**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to prevent a resident with a court-appointed guardian who required supervision with leave of absences, a previous elopement attempt, and wore an elopement alarm monitoring device (Resident #127) from exiting the facility unsupervised and without staff knowledge. The facility also failed to prevent a resident with impaired cognition who had a history of exit seeking behavior and wore an elopement alarm monitoring device (Resident #67) from exiting the facility unsupervised and without staff knowledge. The deficient practice was for 2 of 5 sampled residents reviewed for accidents. On 04/11/23, Resident #127 was last seen in the facility at approximately 10:30 AM walking toward the dining room. At 11:15 AM Nurse Aide (NA) #1 went to look for Resident #127 and when Resident #127 was unable to be located inside the building, a Code [NAME] (missing person) was called at 12:00 PM and a facility-wide search was conducted by staff which included the outside perimeter of the building and surrounding areas. At approximately 1:10 PM, Resident #127 was found at a location off facility property and brought back to the facility by law enforcement. On 02/02/24, Resident #67 was last observed in the facility at approximately 7:10 AM walking toward the front lobby. At approximately 7:15 AM, as NA #2 and NA #3 were leaving work they observed Resident #67 outside in the facility parking lot squatted down between two parked cars. Resident #67 was escorted back into the facility by NA #2 and NA #3. There was a high likelihood Resident #127 and Resident #67 could have suffered serious injury, harm or death when they were outside the facility unsupervised. Findings included: 1. Resident #127 was readmitted to the facility on [DATE] with diagnoses that included diabetes, end-stage renal disease, history of falls, depression, and generalized anxiety disorder. A State of NC Order on Motion for Appointment of Interim Guardian document dated 02/25/21 read in part, A hearing on the movant's Motion for the Appointment of an Interim Guardian was held on this day. From the evidence presented at the hearing, the Court makes the following specific findings of fact: 1) Respondent does not have capacity presently to manage medical care and appointments and has been hospitalized due to not attending medical appointments required to keep him alive, 2) Respondent is currently hospitalized with multiple serious medical conditions, and 3) Respondent will likely die if released from the hospital without assistance of a guardian. Based on these specific findings of fact, the Court concludes that there is reasonable cause to believe that the respondent is incompetent and that the respondent is in a condition that constitutes or reasonably appears to constitute an imminent or foreseeable risk of harm to the respondent's well-being, and there is immediate need for a guardian to provide consent or take other steps to protect the respondent. A State of North Carolina Letter of Appointment Guardian of the Person document dated 04/06/21 revealed Resident #127 was assigned a court-appointed Guardian with the reason marked as incompetent person. A care plan initiated on 06/28/19 revealed Resident #127 had a communication problem related to language barrier. His primary language is Spanish. Interventions included to notify nurse of any changes in ability to communicate and possible factors which cause/make worse/improve any communication problems, speak on an adult level clearly and slower than normal, and validate Resident #127's message by repeating aloud. A care plan initiated on 11/18/22 revealed Resident #127 required supervision on Leave of Absence (LOA) from the facility due to poor safety awareness. Interventions included to educate Resident #127 and his Guardian on LOA policy and procedure and refer to Social Service/designee for review and reeducation if Resident #127 does not follow LOA procedures. A care plan initiated on 12/09/22 revealed Resident #127 was at risk for injury related to an attempted elopement that was stopped by staff before he exited the building, delirium related to believing he still had an apartment locally and expressing intent to leave the facility to go to his apartment or to Florida. Interventions included to monitor and report changes in behavior such as restlessness and pacing and provide diversional activities of interest such as offering a snack or playing music he enjoys. A care plan initiated on 12/15/22 revealed Resident #127 had an acute (sudden in onset) confusional state characterized by changes in consciousness, disorientation, environmental awareness or behavior. Resident #127 continues to have delusions and was recently started on antipsychotic medication. Interventions included to discuss feelings about placement, keep environmental noise/stimulation to a minimum, observe and report any changes in mental status, provide medications to alleviate agitation as ordered by the physician, and monitor/document side effects/effectiveness. A care plan initiated on 04/12/23 revealed Resident #127 had an impaired ability to make self-understood related to primary language other than English. Resident #127 spoke Spanish. Interventions included to arrange for an interpreter as needed, maintain eye contact when communicating, pronounce words correctly, and use an alternative method of communication such as flip chart or translator. A physician order for Resident #127 dated 12/20/22 read in part, check elopement alarm monitoring device via testing machine every day. The order was discontinued on 03/21/23. A physician order for Resident #127 dated 12/20/22 read in part, visually check elopement alarm monitoring device placement every shift. The order was discontinued on 03/21/23. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #127 with intact cognition. Resident #127 was independent with walking and locomotion and displayed no behaviors during the MDS assessment period. Review of Resident #127's medical record revealed an Elopement Assessment was completed on 12/09/22 that revealed Resident #127 was considered high risk for elopement. The assessment consisted of the following 4 sections: • Mobility Status: Is the resident physically capable of leaving the facility? The answer was marked as 'yes.' • Mental Status: Is resident alert and oriented times three? The answer was marked as 'no.' • Wandering Behavior: Does the resident wander within the facility or have a history of wandering? Does the resident verbalize or exhibit exit seeking behavior? Both questions were answered 'yes.' • History: Has there been previous history of attempted or actual elopement or unsafe wandering? The answer was marked 'yes.' There were no further elopement assessments completed after 12/09/22 until 04/11/23. A staff progress note dated 04/11/23 at 3:30 PM written by the Social Worker (SW) read in part, Guardian was notified of incident with Resident #127 as follows: 12:15 PM - notified facility was looking for resident; 1:38 PM - notified Resident #127 was located; 1:43 PM - notified Resident #127 was refusing to come into the facility; 2:20 PM - notified Resident #127 was sent to the hospital for involuntary commitment. The facility's investigation included an unsigned, typed document titled, Abatement Plan, that read in part: On 04/11/23 at 12:00 PM Resident #127 was identified as being on an unauthorized absence away from the facility. The facility initiated elopement procedures and Code [NAME] for Resident #127 at 12:10 PM when he could not be located within the facility. At 12:15 PM, local law enforcement was notified that Resident #127 was missing from the facility. At 1:00 PM, Resident #127 was located at a church in the neighborhood and brought back to the facility at 1:10 PM by law enforcement. Resident #127 refused to enter the facility and at 1:30 PM was taken by law enforcement to the hospital for an evaluation and possible involuntary commitment. Resident #127 returned to the facility from the hospital on [DATE] at 8:30 PM with no new orders or treatment. A handwritten witness statement dated 04/11/23 signed by Nurse Aide (NA) #1 read in part, I last saw Resident #127 around 10:30 AM. He was walking in the hallway as if he was going towards the dining room. After I passed Resident #127 in the hallway, I went on break. I came back around 11:00 AM - 11:15 AM and noticed he wasn't in his room or dining room. I went immediately and notified the nurse on duty that I didn't see him in either of those two places. During a telephone interview on 04/05/24 at 11:58 AM, NA #1 confirmed she was Resident #127's assigned NA on 04/11/23 when he eloped from the facility and was told by Nurse #2 to watch him due to exit seeking behavior. NA #1 could not recall the exact time but said it was before lunch when she was doing her rounds and saw Resident #127 sitting out in the hall dressed in jeans, shirt, shoes and a jacket. She took a break and when she went back up the hall to check on him, she couldn't find him. She immediately told the Nurse, they both started looking for him everywhere and when they couldn't find him, Code [NAME] was called which she described was the facility's missing person procedure. She stated law enforcement was also notified (did not know who called), every inch of the facility was checked and then staff started searching the facility grounds and surrounding neighborhood even knocking on doors to homes in the area and stopping cars on the main road. NA #1 stated at one point during the search she recalled some staff stating he had been talking about going back to where he used to live when he was homeless and some staff (could not recall who) got into their cars, went to the location, found him and brought him back to the facility. NA #1 stated it was around 1:00 PM when Resident #127 was returned to the facility but he wouldn't go back inside so he was taken to the hospital for evaluation and believed he returned to the facility later that same day. She did not recall Resident #127 having any visible injuries or appear in any distress when he was brought back to the facility. NA #1 stated Resident #127 could make his needs known at times but had a communication barrier due to him speaking very limited English. She stated there was a staff member at the time who was fluent in Spanish and could translate for them when they (NAs) couldn't understand what it was he was needing. NA #1 stated she had provided his care frequently prior to his elopement on 4/11/23 and he had never previously displayed exit-seeking behaviors or made any attempts to leave the facility. A witness statement dated 04/11/23 signed by Nurse #2 read in part, I last saw Resident #127 at around 10:30 AM going up the hall toward the dining room. About 11:00 AM - 11:30 AM the Nurse Aide asked where Resident #127 was and I went to look for him and could not locate him. We called a Code [NAME] and all staff started searching the facility for Resident #127. During an interview on 04/10/24 at 9:10 AM, Nurse #2 confirmed she was Resident 127's assigned nurse on 04/11/23 when he eloped from the facility. Nurse #2 recalled she had not been employed at the facility long and was still getting to know Resident #127 and his routine which was typically keeping to himself either sitting in his room, activity room or dining room. Nurse #2 stated she never really noticed him displaying exit-seeking before 04/11/23. Nurse #1 stated on the morning of 04/11/23, Resident #127 was verbalizing wanting to leave and was observed by staff going to the exit doors. She informed the Director of Nursing (DON) and Social Worker (SW) how Resident #127 was acting and was told to keep a close eye on him. Nurse #2 instructed the NAs to keep an eye on Resident #127 and everyone did the best they could to keep him in sight. Around lunchtime, Nurse #2 stated she went to look for Resident #127 to give him his medications and couldn't find him. She along with the NAs started looking in the facility and when they couldn't find him, the Administrator and DON were notified and Code [NAME] was called. Nursing staff conducted a head count of all the residents and all staff started searching the facility premises looking for Resident #127. In addition, management staff left in their cars to search the surrounding neighborhood. Nurse #2 stated at the time of his elopement, Resident #127 had been refusing dialysis and was more confused. She was not really sure how he got out but thinks a visitor may have let him out the front door because he really didn't look like a typical resident. After Resident #127's elopement, the facility conducted elopement drills, re-education and instructed staff not to give the codes for the exit doors out to anyone who did not work at the facility. During a telephone interview on 04/03/24 at 12:48 PM, Unit Manager #2 revealed she was no longer employed at the facility but was working on 04/11/23 when Resident #127 eloped. Unit Manager #2 recalled Resident #127 had refused to go to dialysis that day, she informed the Nurse Practitioner (NP) who ordered blood work and she (Unit Manager #2) went to Resident #127's room to draw his labs. She stated Resident #127 had started refusing to go to dialysis and when she provided him with education as to the importance of going he would still refuse, even when they tried different approaches to get him to go such