Based on observation, interview, and record review, the facility failed to ensure residents diagnosed with dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) had a personalized plan of care to ensure appropriate services to promote the resident's highest level of functioning and psychosocial needs were provided for one resident (Resident #15) out of three sampled residents. The facility census was 39.The facility did not provide a policy regarding dementia care.1. Review of Resident #15's medical record showed:- admission date of 07/02/25;- Diagnoses of vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), moderate, with other behavioral disturbance, and senile degeneration of the brain (progressive decline in cognitive functions associated with old age).Review of the resident's admission Minimum Data Set (MDS - part of a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 07/12/25, showed:- Moderate difficulty hearing and required speaker to increase volume and speak distinctly;- Hearing aides used;- Usually understood with difficulty communicating some words or finishing thoughts but was able if prompted or given time;- Usually understood but missed some part/intent of message but comprehended most conversation;- Severe cognitive impairment.Review of the resident's Care Plan, dated 08/11/25, showed:- Did not address dementia;- Did not address specific problems, interventions, or goals for dementia care.Observations of the resident showed:- On 08/11/25 at 11:07 A.M., the resident lay in bed with his/her eyes closed;- On 08/11/25 at 12:30 P.M., the resident sat in his/her wheelchair at a table in the north side dining room and fed his/herself.- On 08/11/25 at 12:49 P.M., the resident sat in a wheelchair in his/her room and removed his/her sweatpants and a brief wet with urine; - On 08/12/25 at 9:49 A.M., the resident sat in a wheelchair in his/her room, held the television remote in his/her hand, and the television was off. During an interview on 08/14/25 at 1:45 P.M., the Director of Nursing (DON) said a resident's care plan should address dementia. The care plan should show the resident's needs are being met. During an interview on 08/14/25 at 1:45 P.M., the Administrator said the care plan should address the resident's diagnosis and needs.

Based on observation, interview, and record review, the facility failed to follow physician's orders for one resident (Resident #17) out of one sampled resident. The facility failed to to follow physician's orders for one resident (Resident #20) out of 20 sampled residents. The facility failed to obtain a physician's order, evaluate and assess the resident's abilities and provide education for self-care of a colostomy (a surgical procedure where the colon is diverted to an artificial opening in the abdomen) for one resident (Resident #31) out of two sampled residents. The facility also failed to obtain a physician's order and provide trapeze (a bar above the bed designed to assist the patient with a means of self-help to change positions in bed) assessments for one resident (Resident #34) out of one sampled resident. The facility census was 43. The facility did not provide a policy for bed alarms. The facility did not provide a policy for colostomy care. The facility did not provide a policy for trapezes. 1. Review of Resident #17's medical record showed: - Diagnosis of Alzheimer's disease (type of dementia that affects memory, thinking, and behavior); - An order for a bed alarm to the bed when in bed to alert the staff of the resident attempting to get up unassisted and to check the placement and function every shift, dated 11/28/23; - Care Plan, last revised 05/02/24, showed the resident to be checked on every two hours. The resident with memory problems and used a bed alarm to let staff know when he/she moved; Observation on the resident on 06/25/24 at 8:02 A.M., and 2:15 P.M., showed the resident lay in bed with a bed alarm on the bed and turned off. During an interview on 06/27/24 at 10:30 A.M., Certified Nursing Assistant (CNA) I said the bed alarm should be turned on anytime the resident was in the bed. During an interview on 06/27/24 at 1:15 P.M., the Director of Nurses (DON) said the bed alarm should be turned on when the resident was in bed. All physician orders should be followed. During an interview on 06/27/24 at 1:20 P.M., the Administrator said all physician orders should be followed. 2. Review of Resident #20's medical record showed: - Diagnoses of ulcerative colitis (a chronic, inflammatory bowel disease that causes inflammation in the digestive tract) and colostomy status; - An order to change the colostomy wafer or bag or both as needed, dated 05/16/24. Review of the resident's Treatment Administration Record (TAR), dated 05/01/24 through 05/31/24, showed: - An order to change the colostomy wafer or bag or both as needed, dated 05/06/24; - No documentation the colostomy wafer or bag or both were changed. Review of the resident's TAR, dated 06/01/24 through 06/28/24, showed: - An order to change the colostomy wafer or bag or both as needed, dated 05/06/24; - No documentation the colostomy wafer or bag or both were changed. Observation on 06/27/24 at 10:10 A.M., showed the resident changed the colostomy wafer and bag with Registered Nurse (RN) C in the room to assist. During an interview on 06/25/24 at 10:52 A.M., RN B said the resident had a colostomy, and the resident completed the changing of the colostomy bag and wafer him/herself with staff set up and assist as needed. During an interview on 06/27/24 at 10:30 A.M., the resident said he/she changed the colostomy wafer and bag with the assist of staff. During an interview on 06/27/24 at 2:45 P.M., RN C said the resident changed his/her colostomy wafer and bag with staff present and assistance provided as needed. During an interview on 06/27/24 at 3:01 P.M., the DON said she would expect the resident's colostomy care to be documented. During an interview on 06/28/24 at 9:03 A.M., the Administrator said there should be documentation to show the colostomy care was performed. 3. Review of Resident #31's medical record showed: - An admission date of 10/02/23; - Diagnoses of intraspinal abscess and granuloma (the swelling and irritation and the collection of infected material, pus, and germs in or around the spinal cord) and colostomy; - No documentation of an assessment for the self-care of the colostomy; - The resident's care plan, dated 04/19/24, showed the resident will perform his/her own colostomy care. Review of the resident's Physician Order Sheet (POS), dated June 2024, showed: - An order for the colostomy, dated 02/16/24; - An order to change the colostomy wafer or bag or both as needed every shift, every day and night shift, dated 02/21/24; - No documentation of an order for the resident to self-perform the colostomy care. During an interview on 06/27/24 at 4:42 P.M., the DON said resident did his/her own colostomy care and asked for help or supplies from staff when needed. The facility did not complete assessments for colostomy self-care and there was no documentation the resident received education for the colostomy care. During an interview on 06/26/24 at 8:35 A.M., the resident said he/she did his/her own colostomy care. The nursing staff provided the supplies and help if needed. During an interview on 06/28/24 at 8:44 A.M., the Assistant Director of Nursing (ADON) said the resident had a colostomy and did his/her own care. Staff watched over the resident depending on their abilities. The staff provided the supplies and education but did not document it. The resident never had self-care assessments completed in the past but it should be implemented quarterly. 4. Review of Resident #34's medical record showed: - admission date of 08/09/23; - Diagnoses of acquired absence of the right leg below the knee, morbid (severe) obesity due to excess calories, type 2 diabetes mellitus (a disease in which the body's ability to produce or respond to insulin is impaired) with diabetic neuropathy (nerve damage) lower abdominal pain, unspecified. - No order for a trapeze; - No documentation of a trapeze assessment. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff), dated 05/17/24, showed: - Cognition intact; - Substantial/maximal assistance for roll left to right. Review of the resident's care plan, dated 02/21/24, showed for Activities of Daily Living (ADLs) the resident used an overbed trapeze to assist with positioning. Observations of the resident showed: - On 06/25/24 at 10:13 A.M., a trapeze attached to the top of resident's bed and the resident used the trapeze to assist staff in his/her position change and care; - On 06/26/24 at 8:45 A.M., and 06/27/24 at 10:32 A.M., the resident lay in bed with the trapeze attached to the top of the resident's bed. During an interview on 06/25/24 at 10:13 A.M., the resident said he/she used the trapeze to help reposition him/herself in the bed, and to help staff when they needed to transfer or change him/her. No staff completed an assessment for use of the trapeze, or gave any education. When the nurse came in and talked to him/her, the nurse asked if a trapeze would help the resident move around in the bed, and they agreed to try it. During an interview on 06/27/24 at 12:40 P.M., RN C said there was not documentation of a trapeze assessment and there was not an order for the trapeze. RN C talked to the resident in his/her room, and they discussed the use of a trapeze. The resident agreed it would help him/her move while in bed. During an interview on 06/27/24 at 1:11 P.M., the DON said there should be an order for a trapeze and an assessment should be completed for the resident to use the trapeze. During an interview on 06/28/24 at 9:09 A.M., the Administrator said there should be education and an assessment completed for the resident to use a trapeze. There should be an order for the trapeze to assist in bed mobility.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were administered. There were 26 opportunities with three errors made, for an error rate of 11.54%. This practice affected three residents (Resident #2, #20, and #29) of the seven sampled residents. The facility census was 43. Review of the facility's policy titled, Medication Administration, last reviewed 04/25/24, showed: - Medication will be administered safely and accurately to residents for whom they are prescribed in accordance with current standards of practices; - Staff will observe the seven rights in giving each medication: right resident, right time, right medication, right amount, right method/route, right documentation, and right to refuse treatment; - Read medication label three times before administering medications: first when comparing the label with the Medication Administration Record (MAR) or Treatment Administration Record (TAR), second when pulling the medication from the drawer, and third when preparing to administer the medication to the resident. 1. Review of Resident #2's medical record showed: - Diagnosis of gastroesophageal reflux disease (GERD - stomach acid being forced back into the throat region); - An order for ondansetron (antinausea medication) 4 milligram (mg) one tablet three times a day as needed, dated 08/25/22. Observation on 06/26/24 at 8:45 A.M., of the resident's medication administration showed: - Certified Medication Technician (CMT) F documented the resident's ondansetron 4 mg tablet was administered to the resident; - CMT F opened the drawer of the medication cart, removed the ondansetron 4 mg tablet medication from the cart, and did not compare the ondansetron medication against the order; - CMT F administered the ondansetron 4 mg tablet to the resident; - CMT F failed to compare the medication to the medication order prior to administering the medication. 2. Review of Resident #20's medical record showed: - admission date of 02/05/24; - Diagnosis of depression (a serious medical illness that negatively affects how you feel, the way you think and how you act); - An order for fluoxetine (an antidepressant) 40 mg capsule daily, dated 02/06/24. Observation on 06/26/24 at 8:49 A.M., of the resident's medication administration showed: - CMT F began to prepare the resident's medication for administration; - CMT F could not find the resident's fluoxetine 40 mg medication in the medication cart; - CMT F documented the resident's fluoxetine 40 mg as not administered due to not in the building; - CMT F did not notify the resident's nurse the resident didn't take the fluoxetine 40 mg scheduled dose. During an interview on 06/26/24 at 8:50 A.M., CMT F said he/she didn't give the fluoxetine because the resident didn't have any right now and he/she would have to order it. 3. Review of Resident #29's medical record showed: - An admission date of 02/06/23; - Diagnosis of stroke and hemiplegia (paralysis of one side of the body); - An order for Lyrica (medication that treats nerve pain) 75 mg capsule twice a day, dated 02/06/23. Observation on 06/26/24 at 9:04 A.M., of the resident's medication administration showed: - CMT F opened the narcotic drawer of the medication cart, removed the resident's Lyrica 75 mg medication from the cart, and did not compare the Lyrica medication against the order; - CMT F administered the Lyrica to the resident; - CMT F failed to compare the medication to the medication order prior to administering the medication. During an interview on 06/27/24 at 12:28 P.M., Registered Nurse (RN) B said if a pill was dropped on top of the medication cart, he/she would give it since it was a clean surface. If a medication wasn't in stock, then the pharmacy should be contacted and notified the medication was needed as soon as possible. A CMT should notify the nurse when a medication was not administered so if the facility's emergency kit had that medication, it could be removed and administered. During an interview on 06/27/24 at 12:34 P.M., CMT F said if a medication was not on the medication cart, then he/she or the nurse would order it. The resident's medications should be checked against the resident's orders. During an interview on 06/27/24 at 12:45 P.M., the Administrator said if a medication was out of stock, then the nurse should be notified and if it was in the emergency kit, it should be removed and administered. The pharmacy should be called and notified of the medication being out. Medications should be triple checked before being administered. During an interview on 06/27/24 at 1:00 P.M., the Director of Nursing (DON) said if a medication wasn't in the medication cart, then the nurse should be notified and could remove it from the emergency kit if needed. A CMT should let the nurse know the medication wasn't administered and why. When passing medications, the seven rights should be followed and the medications should be compared against the medication orders.

