**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement interventions to ensure that 4 residents (Resident #14, Resident #13, Resident #3, and Resident #12), in a survey sample of 48 residents, maintained an acceptable parameter of nutritional status and as a result, all 4 experienced insidious, severe weight loss that was unplanned resulting in immediate jeopardy being identified. The findings included: On 3/19/24 at approximately 12:05 p.m., an interview was conducted with the Registered Dietician (RD), who was in the dining room. The RD reported that he comes weekly and is at the facility for 8 hours. The RD said, It's not much weight loss in this building, we have one resident losing weight, but they refuse to eat and take supplements. 1. For resident #14 (R14), who lost 46.6 pounds since May 2023, the facility staff failed to identify and take measures to address the weight loss, which constituted harm. On 3/19/24, at approximately 11:30 a.m., observations were conducted of the kitchen to include the meal service/tray line. It was observed that no alternate meal was prepared. Staff interviews conducted with the dietary manager confirmed that only one serving of the alternate had been prepared. On 3/19/24, the lunch meal service was observed in the dining room. R14 was observed to not eat any of her meal and stated that she didn't like what was served. The facility staff did not offer any alternate options and R14 left the dining room having ate nothing. On 3/20/24, R14 was again observed to refuse her lunch meal and reported to the surveyor that she had lost 50 lbs., which R14 related to the inability to eat the food because of lack of flavor and it being cold. On 3/20/24, a clinical record review was conducted. According to the MDS (minimum data set - an assessment tool), dated 3/6/24, R14 was not on a planned weight reduction. R14 was also noted on this same assessment to have a BIMS (brief interview for mental status) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R14's meal intakes noted that it was documented R14 had consumed 76-100% of the meal that had been refused at lunch on 3/19/24. It was documented that R14 ate 26-50% of the lunch meal on 3/20/24. Observations on 3/19/24-3/20/24 revealed that the facility staff did not record the resident's meal consumptions anywhere and didn't immediately document meal consumption upon retrieval of the meal trays. On 3/19/24-3/20/24, interviews were conducted with CNA #5, CNA #6, and CNA #7, all who reported they document meal consumptions by memory, stating that they remember what each person ate when they pick up the meal trays and then record it later. Review of R14's weights noted that on 9/8/23, R14 triggered for a 24-pound weight loss, which was a 7.6 % weight loss in 3 months. Then on 12/3/23, R14 triggered for a 11 % weight loss of 34.6 lbs. in 6 months. As of 3/5/24, R#14 had lost a total of 46.6 lbs. since 5/31/23. There was no evidence that indicated that R14 was on a physician-ordered weight reduction program. There was no evidence that the registered dietician (RD) or physician had been made aware of the significant weight loss. A nutritional review was completed 12/9/23, by a dietary technician, who noted a weight loss trend by indicating the most recent 3 months weights as 279, 292, 297 [December, November, and October weights in pounds]. The Care Plan changes noted Will consult Rd [registered dietician] for follow up as needed. According to R14's nutritional care plan, it had not been reviewed since 9/13/23. There were no interventions implemented to address R14's nutritional deficits and/or to indicate the weight loss was a desired loss. There was an additional care plan entry that read, [R14's name redacted] will order food at times knowing she doesn't have funds to pay for it. Interventions for this care plan read, Resident education on making sure funds are available prior to order take order [sic] and if funds aren't available, she will not order take out. According to R14's physician's order, R14 was on a therapeutic diet, which included no added salt. Observations revealed that on 3/25/24, the physician ordered therapeutic diet was not being followed/provided by the facility, as salt packages were noted on the meal tray. 2. For Resident #13 (R13), who had a significant weight loss, the facility staff failed to implement interventions to prevent insidious weight loss, which constitutes harm. On 3/21/24, a clinical record review revealed that R13 had a significant weight loss. Physician orders dated 1/30/24 indicated that R13 was on a therapeutic which included, 2 g [gram] sodium diet, for edema. On 3/21/24 and again on 3/22/24, the survey team made observations that the physician ordered sodium restriction was not being followed as the resident had salt packages on the meal tray. Nutritional Risk Factors identified for R13 included congested heart failure, arteriosclerotic heart disease, morbid obesity, and chronic kidney disease, noting that R13 had been admitted with 3+ edema to arms and legs. Care plan review noted the following goal: Maintain weight without significant change. On 10/18/23, R13 triggered for a 5.2% weight loss of 13 lbs. On 11/3/23, R13 triggered for an 8% weight loss of 20 lbs. within 2 months. On 12/18/23, R13 had triggered for 7.9% weight loss of 19.6 lbs., in 3 months. On 1/12/24, R13 had been identified with a 25 lb. weight loss, 10% loss in 4 months. On 2/28/24, the physician noted a 20 lb. weight loss and asked that the weight be rechecked. Another weight was not obtained until 3/3/24, but there was no evidence was found that the weight results had been communicated to the physician. According to the nutritional assessments, R13 was seen by the RD (registered dietician) on 10/24/23, and not again 2/7/24. According to the nutritional assessment conducted on 10/24/23, R13 .may not be meeting energy needs on days where PO intake is less than 100%, for which the RD recommend adding supplement Med Pass 30 ml BID [twice a day]. This order was implemented, but was discontinued on 11/24/23, with no reason identified. R13 was seen by the attending physician on 11/24/23, but the doctor didn't address weight loss or the use of a nutritional supplement, nor provide any orders to stop the supplement. No further interventions were implemented until 2/8/24, when Prostat was ordered as a supplement to promote wound healing. On 3/21/24, an interview with the RD was conducted. The RD attributed R13's weight loss to the Lasix (started on 1/30/24. This physician's order for the Lasix read as follows: Furosemide oral tablet 40 mg tablet by mouth one time a day for edema. However, the weight loss had been ongoing since 10/18/23, which was prior to the start of the Furosemide. On the afternoon of 3/21/24, the Assistant Director of Nursing confirmed that the ordered dose of Lasix would not have resulted in such an ongoing loss of weight. According to R13's nutrition care plan, no revisions had been made since 10/31/23, other than a change to the target goal date. This care plan did not indicate that R13 was on a physician ordered weight reduction plan, but it inaccurately noted that the supplement Med Pass was still being provided, when it had been discontinued on 11/24/23. 