Every finding on record at Assumption Home

Based on interview and document review the facility failed to ensure the appropriate size sling was used and the straps on the EZ Way sling were secured to the mechanical EZ Way smart lift during transfer of 1 of 2 residents (R13) reviewed for mechanical lift transfers. This failure resulted in Immediate Jeopardy to resident health and safety when the loop for the lift sling was not secured properly causing it to come undone. This resulted in R13 sliding out of the sling and falling to the floor. R13 and sustained an abrasion to the posterior head (right side).The Immediate Jeopardy began on 8/3/25 when R13 slid out of the lift sling. The administrator was notified of the immediate jeopardy at 9:02 a.m. on 11/20/25. The immediate jeopardy was removed on 8/12/25, prior to survey and was therefore issued at Past Noncompliance.Findings include:R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated R13 had severely impaired cognition, needed extensive assistance with two people for transfers and R13 had a prognosis that indicated a life expectancy of less than six months, including: progressive supranuclear ophthalmoplegia (progressive damage to brain cells that leads to motor and non-motor symptoms), cerebral atherosclerosis (narrowing arteries in the brain due to buildup of fatty plaques), unspecified dementia with psychotic disturbance, delusional disorder, type II diabetes mellitus (DM) with other circulatory complications, and hypertension (elevated blood pressure). R13's care plan dated 3/21/25, indicated R13 needed a mechanical lift with two staff assistance for transfers. R13's care sheet indicated R13 used a size medium sling. R13's medical record lacked evidence that a sling assessment had been completed. R13's weight on 7/16/25 was 124.8 lbs. EZ Way Smart Lift Operation instructions identified a small sling should be used for resident who weigh 70-100 lbs. Residents who weight 90-220 lbs. should use a medium sling. R13's fall investigation report dated 8/3/25, indicated R13 was being transferred with an EZ Way smart lift from her bed to wheelchair. Staff noted they connected straps on the mechanical lift hooks, crossed the bottom strap between the resident's legs and appropriately attached to lift as well. Staff noted that once R13 was suspended in the air, not over the bed, they noted the strap by R13's left shoulder was not attached to lift. R13 began to slip out of the sling and fell to the floor hitting her head. R13 sustained abrasion to the posterior, right side of head. Report indicated no unsafe practices occurred in the reenactment of transfer. Assistant director of nursing (ADON) determined staff was utilizing a small sling verses a medium sling per care plan. R13's progress note dated 8/3/25 at 2:10 p.m., indicated as needed (PRN) Morphine (a Schedule II controlled substance and opioid analgesic used to treat severe pain) was administered at 11:30 a.m. and was needed for pain due to this event. At 5:48 p.m. it was noted that pain medication had been effective. During interview on 11/19/25 at 10:51 a.m., licensed practical nurse (LPN)-A stated re-training on use of EZ Way lift was provided following R13's fall and included review on paper, hands on practice, and the annual skills fair and competencies. The size of the sling needed was determined by the care coordinator and noted on the electronic and paper care plans. LPN-A stated care staff was trained to ensure correct sling size was being used. LPN-A described the sling was then placed under the resident, and then staff needed to ensure straps were connected correctly and securely. LPN-A stated there were two straps up by residents' shoulders and two by thighs. The same loop was used for both top and bottom straps on the sling. The resident was then raised up over bed or chair, then stopped to ensure straps were not loose. LPN-A stated sling loops had come off before, and sometimes didn't clip all the way, or slid off. During interview on 11/19/25 at 10:52 a.m., NA-C stated, following R13's fall, the facility had a new stop-lift-go program they had been practicing. The program included ensuring the proper lift and sling size were used, followed by ensuring straps were hooked securely and resident was safe to transfer. NA-C stated the resident size was listed on the care plan/care sheet. NA-C stated the manufacturer had people come to the facility to train them on the lifts in September. During interview 11/19/25 at 10:58 a.m., NA- D stated the facility had provided pretty extensive re-training on use of EZ Way lift following R13's fall. NA-D stated training video and in person training had been provided when hired. NA-D stated the residents' specific sling size was found on the care sheet. NA-D described the communication with teammate during the resident transfer while using a mechanical lift. NA-D stated they would raise the resident, then ensured all was safe and secured, before proceeding. During interview on 11/19/25 at 11:01 a.m., NA-E stated the registered nurse (RN) care coordinator assessed the residents and determined the appropriate sling size. NA-E stated the facility provided regular training on the use of the mechanical lifts and in late summer the company provided EZ Way product specific training. NA-D stated information covered included positioning, strap colors and placement, time out and communication to ensure straps secured. NA-D stated size of sling needed was noted on the care sheets. During interview on 11/19/25 at 11:03 a.m., NA-F stated the facility had recently gotten new lifts. NA-F stated they received step-by-step training on the devices and slings. NA-F stated the care sheets noted the size needed by the residents. NA-F also stated, the STOP (safety program, in which a resident was raised a couple of inches to verify straps secured as tension was placed on them by the residents body weight) program had been implemented when the educational RN had started. During interview on 11/19/25 at 11:08 a.m., NA-G stated she had taken courses related to using mechanical lifts. NA-G stated the facility had implemented another safety program, in which a resident was raised a couple of inches to verify straps secured. Training was received via email, and they read the information and signed off on it. NA-G stated residents sling size was noted on the care sheet. During interview on 11/19/25 at 11:36 a.m., NA-A stated she had lifted R13 up and pulled lift backwards and sling was noted to be fine. Neither NA-A or NA-B stopped to check the sling to ensure the loops on the sling were correctly hooked on the lift bar before moving the lift away from the bed. NA-A stated the loops on the sling must not have been on the lift bar correctly and slipped causing the front right loop to detach. NA-B was behind R13 when R13 fell. NA-A stated R13 hit the right side of her head on the floor. NA-A stated she could not recall the sling size but thought a medium sling was to be used on R13 per care plan. NA-A indicated assistant director of nursing (ADON) came to facility and had staff reenact incident and provided training via competency checklist and demonstration before they had been able to work with residents again following the incident. During interview on 11/19/25 at 12:24 p.m., lift representative (LR)-D stated they were notified of the incident that occurred. LR-D stated people needed to pay attention and ensure the straps are connected to the machine and LR-D teaches staff to stop and pause once there is tension on the straps to ensure it is secure. LR-D stated staff should ensure right size slings is being utilized. LR-D confirmed additional training had been completed at the facility 8/12/25 following the incident. During interview on 11/19/25 at 1:00 p.m., assistant director of nursing (ADON)-C stated she received a phone call from the facility on 8/3/25 alerting her to R13's fall from the lift. ADON-C came to facility after the fall. ADON stated the staff was 90% certain the loop was on, and that the resident was not lifted very far, so it was a slow fall. ADON assessed R13 who was at her baseline. ADON stated staff used a small sling when a medium sling was care planned but due to R13's weight, she could have used either size sling. ADON stated all information was provided to the director of nursing (DON) and executive director (ED) to determine if it was a reportable event. During interview on 11/19/25 at 1:14 p.m., director or nursing (DON)-B stated registered nurses (RNs) determined sling size based on the residents' body size and weight. Residents were reevaluated depending on their weight and health status. If the wrong sling was used, staff must have grabbed the wrong size, as R13's sling size was indicated on the care sheet. DON-B stated the supply closets housed the extra slings for use when one was soiled or being laundered, and there was no concern of possible shortage being the cause of wrong size being used for R13. During interview on 11/19/25 at 1:34 p.m., executive director (ED)-A stated routine maintenance inspection had been completed on the lift 7/23/25 using the EZ Way routine maintenance checklist. This task had been entered into the TELS (a building management platform designed for maintenance needs in senior living communities) system to be completed annually. The facility also had purchased the preventative maintenance program with the lifts which included annual inspection and maintenance. ED-A stated facility maintenance was scheduled for July annually, and the EZ Way inspection scheduled for January, therefore the lifts would be inspected every six months and as needed. The lift involved in this fall had been pulled off the floor until maintenance was able to inspect it again on 8/3/25. ED-A stated the lifts were less than a year old. ED-A stated R13 could have used either a small or medium sling based on body weight, and she had confirmed this with EZ Way representative during the facility investigation. ED-A stated sling size can be sized down when a resident is in between sizes but should not size up. ED-A stated NAs could not determine appropriate sling size for a resident, and that it was determined by an RN and noted on the care plan, which pulled through to the care sheets. ED-A stated the fall had not been reported to the SA as it had been determined through the investigation that there had been no concern regarding abuse or neglect. The facility investigation found that the NAs took resident safety very seriously and followed the care plan and they felt they were not rushing and followed their training, there had been no supply issue with the sling, the strap coming loose was not intentional or neglectful, the staff involved had no previous care or performance concerns or incidents, R13's injury had not required treatment, R13's neurological assessments and vital readings were stable, and R13 was at baseline. ED-A also noted there had been no concerns voiced by the hospice provider or R13's guardian. ED-A verbalized incident did not clearly meet abuse reporting requirements. During interview on 11/19/25 at 2:38 p.m., DON-B explained the new program as SAFE by Leading Age. DON explained that it is very similar to what staff had previously been trained on, including the expectation of verbalizing correct strap placement and secured correctly with teammate prior to transferring resident. DON-B explained the program as more standardized, with a formal campaign to increase awareness and improve outcomes by decreasing adverse events. DON-B stated all staff will be taking the pledge that the DON's in the organization had taken over the summer. Since then, stop sign stickers had been applied to all the lifts to remind staff of the program and training. During interview on 11/20/25 at 7:43 a.m., LPN-B stated when she responded to residents' room [ROOM NUMBER]/3/25, she had been called on walkie talkie. When she entered the room, resident was laying on the floor with sling beneath her, lift legs were together and one of residents' legs was over the lift legs. LPN- B was not able to recall which leg. LPN-B stated R13 did not appear to be in distress. LPN-B stated after getting resident up and checking her over and obtaining vitals, she called hospice and the on-call RN who came in a short time later. LPN-B stated she then pulled the lift off the floor. NA-A and NA-B were pulled off the floor and advised to write their statements of the incident. LPN-B stated both NAs appeared to be anxious and didn't know how the fall occurred. Facility provided training documents for NA-A and NA-B completed 8/3/25 and again 8/16/25, included lift competency guidelines and checklist total mechanical lift (Hoyer) steps instructed to always verify correct sling size, and ensure all loops secured. In addition, safe transfer competency exams were included for both NA-A and NA-B.Facility Safe-Patient-Handling Program training log dated 11/4/24, for in person training completed with EZ Way Rep for facility staff at the time of new lifts being implemented indicated 21 staff had attended. Facility Safe-Patient-Handling Program training log dated 8/12/24, for in person training completed with EZ Way Rep for facility staff at the time of new lifts being implemented indicated 24 staff had attended. Facility Policy No. POL_SS018, no date, titled Abuse Prevention Plan, page 5, paragraph B, under Reporting of Suspected Resident Abuse and/or Neglect, indicated events in which abuse was not suspected and did not result in bodily injury, it was required to report the incident no later than 24 hours after, also if the event was suspected to be the result of abuse/neglect or resulted in serious bodily injury to report immediately, but no later than 24 hours after.Facility Policy No: POL_NS 803, last revised 9/30/24, titled Using a mechanical lift, indicated resident be measured for proper sling size and purpose, according to manufacturer's instructions. In addition, step 11 in the procedure instructed to attach the sling straps to sling bar clips, before resident was lifted ensuring security of the sling attachment, while also visualizing the fasteners and security. Step 12 instructed to lift resident approximately 2 inches from the surface to check stability and fit of sling prior to lifting further.EZ-Way Smart Life Operator's Instructions revised 5/9/25, indicated EZ Way slings were made specifically for EZ Way Smart Lifts. For the safety of the patient and the caregiver, only EZ Way slings should be used with EZ Way lifts. Instructions also indicate that a small sling should be used for resident who weigh 70-100 lbs. Residents who weight 90-220 lbs. should use a medium sling. Instructions indicated staff should make a final check of all four loop attachment points to ensure each loop is sufficiently attached to the respective hood of the hanger bars. Patient is ready to be lifted. Additionally, instructions indicated staff to push the up button on the hand control to initiate the upward motion until there is tension on the slings legs, making sure all the loops on the sling are securely hooked on the hanger bar prior to advancing. EZ-Way Sling Color Coding System not dated, listed gray as the color for a size small sling for resident weights 70-100 pounds, with a maximum distance from tailbone to base of neck being 21 inches. A medium sling indicated as beige in color, for resident weight 90-220 pounds, with a maximum distance from tailbone to base of neck being 24 inches.

Based on observation, interview, and record review, the facility failed to ensure staff assisted residents with eating in a manner that supported dignity for 5 of 5 residents (R2, R13, R43, R44, and R51) reviewed for dining assistance. Specifically, staff stood over residents while feeding them, rather than assisting them at eye level, which compromised dignity and created the potential for discomfort, decreased meal satisfaction, and a lack of person-centered dining support.Findings include:During observations of the evening meal on 11/18/25 and the breakfast meal on 11/19/25, staff were observed standing next to R2, R13, R43, R44, and R51-who were seated in their wheelchairs in the dining room-while assisting them with eating. R2During observation of the breakfast meal service on 11/19/25 at 8:54 a.m., an unidentified nurse assisted R2 with Jello while standing beside her. At 8:59 a.m., nursing assistant (NA)-J assisted R2 with oatmeal while standing directly over her, leaning down to place the spoon in R2's mouth. At no time did staff sit or kneel to provide eye-level assistance. Record review of R2's care plan indicated R2 required extensive assistance with eating due to impaired cognition. R13During breakfast meal observation on 11/19/25 at 8:41 a.m., NA-H was observed assisting R13 with breakfast while standing upright at the side of R13's wheelchair. R13 looked upward toward NA-H during each bite. NA-H did not attempt to sit or lower herself to R13's level during the interaction. Record review of R13's care plan indicated R13 required extensive assistance with eating due to impaired cognition. R43At 8:47 a.m., NA-K was observed assisting R43 with eating while standing. NA-K did not attempt to sit or lower herself to R43's level during the interaction and remained standing throughout the feeding interaction. Record review of R43's care plan indicated R43 required assistance with eating due to physical decline and advanced dementia. R44At 8:52 a.m., NA-I was observed assisting R44 with eating while standing. NA-I did not attempt to sit or lower herself to R44's level during the interaction and remained standing throughout the feeding interaction. Record review of R44's care plan indicated R44 required assistance with eating due to left-sided weakness and impaired cognition. R51At 8:56 a.m., NA-J was observed assisting R51 with eating while standing. NA-J did not attempt to sit or lower herself to R51's level during the interaction and remained standing throughout the feeding interaction. Record review of R51's care plan indicated R51 required assistance with eating due to normal pressure hydrocephalus (a neurological condition causing gait disturbance, memory issues, and slowed processing), weakness (reduced physical strength), and impaired cognition (difficulty with memory, attention, or problem-solving). During an interview on 11/20/25 at 1:20 p.m., NA-H stated all aides stand next to residents in the dining room when assisting them with eating. During an interview on 11/20/25 at 1:22 p.m., NA-I stated staff are expected to stand next to the resident they are assisting with eating when in the dining room. During an interview on 11/20/25 at 1:38 p.m., RN Clinical Manager (RN)-A stated staff were expected to assist residents at eye level because standing over residents can feel rushed, intimidating, or uncomfortable for them. During an interview on 11/20/25 at 3:16 p.m., the Director of Nursing (DON) stated the expectation was that staff would ensure a dignified dining experience and sit at eye level during feeding. After reviewing the observations, the DON stated, Standing over residents to feed them should not be happening. That is not dignified care. The facility's policy titled Assistance with Meals, dated 2/2018, indicated residents who cannot feed themselves will be assisted with attention to safety, comfort and dignity.

