Based on observation, interview and record review, the facility failed to ensure residents were free from abuse when an allegation of physical abuse was made for one resident (Resident #1). On 2/1/25 at approximately 10:00 A.M., Registered Nurse (RN) A heard banging on the wall inside the resident's room, and someone yelling, Stop that, stop that, do it again, then a loud slap inside the resident's room and when he/she opened the resident's door he/she saw Certified Nurse Aide (CNA) B holding the resident against the wall. RN A notified the Director of Nurses (DON) of an allegation of abuse and the DON directed RN A not to send CNA B home. CNA B remained in the facility providing care to other residents for over five hours after the allegation was reported. The facility did not immediately begin an investigation into the allegation of abuse. Facility staff were not properly educated on the facility's policies of identifying and reporting abuse to ensure residents were free from abuse. The sample was 8. The census was 49. The Assistant Director of Nurses (ADON) and DON were notified on 2/1/25 at 6:45 P.M. of an Immediate Jeopardy (IJ) which began on 2/1/25. The IJ was removed on 2/4/25 as confirmed by surveyor onsite verification. Review of the facility's Abuse Prevention Program policy, revised December 2016, showed: -Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms; -Policy Interpretation and Implementation: -As part of our resident abuse prevention, the administration will: --Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual; --Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents; --Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior; --Implement measures to address factors that may lead to abusive situations; --Identify and assess all possible incidents of abuse; --Investigate and report any allegations of abuse within timeframes as required by federal requirements; --Protect residents during abuse investigations. Review of the facility's Abuse Investigation and Reporting policy, revised July 2017, showed: -Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management; -Policy Interpretation and Implementation: --Role of the Administrator: -If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual; -The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/22/25, showed: -Adequate hearing; -Resident rarely/never understands; -Resident rarely/never understood; -Short and long term memory problem; -Severe impairment for decisions regarding tasks of daily life; -Rejection of care behavior occurred one to three days; -Physical behavioral symptoms occurred one to three days; -Substantial/maximal assist required for upper and lower body dressing, toileting, and personal hygiene; -Diagnoses include Alzheimer's disease (a progressive and irreversible brain disorder that gradually destroys memory, thinking skills, and the ability to perform everyday tasks), anxiety, and depression. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Current functional performance; -Interventions included extensive assist/one-person physical assist for dressing, personal hygiene and toilet use. Extensive assist/two-person physical assist for dressing, personal hygiene, and toilet use; -Focus: The resident is resistive to care at times with activities of daily living (ADLs) care; -Focus: The resident is/has potential to be physically aggressive; -Interventions included assess and anticipate resident's needs. Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Give the resident as many choices as possible about care and activities. When the resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation, and if response is aggressive, staff to walk away calmly and reapproach later. During an interview on 2/1/25 at 1:07 P.M., RN A said at around 10:05 A.M. that morning, he/she heard a voice yelling in the resident's room. The voice sounded threatening and mean, and was yelling, Stop that, stop that, do it again! RN A heard bumping noises inside the room, then a loud slap. The voice yelled, See, I told you, don't do it again! RN A opened the door to the resident's room and saw the resident up against the wall with CNA B standing in front of him/her. The resident's back was to the wall and CNA B had his/her body pushed into the resident's, holding the resident's left arm with his/her right arm. The resident was not attempting to move. When asked if everything was ok, CNA B said yes, sat the resident down on the bed, and immediately left the room. RN A interviewed the resident by asking yes/no questions, but the resident was very confused and was unable to say much. RN A performed a skin assessment and when he/she attempted to check the resident's lower body, the drawstring on the resident's pants was tied so tight, he/she had to cut the string to assess the resident. After assessing the resident, RN A called the DON to inform him of what he/she observed. RN A asked to send CNA B home and the DON said no, the facility was too short on staff. The DON told RN A the resident is very combative and CNA B would never do this type of thing. The DON did not ask RN A for a written statement regarding what happened and said he/she would arrive at the facility soon. RN A left the building at 12:20 P.M., at which time, CNA B was still working in the facility and the DON had not arrived. Observation on 2/1/25 at 2:03 P.M., showed CNA B walked throughout the building, going in and out of resident rooms, providing care to residents. During an interview on 2/1/25 at 2:03 P.M., Licensed Practical Nurse (LPN) H said he/she came in around 12:15 P.M. The DON called him/her in because the nurse from day shift asked the DON to find someone to replace him/her on the schedule. LPN H was not informed of any allegations of abuse. If he/she was made aware of an allegation of abuse perpetrated by an employee, he/she would notify the DON and leave it up to the DON to determine if the employee should be sent home. He/She would not make the decision to send the employee home. The DON is responsible for investigating abuse allegations. During an interview on 2/1/25 at 2:33 P.M., CNA B said the day shift nurse called the DON and told him that he/she was being mean to the resident. The resident is not aggressive, but hits on people. CNA B was in the resident's room this morning, around 9:30 A.M., to get him/her changed and dressed for breakfast. The resident is pretty confused and kept going around the room. Two employees are usually needed to provide care to the resident, but CNA B can do it by him/herself because he/she knows the resident. CNA B told the resident he/she was wet and smelled like pee. He/She kept telling the resident to sit down to change him/her. The resident hit CNA B on the shoulder and CNA B said he/she did not hit the resident back. When the resident tried to hit him/her again, CNA B pushed the resident's arms back. He/She told the resident, Your licks don't hurt me, you need to stop. The resident kept swinging and CNA B pushed the resident's hands while he/she was swinging. CNA B put the resident against the wall so he/she couldn't bend over with CNA B while he/she was trying to pull his/her pants up. When asked to demonstrate how he/she spoke to the resident, CNA B raised his/her voice loudly. He/She said he/she uses a louder pitch to get the resident's attention. The nurse on the day shift was in the hall at the time, and must have heard this. Some people might think there is no way in hell someone should talk to a resident like this, but they don't do this every day and sometimes staff have to raise their voice for a resident to listen. Observation on 2/1/25 at 2:59 P.M., showed LPN H, Certified Medication Technician (CMT) I, and CNA B escorted the resident to his/her room for a skin assessment. LPN H and CMT I said the resident will hit staff. CNA B lifted the resident's shirt in the front and back. When staff attempted to fully remove the shirt for an observation of the resident's arms, the resident shook his/her head no, and wiggled his/her arms away from CNA B. The resident did not attempt to hit staff and left the room. During an attempted interview on 2/1/25 at 3:05 P.M., the resident was confused and was unable to answer specific questions regarding his/her care needs, interactions with staff, or treatment at the facility. During an interview on 2/1/25 at 3:05 P.M., CMT I said the DON called him/her earlier that day and asked which aide was assigned to the resident's hall, which was CNA B. The DON told CMT I the day shift nurse said CNA B was being mean to the resident. The DON did not say anything about sending CNA B home. The resident has Alzheimer's disease. He/She only gets aggressive when he/she has a bowel movement or is receiving care, and then he/she will sucker punch staff. CNA B is the only aide who can provide care to the resident by him/herself. Otherwise, two staff have to provide care so one person can distract the resident and the other person can do the care. During an interview on 2/1/25 at 3:29 P.M., the DON said at around 10:00 A.M., he got a call from RN A. RN A said he/she heard yelling and loud noises coming from the resident's room, like the heads of residents banging on the walls or something. RN A saw CNA B and the resident leaned against the wall while CNA B was getting the resident dressed. RN A wanted to send CNA B home on the basis of abuse and the DON said no, noises are not a good basis to send the employee home. Noises could come from anywhere. He told RN A he would look into it and called the facility. He talked to CMT I, who didn't know what was going on. He has not interviewed the resident or any other staff, yet. Management typically investigates abuse. They get statements from the parties involved and document as necessary. He lets the ADON do most of that, because he is still new and has only been working with the facility for three months. Abuse investigations are conducted in a timely fashion, and the DON did not provide specifics on the definition of timely. During an interview on 2/1/25 at 3:48 P.M., the ADON said the DON did not notify her of the abuse allegation until after 2:30 P.M., when LPN H called to notify her the Department of Health and Senior Services (DHSS) was in the building. The Assistant Administrator was not aware, either. Any employee alleged to have been the perpetrator of abuse should be suspended immediately, pending investigation, to keep all residents safe. CNA B should have been sent home the minute the DON was notified of an abuse allegation. Management should immediately be notified of abuse allegations. An abuse investigation should be started by management the moment they are made aware. Observation on 2/1/25 at 3:48 P.M., showed CNA B in the ADON's office. Review of CNA B's time punches, showed he/she clocked out at 4:42 P.M. During an interview on 2/1/25 at 4:06 P.M., CNA K said the resident has Alzheimer's disease. Staff have to be loud with him/her in order for him/her to understand what they need him/her to do. He/She needs assistance with changing and dressing and can get angry and hit staff when they assist with this. It takes two staff to provide care to the resident on some days. When the resident gets physically aggressive, staff should step back and leave the room. During an interview on 2/1/25 at 4:58 P.M., the Assistant Administrator said staff should engage residents in a normal tone of voice, or speak louder if the resident is hard of hearing. If a resident becomes combative and physically aggressive, staff should leave the room and should not physically engage with the resident. He wasn't notified of the abuse allegation until the ADON contacted him at 2:35 P.M. The day shift nurse reported a concern of abuse to the DON. The alleged incident occurred at 10:00 A.M. The Assistant Administrator should have been notified within 30 minutes to an hour of the DON being notified, and an investigation should have been started right away. The DON should have immediately suspended the CNA pending an investigation to protect the resident and other residents from potential abuse. CNA B should not have remained in the facility, providing care for other residents, for another five hours after the allegation of abuse was reported. During an interview on 2/1/25 at 8:37 P.M., the ADON said the resident was combative when first admitted to the facility, but he/she started anxiety medication and this has not been an issue for a long time. Approach is a lot for the resident. Staff should tell him/her what they want to do and speak to the resident in a low, normal tone of voice. Staff should not yell at the resident; he/she is not hard of hearing. If the resident becomes combative when receiving care, staff should leave and get assistance. Ongoing behaviors and combativeness should be reported to her, but she has not received any reports about this happening. It is not appropriate for staff to keep the resident against the wall when assisting him/her with toileting. Instead, the resident should be taken to the toilet, where he/she can sit down and staff can change him/her. Staff should be educated on the facility's abuse policies. During an interview on 2/1/25 at 2:27 P.M., Housekeeper J said If he/she overheard staff from another department yelling at a resident, or witnessed abusive behavior, he/she would have to wait to tell his/her supervisor. His/Her department does not get involved with what goes on in other departments. Each department handles their own issues. If he/she witnessed yelling or abuse on a weekend, he/she would unfortunately have to wait to speak to his/her supervisor on Monday. During an interview on 2/3/25 at 9:20 A.M., Housekeeper L said he/she has not received training about the facility's abuse policies recently. If he/she heard nursing staff yelling at a resident, or slapping noises coming from a resident's room, he/she would probably tell the nurse. It is not his/her place to get involved with nursing staff, so he/she would not intervene. During an interview on 2/3/25 at 11:29 A.M., the DON said he was not educated on the facility's abuse policies when he began his position with the facility in November 2024. After the abuse allegation was made on 2/1/25, he was in-serviced on the policy. All staff who have worked since the allegation was made, have not been in-serviced in a timely fashion. If any employee hears, witnesses, or suspects abuse, they should intervene first, make sure the resident is safe, then report it to management. During the interview, the DON reviewed the documentation being provided to staff to educate them on the facility's abuse policies. The documentation did not provide guidance for staff to ensure the resident is safe when abuse is suspected, before reporting it to management. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview, and record review completed during the onsite visit, it was determined the facility had implemented corrective action to address and lower the violation at the time. At the time of exit, the severity of the deficiency was lowered to the D level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s). MO00248906

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Review of Resident #8's admission Record indicated the facility admitted the resident on 04/26/2023 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and cerebral infarction. Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility and transfers and was totally dependent on staff for toilet use; walking and locomotion did not occur during the review period. The MDS indicated the resident had no limitations in range of motion and used a wheelchair for mobility. According to the MDS, the resident did not have falls prior to or since admission. Review of Resident #8's electronic medical record (EMR) revealed no comprehensive care plan for the resident. Review of an Initial Plan of Care, dated 04/26/2023, revealed Resident #8 required assistance of one staff for mobility, turning, and transfers. The Initial Plan of Care did not indicate the resident was at risk for falls or include interventions to prevent falls. Review of incident notes, dated 05/29/2023 at 1:35 AM and written by nursing staff, revealed Resident #8 found on the floor in the resident's room. The notes indicated the resident said they were returning to bed from the bathroom when they fell. The notes indicated the resident was assessed and there were no visible injuries; however, range of motion to the left leg was not within normal limits. The resident was unable to straighten the left leg, and ice was applied to the left hip. The resident complained of pain, and pain medications were administered. The incident note indicated Resident #8 was transferred to the hospital. A health status progress note, dated 05/30/2023, indicated the resident's family member phoned the facility and reported the resident had a computed tomography (CT) scan and had a crack in the head of the femur. An admission summary progress note, dated 06/01/2023, indicated Resident #8 returned to the facility. The admission Record was updated to indicate the resident had a diagnosis of nondisplaced intertrochanteric fracture of the left femur. There was no care plan developed to include fall prevention interventions to prevent further falls. 9. Review of Resident #14's admission Record indicated the resident was admitted on [DATE] with diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar) and dementia with other behavioral disturbance. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #14 had short-term and long-term memory problems and moderately impaired cognitive skills for daily decision-making based on the Staff Assessment for Mental Status (SAMS). The MDS indicated the resident was independent with bed mobility and transfers and required limited assistance with toilet use. The MDS indicated Resident #14 had no falls prior to or since admission or the prior assessment. Review of Resident #14's medical record revealed there was no comprehensive care plan for the resident. Review of an Initial Plan of Care, dated 04/26/2023, revealed Resident #14 was independent with mobility, turning, and transfers. The Initial Care Plan did not indicate the resident was at risk for falls and did not include interventions to prevent falls. Review of a health status progress note, dated 03/23/2023 at 4:16 PM and written by nursing staff, revealed the resident found on the floor at the entrance to the dining room. According to the note, the resident did not have any injuries; the resident was assisted to stand and ambulated to their room without difficulty. This fall was not reflected on the quarterly MDS assessment, dated 04/28/2023. Review of a health status progress note, dated 05/08/2023 at 10:44 AM and written by nursing staff, revealed Resident #14 slid out of a recliner chair. The note indicated the resident had no injuries. Review of a health status progress note, dated 05/30/2023 at 8:28 AM and written by nursing staff, revealed, purplish bruising to right outer eye, no swelling noted. The note indicated the resident stated they hit their head. According to the note, the resident's roommate stated the resident was moaning during the night and was on the floor, and the lady across the hall helped the resident up and into bed. Review of an incident note, dated 06/11/2023 at 6:12 PM and written by nursing staff, revealed Resident #14 was heard yelling and was found on the floor, with a blanket tangled between their legs and feet. The note indicated a large hematoma was found on the back of the resident's head and the hematoma was painful to touch. There was no care plan developed to include fall prevention interventions to prevent further falls after any of the resident's falls. 10. Review of Resident #145's admission Record indicated the facility admitted the resident on 05/24/2023 with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction, Alzheimer's disease, and hypertension. Review of Resident #145's electronic medical record (EMR) revealed the resident's required admission Minimum Data Set (MDS) assessment had not been completed. Review of Resident #145's EMR revealed there was no comprehensive care plan for the resident. Review of an Initial Plan of Care, dated 05/24/2023, revealed Resident #145 required assistance of one staff for mobility, turning, and transfers. The Initial Care Plan did not indicate the resident was at risk for falls or include interventions to prevent falls. Review of incident notes, dated 05/29/2023 at 3:05 AM and written by nursing staff, revealed Resident #145 was found on the floor, in the hallway. The note indicated the resident had blood on the inside and outside of their nose and mouth. The resident denied pain but was sent to the hospital. A health status progress noted, dated 05/29/2023 at 2:46 PM and written by nursing staff, indicated Resident #145 returned to the facility with a diagnosis of closed fracture of the nasal bone. Review of a health status note, dated 06/03/2023 at 10:45 PM and written by nursing staff, revealed Resident #145 was found on the floor beside their bed and the resident told staff they were trying to reach something and slid out of the bed. The note indicated the resident had no injuries. A review of a health status note, dated 06/10/2023 at 1:50 PM and written by nursing staff, revealed Resident #145 was found on the floor next to their wheelchair. The resident told the nurse they slid out of the chair. The note indicated the resident had no injuries. There was no care plan developed to include fall prevention interventions to prevent further falls after any of the resident's falls. 11. Review of Resident #2's admission Record indicated the resident admitted on [DATE] with diagnoses including unspecified mood disorder, stage 2 chronic kidney disease, and age-related cognitive decline. Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required supervision from staff with bed mobility, transfers, and eating and limited assistance from staff with toilet use. The MDS did not indicate the resident had other behavioral symptoms not directed toward others. Review of Resident #2's medical record revealed there was no comprehensive care plan for the resident. Review of an Initial Plan of Care, dated 03/07/2023, revealed Resident #2 was independent with mobility, turning, and transfers and used a rolling walker. The Initial Care Plan did not indicate the resident picked at the skin on their face and did not include approaches related to skin picking. During an observation on 06/12/2023 at 11:36 AM, Resident #2 had a light-colored purplish discoloration with spotty red areas on the left cheek. The resident indicated they did not know what happened to their face. During an observation on 06/13/2023 at 1:16 PM, Resident #2 was in the dining room eating the noon meal. The slight discoloration to the left cheek remained. During an interview on 06/14/2023 at 8:52 AM, Nursing Assistant (NA) #4 indicated she did not know what happened to Resident #2's left cheek. During an interview on 06/14/2023 at 9:09 AM, the Restorative Aide (RA) indicated she did not know what happened to Resident #2's left cheek but stated the resident picked at the skin on their face constantly. During an interview on 06/14/2023 at 9:21 AM, NA #7 stated the resident sat and constantly picked at their face. NA #7 indicated they could stop the resident, but the resident would go right back to picking their face. NA #7 stated she did not know if the resident had a care plan that addressed skin picking. During an interview on 06/14/2023 at 12:40 PM, Licensed Practical Nurse (LPN) #2 stated the area to the left cheek was petechiae (pinpoint, round spots that form on the skin- caused by bleeding), and the resident constantly picked at their face. LPN #2 indicated she did not know if skin picking of the face was care planned but would consider it a behavioral symptom. During an interview on 06/14/2023 at 12:56 PM, the Assistant Director of Nursing (ADON) stated she did not consider the area a bruise. The ADON indicated the area to the left cheek was from the resident messing with their cheek. The ADON stated it was a behavior for the resident that obviously was not documented. During an interview on 06/14/2023 at 1:30 PM, the Director of Nursing (DON) stated the area on Resident #2's left cheek was from the resident picking at their skin. During an observation on 06/20/2023 at 11:00 AM, the resident was sitting in the television room picking at the skin on the left side of their face. There was discoloration with red areas and some small open areas. 12. Review of Resident #36's admission Record indicated the facility admitted the resident on 04/18/2023 with diagnoses including hypertension, chronic pulmonary edema, and chronic kidney disease. Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. Review of Resident #36's medical record revealed there was no comprehensive care plan for the resident. Review of an Initial Plan of Care, dated 04/18/2023, revealed Resident #36 required assistance with mobility and transfers. Review of an admission summary in the progress notes, dated 06/05/2023 and written by nursing staff, revealed Resident #36 had a right upper chest tunneled dialysis catheter and was scheduled to receive hemodialysis on Tuesdays, Thursdays, and Saturdays. The resident's care needs related to hemodialysis were not addressed in a comprehensive care plan or added to the Initial Plan of Care. 13. Review of Resident #30's admission Record indicated the facility admitted the resident on 03/11/2021 with diagnoses that included type 2 diabetes mellitus, cerebral infarction, chronic kidney disease, and hypertension. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was totally dependent on the assistance of two staff for transfers and toilet use and required extensive assistance with bed mobility and eating. According to the MDS, the resident had other behavioral symptoms not directed toward others. A review of Resident #30's care plan, that was last revised 10/12/2022, revealed the resident's care plan was due for review on 01/10/2023 but had not yet been reviewed. During an interview on 06/13/2023 at 3:53 PM, the ADON stated if a resident's care plan was not in the electronic medical record (EMR), then the resident only had a baseline care plan (Initial Plan of Care). The ADON said the MDS Coordinator was responsible for completing comprehensive care plans. During an interview on 06/14/2023 at 9:19 AM, NA #8 stated she received verbal report at shift change and checked in with the charge nurse for any updates. During an interview on 06/14/2023 at 11:55 AM, the RA said the facility was in the process of revising their patient care forms. The patient care forms included care information and instructions for resident care that the charge nurse provided to the aides and nursing assistants. The RA further stated there was nothing in writing for staff to refer that included instructions for specific resident care. During an interview on 06/14/2023 at 12:12 PM, NA #7 stated the charge nurse verbally notified the nursing assistants at shift change about the care residents required and if there were any changes in care. NA #7 thought there was a book at the nurses' station that outlined resident care requirements, but she did not know the location of the book. During an interview on 06/14/2023 at 12:32 PM, NA #8 stated the residents had care plans, but she was not sure when they were updated. She said she kept her own piece of paper with notes on it about the residents. NA #8 indicated the care plans were in a binder at the nurses' station. During an interview on 06/14/2023 at 12:21 PM, NA #4 stated the charge nurse verbally notified the nursing assistants at shift change about resident care requirements and let them know if there were any changes. NA #4 stated there was a report sheet that had resident care information on it, but she had never seen it because she was not a nurse. During an interview on 06/14/2023 at 12:40 PM, LPN #2 stated the charge nurse used a report sheet that was updated throughout the day with any changes in resident status, and the charge nurse verbally reported the care each resident required to the nursing assistants. During an interview on 06/14/2023 at 12:55 PM, the ADON stated the charge nurse gave verbal report to the aides and nursing assistants about the care each resident required. During an interview on 06/14/2023 at 1:30 PM, the DON stated she was working on a form for the nursing assistants to reference for guidance about resident care. The DON indicated the form would include things like activities of daily living (ADLs) and care planned interventions to prevent falls. The DON said that currently, resident care needs were verbally relayed between staff members, and the facility did not have that information documented for staff to reference. During an interview on 06/15/2023 at 8:13 AM, the DON stated the DON, ADON, and charge nurse were responsible for care plan development, reviews, and revision. The DON indicated the MDS Coordinator had been responsible for the care plan development, reviews, and revisions until the DON began working at the facility. The DON stated the MDS Coordinator completed the MDS assessments and the comprehensive care plans. During an interview on 06/15/2023 at 8:57 AM, the ADON stated the MDS Coordinator was responsible for initiating, updating, and completing the comprehensive care plans. The ADON said the DON, ADON, and charge nurse met and reviewed care plans and discussed falls, therapy, medications, weight loss, and the resident's overall condition. The ADON said the MDS Coordinator worked remotely but had access to the EMR. The ADON did not know the MDS Coordinator's process for developing and revising care plans and did not know how often she looked at them. During an interview on 06/15/2023 at 9:25 AM, the MDS Coordinator stated she worked offsite and was responsible for completing the MDS assessments, including the admission, comprehensive, quarterly, and 5-day assessments. The MDS Coordinator stated she did not complete the facility's care plans because they were handwritten, and she did not know who was responsible for updating or completing the care plans. During an interview on 06/15/2023 at 10:44 AM, the DON indicated there were no handwritten paper care plans at the facility. During an interview on 06/15/2023 at 10:46 AM, the ADON indicated there were no handwritten paper care plans in the facility. When told the MDS Coordinator said there were handwritten care plans at the facility, the ADON stated she did not know where they were and would contact the MDS Coordinator to ask. During an interview on 06/15/2023 at 10:49 AM, the Social Services Director (SSD) stated the nursing department would know where the care plans were located. The SSD indicated she made notes in the computer for care plan revisions and assumed the MDS Coordinator updated the care plans. During an interview on 06/15/2023 at 12:13 PM, the Physical Therapy Aide (PTA) stated all fall risk interventions were documented in the EMR, and each resident specific intervention should be a part of a resident's comprehensive care plan. During an interview on 06/15/2023 at 12:23 PM, the ADON stated she did not know what the MDS Coordinator was talking about because the facility did not use handwritten paper care plans. During an interview on 06/15/2023 at 12:30 PM, the DON stated that since there was no one in the DON role prior to her starting employment in February 2023, the facility had the MDS Coordinator complete the MDS assessments and then initiate the care plan. The DON stated the residents the surveyors reviewed were new to the facility, and she did not know how things fell through the cracks. The DON stated she knew the care plans were essential for resident care and indicated she was not aware that care plans had not been reviewed for months or that there were residents who had been in the facility for months with no comprehensive care plan in place. During an interview on 06/15/2023 at 12:58 PM, the AA stated the DON was responsible for the care planning process. The AA said the SSD scheduled care planning meetings and notified nursing if an MDS triggered a care plan review. The AA said the previous DON, who was no longer employed since December 2022, completed the MDS assessments and care plans. The AA stated he suspected the MDS Coordinator was supposed to be completing the MDS assessments and care plans, but he was just now finding out these things were not completed. The AA stated the MDS Coordinator initiated the MDS, which then triggered the comprehensive care plan, and the DON was responsible for ensuring the care plan was properly updated. During an interview on 06/15/2023 at 1:40 PM, the Administrator stated someone outside the facility was responsible for MDS completion, and the DON, who had been there four months, was then responsible for completing the associated care plan. The Administrator stated she had no idea what items were included in the care plans but thought information related to resident care while in the facility was included. During an interview on 06/24/2023 at 12:32 PM, the ADON indicated she was unsure of the timeframe for completion and did not know when comprehensive care plans were due but expected the comprehensive care plans to be completed within the required timeframe. During an interview on 06/24/2023 at 1:37 PM, the Administrator stated she expected regulations to be followed for completion of the comprehensive care plans. Based on interviews, record review, observations, and facility policy review, the facility failed to ensure resident-centered comprehensive care plans were developed, implemented, and revised to meet the needs of 13 (Residents #10, #96, #17, #44, #8, #14, #145, #2, #36, #30, #27, #35, and #29) of 29 residents reviewed for comprehensive care plans. The facility failed to develop and implement comprehensive care plans to address residents at risk for falls and residents with a history of multiple falls with injury. The facility also failed to develop and implement comprehensive care plans related to a risk for and current significant weight loss, diabetes monitoring and management, behaviors, chronic kidney disease and dialysis care, treatment, and monitoring, antipsychotic mediation use for a resident with a dementia diagnosis, monitoring of a diuretic medications, and monitoring and management of a resident on anticoagulant therapy. The facility census was 42. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.21 (Comprehensive Resident Centered Care Plan). The IJ began on 12/15/2022 when Resident #10 had a fall after their fall risk care plan was initiated on 09/20/2022. Resident #10 had 12 falls from 12/15/2022 to 04/30/2023, one of which resulted in a right hip fracture, and the facility did not identify new care plan interventions for fall prevention that addressed causal and contributing factors after falls in an effort to prevent further falls. The Administrator and Assistant Administrator (AA) were notified of the IJ and provided with the IJ template on 06/18/2023 at 9:50 AM. A Removal Plan was requested. The IJ was determined to be removed on 06/23/2023 after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of G. Findings included: Review of a facility policy titled, Care Plans, Comprehensive Person-Centered, dated 2001 and revised in December 2016, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy indicated, 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her right to refuse treatment; d. Describe any specialized services to be provided as a result of PASARR [preadmission screening and resident review] recommendations; e. Include the resident's stated goals upon admission and desired outcomes; f. Include the resident's stated preferences and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; i. Build on the resident's strengths; j. Reflect the resident's expressed wishes regarding care and treatment goals; k. Reflect treatment goals, timetables and objectives in measurable outcomes; l. Identify the professional services that are responsible for each element of care; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and o. Reflect currently recognized standards or practice for problem areas and conditions. Further review of the policy revealed, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS [Minimum Data Set]). 1. Review of Resident #10's admission Record indicated the facility admitted the resident on 11/12/2018 with diagnoses including osteoarthritis (Most common form of arthritis characterized by the cartilage within a joint beginning to break down and the underlying bone changing. Most frequently in the hands, hips, and knees), paranoid schizophrenia, bipolar disorder, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and dementia. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #10 was independent with transfers, walking, and locomotion and was steady at all times when walking and during surface-to-surface transfers. The MDS indicated the resident had no falls since admission or the prior assessment. Review of Resident #10's care plan revealed a focus area, with an initiation date of 09/20/2022, that indicated the resident was at risk for falls. Interventions directed staff to assist the resident with ambulation and transfers, determine the resident's ability to transfer, evaluate fall risk on admission and as needed (PRN), and if a fall occurred, staff were to initiate frequent neuro [neurological] and bleeding evaluation per the facility protocol. Review of Resident #10's care plan revealed another focus area, with an initiation date of 11/21/2022, that indicated the resident was at high risk for falls due to Parkinson's disease and psychoactive medication use. Interventions directed staff to anticipate and meet the resident's needs, be sure the resident's call light was within reach and encourage the resident to use the call light, educate the resident about safety reminders and what to do if a fall occurred, ensure that that the resident was wearing appropriate footwear, and ensure the resident was in a safe environment. Review of Resident #10's electronic medical record (EMR) indicated Resident #10's comprehensive care plan was due for review on 02/19/2023 but had not yet been reviewed. There had been no changes to the interventions in the focus areas created for fall risk on 09/20/2022 or 11/21/2022. Review of Resident #10's progress notes revealed the resident had five falls from 12/15/2022 to 01/18/2023. Resident #10 had two falls on 01/18/2023, which resulted in a right hip fracture. Resident #10 was readmitted on [DATE] following a hospitalization with a fractured right hip. Resident #10 then had seven more falls from 02/08/2023 to 04/30/2023. There was no root cause analysis to determine causal and contributing factors after each fall, and there were no new fall prevention interventions added to Resident #10's care plan to prevent further falls. 