Coastal Manor

Based on observations, staff interviews, and facility policy review, the facility failed to ensure food stored in the walk-in freezer was properly stored off the floor; food was properly labeled and dated; equipment was properly cleaned; and dented cans were properly discarded in accordance with professional standards for food service safety. The deficient practice had the potential to affect all 82 residents of the facility who consume food from the kitchen.
Findings include:
Review of the facility's policy titled, Food and Supply Storage, dated 01/25, revealed All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . Cover, label and date unused portions and open packages .Product is protected from the possibility of dust spinning upward during sweeping or mopping through the use of a solid barrier such as a sheet of plastic placed under products on the bottom shelf of open wire shelving .Dry Storage: Maintain designated area for items that are damaged (such as dented cans) that are to be returned for credit .Store foods in their original packages. Foods that must be opened must be stored in NSF (National Sanitation Foundation) approved containers that have tight-fitting lids . Frozen Storage: Store food items 6 (inches) above the floor, and 18 below sprinklers .Store bulk materials in NSF approved containers that have tight fitting lids. Label both the bin and the lid.
During the initial kitchen tour on 05/13/25 at 9:10 AM with the Dietary Manager (DM) the following observations were made:
The DM was observed in the walk-in freezer attempting to put cardboard boxes full of frozen food items onto the storage shelves. The walk-in freezer floor was completely covered in approximately twelve large cardboard boxes. The DM stated that these boxes had arrived with the Saturday (05/10/25) shipment and had not been put away properly until now. The DM confirmed that she did not expect to have food boxes stored on the walk-in freezer floor and was trying to get them stored onto the racks. The DM said that shipments were sent to the facility on Wednesdays and Saturdays.
A reach-in freezer was observed with an opened and undated 4.54 kg (kilogram) box of spicy chicken breast, and an opened and undated 20 lb. (pound) box of beef patties. The DM stated that she expected the boxes to be dated and labeled for storage. The DM said that she had bags to put the opened items into to protect the food and had a label maker for dating and labeling food.
The commercial can opener was observed with dirt and dried debris on the blade.
The large dry bin storage of flour had a lid that was ajar and did not fit properly to seal the container.
On the racks in the pantry, for use, were multiple dented cans:
A 6 lb. 6.5 oz. (ounce) can diced tomatoes.
A 6 lb. 10 oz. can mandarin oranges.
A 6 lb. 8 oz. can marinara sauce.
A 6 lb. 12 oz. can white hominy.
An additional 6 lb. 8 oz. can of marinara sauce was on the floor to the pantry room, holding the door open.
The DM stated that she expected the dietary staff to monitor dented cans when the supplies came in and put them with the dented can section of the pantry. She confirmed the identified cans were in the regular use can section of the pantry. She also stated the can of food should not be on the floor holding a door open.
During an additional observation in the kitchen on 05/15/25 at 10:58 AM, the flour stored in the pantry was identified with the lid still ajar, with exposure to air.
During an interview on 05/15/25 at 3:30 PM, the Registered Dietician (RD) confirmed that food should not be placed or stored on the walk-in freezer floor.
During an additional tour of the kitchen with the DM on 05/16/25 at 1:10 PM, the commercial can opener was again observed to have dried debris on it. The DM stated it needed to be cleaned. The flour was again observed with an improperly fitted lid. She confirmed the flour should be covered properly and readjusted the lid. She confirmed it should be better covered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and facility policy review, the facility failed to ensure a written notification of transfer to the hospital was given or sent to the resident and the resident representative (RR) for three residents (Resident (R)17, R76, and R82) of 27 sampled residents reviewed. This failed practice had the potential to affect the resident and the RR by not having the information of where and why a resident was transferred and/or how to appeal the transfer, if desired.
Findings include:
Review of the facility's undated policy titled Transfer/Discharges stated purpose of the policy is to inform residents, family members, or legal representatives verbally and in writing (in a language and manner they understand) of reasons for a transfer or discharges.
1.Review of R17's Census tab located in the electronic medical record (EMR) revealed that R17 was discharged to the hospital on [DATE] and returned to the facility on [DATE]; discharged to the hospital on [DATE] and returned to the facility on [DATE]. There was no evidence located in the EMR of the facility providing a written notice of transfer to the resident or the RR.
During an interview on 05/16/25 at 11:53 AM, the Director of Nursing (DON) stated that we call the family and note it in the chart. The DON stated that we don't send anything to the resident or the family.
During an interview on 05/16/25 at 11:55 AM, the Social Services Coordinator (SSC)1 stated that she was not sure about sending written transfer notices to the family, but she did send a list of residents transferred to the ombudsman.
During an interview on 05/16/25 at 12:28 PM, the Administrator stated we call the resident's representative and notify them. The Administrator also stated that he was not aware of a regulation requiring a written notice of transfer.
2. Review of the Face Sheet provided by the facility, revealed R76 was initially admitted on [DATE].
Review of the quarterly Minimum Data Set (MDS) located under the MDS tab in the EMR, with an assessment reference date (ARD) of 03/07/25 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated R76 was cognitively intact.
Review of the Clinical Census located under the Census tab in the EMR revealed R76 was hospitalized on [DATE], 01/27/25, and 2/28/25. There was no evidence in the EMR to show that R76 nor the RR was provided a Notice of Transfer or Discharge as required.
During an interview on 05/14/25 at 12:52 PM, R76 denied ever having been given a form titled Notice of Transfer or Discharge when she had been hospitalized .
3. Review of R82's admission Record located in the EMR under the Profile tab revealed an admission date of 08/29/24 and a readmission date of 05/07/25.
Review of R82, progress notes under the Prog Note tab in the EMR revealed on 04/26/25 at 12:46 PM, the resident was transferred to the acute hospital due to lethargy and being difficult to arouse.
Review of R82's EMR revealed no documentation of a written notification of transfer to the resident or RR.

Based on interview, record review, and facility policy review, the facility failed to investigate 5 of 7 allegations of abuse perpetrated by a resident, Resident #2.
Findings included:
A facility policy titled, Abuse Prohibition, effective 02/27/2024, revealed F. Investigation - Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown sources and misappropriation or resident property, the following investigation and reporting procedures shall be followed: 1. The description of the alleged complaint is written on the investigation form. Any physical evidence and description of emotional state shall be documented. 2. Information gathering - The following information shall be gathered: a. Name of suspect b. Name of the resident c. Specific information about what happened d. Specific information about when it happened - include date and time of occurrence e. Specific information about where it happened f. Specific information about why it happened or any extenuating circumstances that you might have information about. 3. The QAPI [quality assurance performance improvement] Coordinator, Director of Nursing, Social Services Coordinator or Chief of Long Term Care Officer a.k.a. [also known as] Nursing Home Administrator shall conduct interviews of all pertinent parties. Written signed statements shall be gathered from the suspect, person making accusations, resident involved, reliable residents who shall have witnessed the incident, and any other person who shall have some information.
An admission Record indicated the facility admitted Resident #2 on 05/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of autistic disorder, moderate intellectual disabilities, developmental disorder of speech and language, violent behavior, and generalized anxiety disorder.
The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2024, revealed Resident #2 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had moderately impaired cognitive skills for daily decision making and short and long-term memory problems. The MDS indicated the resident had other behavioral symptoms not directed toward others one to three days during the assessment period.
Resident #2's care plan, included a focus area initiated 08/05/2024, that indicated the resident had a history of physical aggressiveness related to autistic disorder, a history of agitation, and moderate intellectual abilities. Interventions directed staff to monitor behavior episodes and attempt to determine the underlying cause.
Resident #2's Progress Notes, dated 05/28/2024 at 10:31 AM, revealed as the resident walked past other residents, Resident #2 hit residents in their head on numerous occasions.
Resident #2's Progress Notes, revealed the following:
-
08/08/2024 at 2:30 PM, the resident hit another resident twice on their right arm.
-
08/16/2024 at 5:03 PM, Licensed Practical Nurse #4 observed the resident pinch another resident. Per the Progress Note, the other resident began to bruise but had no other injuries.
-
09/22/2024 at 4:04 PM, the resident had been redirected most of the day. Per the Progress Notes, the resident had been in and out of other residents' room taking and eating their snacks. The Progress Notes indicated the resident showed signs of agitation towards staff, bit themselves, hit another resident, and charged at the staff when staff attempted to remove them from the situation.
-
10/09/2024 at 10:37 PM, the resident attacked two other resident without being provoked. Per the Progress Notes, one of the residents had a skin tear under their right eye and the other resident had no injuries.
During an interview on 02/21/2025 at 11:03 AM, the Director of Nursing (DON) stated the facility did not interview the staff who wrote the Progress Notes dated 08/08/2024, 08/16/2024, 09/22/2024, or 10/09/2024 to determine who the residents were that Resident #2 hit and/or pinched.
During an interview on 02/22/2025 at 4:52 PM, the DON stated for the incident that occurred on 10/09/2024, Resident #2 had experienced an outburst episode with the staff, then the resident approached and grabbed the face of Resident #4. According to the DON, this incident resulted in two small scratches to Resident #4's face that did not break the skin. The DON stated after the incident Resident #2 was removed from the situation and taken to their room to deescalate.
During an interview on 02/22/2025 at 12:30 PM, the DON stated the process for conducting abuse investigations depended on who reported the incident. The DON stated sometimes she documented the statements made, but it depended if the information was pertinent. According to the DON, she would contact the police for resident-to-resident incidents, if the resident had a high BIMS score. The DON reported that after Resident #2 discharged from the facility, she became aware that some of the incidents perpetrated by the resident had not been reported to her or investigated. The DON stated the facility discussed each of the incidents during their quality assurance meeting but decided since Resident #2 had been discharged and the reporting time frame had passed, it was okay to not report them or investigate.
During an interview on 02/22/2025 at 1:23 PM, the Administrator stated the DON was responsible for completing abuse investigation. Per the Administrator, the facility would only contact the police during resident-to-resident abuse, if there was major physical harm. The Adminstartor stated the facility thought about the investigation and reporting of these incidents, but because Resident #2 had been discharged , it was appropriate just to educate the staff.