as getting an outside transport company to take him because he didn't like the facility transport. Unit Manager #2 explained the more Resident #127 refused dialysis, the more confused he became and he started verbalizing he didn't want to be at the facility; however, he did not mention anything to her about wanting to leave the facility the morning of 04/11/23 when she drew his labs. Unit Manager #2 stated it was around 10:00 AM - 10:30 AM when she went into Resident #127's room and he was sitting on the side of his bed wearing a plaid shirt and jeans. She drew his labs and when she left his room, he was calm and in no distress. Unit Manger #2 stated she went on a break and then took the labs drawn to the hospital. She recalled she was only gone from the facility about 30 minutes when she was called and told Resident #127 was missing. She came back to the facility and everyone immediately started searching the facility and grounds for Resident #127. Unit Manager #2 stated she even walked around the perimeter of building but no one was able to locate Resident #127. Unit Manager #2 stated Resident #127 was later brought back to the facility by law enforcement but could not recall the time he returned. She recalled being informed Resident #127 had exited the building from the front entrance, she was not sure how, and walked to a church in the area but did not know the exact location or how far it was from the facility. During an interview on 04/04/24 at 2:31 PM, the DON recalled she had only been employed about a month when Resident #127 eloped from the facility on 04/11/23 and she had never observed him actually attempt to leave the facility prior to that day. The DON stated she personally never heard him make comments about wanting to leave but was told by other staff that a few days prior to him leaving the facility on 04/11/23 he had made comments about wanting to go see his girlfriend. The DON recalled Resident #127 used a walker for ambulation and had an elopement alarm monitoring device attached to his walker. She was not sure why the order for the elopement alarm monitoring device was discontinued on 03/21/23 and explained when he returned from the hospital the order must not have been queued back into the system to show up as an active order. The DON stated when she saw Resident #127 the morning of 04/11/23, he wasn't acting any differently than normal and did remember seeing the elopement alarm monitoring device attached to his walker. She recalled at one point she had tried to get him to allow her to place it on his lower extremity, which only aggravated him because he knew what it was and what it meant and he had refused to wear it. When they later determined he was missing and conducted the facility-wide search, the DON stated they found the elopement alarm monitoring device on the floor in his room that looked like it had been sawed when removed from his walker which she described as torn with jagged edges. She stated facility staff searched everywhere in the facility as well as the facility grounds and when Resident #127 was not located, she (DON) drove around the neighborhood in her car to look for him. The DON did not recall how Resident #127 was able to get out of the facility but remembered being told (could not recall by who) that he had walked to some location in the area, was fed a meal and then taken to a local church where the Pastor spoke Spanish. She was not sure where Resident #127 had walked or how far the location was from the facility. The DON stated when Resident #127 was found and brought back to the facility by law enforcement, he wouldn't come inside the facility and she went with the Administrator to the Magistrates office to obtain paperwork for an Involuntary Commitment (IVC). She couldn't recall the exact time but stated Resident #127 was sent to the hospital for an evaluation but returned to the facility later that same day (04/11/23) which she stated frustrated her because she wanted him medically evaluated due to his frequent refusals to receive dialysis. The DON restated Resident #127 had a history of refusing dialysis and a few weeks after his elopement he was sent out to the hospital for evaluation and passed away. When asked if Resident #127 was safe to be outside unsupervised, the DON stated Resident #127 was able to ambulate with the use of his walker but had the tendency to have poor judgement and decision making skills. During an interview on 04/24/24 at 2:57 PM, the Administrator explained Resident #127's primary language was Spanish which created a language barrier but he did have limited English and often made comments about wanting to go back where he used to live when he was homeless or go see his girlfriend in another state. The Administrator further explained Resident #127 had a history of refusing dialysis and as a result was deemed incompetent to make healthcare decisions and granted a court-appointed Guardian. She stated it was normal for Resident #127 to sit at the front exit doors because that was where he would wait for transportation to take him to dialysis when he was willing to go. She could not recall when but stated at one point, they had to start sending a staff member with him to dialysis because he would wander away from the dialysis center. On 04/11/23, the Administrator stated she was at the facility when notified Resident #127 could not be located, a Code [NAME] was immediately called and a facility-wide search initiated but he could not be found. The Administrator recalled NA #1 was Resident #127's assigned NA on 04/11/23 and after she returned from break around 11:15 AM NA #1 didn't see Resident #127 in his room or dining room, she notified the nurse and they both started looking for him in the facility. When the nurse and NA #1 were unable to locate Resident #127 Code [NAME] was called at 12:00 PM and law enforcement notified. The Administrator stated facility staff searched everywhere in the facility and then expanded the search to the outside grounds and perimeters. She added at the time of his elopement, Resident #127 did have an elopement alarm monitoring device but he had removed it and it was found on the floor of his room when they searched the premises. She recalled it was around 1:10 PM when Resident #127 was located and brought back to the facility by law enforcement. She stated they had informed her Resident #127 walked to one of the neighborhood homes (not sure which one), he asked the homeowners for a ride and they took Resident #127 to a local church where the Pastor spoke Spanish and the Pastor had contacted law enforcement. When Resident #127 arrived back to the facility, he sat on the bench by the front entrance door refusing to go back inside. She explained a staff member employed at the time who was fluent in Spanish was talking to Resident #127 trying to convince him to go back inside the facility but he continued to refuse stating he would kill himself because he felt he was being locked up in the facility. At 1:30 PM, she went with the DON to the Magistrate's office to obtain IVC paperwork and he was sent to the hospital for evaluation but returned to the facility later that same day (04/11/23) and even though they felt he was too high functioning, he was moved to a room on the locked Memory Care Unit for safety. The Administrator stated after Resident #127's elopement, they did a root cause analysis and the best they could determine was some family members had learned the codes to the exit doors and must have let him out thinking he was a visitor because he didn't look like a typical resident of the facility. She stated they changed all the codes to the exit doors on 04/11/23 and facility staff were instructed not to give out the code to anyone and cover their hands when entering the code. The Administrator stated prior to his elopement, Resident #127 had been declining due to his frequent refusals of dialysis and sometime after returning to the facility on [DATE] he went on Hospice care, was sent out to the hospital in May 2023 and later passed away while at the hospital. An observation of the facility grounds was conducted on 04/10/24 08:40 AM. The front of the building sat just off a main road that inclined and curved throughout a residential area with a speed limit of 35 miles per hour. When standing at the front entrance, there was border wall on the opposite side of a circular driveway that led to/from the parking lot located on the right side of the building. There was also a sidewalk that started at the front entrance of the facility and along the side of the building to the parking area. At the end of the sidewalk and driveway was an exit on the left out to the main road and on the right was the facility sign and the parking lot. Houses and/or trees bordered the opposite side of the parking lot, back and left side of the building. An online website named Weather Underground was used to obtain the outside weather in the Hendersonville area on 04/11/23 which noted at 10:54 AM the temperature was 59 degrees Fahrenheit (F), at 11:54 AM the temperature was 63 degrees F, at 12:54 PM the temperature was 66 degrees F, and at 1:54 PM the temperature was 68 degrees F. 2. Resident #67 was admitted to the facility on [DATE] with diagnoses that included vascular dementia moderate with psychotic disturbance, bipolar disorder and hallucinations. A physician order for Resident #67 dated 12/12/23 read in part, check elopement alarm monitoring device via testing machine every day. A care plan initiated on 12/11/23 revealed Resident #67 has a diagnosis of vascular dementia, traumatic brain injury and behaviors which include, in part: wandering, rejecting care, packing up belongings and attempting to leave the facility using the fire exit button to open doors and becoming combative with staff when they attempt to prevent her from leaving. Interventions included one-to-one, every 15 minutes and/or every 30 minutes monitoring for safety as needed, attempt to redirect if/when she is resisting care, and monitor/report/document any mood changes to the nurse. A care plan initiated on 12/11/23 revealed Resident #67 had a diagnosis of vascular dementia which could cause her cognition to vary throughout the day requiring assistance with decisions. Interventions included reorient to date, time and place if appropriate, provide redirection if/when Resident #67 made inappropriate actions and monitor/report/document any changes in cognition. A care plan initiated on 12/12/23 revealed Resident #67 was at risk for elopement due to wandering, vascular dementia, traumatic brain injury, increased confusion at night, may be looking for family, thinks she works at the facility, and elopement alarm monitoring device to right ankle. Interventions included: may leave building when accompanied by staff or responsible adult, notify the Physician or Nurse Practitioner of exiting behavior, provide diversional activity PRN, and redirect from exit doors. A care plan initiated on 12/12/23 revealed Resident #67 had impaired cognitive function and thought processes related to dementia and head injury. Interventions included for staff to cue, reorient and supervise Resident #67 PRN. An activities of daily living Care Area Assessment (CAA) associated with the Minimum Data Set (MDS) assessment dated [DATE] read in part, Resident #67 has had no documented behavioral issues since admission. Per staff interview, Resident #67 will wander throughout the unit and at times, will push on exit doors. Resident #67 does wear an elopement alarm monitoring device for added safety. She was transferred from another facility due to working at that facility and knowing the codes to open the facility's exit doors. A physician order for Resident #67 dated 01/04/24 read in part, visually check elopement alarm monitoring device placement to right ankle every shift. The quarterly MDS assessment dated [DATE] assessed Resident #67 with moderate impairment in cognition. Resident #67 displayed no behaviors, was independent with walking and used an elopement alarm daily during the MDS assessment period. Review of Resident #67's February 2024 Treatment Administration Record (TAR) revealed physician orders for staff to check the elopement alarm monitoring device via testing machine every day shift and to visually check the elopement alarm monitoring device placement to her right ankle every shift. Both orders were initialed as completed daily per physician order. On 02/04/24, Resident #67's elopement alarm monitoring device was noted functioning and intact on the right ankle, each shift. Review of Resident #67's medical record revealed an Elopement Assessment was completed on 03/06/24 that revealed Resident #67 was considered high risk for elopement. The assessment consisted of the following 4 sections: • Mobility Status: Is the resident physically capable of leaving the facility? The answer was marked as 'yes.' • Mental Status: Is resident alert and oriented times three? The answer was marked as 'no.' • Wandering Behavior: Does the resident wander within the facility or have a history of wandering? Does the resident verbalize or exhibit exit seeking behavior? Both questions were answered 'yes.' • History: Has there been previous history of attempted or actual elopement or unsafe wandering? The answer was marked 'yes.' A staff progress note dated 02/02/24 at 5:34 AM written by Nurse #3 read in part, Resident #67 woke