3. For Resident #3 (R3), who experienced significant and ongoing weight loss, the facility staff failed to implement interventions to maintain adequate nutrition and prevent insidious weight loss, which constitutes harm. On 3/21/24, a clinical record review was conducted of R3's chart, which included weights, care plan, physician orders, physician progress notes, and nutritional notes. According to R3's weight records, R3 was not weighed in December 2023. When a weight was obtained on 1/3/24, it noted a significant weight loss of 10%, 11 lbs. in 5 months. R3 continued to experience on-going weight loss. On 2/17/24, R3 weighed 94.2 lbs., which was a 12.2 lb. weight loss, 11.5% loss in 6 months. On 3/18/24, R3's current weight was 91.6 lbs., which was a 13.2 lb. loss, 12.6% loss in 6 months. On 2/13/24, R3 was seen by the RD (registered dietician) and a recommendation was made for dietary supplement of house shakes three times daily. However, as of 3/20/24, the recommendation had not been carried out. R3's physician orders included an order for weekly weight every day shift every Sat, which was ordered 1/27/24. Following this order, Resident #3 had only had 3 weights documented, which were on 2/17/24, 3/16/24, and a re-weight obtained on 3/18/24. According to a clinical record review, R3 was last seen by the physician on 1/29/24, for which documentation made no mention of the weight loss. When R3's questioned about this, the facility administration provided the surveyor with a physician note dated 3/18/24, which was not available within the clinical record. Within that note the physician noted that continual and gradual weight loss since admission .is unavoidable . However, there was no evidence of any clinical testing to determine if it was unavoidable as the additional nutritional supplements recommended by the registered dietician had not been attempted. R3's clinical record documented the last time labs were drawn was on 5/23/23. On 3/20/24, an interview was conducted with the RD. The RD stated he was not aware that the 2/13/24 dietary recommendation for the dietary supplements had not been carried out. On 3/21/24, the RD reported to the survey team that the order for house shakes were started. Review of R3's care plan revealed that the nutritional care plan had been implemented 2/6/22, with a revision on 8/17/23, and noted that R3 was at risk for wt. changes and altered nutrition status RT [related to] self-care deficit . feeding assistance. According to R3's care plan, the interventions had not been revised since 11/02/23 and did not address actual weight loss. Last revised on 1/10/24, the goal read as Maintain adequate nutritional status as evidenced by no significant weight change through review date, which was noted as 5/1/24. Specific interventions included, monitor/record/report to MD PRN [as needed] s/sx [signs/symptoms] of . significant weight loss: 3lbs in 1 week, 10% in 6 months. 4. For R12, who experienced a significant weight loss, the facility staff delayed in implementing interventions and failed to ensure a therapeutic diet was provided, which constituted harm. According to the clinical record, R12's weight on 6/2/23, noted a 7 lb. weight loss in 3 weeks. On 6/20/23, the RD recommended weekly weights to establish a baseline. No weights were documented for the months of July and August. The next weight was obtained 9/13/23 and noted a 19.9% weight loss of 31 lbs. Following this identification, R12 was ordered large portions with meals, which was still an active order. Observations by the survey team on 3/19/24, 3/20/24, 3/21/24, and 3/22/24 revealed R12 was not receiving large portions, as ordered by the physician. According to a social services progress note dated 1/4/24, the social worker (SW) met with R12 regarding him not wanting to eat and take medications. This note documented that R12 verbalized a desire to have a ham and cheese sandwich with lunch. This preference was not noted on his meal ticket and on 3/20/24-3/22/24, and 3/25/24, R12 was not provided a ham and cheese sandwich at lunch, which was observed by the survey team. Review of the facility policy and procedure titled, Weekly Weight Meeting (Quality Assurance), it read in part, A weekly weight meeting will be conducted to review resident weights . No documentation was found to evidence that these meetings were occurring. The survey team conducted a review of the facility policy titled, Weighing the Resident. The policy read in part, Residents will be weighed unless ordered otherwise by the physician: admission/re-admission x 3 days, weekly x 4 weeks, monthly thereafter, as needed . When there is a significant variance from the previous recorded weight the scale should be re-balanced and the resident re-weighed and a licensed nurse to validate. Record weight and alert nurse to any significant change. Nurse to notify the physician of any significant weight change, consult with the director of dietary services and/or dietitian, notify the interdisciplinary team in order to update the plan of care. On 3/25/24, Immediate Jeopardy (IJ) was identified based upon the above findings, and confirmed by the state agency, of which the facility's acting administrator and corporate staff were notified of IJ at 4:20 p.m. On 3/26/24 at 11 a.m., the facility submitted IJ removal plan was approved by the survey team, in collaboration with the state agency. The removal plan read as follows: 1. R14 was weighed by the licensed nurse on 3-25-24 with a documented weight of 275.0 pounds. R13 was weighed on 3-25-24 by the licensed nurse with a documented weight of 198.2 pounds. R3 was weighted by the licensed nurse on 3-25-24 with a documented weight of 92 pounds. R12 was weighed on 3-25-24 by the licensed nurse with a documented weight of 92.6 pounds. The MD reviewed R14, R14, R3, & R12 