Based on observation, interview and record review, the facility failed to store medications in a safe and effective manner when staff left the medication cart unlocked and unattended. This had the potential to affect all residents. The facility census was 43. Review of the facility's policy titled, Medication Administration, last revised 04/25/24, showed: - Medication will be administered safely and accurately to residents for whom they are prescribed in accordance with current standards of practices; - Medication carts must be kept locked when not in use or in plain sight. 1. Observation on 06/26/24 at 11:17 A.M., of the insulin administration for Resident #31 showed: - Licensed Practical Nurse (LPN) D locked the medication cart, entered the resident's room, and performed the blood sugar reading; - LPN D exited the room, unlocked the medication cart, got the resident's insulin pen from the medication cart, and failed to lock the medication cart; - At 11:18 A.M., LPN D entered the resident's room with the medication cart facing the hallway, unlocked and unattended. The medication cart sat to the side of the resident's door out of sight of staff; - LPN D administered the resident's insulin; - LPN D exited the room and returned to the unlocked medication cart at 11:19 A.M. 2. Observation on 06/26/24 at 11:22 A.M., of the insulin administration for Resident #95 showed: - At 11:22 A.M., LPN D entered the resident's room with the medication cart facing the hallway, unlocked and unattended. The medication cart sat to the side of the resident's door out of sight of staff; - LPN D performed the resident's blood sugar reading; - LPN D exited the room and got the resident's insulin pen from the medication cart; - At 11:24 A.M., LPN D entered the resident's room with the medication cart facing the hallway, unlocked and unattended with the top drawer cracked open one inch. The medication cart sat to the side of the resident's door out of sight of staff; - LPN D administered the resident's insulin; - LPN D exited the room and returned to the unlocked medication cart at 11:26 A.M. During an interview on 06/27/24 at 12:34 P.M., Certified Medication Technician (CMT) F said the medication cart should always be locked when left unattended. During an interview on 06/27/24 at 12:28 P.M., Registered Nurse (RN) B, said the medication cart should always be locked when left unattended. During an interview on 06/27/24 at 12:45 P.M., the Administrator said anytime a medication cart was left unattended, it should be locked. During an interview on 06/27/24 at 1:00 P.M., the Director of Nursing (DON) said anytime a medication cart was left unattended, it should be locked.

Based on observation, interview, and record review, the facility failed to maintain adequate infection control practices to prevent the transmission of infection by failing to ensure proper infection control practices during a medication pass when the staff touched medication with their bare finger and allowed medication to touch the top of the unclean medication cart for two residents (Resident #2 and #20) out of seven sampled residents. The facility failed to ensure the appropriate placement of an indwelling catheter (a flexible tube inserted into the bladder to drain urine) tubing and drainage bag for two residents (Resident #24 and #95) out of three sampled residents. The facility failed to maintain proper infection control practices during incontinent care for one resident (Resident #34) out of four sampled residents. The staff also failed to wear gloves during the procedure of insulin administration that involved a possibility of blood contact for one resident (Resident #95) out of two sampled residents. The facility census was 62. Review of the facility's policy titled, Medication Administration, last revised 04/25/24, showed do not touch the medication with your hands. Review of the facility's policy titled, Hand Hygiene, last review date 06/19/24, showed: - Handwashing is the single most effective measure to reduce the risk of transmission of organisms from one person to another or from one site to another on the same resident. Pathogens (bacteria, virus, or other microorganism that can cause disease) can contaminate the hands of a staff person during direct contact with a resident or contact with contaminated equipment and environmental surfaces within close proximity of the resident; - In this facility, hand hygiene is performed by washing hands with soap and water or using alcohol based hand rub (ABHR); - Hands should be washed in the following situations: Before and after contact with a resident; Before and after use of gloves; Wash hands if they come into contact with blood and/or body fluids containing blood or are visibly soiled. 1. Observation of Resident #2's medication administration 06/26/24 at 8:45 A.M., showed: - Certified Medication Technician (CMT) F did not clean the medication cart or place a clean barrier on top prior the medication administration; - CMT F opened the ondansetron 4 mg medication package, dropped the tablet on top of the unclean medication cart, used a spoon and the medication package to pick up the tablet to put it into a medication cup, and administered the unclean tablet to the resident. 2. Observation of Resident #20's medication administration on 06/26/24 at 8:50 A.M., showed: - CMT F opened the bottle of JuiceFestiv Daily Veggie (a multivitamin) medication; - CMT F poured multiple capsules into the medication bottle lid; - CMT F touched one capsule inside of the medication bottle lid with his/her bare finger to hold it while pouring the other capsules back into the bottle; - CMT F put the capsule into a medication cup and administered the unclean capsule to the resident. During an interview on 06/27/24 at 12:34 P.M., CMT F said medication shouldn't be touched with his/her bare finger and it shouldn't touch the top of the cart that hadn't been cleaned. Review of the facility's policy titled, Personal Care-AM and PM Cares, last revised 04/25/24, showed: - If gloves become soiled, remove, wash hands or use hand sanitizer, and reapply clean gloves; - Remove one glove and cover the resident. Remove the other glove, wash or sanitize hands before further straightening of the resident clothing and bedding. 3. Observation on 06/25/24 at 10:13 A.M., of incontinent care for Resident #34 showed: - Certified Nurse Assistant (CNA) G performed hand hygiene and put on gloves; - CNA G removed the resident's brief soiled with fecal material; - CNA G, with the same soiled gloves, cleaned the fecal material from the resident's buttocks and rectal area; - CNA G, with the same soiled gloves placed a Hoyer (a mechanical lift) pad under the resident, attached the pad to the Hoyer lift, touched the foley catheter tubing, touched the foley catheter drainage bag, touched the pillow, touched the doorknob to the bathroom, touched a clean blanket on a shelf, made up the resident's bed with clean linens, touched and placed a clean draw sheet on the bed, opened the closet door, opened the cabinet drawers, touched and placed a clean incontinent pad on the bed, and the clean bed blankets. During an interview on 06/25/24 at 10:40 A.M., CNA G said incontinent care for residents should start with sanitizing his/her hands, putting on gloves, change the gloves when moving from dirty to clean care, and wash his/her hands before leaving a resident's room. During an interview on 06/27/24 at 2:45 P.M., Registered Nurse (RN) C said hand hygiene should be done before going into a resident's room, should change gloves and perform hand hygiene after incontinent care, should change gloves and perform hand hygiene if gloves were visibly soiled, should perform hand hygiene when care was completed, and should perform hand hygiene when leaving a resident's room. When moving from dirty to clean care, gloves should be changed and hand hygiene should be completed. During an interview on 06/27/24 3:01 P.M., the Director of Nursing (DON) said hand hygiene should be performed prior to entry to residents' room and putting on gloves. If contact with urine or fecal material, staff should perform hand hygiene and change gloves prior to placing a new brief or incontinent pad. When moving from dirty to clean care, staff should perform hand hygiene and change gloves. During an interview on 06/28/24 at 9:09 A.M., the Administrator said when staff go in a resident's room, they should wash or sanitize their hands. Before starting a procedure, they should wash hands, put on gloves. After completing the procedure, they should dispose of the gloves and wash their hands again. Staff should change gloves and perform hand hygiene when moving from dirty to clean care. Review of the facility's policy titled, Catheter Care, last reviewed 04/25/24, showed: - Maintain the position of the drainage bag below the level of the bladder; - Do not rest the drainage bag on the floor; - Ensure the drainage bag is securely attached to the bed frame; - The policy did not address the placement of the tubing. 4. Observations of Resident #24 showed: - On 06/25/24 at 11:22 A.M., and 06/27/24 at 2:18 P.M., the resident sat in a wheelchair in his/her room and the catheter tubing lay under the wheelchair in the floor; - On 06/25/24 at 12:28 P.M. the resident propelled him/herself down the hall and the catheter tubing drug the floor; - On 06/25/24 at 03:54 P.M., and 06/27/24 at 12:59 P.M., the resident sat in a wheelchair at the dining room table and the catheter tubing lay under the wheelchair in the floor; The facility failed to maintain adequate infection control practices by ensuring the resident's catheter tubing did not lay on the floor. 5. Observations of Resident #95 on 06/25/24 at 10:46 A.M., and 11:22 A.M., showed the resident lay in bed with the catheter drainage bag and tubing lay in the floor at the foot of the left side of the bed. During an interview on 06/27/24 at 02:18 P.M., CNA A said the catheter drainage bag and tubing should not be on the floor. During an interview on 06/27/24 at 2:34 P.M., CNA J said the catheter tubing and drainage bag should not be on the floor. During an interview on 06/27/24 at 2:36 P.M., CNA H said the catheter drainage bag and tubing should not be on the floor. During an interview on 06/27/24 at 2:38 P.M., RN B said the catheter tubing and drainage bag should not be on the floor. During an interview on 06/27/24 at 2:40 P.M., Licensed Practical Nurse (LPN) E said catheter drainage bags and tubing should not touch the floor. During an interview on 06/27/24 at 2:47 P.M., the DON said she would expect the catheter drainage bags and tubing never touch the floor. Review of the facility's policy titled, Insulin Administration, last revised 04/25/24, showed: - To provide guidelines for the safe administration of insulin to residents with diabetes; - Wash hands, put on gloves, and remove insulin from the storage; - Check the expiration date, ensure the insulin matches the physician order and dose; - Draw up the amount in the syringe; - Select an injection site, clean the site with alcohol and allow to air dry; - Lightly grasp a fold of skin and insert the needle at a 90 degree angle; - Depress the plunger and remove the needle after waiting 6-10 seconds; - Dispose of the needle in a sharps container, remove gloves, and wash hands. 6. Observation on 06/26/24 at 11:21 A.M., of Resident #95's insulin administration showed: - LPN D sanitized hands and put on gloves; - LPN D entered the resident's room and obtained a blood sugar; - LPN D exited the room, removed the gloves, obtained the resident's insulin pen; - LPN D entered the resident's room, did not perform hand hygiene, did not put on gloves, cleaned the resident's arm with alcohol, and administered the resident's insulin; - LPN D exited the resident's room and removed the needle from the insulin pen without gloves on; - LPN D put the insulin pen back in the medication cart. During an interview on 06/27/24 at 12:28 P.M., RN B said if medication was dropped on top of the medication cart, he/she would give it since it's a clean surface. Should really try not to touch medications with bare fingers. Gloves should be worn when administering insulin. During an interview on 06/27/24 at 12:45 P.M., the Administrator said gloves should be worn with insulin administration. Medications shouldn't be touched with bare fingers. Also, if medication touched the top of the medication cart, it should be wasted. A new medication should be obtained or the physician notified if it's was going to be missed. During an interview on 06/27/24 at 1:00 P.M., the DON said gloves should be worn when administering insulin or anytime there was a chance of coming into contact with blood. Medications shouldn't be touched with bare fingers, and if it was, it should be wasted. A new medication should be obtained if possible and if not, then the physician should be notified that the dose was being missed and why.