Review of facility documents revealed no evidence to indicate the allegation of abuse perpetrated by Resident #2 listed above were investigated by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) screening was completed on or before admission or after the resident remained in the facility past 30 days for 1 (Resident #2) of 11 sampled residents.
Findings included:
A facility policy titled, Admissions (LTC), with an original date of 10/29/2001 and an effective date of 04/23/2024, indicated I. Introduction: The Admissions policy applies to residents admitted to the department of Long Term Care without regard to race, color, creed, national origin, age, sex, religion, handicap, ancestry, marital or veteran status, and/or payment source. The policy specified, H. Documentation for Medical Record: included f. PASARR Level I Evaluation.
An admission Record indicated the facility admitted Resident #2 on 05/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of autistic disorder, moderate intellectual disabilities, developmental disorder of speech and language, violent behavior, restlessness and agitation, and generalized anxiety disorder.
The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2024, revealed Resident #2 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had moderately impaired cognitive skills for daily decision making and short and long-term memory problems. The MDS indicated the resident had other behavioral symptoms not directed toward others one to three days during the assessment period.
Resident #2's care plan, included a focus area initiated 08/05/2024, that indicated the resident had a history of physical aggressiveness related to autistic disorder, a history of agitation, and moderate intellectual abilities. Interventions directed staff to monitor behavior episodes and attempt to determine the underlying cause.
Resident #2's medical record revealed no evidence to indicate a PASARR screening was conducted on or before the resident admitted to the facility on [DATE] or after the resident remained in the facility after 30 days. A document dated 08/23/2024, titled Treatment Service: [PASARR] Level II, indicated Resident #2 was not appropriate for skilled nursing facility level of care and should be considered for alternative community setting and the resident had an intellectual disability (ID)/developmental disability (DD) and needed specialized services for ID/DD in a community setting.
During an interview on 02/22/2025 at 9:57 AM, the Administrator stated a PASARR screening was not done when Resident #2 admitted to the facility.
During an interview on 02/22/2025 at 10:13 AM, the Director of Nursing (DON) stated a PASARR was not done because the resident admitted to the facility under respite care. Per the DON, when the facility reached out to state agencies to get a PASARR done, the facility was told the nursing facility was not an appropriate environment for the resident and denied the completion of a PASARR screening. According to the DON, it was expected to always get a PASARR screening for all residents prior to admission to the facility.

Based on interview, record review, and facility policy review, the facility failed to protect the residents' right to be from physical abuse perpetrated by a resident, Resident #2. On 05/28/2024, Resident #2 hit Resident #11 in the head. On 10/09/2024, Resident #2 scratched Resident #4 under their right eye. On 10/16/2024, Resident #2 grabbed Resident #1 by their neck. These deficient practices affected 3 (Residents #1, #4, and #11) of 11 sampled residents.
Findings included:
A facility policy titled Abuse Prohibition, effective 02/27/2024, revealed, It shall be the policy of [facility name] to actively preserve each resident's right to be free from mistreatment, neglect, abuse or misappropriation of resident property. The policy specified, Abuse - the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. Per the policy, Physical Abuse - includes hitting, slapping, pinching and kicking.
An admission Record indicated the facility admitted Resident #2 on 05/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of autistic disorder, moderate intellectual disabilities, developmental disorder of speech and language, violent behavior, and generalized anxiety disorder.
The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2024, revealed Resident #2 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had moderately impaired cognitive skills for daily decision making and short and long-term memory problems. The MDS indicated the resident had other behavioral symptoms not directed toward others one to three days during the assessment period.
Resident #2's care plan, included a focus area initiated 08/05/2024, that indicated the resident had a history of physical aggressiveness related to autistic disorder, a history of agitation, and moderate intellectual abilities. Interventions directed staff to monitor behavior episodes and attempt to determine the underlying cause.
Resident #2's Progress Notes, dated 05/28/2024 at 10:31 AM, revealed as the resident walked past other residents, Resident #2 hit residents in their head on numerous occasions.
During an interview on 02/21/2025 at 3:00 PM, Licensed Practical Nurse (LPN) #6 stated Resident #11 was the resident who Resident #2 hit in their head. Per LPN #6, Resident #2 walked around the unit in an agitated state, looked at Resident #11 and hit the resident.
During a follow-up interview on 02/21/2025 at 3:30 PM, LPN #6 stated she did not recall if she notified the Director of Nursing (DON) about the incident.
An admission Record indicated the facility admitted Resident #11 on 07/19/2019. According to the admission Record, the resident had a medical history to include diagnoses of cerebrovascular disease, aphasia, and dementia.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/06/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident had intact cognition.
Resident #2's Progress Notes, revealed the following:
-
08/08/2024 at 2:30 PM, the resident hit another resident twice on their right arm.
-
08/16/2024 at 5:03 PM, LPN #4 observed the resident pinch another resident. Per the Progress Note, the other resident began to bruise but had no other injuries.
-
09/22/2024 at 4:04 PM, the resident had been redirected most of the day. Per the Progress Notes, the resident had been in and out of other residents' room taking and eating their snacks. The Progress Notes indicated the resident showed signs of agitation towards staff, bit themselves, hit another resident, and charged at the staff when staff attempted to remove them from the situation.
-
10/09/2024 at 10:37 PM, the resident attacked two other resident without being provoked. Per the Progress Notes, one of the residents had a skin tear under their right eye and the other resident had no injuries.
During an interview on 02/20/2025 at 10:07 AM, LPN #4 stated she did not recall the incident that occurred on 08/16/2024.
During an interview on 02/21/2025 at 11:03 AM, the DON stated the facility did not interview the staff who wrote the Progress Notes dated 08/08/2024, 08/16/2024, 09/22/2024, or 10/09/2024 to determine who the residents were that Resident #2 hit and/or pinched.
During an interview on 02/21/2025 at 11:57 AM, LPN #9 stated Resident #2 had been walking around the unit as they normally did on 10/09/2024. According to LPN #9, no one provoked Resident #2 and after the resident kicked and screamed at the staff, the resident was lowered to floor. LPN #9 stated once Resident #2 got back up and started to walk around, for no reason, she scratched Resident #4 under their right eye. LPN #9 stated she could not remember who the other resident was that Resident #2 attacked.
During an interview on 02/22/2025 at 12:52 PM, the DON stated she did remember being notified of the incident that occurred on 08/16/2024.
During an interview on 02/22/2025 at 4:52 PM, the DON stated for the incident that occurred on 10/09/2024, Resident #2 had experienced an outburst episode with the staff, then the resident approached and grabbed the face of Resident #4. According to the DON, this incident resulted in two small scratches to Resident #4's face that did not break the skin. The DON stated after the incident Resident #2 was removed from the situation and taken to their room to deescalate.
During an interview on 02/22/2025 at 6:08 PM, Certified Nursing Assistant #11 stated she would consider Resident #2 hitting anyone as abuse.
An admission Record indicated the facility admitted Resident #4 on 08/10/2023. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, dementia, macular degeneration, dry eye syndrome, glaucoma, and cerebrovascular disease.
A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/10/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) of 3, which indicated the resident had severe cognitive impairment.
Resident #2's Progress Note dated 10/16/2024 at 5:30 PM, indicated the resident showed aggressive behavior towards staff and other residents. Per the Progress Notes, as another resident sat by the window at the nurses' station to make a telephone call, Resident #2 came up and grabbed the other resident (Resident #1) by the neck without being provoked.
An admission Record indicated the facility admitted Resident #1 on 02/27/2023. According to the admission Record, the resident had a medical history that included diagnoses of dementia and unspecified sequelae of cerebral infarction.
An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/17/2025, revealed Resident #1 had a Staff Assessment for Mental Status (SAMS) that indicated the resident was severely impaired in cognitive skills for daily decision making and short and long-term memory problems.
During an interview on 02/19/2025 at 5:04 PM, the DON stated Resident #2 grabbed Resident #1 at their neck with a single palm and left no injuries. Per the DON, Resident #2 was removed from the situation immediately and redirected to their room.
During an interview on 02/20/2025 at 10:07 AM, LPN #4 stated Resident #1 was sitting at the nurses' station to call a family member when Resident #2 came out of nowhere and tried to grab the phone from Resident #1, which caused Resident #1 to receive a scratch on their neck. LPN #4 stated after the incident, Resident #2 was taken to their room to calm down. Per LPN #4, a CNA sat with Resident #2 until the resident fell asleep.
During an interview on 02/22/2025 at 12:30 PM, the DON stated the process for conducting abuse investigations depended on who reported the incident. The DON stated sometimes she documented the statements made, but it depended if the information was pertinent. According to the DON, she would contact the police for resident-to-resident incidents, if the resident had a high BIMS score. The DON reported that after Resident #2 discharged from the facility, she became aware that some of the incidents perpetrated by the resident had not been reported to her or investigated. The DON stated the facility discussed each of the incidents during their quality assurance meeting but decided since Resident #2 had been discharged and the reporting time frame had passed, it was okay to not report them or investigate.
During an interview on 02/22/2025 at 4:52 PM, the DON stated abuse could be physical, verbal, sexual, emotional, mental. The DON stated if someone were punched in the face, pinched, hit, or choked that would be abuse. According to the DON, the incident between Resident #1 and Resident #2 occurred on 10/16/2024 and was not reported to the state within the two-hour reporting timeframe, as this incident was not reported until sometime on 10/17/2024.
During an interview on 02/22/2025 at 1:23 PM, the Administrator stated the DON was responsible for completing abuse investigation. Per the Administrator, the facility would only contact the police during resident-to-resident abuse, if there was major physical harm. The Adminstartor stated the facility thought about the investigation and reporting of these incidents, but because Resident #2 had been discharged , it was appropriate just to educate the staff.
During an interview on 02/22/2025 at 5:59 PM, LPN #13 stated she would consider the incidents between Resident #2 and the other residents as abuse.

Based on interview, record review, and facility policy review, the facility failed to ensure staff reported allegation of abuse immediately to the Administrator/designee. The facility further failed to ensure the administrative staff reported allegations of abuse to the state survey agency. This deficient practice was observed in 5 of 7 allegations of abuse reviewed.