Based on interview and record review, the facility failed to ensure the pneumococcal conjugate vaccine (PCV20) was offered to 4 of 5 residents (R34, R37, R39, and R48) reviewed for pneumococcal immunization. Specifically, each resident had signed consent for pneumococcal vaccination; however, the facility failed to assess eligibility and offer PCV20 in accordance with CDC and facility immunization guidelines. This failure resulted in missed vaccination opportunities and increased the risk for preventable pneumococcal disease.Findings include:R34Record review of R34's electronic medical record on 11/20/25 revealed R34 had diagnoses including metabolic encephalopathy (acute or chronic brain dysfunction caused by metabolic imbalance), type 2 diabetes mellitus (a metabolic disorder causing elevated blood glucose), paroxysmal atrial fibrillation (irregular heart rhythm that occurs intermittently), and chronic kidney disease (long-term reduced kidney function), placing R34 at increased risk for pneumococcal infection. Review of the Pneumococcal Vaccine Consent/Declination form showed R34 had signed consent for pneumococcal vaccination. Review of R34's Immunization Record indicated no documentation of PCV20 administration and no evidence the vaccine had been offered. The last pneumococcal vaccine documented was PPSV23 on 8/28/18, with no follow-up vaccination. R37Record review of R37's electronic medical record on 11/20/25 revealed R37 had diagnoses including type 2 diabetes mellitus, vascular parkinsonism (movement disorder caused by reduced blood flow in the brain), hypertension (chronically elevated blood pressure), and respiratory bronchiolitis interstitial lung disease (lung condition causing inflammation and scarring of airways and lung tissue), placing R37 at increased risk for pneumococcal infection. Review of the Pneumococcal Vaccine Consent/Declination form, dated 3/19/25, showed R37's representative had signed consent for pneumococcal vaccination if/when eligible. Review of R37's Immunization Record indicated no documentation of PCV20 administration and no evidence the vaccine had been offered. The last pneumococcal vaccine documented was PCV13 on 9/28/15, with no follow-up vaccination. R39Record review of R39's electronic medical record on 11/20/25 revealed R39 had diagnoses including hypertensive chronic kidney disease (kidney damage caused by long-term high blood pressure), acute pyelonephritis (sudden bacterial infection of the kidneys), and paroxysmal atrial fibrillation, placing R39 at increased risk for pneumococcal infection. Review of the Pneumococcal Vaccine Consent/Declination form, dated 9/29/25, showed R39 had signed consent for pneumococcal vaccination if/when eligible. Review of R39's Immunization Record indicated no documentation of PCV20 administration and no evidence the vaccine had been offered. The last pneumococcal vaccine documented was PCV13 on 3/25/16, with no follow-up vaccination. R48Record review of R48's electronic medical record on 11/20/25 revealed R48 had diagnoses including metabolic encephalopathy, severe sepsis with septic shock (life-threatening infection causing organ dysfunction and dangerously low blood pressure), heart failure (reduced ability of the heart to pump blood effectively), paroxysmal atrial fibrillation, and cerebral infarction (stroke caused by reduced blood flow to the brain), placing R48 at increased risk for pneumococcal infection. Review of the Pneumococcal Vaccine Consent/Declination form, dated 10/28/25, showed R48's representative had signed consent for pneumococcal vaccination if/when eligible. Review of R48's Immunization Record indicated no documentation of PCV20 administration and no evidence the vaccine had been offered. The last pneumococcal vaccine documented was PCV13 on 11/11/16, with no follow-up vaccination. During an interview on 11/20/25 at 2:39 p.m., Infection Preventionist (IP)-A stated she reviewed each resident's immunizations quarterly and used the PneumoRec App on her phone to determine eligibility for pneumococcal vaccines. IP-A entered information in the app for R34, R37, R39, and R48 and confirmed all four residents should have been offered PCV20. IP-A stated, I didn't really read all of the paragraph, I guess-just the part that stated that if a resident had PPSV23 and PCV13 they would be considered complete. IP-A stated the facility was expected to offer vaccinations to all eligible residents and confirmed all four residents had signed consent but were never offered the vaccine. IP-A stated, If they've signed consent, they should be offered the vaccine. During an interview on 11/20/25 at 3:11 p.m., the Director of Nursing (DON) stated the expectation was that residents with signed consent must be offered the vaccine unless a contraindication or refusal occurred. Review of the facility's policy titled Pneumococcal Vaccines for Residents, last revised 2/7/25, indicated the facility would provide education and administration of pneumococcal vaccines (PPSV23 and PCV13) to residents according to CDC recommendations.

Based on interview and record review, the facility failed to report to the State Agency (SA), as required by federal regulations, a fall involving a mechanical lift transfer, an incident that may indicate potential neglect. This deficient practice affected 1 of 1 residents (R13) reviewed for fall from mechanical lift, however it had the potential to affect all residents requiring the use of mechanical lift for transfers. Findings include:R13's quarterly Minimum Data Set (MDS) dated [DATE], indicated R13 had severely impaired cognition, needed extensive assistance with two people for transfers and R13 had a prognosis that indicated a life expectancy of less than six months, including: progressive supranuclear ophthalmoplegia (progressive damage to brain cells that leads to motor and non-motor symptoms), unspecified dementia with psychotic disturbance, and type II diabetes mellitus (DM) with other circulatory complications.R13's care plan dated 3/21/25, indicated R13 needed a mechanical lift with two staff assistance for transfers.Care sheet indicated R13 used a size medium sling.R13's medical record lacked evidence that a sling assessment had been completed. R13's weight on 7/16/25 was 124.8 lbs.R13's fall investigation report dated 8/3/25, indicated R13 was being transferred with an EZ Way smart lift from her bed to wheelchair. Staff noted they connected straps on the mechanical lift hooks, crossed the bottom strap between the resident's legs and appropriately attached to lift as well. Staff noted that once R13 was suspended in the air, not over the bed, they noted the strap by R13's left shoulder was not attached to lift. R13 began to slip out of the sling and fell to the floor hitting her head. R13 sustained abrasion to the posterior, right side of head. Report indicated no unsafe practices occurred in the reenactment of transfer. Assistant director of nursing (ADON) determined staff was utilizing a small sling verses a medium sling per care plan.During interview on 11/19/25 at 11:36 a.m., NA-A stated she had lifted R13 up and pulled lift backwards and sling was noted to be fine. NA-A stated it must not have been on correctly and slipped causing the front right loop to detach. NA-B was behind R13 when R13 fell. NA-A stated R13 hit the right side of her head on the floor. NA-A stated she could not recall the sling size but thought a medium sling was to be used on R13 per care plan. NA-A indicated assistant director of nursing (ADON) came to facility and had staff reenact incident and provided training via competency checklist and demonstration before they had been able to work with residents again following the incident. During interview on 11/19/25 at 1:00 p.m., assistant director of nursing (ADON)-C stated she received a phone call and came to facility after the fall. ADON stated the staff was 90% certain the loop was on, and that the resident was not lifted very far, so it was a slow fall. ADON assessed R13 who was at her baseline. ADON stated staff used a small sling when a medium sling was care planned but due to R13's weight, she could have used either size sling. ADON stated all information was provided to the director of nursing (DON) and executive director (ED) to determine if it was a reportable event. During interview on 11/19/25 at 1:34 p.m., executive director (ED)-A stated stated the fall had not been reported to the SA as it had been determined through the investigation that there had been no concern regarding abuse or neglect. The facility investigation found that the NAs took resident safety very seriously and followed the care plan and they felt they were not rushing and followed their training, there had been no supply issue with the sling, the strap coming loose was not intentional or neglectful, the staff involved had no previous care or performance concerns or incidents, R13's injury had not required treatment, R13's neurological assessments and vital readings were stable, and R13 was at baseline. ED-A also noted there had been no concerns voiced by the hospice provider or R13's guardian. ED-A verbalized incident did not clearly meet abuse reporting requirements. Facility Policy No. POL_SS018 titled Abuse Prevention Plan, page 5, paragraph B, under Reporting of Suspected Resident Abuse and/or Neglect, indicated events in which abuse was not suspected and did not result in bodily injury, it was required to report the incident no later than 24 hours after, also if the event was suspected to be the result of abuse/neglect or resulted in serious bodily injury to report immediately, but no later than 24 hours after.

Based on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan was developed and maintained to address a resident's cardiac condition and implanted pacemaker for 1 of 1 resident (R10) reviewed for cardiac devices. The failure to include the resident's pacemaker in the care plan created the potential for inadequate monitoring, delayed identification of complications, inappropriate interventions during emergencies, and failure to communicate essential information to direct care staff.Findings include: R10's quarterly Minimum Data Set (MDS) dated [DATE] identified R10 had moderate cognitive impairment and required assistance with activities of daily living (ADLs). R10's diagnoses included non-traumatic brain dysfunction (brain impairment not caused by external injury), heart failure (the heart's reduced ability to pump effectively), hypertension (elevated blood pressure), renal failure (impaired kidney function), diabetes mellitus (a metabolic disorder causing elevated blood glucose), non-Alzheimer's dementia (progressive decline in memory, thinking, or behavior not related to Alzheimer's disease), hemiplegia (paralysis affecting one side of the body), seizure disorder (neurological condition causing recurrent seizures), anxiety disorder (persistent excessive worry or fear) and bipolar disorder (mood disorder involving episodes of depression and elevated or irritable mood). The MDS also indicated R10 had a pacemaker (an implanted device that regulates heart rhythm). Review of R10's individualized care plan, print date of 11/20/25, revealed no care plan problem, goal, or intervention related to R10's implanted pacemaker. There was no documentation addressing monitoring of heart rate or rhythm concerns, signs of pacemaker malfunction, activity precautions, emergency response considerations, or the need for staff to report symptoms such as dizziness, syncope, palpitations, or chest discomfort. Review of R10's Vitals flow sheets for June through October 2025 identified routine vital signs had been documented, but there was no evidence of any monitoring specifically associated with pacemaker function or related cardiac assessments. Review of R10's Provider Orders revealed ongoing orders for the cardiac medication amlodipine. However, there were no corresponding care plan interventions to guide staff regarding enhanced monitoring, parameters for reporting changes, or recognition of complications in a resident with a pacemaker. During an interview on 11/20/25 at 2:59 p.m., the Assistant Director of Nursing (ADON) acknowledged there were no individualized care plan items describing the pacemaker, its purpose, or related precautions. The ADON stated the pacemaker should be addressed in the care plan, so staff are aware of it and know how to respond appropriately. During an interview on 11/20/25 at 3:16 p.m., the Director of Nursing (DON) confirmed the facility expected care plans to include specific medical devices such as pacemakers, including monitoring needs and emergency considerations. The DON stated the pacemaker should definitely be in the care plan because it affects how staff monitor and respond to the resident. The facility's policy titled Comprehensive Assessments and Care Planning, dated 9/27/23, indicated the care plan reflects the resident's stated goals and objectives and includes interventions that address his or her current needs.

Based on observation, interview, and record review, the facility failed to ensure staff provided timely and adequate assistance with eating for 1 of 5 residents (R2) reviewed for dining assistance. Specifically, staff failed to assist a dependent resident within an appropriate timeframe, resulting in the resident's meal becoming cold before assistance was provided. This deficient practice created the potential for reduced nutritional intake, decreased meal satisfaction, and compromised dignity.Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE] identified R2 had impaired cognition and required assistance with activities of daily living (ADLs). R2's diagnoses included neurocognitive disorder with Lewy bodies (a progressive brain disease causing cognitive decline, visual hallucinations, and movement difficulties), arthritis (inflammation of the joints causing pain and decreased mobility), non-Alzheimer's dementia (cognitive decline due to causes other than Alzheimer's disease), and anxiety disorder (a mental health condition characterized by excessive worry, fear, or nervousness). R2's care plan indicated R2 required staff to provide total assistance with eating due to impaired cognition. During observation of the breakfast meal service on 11/19/25 at 8:35 a.m., R2 was seated in the dining room with her meal placed in front of her. The meal consisted of a bowl of oatmeal, a Jello cup, and juice. During continuous observation from 8:35 a.m. to 8:54 a.m., no staff approached R2 to provide assistance with her meal. R2 remained seated with her tray untouched. Steam was no longer visible from the food after several minutes, and by 8:51 a.m., the food appeared visibly cooled and congealed. At 8:54 a.m., an unidentified nurse approached R2 and started to assist her with a container of Jello. Once R2 was finished with the Jello, the nurse left R2 with the oatmeal sitting in front of her. R2 looked at the food and then looked toward staff. At 8:59 a.m., nursing assistant (NA)-K approached R2 and started to assist her with eating the bowl of cold oatmeal, which appeared thick and stiff when the NA was stirring it. During an interview on 11/19/25 at 10:02 a.m., NA-K stated, We were short today, and I didn't get to her in time. I know her food gets cold fast if she can't start eating right away. NA-K acknowledged R2 required staff to feed her immediately after the meal was served. During an interview on 11/20/25 at 1:38 p.m., Clinical Manager (CM)-A stated the resident required full assistance with eating. CM-A stated dependent residents should be assisted first so food remained warm when eating. CM-A stated staff should stay with the resident they were assisting until the resident was finished eating unless there was an emergency situation. CM-A stated when staff assisted residents, staff should be at the same eye level as the resident for comfort and a home-like atmosphere. During an interview on 11/20/25 at 3:16 p.m., the Director of Nursing (DON) stated the expectation was that dependent residents were to be assisted with eating as soon as their meals were delivered. The DON reviewed the observation timeline and stated, She should not have been waiting that long. Her food should not have been cold before staff helped her. Facility policy was requested but was not received.