on 3-25-24 to ensure the residents are clinically stable and are not experiencing an acute change in condition requiring transfer to a higher level of care. The MD reviewed the diets for R14, R13, R3 & R12 to ensure appropriate orders are in place to meet their nutritional needs. The MD ordered labs on R14, R13, R3 & R12 for insight into nutritional status and to ensure clinical stability. The Registered Dietician (RD) reviewed R14, R13, R3 & R12 for nutritional needs and preferences and provided recommendations for therapeutic diets and supplement recommendations for R14, R13, R3 & R12 for new orders which were implemented, as per the md orders. Residents R14, R13, R3, & R12 were screened by Occupational Therapy (OT) and Speech Therapy (ST) for services required to [NAME] the residents' needs. The Licensed Nurse notified the family of weight loss and new orders given by the MD with documentation in the medical record for R14, R13, R3, & R12. The MDs nurse completed a significant changes assessment on R14, R13, R3, & R12, and updated the care plans for R14, R13, R3, & R12 with the therapeutic diets and interventions, as per the MD orders given and dietary preferences. The Nurse Manager completed education with the Responsible Party (RP) for R14, R13, R3, & R12 to explain the risk versus benefits of the therapeutic diets as ordered per the MD. QAPI Was held with the DCS, Medical Director, Infection Preventionist Nurse and at least one additional member from the IDT and a line staff employee to discuss the center's status of immediate jeopardy and the action plan being implemented to ensure the safety and care of the residents at the center. 2. Current residents were weighed on 3-25-24 to obtain baseline weights. Current weights were then reviewed by the dietician to determine any significant weight loss. Based on findings, RD recommendations were obtained for residents to ensure therapeutic diets are in place to meet residents' nutritional needs per residents' preference. MD was then notified of RD recommendations and for new orders to accommodate residents' needs. New orders were then carried out by the licensed nurse and RP was notified of weight loss and new orders accordingly. OT and ST screened current residents to ensure needs. Current residents were observed by the Licensed Nurse Manager and Registered Dietician to be serviced physician ordered therapeutic diets as ordered to include correct consistency, dietary restrictions, and correct portion sizes. Current residents have the option to request and receive an alternate meal if they do not like the first meal offering being served. 3. The center Registered Dietician was educated by the Regional Dietician on ensuring residents are reviewed for nutritional status no less than quarterly and with a significant change in condition to ensure prescribed diets are in place to meet nutritional needs. The Dietary Staff were educated on preparing meal trays as per the prescribed MD diet orders for the center residents. The Dietary Staff were additionally educated on temperature, portion, appearance, and variety to meal portion sizes, serving the proper meal and consistency per the diet order, and preparing meals as per the recipe. The Director of Nursing (DON) was educated by the Regional Nurse on the policy and procedure for maintaining a weight program to include weighing residents upon admission and re-admission, and then weekly x 4 weeks and then at least monthly and more frequently, as per MD orders. Additionally, the DON is to review the weights with the previous months weights to determine the percentage of weight loss or gain to include 5% in a month, 7.5% in 3 months or 10% in 6 months. The MDS nurse was educated by the Regional Nurse to ensure residents care plans are updated with interventions to ensure optimal health. Licensed Nurses were educated by the Nurse Manager on obtaining weights for center residents on admission and re-admission and for 4 weeks thereafter and then at least monthly and with significant changes. Licensed nurses were also educated on notification to the RD, MD and RP for significant weight loss or gain. Nursing staff were educated on checking meals before serving to ensure when they are serving meals that they [sic] are the correct consistency, dietary restrictions, and correct portion sizes. Additionally, the Nursing staff have been educated on accurately recording and then documenting in the system the residents' meal percentages. The IDT team was educated on grievance and grievance resolution to include ongoing concerns, and the responsibility resident council complaints through the Quality Assurance and Performance Improvement process. Completion date and time: 03-26-24 at 11:59 p.m. On 3/27/24, the survey team started verifying that the facility had implemented their IJ removal plan. Facility documentation reviews were conducted, clinical record reviews, and meal observations, which also included resident and staff interviews. Multiple errors were observed with regards to the resident meals and being served in accordance with their prescribed therapeutic diets and portion sizes. The errors observed were not identified by the nursing staff serving the trays to residents and the residents were served trays with incorrect portion sizes with regards to residents who had orders for large and double portions. Several residents who were ordered additional supplements and fortified foods did not receive them. One resident had requested an alternate meal prior to the meal/tray line service, the kitchen was notified of such, but did not provide the alternate as requested. The survey team conducted a review of other clinical records that revealed 3 additional residents who had experienced significant weight loss, for which there had been no assessment by the registered dietician or physician. No interventions had been implemented and the care plans had not been revised. On 3/27/24 at 3 p.m., the facility administration was made aware that the survey team had been unable to abate the IJ, given these findings. The facility administration verbalized that they would be ready for the survey team to attempt verification again on 3/27/24 at 4:45 p.m. On 3/28/24 at 8 a.m., the survey team returned to the facility and again started verifying that the IJ removal plan had been implemented. Clinical records were again reviewed, and it was noted that the 3 additional residents identified on 3/27/24, with significant weight loss, had still not been addressed by the registered dietician