place. 13. Q 30-minute monitoring checks continued to ensure target resident #1 safety through Thursday, May 5, 2022 at 4:30 pm. Monitoring checks were performed and documented by LPN charge nurse. 14. Wednesday, May 4, 2022 body pillows were added to define bed parameters for target resident #1. 15. Monday, May 9, 2022 Geo mattress with wings ordered for target resident #1. 16. Wednesday, May 4, 2022 at approximately 12 noon DON began in-service with all nurses on reporting incidents and the completion of incident and accident reports which was completed on Friday, May 6, 2022. Nurses were not allowed to begin their shift until in-serviced was completed. Weekend RN's working were trained that no lower rails would be used on any bed and we will be working toward using alternative interventions to reduce upper rails. Side rail assessments will determine if resident can use rails. Educated to refer to list at nurses' station of residents that have side rails and to monitor which rail is up and which rail is down. Training began on Saturday, May 7, 2022 and Sunday, May 8, 2022 and was completed on Saturday, May 14, 2022 and Sunday, May 15, 2022. 17. Nurse who did not report incident on March 20, 2022 was individually counseled on Wednesday, May 4, 2022 when non-reported incident was discovered. 18. Friday, May 5, 2022 at approximately 12 noon Bed Bolsters added to target resident #1 for additional safety measures. 19. Saturday, May 14, 2022 Side Rail Utilization Assessment form revised to include risk and benefits of siderail usage. 20. Saturday, May 14, 2022 at approximately 11:00 am all residents with BIMS score of 12 or below was reassessed for upper quarter siderails and reductions completed as identified by the assessment. All remaining residents were then reviewed and or reassessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . 80 - lower side rails were removed from all beds in the building 21 - have had both upper siderails discontinued and secured where could not be used 17 - have been reduced to one rail for bed control/mobility. One rail remains for these residents per resident request and physicians order. 10 - interventions for alternative measures and process shall continue. 21. Saturday, May 14, 2022 at approximately 2:30 pm Maintenance was called to facility to zip-tie upper quarter rails that were discontinued from today's assessments. These rails cannot be removed due to the controls for the bed being built into the siderails. (Hospital beds). 22. Saturday, May 14, 2022 at approximately 10:30 am residents and responsible parties were interviewed and informed of risk and benefits of upper quarter siderail usage. Consents were obtained. 80 - lower side rails were removed from all beds in the building 21 - have had both upper siderails discontinued and secured where could not be used 17 - have been reduced to one rail for bed control/mobility. One rail remains for these residents per resident request and physicians order 10 - interventions for alternative measures and process shall continue Beds kept in lower position Winged mattress Bed wedge Bolster pillows Body length pillows Fall mats Low bed 23. Saturday, May 14, 2022 at approximately 10:00 am Assistant Administrator and RN visually inspected each bed in facility to ensure all upper quarter rails were in accordance to assessments. Guide to Bed Safety Benefits and Risk of Bed Rails were printed and reviewed with residents and/or responsible parties. 24. Sunday, May 15, 2022 at 10:00 am Assistant Administrator and DON reviewed each assessment completed on Saturday, May 14, 2022 for the possibility of further upper quarter side rail reductions. 25. Sunday, May 15, 2022 at approximately 12 noon Assistant Administrator and RN completed rounds throughout the facility and reviewed assessments and discussed with each cognitive resident the need for continued use of upper quarter siderails. Residents remaining with upper quarter side rails demonstrated the use of side rails as an enabler to assist with positioning in bed, steadying their self to stand, and rise from the bed. Resident chooses to be able to use controls on either side. Residents demonstrated and verbalized their need for the assistance of upper quarter bedrail. Alternatives as listed below were offered and implemented as ordered by physician. Beds kept in lower position Winged mattress Bed wedge Bolster pillows Body length pillows Fall mats Low bed 26. Sunday, May 15, 2022 at 3:00 pm DON updated side rail list posted at the nurse's station. 27. FDA Guidelines for Bed Rail Safety Informational brochure has been added to facility admission packet Saturday, May 14, 2022. 28. Sunday, May 15, 2022 at approximately 2:00 pm facility software, American Healthtech was revised to allow CNA's to properly document siderails. Charting section, CNA task was revised to reflect charting option of siderails x 1 rail and x 2 rails. 