Based on interview and record review, the facility failed to ensure a COVID-19 booster vaccination was administered as consented for 1 of 5 residents (R37) reviewed for immunization. Specifically, the facility obtained documented consent for a COVID-19 booster but failed to administer the vaccine, resulting in a missed immunization opportunity and potential increased risk for preventable illness.Findings include: Record review of R37's electronic medical record on 11/20/25 revealed R37 had diagnoses including hypertension (high blood pressure that increases cardiovascular risk), hydrocephalus (abnormal accumulation of cerebrospinal fluid in the brain), respiratory bronchiolitis interstitial lung disease (a chronic lung disorder causing inflammation and scarring that affects breathing efficiency), and diabetes mellitus (a metabolic disorder characterized by elevated blood glucose). These conditions placed the resident at increased risk for complications from COVID-19 infection. Review of the facility's COVID-19 Vaccine Consent/Declination form, dated 9/18/25, revealed R37 had provided written consent to receive the 2025-2026 COVID-19 booster. The form was signed by R37's representative but lacked signature by a facility nurse. Further review of the Immunization Record and Vaccine Administration Log for September, October, and November 2025 revealed no documentation R37 received the COVID-19 booster. The immunization record indicated the COVID-19 vaccine was last received on 11/15/22 outside of the facility. During an interview on 11/20/25 at 2:39 p.m., Infection Preventionist (IP)-A reviewed R37's immunization record and stated, She should have received the booster. If she consented, it should be documented as administered or there should be a reason why it wasn't. IP-A stated the expectation was all consented residents were to be vaccinated as soon as possible, noting the facility could obtain vaccination from the pharmacy the same day. IP-A confirmed there was no documentation of any reason the booster was not given. During an interview on 11/20/25 at 3:16 p.m., the Director of Nursing (DON) stated the facility followed protocols requiring timely administration and documentation of COVID-19 vaccinations. The DON stated, If a resident consents, we must give the booster unless there's a clear medical reason not to. In this case, it looks like we missed it. Review of the facility's policy titled COVID-19 Vaccine and Booster for Residents, last revised 12/23, indicated all eligible residents were to be offered the COVID-19 vaccination and booster doses when available.

Based on interview and document review, the facility failed to ensure a full body mechanical lift was used per manufacturers recommendations for 1 of 3 residents (R1) reviewed for mechanical lift use. This resulted in actual harm for R1 when staff failed to ensure the lift sling was secured prior to transfer causing R1 to fall from the lift causing pain and a fractured clavicle. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had intact cognition and required assistance with all activities of daily living (ADL)'s. R1's diagnoses included history of glioblastoma multiforme of brain, seizure disorder, hemiplegia of left nondominant side and type II diabetes. R1's care plan dated 6/4/24, directed staff to transfer R1 with a Hoyer lift (a brand name full body mechanical lift) with two staff. R1's progress note dated 7/22/24 at 12:40 p.m., indicated that R1 had a witnessed fall in his room from a mechanical lift at 11:28 a.m., nursing assistant (NA)-A and NA-B were transferring R1 from his bed to his wheelchair when R1 fell out of the sling when the right bottom strap came undone from the lift. R1 had complaints of pain in his left hip and head. R1's progress note dated 7/22/24 at 12:25 p.m., indicated R1 left the facility at 12:25 p.m. via ambulance. R1's emergency department (ED) record dated 7/22/24 identified R1 presented to the ED for evaluation of fall injury after sustaining a fall from a full body mechanical lift earlier that day. R1 injured his left shoulder and had pain with any movement of left shoulder. No history of left shoulder injuries. Imaging identified moderately displaced clavicle fracture. R1 was discharged back to the facility with orders for acetaminophen, ice, and sling. R1's progress note dated 7/22/24 at 6:29 p.m., indicated R1 returned to the facility at 5:00 p.m. via Medicab (medical transportation service). R1's progress note dated 7/28/24 at 2:22 a.m., indicated R1 vocalized a pain rating of 5/10 during transfers and repositioning and 2/10 while at rest. R1 also vocalized that current treatment was minimally effective. R1's progress note dated 7/28/24 at 9:01 a.m., indicated RN-A obtained a new order from the on-call physician for hydrocodone-acetaminophen (Norco) 5-325 milligrams (mg), a narcotic, to be taken twice daily and every 8 hours as needed for pain for 10 days. R1's July 2024 medication administration record (MAR) began monitor pain rating 0-10 every four hours on 7/22/24 after R1 returned from the hospital. R1 first vocalized a pain rating of 2 at 10:00 p.m. There were 67 additional entries ranging from 0-8, with the average being 3/10. From 7/22/24 to 7/31/24 (10 days) there were 7 doses of as needed (PRN) Tylenol (acetaminophen) documented as administered for pain. In addition, there were 7 doses of scheduled Norco administered and 7 PRN doses, for a total of 14 doses. R1's August 2024 MAR indicated pain monitoring with 50 entries of pain rating ranging from 0-8, with the average being 3.5/10. From 8/1/24 to 8/13/24 (12 days) there were 25 scheduled doses of Norco administer (twice daily). No PRN Norco was administered. In addition, there were 2 doses of PRN Tylenol administered for pain. Review of the facility's maintenance logs for the Hoyer mechanical lift A Model #PC450S, Serial #A5955 was inspected bi-annually with the last inspection date of 7/10/2024. The checklist indicated the actuator was greased, castors cleaned and oiled, two back leg bumpers were replaced, battery load test finding was 12.9 with evening spare noted, touch up paint was applied to needed areas, and noted lift is in good condition. Lift A had also been inspected earlier in the year (1/10/24) with similar findings. On 8/13/24 at 3:35 p.m., R1 stated his lack of acceptance of his position here may have led to the fall. R1 stated his feet may have slipped out. R1 denied any concerns about safety, the care that he received, or the staff that provided care to him. R1 no longer had pain from the clavicle fracture. On 8/13/24 at 4:27 p.m., NA-A indicated on 7/22/24 her and NA-B were involved with the transfer that led to R1's fall from the mechanical lift. NA-A stated that she was the initial staff in the room and had placed the sling under R1 while he was lying in bed before NA-B entered room to assist with lift and transfer. NA-A stated it was the right bottom strap that came undone. NA-A stated she can't remember which straps she connected to the lift. NA-A stated that she was the one that was using the controls of the lift. NA-A stated that it happened so fast and that both her and NA-B attempted to protect the resident from hitting his head from the fall. NA-A stated she was not sure of what happened or what could have been avoided. On 8/13/24 at 4:18 p.m., NA-B stated she was called into room to assist with a transfer and when she entered room sling was already in place under R1. NA-B stated she attached and secured the straps on the left side of lift and that NA-A had attached and secured the straps on the right side of lift. NA-B confirmed NA-A was using the lift controls. NA-B stated when R1 was up in the air, the right bottom strap came undone and R1 fell out of sling. NA-B stated that she immediately went to protect R1's head. NA-B stated licensed practical nurse (LPN)-A came in and assessed R1. On 8/13/24 at 4:31 p.m., registered nurse (RN)-A stated that he was called into R1's room following the fall. RN-A stated the lift was found on the right side of R1's bed and the top two straps were still secured and that one of the bottom straps was undone. RN-A stated initially R1 had complaints of hip pain. RN-A stated the strap that came undone must not have been secured under the retainer clip on lift. RN-A stated lift was immediately taken off the floor to be inspected and it was verified that lift was functioning properly, and that sling was also assessed with no defects noted. On 8/14/24 at 9:54 a.m. lift representative (LR)-C stated there are sling retainer clips on each of the hangers to secure the straps of the sling. LR-C stated the only way for the strap to become unsecured is that the strap was not all the way on the hoop as it may have gotten hooked on the top of the hook but not under the retainer clip. LR-C indicated causes for loop to come off included operator error. On 8/14/24 at 11:09 a.m. LPN-A stated the aides notified her of R1's fall, she went and got the RN before entering room to assist with assessment. They entered R1's room and found the sling up in the air with one strap hanging. LPN-A could not recall which strap. LPN-A stated assistant director of nursing (ADON) entered room and instructed LPN-A to go and notify family. LPN-A confirmed that if strap was under retainer clip strap should not have come loose. On 8/14/24 at 11:11 a.m., ADON stated she received call from RN-A to come to R1 room. ADON stated when she entered R1's room, R1 was laying on the floor with the mechanical lift in between bed and R1. ADON stated sling was no longer attached to the lift and/or underneath R1. ADON assessed R1 for injuries and instructed LPN-A to notify doctor and family. ADON stated that they initially thought injury had occurred to left hip as it was longer in length and rotated outward. ADON stated R1 had complaints of hip and head pain at that time. ADON stated she notified the director of nursing (DON) and executive director of fall. ADON stated that maintenance was notified immediately to assess lift prior to it being used again. ADON stated that DON compiled all investigation information to submit a vulnerable adult report and she reviewed prior to submission. ADON stated DON also initiated the retraining material and delegated re-training of staff to RN-B. ADON confirmed that re-training forms that were received were the only training completed. On 8/14/24 at 11:36 a.m., DON stated she immediately spoke with NA-A and NA-B who were involved in the incident and had them complete written statements of the incident. DON stated she completed on the spot retraining with NA-A and NA-B that included verification that straps are secure under the retainer clip prior to transfer of resident. DON stated that maintenance assessed lift to ensure proper functioning and sling was also removed for assessment with no defects noted. DON stated that she had RN-B do random audits of floor staffing performing Hoyer lift transfers to ensure proper technique was being completed. DON stated she placed education sheet in the stand-up binder in each unit to have staff read and sign that they understood. Education sheet included reminder to ensure bed was at the appropriate height when transferring and that staff need to verbalize confirmation of secure connection on straps on their side of lift. DON confirmed that not all staff had been re-trained. DON confirmed that incident was operator error. Volaro Series 4 Lift PC450-HD450 Operator's Manual included the following: Safety Notes: Make sure all four loops from the slip are properly nested in the bottom of the hooks before lifting or transferring a patient or resident. Also make sure all four retainer springs are functioning correctly. Lifting from bed to chair using the divided leg sling: Note: Raise until these is tension on the straps and then double-check to make sure the loops are nested in the bottom of the hooks. The facility policy safe patient/resident handling and movement policy, dated 4/1/2005, indicated employees shall use proper techniques, mechanical lifting devices, and other approved equipment/aids during performance of high-risk patient handling tasks per facility policy and manufacturer's guidelines. This is being issued at Past noncompliance (PNC) after it was verified the facility put the following corrective action in place. -On 7/23/24 education was placed in a binder on each unit that identified When utilizing the full mechanical lift please ensure that you have the bed at the appropriate height so that the lift does not have to raise all the way up. Please ensure that you are pausing to double check loops are attached appropriately as well prior to lifting the resident up. Please verbalize double checks when utilizing lifts. Make sure we are double checking our partners work to make sure slings are clipped in all the way. All staff interviewed confirmed that they had seen this training. -Management conducted 16 random audits to confirm staff were utilizing the lifts properly. -On 7/22/24 maintenance inspected the lift for function and safety. Additionally checked the sling for any issues. -On 7/22/24 the executive director (ED)-A emailed requesting bids for all new mechanical Hoyer lifts through a different vendor. On 8/1/24 ED-A received approval to purchase all new EZ-way mechanical lifts.

Based on interview and document review, the facility failed to ensure an allegation of staff to resident abuse was reported immediately (within two hours) to the State Agency (SA) for 1 of 2 residents (R1) reviewed for abuse. Findings include: R1's admission [NAME] Data Set (MDS) dated [DATE], indicated moderate cognitive impairment cognition (mild difficulty with memory). Diagnosis included stroke, cerebral vascular attack (CVA), and hemiparesis (limited bodily movement of one side). R1 care plan dated 3/13/24, indicated R1 had an alteration in mobility and required assistance with peri-cares, and assist of two care providers for transfer with a mechanical lift. A facility Nursing Home Incident Report (NHIR) to the SA dated 4/19/24, indicated the report was submitted on 4/19/24 at 6:23 p.m. In the report R1 stated a staff member preforming every two-hour change had ripped him around and told R1 to get used to the pain. R1 stated he was afraid of the alleged perpetrator (AP) and R1 had reported this to the licensed social worker (LGSW) immediately. The report indicated the time of incident was 4/16/24 at 2:00 am. During interview on 5/14/24 at 9:24 a.m., family member (FM)-A stated she remembered clearly hearing about the incident from 4/16/24. R1 had been very vocal about how he had been handled roughly by the AP and stated he was scared. FM-A stated she remembered hearing staff present on the phone and a staff member asked questions about the events that happened on 4/16/24. FM-A stated she recalled staff being aware the morning after the event happened. During an interview on 5/14/24 at 9:47 a.m., social services director (SSD)-A stated when a resident says they were treated roughly or handled roughly, it was reported immediately to the SA and done so in a 2-hour timeframe. During an interview on 5/14/24 at 10:07 a.m., registered nurse manager (RN)-A stated when a concern of rough care or a resident made a comment of potential abused, it was reported immediately or within 2 hours. Further, RN-A brought it to the attention of her supervisor. During an interview on 5/14/24 at 10:31 a.m., director of nursing (DON) stated when a resident stated they were handled roughly or described being handled roughly, it was reported immediately or at least within 2 hours. DON stated the incident with R1 on 4/16/24, should have been reported sooner. DON stated it was origininally thought the rough cares were nothing more than a customer service issue. DON stated when reviewing the investigation notes and comments, it was determined it should have been reported. Therefore, the incident on 4/19/24 was reported late, and included the comments in the (NHIR). The facility's Abuse Prohibition/Vulnerable Adult Policy revised 7/2022 directed suspected abuse shall be reported to the SA no later than two hours If the event does not involve abuse and does not result in bodily injury, the individual is required to report to the state no later than 24 hours after forming the suspicion.