and/or physician, nor had any interventions been implemented. On 3/28/24, the survey team again notified the facility administration that they were unable to abate the IJ. The facility submitted a revised IJ removal plan which indicated a completion date of Monday, April 2, 2024, at 11:59 p.m. On 4/2/24 at 5:13 p.m., an interview was conducted with the registered dietician (RD). The RD was asked about his involvement in interdisciplinary team meetings to discuss residents who are experiencing weight loss. The RD stated that this past weekend, following the identification of immediate jeopardy, was the first facility meeting of such nature that he had attended. On 4/2/24 at 5:45 p.m., an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that it has always been an expectation of the company that weekly interdisciplinary weight meetings be held. The RDCS further confirmed that this had not been occurring at this facility and that she had no record of any past meetings. Working through implementation of the removal plan, the facility staff obtained and reviewed weights on all the residents, reporting that an additional 25 residents were identified as having experienced weight loss. The facility also reported that eighteen of the 25 had new orders implemented for nutritional interventions to address the identified weight loss. On 4/2/24, the survey team verified implementation of the removal plan through observations, staff interviews, clinical record review, and facility documentation review, subsequently IJ was removed at 6:10 p.m. No additional information was provided. Based on the seriousness of the noncompliance, this deficiency was cited at Level 4, Pattern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to attempt appropriate alternatives prior to the use of side/bed rails, failed to assess residents for risk of entrapment prior to use, failed to review the risks/benefits of side/bed rails with the resident and/or resident representative and failed to obtain informed consent prior to use, failed to have a system in place to ensure residents beds were appropriate for the resident's size and weight, and failed to have a system in place for assessment and ongoing monitoring/supervision of side/bed rails in use. One resident (Resident #1) in the survey sample was identified as having his legs entrapped in the side/bed rails. Five additional residents (Resident #46, #89, #18, #80, and #97) were identified at risk for falls, had bed alarms due to attempts to get out of bed, and had side/bed rails in use. These six residents did not have attempted alternatives prior to the use of side/bed rails, proper assessment, consent, or ongoing monitoring/supervision of the side/bed rails. The facility census was 107 at the time of the survey. Forty-eight (48) residents had side/bed rails in use without assessments. The facility had not implemented the policy and procedure developed by the company, nor had they implemented new assessments and consent forms developed by the company in response to the 2017 regulation, thus identifying a system wide failure. Immediate Jeopardy (IJ) and SQC (substandard quality of care) was identified in the area of Quality of Care on 06/20/2019 at 5:02 p.m. The plan of removal for the immediacy was accepted by the survey team on 06/20/2019 at 9:40 p.m. The IJ was abated on 06/24/2019 at 3:42 p.m. with the Scope and Severity lowered to Level II, Widespread. Findings were: 1. Resident #1 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Diffuse TBI (traumatic brain injury) with loss of consciousness greater than 24 hours without return to pre-existing conscious level, repeated falls, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, mixed receptive-expressive language disorder, cardiac arrhythmia, atherosclerotic heart disease, spinal stenosis, and hypertension. A quarterly MDS with an ARD of 06/07/2019 (completed after his entanglement in the side rails), assessed Resident #1 as severely impaired in his cognitive function with a score of 01. The previous MDS was a annual assessment with an ARD of 03/08/2019, and assessed Resident #1 as moderately impaired in his cognitive status with a score of 09. A review of the electronic clinical record was done on 06/18/2019 at approximately 3:00 p.m Observed in the nurse's note section was the following entry: 06/07/2019 03:11 [3;11 a.m.] Res [resident] personal alarm noted sounding @ [at] 0215 this morning, staff immediately attending to the sound and entered res room. Res noted on the right side of bed at the nightstand, res was on left hand side with arm behind body and head on the fall mat. Res noted [with] bilateral legs in railing of bed, Assessment was performed on res, limitedly due to positioning of res at the time, res stated no pain at all. Multiple staff were attending, staff assisted res back to bed, assessment was completed thoroughly at that time and one noted marking on the back of reddened area, laterally, less than a half inch long . On 06/19/2019 at approximately 9:00 a.m., Resident #1 was observed sitting in his wheelchair next to his bed. A tab alarm was in place on his chair. He was wearing a self-releasing seatbelt. Resident #1 was able to remove the alarming seatbelt on request but he did not communicate verbally. There were no side/bed rails on his bed. An alarm box for a bed alarm was observed on his bed. The clinical record was reviewed on 06/19/2019 and included the following: SBAR (Situation; Background; Appearance; Review and Notify) forms were on the clinical record for the following falls: 12/11/2018: Resident found sitting next to bed facing wall, side rails still up on bed-no injuries noted .; 12/14/2018: Patient observed trying to roll himself out of bed .unable to reach in time to prevent patient from falling, pad alarm sounding .; 4/11/2019: Res found on floor on fall matt [sic] beside bed .; 05/14/2019: Res fell from bed @0155 [1:55 a.m.], landed on L [left] should which has had previous fx [fracture] with dislocation. Res screaming in pain, abrasion noted to L shoulder .sent to ER for eval; 06/07/2019: Staff assisted res when alarm was sounding res noted on floor @0215 .1/2 inch reddened abrasion to L lateral side . On 06/20/2019 at approximately 8:20 a.m., the clinical record was reviewed for bed rail evaluations, consents, and the attempt of alternates prior to using the side/bed rails. A quarterly data collection tool dated 03/08/2019 included: SIDE RAIL EVALUATION. The first area of yes/no questions were in regard to RESIDENT STATUS .Is the