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to provide a safe environment for the residents and staff by not removing miscellaneous items on top of the overbed light fixtures. The deficient practice had the potential to affect all residents and staff in the facility. The facility census was 43. The facility did not provide a policy regarding a safe environment. 1. Observation on 06/25/24 at 10:04 A.M., of room [ROOM NUMBER] showed three 12 inch (in.) stuffed animals on top of the light fixture on the wall near the window and three stuff animals on the light fixture near the door. 2. Observation on 06/25/24 at 10:15 A.M., of room [ROOM NUMBER] showed one 8 in. x 10 in. picture frame on top of the light fixture above the bed next to the window. 3. Observation on 06/28/24 at 8:20 A.M., of room [ROOM NUMBER] showed four 10 in. and four 6 in. stuffed animals on top of the light fixture above the head of the resident's bed next to the door. During an interview on 06/25/24 at 12:15 P.M., the resident in room [ROOM NUMBER] said the wall fixture above the bed had been decorated for months. During an interview on 06/28/24 at 8:25 A.M., Housekeeper K said normally the room lighting was checked to see if the wall fixture was working. He/She wiped the top off on the fixture and nothing should be left stacked on top of it. If a resident had put something on top of the wall fixture, it was set to the side or somewhere safe. The resident was told if items were moved so they know it was not lost. During an interview on 06/28/24 at 8:30 A.M., Housekeeper L said the resident room lighting was checked during cleaning and there shouldn't be anything stacked on the wall fixtures. Items were removed if they were found stacked on the fixture and the residents were informed it was a fire hazard. The resident was made aware the items were moved to a safe location in the room. During an interview on 06/28/24 at 9:40 A.M., the Maintenance Director said the residents should not be stacking things on the wall fixtures. The Certified Nursing Assistant (CNA) and housekeeping staff members should check for items placed on light fixtures and clear them off when necessary. During an interview on 06/28/24 at 9:46 A.M., the Director of Nursing said lighting should not be used as shelving in the residents' rooms, CNA and housekeeping staff should check for items stacked on fixtures and other concerns when they were in the rooms. During an interview on 06/28/24 at 9:48 A.M., the Administrator said wall mounted light fixtures should not be used as shelving in the residents' rooms.

Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to the hospital, including the reason for the transfer, for one resident (Resident #57). The facility census was 45. Record review of the facility's policy entitled Discharge to Hospital or Other Facility, dated 3/31/22, showed the following information: -Order received from attending physician indicating discharge destination and mode of transportation; -Resident/Responsible Party to be notified of order of discharge. Social Service Representative to be notified to assist with discharge; -Complete a Transfer Form to include resident's name, social security number, Medicare/Medicaid numbers, condition of resident's skin, personal belongings being sent with resident. Copies can be made of current face sheet, current physicians' orders, current medication sheets, Advanced Directives and/or other Health Care Directives, and most recent History and Physical and Doctor's Progress Notes to be sent with Transfer Form. List of all copies that are being sent to be on Transfer Form. Original copy of Transfer Form to be sent in a large yellow envelope with resident's name and receiving facility on it, and current code status. Keep a copy for resident's record; -Nurses' notes should include date and time of discharge, mode of transportation, destination, and accompanied by. For hospital discharge, notify Administrator and Director of Nursing (DON) and document in nurses' notes. (The policy did not include information pertaining to a written notice of transfer given to the resident and/or responsible party.) 1. Record review of Resident #57's face sheet (gives brief information about the resident) showed the following information: -admission date of 12/9/2021; -Diagnoses included paroxysmal atrial fibrillation (irregular heart rhythm), MASD (moisture-associated skin damage), high blood pressure, unsteadiness on feet, muscle weakness (generalized), heart failure, localized edema (swelling), non-ST elevation (NSTEMI) myocardial infarction (heart attack), other lack of coordination, and chronic back pain. Record review of the resident's nurses' notes showed staff documented the following: -On 7/17/2022, 9:43 A.M., at approximately 8:30 A.M. the treatment nurse noted resident not alert like normal with resident's oxygen level low, and heart rate irregular, and resident alert by confused. At 8:55 A.M., staff called physician and received order to send resident to emergency room for evaluation. At 9:00 A.M., staff notified resident's responsible party/family. They stated they will meet resident at the hospital. Ambulance came and transferred resident to the hospital at 9:50 A.M. Report was given to paramedics. Record review of the resident's medical record showed staff did not document written notification to the resident or resident's responsible party of the resident's transfer to the hospital on 7/17/2022. During an interview on 10/14/2022, at 1:40 P.M., the DON said when the facility sends a resident out to the hospital, the nurse calls the responsible party to notify them. They give the resident a Bed-Hold Notice to fill out, if applicable and desired. The DON said they do not give the resident or responsible party a written notice of the transfer. During an interview on 10/14/2022, at 1:43 P.M., Social Services A said he/she was unaware of staff sending out a written notification of a resident's transfer to the hospital or notifying the ombudsman of residents' transfers. During an interview on 10/14/2022, at 1:45 P.M., the Administrator said staff gives a verbal notification to the responsible party when a resident is transferred to the hospital, but does not issue a written notification. The facility notifies the ombudsman when a resident is fully discharged , but not upon transfer to a hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident's choice of code status (the level of medical interventions a person wishes to have started if their heart or breathing stops) was clearly and consistently noted throughout the resident's medical record for one resident (Resident #40). The facility census was 45. Record review of the the facility's policy titled Do Not Resuscitate Order, revised [DATE], showed the following: -Upon admission of a resident to the facility, the social service designee will obtain written wishes regarding cardiopulmonary resuscitation; -A copy of the code information form will be placed in the residents chart; -A physician's order will be obtained; -A red dot sticker will be placed on the resident's name tag at the resident's door; -The facility will not use cardiopulmonary resuscitation (CPR - any medical intervention used to restore circulatory and/or respiratory function that has ceased) and related emergency measures to maintain life functions on a resident when there is a DNR (a medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest) order in effect. 1. Record review of Resident #40's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of [DATE]; -Diagnoses included dementia (an altered mental status) and squamous cell carcinoma of the skin (skin cancer). -DNR noted. Record review of the resident's Code Status Information Sheet, dated [DATE], showed the resident's responsible party signed for the resident to be a Full Code (the resident wishes to receive CPR in the event the heart or breathing stops). Record review of the resident's care plan, last reviewed [DATE], showed the following: -The resident and family chose for the resident to be DNR; -If hospitalized send a copy of written DNR order; -Inform new care givers of DNR code status. Record review of the resident's physician order sheet (POS), dated [DATE], showed no order related to code status. Observation on [DATE], at 10:15 A.M., showed a red dot sticker on the resident's name plate outside his/her door. During an interview on [DATE], at 9:20 A.M., Registered Nurse (RN) C said all residents should have a physician's order to indicate their code status. In the event of an emergency staff look at the resident's face sheet and door sticker to see the resident's code status. He/she said the code status is in the upper corner of the face sheet and a red sticker on the residents name plate indicates the resident wishes to be a DNR. During an interview on [DATE], at 10:00 A.M., Certified Nurse Aide (CNA) D said if a resident is found not breathing or without a pulse staff will look at the resident's name plate. A red sticker indicates the resident will not receive CPR. During an interview on [DATE], at 2:40 P.M., the Director of Nursing (DON) and the Administrator said they would expect the resident's code status to match throughout the residents medical record .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate incontinent care and failed to practice appropriate infection control practices during incontinent care for two residents (Resident #44 and #34). A sample of 13 residents selected for review. The facility census was 51. Record review of the facility policy titled, Personal Cares-Females, last revised 12/30/10, and last reviewed on 11/20/18, showed the following information: -Objective is to cleanse the perineum, assist in preventing skin breakdown of the peri-area and to prevent infection and odor; -Wash hands and gather supplies; -Knock on door and identify yourself; -Explain procedure, assemble equipment, and provide privacy; -Wash hands and put on gloves; -Assist resident to supine or side-laying position, place bed protector under buttocks; -Cover resident with towel and bath blanket exposing only area of the body working with; -Expose peri-area. Gently wash the inner legs and outer area along outside the labia. Wash front to back; -Wash the outer skin folds (labia majora) front to back; -Wash the inner labia (labia minora) front to back; -Gently open all the skin folds in the center and wash the inner area front to back; -Wash and rinse the anal area, pat dry; -If gloves become soiled, remove and wash hands, reapply clean gloves; -Remove towel and/or blanket, place soiled linens/pads in large clear bag; -Remove one glove and cover resident. Remove the other glove and wash hands before further straightening of resident clothing or bedding; -The policy did not direct staff to cleanse all skin the urine soaked brief came into contact with. Record review of the facility policy titled, Personal Cares-Males, last revised 12/30/10, and last reviewed on 11/20/18, showed the following information: -Objective is to cleanse the perineum, assist in preventing skin breakdown of the peri-area and to prevent infection and odor; -Wash hands and gather supplies; -Knock on door and identify yourself; -Explain procedure, assemble equipment and provide privacy; -Wash hands and put on gloves; -Assist resident to supine or side-laying position, place bed protector under buttocks; -Cover resident with towel and bath blanket exposing only area of the body working with; -Expose peri-area. Using a circular motion, gently wash the penis by lifting it up and cleaning from tip downward. If the resident is uncircumcised, retract foreskin, cleanse, rinse, dry and replace foreskin; -Wash, rinse and dry scrotum; -Wash, rinse, and dry other skin areas between legs, paying special attention to skin folds; -Wash and rinse the anal area, pat dry; -If gloves become soiled, remove and wash hands, reapply clean gloves; -Remove towel and/or blanket, place soiled linens/pads in large clear bag; -Remove one glove and cover resident. Remove the other glove and wash hands before further straightening of resident clothing or bedding; -The policy did not direct staff to cleanse all skin the urine soaked brief came into contact with. 1. Record review of Resident #44's face sheet (resident profile sheet) showed