Based on observation, interview, and document review, the facility failed to monitor labs with the use of an antipsychotic medication for 1 of 5 residents (R17) reviewed for unnecessary medications. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment. The MDS also indicated R17 took an antipsychotic medication. R17's care plan printed 10/31/23, indicated R17 was at risk for adverse drug reaction (ADR's) related to daily use of psychotropic medications, and included an intervention for medications to be reviewed by Pharmacist. R17's physician orders printed 10/31/23, included orders for Seroquel (antipsychotic) 12.5 milligram (MG) in the morning and 25 mg at bedtime by mouth for dementia with behavioral disorder, mood disorder and anxiety. R17's medical record was reviewed and lacked evidence fasting blood glucose levels were routinely monitored. R17's last fasting blood glucose was dated 5/18/22. Consultant Pharmacist's Medication Regimen Reviews for the months of January 2023 to October 2023 were reviewed, each indicated medication was reviewed for irregularities and no significant irregularities were noted. Recommendations lacked direction to monitor fasting blood glucose levels. On 11/1/23 at 9:57 a.m., consultant pharmacist (PharmD) stated for antipsychotic medications, blood glucose levels should be monitored at least annually. Blood glucose levels needed to be monitor as there is a potential hyperglycemia when taking antipsychotics. At 10:57 a.m. PharmD confirmed that a fasting glucose had not been completed since 5/18/22. PharmD stated it was a mutual responsibility with the facility to monitor labs and when they are due and she had not flagged the review for annual labs to be performed. On 11/1/23 at 2:39 p.m., director of nursing stated they relied on the consultant pharmacist to provide the facility with recommendations for when labs are due for monitoring purposes. A facility psychotropic medication monitoring policy was requested but was not received.

Based on interview and document review, the facility failed to ensure the long-term care (LTC) Ombudsman was notified of hospitalization s (i.e., facility-initiated discharges) for 4 of 4 residents (R8, R56, R61 and R166) reviewed for hospitalization . Findings include: R8's quarterly Minimum Data Set (MDS), dated [DATE], identified moderate impaired cognition. R8 was hospitalized in March, April, May, and September (2023) for various medical complications that included chest pain, chronic obstructive pulmonary disease (COPD) exacerbation, and evaluation from a fall. R8's progress note dated 3/4/23, identified significant chest pain and was sent to the emergency department (ED) for evaluation per R8's request. R8's progress note, dated 3/7/23, identified R8 was readmitted to the nursing home after being hospitalized for monitoring. R8's progress noted dated 4/2/23, identified cough, diminished lung sounds, pain with breathing, hallucinations and delusions and was sent to the ED for evaluation per doctor's orders. R8's progress note, dated 4/3/23, identified R8 was readmitted to the nursing home after being hospitalized COPD exacerbation. R8's progress note dated 5/25/23, identified significant pain following a fall and was sent to the emergency department (ED) for evaluation per R8's request. R8's progress note, dated 5/26/23, identified R8 was readmitted to the nursing home after being hospitalized for monitoring. R8's progress note dated 9/22/23, identified fall occurred where R8 hit her head on the ground and was sent to the emergency department (ED) for evaluation per R8's request. R8's progress note, dated 9/23/23, identified R8 was readmitted to the nursing home after being hospitalized for monitoring. R8's medical record lacked evidence the LTC Ombudsman had been notified of noted hospitalization s. R56's significant change MDS, dated [DATE], identified intact cognition. R56 had been hospitalized in June (2023) for a fracture occurring from a fall. R56's progress note dated 6/8/23, identified fall occurred where R56 had significant pain and could not bear weight and was sent to the ED for evaluation. R56's progress note, dated 6/13/23, identified R56 was readmitted to the nursing home after being hospitalized for hip fracture. However, R56's medical record lacked evidence the LTC Ombudsman had been notified of hospitalization . R61's 5-day MDS, dated [DATE], identified intact cognition. R61 had been hospitalized in September (2023) for critical lab result. R61's progress note dated 9/29/23, identified critical calcium lab result and was sent to the ED for evaluation per doctor's orders. R61's progress note, dated 10/1/23, identified R61 was readmitted to the nursing home after being hospitalized for critical calcium level. However, R61's medical record lacked evidence the LTC Ombudsman had been notified of hospitalization . On 11/1/23 at 10:25 a.m., registered nurse (RN)-A stated when a resident gets discharged , the discharging nurse completed a form and is given to RN-A, who faxes all forms to the Ombudsman at the end of every month. RN-A stated she informs of Ombudsman of all discharges from the facility and that she does not notify on any transfers to hospital. 48740 R166's significant change Minimum Data Set (MDS) dated [DATE], indicated R166 had severe cognitive impairment and had diagnoses which included Alzheimer's disease, coronary artery disease (CAD), Hypertension, Arterial Fibrillation, and anemia. Reviewed of R166 progress notes from 3/30/23 to 4/3/23 reveled R166 was transferred to the hospital on 3/30/23 and returned to the facility on [DATE]. Bed hold was obtained via phone from wife. R166's medical record lacked documentation the Ombudsman had been notified of R166's transfer to the hospital. On 11/1/23 at 10:31 a.m. administrator confirmed that RN-A was the person responsible for sending notifications to that Ombudsman. administrator stated that her expectations are that the Ombudsman would be notified of any voluntary or involuntary discharges with the locations the resident left to. Administrator stated that she did not think of transfers to the ER/hospital as information that the Ombudsman should be notified of. On 11/1/23 at 2:35 p.m., administrator confirmed that Ombudsman should have been notified of all transfers and discharges from the facility, including transfers/discharges to the ER/hospitals and to the community. administrator stated that facility had not been notifying of transfers to the ER/hospital. administrator stated it was important for communication with the Ombudsman, so if a resident transfers to the ER/hospital and is not allowed to come back that the Ombudsman would be notified and aware of situation and to ensure that the resident is in a safe location when transferred/discharged . Reviewed notification reports that were faxed to the Ombudsman for the months of March through September 2023, with none of the hospitalization s being reported. The Transfer and Discharge from Facility policy dated 11/16 indicated the facility will send a copy of the notice to a representative of the State Long-Term Care Ombudsman per requirements. The intent of sending copies of the notice is to provide added protection to resident from been inappropriately discharged , provide residents with access to an advocate who can inform them of their options and rights, and to ensure that the Office of the State LTC Ombudsman must occur before or as close to possible to the actual time of a facility-initiated transfer or discharge. The medical record must contain evident that the notice was sent to the Ombudsman.