resident non-ambulatory? YES; Is the resident comatose, semi-comatose, obtunded, or has fluctuation in levels of consciousness? NO; Does the resident have alteration in safety awareness due to cognitive decline? NO; Does the resident have a history of falls? YES: Has the resident demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed? YES; Does the resident have difficulty with balance or poor trunk control? YES; Does the resident have difficulty with postural hypertension? NO; Is the resident on any medications, which would require safety precautions? NO; Is the resident currently using the side rail for positioning or support? YES; Has the resident expressed a desire to have side rails raised while in bed for their own safety and/or comfort? YES; Has the resident requested that side rails not be released while sleeping? YES; Is the resident visually challenged? NO. The next area was INTERVENTIONS. The following interventions were checked: Periodic assisted toileting for resident at night; Verbal reminders to use the call light .RECOMMENDATIONS: Bilateral Quarter Rails .Side rails are indicated and serve as an enabler to promote independence .COMMENTS/RECOMMENDATIONS: Resident requires bilateral quarter side rails to provide bed mobility. There was no documentation in the clinical record regarding the attempt to use alternative measures prior to the use of side/bed rails, nor was there an informed consent for the use of the side/bed rails. On 06/07/2019, after Resident #1's fall from the bed and entanglement in the side/bed rails, an additional side/bed rail evaluation was completed. Under the area RESIDENT STATUS the questions were answered the same as the March evaluation with the exception of the following: Does the resident have alteration in safety awareness due to cognitive decline? YES; Has the resident requested that side rails not be released while sleeping? NO. Under RECOMMENDATIONS the following was checked: Side rails do not appear to be indicated at this time. COMMENTS/RECOMMENDATIONS: Resident was using bilateral half rails to help position self when in bed however not indicated @ this time due to poor safety and cognition. On 06/20/2019 at approximately 9:00 a.m.,, the DON (director of nursing) was interviewed regarding side/bed rails in the facility. She stated that there was a tool in her office when she came to the facility and she had given it to the maintenance director. She was asked for the investigation regarding Resident #1's fall from his bed on 06/07/2019. A witness statement from 06/07/2019 was presented and contained the following: Res alarm sounded and myself/CNA [certified nursing assistant] [Name] noted res on fall mat on (R) [right] side of bed in front of nightstand. Res appeared in a position of majority of upper body weighted on res (L) side and (L) arm behind body-res noted with bilat legs in railing. Res upper body was fully over railing, at hips body was noted partially on mattress and bilat legs at area of railing. (L) [left] was noted under railing/mat and (R) leg overhead railing to mattress. CNA [Names] and this nurse present at time of transfer due to positioning, bed was slowly moved over for assessment, res stated, 'no' r/t [related to] pain, ROM [range of motion] wnl [within normal limits]; transferred res to bed for further assessment. (L) lateral abrasion noted- [symbol for no] other noted injuries. At approximately, 10:30 a.m., on 06/20/2019 the maintenance director came to the conference room. He stated, I haven't measured the beds .[Name of former DON] developed this tool. He was holding a wooden rod with a flat round disc on the top an another on the bottom. He stated, This measures the sides of the mattresses, the head board and the footboard. [Name of former DON] did measurements on all the beds last year before you came to survey .I don't know where those measurements are and I haven't measured them since .I can look at a bed and see if there are gaps without measuring it. On 06/20/2019 at approximately 10:50 a.m. LPN [licensed practical nurse] #3 was called regarding her witness statement and was asked if she could explain what had happened. She stated, Yes, I was working and there were two CNAs working with me. The CNAs were in other resident rooms. We heard the bed alarm sounding and all went to the room. [Resident name] whole upper body was resting on the fall mat that was on the side of the bed where the air conditioner is .His left leg knee was touching the fall mat, part of his calf on his left leg was under the side rail, his right leg was over the rail. All of his weight was on his upper body on his left side .It looked like if you were doing a cartwheel and your first leg went down and the other leg was trying to come over .that's where he stopped, in the middle of the cartwheel .he couldn't go over any further because he got caught. LPN #3 was asked where the side rails were located on the bed. She stated, They were in the middle of the bed .his whole calf wasn't under the bed, just part of it if all his pressure hadn't been on his upper body he would have been hurt .he's a frail man, very limited in communication .he just had a reddened area on his side when we assessed him. On 06/20/2019 at approximately 11:50 a.m., a meeting was held with the DON, the administrator and the maintenance director. Questions were asked regarding the bed frames and mattresses. The maintenance director stated, All mattresses are purchased from the same company that the bed frames come from .when we replace a mattress I call the company and tell them what I size I need and they send it .all our mattresses come from them, the concave mattresses, air mattresses .all of them .Some of our beds are from hospice and they bring in their beds and mattresses and install them. I can see if the mattress fits the bed, I don't need to measure it .