Findings included:
A facility policy titled, Abuse Prohibition, effective 02/27/2024, revealed E. Reporting Procedures - Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown sources and misappropriation of resident property the incident shall be immediately reported to the Nursing Home Administrator. 1. The Director of Nursing (or his/her designee) or Chief Long Term Care Officer a.k.a. [also known as] Nursing Home Administrator (or his/her designee) shall immediately notify the Complaint Investigation Intake and Referral Unit, the legal representative and/or interested family member, and the attending physician of the incident and the pending investigation. The Ombudsman and Police Department shall also be notified if appropriate. The Chief Long Term Care Officer a.k.a. Nursing Home Administrator shall direct the investigation. 2. The initial report of the investigation shall be completed online within 24 hours of the incident to the Complaint Investigation Intake and Referral Unit.
An admission Record indicated the facility admitted Resident #2 on 05/02/2024. According to the admission Record, the resident had a medical history that included diagnoses of autistic disorder, moderate intellectual disabilities, developmental disorder of speech and language, violent behavior, and generalized anxiety disorder.
The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/07/2024, revealed Resident #2 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had moderately impaired cognitive skills for daily decision making and short and long-term memory problems. The MDS indicated the resident had other behavioral symptoms not directed toward others one to three days during the assessment period.
Resident #2's care plan, included a focus area initiated 08/05/2024, that indicated the resident had a history of physical aggressiveness related to autistic disorder, a history of agitation, and moderate intellectual abilities. Interventions directed staff to monitor behavior episodes and attempt to determine the underlying cause.
Resident #2's Progress Notes, dated 05/28/2024 at 10:31 AM, revealed as the resident walked past other residents, Resident #2 hit residents in their head on numerous occasions.
During an interview on 02/21/2025 at 3:00 PM, Licensed Practical Nurse (LPN) #6 stated Resident #11 was the resident who Resident #2 hit in their head.
During a follow-up interview on 02/21/2025 at 3:30 PM, LPN #6 stated she did not recall if she notified the Director of Nursing (DON) about the incident.
An admission Record indicated the facility admitted Resident #11 on 07/19/2019. According to the admission Record, the resident had a medical history to include diagnoses of cerebrovascular disease, aphasia, and dementia. A quarterly MDS, with an ARD of 12/06/2024, revealed Resident #11 had a BIMS of 15, which indicated the resident had intact cognition.
Review of facility documents revealed no evidence to indicate the allegation of abuse perpetrated by Resident #2 towards Resident #11 was reported to the Administrator/designee or the state survey agency.
Resident #2's Progress Notes, revealed the following:
-
08/08/2024 at 2:30 PM, the resident hit another resident twice on their right arm.
-
08/16/2024 at 5:03 PM, LPN #4 observed the resident pinch another resident. Per the Progress Note, the other resident began to bruise but had no other injuries.
-
09/22/2024 at 4:04 PM, the resident had been redirected most of the day. Per the Progress Notes, the resident had been in and out of other residents' room taking and eating their snacks. The Progress Notes indicated the resident showed signs of agitation towards staff, bit themselves, hit another resident, and charged at the staff when staff attempted to remove them from the situation.
-
10/09/2024 at 10:37 PM, the resident attacked two other resident without being provoked. Per the Progress Notes, one of the residents had a skin tear under their right eye and the other resident had no injuries.
During an interview on 02/21/2025 at 11:57 AM, LPN #9 stated Resident #2 had been walking around the unit as they normally did on 10/09/2024. According to LPN #9, no one provoked Resident #2 and after the resident kicked and screamed at the staff, the resident was lowered to floor. LPN #9 stated once Resident #2 got back up and started to walk around, for no reason, she scratched Resident #4 under their right eye. LPN #9 stated she could not remember who the other resident was that Resident #2 attacked.
During an interview on 02/22/2025 at 12:52 PM, the Director of Nursing (DON) stated she did remember being notified of the incident that occurred on 08/16/2024.
During an interview on 02/22/2025 at 4:52 PM, the DON stated for the incident that occurred on 10/09/2024, Resident #2 had experienced an outburst episode with the staff, then the resident approached and grabbed the face of Resident #4. According to the DON, this incident resulted in two small scratches to Resident #4's face that did not break the skin. The DON stated after the incident Resident #2 was removed from the situation and taken to their room to deescalate.
An admission Record indicated the facility admitted Resident #4 on 08/10/2023. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease, dementia, macular degeneration, dry eye syndrome, glaucoma, and cerebrovascular disease. A quarterly MDS, with an ARD of 01/10/2025, revealed Resident #4 had a BIMS of 3, which indicated the resident had severe cognitive impairment.
Review of facility documents revealed no evidence to indicate the allegation of abuse perpetrated by Resident #2 that were specified in the resident's Progress Notes dated 08/08/2024, 08/16/2024, and 09/22/2024 were reported to the Administrator/designee or the state survey agency.
Resident #2's Progress Note dated 10/16/2024 at 5:30 PM, indicated the resident showed aggressive behavior towards staff and other residents. Per the Progress Notes, as another resident sat by the window at the nurses' station to make a telephone call, Resident #2 came up and grabbed the other resident (Resident #1) by the neck without being provoked.
An admission Record indicated the facility admitted Resident #1 on 02/27/2023. According to the admission Record, the resident had a medical history that included diagnoses of dementia and unspecified sequelae of cerebral infarction. An annual MDS, with an ARD of 01/17/2025, revealed Resident #1 had a Staff Assessment for Mental Status (SAMS) that indicated the resident was severely impaired in cognitive skills for daily decision making and short and long-term memory problems.
During an interview on 02/22/2025 at 12:30 PM, the DON stated after Resident #2 discharged from the facility, she became aware that some of the incidents perpetrated by the resident had not been reported to her or investigated. The DON stated the facility discussed each of the incidents during their quality assurance meeting but decided since Resident #2 had been discharged and the reporting time frame had passed, it was okay to not report them or investigate.
During an interview on 02/22/2025 at 4:52 PM, the DON stated the incident between Resident #1 and Resident #2 occurred on 10/16/2024 and was not reported to the state within the two-hour reporting timeframe, as this incident was not reported until sometime on 10/17/2024.
During an interview on 02/22/2025 at 1:23 PM, the Administrator stated the facility thought about the investigation and reporting of these incidents, but because Resident #2 had been discharged , it was appropriate just to educate the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of a Face Sheet indicated the facility admitted Resident #62 on 05/30/2019 with a diagnosis of cerebral infarction with hemiplegia affecting the nondominant side.
The annual Minimum Data Set (MDS), dated [DATE], revealed Resident #62 had severely impaired cognitive skills for daily decision making based on staff assessment. According to the MDS, the resident required extensive assistance of one person for bed mobility and maximum assistance from staff for transfers. The MDS indicated bed rails were not used as a physical restraint.
Review of Resident #62's Care Plan, with a revision date of 11/03/2022, revealed there was no documentation related to use of bed rails.
Review of Resident #62's Physician's Orders, revealed there was no order for side rails or bed rails.
During observations made on 03/06/2023 at 11:26 AM and 03/07/2023 at 2:24 PM, Resident #62 was lying in bed with half bed rails in the raised position on both sides of the bed.
On 03/08/2023 at 9:00 AM the Director of Nursing (DON) provided Bed Rail/Assist Bar Evaluations for Resident #62. A review of the Bed Rail/Assist Bar Evaluation dated 10/25/2023 (incorrectly dated; should have been 10/25/2022), revealed the form was incomplete and did not indicate what type of bed rail or bar was being evaluated, did not include a Summary of Findings and Interventions, and did not include a date of completion or the signature of the person completing the form. Another Bed Rail/Assist Bar Evaluation, dated 03/07 with no year identified, was provided which indicated the resident used quarter bed rails. Although the evaluation indicated the resident had advanced dementia, the bed rail was not used for positioning or support, the resident had problems with balance or poor trunk control, and the resident was able to voluntarily move their own body. The Summary of Findings and Intervention sections of the form were not completed.
During a phone interview on 03/08/2023 at 2:56 PM, Certified Nursing Assistant (CNA) #7 said that if a resident was a fall risk or always falling or leaning then they needed a bed rail.
During an interview on 03/09/2023 at 11:42 AM, CNA #10 indicated Resident #62 needed a bed rail because the resident leans to one side.
During an interview on 03/09/2023 at 12:06 PM, CNA #11 indicated she knew a resident needed a bed rail if it was convenient for the resident or if the resident leaned and would fall out of bed. CNA #11 indicated Resident #62 needed a bed rail because the resident had an air mattress, and the mattress made the resident become off balanced when the resident turned and repositioned.
During an interview on 03/09/2023 at 2:54 PM, Licensed Practical Nurse (LPN) #13 indicated Resident #62 had half bed rails because the resident could grab the bed rails and the bed rails could be used to help the resident turn. LPN #13 indicated there had been no incidents with the bed rails.
3. A review of a Face Sheet revealed the facility admitted Resident #17 on 11/17/2020 and had diagnoses that included dementia, atrial fibrillation, chronic kidney disease, major depression, hypertension, and anxiety.
Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #17 had severely impaired cognitive skills for daily decision making based on staff assessment. According to the MDS, the resident was independent with bed mobility and transfers and required extensive assistance from staff with dressing, toilet use, and personal hygiene. The MDS indicated the resident had no functional limitations in range of motion in the upper or lower extremities. The MDS indicated the resident was always incontinent of bladder and frequently incontinent of bowel. The MDS indicated the resident had one fall with no injury and one fall with injury (except major) since admission or the prior assessment. The MDS did not indicate that bed rails were used as a physical restraint.
A review of Resident #17's Physician Orders, revealed there was no order for the use of side rails or bed rails.
A review of Resident #17's electronic medical record revealed there was no bed rail assessment, informed consent, or documented attempts to use alternatives to bed rails.
On 03/07/2023 at 3:12 PM, Resident #17 was observed in the resident's room lying in a low bed with bed rails in the raised position on both sides of the bed.
On 03/08/2023 at 9:12 AM, Resident #17 was observed in the resident's room lying in bed with half bed rails in the raised position on both sides of the bed. Soft mats were at the bedside.