up at 4:00 AM and has been exit-seeking ever since. Resident #67 gathered all her belongings and said, I'm going home and no amount of redirection would convince her otherwise. All staff have been alert and monitoring her movement between front and back/side exit. Resident #67 also seems to be aware that if you consistently push the door it will open and has been observed several times leaning her weight on the door. Telephone attempts for an interview with Nurse #3 on 04/05/24 at 10:16 AM, 04/10/24 at 10:16 AM and 04/10/24 at 12:14 PM were unsuccessful. A staff progress note dated 02/02/24 at 7:51 AM written by Unit Manager #1 read in part, Resident #67 was found in the parking lot outside of the facility hiding between two cars. One-to-one immediate intervention initiated. Resident #67 was assessed with no injuries. Family and Nurse Practitioner were notified. During an interview on 04/10/24 at 10:48 AM, Unit Manager #1 recalled on 02/02/24 at shift change, around 7:00 AM, she was notified by Nurse Aide (NA) #2 and NA #3 that Resident #67 was found outside the building in the parking lot. Unit Manager #1 stated upon assessment, Resident #67 had no injuries or signs of distress and was placed on one-to-one staff supervision. She was unable to recall what Resident #67's response was when asked why she went outside. Unit Manager #1 explained Resident #67 always went to the exit doors trying to get out stating she wanted to leave to go see her boyfriend. The facility's investigation included an unsigned, typed document titled, Abatement Plan, that read in part: Resident #67 exited the building on 02/02/24. Resident #67 had an elopement alarm monitoring device in place; however, the door did not alarm due to Resident #67 entering the code and a malfunction of the elopement alarm monitoring device sensor did not trigger the locking mechanism. Resident #67 was out of the facility for less than 5 minutes and was seen in the parking lot by staff and brought back inside the facility. Resident #67 had no injuries. A witness statement dated 02/02/24 obtained from the Receptionist read in part, Resident #67 was at the front door trying to push it open to get out when I arrived about 6:45 AM. She had all her clothes in bags. I went down to the nurses' station and had her moved from door before I left the door. When I was walking back up to my office, I saw NA #2 and NA #3 walking Resident #67 back down the hall. I had told them at the desk Resident #67 was up there trying to get out. They said she had been at the other door also during the night trying to get out. It was about 7ish when NA #2 and NA #3 found Resident #67 out in the parking lot. Resident #67 had let herself out. During a telephone interview on 04/10/24 at 10:31 AM, the Receptionist recalled on 02/02/24 she had just arrived at the facility at approximately 7:00 AM and as she was coming through the front entrance, Resident #67 was standing by the door inside the facility, fully dressed with all her belongings packed in bags. The Receptionist stated she opened the door, making sure it closed behind her, and told Resident #67 she needed to go back to her room and not be standing by the door. The Receptionist went down the hall to clock in and then stopped by the nurses' station per her usual routine to see if there were any discharges. As she was walking back up the hall toward the front where her office was located, she saw NA #2 and NA #3 walking Resident #67 down the hall. She recalled the NAs stating Resident #67 had gotten outside and they had found her in the parking lot. The Receptionist stated it was only about 10 minutes after she saw Resident #67 at the door when the NAs had brought her back into the building. She was not sure how Resident #67 got out of the building because she (Receptionist) made sure the key pad was covered when she entered the code to the door and the door had closed securely before she left the area. The Receptionist explained Resident #67 used to be a NA at another facility and could figure out the codes to the exit doors. She further stated it was normal routine for Resident #67 to push on the exit doors or try to enter codes to get the doors open and staff provided her with frequent redirection throughout the day. She stated Resident #67 was always cooperative with staff redirection but due to her cognition, it wasn't long before she was right back at the exit doors. The Receptionist stated right after it was discovered Resident #67 had gotten out of the building, she sat by the door until it was fixed that day by the Maintenance Director. In addition, staff received immediate re-education on elopement process/procedure, not giving out the codes to the exit doors and making sure you covered your hand when entering the code. A witness statement da[TRUNCATED]

Based on observations, record review and staff interviews, the facility failed to train and verify competency for cleaning and disinfecting a glucometer according to manufacturers' recommendations using an Environmental Protection Agency (EPA) approved disinfectant cloth between residents. Agency Nurse #1 was observed not cleaning and disinfecting a shared glucometer between use of two residents (Resident #57 and Resident #62). Agency Nurse #1 was interviewed and reported she was unaware residents requiring blood sugar monitoring had assigned individual glucometers and was unfamiliar with the EPA approved disinfectant wipe's manufacturer's guidelines for contact time. This was for 1 of 1 nursing staff. The Immediate Jeopardy began on 04/03/24 when the failure to train and verify the competency of Agency Nurse #1 on the cleaning and disinfecting a glucometer resulted in the nurse's failure to clean and disinfect a glucometer between use of two residents. Immediate Jeopardy was removed on 04/05/24 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. Findings included: Cross refer to tag F-880: Based on observations, staff interviews, and record review, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents in accordance with manufacturer's recommended contact time for 2 of 3 residents whose blood glucose levels were checked (Resident #57 and Resident #62). This occurred while there was not a resident with known bloodborne pathogens in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instruction for disinfection, including the correct contact time, of the glucometer has the high likelihood of exposing residents to the spread of bloodborne pathogens. In an interview with Agency Nurse #1 on 04/03/24 at 9:08 AM she stated this was her first shift at the facility. She stated she briefly wiped the glucometer in between checking the blood glucose for Resident #57 and Resident #62 and was not aware of any brand of glucometer that was required to be in contact with a cleaning/disinfection solution for a specified period of time. Agency Nurse #1 confirmed she had not received any training or education on how to disinfect glucometers from the facility prior to beginning her shift and was used to each resident having their own glucometer, which did not require cleaning in between uses unless there was visible blood on the glucometer. She stated she was not aware that each resident had their own glucometer and was unaware of any type of training/communication book was located at the nurses' station. On 04/03/24 at 10:02 AM the Director of Nursing (DON) was informed that Agency Nurse #1 did not follow the manufacturer's guidelines for use of an EPA-approved disinfectant for the recommended contact time for a shared glucometer. The DON stated each resident had their own glucometer, but this was Agency Nurse #1's first day in the facility and she probably wasn't aware. She stated the facility provided orientation for new and agency staff, but she was not sure what the orientation entailed because the Assistant Director of Nursing (ADON) handled training for agency staff. The DON was asked for the training record from the facility or staffing agency for Agency Nurse #1 indicating she had been trained on how to disinfect glucometers. Review of training and competency records for Agency Nurse #1 provided by the facility on 04/03/24 revealed there was no evidence the nurse had been trained on the procedure for cleaning and disinfecting a glucometer. An interview with the ADON on 04/03/24 at 10:36 AM revealed the facility recently changed the process of orientation for agency and facility staff. She stated the Scheduler and Business Office Manager assisted her with providing orientation training and each department head also provided education specific to their department. The ADON confirmed use of glucometer and glucometer disinfection were topics included in orientation but was unable to state who was responsible for completing the education. She stated agency staff should be aware of the policy and procedure for using and disinfecting glucometers and there should be a communication book at each nurses' station with information on how to use and disinfect glucometers that nursing staff could refer to. The ADON confirmed she had not provided any education regarding glucometer use and disinfection for Agency Nurse #1 prior to her beginning her shift on 04/03/24 and had not made her aware of the communication book at the nurses' station. The ADON was unable to describe how agency staff were notified of the communication book kept at the nurses' station. When asked to review the communication book for Agency Nurse #1's assigned hall the ADON was not immediately able to locate the communication book. An interview with the Business Office Manager on 04/03/24 at 2:12 PM revealed she was not involved in the orientation process for agency staff. An interview with the Scheduler on 04/03/24 at 2:16 PM revealed she was responsible for filling in gaps in the nursing staff schedule with agency staff when needed. She stated she was only responsible for obtaining licensing information and did not obtain any training information from staffing agencies. The Scheduler confirmed she did not provide any orientation training to agency staff. The Administrator and Director of Nursing were notified of Immediate Jeopardy on 04/04/24 at 8:32 AM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and Agency Nurse #1 completed a blood glucose check on Resident #57 and placed the blood glucose monitor she used back in the medication cart without cleaning the monitor. Agency Nurse # 1 was preparing to obtain Resident #62's blood sugar and picked up the same glucometer she had used on Resident #57 and wiped the glucometer with disinfecting wipe and failed to wait the 2-minute dwell time per manufacturer guideline of the disinfectant wipe and proceeded into the room of Resident #62 when the surveyor stopped the nurse because the glucometer had not been disinfected. Agency Nurse #1 had not checked any other resident's blood sugar prior to Resident #57. On 4/3/2024 Agency Nurse #1 was educated by the Regional Director of Clinical Services on the cleaning and disinfection of glucose monitoring machines using the manufacturer's guidelines of the blood glucose monitor and that the disinfectant wipes are to be an EPA registered disinfectant and to follow the manufacturer's instructions for contact time. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 4/3/2024 nurses and medication aides that were working on medication carts on 4/3/2024 were educated immediately by the Regional Director of Clinical Services on the cleaning and disinfection of glucose monitoring machines using the manufacturer's guidelines of the blood glucose monitor and that the disinfectant wipes are to be an EPA registered disinfectant and to follow the manufacturer's instructions for contact time. On 4/3/2024 The Director of Nursing/Designee started education with all licensed nurses and medication aides on the cleaning and disinfection of glucose monitoring machines using the manufacturer's guidelines of the blood glucose monitor and that the disinfectant wipes are to be an EPA registered disinfectant and to follow the manufacturer's instructions for contact time. This education will be completed on 4/4/2024. On 4/3/2024 Director of Nursing/designee started education for all licensed nurses and medication aides that each resident has been provided an individual blood glucose monitor labeled with residents' name and a non-porous container labeled with resident name and each resident's blood glucose monitor is to be kept separate and in each individual container and staff only use blood glucose monitor assigned to specific residents to obtain blood glucose. This education will be completed on 4/4/2024. On 4/3/2024 The Director of Nursing/designee started education with licensed nurses and medication aides on cleaning and disinfecting the blood glucose machines before and after each use by following the manufacturer's guidelines of cleaning and disinfecting the blood glucose monitor. The disinfectant wipes are to be an EPA registered disinfectant and staff were instructed to follow the manufacturer's instructions for contact time. This education will be completed on 4/4/2024. On 4/3/2024 The Director of Nursing checked each medication cart and verified that each resident that requires blood glucose monitoring has an individual blood glucose meter that is labeled with the resident's name in non-porous container that is also labeled with each resident's name. There are 20 total residents that require blood glucose monitoring at this time. On 4/3/2024 The Director of Nursing/Designee placed the policy on cleaning and disinfecting the blood glucose machine, the manufacturer's guidelines for cleaning and disinfecting the blood glucose monitor in the communication book at each nurses' station. Guidance to refer to the manufacturer's guidelines of the disinfectant wipes available for contact times and to ensure the wipes are an EPA registered agent effective against blood borne pathogens. On 4/4/2024 The Director of Nursing placed a non-porous container labeled with each individual resident's name on each medication cart for each resident requiring blood glucose monitoring, each container contains a blood glucose monitor that is individually labeled with each resident's name. The Director of Nursing/Designee will educate all newly hired nurses and medication aides during orientation on the following: 1.) Policy and procedure for cleaning and disinfection of glucose monitoring machines before and after each use, following the manufacturer's guidelines for the machine. 