the following information: -admitted on [DATE], readmitted on [DATE]; -Diagnosed with epilepsy (seizure disorder), abnormal posture, dementia, major depressive disorder, and insomnia. Record review of the resident's care plan, last reviewed 5/28/19, showed the following information: -The resident was not able to make needs known to staff related to dementia; -The resident required total assistance from staff for daily cares including toileting and personal hygiene; -The resident was incontinent with elimination and wears peri-pads to protect skin; -The care plan directed staff to assist with peri-care after each incontinent episode ensuring to cleanse area from front to back Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 8/26/19, showed the following information: -Short term and long term memory problems; -Severely impaired decision-making; -Total dependence on staff for toileting and personal hygiene; -Diagnoses included dementia, seizure disorder, and depression; -Always incontinent of bowel and bladder. Observation on 9/25/19, at 9:07 A.M., showed Certified Nursing Assistant (CNA) A and Nursing Assistant (NA) B in the resident's room prepping supplies to provide incontinent care for the resident. The resident sat in a broda chair (reclining wheelchair). CNA A and NA B both donned a pair of clear gloves and then donned a pair of yellow gloves over the clear. The aides did not wash their hands prior to donning the gloves. The aides transferred the resident to the bed using the hoyer lift (mechanical lift). CNA A logrolled the resident towards him/herself. NA B rolled the hoyer pad under the resident and pulled the resident's pants down over the left hip. CNA A checked the resident's brief and said it was slightly wet and rolled the resident towards NA B. CNA A removed the hoyer pad, and the resident's pants and socks. CNA A placed the hoyer lift pad, pants and socks in the broda chair. The aides rolled the resident back towards CNA A. NA B used a wet washcloth to wipe the resident's gluteal cleft (the groove between the buttocks) with one wipe, and bagged the wet cloth. The aides did not wipe the resident's buttock cheeks or legs. The aides did not cleanse the resident's front peri-area or vaginal area. NA B removed the yellow set of gloves. On NA B's left hand, the clear glove came off with the yellow glove. NA B obtained a clear glove and donned the glove. The aides did not wash their hands or change their gloves. CNA A and NA B placed a clean brief on the resident, heel protectors, and pulled up the side rails. During an interview on 9/25/19, at 9:15 A.M., CNA A said the resident is total care, and the staff have to anticipate the needs of the resident. 2. Record review of Resident #34's face sheet showed the following information: -admitted on [DATE], readmitted on [DATE]; -Diagnosed with dementia with behavioral disturbances, restlessness and agitation, intellectual disabilities, and major depressive disorder. Record review of the resident's care plan, last reviewed 12/12/18, showed the following information: -The resident had short term and long-term memory problems; -The resident required total assistance from staff for daily cares including toileting and personal hygiene; -The resident was incontinent of bowel and bladder; -The resident was incontinent with elimination and wears peri-pads to protect the skin; -The care plan directed staff to provide peri-care after every incontinent episode. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Short term and long term memory problems; -Severely impaired decision-making; -Total dependence of staff for toileting and personal hygiene; -Diagnoses included dementia; -Always incontinent of bowel and bladder. Observation on 9/24/19, at 12:19 P.M., NA B obtained gloves in the hall and used hand sanitizer, while CNA A entered the room. The resident lay in bed with eyes closed. CNA A and NA B both donned a pair of clear gloves and then donned a pair of yellow gloves over the clear. NA B closed the resident's door. CNA A said, I learned this trick at the hospital, while pulling on the second pair of gloves. NA B said, There is only one wash cloth in the room, CNA A said That will work, he/she's not dirty, just wet. CNA A rolled the resident up on his/her right side and removed the resident's brief, and pushed it under the resident's buttocks. NA B used the wet washcloth to wipe the resident's gluteal cleft back and forth one time and then changed the position of the cloth and wiped one more time. The aides did not cleanse the resident's legs or buttock cheeks. The aides did not cleanse the front perineal area of the resident. CNA A allowed the resident to roll onto his/her back and then removed the wet brief. CNA A removed the set of yellow gloves, leaving the clear gloves on. CNA A applied a clean brief to the resident. NA B placed the dirty brief into a trash bag and removed the yellow set of gloves. The aides did not wash their hands or don new gloves. NA B assisted with clothing and putting the hoyer pad under the resident. With the same contaminated gloves, the aides transferred the resident with a hoyer pad. With the same contaminated gloves, NA B brushed the resident's hair and CNA A made the resident's bed. The aides removed the clear gloves and propelled the resident to the dining room. 3. During an interview on 9/25/19, at 2:18 P.M., CNA A and NA B said the following: -While providing care to residents, the aide should gather needed supplies, provide privacy and explain the procedure; -The aide should don a pair of gloves, remove the resident's brief and clean the resident's perineal area front to back, never going back to front; -The aide should clean every area of skin on the resident that may have been touched by the wet incontinent brief, including the groin, penis, or inside the vagina; -The aide should change gloves before applying the new brief or clothes; -CNA A said he/she learned to double glove when working at the hospital. 4. During an interview on 9/26/19, at 8:57 A.M., Licensed Practical Nurse (LPN) K said the following: -When the aides are providing peri-care to residents, they should enter the room with needed supplies, provide privacy, explain the procedure, and wash their hands prior to donning gloves; -The aides should provide the peri-care, cleansing all the skin that was in contact with the wet or soiled brief, moving front to back and cleaning the penis or vagina; -The aides should then remove the gloves, wash their hands and don new clean gloves prior to applying any creams, brief or clothing; -It is not appropriate for an aide to wear two sets of gloves, and remove one set to apply the clean brief and clothes. 5. During an interview on 9/26/19, at 11:25 A.M., the Director of Nursing (DON) said the following: -When the aides are providing peri-care to residents, they should enter the room with supplies, provide privacy, explain the procedure, and wash their hands prior to donning gloves; -The aides should provide the peri-care, cleansing all the skin that was in contact with the wet or soiled brief, moving front to back and cleaning the penis or vagina; -The aides should change the position of the cloth with each wipe; -The aides should then remove the gloves, wash their hands and don new clean gloves prior to applying any creams, brief or clothing; -It is not appropriate for an aide to wear two sets of gloves, and remove one set to apply the clean brief and clothes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility staff failed to read two residents' (Resident #13 and #202) tuberculosis (TB) (an infectious disease that mainly affects lungs) tests within the required 48-72 hour timeframe and failed to document the test results in millimeters (mm) for three residents (Resident #13, #202 and #203). A sample of 13 residents was selected for review in a facility with census of 51. 19 CSR 20-20.100 - General requirements for Tuberculosis Testing for Residents in Long-Term Care Facilities states the following: -Long-term care facilities shall screen their residents for tuberculosis. Each facility shall be responsible for ensuring that all test results are completed and that documentation is maintained. -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test. If the initial test is negative, the second test should be given one to three weeks later. -All skin test results are to be documented in millimeters (mm) of induration. Record review of the facility's policy entitled, Infection Control: TB Screening for Residents, dated 7/26/19, showed the following information: -Purpose: To establish a system of screening all admitted residents for infectious TB disease and prevent the spread of the disease to other residents and staff; -When a resident is admitted to the facility with documentation of a prior two-step TB skin test with negative results, no further skin testing is required unless he/she has been exposed to infectious TB or develops signs and symptoms of TB; -When a resident is admitted with no documentation of a prior two-step TB skin test, the resident is to be given the first TB skin test and documented on the Testing and Immunizations form in the resident's chart within the first 48 hours. Results are to be read after 48-72 hours and documented. If result is negative the second TB skin test is to be given within 1-3 weeks with results read and documented on the form in the resident's chart. If result is negative, no further skin testing is required unless exposed to infectious TB or develop signs and symptoms of TB; -If a resident is admitted to the facility with documentation of the first TB skin test within the past year, administer the second step TB skin test and read results within 48-72 hours and document the results in the resident's chart. If result is negative, no further skin testing is required unless exposed to infectious TB or resident develops signs and symptoms of TB; -If resident admitted to the facility with prior history of positive results or has a positive reaction to an TB skin test given with no sign and symptoms of infectious TB, the resident's physician is to be notified for a follow-up chest x-ray within one week. If x-ray results are normal, within three days refer resident to physician for preventative treatment and the medical records designee or director of nursing will notify the Local Public Health Agency; -If resident refuses or cannot continue preventative treatment they will be monitored for signs and symptoms of infectious TB and require annual documentation in resident's record to rule out signs and symptoms of TB; -If result to any TB skin test are positive and results of follow up chest x-ray are abnormal, the resident is referred to the physician immediately. The medial records designee or the director of nursing will notify the Local Public Health Agency within one day and the Department of Health and Senior Services within seven days, and will follow directives of the physician or Local Public Health Agency; -Attending physician will document annually with annual physical and evaluation to rule out signs and symptoms of TB; -Documentation of Mantoux TB skin test are to be completed on the PPD/Mantoux TB skin test flow sheet in each medication room until completed and on each resident's individual immunization record kept in their medical record; -If the facility has a shortage of testing supplies or is unable to obtain testing supplies for TB, the facility will assess new residents at the time of admission for signs and symptoms of TB. This will be documented in the resident record. The facility may postpone the testing until supplies are available. For residents who did not receive testing at admission due to shortage of supplies, they will have testing completed within a reasonable time period when supplies are available. 1. Record review of Resident #202's face sheet (resident profile information) showed the following information: -admitted to the facility post-hospitalization on 9/11/19; -Diagnoses included altered mental status, dementia without behavioral disturbance, high blood pressure, hyperglycemia (high blood sugar), dehydration, and history of urinary tract infection. Record review of the resident's immunization record showed the following information: -Staff administered Step 1 of the two-step TB testing on 9/11/19. Staff read the test on 9/16/19 (greater than 72 hours after administration and documented as -(negative). Staff did not document the test result in mm; -Staff administered Step two on 9/21/19. Staff read the test on 9/24/19 and documented the result as -(negative). Staff did not document the test in mm. 2. Record review of Resident #13's face sheet showed the following information: -He/she admitted to the facility post-hospitalization on 12/21/18; -Diagnoses included stroke, muscle wasting and weakness, coronary artery disease, major depressive disorder, osteoarthritis, dementia, Alzheimer's disease, and Type 2 diabetes. Record review of the resident's immunization record showed the following information: -Staff administered Step 1 of the two-step TB test on 12/21/18. Staff read the test on 12/25/18 (greater than 72 hours after administration) and documented the result as - (negative). Staff did not document the test results in mm; -Staff administered Step 2 on 1/1/19. Staff read the test on 1/4/19 and documented the result as negative. 