On 03/09/2023 at 12:01 PM, Resident #17 was observed in the resident's room lying in a low bed with half bed rails in the raised position on both sides of the bed. Soft mats were at the bedside.
During an interview on 03/08/2023 at 9:00 AM, the Director of Nursing (DON) provided Bed Rail/Assist Bar Evaluations for Resident #17, completed in 10/2022 and 03/2023. The DON acknowledged there was no process in place to ensure the assessments were completed on a quarterly basis and there was no process in place to ensure the assessments were completed on admission. The DON stated the facility beds generally had bed rails installed by the manufacturer. There was no process in place to assess if the bed rails were necessary for an individual resident. There were no consent forms provided to the resident or family to sign indicating consent for the use of bed rails.
During an interview on 03/10/2023 at 2:18 PM, the DON and Administrator stated their expectation was for the bed rail assessments to be completed for all residents who used bed rails on admission and quarterly thereafter.
Based on observations, interviews, record review, and facility policy review, it was determined that facility staff failed to assess risks associated with bed rail use, failed to complete bed rail assessments on admission and quarterly thereafter, failed to ensure the bed rail assessments were fully completed, and failed to obtain consent from the resident or resident representative prior to installing bed rails for 6 (Residents #43, #61, #17, #62, #41, and #55) of 6 residents reviewed for bed rails. From a sample of four of six hallways, this failure affected 53 of 59 residents whose beds were equipped with bed rails.
Findings included:
On 03/10/2023 at 1:27 PM, the Director of Nursing (DON) stated the facility did not have any policies related to resident assessment for bed rail use. Bed rails were addressed in a policy related to restraint use. A review of the facility policy titled, Restraint Use, dated 09/12/2001, specified, Long bed rails will not be used to keep a resident from voluntarily getting out of bed. Long bed rails will be used to enhance a resident's mobility while in bed and to help the resident identify the parameters of the bed.
1. Review of a Face Sheet indicated the facility admitted Resident #43 on 07/29/2022 with diagnoses that included dementia, major depressive disorder, and anxiety disorder.
The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #43 was severely cognitively impaired based on staff assessment. According to the MDS, the resident required extensive to maximum assistance of one to two staff members for activities of daily living (ADLs), including bed mobility and transfers. The MDS did not include documentation indicating the resident used bed rails as a physical restraint.
Review of Resident #43's Physician Orders, revealed there was no order for side rails or bed rails.
On 03/06/2023 at 11:09 PM, Resident #43 was observed lying in bed with bed rails on both sides of the bed in the raised position. The bed rails were positioned in the middle of the bed and extended from the resident's chest area to below the resident's knees. A wedge cushion was observed between the left bed rail and the resident's body.
On 03/06/2023 at 2:53 PM, Resident #43 was observed lying in bed, with bed rails on both sides of the bed in the raised position. The bed mattress was observed to fit tightly against the bed rails.
On 03/06/2023 at 4:15 PM, Resident #43 was observed lying in bed with bed rails on both sides of the bed in the raised position.
On 03/07/2023 at 4:30 PM, Resident #43 was observed lying in bed with bed rails on both sides of the bed in the raised position.
During an interview on 03/07/2023 at 1:00 PM, Family Member (FM) #1, who was also the Resident Representative, stated they were aware of the bed rails being in place but assumed they were being used to prevent Resident #43 from falling out of bed. FM #1 indicated not being aware of any falls the resident had in the past.
During an interview on 03/07/2023 at 1:45 PM, Certified Nursing Assistant (CNA) #1 stated bed rails were used to prevent residents from rolling out of bed. CNA #1 further stated Resident #43 was always trying to get out of bed, and the bed rails prevented the resident from falling. CNA #1 stated she would look at the care plan to determine why bed rails were in place.
During an interview on 03/07/2023 at 1:50 PM, CNA #2 stated the bed rails were used for fall prevention. CNA #2 was unable to state who initiated the bed rails for Resident #43. CNA #2 said Resident #43 would try to get out of the bed at times, and the bed rails prevented the resident from falling out of bed.
During an interview on 03/07/2023 at 2:00 PM, Licensed Practical Nurse (LPN) #3 stated the bed rails were not placed on the beds for any specific purpose. According to LPN #3, there was no decision-making process used to determine the risks and benefits of bed rail use and if the bed rails were a safe approach for a resident. LPN #3 said, if the bed rails were in place on a resident's bed at the time of admission, the resident would have bed rails for the remainder of their stay; the bed rails would not be removed. LPN #3 further stated Resident #43 would attempt to climb out of bed, and the bed rails were being used for fall prevention.
During an interview on 03/07/2023 at 4:00 PM, LPN #4 stated bed rails were used for self-positioning, to enable residents to turn themselves. LPN #4 was unable to state which interdisciplinary team members assessed a resident for bed rail use and determined the need for bed rails and/or who ensured bed rails were a safe approach. LPN #4 was unaware of the bed rails in use for Resident #43 and did not know who made the decision for the bed rails to be installed on the resident's bed.
During an interview on 03/07/2023 at 4:37 PM, the DON stated the interdisciplinary team assessed the need for bed rails, and the maintenance department added or removed the bed rails as instructed. The DON was unable to state who was responsible for assessing the risks associated with bed rail utilization.
During an interview on 03/08/2023 at 9:00 AM, the DON stated the bed rails had been removed from Resident #43's bed on the evening of 03/07/2023. The DON provided the Bed Rail/Assist Bar Evaluation at that time.
Review of Resident #43's Bed Rail/Assist Bar Evaluation revealed the assessment was to be completed quarterly and was completed on 10/2 (no year specified) and 03/07 (no year specified). The Evaluation Factors section indicated the resident had fluctuations in levels of consciousness or a cognitive deficit, was not physically able to release the bed rails, was unable to follow directions, and had a problem with balance or poor trunk control. The evaluation also indicated the resident would use the bed rails for positioning or support and there was no risk to the resident if bed rails were used. Instructions provided on the form indicated, for each evaluation factor, If yes, summarize on reverse [the back of the document/second page]. The Summary of Findings sections for these dates were not completed despite yes responses under the evaluation columns. The document was not signed by the person(s) who completed the evaluations.
During the interview on 03/08/2023 at 9:00 AM, the DON stated that in October 2022 she realized there were no assessments for the use of bed rails, and she instructed the registered nurse (RN) supervisors at that time to complete assessments for all residents in the building who used bed rails using the Bed Rail/Assist Bar Evaluation form. The DON stated the nursing staff were not provided education on how to complete the assessments or what constituted a risk for entrapment. The DON stated there was no follow-up to the assessments other than the daily walking rounds conducted by department heads. The DON indicated that the maintenance department did not have a role in bed rail safety assessments. The DON further stated there was a protocol related to proper installation of bed rails, but the maintenance staff had not been provided the protocol or education related to the protocol. The DON presented the regulatory guidance as their protocol. The DON stated there were no consent forms presented to the resident or family for signature, and the nursing staff had not been educated on a process for conducting assessments, obtaining consents, or determining the necessity of bed rails.
During an interview on 03/09/2023 at 11:10 AM, the Therapy Coordinator (TC) stated that as part of their therapy screen, bed rails were not addressed as it was a nursing assessment. The TC further stated the therapy department would make a recommendation for bed rail use only if it was felt a resident would benefit from bed rails. The TC stated Resident #43 was assessed by therapy and there were no recommendations made for bed rails. The TC further stated the therapy department had not been asked to evaluate Resident #43 or any other resident for use of bed rails.
During an interview on 03/09/2023 at 1:29 PM, Registered Nurse Supervisor #5 stated she was provided with the Bed Rail/Assist Bar Evaluation forms in October 2022, and RN supervisors were instructed to complete the evaluations for all residents. RN Supervisor #5 stated she was not provided training, but the forms were self-explanatory. RN Supervisor #5 was unable to define risk as it related to bed rail use but stated cognition was a big part of the assessment. RN Supervisor #5 indicated if the resident was cognitively intact, the resident knew how to use the bed rails safely. RN Supervisor #5 stated she had not received training on risks associated with bed rail use. She did not know who decided when bed rails were installed or removed.
During an interview on 03/10/2023 at 2:18 PM in the presence of the Administrator, the DON stated she had implemented the bed rail assessments following a survey preparedness initiative. The DON acknowledged that residents currently using bed rails had not been adequately assessed and indicated the staff were not conducting the assessments accurately or completely. The DON further stated it was her expectation that staff completed the bed rail assessments quarterly, but it just did not happen.
2. A review of a Face Sheet indicated the facility admitted Resident #61 on 07/23/2020 with diagnoses that included dementia, anxiety disorder, pubic fracture, and major depressive disorder.
The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #61 was severely cognitively impaired based on staff assessment. According to the MDS, the resident required maximum assistance of one to two staff members for activities of daily living (ADLs), including bed mobility and transfers. The MDS did not include documentation indicating the resident used bed rails as a physical restraint.
Review of Resident #61's Care Plan, with a review date of 12/22/22, revealed there was no documentation related to use of bed rails.
Review of Resident #61's Physician Orders, revealed no order for side rails or bed rails.
During an observation on 03/06/2023 at 11:11 AM, Resident #61 was observed lying in bed with their eyes closed. The bed rails on both sides of the bed were in the raised position. The bed rails were positioned in the middle of the bed and extended from approximately the resident's chest/abdomen to below the resident's knees.
During an observation on 03/07/2023 at 1:45 PM, Resident #61 was observed sitting in bed with the head of the bed elevated and bed rails on either side of the bed in the raised position. An unidentified certified nursing assistant (CNA) was at the bedside assisting the resident to eat.
During an observation on 03/07/2023 at 4:00 PM, Resident #61 was observed lying in bed with bed rails on both sides of the bed in the raised position.
During an observation on 03/08/2023 at 11:27 AM, Resident #61 was observed lying in bed. The bed rails had been removed from the bed.
During an interview on 03/07/2023 at 1:25 PM, Family Member (FM) #2, who was also the Resident Representative, stated they previously observed the bed rails in place but had not asked about them. FM #2 said facility staff had not discussed the use of bed rails either directly or during the care planning meetings. FM #2 thought the bed rails were being used to prevent Resident #61 from falling out of bed.