[Name of former DON] measured all the beds a year ago .he made the tool I showed you .he and [name of another employee] went room to room and made sure the rails did not exceed the tool measurements. The DON stated, We are looking for those measurements now. The DON was asked when the side/bed rails were removed from Resident #1's bed. She stated, They were removed after the fall [06/07/2019]. She was asked if any alternatives had been attempted with Resident #1 prior to the use of his side/bed rails. She stated, I can't answer that I wasn't here at the time. The administrative team was asked how it was ascertained if the beds were the right size based on a resident's size and weight. The DON stated, We get the height and weight at admission. They were asked what the guidelines were regarding height and weight of the beds in use. The maintenance director stated, All the mattresses are 80 inches long .the maximum weight on the bed frame is 500 pounds, I don't know what the mattress is. The DON was asked why bed alarms were used in the facility. She stated, To alert staff when they are trying to get out of bed and they can try to get to them before they fall. At approximately 12:30 p.m. the survey team conducted a walk through of the facility to determine what residents had side/bed rails either in use or available for use. It was determined that every bed in the facility except two had side/bed rails in place and available for use by the residents. Multiple beds had side/bed rails in the upright position at the time of the walk through. Five additional residents with side/bed rails up, bed alarms in place, and a history of falls, were identified at that time. Review of the five residents identified indicated that no alternatives to side/bed rails had been attempted prior to their use, no measurements or assessments were present to prevent the risk of entrapment, there were no informed consents present for the use of side/bed rails, nor was there a system in place for ongoing monitoring and supervision of side/bed rails in use. The team supervisor and the State Agency were contacted with the concerns identified by the survey team. The office concurred and Immediate Jeopardy with subsequent Substandard Quality of Care identified. At 5:00 p.m., on 06/20/2019 the administrator and the DON were called to the conference room. They were informed at 5:02 p.m., that the survey team with concurrence from the State Agency had identified immediate jeopardy with subsequent substandard quality of care. A system wide failure was identified due to the facility's failure to attempt appropriate alternatives prior to the installation of side/bed rails, had failed to assess residents for the risk of entrapment, had failed to review the risks of side/bed rails with residents or their representatives and obtain an informed consent for their usage. They had also failed to have a system in place to ensure that resident beds were appropriate for the resident's size and weight and failed to have a system in place for assessment and ongoing monitoring/supervision of side/bed rails in use. The administrative team was informed that one resident (Resident #1) had been identified as having his legs entrapped in his side/bed rails and five additional residents had been identified as having bed alarms due to the risk of falls and having side/bed rails in use without proper assessment and monitoring. The DON was asked to verify how many residents in the facility were using the side/bed rails on their beds. She verified that of the 107 residents residing in the facility, 48 had side/bed rails in use. At approximately 7:00 p.m., the facility administrator presented a blank side/bed rail evaluation form. The revision date on the form was 04/18. This form had been revised to include the regulatory requirements set forth in the 2017 Federal Long Term Care regulations for bed/side rails. Also presented with the side rail evaluation was an INFORMED CONSENT FOR THE USE OF BED RAILS form that was dated 05/18 and contained information regarding the benefits and potential risks/negative outcomes associated with bed rail usage. The back of the consent contained the following: Assessed medical needs addressed by the use of bed rails, the type of rails recommended for the resident, and the actual consent stating that the resident or representative had been informed of the medical need for the bed rails as well as the risks versus benefits of the rails. There were two choices for the person signing the form, I DO voluntarily consent to the use of bed rails . or I DO NOT consent to the use of bed rails . The bottom of the consent had a line for signatures, additional comments and the following Physician order has been obtained, including medical symptom/condition. In addition to the two forms detailed above, a policy and procedure for Side Rail/Bed Rail was presented. The effective date of the policy was 04/19/2018 and contained the following: POLICY: The Center, will attempt alternative interventions, and document in the medical record, prior to the use of side rail/bed rail. Side Rail/Bed rail may include but not limited to: Side rails, bed rails, safety rails, grab bars and assist bars. Procedure: 1. Prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. 2. Review the risk and benefits with the resident and/or representative. 3. Obtain consent from the resident and/or resident representative. 4. Obtain physician order for side rail/bed rail. 5. Update the care plan and kardex. 6. Re-evaluate the use of side rail/bed rail, quarterly, with a change in condition or as needed. 7. Follow the manufacturers' recommendations and specifications for installing and maintaining side rails/bed rails. After reviewing the documents above, the administrator was asked where the forms had come from. He stated, They came from the corporate office. The revision dates on the two forms were pointed out to the administrator. He was asked if the revision dates/effective dates (April 2018 and May 2018) indicated the forms were implemented by the corporate office and should have been put into use at the facility at that time. He stated, Yes. He was asked how the information was communicated to the facility. He stated, An email was sent to either the administrator or the DON [director of nursing]. He was asked if he had received the email. He stated, I don't recall ever seeing it. He was asked if the former DON had received it should it have been communicated to him. He stated, Yes. The plan of removal was accepted on 06/20/2019 at 9:40 p.m. and contained the following information: 1. The corrective action for the alleged deficient practice will be accomplished by: * The 5 identified residents were observed, the resident or RP was interviewed to identify who requested the bed rail to be installed, and assessed for the risk of entrapment from bed rails. * The bed rails were removed for 4 residents identified on 6/20/19. * Bed rails will be removed from beds of current residents with no assessment in place, an alternative measure will be put in place to assess the effectiveness prior to installing a side rail by 6/23/19. * [Resident #18's Name] RP [responsible party] was educated on the risks/benefits