3. Record review of Resident #203's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included high blood pressure, Type 2 diabetes, dementia, anxiety and depression. Record review of the resident's immunization record showed the following information: -Staff administered Step 1 of the two-step TB test on 12/6/18. Staff read the test on 12/9/18 and documented the result as negative. Staff did not document the test result in mm; -Staff administered Step 2 on 12/16/18. Staff read the test on 12/19/18 and documented the result as negative. Staff did not document the test result in mm. 4. During an interview on 9/25/19, at 2:30 P.M., Registered Nurse (RN) E said: -Residents receive the two-step TB test upon admission; -The results should be read 48-72 hours after administration and recorded in the resident's medical record as negative; -The second step is administered 10 days later, is read 48-72 hours after administration, and is recorded in the resident's medical record as negative; -If the result is read outside of the 48-72 hours, then they begin the whole series again. 5. During an interview on 9/26/19, at 11:05 A.M., the Director of Nursing (DON) said when a resident is admitted , the charge nurse on on duty is responsible for initiating the TB two-step testing. Information regarding the process is passed along to the next shifts via a form posted on the medication room door. The form indicates when staff administered the test and when it should be read. TB tests should be read within 72 hours. Staff should document the test results in mm and also negative if applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report two allegations of resident-to-resident abuse involving two residents (Resident #18 and Resident #15) to the state licensing agency (Department of Health & Senior Services- DHSS) within the required two-hour timeframe. A sample of 13 residents was selected for review in a facility with a census of 51. Record review of the facility's policy and procedure entitled, Abuse Prevention, Intervention, Reporting and Investigation (revision Date 8/11/17), showed the following information: -Residents are to be free from verbal, sexual, physical, and emotional/mental abuse; neglect; self abuse/self-neglect; medical neglect; misappropriation of resident property; corporal punishment; and involuntary seclusion at all times; -Abuse is defined as the willful infliction of injury; -Abuse may be resident to resident, staff to resident, or visitor to resident; -All alleged violations involving abuse are reported immediately, but no later than (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; -The administrator provides a written report of the results of the investigation and action taken to the State survey agency within five (5) working days. 1. Record review of Resident #18's face sheet (gives basic profile information regarding the resident) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included Alzheimer's disease, recurrent urinary tract infection (UTI), and anxiety disorder. Record review of the Resident #18's care plan, dated 6/26/19, showed the following information: -Started on medication related to decline in mood, crying frequently, not sleeping at night, and having some agitation; -Confused at all times; -Has become agitated at other residents, threatening to push them down or grab their hand and refuse to let go. Potential for disruption in the living environment related to agitation; currently on medication to help control anxiety/behaviors/agitation. Record review of Resident #15's face sheet showed the following information: -Latest readmission to the facility on 2/4/16; -Diagnoses included moderate intellectual disabilities, muscle weakness, unsteady on feet, and anxiety disorder. Record review of Resident #15's care plan, last updated 7/29/19, showed the following information: -Moderate mental retardation; mentality of a 5-year old. -Enjoys sitting in the chair by the front door (in between the main dining room and the north hallways) and visiting with passersby; -Wants to be part of everything. Gets very excited about activities and needs reminders to slow down when going room to room; -Can become too hyperactive with too much environmental stimuli; decrease stimuli by promoting a calm, quiet environment; -Has had conflicts with other residents; may start arguments with that same resident later. Takes medication that helps with agitation; watch for side effects. 2. Record review of Resident #18's nurse's note, dated 7/25/19, at 9:25 P.M., showed staff documented Resident #18 stood in the doorway to the main dining room. When Resident #15 attempted to go into the dining room, Resident #18 grabbed Resident #15's arm and started slapping him/her and telling him/her, No. Resident #15 told Resident #18 to let go. Resident #18 continued to grab Resident #15's arm and slap at him/her. Resident #15 then hit Resident #18 on the head with a comic book, magazine, and purse. Staff notified the physician and resident's family member of the incident. Record review of Resident #15's nurse's note, dated 7/25/19, at 9:00 P.M. , showed staff documented that Resident #15 attempted to go into the main dining room when Resident #18 told him/her, No, grabbed his/her arm, and started slapping his/her arm. Resident #15 told him/her to let him/her go, but Resident #18 refused to stop. Resident #15 hit Resident #18 on the head with a comic book, magazine, and a purse. Staff notified Resident #15's physician, family, and local guardian. Record review of a facility Incident/Accident Report for Resident #18, dated/timed 7/25/19, at 7:05 P.M., showed the following information: -Resident #18 stood in the main dining room doorway when Resident #15 attempted to get through the doors. Resident #18 grabbed Resident #15's right arm and started slapping his/her right arm. -Resident #15 told him/her to stop and then hit Resident #18 on the head with a coloring book, magazine, and a purse; -There were no apparent injuries; -Resident #18 was noted to be disoriented; normal for the resident; -Staff notified Resident #18's physician and his/her family; -The administrator signed off on the report. Record review of a facility Incident/Accident Report for Resident #15, dated/timed 7/25/19, at 7:05 P.M., showed the following information: -Resident #18 stood in the main dining room doorway, when Resident #15 attempted to get through the doors. Resident #18 refused to let Resident #15 pass, grabbed his/her right arm, told him/her, No and started slapping the right arm. Resident #15 told him/her to leave him/her alone; when Resident #18 did not let go, this resident then hit Resident #18 on the head with a coloring book, magazine, and a purse; -There were no apparent injuries; -The resident's level of consciousness normal for the resident; -Staff notified Resident #15's physician and his/her legal guardian; -The administrator signed off on the report. Record review of DHSS records showed the facility did not report the resident to resident altercation that occurred on 7/25/19 to the State agency. 3. Record review of Resident #18's nurse's note, dated 7/29/19, at 8:00 P.M., showed staff documented at 5:20 P.M., Resident #18 was in the main dining room attempting to take glasses and the tablecloth off the table. Resident #15 told him/her to stop doing that. Resident #18 turned to Resident #15, told him/her to shut up, and slapped his/her right cheek. Record review of Resident #15's nurse's note, dated 7/29/19, at 8:20 P.M., showed staff documented Resident #15 sat at his/her table in the main dining room, when Resident #18 started taking things off of the table. Resident #15 told him/her to stop doing that. Resident #18 turned, told Resident #15 to Shut up, and then slapped him/her on the right cheek. Record review of a facility Incident/Accident Report for Resident #18, dated/timed 7/29/19, at 5:20 P.M., showed the following information: -Resident #18 was in the main dining room before supper and attempted to take things off of the table. Resident #15 told Resident #18 to stop it. Resident #18 told Resident #15 to shut up and slapped him/her on the right cheek; -Staff notified the physician and the resident's family; -Staff documented notification of the administrator, who signed off on the report. Record review of a facility Incident/Accident Report for Resident #15, dated/timed 7/29/19, at 5:20 P.M., showed the following information: -Resident #15 sat at a table in the main dining room before supper. Resident #18 began to take things off of the table, stating it was messy. Resident #15 told Resident #18 to leave the stuff alone. Resident #18 slapped the right side of Resident #15's face; -Staff notified the physician and the resident's legal guardian; -Staff documented notification of the administrator, who signed off on the report. Record review of DHSS records showed the facility did not report the resident to resident altercation that occurred on 7/29/19 to the State agency. 4. During an interview on 9/26/19, at 11:05 A.M., the Director of Nursing (DON) said regarding any type of abuse from any source, staff should first get the residents to safety and protect them. All incidents involving resident to resident or employee to resident abuse should be reported to him/her and notification made to the administrator. An investigation should be completed and the State notified. The Assistant Director of Nursing (ADON) said the facility in-services include stressing to staff the 2-hr reporting time to the State and to notify the physicians and families/guardians of involved residents. The administrator said staff did report to him/her both incidents involving Resident #18 and #15, but did not assess the actions as intent to harm the other resident. Staff notified physicians and families. 5. During an interview on 9/26/19, at 8:46 A.M., the administrator said the facility had not completed any investigations during July 2019. He/she said if a resident to resident altercation was determined to be abuse, they would report the incident to the State agency. Resident #18 might push or swat at Resident #15; the facility would report an incident that involved actual contact that was intended to harm another resident. Staff would tell the administrator about the incident, who would then report it to the State agency. Staff could also call in a facility self report to the State.