During an interview on 03/07/2023 at 1:45 PM, CNA #1 stated bed rails were used to prevent residents from rolling out of bed. CNA #1 further stated the bed rails prevented Resident #61 from falling out of bed. CNA #1 stated she would look at the care plan to determine why bed rails were in place.
During an interview on 03/07/2023 at 1:50 PM, CNA #2 stated the bed rails were used for fall prevention. CNA #2 was unable to state who initiated the bed rails for Resident #61. CNA #2 said that in the past, Resident #61 would try to get out of bed, and the bed rails prevented the resident from falling out of bed.
During an interview on 03/07/2023 at 2:00 PM, Licensed Practical Nurse (LPN) #3 stated the bed rails were not placed on the beds for any specific purpose. LPN #3 indicated there was no decision-making process used to determine the risks and benefits of bed rail use and if the bed rails were a safe approach for a resident. LPN #3 said, if the bed rails were in place on a resident's bed at the time of admission, the resident would have bed rails for the remainder of their stay; the bed rails would not be removed. LPN #3 further stated Resident #61 had never fallen out of bed, so she did not know why bed rails were in use for the resident.
During an interview on 03/07/2023 at 4:00 PM, LPN #4 stated bed rails were used for self-positioning, to enable residents to turn themselves. LPN #4 was unable to state which interdisciplinary team members assessed a resident for bed rail use and determined the need for bed rails and/or who ensured bed rails were a safe approach. LPN #4 was unaware of the bed rails in use for Resident #61 and did not know who made the decision for the bed rails to be installed on the resident's bed.
During an interview on 03/08/2023 at 9:00 AM, the Director of Nursing (DON) stated the bed rails had been removed from Resident #61's bed on the evening of 03/07/2023. The DON provided the Bed Rail/Assist Bar Evaluation at that time.
Review of Resident #61's Bed Rail/Assist Bar Evaluation revealed the assessment was to be completed quarterly and was completed on 10/21 (no year specified) and 03/07 (no year specified). The Evaluation Factors section indicated the resident had fluctuations in levels of consciousness or a cognitive deficit, was physically able to release the bed rails, was unable to follow directions, was voluntarily able to move their own body, and had a problem with balance or poor trunk control. The evaluation also indicated the resident would use the bed rails for positioning or support and there was no risk to the resident if bed rails were used. Instructions provided on the form indicated, for each evaluation factor, If yes, summarize on reverse. The Summary of Findings sections were not completed despite yes responses under the evaluation columns. The document was not signed by the person(s) who completed the evaluations.
During the interview on 03/08/2023, the DON stated that in October 2022 she realized there were no assessments for the use of bed rails, and she instructed the registered nurse (RN) supervisors at that time to complete assessments for all residents in the building who used bed rails. The DON stated the nursing staff were not provided education on how to complete the assessments or what constituted a risk for entrapment. The DON stated there was no follow-up to the assessments other than the daily walking rounds conducted by department heads. The DON indicated that the maintenance department did not have a role in bed rail safety assessments. The DON further stated there was a protocol related to proper installation of bed rails, but the maintenance staff had not been provided the protocol or education related to the protocol. The DON presented the regulatory guidance as their protocol. The DON stated there were no consent forms presented to the resident or family for signature, and nursing staff had not been educated on a process for conducting assessments, obtaining consents, or determining the necessity of bed rails.
During an interview on 03/09/2023 at 11:10 AM, the Therapy Coordinator (TC) stated that as part of their therapy screen, bed rails were not addressed as it was a nursing assessment. The TC further stated the therapy department would make a recommendation for bed rail use only if it was felt a resident would benefit from bed rails. The TC stated Resident #61 was not assessed by therapy and there were no recommendations made for bed rails. The TC further stated the therapy department had not been asked to evaluate Resident #61 or any other resident for use if bed rails.
During an interview on 03/09/2023 at 1:29 PM, RN Supervisor #5 stated she was provided with the Bed Rail/Assist Bar Evaluation forms in October 2022, and RN Supervisors were instructed to complete the evaluations for all residents. RN Supervisor #5 stated she was not provided training, but the forms were self-explanatory. RN Supervisor #5 was unable to define risk as it related to bed rail use but stated cognition was a big part of the assessment. RN Supervisor #5 indicated if the resident was cognitively intact, the resident knew how to use the bed rails safely. RN Supervisor #5 stated she had not received training on risks associated with bed rail use. She did not know who decided when bed rails were installed or removed.
During an interview on 03/10/2023 at 2:18 PM in the presence of the Administrator, the DON stated she had implemented the bed rail assessments following a survey preparedness initiative. The DON acknowledged that residents currently using bed rails had not been adequately assessed and indicated the staff were not conducting the assessments accurately or completely. The DON further stated it was her expectation that staff completed the bed rail assessments quarterly, but it just did not happen.
5. A review of a Face Sheet indicated the facility admitted Resident #41 on 04/04/2017 with diagnoses including muscle weakness and hemiplegia following cerebral infarction affecting the nondominant side.
The annual Minimum Data Set (MDS), dated [DATE], revealed Resident #41 had severely impaired cognitive skills for daily decision making based on staff assessment. According to the MDS, the resident had functional limitations in range of motion in the upper and lower extremities on one side and required extensive assistance of one person for bed mobility and maximum assistance from staff for transfers. The MDS indicated bed rails were not used as a physical restraint.
Review of Resident #41's Care Plan, with an annual review date of 02/08/2023, revealed the resident was at risk for falls and used bed rails to define the parameters of the bed.
On 03/08/2023 at 9:00 AM the DON provided Bed Rail/Assist Bar Evaluations for Resident #41. A review of a Bed Rail/Assist Bar Evaluation, dated 10/21 with no year identified, revealed the form was incomplete with Evaluation Factors not identified and the Summary of Findings left blank. The form did not include a completion date or the signature of the person completing the form. Another Bed Rail/Assist Bar Evaluation, dated 03/07 with no year identified, was provided which indicated the resident used quarter bed rails. Although the evaluation indicated the resident had fluctuations in levels of consciousness or a cognitive deficit, the resident had problems with balance or poor trunk control, and the resident was able to voluntarily move their own body, the Summary of Findings and Intervention sections of the form were not completed.
During an interview on 03/09/2023 at 11:42 AM, Certified Nursing Assistant (CNA) #10 indicated residents needed the bed rail if they leaned to one side and might fall out of bed. CNA #10 indicated she did not know who decided which residents needed a bed rail or bed rails on their bed.
During an interview on 03/09/2023 at 2:58 PM, Licensed Practical Nurse (LPN) #13 indicated Resident #41 needed half bed rails for movement and safety. LPN #13 indicated she was not aware of any incidents involving bed rails.
During an interview on 03/09/2023 at 3:17 PM, LPN #4 indicated Resident #41 needed the half bed rails because the resident could use the bed rails to turn and reposition in bed.
6. A review of the Face Sheet indicated the facility admitted Resident #55 on 01/07/2019 with diagnoses that included dementia without behavioral disturbance, depression, and type 2 diabetes mellitus.
The quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #55 had severely impaired cognitive skills for daily decision making based on staff assessment. According to the MDS, the resident required extensive to maximum assistance from staff with all activities of daily living (ADLs). The MDS indicated Resident #55 did not use bed rails as a physical restraint.
Record review for Resident #55 revealed there was no bed rail assessment, informed consent, or documented attempts to use alternatives to bed rails in the resident's electronic health record.
A review of Resident #55's physician orders revealed there were no orders for the use of bed rails or side rails.
On 03/08/2023 at 9:00 AM, the Director of Nursing (DON) provided the Bed Rail/Assist Bar Evaluation that indicated Resident #55 used bilateral half bed rails.
Review of Resident #55's Bed Rail/Assist Bar Evaluation revealed the assessment was to be completed quarterly and was completed on 10/21 (the year was not documented) and 03/07 (the year was not documented). The 10/21 Evaluation Factors indicated the resident had fluctuations in levels of consciousness or a cognitive deficit, had a history of falls, had a problem with balance or poor trunk control, was able to move their body voluntarily, and indicated there was a risk to the resident if bed rails/assist bars were used. The Evaluation Factors on the 03/07 assessment also indicated the resident had fluctuations in levels of consciousness or a cognitive deficit, had a history of falls, had a problem with balance or poor trunk control, and was able to move their body in bed. The Summary of Findings section of the forms corresponding with these dates was not completed and the document was not signed by the person(s) who conducted the evaluations.
During an interview on 03/08/2023 at 9:05 AM, the Director of Nursing (DON) acknowledged there was no process in place to ensure bed rail assessments were completed on admission and on a quarterly basis thereafter. The DON stated resident beds generally had bed rails installed by the manufacturer, and there was no process in place to determine if they were necessary or safe for resident use. There was no consent form provided to residents or family members for signature authorizing the use of bed rails and acknowledging risks and benefits.
During an interview on 03/09/2023 at 11:12 AM, the Therapy Coordinator (TC) stated she screened all residents following admission to the facility, but the TC did not do an assessment for bed rails. The TC stated she did not recall being asked by nursing to evaluate the bed rails for appropriateness.
During an interview on 03/10/2023 at 2:18 PM, the DON and Administrator stated their expectation was for the bed rail assessments to be completed for all residents at admission and quarterly, thereafter.

Based on observations, interviews, record reviews, and review of facility policy titled Administering Medications,, it was determined that the facility failed to ensure a medication error rate of less than 5%. There were two medication errors out of 26 opportunities, which resulted in a 7.69% medication error rate. This deficient practice affected 2 (Resident #25 and Resident #50) of 6 residents observed for medication administration.
Findings included:
Review of a facility policy titled, Administering Medications, dated 08/25/2020, specified, Medications will be administered in a timely manner and in accordance with the attending physician's written/verbal orders.
1. A review of a Face Sheet indicated the facility admitted Resident #25 with diagnoses that included dementia, peripheral vascular disease, and cerebrovascular disease.
A review of Resident #25's Physician Orders, for the month of March 2023, revealed an order, dated 03/23/2022, for acetaminophen 325 milligrams (mg), one tablet by mouth once a day for pain.