2. Review of Resident #96's admission Record revealed the facility admitted the resident on 04/22/2023 with diagnoses including acute respiratory failure, adjustment disorder with mixed anxiety and depressed mood, macular degeneration, and age-related osteoporosis. Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident #96 transferred and walked with one-person limited assistance and used a wheelchair for mobility. According to the MDS, the resident had no falls in the two to six months prior to admission and had no falls since admission. Review of Resident #96's electronic medical record (EMR) on 06/13/2023 revealed there was no comprehensive care plan for the resident. Review of Resident #96's Initial Plan of Care, dated 04/22/2023, indicated the resident required assistance with mobility, turning, and transfers. The Initial Care Plan did not indicate the resident was at risk for falls or include interventions for fall prevention. Review of Resident #96's health status progress notes, dated 06/09/2023 and written by nursing staff, indicated that at 2:57 AM, Resident #96 fell forward out of their wheelchair after falling asleep, suffering a large hematoma to the right side of their forehead. Resident #96 was transported to the emergency room (ER). The resident returned from the ER at 11:30 AM with no further injuries noted. There was no root cause analysis to determine causal and contributing factors of the fall and no fall prevention interventions developed and care planned to prevent further falls for the resident. 3. Review of Resident #17's admission Record revealed the facility admitted the resident on 03/06/2023 with diagnoses hypothyroidism (underactive thyroid), dementia, and congestive heart failure. Review of the admission Record revealed there was no documented diagnosis of anorexia (a condition when pertaining to the elderly including a loss of appetite, decreased food intake or both). Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #17 required extensive assistance of one person with eating. According to the MDS, Resident #17 had a weight loss of 5% (percent) or more in the last month or 10% or more in the last six months and was not on a physician-prescribed weight loss regimen. The MDS also indicated Resident #17 was at risk for developing pressure ulcers. The resident was receiving hospice care. Review of Resident #17's electronic medical record (EMR) on 06/12/2023 revealed there was no comprehensive care plan for the resident. Review of the resident's Initial Plan of Care, dated 03/07/2023, revealed the resident required total assistance with eating. The Initial Plan of Care did not indicate the resident was at risk of weight loss or pressure injuries/ulcers. A review of Resident #17's weight record in the EMR revealed the resident weighed the following: - On 03/13/2023, 141.4 pounds - On 03/20/2023, 130.0 pounds, an 11.4-pound (8.06%) weight loss in seven days - On 03/27/2023, 128.0 pounds - On 04/10/2023, 120.4 pounds, a 21.0-pounds (14.85%) weight loss in 28 days - On 04/17/2023, 120.2 pounds A review of Resident #17's March 2023 and April 2023 meal intake records indicated the resident consumed 50-100% at each meal. There was no documentation indicating snack or nutritional supplements were offered or consumed. Review of Resident #17's hospice notes, dated 05/03/2023, revealed the resident had a diagnosis of anorexia as of 03/06/2023. The notes indicated facility staff reported to hospice staff that Resident #17 consumed about 25% of one to two meals per day. The notes indicated that Resident #17 had decreased intake, and weight loss was significant and ongoing. Review of Resident #17's nutrition/dietary progress notes, dated 05/26/2023, revealed the resident weighed 122.4 pounds and was down 23.8 pounds (16.3%) in the past quarter. The notes indicated the resident had no skin issues, per nursing assessment. The notes indicated the resident's weights were more stable in the last month and there were no recommended changes due to stable weight. Review of Resident #17's health status progress notes, dated 06/06/2023, indicated the hospice aide and nurse identified new, facility-acquired pressure ulcers on the resident's bilateral heels; an unstageable pressure injury on the left heel and a stage 3 pressure ulcer on the right heel. The hospice nurse notified the physician and family and obtained wound treatment orders. There was no care plan developed to address the resident's risk for weight loss with nutritional interventions or risk for pressure injuries/ulcers with interventions to prevent skin breakdown. 4. Review of Resident #44's admission Record indicated the facility admit[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #8's admission Record indicated the facility admitted the resident on 04/26/2023 with diagnoses that included chronic obstructive pulmonary disease, type 2 diabetes mellitus, and cerebral infarction. The admission Minimum Data Set (MDS) dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The resident required extensive assistance from staff with bed mobility and transfer and was totally dependent on staff for toilet use; walking and locomotion did not occur during the review period. The resident had no limitations in range of motion and used a wheelchair for mobility. The MDS indicated the resident had no falls since admission or prior to admission. A review of Resident #8's medical record revealed there was no comprehensive care plan for Resident #8. A review of Resident #8's clinical record revealed the resident was not assessed for fall risk upon admission. A review of the Initial Plan of Care, dated 04/26/2023, revealed Resident #8 required assistance of one staff for mobility, turning, and transfers. The Initial Plan of Care did not indicate the resident was at risk for falls or include interventions to prevent falls. A review of nursing Progress Notes, dated 05/29/2023 at 1:35 AM, revealed Resident #8 was found on the floor in the resident's room. The resident said they were returning to bed from the bathroom. The note indicated there was no visible injury, but the resident was unable to straighten the left leg, and ice was applied to the left hip. The resident complained of pain, and pain medications were administered. The note indicated Resident #8 was transferred to the hospital for evaluation. A review of the risk management form presented by the Director of Nursing (DON), dated 05/29/2023 at 1:08 AM, revealed the resident was found in the resident's room on their left side. The form indicated no injuries were observed at the time of the incident. A note indicated the resident could not extend the left leg after the fall and range of motion was not within normal limits. The Injuries Report Post Incident section indicated no injuries were observed after the incident. The form also indicated a pain level of 0. The form did not match the incident that was documented in the progress note on 05/29/2023 at 1:35 AM which indicated the resident complained with pain and was treated with medication after the fall. The form also did not indicate a root cause analysis was completed for the fall or interventions to prevent further falls were implemented. A review of nursing Progress Notes, dated 05/30/2023, indicated Resident #8's family member called the facility to report a computed tomography (CT) scan was completed at the hospital and revealed the resident had a crack in the head of the femur. A review of the clinical record for Resident #8 revealed no evidence the facility attempted to determine what may have caused or contributed to the resident's fall and develop a care plan with interventions to reduce the likelihood of another fall following Resident #8's falls. During an interview on 06/14/2023 at 8:52 AM, Nursing Assistant (NA) #4 said they were not aware of any fall interventions for Resident #8. During an interview on 06/14/2023 at 9:09 AM, the Restorative Aide (RA) indicated she was informed in verbal report that fall interventions for Resident #8 was that the resident was a two-person transfer since the fall. During an interview on 06/14/2023 at 9:21 AM, NA #7 stated she was verbally told Resident #8 had a fall and the intervention for the resident was to bring them to the TV room or desk to keep them from being in their room at the end of the hall. During an interview on 06/14/2023 at 12:32 PM, NA #8 stated she did not know the fall interventions for Resident #8. She said she would have to ask the nurse. During an interview on 06/14/2023 at 12:40 PM, Licensed Practical Nurse (LPN) #2 stated they completed a fall risk assessment to know if someone was a fall risk and then verbally told the aides. LPN #2 indicated fall risk interventions were verbally passed on to staff. LPN #2 indicated Resident #8 did not have fall interventions because the fall was an isolated incident. During an interview on 06/14/2023 at 12:56 PM, the Assistant Director of Nursing (ADON) indicated she guessed Resident #8 was a fall risk since he had a fall. She indicated fall interventions implemented since the fall on 05/29/2023 included a two-person transfer and working with therapy. She said the resident would tell the CNAs he did not need two people to transfer. 4. Review of Resident #145's admission Record indicated the facility admitted the resident on 05/24/2023 with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction, Alzheimer's disease, and hypertension. Review of the National Institute of Diabetes and Digestive and Kidney Diseases website showed: - Diabetic neuropathy is nerve damage that can occur in people with diabetes. - Nerve damage symptoms can range from pain and numbness in feet to problems with the functions of internal organs, such as your heart and bladder. Review of Resident #145's electronic medical record (EMR) revealed the resident's required admission Minimum Data Set (MDS) assessment had not been completed. Review of Resident #145's EMR revealed there was no comprehensive care plan for the resident. A review of the Initial Plan of Care, dated 05/24/2023, revealed Resident #145 required assistance of one staff for mobility, turning, and transfers. The Initial Care Plan did not indicate the resident was at risk for falls or include interventions to prevent falls. A review of the clinical record for Resident #145 revealed no evidence a fall risk assessment was completed for the resident. A review of a nursing Progress Notes, dated 05/29/2023 at 3:05 AM, revealed Resident #145 was found on the floor, in the hallway. The resident had blood on the inside and outside of the nose and mouth. The resident denied pain but was sent to the hospital. A Progress Note, dated 05/29/2023 at 2:46 PM, indicated Resident #145 returned to the facility with a diagnosis of closed fracture of the nasal bone. A review of nursing Progress Notes, dated 06/03/2023 at 10:45 PM, revealed Resident #145 was on the floor beside the bed and told staff they were trying to reach something and slid out of the bed. The note indicated the resident had no injuries. A review of nursing Progress Notes, dated 06/10/2023 at 1:50 PM, revealed Resident #145 was found on the floor next to the wheelchair. The resident told the nurse they slid out of the chair. The note indicated the resident had no injuries. A form provided by the Director of Nursing (DON) as the risk management form, dated 06/15/2023 at 3:05 PM, revealed Resident #145 slid out of the wheelchair in the dayroom and had no injuries. The resident did not recall sliding out of the chair. The form indicated the physician was notified on 06/10/2023 at 3:35 PM. The form did not indicate a root cause analysis was completed for the fall or interventions to prevent further falls were implemented. The DON provided no further risk management forms related to falls for Resident #145. A review of the clinical record for Resident #145 revealed no evidence the facility attempted to determine what may have caused or contributed to the resident's falls and developed a care plan with interventions to reduce the likelihood of another fall following each of Resident #145's falls. A review of the clinical record revealed no evidence Resident #145 was assessed for their risk for falls after falls on 05/29/2023, 06/03/2023 and 06/15/2023. 5. Review of Resident #14's admission Record indicated the resident was admitted on [DATE] with diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar) and dementia with other behavioral disturbance. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #14 had short-term and long-term memory problems and moderately impaired cognitive skills for daily decision-making based on the Staff Assessment for Mental Status (SAMS). The MDS indicated the resident was independent with bed mobility and transfers and required limited assistance with toilet use. The MDS indicated Resident #14 had no falls prior to or since admission or the prior assessment. Review of Resident #14's medical record revealed there was no comprehensive care plan for the resident. Review of an Initial Plan of Care, dated 04/26/2023, revealed Resident #14 was independent with mobility, turning, and transfers. The Initial Care Plan did not indicate the resident was at risk for falls and did not include interventions to prevent falls. Review of a health status progress note, dated 03/23/2023 at 4:16 PM and written by nursing staff, revealed the resident found on the floor at the entrance to the dining room. According to the note, the resident did not have any injuries; the resident was assisted to stand and ambulated to their room without difficulty. This fall was not reflected on the quarterly MDS assessment, dated 04/28/2023. Review of a health status progress note, dated 05/08/2023 at 10:44 AM and written by nursing staff, revealed Resident #14 slid out of a recliner chair. The note indicated the resident had no injuries. Review of a health status progress note, dated 05/30/2023 at 8:28 AM and written by nursing staff, revealed, purplish bruising to right outer eye, no swelling noted. The note indicated the resident stated they hit their head. According to the note, the resident's roommate stated the resident was moaning during the night and was on the floor, and the lady across the hall helped the resident up and into bed. Review of an incident note, dated 06/11/2023 at 6:12 PM and written by nursing staff, revealed Resident #14 was heard yelling and was found on the floor, with a blanket tangled between their legs and feet. The note indicated a large hematoma was found on the back of the resident's head and the hematoma was painful to touch. There was no care plan developed to include fall prevention interventions to prevent further falls after any of the resident's falls. 6. During an interview on 06/14/2023 at 9:19 AM, Nursing Assistant (NA) #8 stated she received verbal report at shift change and checked in with the charge nurse for any updates on residents needs for care. During an interview on 06/14/2023 at 11:55 AM, the Restorative Aide (RA) said the facility was in the process of revising their patient care forms. The patient care forms included care information and instructions for resident care that the charge nurse provided to the aides and nursing assistants. The RA further stated there was nothing in writing for staff to refer to that included instructions for specific resident care. During an interview on 06/14/2023 at 12:12 PM, NA #7 stated the charge nurse verbally notified the nursing assistants at shift change about the care residents required and if there were any changes in care. NA #7 indicated she thought there was a book at the nurses' station that outlined resident care requirements, but she did not know the location of the book. During an interview on 06/14/2023 at 12:21 PM, NA #4 stated the charge nurse verbally notified the nursing assistants at shift change about resident care requirements and let them know if there were any changes. NA #4 further stated there was a report sheet for the nurses that had resident care information on it, but she had never seen it because she was not a nurse. During an interview on 06/15/2023 at 12:13 PM, the Physical Therapy Aide (PTA) stated all fall risk interventions were documented in the EMR, and each resident specific intervention should be a part of a resident's comprehensive care plan. During an interview on 06/14/2023 at 12:40 PM, Licensed Practical Nurse (LPN) #2 stated the charge nurse used a report sheet that was updated throughout the day with any changes in resident status, and the charge nurse verbally reported the care each resident required to the nursing assistants. She said there was nothing in writing for care staff to refer to. During an interview on 06/14/2023 at 12:55 PM, the Assistant Director of Nursing (ADON) stated the charge nurse gave verbal report to the aides and nursing assistants about the care each resident required. During an interview on 06/14/2023 at 1:30 PM, the Director of Nursing (DON) stated she was working on a form for the nursing assistants to reference for guidance about resident care. The DON indicated the form would include things like activities of daily living (ADLs) and care planned interventions to prevent falls. The DON said that currently, resident care needs were verbally relayed between staff members, and the facility did not have that information documented for staff to reference. The DON stated the DON, ADON, and the charge nurse determined fall interventions and interventions were reassessed every three to six months. During an interview on 06/15/2023 at 12:23 PM, the ADON stated any interventions in place to prevent falls should be included in a resident's care plan. The ADON stated she did not know that fall risk interventions were not being addressed on the care plan, and the DON was responsible for ensuring care plans were complete and up to date with a resident's fall risk. During an interview on 06/15/2023 at 12:30 PM, the DON stated the residents the survey team sampled were newer to the facility, and she was not sure how things fell through the cracks. The DON stated if a resident had a fall, it should be documented in the progress notes and the physician and responsible party (RP) should be notified. Comprehensive care plans should be revised with new fall risk interventions and once properly trained, she would be responsible for updating and completing care plans. The DON stated fall risk assessments were done upon admission and should be updated as the resident's status changed. During an interview on 06/15/2023 at 12:58 PM, the Assistant Administrator stated nursing was responsible for fall risk assessments, incident reports, treatment, and any follow-up assessments after a resident's fall. The facility discussed resident falls in their weekly meeting but could not elaborate any further on a resident's fall risk. During an interview on 06/15/2023 at 1:40 PM, the Administrator stated resident falls were discussed in a weekly meeting to try and prevent it from happening again but did not elaborate any further. During an interview on 06/24/2023 at 12:32 PM, the ADON stated the Administrator wanted the ADON to complete the expectation interviews in place of the DON. The ADON stated when a resident had a fall, she expected nursing staff to document the fall in a resident's EMR, complete risk management, complete a new fall risk assessment, update the care plan, and notify the physician and RP. During an interview on 06/15/2023 at 12:58 PM, the AA stated he expected nursing to be on top of the falls, to do an assessment, and complete an incident report. During an interview on 06/24/2023 at 1:37 PM, the Administrator stated she expected facility staff to follow their policy related to resident falls. Based on observations, interviews, and record review, the facility failed to determine causative factors of resident falls, implement and evaluate interventions to prevent falls, and develop an effective communication system that identified residents at risk for falls and provided care staff with interventions to prevent more falls for 4 (Residents #10, #8, #145, #96 and #14) of 4 residents reviewed for falls. Specifically, the facility failed to: - Determine causal factors and implement new interventions following multiple falls for Resident #10 that resulted in a fractured right hip. - Ensure a fall risk assessment was completed upon admission and investigate a fall that resulted in a fractured hip to determine causal factors for Resident #8. - Ensure a fall that resulted in a nasal bone fracture was investigated for causal factors for Resident #145. - Identify side rails as a possible fall risk, determine causal factors and implement new interventions to prevent further falls for Resident #96. -Determine causal factors and implement new interventions following multiple falls for Resident #14 that resulted in brusing to the right eye and a large hematoma on the back of the resident's head. - Develop an effective communication method that relayed information to staff in the prevention of resident falls. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care). The IJ began on 12/15/2022 when Resident #10 had a fall after their fall risk care plan was initiated on 09/20/2022. Resident #10 had 12 falls from 12/15/2022 to 04/30/2023, one of which resulted in a right hip fracture, and there were no attempts to determine the cause of Resident #10's falls, no evaluation of the effectiveness of fall interventions, and no new fall prevention interventions added to Resident #10's care plan following each fall in order to prevent further falls. The Administrator and Assistant Administrator (AA) were notified of the IJ and provided with the IJ template on 06/15/2023 at 3:44 PM. A Removal Plan was requested. The IJ was determined to be removed on 06/23/2023 after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of G. This deficient practice had the potential to affect all residents. Findings included: Review of the facility policy titled, Assessing Falls and Their Causes, dated 2001 and revised in October 2010, indicated, The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. The policy indicated, in part: 1. Review the resident's care plan to assess for any special needs of the resident and 5. Residents must be assessed in a timely manner for potential causes of falls. 6. Relevant environmental issues should be addressed promptly. The policy further indicated, An incident report must be completed for resident falls. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing (DON) services no later than 24 hours after the fall occurs. The policy indicated, 1. Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. They will refer to resident-specific evidence including medical history, known functional impairments, etc. 2. Staff will evaluate chains of events or circumstances preceding a recent fall. 3. The staff will continue to collect and evaluate information until they either identify the cause of falling or determine that the cause cannot be found. The policy indicated, When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found. 2. Assessment data including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family as indicated. 5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls. 7. The signature and title of the person recording the data. 1. Review of Resident #10's admission Record indicated the facility admitted the resident on 11/12/2018 with diagnoses including osteoarthritis (Most common form of arthritis characterized by the cartilage within a joint beginning to break down and the underlying bone changing. Most frequently in the hands, hips, and knees), paranoid schizophrenia, bipolar disorder, Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severely impaired cognition. The MDS indicated Resident #10 was independent with transfers, walking, and locomotion and was steady at all times when walking and during surface-to-surface transfers. The MDS indicated the resident had no falls since admission or the prior assessment. Review of Resident #10's care plan revealed a focus area, with an initiation date of 09/20/2022, indicated the resident was at risk for falls. Interventions directed staff to assist the resident with ambulation and transfers, determine the resident's ability to transfer, evaluate fall risk on admission and as needed (PRN), and if a fall occurred, staff were to initiate frequent neuro [neurological] and bleeding evaluation per the facility protocol. Review of Resident #10's care plan revealed another focus area, with an initiation date of 11/21/2022, that indicated the resident was at high risk for falls due to Parkinson's disease and psychoactive medication use. Interventions directed staff to anticipate and meet the resident's needs, be sure the resident's call light was within reach and encourage the resident to use the call light, educate the resident about safety reminders and what to do if a fall occurred, ensure that that the resident was wearing appropriate footwear, and ensure the resident was in a safe environment. A review of Resident #10's electronic medical record (EMR) revealed fall risk assessments were completed on 09/10/2022, 12/10/2022, and 04/18/2023 indicating Resident #10 was at risk for falls. A review of Resident #10's Progress Notes revealed five falls occurred from 12/15/2022 to 01/18/2023. Resident #10 was noted to have two falls on 01/18/2023, which resulted in a right hip fracture. Resident #10 readmitted to the facility on [DATE] following a hospitalization with a fractured right