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to thoroughly investigate two allegations of resident-to-resident abuse involving two residents (Resident #18 and #15) and submit copies of the investigations to the state agency (Department of Health and Senior Services-DHSS) within the required five days. A sample of 13 residents was selected for review in a facility with a census of 51. Record review of the facility's policy and procedure entitled, Abuse Prevention, Intervention, Reporting and Investigation (revision Date 8/11/17), showed the following information: -Residents are to be free from verbal, sexual, physical, and emotional/mental abuse; neglect; self abuse/self-neglect; medical neglect; misappropriation of resident property; corporal punishment; and involuntary seclusion at all times; -All reports of the above are promptly and thoroughly investigated by facility management; -Abuse is defined as the willful infliction of injury; -Abuse may be resident to resident, staff to resident, or visitor to resident; -All alleged violations involving abuse are reported immediately, but no later than (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury; -When an abuse incident or suspected incident occurs, the administrator, Director of Nursing, or nursing designee investigates the allegation, inclusive, at a minimum, of the following: -Reviews the completed resident Potential Resident Abuse Report form; -Interviews the persons reporting the incident; -Interviews the resident (if appropriate); -Interviews any witnesses to the incident; -Interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; -Witness reports are documented in writing by the investigator and are signed and dated by both the interviewer and witness. A copy of each report is attached to the Abuse Investigation Report Form; -The administrator provides a written report of the results of the investigation and action taken to the state survey agency within five (5) working days. 1. Record review of Resident #18's face sheet (gives basic profile information regarding the resident) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included Alzheimer's disease, recurrent urinary tract infection (UTI), and anxiety disorder. Record review of the Resident #18's care plan, dated 6/26/19, showed the following information: -Started on medication related to decline in mood, crying frequently, not sleeping at night, and having some agitation; -Confused at all times; -Has become agitated at other residents, threatening to push them down or grab their hand and refuse to let go. Potential for disruption in the living environment related to agitation; currently on medication to help control anxiety/behaviors/agitation. Record review of Resident #15's face sheet showed the following information: -Latest readmission to the facility on 2/4/16; -Diagnoses included moderate intellectual disabilities, muscle weakness, unsteady on feet, and anxiety disorder. Record review of Resident #15's care plan, last updated 7/29/19, showed the following information: -Moderate mental retardation; mentality of a 5-year old. -Enjoys sitting in the chair by the front door (in between the main dining room and the north hallways) and visiting with passersby; -Wants to be part of everything. Gets very excited about activities and needs reminders to slow down when going room to room; -Can become too hyperactive with too much environmental stimuli; decrease stimuli by promoting a calm, quiet environment; -Has had conflicts with other residents; may start arguments with that same resident later. Takes medication that helps with agitation; watch for side effects. 2. Record review of Resident #18's nurse's note, dated 7/25/19, at 9:25 P.M., showed staff documented Resident #18 stood in the doorway to the main dining room. When Resident #15 attempted to go into the dining room, Resident #18 grabbed Resident #15's arm and started slapping him/her and telling him/her, No. Resident #15 told Resident #18 to let go. Resident #18 continued to grab Resident #15's arm and slap at him/her. Resident #15 then hit Resident #18 on the head with a comic book, magazine, and purse. Staff notified the physician and resident's family member of the incident. Record review of Resident #15's nurse's note, dated 7/25/19, at 9:00 P.M. , showed staff documented that Resident #15 attempted to go into the main dining room when Resident #18 told him/her, No, grabbed his/her arm, and started slapping his/her arm. Resident #15 told him/her to let him/her go, but Resident #18 refused to stop. Resident #15 hit Resident #18 on the head with a comic book, magazine, and a purse. Staff notified Resident #15's physician, family, and local guardian. Record review of a facility Incident/Accident Report for Resident #18, dated/timed 7/25/19, at 7:05 P.M., showed the following information: -Resident #18 stood in the main dining room doorway when Resident #15 attempted to get through the doors. Resident #18 grabbed Resident #15's right arm and started slapping his/her right arm. -Resident #15 told him/her to stop and then hit Resident #18 on the head with a coloring book, magazine, and a purse; -There were no apparent injuries; -Resident #18 was noted to be disoriented; normal for the resident; -Staff notified Resident #18's physician and his/her family; -The administrator signed off on the report. Record review of a facility Incident/Accident Report for Resident #15, dated/timed 7/25/19, at 7:05 P.M., showed the following information: -Resident #18 stood in the main dining room doorway, when Resident #15 attempted to get through the doors. Resident #18 refused to let Resident #15 pass, grabbed his/her right arm, told him/her, No and started slapping the right arm. Resident #15 told him/her to leave him/her alone; when Resident #18 did not let go, this resident then hit Resident #18 on the head with a coloring book, magazine, and a purse; -There were no apparent injuries; -The resident's level of consciousness normal for the resident; -Staff notified Resident #15's physician and his/her legal guardian; -The administrator signed off on the report. Record review showed no thorough investigation documented for the above referenced resident to resident altercation on 7/25/19. 3. Record review of Resident #18's nurse's note, dated 7/29/19, at 8:00 P.M., showed staff documented at 5:20 P.M., Resident #18 was in the main dining room attempting to take glasses and the tablecloth off the table. Resident #15 told him/her to stop doing that. Resident #18 turned to Resident #15, told him/her to shut up, and slapped his/her right cheek. Record review of Resident #15's nurse's note, dated 7/29/19, at 8:20 P.M., showed staff documented Resident #15 sat at his/her table in the main dining room, when Resident #18 started taking things off of the table. Resident #15 told him/her to stop doing that. Resident #18 turned, told Resident #15 to Shut up, and then slapped him/her on the right cheek. Record review of a facility Incident/Accident Report for Resident #18, dated/timed 7/29/19, at 5:20 P.M., showed the following information: -Resident #18 was in the main dining room before supper and attempted to take things off of the table. Resident #15 told Resident #18 to stop it. Resident #18 told Resident #15 to shut up and slapped him/her on the right cheek; -Staff notified the physician and the resident's family; -Staff documented notification of the administrator, who signed off on the report. Record review of a facility Incident/Accident Report for Resident #15, dated/timed 7/29/19, at 5:20 P.M., showed the following information: -Resident #15 sat at a table in the main dining room before supper. Resident #18 began to take things off of the table, stating it was messy. Resident #15 told Resident #18 to leave the stuff alone. Resident #18 slapped the right side of Resident #15's face; -Staff notified the physician and the resident's legal guardian; -Staff documented notification of the administrator, who signed off on the report. Record review of Resident #15's care plan, last updated 7/29/19, showed staff noted incidents of 7/25/19 and 7/29/19 on the care plan; staff to increase distance between this resident and others that agitate him/her. Record review showed no thorough investigation documented for the above referenced resident to resident altercation on 7/29/19. 4. Record review of DHSS records showed the facility did not forward any investigations to the State agency regarding resident to resident altercations that occurred on 7/25/19 and 7/29/19. 5. During an interview on 9/26/19, at 8:46 A.M., the administrator said they had not completed any investigations during July 2019. He/she said if a resident to resident altercation was determined to be abuse, they would report the incident to the state agency. Resident #18 might push or swat at Resident #15; the facility would report an incident that involved actual contact that was intended to harm another resident. 6. During an interview on 9/26/19, at 11:05 A.M., the Director of Nursing (DON) said regarding any type of abuse from any source, staff should first get the residents to safety and protect them. All incidents involving resident to resident or employee to resident abuse should be reported to him/her and notification made to the administrator. An investigation should be completed. The administrator said staff did report to him/her both incidents involving Residents #18 and #15, but did not assess the actions as intent to harm the other resident. Interventions were placed to keep the residents separated, watch Resident #15 for actions and agitation, and watch his/her sugar intake which historically had increased actions. The incident reports on 7/25/19 and 7/29/19 were considered investigations, and staff notified physicians and families.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a Bed Rail Safety Check to include measurements of the bed frame and bed rails for risk of entrapment; failed to ensure all consents, physician orders, assessments, and care plans were updated and matched the current side rail on the resident's bed for five residents (Resident #44, #34, #22, #27 and #41). A sample of 13 residents was chosen with a facility census of 51. Record review of the guidance for industry and Food and Drug Administration (FDA) staff, hospital bed system dimensional and assessment guidance to reduce entrapment, issued on 3/10/2006, from the FDA, Center for Devices and Radiological Health, showed the following information: -The term medical bed and hospital bed are used interchangeably and include adult medical beds with side rails; -Evaluating the dimensional limits of the gaps in hospital beds may be one component of a bed safety program, which includes a comprehensive plan for patient and bed assessment; -Bed safety programs may also include plans for reassessment of hospital bed systems; -Reassessment may be appropriate when there is reason to believe that some components are worn, such as rails wobble, rails have been damaged, mattresses are softer, and could cause increased spaces within the bed system; when accessories such as mattress overlays or positioning poles are added or removed; when components in the bed system are changed or replaced, such as new bed rails or mattresses; -Bed rails are rigid bars that are attached to the bed and are available in a variety of sizes and configurations from full length to half, one-quarter, and one-eighth length and are used as restraints, reminders, or as assistive devices; -Zone 1 is the measurement within the rail, any open space within the perimeter of the rail, a loosened bar or rail can change the size of the space; -Zone 2 is the gap under the rail between a mattress compressed by the weight of a patient's head and the bottom edge of the rail at a location between the rail supports or next to a size rail support. Factors to consider are the mattress compressibility, which may change over time due to wear, the lateral shift of the mattress or rail, and any degree of play from loosened rails or rail supports. A restless patient may enlarge the space by compressing the mattress beyond the specified dimensional limit. This space may also change with different rail height positions and as the head or foot sections are raised or lowered; -Zone 3 is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head; -Zone 4 space is the gap that forms between the mattress compressed by the patient and the lowermost portion of the rail, at the end of the rail. Factors that may increase the gap size are mattress compressibility, lateral shift of the mattress or rail, and degree of play from loosened rails; -General testing considerations include for ease of mattress movement and measurement, and general safety, the patient should not be in the bed during the measurement procedures. Record review of the facility policy, titled Bed Rail Policy and Procedure, revised 8/9/2010 and reviewed on 4/29/19, showed the following information: -The purpose of the policy is to ensure residents who use bed rails remain as safe as possible, through appropriate use and maintenance of such devices; -Bed rails are solely intended to prevent individuals from falling from bed and for repositioning; -Bed rails should not be used as a restraint and must be solely used for medical necessity; -Staff will complete a side rail and alternative equipment tree and the resident or responsible party will sign a consent form; -A physician's order must be in place for use of bed rails; -At admission, the staff will complete an evaluation of side rail usage as part of the comprehensive resident assessment. From this assessment, if the resident or responsible party express interest in side rails, the staff will give them information about alternatives to side rails and the risks involved with side rail use; -The staff will notify the resident's physician to obtain an order for side rail use, including the type of side rail, and why they are being used; -If the resident and/or responsible party want side rails, staff should have a consent form signed and place it in the chart; -Documentation will be included in the nurse's notes and reviewed with each full, significant change and quarterly assessments, and addressed in care plans. Ongoing assessments will be completed as change in resident conditions or beds warrant and will be reviewed with quality assurance audits as determined by the quality assurance team; -The facility policy failed to direct staff to obtain safety measurements of the bed frame and bed rails for risk of entrapment. 