During observation of medication administration on 03/08/2023 at 8:39 AM, Licensed Practical Nurse (LPN) #6 administered two acetaminophen 325 mg tablets to Resident #25.
During an interview on 03/09/2023 at 2:42 PM, LPN #6 confirmed she administered two acetaminophen 325 mg tablets to Resident #25. LPN #6 checked the resident's physician's order and confirmed the physician order as one tablet of acetaminophen 325 mg.
2. A review of a Face Sheet indicated the facility admitted Resident #50 with a diagnosis of glaucoma.
A review of Resident #50's Physician Orders for the month of March 2023 revealed an order, dated 01/27/2023, for artificial tears, one drop in each eye four times daily for dry/irritated eyes.
During observation of medication administration on 03/08/2023 at 4:09 PM, LPN #14 did not administer artificial tears to Resident #50.
During an interview on 03/09/2023 at 4:00 PM, LPN #14 indicated she followed the resident's Medication Administration Record but missed the artificial tears.
During an interview on 03/09/2023 at 4:07 PM, the Director of Nursing indicated her expectation was for the facility's medication error rate to be less than 3%.

Based on observations, interviews, and review of facility policy titled, Food Handling Guidelines, Cleaning of Food and Nonfood Contact Surfaces, Food Handing Guidelines, Hand Hygiene, and Sanitation Inspection and Checklist, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Specifically, the facility failed to thaw chicken properly, use the three compartment sink appropriately while washing a food processor, transfer food to the tray line appropriately, ensure staff put on a hairnet prior to entering the kitchen, ensure staff washed their hands between glove changes, and ensure food was stored properly. This deficient practice had the potential to affect 83 of 84 residents who received meals from the facility kitchen.
Findings included:
1. Review of the facility policy titled, Food Handling Guidelines, revised February 2023, revealed procedures for thawing frozen meat/poultry/seafood and indicated the meat should be thawed Under running water: Submerged under potable running water at a temperature of 70 [degrees Fahrenheit] or below with sufficient velocity to agitate and float off loose food particles into the overflow.
Observations during the initial tour of the kitchen on 03/06/2023 at 10:32 AM revealed frozen chicken was in the sink in a pan of cold water, without the water running over the chicken. Interview with [NAME] #28 at the time of the observation revealed the chicken had been placed in the cold water at approximately 9:00 AM and indicated the water was changed every 10 minutes until the chicken was thawed.
Interviews with the Regional Dietary Manager (RDM) and Dietary Manager (DM) #21 at the time of the observations revealed they stated the chicken should be thawed according to proper procedures.
2. Review of the facility policy titled, Cleaning of Food and Nonfood Contact Surfaces, revised January 2023, indicated, When a three-compartment sink is used, the first compartment must contain the cleaning solution, the second must contain clean rinsing water and the third must contain sanitizer solution at the proper concentration.
Observations in the kitchen on 03/08/2023 beginning at 10:42 AM revealed kitchen staff were washing the food processor and were only using the wash sink and the sanitize sink; the rinse sink was not used during the process.
Interviews on 03/08/2023 at 5:07 PM with [NAME] #22, Dietary Manager (DM) #21, and DM #27 revealed [NAME] #22 stated she usually used all three compartments, but the middle sink was full of large baking sheets. DM #21 and DM #27 stated it was required to use all three compartments, and they expected all staff to use the sink appropriately.
3. Review of the facility policy titled, Food Handing Guidelines, revised February 2023, indicated, Food is handled using a HACCP [Hazard Analysis and Critical Control Points] process in accordance with regulatory guidelines.
Observations in the kitchen on 03/08/2023 beginning at 10:42 AM revealed staff stacked two uncovered pans of food on top of each other and took them to the tray line area.
During an interview with [NAME] #22 on 03/08/2023 at 5:07 PM, [NAME] #22 stated she usually did not do that, but she was in a hurry. Dietary Manager (DM) #21 and DM #27 were present during the interview, and both agreed the pan should have been carried separately.
4. A policy for food service employees wearing hairnets was requested but was not received from the Regional Dietary Manager (RDM) by the end of the survey.
Observations in the kitchen on 03/08/2023 beginning at 10:42 AM revealed that Dietary Staff (DS) #23 walked into the kitchen from the dining room to the back of the kitchen to get a hairnet to put on before starting work.
An interview with Dietary Manager (DM) #27 and DS #23 on 03/08/2023 at 5:07 PM revealed DM #27 stated they expected all kitchen staff to wear a hair net upon entry in the kitchen. DS #23 stated they were unable to enter from the back as usual due to the door being locked, so they went through the dining room and kitchen directly to get a hairnet.
5. Review of the facility policy titled, Hand Hygiene, revised January 2023, indicated, Hands are to be washed with soap and water at the following times: before putting on gloves; before handling food or clean utensils/dishes/equipment; and after removing gloves. The policy further indicated, Hands must be washed with soap and water when plating food and Hand sanitizer may be used for tray delivery process only.
During observations of food service on the tray line on 03/08/2023 beginning at 10:42 AM, DS #25 was observed removing gloves and discarding them, using hand sanitizer, then putting on another pair of gloves. She returned to placing utensils, napkins, tray cards, and desserts on the resident trays.
An interview with the Registered Dietitian (RD) on 03/10/2023 at 9:24 AM revealed the RD came to the facility at least two to three days monthly and spent some time observing in the kitchen. She stated staff were to always wash hands, and it was their expectation that all staff did proper handwashing.
6. A review of the facility policy titled, Sanitation Inspection and Checklist, revised January 2023, revealed, A basic sanitation inspection is conducted at least once per month to ensure that established procedures are being followed and that sanitation standards are maintained. The policy included a Basic Sanitation Checklist that indicated out of date food should be discarded and food should be stored according to policy.
Observations during the initial tour of the kitchen on 03/06/2023 beginning at 10:10 AM, revealed a bottle of Worcestershire sauce in the dry storage area with a use-by date of 05/23/2022. Further observations revealed a bottle of stir fry sauce that was opened, but there was no date on the bottle indicating when the bottle was opened. There was a manufacturers statement on the side of the bottle that noted, Refrigerate after opening.
Interviews with the Regional Dietary Manager (RDM) and Dietary Manager (DM) #21 at the time of the observations on 03/06/2023 revealed both bottles of sauce should be discarded, and all foods past the expiration or use-by date should not be served. They stated all foods that were to be stored in the refrigerator after opening should be refrigerated immediately after opening the container. Both containers were immediately discarded in the trash.
On 03/08/2023, during kitchen observations beginning at 10:42 AM, it was noted that a box of butter was on the shelf in the tray line area. It had a manufacturer note on the side of the box that specified, keep refrigerated. Observations in the kitchen at 5:07 PM on 03/08/2023 revealed the box of butter was noted to still be on the shelf.
Interviews on 03/08/2023 at 5:07 PM with the staff that were working the tray line, Dietary Staff (DS) #23, DS #26, and DS #24, revealed they had not taken the box from the cooler.
Interview with DM #27 on 03/08/2023 at 5:07 PM revealed the butter should be kept in the cooler and should be discarded.
The Director of Nursing and the Administrator were interviewed on 03/10/2023 at 3:06 PM. The Administrator stated he expected the kitchen to follow all guidelines, and the problems that were found during survey should never happen.

Based on observations, interviews, record review, facility document review, and facility policy titled Quality Assurance and Performance Improvement Program (QAPI), it was determined that the facility failed to develop and implement an effective plan of action to address the use of bed rails in the facility. In October 2022, the facility identified assessments were not being completed for residents with bedrails/side rails to determine safety and appropriateness; however, the facility failed to develop a plan of action to address the lack of assessment. This deficient practice affected all 84 residents who currently reside in the facility.
Findings included:
Review of a facility policy titled, Quality Assurance and Performance Improvement Program (QAPI), effective 02/25/2020, specified, Purpose of policy: A. To provide a proactive approach to continually improve resident care. B. To ensure a safe and secure environment for residents. The policy further indicated, The QAPI Program will provide for the safety and high quality with all clinical interventions while emphasizing autonomy and choice in daily life for residents (or resident's agents), by ensuring data collection and monitoring systems are in place and are consistent for a proactive analysis.
Review of the QAPI meeting notes for October 2022 and February 2023 revealed no evidence of documentation related to the use of bed rails in the facility or the concern for lack of assessments related to bed rails.
During an interview on 03/08/2023 at 9:00 AM, the Director of Nursing (DON) stated that in October 2022, while conducting a survey readiness audit, she discovered bedrail/siderail assessments had not been completed for any residents in the building. At that time, the DON provided Bed Rail Assessment forms to the Registered Nurse (RN) Supervisors to be completed on all residents in the building. The DON stated the RNs were not provided with any instruction/training for the completion of the form, and the nurses answered the questions on the forms based on their knowledge of the residents being assessed. The DON stated the nursing staff were not educated on how bedrails could constitute a risk for the resident, and they were unaware of how to identify entrapment zones around the bedrails in use. The DON further stated there was no process in place to ensure the assessments were completed on admission and on a quarterly basis. The DON stated most of the beds already had bedrails installed and there was no process in place to assess the bedrails when a resident was placed in that bed. The DON stated the families were not notified or educated on the use of bedrails, and the facility did not obtain consents from the families to utilize bedrails. The DON stated she should have initiated a performance improvement plan (PIP) in October when she realized assessments were not being done, and the concern should have been introduced in QAPI and a plan of action placed. The DON stated the expectation was for concerns to be assessed and brought to QAPI for consideration, and it was not done.
On 03/10/2023 at 2:18 PM, the Administrator was in attendance with the DON for an interview, and he emphasized that an identified process failure should be brought to QAPI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of a facility policy titled, Administering Medications, with an effective date of 08/25/2020, specified, Appropriate Infection Prevention procedures will be followed during the administration of medications.
A review of Resident #33's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. The MDS indicated the resident was totally dependent on staff for most activities of daily living and had a feeding tube. The MDS further indicated the resident had active diagnoses that included dementia and malnutrition.