Based on interview and document review, the facility failed to comprehensively assess fall risk and implement individualized interventions to reduce the risk of falls for 2 of 3 residents (R1, R3) reviewed for accidents. This resulted in actual harm for R1 who sustained fractures and for R3 who sustained a subdural hematoma after repeated falls and whom both required medical treatment or services. Findings include: R1's Inpatient Discharge Summary, dated 11/16/22, identified R1 fell three times prior to her hospital admission in which she sustained nasal fractures, left great toe fracture, distal right fibula fracture, and a left wrist fracture. She was discharged to the facility in stable condition with a good rehab potential and was expected to require services for less than 30 days. R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 admitted to the facility on [DATE]. She was severely cognitively impaired and received extensive physical assist for most cares. R1 relied on a wheelchair for locomotion and did not walk. She required staff assist to stabilize during transfers. R1 was diagnosed with a right fibula (lower leg) fracture, muscle weakness, urinary tract infection (UTI), dementia, anxiety disorder, and repeated falls. R1 lacked condition(s) or chronic disease(s) which resulted in a life expectancy of less than six months. R1's baseline care plan, dated 11/16/22, identified R1 to be at risk for falls related to her impaired mobility, multiple fractures, and history of falls in which R1 would be safe and free from falls. The care plan directed staff to orient R1 to her room and call light system and to provide R1 with reminders as often as necessary, along with reviewing fall prevention with R1's representative on admission and to follow physical therapy (PT) and occupational therapy (OT) instructions for mobility function. The care plan identified R1 was non-weight bearing to her right leg, was not to ambulate, and required full assist for transfers and further directed staff to assess for incontinence every two hours and as needed (PRN). R1's discharge goal was to turn to her prior living facility. R1's medical record identified the following entries and identified information: -A progress note, dated 11/17/22, at 9:00 p.m. R1 was found on the floor. Per R1's statement, she tried to reach the door and slipped from the wheelchair (w/c). R1 was educated to use her call light and ask for help. -A progress note, dated 11/18/22, at 3:52 a.m. R1 was checked on every 30 minutes throughout the shift to prevent falls. -A progress note, dated 11/20/22, at 9:15 p.m. R1 required assist of 2 staff with a standing mechanical lift, was non-compliant with non-weight bearing transfer orders, and self-transferred during shift. -A progress note, dated 11/21/22, at 1:26 a.m. R1 self-transfers most of the time. [R1] should be monitored every 30 minutes for fall risk. -A progress note, dated 11/21/22, at 1:40 a.m. R1 was checked every 15 to 30 min[utes] to ensure she was not self-transferring or unstable. R1 was very confused and writer stayed with [R1] throughout the shift as it was unsafe for [R1] to leave her alone in her room. -A progress note, dated 11/21/22, at 10:41 a.m. R1 was found seated on the floor by her doorway around 7:10 a.m. R1 stated she got herself up from the bed and lowered herself to the floor as no one came when she needed help. An associated, same day, Risk Management (incident report) identified an intervention for anti-roll back breaks to be applied to her w/c. R3's care plan identified, on 1/9/23 (over a month and a half later), anti-roll breaks were initiated. -A progress note, dated 11/22/22, at 12:59 a.m. R1 self-transferred into her w/c from her bed. R1 was kept in one of the day rooms since she felt anxious in her room. Music was played for her which helped calm her. R1 will be monitored closely. A Fall Review Evaluation, locked 11/23/22, identified R1's prior falls and identified the following factors which contributed to R1's fall risk: psychotropic drug use, memory loss, occasional bladder incontinence, use of assistive device(s), and decrease in muscle coordination. The evaluation summary identified R1 was at risk for falls related to her fracture diagnoses, muscle weakness, UTI, dementia and history of falls, her required assist for transfers and the use of a mechanical lift, and her non-ambulation status. The summary interventions directed staff to orient her to her room, the call light system, and to give reminders. In addition, anti-roll back breaks were to be added to her wheelchair and staff were to ensure R1 wore non-slip footwear at all times as she allowed. R1 also worked with physical and occupational therapy to improve her mobility. The evaluation lacked identification of R1's numerous self-transfer attempts, observed anxiety, and/or analysis related to the falls on 11/17/22 and 11/21/22. R1's progress notes, dated 11/23/22 through 11/28/22, identify each day R1 displayed self-transfer actions. Falls Care Area Assessment (CAA), dated 11/29/22, identified R1 was at risk for falls related to her fall history and casts, antipsychotic and antidepressant medications, wandering behavior, infection, incontinence, anxiety disorder, and dementia in which R1 was pleasantly confused. The CAA's Care Plan Considerations section indicated the care plan objective was to avoid complications with the hopes R1 would be able to return to her assisted living facility after she worked with therapy. The CAA lacked details of R1's 11/17/22 and 11/21/22 falls or her self-transfer habits. The CAA lacked evidence staff completed a comprehensive fall assessment and/or analysis or individualized intervention(s) identification based on R1's fall risk. A review of R1's comprehensive care plan demonstrated a lack of additions and/or adjustments to fall risk related problems, goals, and/or interventions after the 11/29/22 CAA process. In addition, R1's care plan lacked R1's self-transfer actions. R1's subsequent medical record identified the following entries and identified information: -An incident report, dated 12/14/22, at 7:00 a.m. R1 was found sitting on the floor in her room's entryway with a sustained skin tear on her lower leg. Her locked w/c was next to her bed. R1 stated she wanted to get up for the day and fell . R1's symptoms were reviewed with her provider, and she tested positive for a UTI. -A progress note, dated 1/3/23, R1 was found sitting on the floor in her room's doorway at 5:35 p.m. Her locked w/c was next to her bed. R1 stated she tried to get out of bed. The incident report identified to offer afternoon activity. R1's care plan lacked the intervention. -A progress note, dated 1/12/23, R1 was found sitting in her room's doorway: her w/c in the bathroom (BR). R1 self-transferred frequently this night and utilized the [BR] many times. The incident report identified R1 stated she fell in the BR and pushed herself toward the door. R1 was reminded to utilize her call light and wait for staff assistance (despite this intervention have not been effective and R1's diagnosis of severely cognitively impaired). -A progress note, dated 1/20/23, at 3:00 a.m., on 1/19/23, at 11:30 p.m. R1 informed staff she fell in the BR. Staff identified a left elbow bruise. In addition, R1 was found sitting on the therapy room floor at 1:30 a.m. R1's w/c was in her BR turned upside down. R1 stated her left rib hurt and she had new bruising to her left leg and breast. The incident report identified R1 was provided with a snack and placed within sight of staff for about an hour and then assisted into bed. -A progress note, dated 1/23/23, R1 was found sitting on the floor in her room's doorway at 11:50 a.m. Her w/c was behind the door. R1 stated she tried to walk out to look around. The incident report identified R1's care plan was updated to keep R1's w/c next to her bed with the breaks locked at all times when R1 was in bed. The care plan lacked the intervention. -A progress note, dated 2/8/23, R1 was found sitting on the hallway floor outside of her room at 3:00 a.m. R1 was toileted and assisted back to bed. The incident report identified an intervention for Actogram (sleep/wake cycle monitoring) watch to be performed for three days and reviewed upon completion. R1's medical record lacked documented evidence the Actogram recording period from 12/8/22 to 12/13/22 was reviewed and/or followed up on. -A progress note, dated 1/25/23, R1 demonstrated urinary frequency and urgency, increased confusion, and noted to have multiple falls recently. Orders provided to test R1's urine for infection. A subsequent progress note, dated 1/26/23, identified positive urine results and an antibiotic was started. -A progress note, dated 1/27/23, at 8:57 p.m. R1 was found scooting on the floor coming out of her room with an abrasion on her forehead. The incident report identified R1 stated she tried to go to the BR and fell . Staff followed up with therapy about an ambulation program (per a progress note, this follow-up occurred on 1/30/23); however, therapy deemed it inappropriate due to safety concerns. Instead, staff were to utilize as needed (PRN) essential oils on her pillow to encourage rest and relaxation. R1's care plan identified, on 2/2/23 essential oil use was added. -A follow-up progress note, dated 1/27/23, at 9:09 p.m. causal factors for R1's 1/27/23 fall were determined to be R1's current UTI, toileting needs, and that R1 failed to use her call light to ask for assistance. R1 had a history of multiple falls. Interventions included bowel and bladder evaluation and aromatherapy. -R1's treatment administration records (TAR), dated 1/23, identified PRN essential oil aromatherapy orders initiated on 11/16/23. The TAR lacked evidence R1 was provided with essential oil aromatherapy on 1/27/23 through 1/31/23. -A progress note, dated 1/28/23, at 12:24 a.m. R1 was found sitting on the hallway floor outside of her room at 11:00 p.m. R1's unlocked w/c was in her BR. R1 stated she attempted to go to the BR. The incident report, identified R1's provider and dietary were consulted (per a progress note, dated 1/30/23, this consult occurred) to add a nutritional supplement to promote adequate caloric intake to help reduce falls if R1 possibly experienced discomfort due to hunger and inability to communicate hunger (per a progress note, dated 1/31/23, the order was provided). -A progress note, dated 1/31/23, at 12:00 a.m. identified R1 was found on her BR floor. Her unlocked w/c was in the BR doorway. R1's left shoulder was assessed to be more distended out of place than her right and R1 complained her shoulder and left hip hurt. Per a follow-up note, at 2:58 a.m. R1 was sent to the emergency room (ER). R1's care plan identified on 2/2/23 intervention implementation that directed staff to review information on past falls and attempt to determine the cause of the falls with recording of possible root causes, removal or alter any potential causes if possible, and to educate R1/family/caregivers/interdisciplinary team. R1's medical record lacked evidence such a review was completed. R1's Inpatient Discharge Summary, dated 2/3/23, identified R1 was diagnosed with failure to thrive with recurrent falls and fall injuries of a left shoulder dislocation, L1 and L2 lumbar spinal fractures, 12th rib fracture, left sacral (base of spine) fracture, and left pubic rami (pelvic) fractures. R1's physical condition at discharge was terminal and hospice end of life/comfort care was ordered. A progress note, dated 2/7/23, identified R1 displayed restlessness, yelled out 'help me,' and was observed to sit up in bed four times. A Fall Review Evaluation, dated 2/10/23, identified R1 was at risk for falls related to fractures, muscle weakness, UTI, dementia, and history of falls. R1 was unresponsive and bedbound in which comfort care and safety while in bed continued. A progress note, dated 2/10/23, identified R1 passed away at 12:15 a.m. R1's medical record identified R1's fall risk was assessed on 11/23/22 and 2/10/23 based on the MDS process; however, the record lacked comprehensive fall risk assessments and/or analysis were completed after R1's multiple falls in order to develop, adjust, and/or monitor for effectiveness, individualized care plan interventions to mitigate R1's fall and/or fall injury risk. When interviewed on 2/13/22, at 2:47 p.m. trained medication aide (TMA)-A stated she would find fall interventions in the resident's care plan or on the Kardex. TMA-A explained R1 constantly utilized the BR and did not sleep well at night. Staff assisted R1 to bed and a minute after staff walked away R1 would self-transfer. Once R1 returned from the hospital, R1 often requested the bedpan and she witnessed R1 lean forward in bed. TMA-A stated she heard in report R1 was observed seated edge of bed when she was not supposed to. TMA-A explained that prior to R1's hospital stay being around people was overall the only thing that calmed R1. She indicated R1's status upon her return was a shock as R1 was making progress in her prior recovery and staff talked about R1's return to her previous facility. TMA-A denied involvement in a comprehensive analysis of R1's falls and she stated she lacked knowledge of any new fall risk interventions for R1 once she returned from the hospital. When interviewed on 2/14/23, at 10:50 a.m. R1's nurse practitioner (NP)-A stated R1 was a ball of anxiety when she was admitted in which she had a history of falls. Despite this, R1's discharge plan was for her to rehab and return back to her previous facility. R1's anxiety and impulsiveness improved with medication changes; however, she continued to have significant poor safety awareness. NP-A acknowledged other than trying to settle [R1's] mind to keep her from going so fast, she was unaware of R1's care planned fall interventions. She verbalized she was unaware of R1's urinary status and the frequency of which staff assisted her to the BR. NP-A denied she was involved in a comprehensive analysis of R1's falls to determine details that may have been used to decrease R1's fall risk or fall related injuries. NA-A confirmed she was unaware of the exact cause of R1's death; however, she explained the fall and fractures did not help. During interview on 2/14/23, at 11:13 a.m. R1's family (FM)-A stated R1 had a long history of falls in which she knew at some point a fall related break was going to be the death of [R1]. FM-A identified she was involved in care conferences with the facility in which they discussed R1's overall health; however, she denied they discussed R1's falls. She explained those meetings focused on the progress R1 made with therapy and the hope R1 would be able to return to her prior memory care facility. When interviewed on 2/14/23, at 1:09 p.m. nursing assistant (NA)-C confirmed she took care of R1 on 1/30/23 in which R1 was her usual self: super confused, hard to redirect, and had a short attention span. She denied that on 1/30/23 R1 displayed any signs or symptoms which would have identified declines in her medical or overall status. NA-C explained R1 often self-transferred and was hard to catch: one moment R1 was in her w/c and the next in bed or vice versa. NA-C stated R1 slept poorly at night and often napped much of the shift prior. R1 also frequently utilized the BR which NA-C thought R1 used to calm herself down. NA-C explained she often attempted to keep R1 distracted, entertained, and within her sight as much as able. NA-C denied management staff talked with her related to R1's fall risk factors and which interventions were effective and which ones were not. During interview on 2/14/23, at 1:24 p.m. licensed practical nurse (LPN)-A stated she was expected to initially investigate a resident's fall, initiate a Risk Management incident report, and implement an immediate fall risk intervention to mitigate further falls. After that, a care coordinator would review, adjust the intervention as needed, and care plan it. LPN-A confirmed the coordinator followed up with her after she managed a residents fall; however, she denied she was ever involved in any sort of comprehensive analysis of resident fall(s) to determine details that may have been used to decrease resident fall risks or fall related injuries with R1. LPN-A stated R1 was a roamer and she attempted to keep R1 as close to her as able. She explained R1 was quick, and staff could assist her to bed one moment and then the next she was by them needing some sort of assist. R1 always had to go to the BR and staff could tell her over and over she needed help, but she did not have the capability to remember that. LPN-A confirmed not all of the interventions they attempted with R1 were on her care plan and/or Kardex: We should all know the interventions, but probably could have been in the Kardex. LPN-A explained she was unsure of what interventions would have worked for R1 other than to provide R1 with 1:1 supervision at all times. LPN-A confirmed R1 was not provided 1:1 supervision at all times. LPN-A stated R1 was stable before her hospital stay: They were talking about sending her back to [prior memory care facility]. When interviewed on 2/14/23, at 1:40 p.m. registered nurse (RN)-C stated she expected staff to make sure an immediate intervention was implemented after a resident fall which was based on the nature of the fall and either documented in the progress notes or on the incident report: not just passed on during shift to shift report. Then, she explained, they reviewed the fall, the intervention, adjusted the intervention as needed, and initiated it within the care plan. RN-C stated fall risk assessments were completed with the MDS process and she denied they completed a comprehensive fall risk assessment and/or analysis of R1's falls outside of this process or met with the IDT (interdisciplinary team) to discuss and analyze R1's falls. She verbalized if a resident had multiple falls, a comprehensive fall and fall risk analysis was very important in order to determine the root cause of the fall, to prevent injury, and to keep residents safe; however, she was unaware of the facility policy and/or protocols on fall assessments if a resident were to have multiple falls. After RN-C reviewed a Fall Review Evaluation, she stated the evaluation did not have everything you would look at to analyze falls and fall risk. RN-C explained R1 was compulsive with her transfers in which she followed up with therapy about a walking program or exercising; however, therapy disagreed related to R1's dementia and not wanting R1 to be triggered into thinking she could walk on her own. RN-C described interventions attempted for R1 which were present on her care plan prior to her hospitalization . RN-C confirmed R1's fall interventions were not adjusted and/or new interventions implemented once R1 returned. RN-C stated R1 was stable prior to her hospitalization . R3: R3's Initial Intake provider visit progress note, dated 11/4/23, identified R3 was admitted to the facility on [DATE], after he required hospitalization as a result of frequent falls and a UTI. R3's admission MDS, dated [DATE], identified R3 was severely cognitively impaired and required limited to extensive physical assist for cares. R3 relied on a w/c for locomotion and showed minimal walking. R3 diagnosis was polyneuropathy, UTI, Alzheimer's Disease, dementia, muscle weakness, and repeated falls. R3's baseline care plan, initiated 11/3/22, identified R3's fall risk related to impaired mobility and cognition, and history of falls in which he would be safe and free from falls. The care plan directed staff to orient R3 to his room and call light system and to provide R3 with reminders as often as necessary, along with reviewing fall prevention with R3's representative on admission and to follow physical therapy (PT) and occupational therapy (OT) instructions for mobility function. The care plan identified R3 required a Foley catheter in which staff were not to leave R3 unattended on the commode. On 11/10/22, the care plan was updated, after a bowel assessment was completed, which directed staff to offer and encourage R3 to toilet every two to three hours while awake. R3's medical record identified the following entries and identified information: -Progress notes, dated 11/5/22, 11/6/22, 11/7/22, 11/8/22, all identified R3 was alert and oriented to self only and often tried to self-transfer. -A progress note, dated 11/11/22, R3 ambulated with his walker to the manager's office while he held his catheter bag. He was assisted to his room and staff were to monitor for further episodes of self-transfers. A Fall Review Evaluation, locked 11/10/22, identified R3's prior to admission falls and identified the following factors which increased R3's fall risk: Alzheimer's Disease, dementia, polyneuropathy, osteoarthritis, weakness, altered mobility, indwelling urinary catheter, frequent bowel incontinence, and new admission. The evaluation summary identified the risk factors and directed staff to orient him to his new room, ensure the call light was within reach and to encourage him to wear proper footwear when out of bed. R3 also worked with PT and OT. The evaluation lacked identification of R3's numerous self-transfer/ambulation attempts. Fall CAA, dated 11/10/22, identified R3's fall review evaluation risk factors and the use of antidepressant medication. The CAA's Care Plan Considerations section indicated the care plan objective was to avoid complications and to maintain his current level of functioning. R3's subsequent medical record identified the following entries and identified information: -A Fall Investigation report, dated 11/15/22, R3 self-ambulated in the hallway and staff intercepted his fall by lowering him to the floor. R3 stated he tried to 'fix/ find missing cable.' R3's Foley catheter tubing was pulled from his bladder and he was incontinence of bowel. R3 was brought back to his room, incontinence hygiene provided, a new catheter inserted, and he was encouraged to use his call light. R3's progress notes did not identify R3's 11/15/22 fall. -Progress notes, dated 11/16/22 and 11/17/22, R3 tested positive for COVID-19 with required room isolation and experienced increased weakness and difficulty with transfers. -An incident report, dated 11/17/22, at 2:35 p.m. R3 was found on the floor next to his bed. A progress note, dated 11/17/22, lacked evidence of R3's fall; however, the note identified R3 was free of injury, his vitals were stable, and he was encouraged to use his call light (despite the intervention or reminder not effective due to dementia). -A progress note, dated 11/18/22, R3 was ordered antibiotics based on urinalysis results [R3 was diagnosed with a UTI]. -A progress note, dated 11/20/22, at 2:18 a.m. R3 often forgets and required redirection back to room in which staff found him back out of room/self transferring. -A progress note, dated 11/20/22, at 5:30 p.m. R3 was observed to be in his BR doorway when staff intercepted a fall and lowered him to the floor. Staff placed him in bed after. The progress note and incident report lacked an identified fall analysis or new intervention. -A progress note, dated 11/24/22, R3 was observed self-ambulating down the hallway. -A progress note, dated 11/25/22, R3 face planted and sustained an abrasion to his forehead, fixed pupils, and double vision. [R3 was sent to the ER and admitted ]. -A progress note, dated 11/29/22, at 1:34 a.m. R3 returned to the facility and required assist of two staff with a mechanical standing lift for transfers and that R3 was noted to self transfer x1. A provider visit progress note, dated 12/5/22, identified R3 fell in November during isolation with subdural hematoma and neuro changes, send to ER and hospitalized for [three] days. -A progress note, dated 12/2/22, at 3:21 p.m. R3 was found on the floor about a foot from his w/c. R3 stated he hit his head. Family denied ER transport. The incident report identified staff collaborated with therapy on R3's transfers and he had a UTI which required antibiotics. -A progress note, dated 12/5/22, R3 was found on the floor at 2:50 a.m. The incident report identified R3 was to have his w/c next to the bed when he was in bed. R3's care plan identified, on 1/10/23 (more than a month later), the intervention was initiated. A Fall Review Evaluation, dated 12/5/22, completed per facility MDS process(es), identified R3's fall history prior to and during his stay and identified the same evaluation summary and interventions as the 11/10/22 fall review evaluation, with the addition of the subdural hematoma diagnosis. The evaluation lacked identification of R3's numerous self-transfer/ambulation attempts and/or analysis related to the falls which occurred after admission and hospital return. R3's subsequent medical record identified the following entries and identified information: -A progress note, dated 12/9/22, at 2:48 a.m. R3 was lowered to the floor when he became weak after he was found attempting to walk with his w/c near the dining room (DR). The incident report identified Actogram watch would start on 12/12/22. R3's medical record lacked documented evidence the Actogram recording period was reviewed and/or followed up on. -Progress notes, dated 12/9/22, 12/10/22, and 12/12/22, R3 self-transferred multiple times each day. -A progress note, dated 12/12/22, R3 was found on the floor at 3:00 p.m. after he was in his bed. Identified intervention directed for gripper socks instead of regular socks. R3's care plan identified, on 12/15/22 (three days later), R3 was to be highly encourage[d] to use non-slip footwear at all times. -A progress note, dated 12/17/22, R3 was found sitting on the floor with his back against the bed at 8:20 p.m. R3 was incontinent of bowel and a spilled water cup was on the floor by his bed. He was assisted into bed and bowel hygiene provided. The incident report identified staff were to ensure R3's bed was kept at a therapeutic height to set R3 up for successful self-transfers due to history of impulsivity and self-transferring. On 12/19/22, R3's care plan identified Low Bed and lacked identification of therapeutic height directives. -Progress notes, dated 12/19/22 and 12/29/21, R3 self-ambulated from his room down Northwoods hallway and self-transferred and ambulated in the DR, respectively. A Fall Review Evaluation, dated 12/30/22, completed per facility MDS process(es), identified R3's fall history prior to and during his stay and identified the same diagnoses as past evaluations; however, included R3 showed poor safety awareness and impulsivity which increased his fall risk. The fall summary identified the following interventions: Actigraphy PRN, therapeutic bed height, non-slip footwear at all times (highly encouraged), assistance with safety reminders PRN, and orientation to room and call light. The evaluation lacked identification of R3's numerous self-transfer/ambulation attempts and/or analysis related to the falls which occurred after admission and hospital return. R3's subsequent medical record identified the following entries and identified information: -A progress note, dated 1/1/23, at 3:24 p.m. R3 was found sitting on the floor in an adjacent unit Pod area. The incident report identified foot pedals to be stored in w/c bag when R3 was not assisted with locomotion. R3's care plan identified, on 1/19/23 (18 days later), initiation of the intervention. -A progress note, dated 1/5/23, R3 was found lying on the floor next to his w/c in the DR at 4:30 p.m. R3 sustained a right elbow scrape. The incident report identified staff collaborated with R3's provider in which orders were provided for an antipsychotic medication related to impulsivity, poor safety awareness, and behaviors. -A progress note, dated 1/6/23, at 2:16 p.m. R3 was found outside of his room on his hands and knees. R3 was brought to the DR and provided a snack. The incident report identified R3 was unsafe to be in his room alone while in his w/c. R3's care plan identified, on 1/10/23 (four days later), R3's unsafe room status. -A progress note, dated 1/8/23, at 11:09 p.m. R3 was found sitting on the DR floor. He was incontinent of bowel. R3 was provided bowel hygiene care and assisted to bed. The incident report identified to offer R3 toileting after meals. R3's care plan identified, on 1/10/23 (two days later), the intervention was initiated. -A progress note, dated 1/9/23, R3 was found on his BR floor leaning against his BR door around 1:50 p.m. R3 was previously in his recliner. At the time of the fall, the recliner footrest remained elevated. An intervention was implemented to unplug the recliner, leave in a stationary position, and to store the remote in a manager's office. R3's care plan lacked the intervention. -A progress note, dated 1/13/22, R3 started an antibiotic for a UTI. -A progress note, dated 1/16/23, R3 attempted to standup from his w/c throughout the shift despite a bath, snacks, and being kept as close to staff, as much as possible or with in eyesight. -A progress note, dated 1/17/23, at 8:03 p.m. R3 was found on the floor near the nurse's station. R3 stated he attempted to walk to another resident so he could help him. The incident report identified an intervention for a hospice evaluation and medication review with rounding provider. R3's care plan identified, on 1/17/23, an intervention to keep frequently used items within R2's reach with each interaction. -A progress note, dated 1/18/23, at 9:14 a.m. activity staff were to increase one on one (1:1) activities with R3. R3's care plan lacked the intervention. -A progress note, dated 1/19/23, at 6:49 p.m. R3 was found kneeling on the floor next to his w/c in the DR. R3 stated he attempted to get into another chair situated next to the DR table. R3 was assisted to the BR and had a BM. -A progress note, dated 1/21/23, R3 was found crawling on the DR floor at 6:00 p.m. The incident report identified hourly safety checks. R3's care plan identified, on 1/23/23 (two days later), the intervention was initiated. -A progress note, dated 1/22/23, at 1:29 a.m., R3 was found on his BR floor at 12:30 a.m. during midnight rounds and assessed to have a skin tear on his knee. He was taken to the BR and had a BM. The incident report identified to offer R3 toileting after all meals and prior to bedtime. R3's care plan identified, on 1/23/23 (one day later), R3's toileting plan was revised. -A progress note, dated 1/22/23, at 10:34 a.m. R3 was found kneeling on his bedroom floor by his recliner with his locked w/c next to the bed. R3 stated he 'needed to go over there.' The incident report identified a medication review and hospice nurse consult with another review on 1/26/23 to see if recommended increased PRN medication usage was effective. A Fall Review Evaluation, dated 1/25/23, completed per facility MDS process(es), identified the following fall risk summary for R3: R3 was alert but lethargic and only oriented to self. He required mechanical sit to stand lift for transfers and was non-ambulatory in which he continued to make multiple self-transfer attempts per day and attempted to walk. He was unsuccessful in this which led to numerous falls in the past quarter. Will continue to closely work with hospice team and [medical provider] to monitor and minimize falls. The summary listed the following fall interventions: those listed with the 12/30/22 fall evaluation, foot pedals storage, items within reach, hourly safety checks, medication reviews, offer toileting plan, unsafe to be in room alone in w/c, and w/c next to bed when in bed. The evaluation lacked specific information related to R3's falls. R3's subsequent medical record identified the following entries and identified information: -A progress note, dated 1/31/23, at 3:58 p.m. R3 was found lying on his back on his bedroom floor. The incident report identified medications were reviewed with R3's provider and medication changes were o