of the side rails and verbalized understanding and signed consent on 6/20/19. * Current staff working have been in serviced on the side rail/bed rail policy and F770 [typo should be 700] 6/20/19. * Staff not working will be in serviced on the side rail/bed rail policy and F770 [typo] prior to working their next scheduled shift by 6/23/19. Any staff currently on leave will be educated upon return. * For the 5 identified residents their bed was measured to ensure appropriate size and dimensions on 6/20/19 *The facility Executive Director and Director of Nursing have been educated via telephone on 6/20/2019 at 5:30 pm by the Regional Director of Clinical Services on the policy and federal regulations for side rails. The interdisciplinary team will be educated on the same policy by the Regional Director of Business Development on 6/20/2019 by 6:05 pm. 2. Residents with the potential to be affected by alleged deficient practice: Quality review of all residents currently with side rails in-house will be evaluated by a licensed nurse by 6/23/19 and alternative measures will be put in place i.e. - bed bolsters, bed alarm, tab alarm, low bed. Physician orders to be obtained and care plan revised by 6/23/19. Residents identified as candidates for side rail usage, will have risk and benefits reviewed and consent signed per the policy. Maintenance to provide measurements for bed and side rail to ensure no potential risk for entrapment by 6/23/2019. 3. Systemic Changes: I. Facility staff currently in the facility will be educated on policy regarding bed rails/side rails to include assessment schedule as well as risk on 6-20-2019. All other clinic staff will be educated prior to working their next shift. Staff not working will be in serviced on the side rail/bed rail policy and F770 [typo] prior to working their next scheduled shift by 6/23/19. Any staff currently on leave will be educated upon return. II. Residents with side rails/bed rails will be assessed quarterly and with any change of condition. III. Quality Review of residents with side rails weekly X 4 to ensure that risk and benefits, measurements, consent signed then monthly X 6 months IV. The quarterly assurance committee will meet monthly to review the results of quality review and make changes as necessary. On 06/21/2019 at approximately 9:00 a.m., the SBARs for Resident #1's falls out of bed were reviewed. After review, the DON was asked if Resident #1's side rails had been in the up position at the time of the falls, as only the fall out of bed on 12/11/2018 included information regarding the side rails. She stated, I don't know, I wasn't here then. I have looked for witness statements and I can't find them for any of the falls out of bed except the one on 06/07/2019. She was asked when the bed rails were removed for Resident #1. She stated, We removed them right after that fall. A meeting was held with the DON, the corporate nurse consultant and the administrator on 06/21/2019 at approximately 11:30 a.m. While discussing side rails the corporate nurse consultant stated, We know we need to put a process in place, it is broken. On 06/24/2019 the survey team returned to the facility. The plan of removal was reviewed for evidence verifying the plan had been fully implemented and no residents in the facility were in jeopardy. Information reviewed included the bed/side rail evaluations for the 48 residents identified by the facility as having bed/side rails in use. Of those 48 residents, the facility determined by use of the bed/side rail evaluation, that bed/side rails were not indicated for 30 of those residents. The remaining 18 residents or their RPs (responsible party) refused the use of alternatives to bed/side rails. For those 18 residents, bed/side rail assessments were completed, consents were signed, physician orders were obtained and the care plans were updated. The facility bed/side rail policy was also updated to include the following: Addendum: On going [sic] monitoring will include: 1) Side rail/bed rail will be monitored by licensed nurse per physician order; 2) Side rails will be lowered as indicated to provide care. toileting, hydration, meals and positioning; 3) Re-evaluate the use of side rail/bed rail, on admission, quarterly, and with any change of condition as needed by a licensed nurse. If the side rail/bed rail is no longer indicated the licensed nurse will notify maintenance for removal of the bed rail/side rail; 4) Maintenance will conduct routine maintenance of beds and side rail/bed rail to ensure they meet safety standards and are not in need of repair upon resident admission, readmission, significant change and quarterly. Education of staff regarding the changes to the use of bed/side rails was evidenced by in-service records and staff interviews. The Immediate Jeopardy was abated at 06/24/2019 at 3:42 p.m. The Scope and Severity was lowered from a pattern of Immediacy to a Level II, widespread. No further information was obtained prior to the exit conference. 2. Resident #46 was originally admitted to the facility on [DATE] and was recently readmitted on [DATE]. Her diagnoses included but were not limited to: Unspecified dementia with behaviors, unspecified psychosis, Parkinson's Disease, scoliosis, and hypertension. A significant change MDS (minimum data set) with an ARD (assessment reference date) of 05/04/2019, assessed Resident #46 as severely impaired in her cognitive status with a summary score of 00. On 06/18/19 at approximately 12:00 p.m., Resident #46 was observed in bed, asleep, a tab alarm was in place, a fall mat was on the right side of her bed between her bed and the wall, a wedge cushion was on her left side, and an air mattress overlay was in place on her bed. At approximately 12:30 p.m., Resident #46 was heard yelling in her room, I can't breath, I can't breath. Staff went to the room and Resident #46 was observed with the head of her bed up, a lunch tray was in the room, Resident #46 was attempting to sit up in the bed. Staff went to the room and assisted her. The electronic record was reviewed at approximately 3;15 p.m., on 06/18/2019. Included in the documentation was the following note: 05/18/2019 19:46 [7:46 p.m.] Patient's bed alarm sounding off, patient found in the floor, between her bed and wall. Appears that patient had thrown her legs over the side of the bed. And d/t [due to] contractures in her legs, caused her whole body to fall. Patient states that she was making cookies when asked what had happened .Patient assisted back into bed, alarm