During medication administration observation on 03/08/2023 beginning at 8:52 AM, Licensed Practical Nurse (LPN) #13 administered medications to Resident #33 through the resident's percutaneous endoscopic gastrostomy (PEG) tube. LPN #13 used a 60 cubic centimeter (cc) syringe during the medication administration observation. At 9:00 AM, LPN #13 removed the plunger from the syringe and placed the plunger directly on the bed linen on the resident's bed, picked up the plunger, put the syringe back together, and mixed and stirred a powdered medication. LPN #13 then removed the plunger from the syringe and placed the plunger directly on the bed linen a second time. At 9:01 AM, LPN #13 picked up the plunger, put the syringe back together, and obtained a stethoscope. LPN #13 removed the plunger from the syringe and placed the plunger directly on the bed linen for a third time while she checked placement of the PEG tube and administered the resident's medications using the barrel of the syringe to administer the medication and water flushes by way of gravity. After medication administration, LPN #13 took the 60-cc syringe into the bathroom, rinsed the syringe, and placed the syringe in a container dated 03/08/2023 that was located on the overbed table.
During an interview on 03/08/2023 at 9:12 AM, LPN #13 indicated the plunger should not be placed on the bed due to potential contamination.
During an interview on 03/09/2023 at 3:31 PM, LPN #4 indicated there should be a barrier for the placement of all supplies when medications were administered through a PEG tube to prevent infection control issues.
During an interview on 03/09/2023 at 4:11 PM, the Director of Nursing indicated her expectation was to have a clean barrier for placement of supplies and to ensure infection control policies were followed during medication administration.
During an interview on 03/09/2023 at 4:58 PM, the Infection Preventionist (IP) stated the plunger should have been placed on a barrier, even if it was just a clean paper towel from the bathroom. The IP indicated the plunger should not have been placed on the bed.
Based on observations, interviews, record review, and review of facility policies titled Policy/Procedure Housekeeping/Laundry Dept [Department] and Administering Medications, the facility failed to process soiled laundry in a safe and sanitary manner and in accordance with facility policy in one of one laundry room used for processing laundry. The facility further failed to administer medication through a feeding tube using appropriate infection prevention procedures for one (Resident #33) of 6 residents observed for medication administration.
Findings included:
1. Review of an undated facility document titled, Policy/Procedure Housekeeping/Laundry Dept [Department], revealed Regular, 'Normal Soiled' Laundry1. When handling soiled laundry, staff are to wear the appropriate PPE [personal protective equipment]: gloves and gowns at all times and masks and eye protection if sprays or splashes are likely.
During an observation in the laundry room on 03/06/2023 at 11:20 AM, Laundry Aide (LA) #18 donned gloves, uncovered the soiled laundry bin, and started to open clear plastic bags that contained soiled linen. LA #18 then lifted the soiled linen out of a bag and shook the soiled linen gently to dislodge any items or debris. She then gathered the soiled linen and placed the linen in an open washer. LA #18 continued the process until she had placed approximately half of the laundry from the soiled laundry bin into the washer. LA #18 then said to the surveyor, Normally I would wear one of those gowns over there, but it is just too hot. LA #18 continued the process until all the soiled linen was placed in the washer, closed the washer door, and started the machine.
On 03/06/2023 at 11:25 AM, a yellow disposable gown in a clear package was observed on a small table in the laundry room. The laundry room had a large fan mounted on the wall. The fan was on and blew air over the sorting area. The door between the clean and dirty laundry rooms was propped open with a garbage can. After the door was closed in the presence of LA #18 and LA #19, a large sign was observed on the door that read, Keep this door closed at all times.
During an interview on 03/06/2023 at 11:27 AM, LA #18 stated she knew she should have worn a gown, but she was so hot that she did not don the gown. LA #18 then acknowledged the door between the two rooms should have been closed.
During an interview on 03/06/2023 at 11:59 AM, the Housekeeping Director stated LA #18 should have worn a gown when she sorted soiled laundry, and the door between the clean and dirty laundry rooms should have been closed as the sign indicated.
During an interview on 03/07/2023 at 1:23 PM, the Director of Nursing stated her expectation was that laundry personnel wear a gown and gloves when they sorted soiled linen, and the door between the clean and dirty laundry rooms should have been closed and not propped open.

Based on observations, interviews, record review, and facility document review, it was determined the facility failed to conduct regular inspection of bed frames, mattresses, and bed rails to ensure compatibility and to identify areas of possible entrapment for 53 of 59 occupied beds equipped with bed rails.
Findings included:
A tour conducted on 03/06/2023 of four of six hallways revealed 53 of 59 occupied beds were observed with some type of bed rail, ranging from quarter rails to half rails.
At the end of the day on 03/06/2023, the Director of Nursing (DON) was asked to provide bed rail assessments for six residents (Residents #43, #61, #55, #62, #17, and #41) who had bed rails in use on their beds.
On 03/08/2023 at 9:00 AM, the DON provided Bed Rail/Assist Bar Evaluation forms for the six residents. The completed forms did not include inspection of bed frames, mattresses, and bed rails and no other evidence was provided indicating regular inspections were conducted.
On 03/07/2023 at 4:37 PM, the DON stated the interdisciplinary team assessed the need for bed rails, and the maintenance department added or removed the bed rails as instructed. The DON was unable to state who was responsible for regular inspection of all bed frames, mattresses, and bed rails to ensure compatibility and to identify areas of possible entrapment.
During an interview on 03/08/2023 at 9:39 AM, Plant Engineering (PE) #1 stated his only responsibility related to bed rails was to ensure they fit tightly against the mattress, so residents did not slip or fall when using the bed rails. PE #1 stated he had not received education about bed rails including the risks associated with bed rail use.
During an interview on 03/10/2023 at 1:07 PM, the Director of Plant Engineering (DPE) stated the last administrator of the facility had taken over the daily maintenance operations, and in May of 2022, the previous administrator had discussed the removal of bed rails from the beds. According to the DPE, the large, long bed rails that extended the length of a bed were scheduled to be removed in July 2022, but the DPE was unable to state what prompted that initiative and was unaware the bed rails were still in place.
During an interview on 03/10/2023 at 1:27 PM, the DON stated she did not have a policy or procedure related to the regular inspection of bed frames, mattresses, and bed rails to ensure compatibility and to identify possible areas of entrapment.
During an interview on 03/10/2023 at 2:18 PM, the DON and Administrator stated there was no process for regular inspection of bed frames, mattresses, and bed rails for compatibility and to identify areas of possible entrapment, and the maintenance team had not been provided instruction or education on the inspection of bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, it was determined that the facility failed to ensure a proper transfer was provided for one of six residents (Resident #41) reviewed for accidents. Actual harm was identified on 2/21/2023 when Certified Nursing Assistant (CNA)#7 transferred R#41 without assistance, and this resulted in Resident #41 sustaining a left tibia fracture.
Findings included:
A review of a Face Sheet indicated the facility admitted Resident #41 with diagnoses that included muscle weakness and hemiplegia affecting the nondominant side following cerebral infarction.
The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 had severely impaired cognitive skills for daily decision making based on staff assessment; the resident was totally dependent on staff for transfers and required two persons physical assistance; the resident had functional limitations in range of motion in the upper and lower extremities on one side; and the resident used a wheelchair for mobility.
Review of Resident #41's Care Plan, with an annual review date of 02/08/2023, revealed the resident had a self-care deficit and required limited to dependent assistance in daily ADLs [Activities of Daily Living]. An approach on the care plan directed staff to utilize a mechanical lift and two-person assistance with all transfers.
A review of nursing Progress Notes, dated 02/21/2023 at 2:14 PM and signed by Licensed Practical Nurse (LPN) #3, revealed that when CNA #7 transferred Resident #41 from a wheelchair to bed, the resident yelled ouch and a popping noise was heard. The Progress Note indicated Resident #41 complained of pain in the left knee, swelling of the left knee was noted, and outer rotation of the left foot was observed. According to the documentation, the physician was notified, and the resident was sent to the hospital.
A review of a hospital Radiology Report, dated 02/21/2023, indicated Resident #41 had a suspected acute depressed fracture at the lateral tibial plateau.
A hospital Discharge Summary, dated 02/23/2023, revealed a discharge diagnosis of a tibial plateau fracture.
During an observation on 03/06/2023 at 11:22 AM, Resident #41 was observed lying in bed with a brace on the resident's left leg. When asked about the brace, Resident #41 indicated one person attempted to transfer the resident instead of two and the resident sustained a fracture. Resident #41 indicated that since the incident, a mechanical lift had been used for transfers.
During a telephone interview on 03/08/2023 at 2:51 PM, CNA #7 who was involved in the incident, indicated resident information and instructions for care delivery were routinely obtained in report, daily huddle, and through walking rounds. CNA #7 stated she transferred Resident #41 by herself on 02/21/2023 and heard a pop. CNA #7 indicated she assisted the resident to sit on the bed and informed LPN #3. CNA #7 indicated she was told in report prior to the incident, that Resident #41 required the assistance of one staff member with transfers.
During a telephone interview on 03/08/2023 at 2:58 PM, LPN #3 who responded during the incident, stated resident information and instructions for care delivery were on the care plans, and the huddle sheet. The huddle sheet, which contained important information, was read aloud every morning. LPN #3 indicated he was unsure if CNAs had access to the residents' care plans. LPN #3 indicated that on the day Resident #41 sustained the fracture, CNA #7 said she transferred the resident and heard a pop. LPN #3 stated that when he assessed Resident #41, the resident's foot was sideways, and the resident was complaining of pain, so the resident was sent to the hospital. LPN #3 reported he thought Resident #41 should have been transferred using a mechanical lift.
During an interview on 03/08/2023 at 3:11 PM, CNA #2 indicated Resident #41 used a mechanical lift for transfers prior to the fracture but could sometimes stand.
During an interview on 03/08/2023 at 4:19 PM, CNA #8 stated if staff did not know the type of assistance a resident required to transfer, they should ask the resident if the resident was not confused or ask the resident's nurse.
During an interview on 03/08/2023 at 4:21 PM, CNA #9 indicated staff should ask the nurse if they did not know how a resident should be transferred.