Based on interview, and record review, the facility failed to ensure the Infection Control policies were reviewed annually and failed to conduct ongoing surveillance for healthcare-associated infections (HAIs) in the facility. This had the potential to affect all 56 residents in the facility. Findings include: During an interview on 01/19/23, at 1:49 p.m. the Infection Preventionist (IP) revealed the overall infection control policies were not reviewed in the last year. During an interview on 01/19/23, at 3:29 p.m. the Interim administrator and the director of nursing (DON) explained the facility does not have a process in place to review the Infection Control Policies and were not aware they needed to be updated annually. During an interview on 01/19/23, at 2:30 p.m. the IP revealed there was no month to month tracking or line list surveillance for the residents, to track any potential HAIs. During an interview on 01/19/23, at 3:29 p.m. the Interim administrator and the DON explained they were not aware the IP was not using line listing for potential HAIs for resident surveillance and should be doing so. Review of facility policy titled, Surveillance for Infections, revised 03/22, indicated The infection preventionist will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions.

Based on interview and document review, the facility failed to develop and implement appropriate action plans to correct quality deficiencies identified during the survey that the facility was aware of or should have been aware of. This deficient practice had the potential to affect at 56 residents currently residing in the facility. Findings include: During an interview on 01/19/23 at 2:30 PM, the Infection Preventionist (IP) revealed there was no month to month tracking or line list surveillance for the residents to track any potential health care acquired infections. The only tracking being done was if residents had COVID-19. On 1/19/23, at a concurrent interview with the Administrator the director of nursing (DON) the Administrator stated, the infection preventionist (IP) was an active participant at the Quality Assurance and Performance improvement (QAPI) meetings and did review her findings regarding COVID-19 and antibiotic use in regards to urinary tract infections (UTI). The IP would also review concerns such as skin infections and other respiratory infections but only if she noted a group of residents in a specific area of the facility experienced the same concern. The Administrator and DON confirmed they were not aware the IP was not maintaining a line listing to consistently track each individual area of concern. During this same interview, review of the recertification survey on 3/10/22 when federal regulation F880 for surveillance was cited, was completed. It was unclear if either the Administrator or the DON were aware that the same concern being reviewed for the current recertification survey was also cited during the previous recertification survey. Both the Administrator and the DON indicated it is important for the IP to consistently monitor all infections, use of antibiotics and health concerns with the residents so trends can be reviewed during QAPI meetings.

Based on document review and interview, the facility failed to communicate changes in medication for 1 of 1 residents (R34) reviewed for notification of change in medications. Findings include: R34's diagnosis report printed 1/19/23, indicated R34's diagnoses included malignant neoplasm of the prostate (cancer). R34's admission Minimum Data Set (MDS) dated [DATE], indicated R34 was able to understand others and make himself understood. R34's cognition was moderately impaired. R34's provider note dated 12/5/22, noted urinary obstruction was controlled. R34's provider note dated 1/3/23, noted no difficulties with bladder. R34's provider order signed on 1/6/23, at the recommendation of the pharmacist, was to discontinue Flomax (medication used to treat an enlarged prostate). R34's medication administration record (MAR) printed 1/19/23, indicated Flomax was discontinued on 1/6/23. R34's nurse progress notes reviewed 1/1/23-1/17/23, failed to note the change in medication and failed to indicate if R34 or his family was notified of the medication change. When interviewed on 1/17/23, at 2:19 p.m. R34 reported his Flomax was stopped and he was not told about it. R34 did not know why the medication was stopped. R34 stated he has managed his medications for many years and it was important to him that he continue to have some level control over his medications. When interviewed on 1/18/23, at 10:21 a.m. R34's family member (FM)-D stated she was not aware of the medication change. R34 had always been aware of what medications he was taking and why. It would be important to R34's family and to R34 that he was told of any medication changes. When interviewed on 1/18/23, at 10:53 a.m. licensed practical nurse (LPN)-B stated changes to medications were communicated to family and to the resident if they were cognitively able to understand. LPN-B confirmed R34 was able understand and to communicate his needs. When interviewed on 1/18/23, at 4:36 p.m. registered nurse clinical manager (RN)-B confirmed R34's progress notes failed to note that R34 or his family was made aware of the medication change. RN-B stated R34 is aware of his medications and can understand and communicate his needs and he should have been made aware of the change to his medications. RN-B stated it was important to communicate medication changes to residents and their family to ensure they can actively participate in their care and in reporting changes. When interviewed on 1/19/23, at 10:07 a.m. director of nursing (DON) stated she expected residents and families were updated with all medication changes. Facility policy, Processing of Orders revision date 11/2014, instructed the person processing the order to call and update responsible party of all orders received.

Based on observation, interview and document review, the facility failed to ensure a self administration assessment was completed for 1 of 1 residents (R4), who was observed with an open bottle of over the counter sinus spray on her bedside table. Findings include: R4's quarterly Minimum Data Set (MDS) dated [DATE], identified R4 was cognitively intact, and able to express needs. R4 was identified as receiving extensive assistance to complete activities of daily living (ADLs), however, was an active participant with cares. The following diagnoses were identified within the MDS: coronary artery disease, hypertension (high blood pressure), asthma/chronic obstructive pulmonary disease (COPD) or chronic lung disease (CLD) (all medical conditions which can impact breathing conditions). On 1/17/23, at 11:34 a.m. R4 was observed seated in her recliner in her room. R4 was noted to have a bottle of [NAME] Severe (a nasal decongestant) on her bedside table. R4 stated she generally uses the nasal spray in the morning to help her nasal congestion and breathing. R4 stated she was short of breath at times related to her lung condition. During interview on 1/19/23, at 11:17 a.m., clinical manager registered nurse (RN)-C stated she was unaware of Vicks Sinus Severe on the bedside table in R4's room. RN-C stated R4 had not expressed desire to self administer any medications, so therefore had no self administration of medication (SAM) assessment completed. RN-C stated the SAM assessment was completed to assure the resident was physically and mentally able to self administer medication. Additionally, RN-C stated the SAM assessment was completed so any potential concerns with medication interactions and medical conditions could be identified and appropriate interactions put in place. An undated document on the product website, vicks.com, advised potential users to ask a doctor before use if they had heart disease or high blood pressure. A review of R4's January 2023 medication administration record (MAR) indicated R4 routinely received the following medications for hypertension and coronary artery disease: Lisinopril, Aspirin (Aspirin) daily, Lasix, Isosorbide Mononitrate Extended Release 24 Hour, Lisinopril Tablet, Norvasc, Plavix, and Lopressor. Additionally, R4 received the following medications to improve her breathing status: Fluticasone Propionate Suspension nasal spray in each nostril daily, and Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3 ml per nebulization (breathing machine). The Self Administration of Medications policy, last reviewed February of 2020, identified all residents admitted to the facility were asked if they wished to self administer medications. If desired, the individual was to be assessed by the registered nurse/clinical coordinator to determine if the resident can self administer safely and if this was clinically appropriate. The policy identified if resident was able to do so, additional education was to be done which would identify proper storage, tracking of usage, and reviewing this process on an ongoing basis.