hip. The Progress Notes revealed Resident #10 had seven more falls from 02/08/2023 to 04/30/2023. The Progress Notes related to Resident #10's falls included: - On 12/15/2022 at 5:23 PM, Resident #10 was found on the floor of the television room with no injuries noted. - On 12/22/2022 at 6:29 PM, Resident #10 was found on the floor in front of their wheelchair next to the bed. The wheelchair was unlocked. Resident #10 had on socks had no injuries were noted. - On 12/25/2022 at 8:38 AM, Resident #10 was found on the floor in front of their bed, but by the time we got back to the room, [Resident #10] had scooted to the bathroom attempting to get up. There were no injuries noted. - On 12/26/2022 at 5:21 PM, Resident #10 was found on the floor of their room with no injuries noted. The resident indicated she was trying to change clothes. - On 01/03/2023 at 2:45 PM, Resident #10 was found lying on the floor of a sitting area with no injuries noted. The wheelchair was behind the resident and was unlocked. - On 01/18/2023 at 12:41 PM, Resident #10 was found on the floor at the foot of their bed on their right side with no injuries noted. - On 01/18/2023 at 2:46 PM, Resident #10 was observed to be ambulating in their room unassisted, with difficulty, while holding their right leg. A small purplish bruise was discovered on Resident #10's right hip. A physician's order was obtained for a right hip x-ray. - On 01/18/2023 at 5:30 PM, Resident #10 was found on the floor in their room holding their right thigh and yelling out in pain. Three staff members transferred Resident #10 to the bed where staff noted Resident #10's right leg was visibly shortened. An order was obtained to send Resident #10 to the emergency room. - On 02/08/2023 at 2:00 PM (which was a late entry for 12:00 PM), Resident #10 returned to the facility following a hospital stay for a right hip fracture. - On 02/08/2023 at 2:45 PM, Resident #10 was found sitting on the floor at the foot of their bed with no injuries noted. - On 02/18/2023 at 9:36 PM, Resident #10 appeared drowsy while sitting in their wheelchair at 9:00 PM. Staff found Resident #10 on the floor next to their bed at 9:15 PM and transferred Resident #10 back to their wheelchair and brought the resident out to the nurses' station. No assessment for injuries was noted. - On 03/15/2023 at 9:34 PM, staff found Resident #10 on the floor next to their bed with no injuries noted. - On 04/10/2023 at 8:18 AM, Resident #10 was kneeling at their bedside, appears resident OOB [out of bed] without assist d/t [due to] to both side rails being up. Resident #10 was assessed with no injuries noted. - On 04/18/2023 at 8:30 PM, Resident #10 sat at the nurses' station at 8:15 PM and then fell at the nurse's station after attempting to stand up from the wheelchair sustaining a contusion to the forehead about the size of a half dollar. - On 04/20/2023 at 3:29 PM, staff heard Resident #10 yelling out at 12:20 PM. Resident #10 was found on the floor of the nurses' station with one wheel of their wheelchair unlocked, no injuries were noted. Resident #10 was holding their head and rolling back and forth. - On 04/30/2023 at 3:51 PM (this note was still a draft and not finalized), a staff member found Resident #10 on the floor with no injuries noted. During an interview on 06/15/2023 at 2:06 PM, the DON stated when someone fell or had an incident, she was notified and the next day she would put it in to risk management. The DON stated it was kind of like an incident report. The risk management gave a graph of information, such as how many falls occurred during a certain period. The DON indicated there was not a risk management team, it was a section in the computer that could be printed out to see the number of falls. A review of Resident #10's clinical record from 12/15/2022 through 06/15/2023 revealed no evidence the facility attempted to determine what may have caused or contributed to Resident #10's falls. A review of Resident #10's care plan with the focus area of the resident being at risk of falls, initiated on 09/20/2022, revealed no evidence the fall risk care plan was reviewed and revised to reduce the likelihood of another fall after each of the falls Resident #10 experienced. During an interview on 06/13/2023 at 4:45 PM, the Assistant Director of Nursing (ADON) stated all documentation related to resident falls was in the progress notes. The ADON said there were no incident reports, forms, or other fall details included elsewhere in the resident's EMR. During an interview on 06/14/2023 at 8:55 AM, Certified Medicine Technician (CMT) #19 stated the nurse aides were there to make sure Resident #10 did not try to stand up, and the nurses were responsible for any implemented fall risk interventions. She said if Resident #10 started to stand up, the certified nursing assistants (CNAs) would tell them to sit back down. During an interview on 06/14/2023 at 9:19 AM, Nursing Assistant (NA) #8 stated she received verbal report at shift change and checked in with the charge nurse for any updates on residents needs for care. NA #8 said Resident #10 tried to stand up occasionally. NA #8 stated she was not sure if Resident #10 had any falls or if they were a high fall risk. She said she would have to ask the nurse for that information. During an interview on 06/14/2023 at 11:55 AM, the Restorative Aide (RA) said the facility was in the process of revising their patient care forms. The patient care forms included care information and instructions for resident care that the charge nurse provided to the aides and nursing assistants. The RA further stated there was nothing in writing for staff to refer to that included instructions for specific resident care. The RA stated Resident #10 was not steady on their feet, constantly tried to stand up, and was a high fall risk. The RA stated there may be a tilt seat in Resident #10's wheelchair to prevent them from getting up, and staff also gave Resident #10 coloring books to take their mind off trying to stand up. The RA did not know of any other fall risk interventions in place for Resident #10. During an interview on 06/14/2023 at 12:12 PM, NA #7 stated the charge nurse verbally notified the nursing assistants at shift change about the care residents required and if there were any changes in care. NA #7 indicated she thought there was a book at the nurses' station that outlined resident care requirements, but she did not know the location of the book. NA #7 stated staff kept Resident #10 at the nurses' station for increased supervision because the resident was a high fall risk. NA #7 further stated the charge nurse told her that Resident #10 was a high fall risk, but she did not know of any other intervention to prevent falls in place. During an interview on 06/14/2023 at 12:21 PM, NA #4 stated the charge nurse verbally notified the nursing assistants at shift change about resident care requirements and let them know if there were any changes. NA #4 further stated there was a report sheet for the nurses that had resident care information on it, but she had never seen it because she was not a nurse. NA #4 said the charge nurse told her Resident #10 was a high fall risk, had multiple falls while in the facility, and used two side rails to prevent falls out of bed. NA #4 said if Resident #10 tried to get out of bed unassisted, staff would put Resident #10 in their wheelchair and place them at the nurses' station for increased observation if she was not sleeping in bed. During an interview on 06/14/2023 at 12:40 PM, Licensed Practical Nurse (LPN) #2 stated the charge nurse used a report sheet that was updated throughout the day with any changes in resident status, and the charge nurse verbally reported the care each resident required to the nursing assistants. She said there was nothing in writing for care staff to refer to. LPN #2 stated Resident #10 was a high fall risk due to attempts at transferring without assistance. She said Resident #10 had frequent falls so staff kept them near the nurses' station, and LPN #2 did not think Resident #10 had any falls from bed. During an interview on 06/14/2023 at 12:55 PM, the ADON stated the charge nurse gave verbal report to the aides and nursing assistants about the care each resident required. The ADON stated she did not know if Resident #10 was a high fall risk. She said Resident #10 had multiple falls at the facility. She said she did not know when the last fall was and did not know what fall interventions were in place for Resident #10. During an interview on 06/14/2023 at 1:30 PM, the DON stated she was working on a form for the nursing assistants to reference for guidance about resident care. The DON indicated the form would include things like activities of daily living (ADLs) and care planned interventions to prevent falls. The DON said that currently, resident care needs were verbally relayed between staff members, and the facility did not have that information documented for staff to reference. The DON stated Resident #10 was a high fall risk and continuously tried to stand up out of their wheelchair, so they kept Resident #10 in a common area for increased supervision. The DON stated the DON, ADON, and the charge nurse determined fall interventions and interventions were reassessed[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, the facility failed to assess and/or reassess residents for the safe use of side rails, review the risks and benefits of side rails with the resident and/or the resident's responsible party (RP), obtain informed consent, and attempt appropriate alternatives prior to installing and using side rails on resident beds for 2 (Resident #96 and Resident #10) of 7 residents reviewed for side rail use. Resident #96 stated the side rails were barriers, made her feel confined and stranded, and she had a fear of not being able to get out of bed because of them- causing her to not want to get into her bed to sleep at night. As a result she fell asleep in her chair, fell forward and obtained a large hematoma on the right side of her forehead. Resident #10 had severe impaired cognition, a history of falls, and a history of getting out of bed via the foot of the bed with the side rails up. Facility staff reported putting up both side rails and raising the foot of the bed in an effort to prevent the resident from getting out of bed, increasing the risk of falls. The facility also failed to properly assess the safety of side rail use in conjunction with a low air loss mattress for 5 (Residents #20, #17, #5, #18, and #8) of 5 residents reviewed who used a low air loss mattress and had bilateral side rails. Failure to ensure bed rails and mattresses were compatible increases the risk of residents becoming entrapped in the side rails. The facility census was 42. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care). The IJ began on 04/10/2023. The Administrator and Assistant Administrator (AA) were notified of the IJ and provided with the IJ template on 06/15/2023 at 3:44 PM. With additional information, an updated IJ template was provided to the Administrator on 06/20/2023 at 8:59 AM. A Removal Plan was requested. The IJ was determined to be removed on 06/23/2023 after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at the lower scope and severity of E. Findings included: A review of the facility's undated Policy on Restraint Usage, that was included in the admission Agreement, indicated, Physical restraints are considered to be any practice or device that the resident cannot remove easily, which restricts the resident's freedom of movement or access to his or her body. Further review of the policy indicated, Restraints will be used in non-life threatening situations only: (1) when an assessment of the resident determines a restraint is required to treat a medical symptom and is the least restrictive therapeutic intervention; (2) with a physician's order; (3) after the use of the restraint has been explained to the resident and any involved family member or legally- authorized representative; (4) when the benefits of the restraint outweigh the identified risks; and (5) if the resident or legally-authorized representative does not refuse the restraint. A review of the facility's policy titled, Proper Use of Side Rails, revised in October 2010, revealed, Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances.) The policy indicated, 3. An assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's a. bed mobility; and b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet. 4. The use of side rails as an assistive device will be addressed in the resident care plan. Regarding consent, the policy indicated, 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Further review of the policy revealed the following: 11. If side rail use is associated with symptoms of distress, such as screaming or agitation, the resident's needs and use of side rails will be reassessed. 12. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment (the amount of safe space may vary, depending on the type of bed and mattress being used). 1. Review of Resident #96's admission Record revealed the facility admitted the resident on 04/22/2023 with diagnoses including acute respiratory failure, adjustment disorder with mixed anxiety and depressed mood, macular degeneration, and age-related osteoporosis. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #96 had a Brief Interview of Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment. The MDS indicated that Resident #96 required limited assistance from one staff with bed mobility and transfers and used a wheelchair for mobility. According to the MDS, the resident had no falls in the two to six months prior to admission and no falls since admission to the facility. The MDS indicated the resident did not use bed (side) rails as a physical restraint. Review of Resident #96's Initial Plan of Care, dated 04/22/2023, indicated the resident was blind, used glasses, and required assistance with mobility, turning, and transfers. The Initial Plan of Care did not indicate the resident was at risk for falls or used side rails. Review of Resident #96's electronic medical record (EMR) on 06/13/2023 revealed there was no comprehensive care plan for the resident. Review of Resident #96's progress notes revealed side rails were used on the following dates and times from 05/09/2023 to 06/06/2023: - On 05/09/2023 at 3:51 AM - siderails x 2 [two side rails] for positioning - On 05/11/2023 at 8:27 AM - siderails x 2 for positioning - On 05/13/2023 at 7:45 AM - siderails x 2 for positioning - On 05/13/2023 at 7:06 PM - siderails x 2 for positioning - On 05/16/2023 at 7:10 AM - siderails x 2 for positioning - On 06/06/2023 at 4:10 AM - siderails for positioning Review of a health status progress note, dated 06/04/2023 at 4:51 AM and written by nursing staff, indicated Resident #96 was awake the entire shift propelling themselves in their wheelchair in the hallway verbalizing the desire to leave. The note indicated staff attempted to guide Resident #96 to their room and into bed, but the resident repeatedly refused. Review of a health status progress note, dated 06/09/2023 at 3:29 AM and written by nursing staff, indicated that at 2:57 AM, Resident #96 fell asleep in their wheelchair and fell forward suffering a large hematoma to the right side of their forehead. Resident #96 was transported to the emergency room with no further injuries noted. A health status progress note indicated the resident returned to the facility on [DATE] at 11:30 AM. Review of Resident #96's EMR indicated no side rail assessment had been completed to determine if side rails were a safe approach for the resident. Further review of Resident #96's medical record revealed there was no informed consent, or physician's order for side rail use. During an interview on 06/12/2023 at 10:15 AM, Resident #96 stated they fell forward out of their wheelchair after falling asleep a few days prior. Resident #96 stated they did not know why staff put those barriers up on each side of the bed when they were in the bed and said that was why they fell asleep in their wheelchair that night. Resident #96 stated they did not like getting into bed because of the barriers in place keeping them in the bed. Resident #96 made these statements while pointing toward the side rails on their bed. During an observation on 06/13/2023 at 7:15 AM, Resident #96 was in a low bed with two side rails in the raised position. The side rails were on both sides of the bed and extended approximately 3/4 the length of the bed. It was determined on 06/14/2023 that the side rails were 42.5 inches long. During an interview on 06/13/2023 at 2:08 PM, Resident #96 stated they felt confined and stranded, and had a fear of not being able to get out of bed because of those stoppers staff put in place on their bed. Resident #96 made these statements while pointing at the side rails on their bed. During this interview, Resident #96's family member signaled to the surveyor that Resident #96 was mostly blind. During an interview on 06/14/2023 at 9:19 AM, Nursing Assistant (NA) #8 stated she did not know if Resident #96 was at high risk for falls. NA #8 said some residents who were at high fall risk used two side rails when in bed. NA #8 then stated she knew two side rails in the raised position constituted a (physical) restraint. During an interview on 06/14/2023 at 11:55 AM, the Restorative Aide (RA) stated Resident #96 was not at risk for falls and she was not aware of any falls the resident had since admission. The RA stated Resident #96 had two side rails up (raised) when in bed for safety. The RA did not know if Resident #96 attempted to get out of bed independently. During an interview on 06/14/2023 at 12:12 PM, NA #7 stated that when she came into work after Resident #96's fall and saw the resident's face, she asked the charge nurse what happened. NA #7 stated she thought Resident #96 was at high risk for falls. NA #7 said Resident #96 used two side rails when in bed because the resident tried to get out of bed on their own. During an interview on 06/14/2023 at 12:32 PM, NA #8 stated the charge nurse informed the nursing assistants if a resident used one or two side rails. She stated she did not know if Resident #96 used one or two side rails when in bed. During an interview on 06/14/2023 at 12:40 PM, Licensed Practical Nurse (LPN) #2 stated Resident #96 recently had a fall out of their wheelchair. She said the next morning (06/09/2023), she received report from the night nurse who stated that Resident #96 refused to go to bed that night, and LPN #2 had not received reports about the resident refusing to go to bed before. LPN #2 stated Resident #96 used one side rail for turning and repositioning. She said staff only placed two side rails in the raised position if a resident requested the side rails be raised or if a resident had a low air loss mattress. LPN #2 stated there was no other reason a resident would have two side rails in the raised position when in bed. LPN #2 further stated licensed nurses completed side rail assessments and passed information from the assessments on to the nursing assistants. During an interview on 06/14/2023 at 12:55 PM, the Assistant Director of Nursing (ADON) stated side rail use was assessed upon admission, and staff only used two side rails in the raised position based on a resident's request. The ADON stated one side rail was typically used to aid residents with sitting up in bed or transfers. She said side rail use was determined in collaboration with nursing and the physician. The ADON then stated she did not know if Resident #96 used side rails when in bed. During an interview on 06/14/2023 at 1:30 PM, the Director of Nursing (DON) stated she thought Resident #96 used one side rail in bed for call light and bed adjustment control placement so Resident #96 knew where the devices were located. The DON stated the only time staff used two side rails for a resident was if the resident was at high risk for falls or at risk of rolling out of bed, because otherwise two side rails were considered a physical restraint. During an interview on 06/15/2023 at 12:30 PM, the DON stated Resident #96 was new to the facility, and she was not sure if things fell through the cracks for the resident. The DON stated the necessity for side rail use was probably determined from assessments completed upon admission that indicated a resident's fall risk. The DON further stated she expected side rail assessments to be completed prior to resident use, and side rail use should be included in a resident's care plan. During an interview on 06/17/2023 at 3:25 PM, Resident #96 stated the previous night was their first night in the facility without those stoppers on their bed and they had the best night of sleep since admission. Resident #96 pointed to the bed which had the side rails removed/secured in the low position as they made this statement and then requested to please continue to keep it that way. The resident's side rails were removed on 06/16/2023 following surveyor inquiry. 2. A review of Resident #10's admission Record indicated the facility admitted Resident #10 on 11/12/2018 with diagnoses including osteoarthritis, paranoid schizophrenia, bipolar disorder, Parkinson's disease, and dementia. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severely impaired cognition. The MDS indicated Resident #10 was independent with bed mobility, transfers, and walking. According to the MDS, Resident #10 had no falls since admission or the prior assessment. The MDS indicated the resident did not use bed (side) rails as a physical restraint. Review of Resident #10's comprehensive care plan revealed focus areas, with initiation dates of 09/20/2022 and 11/21/2022, showed the resident at risk for falls. Resident #10's comprehensive care plan did not indicate the resident used side rails when in bed. Review of Resident #10's Bed Rail Assessment, dated 12/10/2022, indicated Resident #10 did not express a desire to have side rails or an assist bar for safety and/or comfort and had a history of falls. The Bed Rail Assessment indicated Side Rails/Assist Bar are not indicated at this time. This was the resident's most recent side rail assessment. There was no informed consent, or physician's order for side rail use in the electronic medical record (EMR). Review of a health status progress note, dated 04/10/2023 at 8:18 AM and written by nursing staff, revealed Resident #10 was found kneeling at the bedside and appeared to have gotten out of bed (OOB) w/o [without assistance] due to both side rails being up. A review of Resident #10's progress notes dated from 09/01/2022 to 06/15/2023 indicated repeated use of two side rails when in bed for positioning. For example, the following progress notes written from 05/13/2023 to 06/15/2023 referred to side rail use: - On 05/12/2023 at 9:13 AM - siderails x 2 [two side rails] for positioning - On 05/16/2023 at 7:16 AM - siderails x 2 for positioning - On 05/18/2023 at 5:28 AM - siderails x 2 for positioning - On 05/20/2023 at 4:19 AM - siderails x 2 for positioning - On 05/20/2023 at 7:54 AM - siderails x 2 for positioning - On 05/22/2023 at 6:41 AM - siderails x 2 for positioning - On 05/23/2023 at 7:35 AM - siderails x 2 for positioning - On 05/25/2023 at 9:16 AM - siderails x 2 for positioning - On 06/04/2023 at 5:14 AM - siderails x 2 for positioning - On 06/06/2023 at 8:59 AM - siderails x 2 for positioning - On 06/08/2023 at 7:53 AM - siderails x 2 for positioning - On 06/15/2023 at 5:16 AM - siderails x 2 for positioning During an observation of all occupied resident beds in the facility on 06/14/2023, 42 of 43 occupied beds, including Resident #10's, were equipped with bilateral side rails that measured 42.5 inches long as measured by Licensed Practical Nurse (LPN) #2 at 4:40 PM. During an interview on 06/14/2023 at 11:55 AM, the Restorative Aide (RA) stated Resident #10 used two side rails when in bed to prevent falls because Resident #10 occasionally scooted to the foot of the bed and tried to get out that way. During an interview on 06/14/2023 at 12:12 PM, Nursing Assistant (NA) #7 stated Resident #10 used two side rails when in bed because Resident #10 liked to get up on their own. NA #7 stated Resident #10 often scooted to the foot of the bed, so staff raised the foot of the bed to prevent Resident #10 from getting out of bed. During an interview on 06/14/2023 at 12:21 PM, NA #4 stated Resident #10 used two side rails when in bed to prevent them from getting out of bed because they were at high risk for falls. During an interview on 06/14/2023 at 12:32 PM, NA #8 thought Resident #10 used one side rail when in bed and did not know if Resident #10 was at high risk for falls. During an interview on 06/14/2023 at 12:40 PM, LPN #2 stated licensed nurses completed side rail assessments then passed that information on to the nursing assistants. LPN #2 stated two side rails were only used if a resident requested them or if they had a low air loss mattress; there was no other reason a resident would have two side rails in the raised position when in bed. LPN #2 then stated she did not know if Resident #10 used side rails when in bed, had not received reports that Resident #10 tried to get out of bed, and was not aware of any falls the resident had from bed. During an interview on 06/14/2023 at 12:55 PM, the Assistant Director of Nursing (ADON) stated the appropriateness of side rail use was assessed upon a resident's admission. She said residents typically only used one side rail for positioning or to aid with transfers and two side rails were only used when a resident requested them. The ADON did not know if Resident #10 used side rails when in bed. The ADON further stated she did not know if a physician's order was required for side rail