in place and on. Wedge under patient's right side. Bed in low position The clinical record was reviewed for bed/side rail assessments. Two quarterly data collection tools, one dated 03/12/2019 and the other dated 03/19/2019, were reviewed. There was a section on the tool, SIDE RAILS with a yes or no question, Is the resident using Side Rails? Both tools were checked Yes and the type entered was Bil [bilateral] quarterly. Further instructions on the form were: If yes, complete additional Side Rails Evaluation. Side rails include bed rails, grab bars, assist rails. There were no Side Rails Evaluation observed in the clinical record. The care plan was reviewed. There was no mention of bed/side rails on the care plan. There were no physician orders, consent, or attempts at alternatives to bed/side rails documented in the clinical record. At approximately, 11:50 a.m., on 06/20/2019 the maintenance director was interviewed about measuring beds to ensure they were the proper size for a resident's height and weight with the use of bed/side rails. He stated that he had not measured the beds but that mattresses were ordered from the same company that the bed frames came from to ensure proper fit. He was asked about the air mattress overlay used by Resident #46. He stated, She is hospice, they bring in their own beds and mattresses and install them .that air overlay is over the LAL mattress (low air loss) . I can see if the mattress fits the bed, I don't need to measure it . The DON was asked why bed alarms were used in the facility. She stated, To alert staff when they are trying to get out of bed and they can try to get to them before they fall. A system wide failure regarding side rails was identified by the survey team and Immediate Jeopardy was called at 5:02 p.m., on 06/20/2019. Resident #46 was included in the immediacy due to her lack of assessment for the use of her bed/side rails, her history of falls, and the use of a bed alarm to alert staff when she was trying to get out of bed. During the plan of removal the facility staff identified 48 residents with bed/side rails in use in the facility. Resident #46 was one of those residents. After a side rail evaluation was completed on 06/20/2019, it was determined by the facility staff that side rails were not indicated for Resident #46. On 06/24/2019 a walk through of the facility was conducted by the survey team. There were no bed/side rails on Resident #46's bed. During a meeting with facility staff on 06/24/2019 at approximately 4:30 p.m., the DON was asked if the bed/side rails had been up at the time of Resident #46's fall from her bed. She stated that she had been unable to find a witness statement regarding the fall and was unable to determine by the SBAR if the bed/side rails had been in the up position or not. No further information was obtained prior to the exit conference on 06/24/2019. 3. Resident #89 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Alzheimer's Disease, weight loss, Chronic diastolic heart failure, anxiety, history of TIA (transient ischemic attacks), history of falls, and abnormal posture. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/29/2019, assessed Resident #89 as severely impaired in her cognitive status with a summary score of 03. On 06/18/2019 at approximately 12:00 p.m., Resident #89 was observed lying in her bed. A tab alarm was observed on her bed, and bilateral bed/side rails were in use. The clinical record was reviewed on 06/19/2019. The note dated 06/18/2019 written by the interdisciplinary team documented that Resident #89 continued to need her bed alarm. (A copy of the note was requested but was not received.) The care plan was reviewed. A focus areas, At Risk for Falls r/t [related to] poor safety awareness .frequent falls was observed. Interventions included but were not limited to: Resident has Velcro self release seatbelt for safety; Tab alarm in Bed-check function & placement Q [every] shift . Another focus area: .ADL self-care included the following intervention: Bed Mobility: The resident requires assistance from staff with bed mobility. There was no mention of side rails on the care plan. There were no physician orders, consent or attempts at alternatives prior to the implementation of bed/side rails documented in the clinical record. On 06/20/2019 at approximately 11:50 a.m., a meeting was held with the DON, the administrator and the maintenance director. The DON was asked why bed alarms were used in the facility. She stated, To alert staff when they are trying to get out of bed and they can try to get to them before they fall. A system wide failure regarding bed/side rails was identified by the survey team and Immediate Jeopardy was called at 5:02 p.m., on 06/20/2019. Resident #89 was included in the immediacy due to her lack of assessment for the use of her bed/side rails, her history of falls, and the use of a bed alarm to alert staff when she was trying to get out of bed. During a meeting with the DON (director of nursing), the corporate nurse consultant and the administrator on 06/21/2019 at approximately 11:30 a.m. The DON was asked why Resident #89 had bed/side rails. She stated,I don't know why she had them, she's not using them for bed mobility. During the plan of removal the facility staff identified 48 residents with bed/side rails in use in the facility. Resident #89 was one of those residents. After a bed/side rail evaluation was completed on 06/20/2019, it was determined by the facility staff that bed/side rails were not indicated for Resident #89. On 06/24/2019 a walk through of the facility was conducted by the survey team. There were no bed/side rails on Resident #89's bed. A meeting was held with the facility administrator, DON and corporate nurse consultant on 06/24/2019 at approximately 4:40 p.m., the DON was asked why the IDT had elected to leave Resident #89's bed alarm on during their last meeting. She stated, They continued the bed alarm because she sits up in the bed. It is to alert them before she gets up. No further information was obtained prior to the exit conference on 06/24/2019. 4. Resident # 18 was admitted to the facility 12/19/15 with a readmission date of 3/12/19. Diagnoses for Resident # 18 included, but were not limited to: syncope and collapse, unspecified abdominal pain, history of falling, Parkinson's disease, and depression. The most recent MDS (minimum data set) was a significant change assessment and had Resident # 18 with severe impairment in cognition with a total summary score of 00 out[TRUNCATED]