2.) The dwell times for the EPA approved disinfectant for blood borne pathogens. 3.) Each resident has been provided an individual blood glucose monitor labeled with resident's name and a non-porous container labeled with resident name, which are located on each medication cart. Each resident's blood glucose monitor is to be kept separate in each individual container. Staff is to only use blood glucose monitor assigned to each specific resident to obtain blood glucose reading. 4.) Policy and procedure for cleaning and disinfecting the blood glucose machine as well as the manufacturer's guidelines for cleaning and disinfecting the blood glucose monitor can be found in the communication book at each nurse station. The Director of Nursing/Designee will ensure all agency nurses have received the following education prior to working their first shift: 1.) Policy and procedure for cleaning and disinfection of glucose monitoring machines before and after each use, following the manufacturer's guidelines for the machine. 2.) The dwell times for the EPA approved disinfectant for blood borne pathogens. 3.) Each resident has been provided an individual blood glucose monitor labeled with resident's name and a non-porous container labeled with resident name, which are located on each medication cart. Each resident's blood glucose monitor is to be kept separate in each individual container. Staff is to only use blood glucose monitor assigned to each specific resident to obtain blood glucose reading. 4.) Policy and procedure for cleaning and disinfecting the blood glucose machine as well as the manufacturer guidelines for cleaning and disinfecting the blood glucose monitor can be found in the communication book at each nurse station. On 4/4/2024 The Nursing Home Administrator contacted the local Health Departments Communicable Disease Nurse to inform her of the F-880 Infection Control citation regarding cleaning and disinfection blood glucose monitors. Alleged date of Immediate Jeopardy removal is 04/05/24. The Immediate Jeopardy was removed on 04/05/24. The facility's credible allegation of Immediate Jeopardy was validated on 04/10/24 through staff interview and review of in-service training records. Nurses and medication aides were able to verbalize they had received training on the proper procedure for disinfecting the glucometer before and after use with an EPA-approved disinfecting wipe and ensuring contact time was performed per manufacturer's guidelines before they were allowed to begin their shift. Skill Competency for Point of Care Blood Testing Meter Disinfection and Use for nurses and medication aides was reviewed, and all received satisfactory scores. The credible allegation was validated, and the Immediate Jeopardy was removed on 04/05/24.

Based on observations, staff interviews, and record review, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents in accordance with manufacturer's recommended contact time for 2 of 3 residents whose blood glucose levels were checked (Resident #57 and Resident #62). This occurred while there was not a resident with known bloodborne pathogens in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer's instruction for disinfection, including the correct contact time, of the glucometer has the high likelihood of exposing residents to the spread of bloodborne pathogens. Immediate Jeopardy began on 04/03/24 when Agency Nurse #1 cleaned the glucometer between the two residents with an approved EPA disinfecting wipe but did not follow the manufacturer's recommendation for contact time. Immediate Jeopardy was removed on 04/05/24 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: A review of the facility's policy entitled Glucometer/Point of Care Blood Testing and Disinfection Procedure last revised 12/27/23 read in part as follows: Policy: Whether shared or assigned to a singular resident, blood testing meters will be disinfected between each use (before use the clinical staff should assume the meter is dirty and disinfect before use) according to manufacturer instructions and infection prevention guidelines. Procedure: - Wipe meter using friction with recommended type of germicidal wipe. - Maintain visible wetness of meter for required kill time according to disinfectant instructions. Use multiple wipes if necessary. Do not reuse wipes. The manufacturer's User Guide for the glucometer used at the facility included Caring for Your System. These instructions read in part, To minimize the risk of transmission of bloodborne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below. The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter before performing the disinfection. The meter should be cleaned and disinfected after use on each patient. This blood glucose monitoring system may only be used for testing multiple patients when Standard Precautions and the manufacturer's disinfection procedures are followed. We have validated [Brand Name] Germicidal Disposable Wipes for disinfecting the [Brand Name] meter. A list of additional products approved for cleaning and disinfecting the glucometer was provided by the manufacturer. The glucometer's manufacturer also noted, Disinfectants were validated separately and only one cleaning/disinfection solution should be used on the device for the life of the device as the effect of using more than one cleaner/disinfectant interchangeably has not been evaluated. Review of the manufacturer's guidelines and instructions for use of the EPA approved disinfectant wipe used by the facility specified a contact time of two minutes for disinfecting the [Brand Name] glucometer. A review of a facility document titled Diagnosis Report dated 04/03/24 revealed there were no residents with known bloodborne pathogens residing in the facility. A continuous observation of Agency Nurse #1 passing medication and performing blood glucose monitoring on 04/03/24 from 8:10 AM through 9:08 AM was conducted. At 8:10 AM Agency Nurse #1 checked Resident #57's blood glucose and placed the blood glucose monitor in the top drawer of the medication cart without disinfecting the monitor. At 9:08 AM Agency Nurse #1 quickly wiped the same blood glucose monitor used to check Resident #57's blood sugar with a [Brand Name] disinfecting wipe that was sitting on top of the medication cart. No friction was observed when Agency Nurse #1 wiped the glucometer. She removed the bottle of test strips from the cart, applied gloves, removed an alcohol pad and lancet from the cart, placed the test strip in the blood glucose monitor, and crossed the threshold of Resident #62's door to check his blood glucose. Less than one minute had elapsed. At 9:08 AM surveyor stopped Agency Nurse #1 from completing the blood glucose check for Resident #62 because Agency Nurse #1 failed to disinfect the blood glucose monitor in accordance with manufacturer's guidelines after use on Resident #57. In an interview with Agency Nurse #1 on 04/03/24 at 9:08 AM she stated this was her first shift at the facility. She stated she briefly wiped the glucometer in between checking the blood glucose for Resident #57 and Resident #62 and was not aware of any brand of glucometer that was required to be in contact with a cleaning/disinfection solution for a specified period of time. Agency Nurse #1 confirmed she had not received any training or education on how to clean the glucometer prior to beginning her shift and was used to each resident having their own glucometer, which did not require cleaning in between uses unless there was visible blood on the glucometer. She stated she had not checked any other residents' blood glucose on 04/03/24 before checking Resident #57's at 8:10 AM. No timer was observed on Agency Nurse #1's medication cart. An interview with Unit Manager #1 on 04/03/24 at 9:13 AM revealed each resident had their own glucometer, but Agency Nurse #1 was probably not aware because that was her first shift at the facility. She stated each glucometer was different and required a different cleaning process and there was a binder at the nurses' station with information on how to clean different glucometers. Unit Manager #1 indicated the [Brand Name} disinfectant wipes sitting on top of Agency Nurse #1's medication cart were probably the wipes that should have been used for cleaning the glucometer after Resident #57's blood sugar check. She stated if the manufacturer of the [Brand Name] disinfecting wipes on the medication cart recommended a contact time of two minutes, then the glucometer should be in contact with the wipe for two minutes. On 04/03/24 at 10:02 AM the Director of Nursing (DON) was informed of the concern related to the facility's failure to follow the manufacturer's recommended contact time for a shared glucometer. During the interview the DON was informed Agency Nurse #1 checked Resident #57's blood sugar, placed the glucometer in the top drawer of the medication cart without cleaning the glucometer, administered medications to two residents, removed the glucometer used to check Resident #57's blood sugar at 8:10 AM, wiped the glucometer briefly with a [Brand Name] disinfecting wipe, gathered additional supplies for checking a blood glucose, walked to Resident #62's room, and was stopped during the observation before the shared glucometer could be used for a second resident. The DON stated each resident had their own glucometer, but this was Agency Nurse #1's first day in the facility and she probably wasn't aware. She stated glucometers should be cleaned after each use with [Brand Name] disinfecting wipes, have a contact time of two minutes with the glucometer, and then air dry. The DON stated after the disinfecting process was complete, the glucometer would be ready for use again. An interview with the Regional Director of Clinical Services on 04/04/24 at 5:57 PM revealed she had spoken with Agency Nurse #1, and Agency Nurse #1 confirmed she did not clean the glucometer after she checked Resident #57's blood glucose. The Administrator and Regional Director of Clinical Services were informed of the Immediate Jeopardy on 04/03/24 at 5:57 PM. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and Agency Nurse #1 completed a blood glucose check on resident #57 and placed the blood glucose monitor she used back in the medication cart without cleaning the monitor. Agency Nurse # 1 was preparing to obtain Resident #62's blood sugar and picked up the same glucometer she had used on Resident #57 and wiped the glucometer with disinfecting wipe and failed to wait the 2-minute dwell time per manufacturer's guideline of the disinfectant wipe and proceeded into the room of Resident #62 when the surveyor stopped the nurse because the glucometer had not been disinfected. Agency Nurse #1 had not checked any other resident's blood sugar prior to Resident #57. On 4/3/2024 Agency Nurse #1 was educated by the Regional Director of Clinical Services on the cleaning and disinfection of glucose monitoring machines using the manufacturer's guidelines of the blood glucose monitor and that the disinfectant wipes are to be an EPA registered disinfectant and to follow the manufacturer's instructions for contact time. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 4/3/2024 Nurses and Medication Aides that were working on medication carts on 4/3/2024 were educated immediately by the Regional Director of Clinical Services on the cleaning and disinfection of glucose monitoring machines using the manufacturer's guidelines of the blood glucose monitor and that the disinfectant wipes are to be an EPA registered disinfectant and to follow the manufacturer's instructions for contact time. On 4/3/2024 The Director of Nursing/Designee started education with all licensed nurses and medications aide on the cleaning and disinfection of glucose monitoring machines using the manufacturer's guidelines of the blood glucose monitor and that the disinfectant wipes are to be an EPA registered disinfectant and to follow the manufacturer's instructions for contact time. This education will be completed on 4/4/2024. On 4/3/2024 Director of Nursing/designee started education for all licensed nurses and medication aides that each resident has been provided an individual blood glucose monitor labeled with resident's name and a non-porous container labeled with resident name and each resident's blood glucose monitor is to be kept separate and in each individual container and staff only use blood glucose monitor assigned to specific residents to obtain blood glucose. This education will be completed on 4/4/2024. On 4/3/2024 The Director of Nursing/designee started education with licensed nurses and medication aides on cleaning and disinfecting the blood glucose machines before and after each use by following the manufacturer's guidelines of cleaning and disinfecting the blood glucose monitor. The disinfectant wipes are to be an EPA registered disinfectant and staff were instructed to follow the manufacturer's instructions for contact time. This education will be completed on 4/4/2024. On 4/3/2024 The Director of Nursing checked each medication cart and verified that each resident that requires blood glucose monitoring has an individual blood glucose meter that is labeled with the resident's name in non-porous container that is also labeled with each resident's name. There are 20 total residents that require blood glucose monitoring at this time. On 4/3/2024 The Director of Nursing/Designee placed the policy on cleaning and disinfecting the blood glucose machine, the manufacturer's guidelines for cleaning and disinfecting the blood glucose monitor in the communication book at each nurses' station. Guidance to refer to the manufacturer's guidelines of the disinfectant wipes available for contact times and to ensure the wipes are an EPA registered agent effective against blood borne pathogens. On 4/4/2024 The Director of Nursing placed a non-porous container labeled with each individual resident's name on each medication cart for each resident requiring blood glucose monitoring, each container contains a blood glucose monitor that is individually labeled with each resident's name. The Director of Nursing/Designee will educate all newly hired nurses and medication aides during orientation on the following: 1.) Policy and procedure for cleaning and disinfection of glucose monitoring machines before and after each use, following the manufacturer's guidelines for the machine. 2.) The dwell times for the EPA approved disinfectant for bloodborne pathogens. 3.) Each resident has been provided an individual blood glucose monitor labeled with the resident's name and a non-porous container labeled with resident name, which are located on each medication cart. Each resident's blood glucose monitor is to be kept separate in each individual container. Staff is to only use blood glucose monitor assigned to each specific resident to obtain blood glucose reading. 4.) Policy and procedure for cleaning and disinfecting the blood glucose machine as well as the manufacturer guidelines for cleaning and disinfecting the blood glucose monitor can be found in the communication book at each nurse station. The Director of Nursing/Designee will ensure all agency nurses have received the following education prior to working their first shift: 1.) Policy and procedure for cleaning and disinfection of glucose monitoring machines before and after each use, following the manufacturer's guidelines for the machine. 2.) The dwell times for the EPA approved disinfectant for bloodborne pathogens. 3.) Each resident has been provided an individual blood glucose monitor labeled with the resident's name and a non-porous container labeled with resident name, which are located on each medication cart. Each resident's blood glucose monitor is to be kept separate in each individual container. Staff is to only use blood glucose monitor assigned to each specific resident to obtain blood glucose reading. 4.) Policy and procedure for cleaning and disinfecting the blood glucose machine as well as the manufacturer guidelines for cleaning and disinfecting the blood glucose monitor can be found in the communication book at each nurse station. On 4/4/2024 The Nursing Home Administrator contacted the local Health Departments communicable disease nurse to inform her of the F880 Infection Control citation regarding cleaning and disinfection blood glucose monitors. Alleged date of Immediate Jeopardy removal is 04/05/24. The Immediate Jeopardy was removed on 04/05/24. The facility's credible allegation of Immediate Jeopardy removal was validated on 04/10/24 through staff interview and review of in-service training records. Staff were able to verbalize that each resident had their own individual glucometer which was stored on the medication cart, glucometers were to be cleaned before and after each use according to manufacturer's guidelines with an EPA-approved disinfectant for the recommended contact time. Information regarding disinfecting blood glucose monitoring could be found in the Communication Book at each nurses' station. Observations were conducted of all medication carts and revealed each resident had their own individual glucometer which was labeled with their name and serial number of their assigned glucometer. Observations also confirmed EPA-approved disinfectant wipes were stored on each medication cart. The credible allegation was validated, and the Immediate Jeopardy was removed on 04/05/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews with the Emergency Medical Technician, the Medical Doctor, and staff the facility failed to safeguard a resident with severe cognitive impairment from an avoidable hazard when bilateral quarter bed rails were utilized in conjunction with an alternating air pressure mattress. Resident #1 was found with no signs of life on 11/19/23 after experiencing a fall from a bed with bed rails in the up position. The resident was observed with his buttocks on the ground and his head laying face up on the mattress with his chin and neck pressed against the bed rail. This occurred for 1 of 3 residents reviewed for accidents (Resident #1). Findings included: The hospital history and physical dated 09/03/23 revealed Resident #1's diagnoses included generalized weakness and severe dementia. The history and physical included assessment notes completed by the Physical Therapist (PT) and Occupational Therapist (OT). The PT notes provided a list of problems Resident #1 had including decreased cognition, decreased strength and range of motion, and being a fall risk. Resident #1 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive and dementia. The admission bed rail assessment dated [DATE] signed by Nurse #1 indicated the medical needs considered for the use of the side rails was positioning and indicated Resident #1 would benefit from the use of side rails to aid in positioning. PT and OT were listed on the assessment as the alternatives attempted but failed to meet the needs of Resident #1. None of the potential risks from the use of side rails were checked including if the resident or part of his body would be caught between rails, the opening of rails, or between the bed rails and the mattress. The type of bed rails being used was not included as part of the assessment. The physician order dated 09/07/23 read Do Not Resuscitate - DNR meaning Resident #1 wished not to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest or if he stopped breathing. The fall risk evaluation dated 09/07/23 indicated Resident #1 was a high risk for falls. Review of the admission note dated 09/08/23 revealed Resident #1 was oriented only to self with periods of agitation and aggression. He was incontinent of bowel and bladder and required a mechanical lift for transfers and 2-person assistance with bed mobility and toileting. The fall care plan initiated on 09/08/23 revealed Resident #1 was at risk for falls related to immobility. Interventions included educate resident and family preventative fall interventions; implement preventative fall interventions and devices; maintain call bell within reach and educate resident to use call bell; physical, occupational, and speech therapy to screen and treat as necessary per physician order; and maintain resident's needed items within reach. There was no care plan to indicate Resident #1 used bed rails for positioning. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #1's cognition as being severely impaired. Extensive 2-person assistance was needed for bed mobility and toilet use. Assist with transfers occurred 1 to 2 times by extensive 2-person assistance. Walking or locomotion did not occur during the lookback period and no falls had occurred since admission. Resident #1 was always incontinent of bladder and bowel. The assessment indicated bed rails were not being used as a physical restraint. The admission Care Area Assessments for the MDS dated [DATE] described Resident #1 would be long term care due to his cognition and was a fall risk due to poor safety awareness and limited mobility. Staff assistance was needed for incontinence due to mobility and cognition and needed for repositioning to relieve pressure due to being at risk for pressure ulcers. It was noted Resident #1 had demonstrated verbal and physical behaviors described as grabbing at bars and the mechanical lift. The incident report documented by the nurse on 09/27/23 revealed a skin assessment identified Resident #1 had a new pressure ulcer wound on the sacrum. A second bed rail assessment dated [DATE] completed by Nurse #1 revealed no changes were made to the assessment and indicated Resident #1 would benefit from the use of side rails to aid in positioning and alternatives attempted that failed were PT and OT. None of the potential risks from the use of side rails were checked including: The resident or part of his body would be caught between rails, the opening of rails, or between the bed rails and the mattress or skin integrity issues. The type of bed rails being used was not included as part of the assessment. Review of the delivery order revealed on 10/04/23 an alternating pressure mattress was placed on the bed of Resident #1. There was no bed rail assessment completed for Resident #1 from 10/04/23 through 11/19/23. Resident #1 was discharged to the hospital on [DATE] for the chief complaint emesis and possible coffee ground colored emesis. Resident #1 was discharged back to the facility on [DATE]. Review of the progress note written by Nurse #2 on 11/19/23 at 7:55 AM revealed she was alerted by Nurse Aide (NA) #1 Resident #1 partially fell from the bed. Resident #1 was assessed with no pulse present and Emergency Medical Services (EMS) was called. The on-call Nurse Practitioner for the Medical Doctor and Administration were notified. Review of the EMS incident report revealed on 11/19/23 at 5:30 AM Resident #1 had fallen from the bed. The lead Emergency Medical Technician (EMT) documented narrative read in part, EMS was dispatched for a fall and when arrived on the scene was met by and followed facility staff to the room. While walking to the room staff on the scene advised the patient was gone and they had found him lying halfway off the bed and his head was stuck in the railing. The EMT found Resident #1 lying on the floor in a supine position (flat on one's back) and described the resident as apneic (without breaths), pulseless and the skin was pale and cool to touch. The note indicated the EMT was advised by staff Resident #1 was last seen at 3:15 AM and found at 5:30 AM in the initial position described. At 6:32 AM the EMS assessment of a cardiac monitoring device showed an asystole (without a heartbeat) heart rhythm. A telephone interview was conducted on 1/11/24 at 2:13 PM with the lead EMT who wrote the narrative on the EMS report. The EMT confirmed Resident #1 was laying on the floor in supine (flat on one's back) position when they entered the room. He stated the call came in as fall and when they arrived at the facility a staff member, he was unable to identify, walked him to the room and said Resident #1 was gone and was Do Not Resuscitate. He thought it was the same person who told him Resident #1's head was stuck in the bed rail and confirmed that was said to him. During the assessment of Resident #1 he did not notice any bruising or impression of a bed rail on the resident or see anything that stood out to him. Review of the facility's investigation revealed a statement from NA#1 dated 11/19/23 that read in part, Doing my 5:00 AM rounds I noticed resident was on the floor in between the bed rail. I went to notify the nurse. The last time I did a round was at 3:00 AM. I changed resident and he was laying down on his back. A clarification was made to NA #1's statement dated 11/19/23 and read in part, At 3:00 AM I went in the room to change brief and Resident #1 was laying on his back holding the rail and fighting as usual. His left leg was coming out of the bed. I redirected his arms to the right side to hold onto the rail so I could change his brief. When I left the room put the bed in the lowest position. At 5:15 AM I walked into Resident #1's room and noticed he was laying with jaw line in rail and his body was on left side of bed on floor with his brief halfway off with the sheets and some his blanket. I walked over to see if his chest was rising up and down and noticed it wasn't. I went out of the room to find nurse. She and I walked back to room, and she confirmed Resident #1 was deceased . I assist to get into the bed with other NAs. Other staff statements included in the investigation did not provide information related to the position they saw Resident #1 after being made aware he had passed and before his body was