use. During an interview on 06/14/2023 at 1:30 PM, the Director of Nursing (DON) stated side rail use was reassessed every three to six months, and the facility used side rails to prevent residents from rolling out of bed. During an interview on 06/15/2023 at 12:23 PM, the ADON stated side rail use should be included in a resident's care plan and thought the Minimum Data Set (MDS) Coordinator updated and completed the comprehensive care plans. During an interview on 06/15/2023 at 12:30 PM, the DON stated Resident #10 was new to the facility, and she was not sure if things fell through the cracks for the resident. The DON stated the necessity for side rail use was probably determined from assessments completed upon admission that indicated a resident's fall risk. The DON further stated she expected side rail assessments to be completed prior to resident use, and side rail use should be included in a resident's care plan. 3. Review of Resident #17's admission Record revealed the facility admitted the resident on 03/06/2023 with diagnoses including atherosclerotic heart disease, hypothyroidism, hyperlipidemia, dementia, and congestive heart failure. Review of an admission Minimum Data Set (MDS), dated [DATE], revealed Resident #17 had a Brief Interview for Mental Status Score (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was totally dependent upon staff for bed mobility and transfers. According to the MDS, Resident #17 had no falls in the six months prior to admission or since admission. The MDS indicated the resident did not use bed (side) rails as a physical restraint. Per the MDS, the resident was receiving hospice care. During an observation of all occupied resident beds in the facility on 06/14/2023, 42 of 43 occupied beds were equipped with bilateral side rails that measured 42.5 inches long as measured by Licensed Practical Nurse (LPN) #2 at 4:40 PM. Low air loss mattresses were in use on five of the beds with bilateral side rails. Resident #17's bed was one of the beds with a low air loss mattress and bilateral side rails. Review of Resident #17's Initial Plan of Care, dated 03/07/2023, revealed the resident was dependent upon staff for activities of daily living. The Initial Care Plan did not indicate the resident used side rails when in bed. Review of Resident #17's medical record on 06/12/2023 revealed there was no comprehensive care plan for the resident. A review of Resident #17's Order Summary Report, that included active physician's orders as of 06/15/2023, revealed no order for the use of side rails. Review of a health status progress note, dated 06/15/2023 and written following inquiry by the surveyors, indicated an order was received from the medical doctor for Side rails up x 2 with Alternating Low Air Loss Mattress while in bed. The note indicated the resident's responsible party (RP) was aware and voiced no concerns. A review of Resident #17's admission Bed Rail Assessment, dated 06/15/2023 and written following inquiry by the surveyors, indicated the resident had no history of falls. According to the Bed Rail Assessment, use of side rails was indicated for use as bilateral enablers to promote independence. The assessment was completed by the Assistant Director of Nursing (ADON) (a Licensed Practical Nurse), who signed in the RN [registered nurse] signature and Date box. During an interview on 06/14/2023 at 12:40 PM, LPN #2 stated staff used two side rails in the up (raised) position only if a resident requested the side rails be raised or if the resident had a low air loss mattress. During an interview on 06/18/2023 at 9:15 AM, LPN #2 stated there was nothing in writing for staff to refer to regarding the use of a low air loss mattress in conjunction with side rails. No evaluation was conducted of the 'fit' of the low air loss mattress to the bed frame, i.e. gaps between the side rails and mattress when the bed was unoccupied or occupied. 4. Review of Resident #8's admission Record indicated the facility admitted the resident on 04/26/2023 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and cerebral infarction. Review of an admission Minimum Data Set (MDS) dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance from staff with bed mobility and transfers and was totally dependent upon staff for toilet use. The MDS indicated the resident used a wheelchair for mobility. According to the MDS, Resident #8 had no falls in the six months prior to admission or since admission. The MDS indicated the resident did not use bed (side) rails as a physical restraint. During an observation of all occupied resident beds in the facility on 06/14/2023, 42 of 43 occupied beds were equipped with bilateral side rails that measured 42.5 inches long as measured by Licensed Practical Nurse (LPN) #2 at 4:40 PM. Low air loss mattresses were in use on five of the beds with bilateral side rails. Resident #8's bed was one of the beds with a low air loss mattress and bilateral side rails. Review of the Initial Plan of Care, dated 04/26/2023, revealed Resident #8 required assistance of one staff for mobility, turning, and transfers. The Initial Plan of Care did not indicate the resident used side rails. Review of Resident #8's medical record revealed there was no comprehensive care plan for the resident. Further review of Resident #8's medical record revealed there was no side rail assessment, informed consent, or physician's order for side rail use. During an interview on 06/14/2023 at 12:40 PM, LPN #2 stated staff used two side rails in the raised position only if a resident requested the side rails be raised or if the resident had a low air loss mattress. During an interview on 06/18/2023 at 9:15 AM, LPN #2 stated there was nothing in writing for staff to refer to regarding the use of a low air loss mattress in conjunction with side rails. No evaluation was conducted of the 'fit' of the low air loss mattress to the bed frame, i.e. gaps between the side rails and mattress when the bed was unoccupied or occupied. 5. Review of Resident #20's admission Record revealed the facility admitted the resident on 08/14/2015 with diagnoses including protein-calorie malnutrition, vascular dementia, depression, and hemiplegia. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #20 had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making based on the Staff Assessment for Mental Status (SAMS). The MDS indicated the resident was totally dependent upon staff for bed mobility and transfers. According to the MDS, the resident had a functional limitation in range of motion in one upper extremity and both lower extremities. The MDS indicated the resident did not use bed (side) rails as a physical restraint. During an observation of all occupied resident beds in the facility on 06/14/2023, 42 of 43 occupied beds were equipped with bilateral side rails that measured 42.5 inches long as measured by Licensed Practical Nurse (LPN) #2 at 4:40 PM. Low air loss mattresses were in use on five of the beds with bilateral side rails. Resident #20's bed was one of the beds with a low air loss mattress and bilateral side rails. Review of Resident #20's care plan revealed a focus area, with an initiation date of 11/03/2022, that indicated the resident had a potential for pressure ulcer development. An intervention was added on 06/15/2023 that directed staff as follows: SR [side rails] up x 2 [two side rails] per mattress manufacturer's recommendations. This intervention was added following surveyor inquiry about side rail use. Review of Resident #20's Bed Rail Assessment, dated 06/15/2023 and written following inquiry by the surveyors, indicated the resident had a history of falls. According to the Bed Rail Assessment, Side Rails/Assist bar are indicated and serve as an enabler to promote independence. The assessment was completed by LPN #2, who signed under the heading RN [registered nurse] Signature and Date. Review of Resident #20's Order Summary Report revealed a physician's order, dated 06/15/2023 (following inquiry by the surveyors), for Side rails up x 2 with Alternating Low Air Loss Mattress while in bed. During an interview on 06/14/2023 at 12:40 PM, LPN #2 stated staff used two side rails in the raised position only if a resident requested the side rails be raised or if the resident had a low air loss mattress. During an observation on 06/18/2023 at 8:30 AM, Resident #20 was in bed lying on a low air loss mattress with bilateral side rails in the raised position. During an interview on 06/18/2023 at 9:15 AM, LPN #2 stated there was nothing in writing for staff to refer to regarding the use of a low air loss mattresses in conjunction with side rails. No evaluation was conducted of the 'fit' of the low air loss mattress to the bed frame, i.e. gaps between the side rails and mattress when the bed was unoccupied or occupied. 6. Review of Resident #5's admission Record revealed the facility admitted the resident on 08/10/2022 and readmitted the resident on 12/17/2022 with diagnoses that included metabolic encephalopathy, functional quadriplegia, depression, and anxiety. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required extensive assistance from staff with bed mobility and transfers. According to the MDS, Resident #5 had functional limitations in range of motion in the bilateral upper and lower extremities. The MDS indicated the resident did not use bed (side) rails as a physical restraint. During an observation of all occupied resident beds in the facility on 06/14/2023, 42 of 43 occupied beds were equipped with bilateral side rails that measured 42.5 inches long as measured by LPN #2 at 4:40 PM. Low air loss mattresses were in use on five of the beds with bilateral side rails. Resident #5's bed was one of the beds with a low air loss mattress and bilateral side rails. Review of Resident #5's care plan revealed a focus area, with an initiation date of 10/06/2022, that indicated the resident had an activities of daily living (ADL) self-care performance deficit related to quadriplegia. The care plan also included a focus area, with an initiation date of 09/20/2022, that indicated the resident had the potential for impaired skin integrity. On 06/15/2023, following inquiry by the surveyors, the following intervention was added to this focus area: SR [side rails] x 2 [two side rails] per therapeutic mattress manufacture [manufacturer's] recommendations. Review of Resident #5's Bed Rail Assessment, dated 06/15/2023 and completed following inquiry by the surveyors, indicated the resident did not have a history of falls. The Bed Rail Assessment revealed side rails were indicated for use as bilateral enablers to promote independence. The assessment was completed by LPN #2, who signed under the heading RN [registered nurse] signature and date. Review of Resident #5's Order Summary Report revealed a physician's order dated 06/15/2023 (following inquiry by the surveyors) for Side rails up x 2 with Alternating Low Air Loss Mattress while in bed. During an interview on 06/14/2023 at 12:40 PM, LPN #2 stated staff used two side rails in the raised position only if the resident requested it or if they had a low air loss mattress. During an interview on 06/18/2023 at 9:15 AM, LPN #2 stated there was nothing in writing for staff to refer to regarding the use of a low air loss mattress in conjunction with side rails. No evaluation was conducted of the 'fit' of the low air loss mattress to the bed frame, i.e. gaps between the side rails and mattress when the bed was unoccupied or occupied. 7. Review of Resident #18's admission Record revealed the facility admitted the resident on 11/03/2019 with diagnoses including dementia, osteoporosis, right and left femur fractures, and Alzheimer's disease. Review of a quarterly Minimum [NAME] Set (MDS), dated [DATE], revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. According to the MDS, the resident required extensive assistance with bed mobility and transfers. The MDS indicated the resident did not use a bed (side) rail as a physical restraint. During an observation of all occupied resident beds in the facility on 06/14/2023, 42 of 43 occupied beds were equipped with bilateral side rails that measured 42.5 inches long as measured by Licensed Practical Nurse (LPN) #2 at 4:40 PM. Low air loss mattresses were in use on five of the beds with bilateral side rails. Resident #18's bed was one of the beds with a low air loss mattress and bilateral side rails. Review of Resident #18's care plan revealed a focus area, with an initiation date of 09/21/2022, that indicated the resident had a potential for impaired skin integrity. On 06/15/2023, following inquiry by the surveyors, the following intervention was added to this focus area: SR [side rails] x 2 [two side rails] per therapeutic mattress manufacture [manufacturer's] recommendations. A review of Resident #18's Bed Rail Assessment, dated 06/15/2023 and completed following inquiry by the[TRUNCATED]