Based on interview and document review, the facility failed to consistently assess a pressure ulcer to determine if there was an improvement, decline or need need for change of treatment for 1 of 1 resident (R9) reviewed for pressure ulcers. Findings include: R9's admission Minimum Data Set (MDS) dated [DATE], identified cognitively intact with a diagnosis of paraplegia (paralysis of the lower body) due to a demyelinating disease of the central nervous system. R9 required extensive assistance for bed mobility and transfers. R9 was at risk for developing pressure ulcers, but did not have a current pressure ulcer. R9's pressure ulcer Care Area Assessment (CAA) identified a care plan would be developed to prevent pressure ulcer formation. R9's Braden Skin Risk/Tissue Tolerance Test dated 10/17/22, identified a moderate risk for developing a pressure ulcer. A GEO (pressure reducing) mattress and a ROHO (weight distributing) cushion for wheel chair were initiated. R9's Skin Observation form dated 10/8/22, did not identify a pressure ulcer on the right heel. R9's Braden Skin Risk/Tissue Tolerance Test, dated 10/24/22, identified a moderate risk for pressure ulcer development. R9's progress note dated 10/26/22, identified a change in condition and was sent to the local hospital for evaluation and treatment. R9's hospital Orders Discharge Report, dated 10/31/22, identified a pressure ulcer on the right heel, and it was to be treated with Mepilex heel dressing using spandage/stretch stockinette to hold dressing in place and to change the Mepilex every five days and as needed. R9's Weekly Skin Inspection dated 10/31/22, indicated R9 had a new alteration noted upon readmission to his right heel. The description included an open area 2 x 0.9 centimeters (cm) and a non-blanchable area which measured 1 x 0.4 cm and to apply Mepilex to the heel. There was no staging of the right heel pressure ulcer on this document which was completed by clinical staff. R9's Treatment Administration Record (TAR) dated 11/1/22, indicated R9 was to have Mepilex applied every five days, or as needed to his right heel, and to use spandage/stretch stockinette to keep the dressing in place if needed. In addition, the TAR directed staff to lift/remove dressing for skin assessments. The TAR indicated the resident received wound treatment daily until it was discontinued on 11/11/22. The treatment was reordered on 11/12/22 until it was discontinued on 12/05/22. The TAR indicated the resident received treatment every five days. R9's care plan, undated, indicated the resident was at risk for dermal (skin) impairments. The goal for the resident's care plan was to maintain intact skin integrity. The interventions were to implement a pressure relieving cushion to the resident's wheelchair and to implement a pressure reliving mattress to the resident's bed. In addition, staff were to complete a head-to-toe skin assessment on a weekly basis. R9's Nutritional progress note dated 11/7/22, indicated R9 was provided supplements for wound healing twice a day. R9's Weekly Skin Inspection, dated 11/21/22, indicated R9 had a pressure ulcer on his right heel. Under the description column included, On-going alteration noted to right heel. Non-blanchable area. Applied Mepilex to heel per orders. There was no stage of the pressure ulcer, no description, and there were no measurements identified. There were no prior weekly skin inspections completed prior to this assessment during the month of November 2022. R9's Weekly Skin Inspection dated 11/25/22, indicated R9 had an on-going right heel pressure ulcer. The note revealed the Mepilex was done since there was no dressing upon morning cares. The note indicated the right heel was blanchable and the wound measured 2 x 2 cm and the wound was not open nor was it draining. R9's Weekly Pressure Wound Evaluation, dated 11/28/22, indicated R9's right heel pressure ulcer was first identified on 11/21/22. The document revealed the resident's right heel wound had now deteriorated to an unstageable pressure ulcer which measured 2.5 cm x 2.4 cm with no depth. There was no specific information identified on this document which would reveal if there were any descriptors, such as the condition of the peri-wound and if there was drainage or odor present, since there were two other wounds present on the resident during this assessment. The document identified the resident's current treatment plan indicated the wound was noted upon admission from the hospital. The current orders from the hospital provider were to apply Mepilex to the resident's right heel and to hold the dressing in place with spandage/stretch stockinette. To remove/lift dressing for skin assessment and reapply and to change every five days or as needed. The document revealed the clinical manager registered nurse (RN)-A notified the wound nurse. There were no changes made to the wound care ordered from when the resident was readmitted from the hospital on 10/31/22. RN-A marked there were no changes in the resident's wound. R9's Weekly Pressure Wound Evaluation, dated 12/05/22, indicated R9 had an unstageable right heel wound and it now measured 2.7 cm x 4. There was no identified if the resident had any depth to this area. There was no specific information identified on this document which would reveal if there were any descriptors, such as the condition of the peri-wound and if there was drainage or odor present, since there were four other wounds present on the resident during this assessment. The clinical staff member identified the resident's wound had declined and the physician and responsible party were notified of the change in status. Review of a document provided by the facility titled, Diagnosis, Assessment and Plan, dated 12/05/22, indicated R9 had an unstageable pressure ulcer. The document directed the clinical staff to continue to monitor. The document revealed there were interventions in place for offloading and to continue to encourage nutritional interventions. The medical provider continued the order of Mepilex to be applied to the resident's right heel every five days and as needed. During an interview on 1/19/23, at 8:41 a.m. the Interim director of nursing (DON) confirmed there were no weekly skin assessments completed from 11/01/22 through 11/20/22. The Interim DON B confirmed there were no weekly wound evaluations completed from 11/01/22 through 11/27/22. During this interview, the Interim DON went through R9's medical record and verified there were no progress notes which would reflect changes in the resident's skin. The Interim DON stated the nursing staff were to complete weekly skin assessments. During an interview on 1/19/23, at 9:35 a.m. RN-A confirmed she was the one who completed R9's 11/28/22 wound assessment. RN-A stated the resident was hospitalized early in his admission to the facility and never got to see his wounds, therefore, the admission MDS assessment did not reflect the resident's current wounds. CMA stated the resident was transferred to the hospital during this assessment period. RN-A stated the weekly skin assessments were to be completed by the floor nurses. RN-A stated the wound assessments were additional assessments and this was the one she completed on 11/28/22. The intention of the skin assessments were to observe all skin problems and document and measure all areas of concern. RN-A stated she was not aware the weekly skin assessments were not completed from 11/01/22 through 11/20/22. CMA stated during this time, a new process was developed by the interim DON. The nursing staff were documenting the condition of residents' skin in different places. RN-A stated during this time, there was lots of education happening to get the nurses to move to the weekly skin assessments and to be consistent with their documentation. RN-A stated this was an adjustment period and stated the weekly skin assessments were in place now. R9 wears pressure relieving boots each day and they come off during morning and evening cares. RN-A was asked if there was a physician or Nurse Practitioner (NP) note, which was written in 11/22 which would indicate the resident's pressure ulcers were an expected decline. RN-A stated the resident's overall health had been declining. A request for a wound treatment observation was again requested and RN-A stated a nurse practitioner wrote an order today that there was not to be any wound care treatments until 01/20/23, therefore the surveyor could not visualize the pressure ulcer. An interview on 01/19/23, at 10:10 a.m. with the administrator and Interim DON. DON stated the skin assessments was a new process to streamline the documentation. DON stated currently there is better and more consistent documentation on the status of the resident's right heel pressure ulcer. During this interview, a request was made for a medical provider note which would indicate R9's heel pressure ulcer was unavoidable or not. This information was not provided by the end of the survey. During an interview on 01/19/23, at 11:49 a.m. R9's family member (FM)-F stated R9 was using the pressure reducing boots prior to his admission to the facility. FM-F stated she was aware of the deterioration of the resident's pressure ulcer on his right heel. FM-F stated the resident's right heel initially had a small pressure ulcer and now it was, really bad. During an interview on 01/19/23, at 11:55 the nurse practitioner (NP)-E stated she was familiar with R9's care and his pressure ulcer on the right heel. NP-E stated the wound was chronic and he was at risk for a decline in his status due to poor functional ability and lack of solid nutrition. NP-E confirmed the resident received nutritional supplements. During an interview on 01/19/23, at 1:09 p.m. the Interim DON stated it was her expectation nursing staff were to measure and provide descriptions of a resident's wound for consistency of care. The Interim DON B stated to measure and provide a description was to alert the clinical staff for improvement of a wound, deterioration, or identify a possible infection. Review of a document provided by the facility titled, Skin and Wound Management, dated 01/17/23, .The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s) .In addition, the nurse shall describe and document/report the following.Full assessment of the pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue.Pain assessment.Resident's mobility status .Current treatments, including support services.and.All active diagnosis.The physician will help identify and define any complications related to pressure ulcers.The physician will help staff characterize the likelihood of wound healing, based on a review of pertinent factors.for example.Healing or Prevention Unlikely.The resident is likely to decline or die because of his/her overall medical instability.wounds reflect the individual's overall medical instability.an existing would is unlikely to improve significantly .additional wounds are likely to occur despite preventative efforts.

Based on interview and record review, the facility failed to completely reassess a resident following a medication change for 1 of 1 residents (R34) reviewed for medication changes. Findings include: R34's diagnosis report printed 1/19/23, indicated R34's diagnoses included malignant neoplasm of the prostate (cancer). R34's admission Minimum Data Set (MDS) dated [DATE], indicated R34 was able to understand others and make himself understood. R34's cognition was moderately impaired. Provider order signed on 1/6/23, at the recommendation of the pharmacist, an order to discontinue Flomax and to monitor post void residual (PVR) (check contents of bladder after voiding) three times each day for seven days. R34's medication administration record (MAR) printed 1/19/23, indicated Flomax (medication for urine retention) was discontinued on 1/6/23. PVR's were monitored as ordered. R34's nurse notes reviewed 1/1/23-1/17/23 failed to indicate that R34 was asked about his ability to fully empty his bladder and if he was having difficulty voiding. On 1/17/23, at 2:19 p.m. R34 reported his Flomax was stopped and he was not told about it. R34 did not know why the medication was stopped. R34 stated since the medication stopped, he felt he was not able to fully empty his bladder and was not able to maintain a urine stream after he started urinating. No staff have asked him if he was having difficulty with this or if he was able to maintain a urine stream once he started urinating. On 1/18/23, at 1:58 p.m. nursing assistant (NA)-D stated each time she has worked with R34 he was continent of bladder. On 1/18/23, at 3:17 p.m. NA-E stated R34 sits on the toilet and is continent of bladder. On 1/18/23, at 4:36 p.m. registered nurse clinical manager (RN)-B confirmed no nurse notes were found indicating R34 was monitored for quality of urine stream following medication change and R34 if able to effectively communicate his needs. RN-B stated she expected nurses would follow up with R34 following medication changes. RN-B stated it would be important to ask R34 about signs or symptoms following a medication change to ensure changes are reported to the provider and to prevent potentially serious outcomes. On 1/19/23, at 10:07 a.m. director of nursing (DON) stated she expected residents are monitored following changes to medications. Monitoring included verbal, visual and physical assessments. DON stated it is important to complete these assessments to prevent potentially serious outcomes. A facility policy regarding assessment and monitoring after medication changes was requested but was not received.

Based on interview and document review, the facility failed to ensure the state long-term care ombudsman was notified for 1 of 1 resident (R57) reviewed for discharge. Findings include: R57's discharge, return not anticipated Minimum Data Set, dated dated dated [DATE], identified they had discharged to the community which had been unplanned. R57's medical record did not identify the ombudsman had been notified of the unplanned discharge. During an interview on 01/19/23 at 12:13 PM, the admission coordinator confirmed the facility was currently not notifying the ombudsman's office when a resident is discharged or transferred. Review of facility policy titled, Discharge of Resident, reviewed 04/28/22, indicated, Notice of Resident Transfer or Discharge will be routed to Admission Nurse and will be sent to Ombudsman.

Based on document review and interview, the facility failed to ensure the Minimum Data Set (MDS) was accurate for 1 of 4 residents (R44) reviewed who received an antipsychotic medication. Findings include: R44's quarterly MDS dated [DATE], 6/3/22 and 9/2/22, did not identify R44 received an antipsychotic medication. R44's physician orders identified an order for Nuplazid (an antipsychotic medication) 10 milligrams and was ordered daily for delusions and hallucinations related to Parkinson's disease. The medication had been ordered since 12/30/21. During an interview on 01/18/23 at 10:39 AM, the MDS coordinator registered nurse (RN)-C stated she was unaware the Nuplazid was an antipsychotic. RN-C confirmed she made a coding error in the MDS assessments. During an interview on 01/19/23 at 1:09 PM, the interim director of nursing (DON) stated it was her expectation the MDS was to be correct. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/01/19, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment.