29. Facility will follow QA plan and QIPA plan to assure and maintain plan of correction. FDA safety checks for siderails Maintenance /Administrator performed safety checks: Sunday, May 1, 2022 at approximately 9:30 am Monday, May 2, 2022 at approximately 7:30 am Tuesday, May 3, 2022 at approximately 9:00 am Wednesday, May 4, 2022 at approximately 9:00 am Monitoring shall continue once a month x 3 months and if compliance achieved will review quarterly thereafter. Monitoring compliance shall be performed by maintenance, administrator, assistant administrator, or designee. QA team and Medical Director shall review documentation. Monitoring of 24-hour reports to indicate the need of incident and accident reports to be completed. All incident & accident reports are reviewed daily by DON or designee. 24-hour reports will be utilized to determine if any occurrence should have been reported on incident and accident report. The 24-hour report is a facility's internal document that reports any significant occurrence that happened within the past 24-hour period. Example: Resident skin issues, behaviors, new orders, incident and accidents, family concerns etc. Monitoring of the 24 hours reports will be reviewed daily by the DON/Weekend RN, administrator or assistant administrator. QA team shall review 24-hour reports weekly for compliance. QA shall be performed weekly for 12 weeks then monthly until full compliance is achieved then quarterly through QA with medical director. Remaining siderails will be checked for compliance. DON/designee will review position of rail q day x 4 weeks, then monthly x3 months, then quarterly thereafter until compliance is achieved. QA team shall review 24-hour reports weekly for compliance. QA shall be performed weekly for 12 weeks then monthly until full compliance is achieved then quarterly through QA with medical director. 30. Monday, May 16, 2022 at 9:00 am American Healthtech software was modified by DON to require more frequent monitoring and documentation by nurses of residents positioning in bed. This was modified to increase nurse awareness and resident safety and monitoring due to decreased siderail usage. 31. Monday, May 16, 2022 at 6:30 am side rail alternative form initiated and all residents that have side rails in use shall be offered alternative measures. Beds kept in lower position Winged mattress Bed wedge Bolster pillows Body length pillows Fall mats Low bed After new assessment form was initiated and completed on May 16, 2022 and alternative measures offered the current status of siderails in the building on Tuesday, May 17, 2022 at 10:00 am are as listed below: 80 - lower side rails were removed from all beds in the building 27 - have had both upper siderails discontinued and secured where could not be used 29 - have been reduced to one rail for bed control/mobility. One rail remains for these residents per resident request and physicians order. 15 - residents remain with 2 rails in place per resident request for bed/control and mobility with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Further assessments and alternative measures process shall continue Beds currently at West [NAME] Care Center are hospital grade beds which have controls built into the siderails requiring at least one rail to be up for resident to be able to control the bed. 80 new beds shall be purchased for the facility that will meet CMS compliance to decrease the use of siderails. The new beds will have no siderails and the facility will continue to use alternative methods as listed below to ensure resident safety. Current beds shall be removed from facility upon receipt of new beds. Bed rail assessments have been completed by DON, RN, LPN, Administrator, and Assistant Administrator. Compliance shall be monitored by Administrator and QA team once a month for 3 months and if compliance is achieved will review quarterly thereafter. QA and Medical Director shall review documentation. Tuesday, May 17, 2022 at 11:30 am side rail policies have been revised and updated to include side rail assessments, risk and benefits of side rails, alternative measures, consents, and Attending Physician involvement. Further interventions and alternative measures continue today with additional alternative devices delivered to facility Tuesday, May 17, 2022 at 11:40 am. Beds kept in lower position Winged mattress Bed wedge Bolster pillows Body length pillows Fall mats Low bed Findings: Review of the facility's current Policy and Procedures for Proper Use of Side Rails (as of 05/05/2022) revealed: 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. bed mobility; b. ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. risk of entrapment from the use of side rails; and d. that the bed's dimensions are appropriate for the resident's size and weight. 6. Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 7. The risk and benefits of side rails will be considered for each resident. 8. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. On 05/03/2022 review of the census list provided by S2DON (Director of Nursing) on 05/03/2022 revealed 67 residents out of a total of 68 residents used upper quarter rails times two. Review of the census list provided by S2DON on 05/13/2022 revealed 47 residents residing in the building had moderate to severe cognitive impairment (Brief Interview for Mental Status score of 12 or less). Resident 1 Review of the medical record for sampled resident #1 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment for daily decision making and required extensive assistance with two or more persons for bed mobility, transfers dressing, toileting and personal hygiene. Review of the care plan dated 02/16/2022 revealed the resident required staff assistance for all activities of daily living, and required side rails up times two to aid in turning and repositioning. Review of the May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurses' notes dated 03/20/2022 at 1:29AM revealed the aide went into the resident's room due to yelling and found resident's right leg caught in bedrail. His leg was removed and there was an approximately 8 inch red mark located on the upper portion of his right leg near the groin area. No open area or bruising noted. Review of the medical record for resident #1 revealed no documented evidence of the following: an assessment for the risk of entrapment; attempted alternate measures prior to using side rails; a review of risks and benefits with resident or responsible party; and no documented evidence that the facility obtained a consent prior to the use of side rails for resident #1. Review of the Incident/Accident report dated 05/01/2022 at 5:50AM revealed the nurse was called to the room by an aide due to the resident being caught between the side rails. Upon entering the room the resident's bottom half of him was on the floor and the top half was on the bed. When the side rail was release the resident went limp. The resident was rushed to the Emergency Department for evaluation and treatment. A red area approximately six inches long was at the bottom of the sternum. Further review of the report revealed the bed rails were up and the height of the bed was down. Review of the Emergency Department notes dated 05/01/2022 at 5:45AM revealed: Noted shallow guppy breaths, does have a red mark going across the mid lower ribs, no popping or deformities notes to lower rib area. Respirations 22, heart rate 88, temperature 96.9, blood pressure 157/69 and oxygen saturation was 100% on room air. Resident was discharged to nursing home at 6:30AM with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the final Radiology Report for the chest x-ray dated 05/01/2022 at 5:55AM revealed no gross displaced rib fractures or mediastinal widening seen. On 05/04/2022 at 1:20PM a phone interview was conducted with the S3TNA (Temporary Nursing Assistant) S3TNA revealed she worked the night shift from 11:00PM - 7:00AM on 4/30/2022. S3TNA revealed she worked with S4CNA that night and they both took care of resident #1. S3TNA revealed her first visit with resident #1 after her shift started she noticed the 2 side rails up on one side of the bed and the other side of the bed was against the wall. She revealed she didn't tell anyone that both rails were up on one side of the bed. S3TNA revealed she knew that the bottom rail should not have been in the up position. S3TNA revealed resident #1 does try to get out of the bed and she would tell the nurse and they would reposition him in the bed. S3TNA revealed S4CNA saw the resident's legs on the floor and went into the room to check on him. She revealed they called for the nurse and took him to the Emergency Department immediately. On 05/04/2022 at 3:00PM a phone interview with S5LPN (Licensed Practical Nurse) revealed she worked from 7:00PM - 7:00AM on 04/30/2022. S5LPN revealed she was called to resident #1's room by a CNA and he was in the middle between the upper and lower side rails on the right side of the bed. S5LPN revealed the resident was moaning and she released the top side rail and the resident went slightly limp. S5LPN revealed they placed him in the bed and immediately rolled him to the emergency department which is connected to the nursing home. S5LPN revealed she did not have a time frame of how long the upper and lower rails had been up on the one side of the resident's bed. On 05/05/2022 at 1:45PM an interview with S2DON (Director of Nursing) confirmed the facility failed to assess resident #1 with side rails for the risk of entrapment, attempt to use alternate measures prior to using side rails, review the risks and benefits of side rails with residents or the residents' representative, and failed to obtained a consent prior to using side rails. Resident 2 Review of the medical record for resident #2 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had intact cognition for daily decision making and required extensive assistance with two or more persons for bed mobility, transfers, dressing, and hygiene. Review of the care plan dated 04/27/2015 revealed the resident had impaired mobility and to place side rails up times two to aid in bed mobility. Review of the May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/03/2022 at 11:10AM and 05/05/2022 at 9:30AM observations of resident #2 revealed she was in the bed with quarter rails up times two at the top of the bed. Review of the medical record for resident #2 revealed no documented evidence of the following: an assessment for the risk of entrapment; attempted alternate measures prior to using side rails; review of risks and benefits with resident or responsible party; and no documented evidence that the facility obtained a consent prior to the use of side rails for resident #2. On 05/05/2022 at 1:45PM an interview with S2DON (Director of