moved. During a telephone interview on 01/11/24 at 1:29 PM Nurse #1 confirmed she had completed the bed rail assessments for Resident #1. She explained if a resident was cognitively impaired, climbed out of bed, was a high fall risk or did not understand why or how they would use a bed rail she would not recommend rails and stated Resident #1 was not like that. Nurse #1 stated Resident #1 had dementia but most of the time he was able to use the bed rails. She reported he had a rapid decline after developing a pressure ulcer on his sacrum. During a telephone interview on 1/10/24 at 4:33 PM NA #1 confirmed she worked the night shift on 11/18/23 from 6:45 PM to 7:15 AM the morning of 11/19/23 and was assigned to care for Resident #1. NA #1 stated when she found Resident #1 (5:15 AM), he was laying on his left side towards the window with the left leg bent under his right leg and his buttocks was on the floor. His lower body was lying on the floor, but his head was on the bed face up and his jaw was leaning and/or pressing into the rail but not in between the rails. The air mattress was on the bed and the bed was always kept low to ground, and the bed rail was in an up position. She went around the bed and put her hand on Resident #1's chest to check for breathing and he wasn't. She left the room and did not see the nurse and got NA #2. NA #2 did not enter the room but stated she could tell Resident #1 was dead and they (NA #1 and NA #2) both went to find the nurse. NA #1 stated she last changed Resident #1 around 3:30 AM and her next check was around 5:15 AM and that's when she found him. She was told by Nurse #2 not to move Resident #1 until the Administrator came to the facility. NA #1 stated it did not appear Resident #1 was stuck in the bed rail or between the rail and mattress. She stated Resident #1 was combative with care and was a 2-person assist and needed a mechanical lift for transfer. She revealed Resident #1 would grab onto the bed rails, but he did not follow cues to use the bed rail and pull himself over onto his side for bed mobility. During a telephone interview on 01/10/24 at 5:48 PM Nurse #2 revealed she was the assigned nurse for Resident #1 on the night of 11/18/23 to morning of 11/9/23. Nurse #2 revealed she was not very familiar with Resident #1 and been his assigned nurse a few times prior to the incident. She described during her conversations with Resident #1 he did not make sense and was confused. During her shift on the morning of 11/19/23 NA #1 said she needed to come to the room and when she entered, she walked around the bed to the side by window and found Resident #1 halfway on the floor and halfway on the bed and described Resident #1 was sitting on his buttocks on the floor with his arms bedside him and his back up against the side of the bed. His head was laying on the mattress facing up and his chin and neck were against the bed rail. She checked for a pulse and described Resident #1 felt warm to touch but had no pulse. She asked Nurse #3 if she would check Resident #1 and stated Nurse #3 did not find a pulse. Nurse #3 told her to call the Administrator then EMS and that was what she did. The Administrator told her not to move Resident #1. Nurse #2 revealed she spoke to EMS on the phone to give a report and only recalled telling them Resident #1 was not breathing and was on the floor. The Administrator arrived approximately 7 minutes later and took over the situation and Nurse #2 stated she continued with her medication administration pass. A telephone interview was conducted on 01/11/24 at 9:25 AM with NA #2. NA #2 stated on the morning of 11/19/23 NA #1 told her Resident #1 slid out of bed and asked if she could help. NA #2 stated when she got to the door, she could see the top half of Resident #1's body was on the bed and his buttocks was on the floor with his back was against the side of the bed and bed was in lowest position to floor. NA #2 stated she did not walk in the room but saw Resident #1's face and could tell he was deceased because his eyes were open. She stated the left part of Resident #1's head was at the edge of the rail, but she could not say it was stuck in the rail or the rail kept him from falling to the floor and stated it was hard for her recall and she was having a difficult time trying to picture what she saw. NA #2 revealed she had provided care for Resident #1 before the incident and stated usually it took 2 to 3 persons because he was combative during care. When first admitted (9/7/23) and before going to the hospital (11/14/23) she stated Resident #1 followed cues and would grab the bed rail and pull himself over during care but after coming back from the hospital (11/16/23) that's when the behaviors increased, and he needed more staff due to increased behaviors and didn't follow cues. A telephone interview was conducted on 01/11/24 at 11:26 AM with Nurse #3. Nurse #3 stated Nurse #2 requested she come and help assess Resident #1 on the morning of 11/19/23 and asked what she needed to do. Nurse #3 stated it was obvious Resident #1 had expired because he had no respirations, and his skin coloring was very pale. Nurse #3 stated she listened for respirations and checked for a pulse and Resident #1 had neither and advised Nurse #2 to call the Administrator. Nurse #3 described what she saw when she entered the room and stated the top half of Resident #1's body was on the mattress and his lower body was on the floor with his legs out and facing the window. Nurse #3 stated Resident #1's left shoulder and neck were braced into the bed rail, and it appeared he was caught in the rail. Nurse #3 stated the bed was in the lowest position to the floor and it was alarming to her seeing Resident #1 braced against the bed rail and it appeared to her the bed rail kept Resident #1 from sliding off the bed onto the floor. A telephone interview was conducted on 01/10/24 at 1:46 PM with Medication Aide (MA) #1 who worked on the same unit Resident #1 was located on the night of 11/18/23 through the morning of 11/19/23. MA #1 stated she did not see Resident #1 that night until NA #2 told her he passed away. MA #1 revealed the staff on the unit went to see what happened and stated what she saw was Resident #1's head between the mattress and bed rail and he was half in the bed and half out the bed. She stated it appeared to her Resident #1 was trapped in the bed rail, and the bed rail kept him from falling to the floor. MA #1 revealed staff had to anticipate Resident #1's care needs and he did not use the call light to request care and was a 2-person assist with care. She revealed Resident #1 would grab the bed rail and not let go as a behavior, but he did not use them to reposition for mobility during care. During an interview on 01/10/24 at 4:06 PM the Administrator stated she did the investigation for the incident that occurred on morning of 11/19/23 with Resident #1. She reported she came to the facility after being notified by Nurse #2. The Administrator described the position she saw Resident #1 and stated his legs were on the floor and the left side of his head was resting on the air mattress and his chin was on the bed rail, but it did not appear stuck in the rail. She stated Resident #1 had a large bowel movement and had pulled the brief halfway off and it was thought with his history of cardiac issues and having a large bowel movement he had a vagal (vasovagal syncope triggered by a reaction to something causing a drop in blood pressure and heart rate causing loss of consciousness) response and passed. During a follow-up interview on 01/11/24 at 1:06 PM and at 3:22 PM the Administrator stated Resident #1 did not have a significant change in his physical mobility and used the bed rails to grab onto during incontinent changes and as a security he liked to hold on to the bed rail. She stated she saw a potential risk with entrapment in the bed rail on 11/19/23, and reiterated Resident #1 was not entrapped but she did come to the facility to investigate. Her investigation included statements from staff and bed rail safety assessments and removal of bed rails no longer necessary. During a telephone interview on 01/16/24 at 1:04 PM the Medical Doctor (MD) reviewed his notes and stated Resident #1 required extensive assistance from staff for activities of daily living and was cognitively impaired and he questioned the ability Resident #1 could physically use the bed rail and if the resident had the cognitive awareness to be safe when using the bed rails. He explained a bedside assessment would need to be done that provided information related to Resident #1's ability to move in bed and if not, he would raise the questions if bed rails were beneficial if the resident could not turn himself while in bed and was dependent on staff for assistance with bed mobility. The MD stated if Resident #1 could use the bed rails and was able to grab hold and follow cues with staff assistance to roll over, then bed rails would be beneficial but based on the therapy's information he would question if Resident #1 had the strength to move himself and safely reposition. He stated if a resident refused to participate in therapy, he would expect a significant decline in their ability to perform activities of daily living and at that point a review of the care plan would need to be done and that would include reviewing the need for bed rails. The MD stated he would expect the bed rail assessment would identify how a resident would use the bed rail to benefit themselves such as could they grab hold and physically turn themselves using the bed rail. The MD stated if a patient could grab the bed rail but was too weak to physically use it to reposition or free themselves if needed, he would question if bed rail was beneficial and would expect staff were trained to recognize residents that could or could not use bed rails. The MD stated based on therapy notes and the bed rail assessments it sounds like there were inconsistencies with Resident #1's capability that he could use the bed rail for mobility. For cognitively impaired residents the MD stated he would question if they were capable of safely using the bed rail and could free themselves if there was a situation, they were against the bed rail. On 01/12/24 at 9:01 PM the Administrator was notified of Immediate Jeopardy. The facility provided the following corrective action plan with the completion date of 11/20/23: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 expired on 11/19/23. On 11/19/2023, facility IDT team completed an investigation for the alleged incident, the regional clinical nursing team reviewed the investigation in full. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: On 11/19/2023, the Interdisciplinary Team (IDT) team, which included: Social Services (SSW), Nursing, Therapy and Maintenance, completed a facility sweep and identified all residents that had bedrails and air mattresses. On 11/19/2023, bed rails assessments were reviewed/completed on all residents. 10 residents had bed rails removed based on new bed rail assessment. On 11/19/2023, IDT reviewed care plans related to bed rails and updates made to the care plan as indicated, licensed nursing staff and Certified Nursing Aide staff were updated on changes to care plans. On 11/19/2023 and will be updated immediately on any future changes to care plan. On 11/19/2023, the Director of Nursing (DON)/Designee reviewed all residents with an air mattress to ensure that they were appropriate based on recommendations from provider for wound healing, comfort, and/or pain management. Only one other resident has an air mattress that was recommended by the provider for pain control related to an unstageable wound and prevention of worsening of that wound for that resident at end of life. This intervention was determined to be appropriate for this resident, this resident did not have bed rails. On 11/19/2023, the SSW/Designee called and explained the risks and benefits of the bed rails to appropriate residents and or responsible parties and obtained the informed consent. On 11/19/2023, DON/Designee reviewed and updated the restraint decision trees for the side rails as per company policy. On 11/19/2023, the Maintenance supervisor/designee completed the Bed and Bed Rail Safety Inspection on all beds in the facility per company bed safety inspection policy and Food and Drug Administration (FDA) Bed Dimensional Limit recommendations. - No negative findings. On 11/19/2023, the Minimum Data Set (MDS) nurse/designee reviewed all care plans to ensure bed rails, and specialized air mattress was care planned appropriately. On 11/19/2023, facility IDT team completed an investigation for the alleged incident, the regional clinical nursing team reviewed the investigation in full. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Education 11/19/2023: On 11/19/2023, the Licensed Nursing Home Administrator (LNHA) educated the maintenance supervisor on Bed Identification and Safety Inspection Policy On 11/19/2023, the LNHA educated the DON on the Bed Rail Policy and Restraint Policy On 11/19/2023, the LNHA educated all staff on Bed Rail Policy and bed identification and safety inspection policy. On 11/19/2023, the LNHA educated all staff on entrapment, restraints, and neglect. On 11/19/2023, the LNHA/Designee educated all in house nursing staff on how to complete a bed rail assessment accurately as well as the restraint decision tree assessment, this would guide nursing staff in the decision to add bed rails based the bed rail assessment. Licensed nursing staff will complete a bed rail assessment to determine resident's ability and need for bed rail utilization, this assessment will be done on admission and periodically as needed, including any significant ADL change. On 11/19/2024 Education on following physician orders, as well as ensuring that the resident is able to utilize the bed rails was completed with all licensed nursing staff. On 11/19/2023, education provided with all staff on appropriate linen for air mattresses. All facility staff was educated either in person or by phone and education was completed on 11/19/2023. Ongoing education will be provided to all newly hired staff as well as any agency staff. On 11/19/2023, LNHA educated the IDT and Nursing team on notification of new mattress and ensuring that maintenance/designee is aware, and assessment is completed. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Ongoing Quality Assurance and Performance Improvement: 11/19/2023, DON/Designee will audit new admissions for bed rail assessments weekly x 4 weeks, then monthly x 2 months 11/19/2023, LNHA/Designee will audit any bed frame, mattress changes, or any changes to bed rails to ensure that the bed safety inspection has been completed, weekly x 4 weeks, then monthly x 2 months. 11/19/2023, the results of the audits to be forwarded to the facility Quality Assurance and Performance Improvement (QAPI) committee for further review and recommendations. Ad hoc QAPI meeting held with the DON, LNHA and Medical Director, RDCS, and the ID team on to review the event and the QAPI plan put in place 11-20-2023. No additional recommendation. Alleged date of compliance: 11/20/23 The correction action plan was validated on 01/17/24 and concluded the facility had implemented an acceptable corrective action plan on 11/20/23 once staff education was completed and the corrective action plan was reviewed and implemented during a QAPI meeting held on 11/20/23. Interviews with staff, including agency staff, revealed the facility had provided education on the facility's bed rail policy, safety inspection policy, entrapment, restraints, and neglect. Licensed nursing staff were able to verbalize when and how to complete a bed rail assessment to determine the resident's ability and need for bed rail utilization and who to inform when residents no longer needed bed rails. Nursing staff were also able to verbalize checking for proper fit of the mattress with the bed rail to ensure there were no gaps or other risks for injury and who they inform if any concerns were identified. Observations conducted of all beds in the facility revealed bed rails were not installed on the bed unless the resident had a bed rail assessment and safety inspection completed before installation of the bed rails. Review of the monitoring tools that began on 11/24/23 were completed weekly/monthly as outlined in the corrective action plan with no concerns identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews with the Emergency Medical Technician, the Medical Doctor, and staff the facility failed to comprehensively assess the risk of entrapment and the use of quarter length bilateral bed rails for a dependent resident with severe cognitive impairment who required extensive 2-person assistance with bed mobility after the placement of an alternating pressure air mattress. The resident experienced a fall from the bed equipped with the alternating pressure air mattress and quarter rails on both sides of the bed in an up position. The resident was found with no signs of life and observed to be partially on the floor and partially on the bed with his head pressed against the bed rail. This deficient practice occurred for 1 of 3 residents reviewed for bed rails (Resident #1). Findings included: The hospital history and physical dated [DATE] revealed Resident #1's diagnoses included generalized weakness and severe dementia. The Physical Therapist (PT) and Occupational Therapist (OT) notes indicated Resident #1 had decreased cognition, decreased strength and range of motion, as being a fall risk; and was able to minimally assist using bed rails to roll and reposition but unable to hold a position and needed physical assistance by 2-person to scoot up in bed. Resident #1 was admitted to the facility on [DATE] with diagnoses including adult failure to thrive and dementia. The admission bed rail assessment dated [DATE] indicated the medical needs considered for the use of the side rails was positioning and Resident #1 would benefit from the use of side rails to aid in positioning. PT and OT were listed on the assessment as the alternatives attempted but failed to meet the needs of Resident #1. None of the potential risks from the use of side rails were checked including: 2. The resident or part of his body would be caught between rails, the opening of rails, or between the bed rails and the mattress. 6. Decline in function such as muscle functioning and balance. 7. Skin integrity issues. 8. Decline in other areas of daily living such as using the bathroom, continence, eating, hydration, walking, and mobility. 11. Induces agitation or anxiety. The assessment (dated [DATE]) indicated the information was presented to the representative of Resident #1 and informed consent was obtained prior to installing the bed rail on [DATE]. The bed rail assessment used did not include the use of an air mattress as a risk for entrapment or type of bed rails used. The assessment was signed by Nurse #1. Review of the admission note dated [DATE] revealed Resident #1 was oriented only to self with periods of agitation and aggression. He was incontinent of bowel and bladder and required a mechanical lift for transfers and 2-person assistance with bed mobility and toileting. A fall care plan initiated on [DATE] revealed Resident #1 was at risk for falls related to immobility. Interventions included educate resident and family preventative fall interventions; implement preventative fall interventions and devices; maintain call bell within reach and educate resident to use; PT/OT/Speech Therapy (ST) to screen and treat as necessary per physician order; and maintain resident's needed items within reach. There was no care plan to indicate Resident #1 used bed rails for positioning. Review of the PT progress notes for the initial evaluation dated on [DATE] revealed Resident #1 was unable to provide his mobility ability due to his cognitive status. Resident #1's baseline for transfers indicated he was totally dependent, and the PT recommended the use of mechanical lift. The note indicated the PT was unable to assess bed mobility and wheelchair mobility due to Resident #1 refusing. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #1 as being severely impaired cognitively and needed extensive 2-person assistance with bed mobility and toilet use and transfers occurred 1 to 2 times using extensive 2-person assistance. Walking, or locomotion did not occur during the lookback period and no falls had occurred since admission. Resident #1 was always incontinent of bladder and bowel and bed rails were not being used as a restraint. The Care Area Assessments for the admission MDS dated [DATE] described Resident #1 would be long term care due to his cognition and was a fall risk due to poor safety awareness and limited mobility. Staff assistance was needed for incontinence due to mobility and cognition and for repositioning to relieve pressure due to being at risk for pressure ulcers. Review of the PT progress notes revealed on [DATE] Resident #1 was discharged from PT services for refusing treatment. His functional abilities on discharge to safely perform bed mobility tasks revealed he was totally dependent and required 100% of tactile (physical touch) cueing. In summary Resident #1 was discharged from therapy, due to poor motivation and participation due to cognitive status and dementia techniques used to increase participation were not working. The incident report documented by the nurse on [DATE] revealed a skin assessment identified Resident #1 had a new pressure ulcer wound on the sacrum. A second bed rail assessment dated [DATE] revealed no changes were made to the assessment and indicated Resident #1 would benefit from the use of side rails to aid in positioning and alternatives attempted that failed were PT and OT. None of the potential risks from the use of side rails were checked including skin integrity issues or decline in other areas of daily living such as mobility. Informed consent was obtained from the representative of Resident #1 on [DATE]. The bed rail assessment did not include the use of an air mattress as a risk for entrapment or type of bed rails used. The assessment was signed by Nurse #1. During a telephone interview on [DATE] at 1:29 PM Nurse #1 confirmed she had completed both the admission ([DATE]) and second bed rail assessment ([DATE]) for Resident #1 and stated he was able to use bed rails for turning and repositioning and they did not restrict him. Nurse #1 explained she completed the bed rail assessments and reviewed if rails were beneficial or put the resident at risk. She explained if a resident was cognitively impaired, climbed out of bed, was a high fall risk or did not understand why or how they would use a bed rail she would not recommend. Nurse #1 stated Resident #1 had dementia and was unable to consent and recalled the Responsible Party (RP) was present during the admission bed rail assessment and agreed bed rails would make Resident #1 safer. Nurse #1 stated most of the time Resident #1 was able to use the bed rails but had a rapid decline after developing a pressure ulcer on his sacrum. Review of the delivery order dated [DATE] revealed an alternating pressure mattress was placed on the bed of Resident #1. Review of a nurse note written on [DATE] revealed the nurse spoke to the company who delivered and placed the alternating pressure air mattress on the bed for Resident #1. The note indicated the representative from the company assured the mattress placed on the bed of Resident #1 would fit any standard bed frame and there was no contraindication for the use of side rails, and it could be used with or without rails. There was no bed rail assessment completed for Resident #1 when the alternating pressure air mattress was placed on the bed from [DATE] through [DATE]. Resident #1 was discharged to the hospital on [DATE]. The hospital notes indicated Resident #1 was unable to provide any history due to advanced dementia and was receiving wound care for a pressure ulcer on the sacrum. Resident #1 was discharged back to the facility on [DATE]. A telephone interview was conducted on [DATE] at 9:25 AM with Nurse Aide (NA) #2. NA #2 stated when first admitted ([DATE]) and before going to the hospital ([DATE]), Resident #1 followed cues and would grab the bed rail and pull himself over during care but after coming back from the hospital that's when the behaviors increased, and he needed more staff to assist with activities of daily living and he did not follow cues. Review of the palliative care Nurse Practitioner progress note dated [DATE] revealed Resident #1 was referred for symptom management and medical decision making related to dementia and for a wound on the sacrum. The note indicated he remained total care and was bedbound requiring a mechanical lift for transfer but was not currently getting out of bed. A telephone interview was conducted on [DATE] at 1:46 PM with Medication Aide (MA) #1 who worked on the same unit Resident #1's room was located during her shift on the night of [DATE] through the morning of [DATE]. MA #1 stated she did not see Resident #1 that night until NA #2 told her he passed away the next morning on [DATE]. MA #1 revealed the staff on the unit went to see what happened and stated what she saw was Resident #1's head between the mattress and bed rail and he was half in the bed and half out the bed. She stated it appeared to her Resident #1 was trapped in the bed rail, and the bed rail kept him from falling to the floor. MA #1 revealed staff had to anticipate Resident #1's care needs and he did not use the call light to request care and was a 2-person assist with care. She revealed Resident #1 would grab the bed rail and not let go as a behavior, but he did not use them to reposition for mobility during care. Review of the facility's investigation revealed a statement from NA#1 dated [DATE] that read in part, Doing my 5:00 AM rounds I noticed resident was on the floor in between the bed rail. I went to notify the nurse. The last time I did a round was at 3:00 AM. I changed resident and he was laying down on his back. A clarification was made to NA #1's statement dated [DATE] and read in part, At 3:00 AM I went in the room to change brief and Resident #1 was laying on his back holding the rail and fighting as usual. His left leg was coming out of the bed. I redirected his arms to the right side to hold onto the rail so I could change his brief. When I left the room put the bed in the lowest position. At 5:15 AM I walked into Resident #1's room and noticed he was laying with jaw line in rail and his body was on left side of bed on floor with his brief halfway off with the sheets and some his blanket. I walked over to see if his chest was rising up and down and noticed it