During an interview on 03/09/2023 at 11:15 AM, the Therapy Coordinator (TC) indicated Resident #41 required at best, moderate to minimal assistance with transfers. The TC indicated minimal assistance meant the resident needed 25% assistance from staff, and moderate meant the resident needed 50% assistance. The TC stated Resident #41 should not have been transferred with the assistance of only one person prior to the fracture.
During an interview on 03/09/2023 at 11:42 AM, CNA #10 indicated Resident #41 required a mechanical lift for transfers because the resident was weak on one side. CNA #10 reported Resident #41 required a mechanical lift for transfers at the time the resident's leg was fractured. CNA #10 stated staff always transferred Resident #41 with two staff and a mechanical lift.
During an interview on 03/09/2023 at 12:06 PM, CNA #11 indicated Resident #41 had always been transferred using a mechanical lift.
During an interview on 03/09/2023 at 4:14 PM, the Director of Nursing (DON) stated staff were informed of resident care needs in morning huddles and by utilizing continuity of care meaning the same staff worked with the same residents. The DON indicated Resident #41 was transferred from the wheelchair to the bed on 02/21/2023 using a stand-pivot transfer when the fracture occurred. When asked how the resident should have been transferred, the DON indicated Resident #41 had fluctuations in cognition and physical ability. The DON stated her expectation to ensure a resident was transferred properly to prevent a fracture, was to educate the CNAs and if they were unsure or unfamiliar with a resident, CNAs were instructed to obtain the information from the resident's nurse or look at the care plan to find therapy recommendations. The DON indicated CNA #7 did not normally work on that side of the building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of facility policy titled Care Plans, it was determined that the facility failed to develop a care plan to describe the need for, and use of, bed rails for four (Residents #17, #43, #61, and #62) of six residents reviewed for comprehensive care plans.
Findings included:
Review of a facility policy titled, Care Plans, with an effective date of 10/27/2020, revealed, The Comprehensive Care Plan will provide direction to: 1. Incorporate identified problem areas: 2. Incorporate risk factors associated with identified problems; 3. Build on the resident's strengths; 4. Reflect treatment goals and objectives in measurable outcomes; 5. Identify the professional services that will be responsible for each element of care. The policy also revealed, The care plan will be used in developing the resident's daily care routines. The policy did not specifically address or mention the use of bed rails.
1. A review of a Face Sheet indicated the facility admitted Resident #43 with diagnoses that included senile degeneration of the brain, major depressive disorder, and anxiety disorder.
The quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #43 was unable to answer the questions on the Brief Interview for Mental Status (BIMS). A staff assessment conducted for the resident's mental status indicated short-term and long-term memory problems. The assessment of cognitive skills for daily decision making indicated Resident #43 was severely impaired. The resident required extensive assistance to total dependence of one to two staff members for activities of daily living (ADLs), including bed mobility and transfers. The MDS indicated bed rails were not used as a physical restraint.
Resident #43's Care Plan, with a review date of 11/14/2022, revealed there was no documentation related to the use of bed rails. The facility provided an updated copy of the Care Plan that had been revised on 03/09/2023 to include bed rails as an approach to prevent falls.
On 03/06/2023 at 11:09 AM, Resident #43 was observed lying in bed with bed rails on both sides of the bed in the raised position. The bed rails were positioned in the middle of the bed and extended from the resident's chest area to below the resident's knees.
On 03/06/2023 at 2:53 PM, Resident #43 was observed lying in bed with bed rails on both sides of the bed in the raised position.
On 03/06/2023 at 4:15 PM, Resident #43 was observed lying in bed on their left side with bed rails on both sides of the bed in the raised position.
On 03/07/2023 at 4:30 PM, Resident #43 was observed lying in bed with bed rails on both sides of the bed in the raised position.
During an interview on 03/07/2023 at 1:00 PM, Resident #43's Family Member (FM) #1, who was also the Resident Representative, stated they were unaware of the bed rails being in place but assumed they were being used to prevent Resident #43 from falling out of the bed. FM #1 was unaware of any falls in the past and said they did not think the bed rails had been discussed during care plan meetings.
During an interview on 03/07/2023 at 1:55 PM, Licensed Practical Nurse (LPN) #6 stated if there were any bed rails in the facility they would have to be care planned. LPN #6 stated Registered Nurse (RN) Supervisor #5 would be responsible for the care plan.
During an interview on 03/07/2023 at 4:00 PM, LPN #4 stated she was not responsible for care plans, and they were done primarily by the MDS Coordinator.
During an interview on 03/09/2023 at 12:59 PM, the MDS Coordinator stated there were no care plans developed for any residents with bed rails. The MDS Coordinator stated she had not developed a care plan for the use of bed rails for Resident #43.
During an interview conducted on 03/10/2023 at 2:18 PM with the Director of Nursing (DON) and the Administrator, the DON stated a Care Plan for Resident #43 should have been developed to address the purpose and management of bed rails.
2. A review of a Face Sheet indicated the facility admitted Resident #61 with diagnoses that included dementia, anxiety disorder, pubic fracture, and major depressive disorder.
The quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident #61 was unable to answer the questions on the Brief Interview for Mental Status (BIMS). A staff assessment was conducted for the resident's mental status and cognitive skills for daily decision making that indicated Resident #61 was severely cognitively impaired. The resident was totally dependent and required assistance of one to two staff members for activities of daily living (ADLs), including bed mobility and transfers.
Review of Resident #61's Care Plan, dated 08/17/2020, revealed there was no documentation related to the use of bed rails.
During an observation on 03/06/2023 at 11:11 AM, Resident #61 was observed lying in bed with their eyes closed. The bed rails on both sides of the bed were in the raised position. The bed rails were positioned in the middle of the bed and extended from approximately the resident's chest/abdomen to below the resident's knees.
During an observation on 03/07/2023 at 1:45 PM, Resident #61 was observed sitting in bed with the head of the bed elevated and bed rails on either side of the bed in the raised position. An unidentified certified nursing assistant (CNA) was at the bedside assisting the resident to eat.
During an observation on 03/07/2023 at 4:00 PM, Resident #61 was observed lying in bed with bed rails on both sides of the bed in the raised position.
During an observation on 03/08/2023 at 11:27 AM, Resident #61 was observed lying in bed. The bilateral bed rails had been removed from the bed.
During an interview on 03/07/2023 at 1:25 PM, Family Member (FM) #2, who was also the Resident Representative, stated the facility staff had not discussed the use of bed rails either directly or during the care planning meetings.
During an interview on 03/09/2023 at 12:59 PM, the MDS Coordinator stated she had not developed a care plan for the use of bed rails for Resident #61.
During an interview conducted on 03/10/2023 at 2:18 PM with the Director of Nursing (DON) and the Administrator, the DON stated a Care Plan for Resident #61 should have been developed to address the purpose and management of bed rails.
3. A review of a Face Sheet revealed Resident #17 had diagnoses that included dementia, cellulitis, atrial fibrillation, chronic kidney disease, major depression, hypertension, and anxiety.
Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #17 had severely impaired cognitive skills for daily decision making based on staff assessment. According to the MDS, the resident was independent with bed mobility and transfers and required extensive assistance from staff with dressing, toilet use, and personal hygiene. The MDS indicated the resident had one fall with no injury and one fall with injury (except major) since admission or the prior assessment. The MDS did not indicate that bed rails were used as a physical restraint.
Review of Resident #17's Care Plan, last reviewed on 12/05/2022, revealed Resident #17 was at increased risk for falls and fall-related injuries due to decreased safety awareness, cognitive loss, and impaired mobility. The Care Plan did not address the use of bed rails.
On 03/07/2023 at 3:12 PM, Resident #17 was observed in the resident's room lying in a low bed with bed rails in the raised position on both sides of the bed.
On 03/08/2023 at 9:12 AM, Resident #17 was observed in the resident's room lying in bed with half bed rails in the raised position on both sides of the bed.
On 03/09/2023 at 12:01 PM, Resident #17 was observed in the resident's room lying in a low bed with half bed rails in the raised position on both sides of the bed.
During an interview on 03/07/2023 at 1:55 PM, Licensed Practical Nurse (LPN) #6 stated Registered Nurse (RN) Supervisor #5 would be responsible for the care plan.
4. A review of a Face Sheet indicated the facility admitted Resident #62 with diagnoses of cerebral infarction and hemiplegia affecting nondominant side.
The annual Minimum Data Set (MDS), dated [DATE], revealed Resident #62 had severely impaired cognitive skills for daily decision making based on staff assessment. The resident required extensive assistance of one person for bed mobility and maximum assistance from staff for transfers. The MDS indicated bed rails were not used as a physical restraint.
During observations made on 03/06/2023 at 11:26 AM and 03/07/2023 at 2:24 PM, Resident #62 was lying in bed with half bed rails in the raised position on both sides of the bed.
Review of Resident #62's Care Plan, with a revision date of 11/03/2022, revealed there was no documentation related to use of bed rails.
During an interview on 03/09/2023 at 1:00 PM, the MDS Coordinator stated Resident #62 did not have a Care Plan for bed rails.
During an interview on 03/07/2023 at 1:55 PM, Licensed Practical Nurse (LPN) #6 stated if there were any bed rails in the facility they would have to be care planned. LPN #6 stated Registered Nurse (RN) Supervisor #5 would be responsible for the care plan.
During an interview on 03/07/2023 at 4:00 PM, LPN #4 stated she was not responsible for care plans, and they were done primarily by the MDS Coordinator. LPN #4 further stated the bed rails were used for positioning, and she did not know who determined the need for bed rails.
During an interview on 03/09/2023 at 12:59 PM, the MDS Coordinator stated there were no care plans developed for any residents with bed rails.
During an interview on 03/09/2023 at 1:29 PM, RN Supervisor #5 stated she did not update/develop care plans and had never been instructed to develop care plans for the use of bed rails.
During an interview conducted on 03/10/2023 at 2:18 PM with the Director of Nursing (DON) and the Administrator, the DON stated the comprehensive care plan should have been developed within the first 14 days of admission, and each department had the ability to update care plans. The use of bed rails should have been documented on the initial comprehensive care plan, and the interdisciplinary team should have documented and ensured it was reflected on the care plan. The DON stated it was her expectation that the care plans provided an accurate representation of the care provided to residents and the assistive devices needed, including bed rails.