1. Record review of Resident #41's face sheet (brief resident profile information) showed the following information: -admitted [DATE]; -Diagnoses included contracture of muscle, abnormal posture, psychotic disorder with delusions, transient cerebral ischemic attack (stroke that lasts for a few minutes), muscle weakness, abnormalities of gait and mobility, insomnia, high blood pressure, and dementia with behavioral disturbance and psychosis. Record review of the resident's Consent for use of Physical Restraints, dated 7/24/17, showed the following information: -Staff documented the use of two short side rails (1/2 length) and a winged mattress; -The resident's family member signed the consent form on 7/29/17; -Facility staff reviewed the consent form on: 1/1/18, 5/8/18, 9/6/18, 10/29/18, 1/9/19, and 5/2/19. Record review of the resident's Restraint: Side rail and Alternative Equipment Intervention Decision Tree, dated 7/24/17, showed the following information: -Staff highlighted the path on the decision tree to the box indicating the resident should be referred to physical or occupational therapy for trial use of ½ or ¼ side rails; -Staff noted to the side of this box the resident currently received restorative nursing for mobility. Record review of the resident's physician order sheet (POS), dated September 2019, showed an order dated 9/13/18, okay to use two short side rails with winged mattress, check every shift. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 8/18/19, showed the following information: -Significantly cognitively impaired; -Total dependence on two staff members for bed mobility, transfers, dressing, and toilet use; -Total dependence on one staff member for locomotion, eating, and personal hygiene; -Diagnoses included dementia; -Bed rails not used. Record review of the resident's care plan, last reviewed 9/7/19, showed the following information: -The resident was not able to make needs known to staff related to dementia; -The resident required total assistance from staff for daily cares, transfers, toilet use, and bed mobility; -The resident was okay to use two short side rails (1/2 side rails) with a winged mattress, check every shift. Record review of the resident's medical record showed staff did not complete the Bed Rail Safety Check to include measurements of the bed frame and side rails for risk of entrapment. Observation on 9/23/19, beginning at 10:03 A.M., showed the following information: -Resident's bed had two ¾ side rails (long metal rail with three cross bars that is placed in the middle of the bed and measured 45 inches in length with a 12 inch gap at the head of the bed and an 18 inch gap at the foot of bed) in the raised position. Observation on 9/23/19, at 4:00 P.M., showed the following: -Resident's bed had two ¾ side rails in the raised position; -Resident lay in bed and grasped the left side rail with both hands; -Resident pulled him/herself up against the side rail. Observation on 9/24/19, at 9:01 A.M., showed the resident's bed had two ¾ side rails in the raised position. Observation on 9/24/19, from 3:14 P.M. to 3:45 P.M , showed the following: -Resident lay in bed; -Resident's bed had two ¾ side rails in the raised position; -Resident grasped the left side rail with both hands and pulled him/herself into a seated position; -Resident placed his/her chest on top of the left side rail and yelled, I want to get out of bed; -Resident laid back down in the bed; -Resident continued to grasp the left side rail, pulled his/her upper torso against the left side rail, and placed his/her forehead against the left side rail; -Resident alternated between rising into a seated position and pushing his/her forehead against the left side rail while yelling, I want to get out of bed; -Staff did not respond to the resident. Observation on 9/25/19, at 8:43 A.M., showed the resident's bed had two ¾ side rails in the raised position. Observation on 9/25/19, at 2:21 P.M., showed the following: -Resident lay in bed; -Resident's bed had two ½ side rails in the raised position; -Resident grabbed the left side rail and pulled him/herself into a seated position and yelled, I want to get out of bed. During an interview on 9/25/19, at 2:21 P.M., Certified Nursing Assistant (CNA) C said: -He/she notifies a nurse when a resident is no longer utilizing the side rails as they should be or when he/she feels a side rail would be useful for a resident; -Resident #41 had ¾ side rails prior to this morning; -Resident #41 now has ½ side rails which allow him/her to get out of the bed; -Resident #41 needs the ¾ side rails to keep him/her in the bed; -Resident #41 does utilize the side rails for bed mobility and will pull him/herself into a seated position or up in bed when someone walks by his/her room. During an interview on 9/25/19, at 2:26 P.M., CNA D said: -He/she notifies the charge nurse if he/she feels a resident could benefit from a side rail; -Resident #41 uses his/her side rail to assist with getting out of bed; -Staff changed Resident #41's side rails this morning from the ¾ side rails to the ½ side rails; -Resident #41 requires the ¾ side rails to keep his/her butt in bed, otherwise the resident is able to get out of bed without the aides knowing it; -A few months ago, staff changed the resident's rails to the shorter ½ side rails; -Staff switched the rails, unsure of the exact date, back to the longer rails; -He/she is going to speak with the charge nurse about putting the longer side rails back on the bed because that is what the resident needs and it will keep the resident in the bed. During an interview on 9/25/19, at 3:22 P.M., CNA G said: -Resident #41 had short rails on his/her bed about 3 weeks ago; -The ¾ rails appeared recently, but is uncertain on the exact date; -The resident is able to pull him/herself into a seated position by utilizing the side rails for bed mobility; -The resident does not try to get out of bed by him/herself but he/she will fall out of bed due to wiggling around; -The purpose of the rails is to keep the resident from falling out of bed. During an interview on 9/25/19, at 2:30 P.M., Registered Nurse (RN) F said: -Resident #41 should have had short rails on both sides of the bed since that is what the order is for; -He/she is not sure when staff put the longer rails on the bed, but the resident's bed had ¾ side rails on both sides of the bed; -But, he/she changed them back this morning to the correct rails; -Resident #41 does utilize the side rails for bed mobility and to assist with transfers; -He/she has had to educate CNAs and other staff that ¾ side rails are considered a restraint and cannot be used. During an interview on 9/26/19, beginning at 11:05 A.M., the administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) said: -Resident #41 was not supposed to have ¾ side rails on his/her bed, it should have been the short rails; -The facility would not utilize ¾ side rails to keep a resident in bed and staff have been educated on this. 2. Record review of Resident #44's face sheet showed the following information: -admitted on [DATE], readmitted on [DATE]; -Diagnosed with epilepsy (seizure disorder), abnormal posture, dementia, major depressive disorder, and insomnia. Record review of the resident's Consent for use of Physical Restraints, dated 7/25/17, showed the following information: -Staff documented the use of two ½-length side rails; -The resident's family member signed the consent form on 7/27/17; -Facility staff reviewed the consent form on 1/3/18, 5/16/18, 6/28/18, 10/29/18, 1/8/19, and 4/30/19. Record review of the resident's POS, dated September 2019, showed an order dated 7/25/17, for ½ length side rails up on both sides when the resident is in bed, for feeling of security. Record review of the resident's Restraint: Side rail and Alternative Equipment Intervention Decision Tree, dated 7/25/17, showed the staff documented to refer to team for removal of side rails. Record review of the resident's care plan, last reviewed 5/28/19, showed the following information: -The resident was not able to make needs known to staff related to dementia; -The resident required total assistance from staff for daily cares and bed mobility; -The resident's bed had two ½-side rails up when in bed to aide in bed mobility and promote the feeling of security. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Short term and long term memory problems; -Severely impaired decision-making; -Total dependence on staff for bed mobility and transfers; -Diagnoses included dementia, seizure disorder, and depression; -Bed rails not used; -No falls; -No behaviors. Record review of the resident's medical record showed no Bed Rail Safety Check to include measurements of the bed frame and side rails for risk of entrapment. Observation on 9/23/19, at 10:45 A.M., showed the resident in bed with side rails up on both sides of the bed. The side rails extended approximately from the resident's head to approximately the resident's mid-calf. Observation on 9/24/19, at 9:43 A.M., showed the resident in bed with side rails up on both sides of the bed. Observation on 9/24/19, at 12:07 P.M., showed the resident in bed with side rails up on both sides of the bed. CNA A and Nurse Aide (NA) B lowered the side rails and performed personal cares on the resident, rolling the resident back and forth and having to hold the resident in position for the cares. The resident did not grab the side rails or assist in the turning back and forth for the cares. Observation and interview on 9/25/19, at 9:07 A.M., showed CNA A and NA B transferred the resident to the bed and performed personal cares for the resident, rolling the resident back and forth and having to hold the resident in position for the cares. The resident did not grab the side rails or assist in the turning back and forth for the care. When the aides finished positioning the resident for comfort, they raised the side rails on both sides of the bed. CNA A said the resident is total care, and the staff have to anticipate his/her needs. The resident can move around in bed to itch his/her back, but does not use the side rails to position self. If staff are log rolling the resident and side rails are up, the resident will grab the bar instinctively, but the resident does not use the side rail to assist staff in turning or log rolling. During an interview on 9/25/19, at 10:49 A.M., the DON said the resident is due for an assessment and they are doing away with his/her side rails. The resident has declined and no longer uses them to position or assist with cares. During an interview on 9/25/19, at 3:39 P.M., the MDS/Care Plan Coordinator said the following: -The resident's family wanted to keep the side rails after the decision tree showed to remove the side rails to position in bed; -He/she had an order for short, ¼ side rails, but the bed would not function properly with them attached, so they applied the ¾ length side rails; -The resident has had a decline and can no longer use the side rails for positioning. 