wasn't. I went out of the room to find nurse. She and I walked back to room, and she confirmed Resident #1 was deceased . I assist to get into the bed with other NAs. Other staff statements included in the investigation did not provide information related to the position they saw Resident #1 after being made aware he had passed and before his body was moved. During a telephone interview on [DATE] at 4:33 PM NA #1 confirmed she worked on the night of [DATE] from 6:45 PM to [DATE] at 7:15 AM and was assigned to care for Resident #1. NA #1 stated when she found Resident #1, he was laying on his left side towards the window with the left leg bent under right leg and his buttocks sitting on the floor. His lower body was lying on the floor, but his head was on the bed face up and his jaw was leaning and/or pressing into the rail but not in between the rails. She stated the air mattress was on the bed, quarter bilateral rails were up, and the bed was always kept low to ground. She stated Resident #1 was combative with care and was a 2-person assist with care and needed a mechanical lift for transfer. She described when she provided care Resident #1 would grab onto the bed rails and not let go was a behavior, but he did not follow cues to use the bed rail and pull himself over onto his side for bed mobility. Review of the progress note written by Nurse #2 on [DATE] at 7:55 AM revealed she was alerted by NA #1 that Resident #1 partially fell from the bed. Resident #1 was assessed with no pulse and Emergency Medical Services (EMS) was called. The on-call Nurse Practitioner for the Medical Doctor and Administration were notified. During a telephone interview on [DATE] at 5:48 PM Nurse #2 confirmed she was the assigned nurse for Resident #1 on the night of [DATE] through the morning of [DATE]. Nurse #2 revealed she was not very familiar with Resident #1 and had only been his assigned nurse a few times. She described during her conversations with Resident #1 he did not make sense and was confused. During her shift on the morning of [DATE] NA #1 said she needed to come to the room and when she entered, she walked around the bed to the side by window and found Resident #1 halfway on the floor and halfway on the bed and described Resident #1 was sitting on his buttocks on the floor with his arms bedside him and his back up against the side of the bed. His head was laying on the mattress facing up and his chin and neck were against the bed rail. She checked for a pulse and described Resident #1 felt warm to touch but had no pulse. She asked Nurse #3 if she would check Resident #1 and stated Nurse #3 did not find a pulse. Nurse #3 told her to call the Administrator then EMS and that was what she did. A telephone interview was conducted on [DATE] at 11:26 AM with Nurse #3. Nurse #3 described what she saw on the morning of [DATE] when she entered the room and stated the top half of Resident #1's body was on the mattress and his lower body was on the floor with his legs out and facing the window. Nurse #3 stated Resident #1's left shoulder and neck were braced into the bed rail, and it appeared he was caught in the rail. Nurse #3 stated the bed was in the lowest position to the floor and it was alarming to her seeing Resident #1 braced against the bed rail and it appeared to her the bed rail kept Resident #1 from sliding off the bed onto the floor. Review of the EMS incident report revealed on [DATE] at 5:30 AM Resident #1 had fallen from the bed. The lead Emergency Medical Technician (EMT) documented narrative read in part, EMS was dispatched for a fall and when arrived on the scene staff reported they found Resident #1 lying halfway off the bed and his head was stuck in the railing. The EMT noted they found Resident #1 lying on the floor in a supine position (flat on one's back) and described the resident as apneic (without breaths), pulseless, and the skin was pale and cool to touch. A telephone interview was conducted on [DATE] at 2:13 PM with the lead EMT who wrote the narrative on the EMS report. The EMT confirmed Resident #1 was laying on the floor in supine (flat on one's back) position when they entered the room. He stated the call came in as fall and when they arrived at the facility a staff member reported Resident #1's head was stuck in the bed rail. During the assessment of Resident #1 he did not notice any bruising or impression of a bed rail on the resident or see anything that stood out to him. During an interview on [DATE] at 1:18 PM the Maintenance Director stated he had worked at the facility for approximately one- and one-half years and the bed rail safety inspection audit dated [DATE] was the first one he had done since his employment. He stated he was unable to find documentation or records of bed rail safety inspections being done prior to the new company taking over. He reported either him or the Maintenance Assistant placed bed rails but could not recall if he placed the rails on Resident #1's bed. He stated after Resident #1's fall he conducted bed rail safety inspections and used the bed rail assessment tool to conduct those on all beds with rails and would be done annually or as needed including when a new mattress/air mattress was placed. He confirmed maintenance was responsible for completing the bed safety inspections and installing bed rails. He stated he completed a bed rail safety inspection on [DATE] for Resident #1 with the air mattress in place and inflated and there were no negative findings based on the guidelines of the facility's assessment tool used. He stated there were times beds were switched out if it stopped working and a resident might be put in a bed with rails. During an interview on [DATE] at 3:22 PM the Administrator revealed a company used by the facility placed the air mattress on the bed and it was placed to assist Resident #1 with repositioning due to him having a pressure ulcer on his sacrum. She stated she did recognize there was a potential risk for entrapment related to the fall on [DATE] and reiterated Resident #1 was not trapped in the bed rail. She started an investigation and identified one other resident with an air mattress, but the bed did not have rails in place. She revealed the Interdisciplinary Team (IDT), and nursing staff were educated to report any mattress changes to maintenance and if bed rails were in place a safety inspection was completed and she continued her audits to identify any mattress changes and beds with rails. She revealed either the Maintenance Director or Maintenance Assistant was responsible for checking the bed rails using the safety inspection tool but had no records to show bed rail safety checks were done for Resident #1 prior to [DATE]. During a telephone interview on [DATE] at 1:04 PM the Medical Doctor (MD) stated Resident #1 required extensive assistance from staff for activities of daily living and was cognitively impaired. The MD stated he would question Resident #1's abilities to physically use the bed rail and if the resident had the cognitive awareness to be safe when using the bed rails. He explained a bedside assessment would need to be done that provided information related to Resident #1's abilities to move in bed and if not, he would raise the question if bed rails were beneficial. The MD stated based on therapy notes and the bed rail assessments it sounded like there were inconsistencies with Resident #1's capability that he could use the bed rail for mobility. For cognitively impaired residents the MD stated he would question if they were capable of safely using the bed rail and could free themselves if there was a situation when they were against the bed rail. On [DATE] at 5:02 PM the Administrator was notified of immediate jeopardy. The facility provided the following corrective action plan with the correction date of [DATE]: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; Resident #1 expired on [DATE]. On [DATE], facility IDT team completed an investigation for the alleged incident, the regional clinical nursing team reviewed the investigation in full. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On [DATE], the IDT team, which included: Social Services, Nursing, Therapy and Maintenance, completed a facility sweep and identified all residents that had bedrails and air mattresses. On [DATE], bed rails assessments were reviewed/completed on all residents. 10 residents had bed rails removed based on new bed rail assessment. On [DATE], IDT reviewed care plans related to bed rails and updates made to the care plan as indicated, licensed nursing staff and CNA staff were updated on changes to care plans on [DATE] and will be updated immediately on any future changes to care plan. On [DATE], the DON/Designee reviewed all residents with an air mattress to ensure that they were appropriate based on recommendations from provider for wound healing, comfort, and/or pain management. Only one other resident has an air mattress that was recommended by the provider for pain control related to an unstageable wound and prevention of worsening of that wound for that resident at end of life. This intervention was determined to be appropriate for this resident, this resident did not have bed rails. On [DATE], the SSW/Designee called and explained the risks and benefits of the bed rails to appropriate residents and or responsible parties and obtained the informed consent. On [DATE], DON/Designee reviewed and updated the restraint decision trees for the side rails as per company policy. On [DATE], the Maintenance supervisor/designee completed the Bed and Bed Rail Safety Inspection on all beds in the facility per company bed safety inspection policy and FDA Bed Dimensional Limit recommendations. - No negative findings. On [DATE], the MDS nurse/designee reviewed all care plans to ensure bed rails, and specialized air mattress was care planned appropriately. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; Education [DATE]: On [DATE], the LNHA educated the maintenance supervisor on Bed Identification and Safety Inspection Policy On [DATE], the LNHA educated the DON on the Bed Rail Policy and Restraint Policy On [DATE], the LNHA educated all staff on Bed Rail Policy and bed identification and safety inspection policy. On [DATE], the LNHA educated all staff on entrapment, restraints and neglect. On [DATE], the LNHA/Designee educated all in house nursing staff on how to complete a bed rail assessment accurately as well as the restraint decision tree assessment, this would guide nursing staff in the decision to add bed rails based the bed rail assessment. Licensed nursing staff will complete a bed rail assessment to determine resident's ability and need for bed rail utilization, this assessment will be done on admission and periodically as needed, including any significant ADL change. On [DATE] Education on following physician orders, as well as ensuring that the resident is able to utilize the bed rails was completed with all licensed nursing staff. On [DATE], education provided with all staff on appropriate linen for air mattresses. All facility staff was educated either in person or by phone and education was completed on [DATE]. Ongoing education will be provided to all newly hired staff as well as any agency staff. On [DATE], LNHA educated the IDT and Nursing team on notification of new mattress and ensuring that maintenance/designee is aware, and assessment is completed. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; Ongoing Quality Assurance and Performance Improvement: [DATE], DON/Designee will audit new admissions for bed rail assessments weekly x 4 weeks, then monthly x 2 months [DATE], LNHA/Designee will audit any bed frame, mattress changes, or any changes to bed rails to ensure that the bed safety inspection has been completed, weekly x 4 weeks, then monthly x 2 months. [DATE], the results of the audits to be forwarded to the facility QAPI committee for further review and recommendations. Ad hoc QAPI meeting held with the DON, LNHA and Medical Director, RDCS, and the ID team on to review the event and the QAPI plan put in place 11-20-2023. No additional recommendation. Alleged date of compliance: [DATE] The Corrective Action plan was validated on [DATE] and concluded the facility had implemented an acceptable corrective action plan on [DATE] once staff education was completed and the corrective action plan was reviewed and implemented during a QAPI meeting held on [DATE]. Interviews with staff, including agency staff, revealed the facility had provided education on the facility's bed rail policy, safety inspection policy, entrapment, restraints, and neglect. Licensed nursing staff were able to verbalize when and how to complete a bed rail assessment to determine the resident's ability and need for bed rail utilization and who to inform when residents no longer needed bed rails. Nursing staff were also able to verbalize checking for proper fit of the mattress with the bed rail to ensure there were no gaps or other risks for injury and who they inform if any concerns were identified. Observations conducted of all beds in the facility revealed bed rails were not installed on the bed unless the resident had a bed rail assessment and safety inspection completed before installation of the bed rails. Review of the monitoring tools that began on [DATE] were completed weekly/monthly as outlined in the corrective action plan with no concerns identified.