Nursing) confirmed they failed to assess resident #2 with side rails for the for risk of entrapment, attempt to use alternate measures prior to using side rails, review the risks and benefits of bed rails with residents or the residents' representative, and failed to obtain a consent prior to using side rails. Resident 3 Review of the medical record for sampled resident #3 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment for daily decision making. Further review of the MDS revealed the resident required extensive assistance with two or more persons for bed mobility, dressing, toileting and hygiene. Review of the care plan revealed the resident had impaired mobility and to place side rails up times two to aid in bed mobility. Review of the May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/03/2022 at 11:45AM observation of the resident revealed the resident was in the bed with quarter rails up times two at the top of the bed. Review of the medical record for resident #3 revealed no documented evidence of the following: an assessment for the risk of entrapment; attempted alternate measures prior to using side rails; review of risks and benefits with resident or responsible party; and no documented evidence that the facility obtained a consent prior to the use of side rails for resident #3. On 05/05/2022 at 1:45PM an interview with S2DON (Director of Nursing) confirmed they failed to assess resident #3 with side rails for the for risk of entrapment, attempt to use alternate measures prior to using side rails, review the risks and benefits of side rails with residents or the residents' representative, and failed to obtain a consent prior to using side rails. Resident 4 Review of the medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set revealed the facility was unable to determine cognitive status and the resident required assistance with activities of daily living. Review of the care plan revealed the resident was at risk for falls and to place side rail up times two to aid in bed mobility and transfers. Review of the May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/03/2022 at 2:30PM observation of resident #4 revealed she was in the bed with quarter rails up times two at the top of the bed. Review of the medical record for resident #4 revealed no documented evidence of the following: an assessment for the risk of entrapment; attempted alternate measures prior to using side rails; review of risks and benefits with resident or responsible party; and no documented evidence that the facility obtained a consent prior to the use of side rails for resident #4. On 05/05/2022 at 1:45PM an interview with S2DON (Director of Nursing) confirmed they failed to assess resident #4 with side rails for the for risk of entrapment, attempt to use alternate measures prior to using side rails, review the risks and benefits of side rails with residents or the residents' representative, and failed to obtain a consent prior to using side rails. Resident 5 Review of the medical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate impaired cognition for daily decision making and required extensive assistance with two or more persons for bed mobility, transfers, dressing, toileting and hygiene. Review of the care plan revealed potential for harm related to needs assistance with transfers and to place side rail up times two for turning and repositioning. Review of the May 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/03/2022 at 12:10PM and 05/04/2022 at 9:10AM observations of resident #5 revealed he was in the bed with quarter rails up times two at the top of the bed. Review of the medical record for resident #5 revealed no documented evidence of the following: an assessment for the risk of entrapment; attempted alternate measures prior to using side rails; review of risks and benefits with resident or responsible party; and no documented evidence that the facility obtained a consent prior to the use of side rails for resident #5. On 05/05/2022 at 1:45PM an interview with S2DON (Director of Nursing) confirmed they failed to assess resident #5 with side rails for the for risk of entrapment, attempt to use alternate measures prior to using side rails, review the risks and benefits of side rails with residents or the residents' representative, and failed to obtain a consent prior to using side rails. On 05/17/2022 at 1:45PM an interview with S7 Physician, whom has numerous residents in the facility, revealed he was aware of the recent incident with the side rails. He stated S1Administrator, S2DON, and S6Assistant Administrator have discussed with him and he agreed the need for side rail assessments for resident use. He revealed after the residents are appropriately assessed for side rail use he will write an order specifically and individualized for each resident. On 05/05/2022 at 2:00PM the S1Administrator was notified of the above issues and she confirmed they failed to assess residents that use side rails for the for risk of entrapment, attempt to use alternate measures prior to using side rails, review the risks and benefits of side rails with residents or the residents' representative, and failed to obtain a consent prior to using side rails for sampled residents #1- #5.