3. Record review of Resident #34's face sheet showed the following information: -admitted on [DATE], readmitted on [DATE]; -Diagnosed with dementia with behavioral disturbances, restlessness and agitation, intellectual disabilities, and major depressive disorder. Record review of the resident's Restraint: Side rail and Alternative Equipment Intervention Decision Tree, dated 1/3/18, showed staff documented the resident did not use side rails and the resident currently had two hand rails. Record review of the resident's Restraint: Side rail and Alternative Equipment Intervention Decision Tree, dated 5/16/18, showed the staff documented to refer to the team for removal of side rails. Record review of the resident's Consent for use of Physical Restraints, dated 5/16/18, showed the following information: -Staff documented the use of one short side rail to the open side of the bed; -On 1/8/19, the staff documented the resident was currently using two ½ length side rails; - Staff documented the resident used the side rail for enabling bed mobility and the feeling of security; -The resident's guardian signed the consent form, but did not date it when they signed it; -The facility staff signed and dated the form on 6/5/18; -Facility staff reviewed the consent form on 6/28/18, 10/29/18, 1/8/19, and 4/30/19; -The staff did not have the guardian sign after the change of side rails on 1/8/19. Record review of the resident's Restraint: Side rail and Alternative Equipment Intervention Decision Tree, dated 7/12/18, showed the staff highlighted a path on the decision tree to the box indicating the staff should refer the resident for removal of side rails. The staff then documented on the side of the form the resident now has an air loss mattress with side rails due to manufacturer's guidelines. The staff did not document the type or length of side rails used. Record review of the resident's care plan, last reviewed 12/12/18, showed the following information: -The resident had short term and long term memory problems; -The resident required total assistance from staff for daily cares and bed mobility; -The staff drew a line through the care plan showing the resident used two short side rails and documented above it the resident's bed has two ½-side rails up when in bed. The resident had a low air loss mattress and had the bed against the wall. Record review of the resident's POS, dated September 2019, showed staff did not obtain an order for the use of side rails. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Short term and long term memory problems; -Severely impaired decision-making; -Total dependence of staff for bed mobility and transfers; -Diagnoses included dementia; -Bed rails not used; -No falls; -No behaviors. Record review of the resident's medical record showed no Bed Rail Safety Check to include measurements of the bed frame and side rails for risk of entrapment. Observation on 9/23/19, at 10:50 A.M., showed the resident in bed with side rail up the resident's right side. The left side of the bed was against the wall. The side rails extended approximately from the resident's head to approximately the resident's mid-calf. Observation on 9/24/19, at 9:43 A.M., showed the resident in bed with the side rail up on the resident's right side and the left side against the wall. Observation on 9/24/19, at 12:19 P.M., showed CNA A and NA B performed personal care for the resident log rolling the resident back and forth. The resident did not grab the side rail or assist the aides in positioning or rolling back and forth. CNA A said the side rails on this resident's bed are the ¾ length side rails. During an interview on 9/25/19, at 9:15 A.M., CNA A said the resident does not use the side rail for positioning in bed or assisting with rolling. The aide said the resident is total care. During an interview on 9/25/19, at 3:39 P.M., the MDS/Care Plan Coordinator said the following: -The resident used to be on an air mattress that required side rails; -He/she did not know the resident did not have the air mattress anymore; -The resident cannot use the side rails for positioning. 4. Record review of Resident #22's face sheet showed the following information: -admitted on [DATE]; -Diagnosed with restlessness and agitation, conduct disorder, major depressive disorder, and hemiplegia of left side due to stroke. Record review of the resident's Consent for use of Physical Restraints, dated 1/1/18, showed the following information: -Staff documented the use of one short side rail. Staff then documented discontinuing the short rail and the resident used one ½ side rail; -Staff did not document when this change occurred; -Staff documented the resident used the side rail for enabling bed mobility and the feeling of security; -The resident's family member signed the consent form on 1/10/18; -Facility staff reviewed the consent form on 5/16/18, 6/28/18, 10/29/18, 1/8/19, and 4/30/19. The review on 4/30/18, staff documented updated after his/her signature. Record review of the resident's (undated) Restraint: Side rail and Alternative Equipment Intervention Decision Tree, showed the staff highlighted a path on the decision tree to the box indicating the staff should refer the resident to physical therapy or occupational therapy and consider a trial of ½ or ¼ side rails or bar. The staff documented to the side of the box the resident currently participated in physical therapy. Record review of the resident's care plan, last reviewed 1/22/19, showed the following information: -The resident required extensive total assistance from staff for daily cares, transfers and bed mobility; -The resident had behaviors of hitting and scratching when staff assisted with transfers; -The staff did not address the use of side rails on the resident's bed. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Severely impaired cognition; -Displayed behaviors 1-3 days of physical and verbal symptoms; -Required extensive assistance of staff for bed mobility and transfers; -Diagnoses of dementia and depression; -Bed rails used daily; -No falls. Record review of the resident's POS, dated September 2019, showed an order dated 4/30/19, for one ½ length side rail up on the open side of the resident's bed. Record review of the resident's medical record showed no Bed Rail Safety Check to include measurements of the bed frame and side rails for risk of entrapment. Observations on 9/23/19, at 9:45 A.M., showed the resident's bed with ¼ side rail at the head of the bed, on the side of the bed not against the wall. The side rail extended from the head of the bed to just below the pillow. During an interview on 9/25/19, at 9:15 A.M., CNA A said he/she is not sure if the resident can use the side rails or not for bed positioning or transfers. The resident is usually already up when he/she arrives at work, and the resident refuses to lay back down during the day. During an interview on 9/25/19, at 3:39 P.M., the MDS/Care Plan Coordinator said the resident does use the side rails for positioning. 5. Record review of Resident #27's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnosed with metabolic encephalopathy, muscle wasting, lack of coordination, pain in both knees, dizziness and giddiness, difficulty walking, unsteady on feet, and repeated falls. Record review of the resident's care plan, last reviewed 10/25/18, showed the following information: -The resident required extensive assistance from staff for daily cares and transfers; -The resident had a potential for falls related to vertigo; -Staff did not address the use of the side rails on the resident's bed. Record review of the resident's Consent for use of Physical Restraints, dated 1/8/19, showed the following information: -Staff documented the use of two handrails. Staff documented no decision tree was needed; -Staff documented the resident used the handrails for enabling bed mobility; -The resident signed the consent form on 1/8/19; -Facility staff reviewed the consent form on 4/30/19. Record review of the resident's POS, dated September 2019, showed an order dated 1/8/19, for two side rails when in bed to aid in bed mobility. Record review of the resident's medical record showed no Restraint: Side rail and Alternative Equipment Intervention Decision Tree. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -Cognitively intact; -Required extensive assistance of staff for bed mobility and transfers; -Chronic pain, osteoarthritis, low back pain, insomnia, and vertigo; -No bed rails used; -The resident had two non-injury falls and one injury fall since the last assessment. Record review of the resident's face sheet showed the resident readmitted to the facility on [DATE]. Record review of the resident's medical record showed no Bed Rail Safety Check to include measurements of the bed frame and side rails for risk of entrapment. Observations on 9/23/19, at 9:45 A.M., showed the resident's bed with two short handgrip side rails at the head of the bed, one on each side. The side rail measured approximately six inches wide. During an interview on 9/25/19, at 9:15 A.M., CNA A said the resident uses the transfer loops (small side rails) to pull up in bed and change his/her position in bed. During an interview on 9/25/19, at 3:39 P.M., the MDS/Care Plan Coordinator said the following: -The staff switched the resident's bed to one that had the handrails on both sides; -The resident does use them for bed positioning. 6. During an interview on 9/25/19, at 10:49 A.M., the DON said the facility is behind on their side rail audit. The audit is supposed to be done every 3 months. The facility is behind due to vacations and trainings. The audit consisted of looking at what the resident needed and the least restrictive side rail. If the side rail then triggered as a restraint, they went back and looked at it again and completed the decision tree. Staff obtain an order for the side rail from the physician, and had the resident or responsible party sign a consent form and then add the side rail to the resident's care plan. The DON would expect all the documentation to match what is currently on the bed, and if a resident changed beds or mattresses, the decision tree and all should be updated. They have no measurements for any side rails. 7. During an interview on 9/25/19, at 2:30 P.M. and 3:39 P.M., RN F said: -His/her main job is to update the care plans and he/she is the MDS Coordinator; -It is a team effort to get the side rail information completed; -The information includes obtaining a signed consent, completing the restraint decision tree, updating the care plan, and obtaining a physician's order; -The charge nurse is responsible for informing the CNAs that there have been side rails added to a resident's bed; -They do not take measurements of the side rails and ensure they are the proper fit for the bed; -When residents are admitted to the facility, they complete a skin assessment sheet, which includes a small side rail assessment; -If the resident or family indicates they want the resident to have a side rail or if the admitting nurse determines there might be a need for side rails, this short assessment is completed; -Once the initial assessment is completed, he/she looks at the bed, completes the decision tree, and determines what type of side rails the resident would need; -Once the size is determined, he/she obtains a signed consent, obtains a physician's order, and updates the care plan to reflect the information; -They have never and do not currently take measurements prior to using the side rails; -This form as well as the decision tree and any other paperwork from physical therapy stays in the resident's medical record; -He/she completes quarterly reviews; -This quarterly review includes checking that the consent form is signed and up-to-date with the current side rail being used, checking to ensure the care plan and physician's order match the side rails the resident is using, and reviewing the decision tree to ensure the information is up-to-date; -Once this has been completed, he/she initials and dates the consent form with the date the review was completed; -No one goes back to check the bed to ensure the side rail on the bed matches what is on the consent form, the decision tree, the care plan, and the physician's order; -He/she is supposed to be informed when a new bed or mattress is put in for the resident so he/she can make sure all documentation is updated and matches, but this does not always happen, so sometimes the side rails do not match the paperwork; -The documentation should match what is currently used by the resident. -They do not get the consent form re-signed when they change the size of the bed rail; -The responsible party is not informed of the change until the next care plan meeting; -Short rails are considered ½ size or smaller; -No one in the facility checks the beds for safety to ensure the side rails are functioning properly or are secured properly to the beds. 8. During an interview on 9/26/19, beginning at 11:05 A.M., the administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) said: -When a resident admits to the facility, the admitting nurse utilizes the mini side rail assessment on the admission skin assessment form to determine if the resident would like to use or needs to use side rails; -The MDS Coordinator (RN F), will then complete the side rail decision tree to make sure the side rails are a good fit for the resident; -The facility obtains a signed consent, completes the side rail decision tree, obtains a physician's order, and updates the care plan; -The MDS Coordinator audits this information quarterly; -No one has been doing measurements prior to the side rails being put on the bed and utilized by residents.