Based on observation, interview and document review the facility failed to ensure appropriate use of grab bars for 1 of 3 (R1) residents reviewed with recurrent falls from bed. R1 fell out of bed and became entrapped in the grab bar. In addition the facility failed to complete a comprehensive assessment and obtain physician orders for the use of side rails for 2 of 3 (R2, R3) residents reviewed. Findings include: Observation on 1/30/2013 at 10:00 a.m. of R1's bed revealed that R1 had a hi/low bed and grab bars on the left and right side of the bed. The gap between the mattress and the grab bars measured 3.5 inches on the left side. Both grab bars were affixed to the bed properly, formed a closed U shape and had a 3 inch gap between the space of the bars. When the bars were in the upright position the grab bars measured 17 inches in length. R1's medical record was reviewed and noted a fall risk/physical device assessment dated [DATE] indicated that R1 had a history of [REDACTED]. A Care Plan Review section of the assessment identified that R1 was to have a grab bar to aid in transfers and ambulation. The assessment failed to identify if the resident was able to to use the grab bar, the location of the grab bar, and if two grab bars were to be in use. An informed choice consent for physical devices document reveals that R1 was to have a right side grab bar for use of mobility when in bed. R1's family was informed of the risks of the device use and signed the consent from on 4/28/2011. Documentation failed to support evidence of an assessment and consent form for the use of the left side grab bar. R1's medical record was reviewed and revealed that R1 had dementia. A brief interview for mental status (BIMS) completed on 12/28/2012 revealed a score of 7, indicating severe cognitive impairment. R1's care plan dated 1/8/2013 was reviewed and revealed that R1 was at risk for falls and required the following : a left side grab bar to aid with bed mobility and transfers in and out of bed, assistance of two staff members for bed mobility, personal TAB alarm when in bed or recliner, and a hi/low bed with the bed to be in low position when R1 is in bed. R1's care plan indicated that R1 required the assistance of two staff for transfers and assistance of two staff for bed mobility. Review of R1's falls from August 2012-January 2012 revealed that R1 had 5 falls in the last 6 months, 3 falls (11/14/2012, 1/2/2013 and 1/19/2013 were falls out of bed during the night shift. A fall report dated 11/14/2012 at 12:30 a.m. indicated that R1 was found with R1's TAB alarm sounding. The fall report revealed that the lower half of R1's body was on floor mat. The upper half of R1's body was pressed up against the left side rail. A progress note dated 11/15/2012 at 3:47 p.m. indicates that R1's 11/14/2012 fall was reviewed by the interdisciplinary team (IDT). The progress note reveals that the IDT analysis of the R1's fall determined that the fall was caused by the resident attempting to get out of bed due to decreased mobility and that the fall was an isolated incident. New interventions implemented were to monitor the resident and monitor for a pattern of falls. Documentation failed to include evidence that continued monitoring of the resident for a pattern of falls were completed. Documentation lacked to identify that R1's use of the bed grab bar was reassessed. A fall report dated 1/2/2013 at 1:30 a.m. revealed that R1 was found on the floor on the side of R1's bed. R1 was lying supine against the bed frame. The fall report indicated that staff will monitor R1 more frequently to prevent further falls. Documentation failed to include evidence of monitoring of R1 to prevent further falls. A progress note dated 1/2/2013 at 3:49 a.m. revealed that fall prevention interventions initiated at the time of the 1/2/2013 fall were to encourage R1 to use the call light for assistance. A progress noted dated 1/2/2013 at 10:51 a.m. revealed that R1's fall from 1/2/2013 was reviewed and that the IDT determined that the fall was a result of cognitive impairment and weakness. New interventions were to reposition R1 side to side with a pillow every 2-3 hours and as needed when in bed. A fall report dated 1/19/2013 at 6:45 a.m. revealed that R1 ' s TAB alarm was sounding and staff found R1 laying on R1's left side (hip, shoulder and bilateral knees were touching on the floor). The fall report indicated that staff will prevent further falls by providing R1 with a hi/low bed and gripper socks on while in bed. A progress note dated 1/21/2013 at 11:49 a.m. revealed that the IDT reviewed R1's fall from 1/19/2013 and determined R1's fall was related to R1 rolling out of bed. IDT interventions were to change R1 back to a hi/low bed. A progress note dated 1/26/2013 at 1:25 p.m. revealed that at 6:20 a.m. staff found R1 with legs and body out of bed and R1's neck between the mattress and the grab bar of the bed. Staff assessed R1 for signs of life; staff were unable to obtain an apical pulse or a blood pressure. Staff then contacted police, the medical examiner and R1's physician and family regarding the death of R1. R1's death certificate dated 1/26/2013 was reviewed and revealed that R1's cause of death was positional asphyxiation and neck entrapment between the mattress and bedrail. An interview with RN(A) on 1/30/2013 at 2:25 p.m. revealed that R1 had frequent falls. RN-A also stated that R1 had a hi/low bed when the 11/18/2012 fall occurred but stated that the 1/2/2013 and 1/19/2013 falls occurred from a standard bed. RN-A stated that R1 was given a standard bed in December 2012 because R1 had a period without falls. RN-A stated that R1 was given a hi/low bed following the 1/19/2013 fall. RN-A could not recall the date that the hi/low bed was removed from R1's room or the date that the hi/low bed was placed back in R1's room. An interview with RN-B on 1/30/2013 at 1:40 p.m. revealed that the last mobility assessment that RN-B completed for R1 was completed without witnessing R1 use the grab bar. RN-B stated that staff interviews were used to complete the mobility assessment for R1's use of the grab bar. RN-B also confirmed that R1's care plan included the use of a left side grab bar, however the assessment and consent form indicated that R1 used a right side grab bar. An interview with nursing assistant (NA-A) on 1/30/2013 at 9:40 a.m. revealed that NA-A discovered R1 on the floor on 1/26/2013 when NA-A went in to assist R1 with morning cares. NA-A stated that when NA-A pulled the curtain back in R1's room, R1 was on the floor. NA-A stated that R1 had poor color and R1's neck "looked like it may have been stuck" between the mattress and the grab bar on the bed. R1's bed was in the low position on the floor and R1's body was halfway on the floor with R1's neck resting between the mattress and the grab bar. NA-A stated that R1's TAB alarm had not sounded as it was still clipped to R1's clothing. NA-A then called for the charge nurse to assess R1. An interview with a licensed practical nurse (LPN-C) on 2/1/2013 at 10:09 a.m. revealed that NA-A alerted LPN-C immediately upon finding R1 on the floor on 1/26/2013. LPN-C stated that R1's body was out of bed with R1's neck between the mattress and the grab bar with R1's face towards the bar. LPN-C indicated that another staff nurse assessed R1 for an apical pulse and blood pressure, which were unable to be obtained. LPN-C indicated that staff then alerted the on-call nurse, the medical examiner, R1's physician, the nursing home administrator, and the police department. LPN-C indicated that once the medical examiner and police "gave the ok" to move R1's body, LPN-C observed that R1 had a bruise across R1's neck. LPN-C described the bruise as "faint blue" and stated that the bruise was across the front of R1's neck under R1's chin. Observation of R2's bed on 1/30/2013 at 1:00 p.m. revealed that R2 had bilateral ? side rails. R2's care plan was reviewed and revealed that R2 had an alteration in mobility and required the assistance of 2 staff and a medi-lift for transfers and bilateral grab bars in bed to aid in bed mobility. An informed choice consent for physical devices was reviewed and revealed that R2's responsible party was educated on the risks of grab bars and signed the consent form on 12/28/2011 for R2 to use grab bars for mobility while in bed. A fall risk/physical device assessment dated [DATE] was reviewed. Under the physical device box, staff had selected the type of physical device used was a ? side rail or grab bar. The assessment did not reveal which type of physical device was being used by R2. The assessment also revealed that R2 did not have a physician's order for the bilateral ? side rails that were on R2's bed. Review of R2's physician orders reveals that no order was obtained for the use of ? side rails. An interview on 1/30/2013 at 1:00 p.m. with RN-A revealed that that R2 had bilateral ? rails on the bed. R2 confirmed that R2's consent form and care plan indicated that R2 was to have bilateral grab bars. R3 was observed on 1/30/2013 at 1:00 p.m. to have bilateral ? side rails on R3's bed. R3's care plan dated 12/28/2012 was reviewed and revealed that R3 required the assistance of 2 staff and a Hoyer Lift for bed mobility. R3 required the assistance of one staff member for wheelchair locomotion. An informed choice consent for physical devices was reviewed and revealed that R3 was to be using bilateral grab bars with a trapeze for bed mobility. The consent form indicates that R3's responsible party was informed of the risks of grab bars and provided consent on 3/15/2012. A fall risk/ physical device assessment dated [DATE] revealed that staff selected R3 to be using ? side rails or grab bar when completing the assessment. The assessment does not indicate which device R3 was using. The assessment also reveals that there was no physician order for [REDACTED]. Review of R3's physician orders revealed that R3 did not have orders for the use of ? side rails. An interview on 1/30/2013 at 1:00 p.m. with RN(C ) confirmed that R3's bed did have ? side rails and did not include a trapeze. RN-C also confirmed that the care plan and consent form directed that R3 was to have grab bars and a trapeze to aid in bed mobility. An interview with RN (B) on 1/30/2013 at 1:40 p.m. revealed that staff complete assessments for grab bars but do not document if the resident is able to use the device. RN-B stated that it is " not documented in the assessment or MDS " if the resident is able to use the grab bar. RN-B stated that " we do it in our heads " when we complete the head to toe assessment on a resident. A facility policy titled Assistive Device (Bed Mobility) effective January 2013 states that "appropriate use of bed devices will be assessed on the Mobility Assessment". The policy also states that "assistive devices will be care planned under the mobility section of the care plan. The care plan will be reviewed and updated based on assessment" and "consent to use an assistive device will include risk/benefit statement".

Based on observations, interview and record review, the facility failed to ensure residents received appropriate interventions to decrease pain during passive range of motion (PROM) for 1 of 2 residents (R19) with identified pain during PROM which resulted in actual harm. Furthermore, the facility failed to ensure proper wheel chair positioning was conducted for 3 of 3 residents (R19, R63 and R59) who had identified wheel chair positioning concerns. Findings include: PAIN Resident 19 (R19) was identified as having pain during passive range of motion exercises. The facility failed to provide adequate interventions to decrease this pain which caused actual harm to R19. R19 [DIAGNOSES REDACTED]. Her quarterly MDS (Minimum Data Set) dated 7/19/11 indicated she had short and long term memory deficits, had daily physical behaviors, required extensive assistance for all ADL's (activities of daily living). Further, it identified R19 with functional limitations of range of motion in both upper extremities; she was on scheduled pain medication but had daily indicators of pain or possible pain including facial expressions (MDS defined as grimacing, wincing, wrinkled forehead, furrowed brow or clenching teeth or jaw) and protective body movements indicative of pain such as guarding, rubbing or massaging body part. R19 was observed on 8/8/11 at 5:03 p.m. fidgeting in her wheelchair with constant motions of arms and hands, with her fingers tightly against her palms and thumbs protruding out. R19 was rubbing her fists against her hands and forearms. On 8/9/11 at 11:42 a.m. R19 continued to fidget, rub her hands that were curled into fists against each other. R19 was observed on 8/10/11 at 6:45 a.m. in her wheel chair. At 12:50 p.m., Nursing Assistant (NA)-G stated she provided morning cares for R19 before 7:00 a.m. and performed Passive Range of Motion (PROM) to her hands while she provided care. NA-G stated she always does the PROM during a.m. cares as R19 is more cooperative. She stated she was only able to get R19's fingers opened a little. The left hand was better than her right, but R19 was so resistive when she performed PROM because "it hurts." NA-G was unaware if R19 received any pain medication prior to the PROM nor did NA-G use warm wash cloths to relax R19 prior to performing PROM as directed by R19's care plan. A review of the August 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R19 was observed on 8/11/11 at 8:52 a.m. during her passive range of motion (PROM) treatment performed by nursing assistant (NA)-H and NA-I. During PROM of R19's right hand R19 grimaced with each movement as NA -H made an attempts to straighten each digit (finger). NA-H was only able to move R19's thumb and 5th digit. The other digits were curled into R19's palm and NA-H was unable to straighten them. NA-I then attempted to do PROM on R19's left hand. while NA-I attempted to straighten R19's fingers, she grimaced and pulled away with each attempt. When NA-I abducted R19's thumb R19 gasped, grimaced and pulled her left hand away. NA-H stated, "See it hurts." Both NA-H and NA-I stated R19 always acts like it hurts when they do her PROM, but "really hurts if she hasn't gotten her pain medicine first." They added that R19 was actually doing better today than usual, it was a "good today" and R19 seemed to have less pain than she usually does. NA-I stated the nurse will usually let them know when R19 has had her pain medication so they can perform the PROM. NA-I will often run warm water over R19's hands prior to the treatment which helps. Neither NA-I or NA-H had ever tried warm wash clothes before attempting PROM for R19. Both stated they usually perform the PROM during morning personal cares because R19 is sleepier, but waited today for the surveyor. A review of the August 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review identified R19's plan of care updated 7/21/11, "Potential for alteration in comfort related to impaired mobility...history of bilateral [MEDICAL CONDITION].contracture right hand. Resident does not verbalize pain, but does have physical signs and symptoms of pain noted with ROM (range of motion) and cares, especially ROM to right hand. Pain subsides when complete. Res (resident) is on narcotic pain medications prior to painful procedures (ROM)." Her care plan goal was listed as "Resident will allow staff to perform ROM to bilateral upper extremities." Interventions included, "Warm packs as needed. Use warm wash cloth to relax resident prior to ROM. Update MD (doctor) PRN (as needed) with pain concerns, and pain medications prior to painful procedures, such as ROM." Review of the medical record indicated the physician prescribed on 12-1-10, "[MEDICATION NAME] (a narcotic pain medication) 20 mg/cc 5 mg sublingual (under the tongue) BID (twice a day) AM (morning) and PM (evening) 1 hour prior to painful procedures with hand and [MEDICATION NAME] ([MEDICATION NAME]) 1000 mg by mouth TID (three times a day) at 8:00, 14:00, 20:00." R19 also had a "Mobility/wheelchair Assessment" dated 7/13/11 which included, "Resident and family goals are comfort." Her "Fall Risk/Physical Device Assessment" dated 7/13/11 also identified "Resident does grimace, guard/pull away and bite with ROM." R19's "Pain Assessment" dated 7/13/11 included a physical assessment "physical signs of pain present" with the following areas identified: "grimacing, wincing, tight, pursed lips, clenched teeth, narrowed eyes, frequent movement or repositioning, restlessness, pacing, guarding, hitting, scratching, kicking, pulling away." The assessment also indicated pain was interfering with her daily care activities, "Resident can be resistive with ROM and daily cares, especially right hand." The form indicated R19 was unable to verbalize her pain therefore a staff evaluation of pain should be performed which identified "facial expressions (i.e. grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) and for protective body movements or postures (e.g. bracing, guarding, rubbing or massaging a body part or clutching/holding a body part during movement." The form goes on to say R19 "has history of pain in back and bilateral hips. Resident also has pain with ROM to bilateral hands, right worse than left." The form further identified R19 was not meeting her pain management goals "Resident does have physical s/s (signs and symptoms) of pain with ROM. Goal of pain free may not be realistic as resident has painful contractures. Resident is medicated prior to ROM. Resident does not present with s/s of pain at any other times. Will discuss with MD on other options or increase in pain medication prior to ROM. Will change goal to: resident will allow staff to perform ROM to bilateral upper extremities and continue to monitor." Licensed Practical Nurse (LPN)-F was interviewed on 8/10/11 at 12:15 p.m. and she stated the [MEDICATION NAME] helps R19 "minimally" and the PROM is always painful. She did state she lets the NA's know when she gives R19 the pain medication which is usually after breakfast. She was unaware NA-H, NA-I and NA-G stated they perform the PROM during morning personal cares prior to the 8:00 a.m. breakfast. A review of the August Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Clinical Coordinator Registered Nurse (RN)-B was interviewed on 8/10/11 at 1:30 p.m. She was unable to find any indication that R19's physician had ever been notified of R19 ongoing pain with range of motion after her 7/13/11 pain assessment. RN-B was again interviewed on 8/11/11 at 8:45 a.m. She stated there was no pain flow sheet or ongoing monitoring of R19's pain other than the 7/13/11 pain assessment. R19's primary care physician was contacted via telephone on 8/11/11 at 12:08 p.m., he stated he has a number of different residents. Any information about R19 would be in "his progress notes." R19's physician progress notes [REDACTED]. The patient is using rolled gauze to prevent secondary pressure ulcers." The physician did not identify any concerns about pain management in this progress note. Even though the facility identified R19 grimaced, gasped and pulled away routinely while PROM was performed and the Roxinal helped "minimally," the facility did not implement adequate interventions to help decrease or eliminate R19's pain of her bilateral hand contractures while PROM was performed. Pain medications were implemented on 12/1/10, but there has been no adjustments to these medications since 12/1/10. Also, the facility did not inform the physician about R19 pain with PROM, even though the 7/13/11 assessment, identified this would be completed. As a result of this, R19 was experiencing pain with PROM in her bilateral hands which resulted in actual harm. A facility policy entitled, "Pain Scale/FLACC/ and intervention" dated October 2010 included, "If pain management interventions are not effective for resident, floor nurse will update physician as needed to consult for additional pain management interventions. Decision for update will be on case by case basis, and at the discretion of the licensed nurse assigned to care for resident. " "If pain is noted to be a consistent pattern for resident, nursing staff will update Clinical Coordinator to assist in pain evaluation and treatment." Wheel chair positioning: Resident 19 (R19) was not positioned properly in her wheelchair. R19 [DIAGNOSES REDACTED]. Her quarterly MDS (Minimum Data Set) dated 7/19/11 indicated she had short and long term memory deficits, was rarely or never understood, did not refuse cares, had physical behaviors daily, required extensive assistance for all ADL's (activities of daily living) but did not ambulate and required total assistance with hygiene. Further, it identified her with functional limitations of range of motion in both upper extremities and utilizing a wheel chair. R19's care plan dated 7/21/11 included "Alteration in mobility related to ms (muscular skeletal), cognitive impairment ....unable to ambulate ..." The care plans interventions included: " Resident frequently leans back in wheelchair which leads to improper positioning due to using feet to propel wheelchair. Encourage proper position as needed, but don't push if resisting." R19's "mobility/wheelchair assessment" dated 7/13/11 included "Resident presents with appropriate wheelchair positioning at this time. Resident presents with history of forward sliding. Resident is able to reposition self when this occurs. Resident presents with ability to propel self in her wheelchair and does not currently utilized foot pedals ...does present with ability of feet to reach ground ...." R19 was observed on 8/8/11 at 2:50 p.m. sitting in a high backed wheel chair. R19's toes were touching the floor, but her legs were sloped downwards and her buttocks slightly forward with her pants pulled up in her groin. She was again observed in the dining room at 5:03 p.m. with her knees much lower than 90 degrees with her hips, her pants remained pulled up in her groin. At 6:28 p.m. she was observed in a commons area scooted back in her chair straight, knees lower than hips and feet were not touching the floor, she was able to swing her feet back and forth without touching the floor. She was again observed on 8/9/11 at 8:15 a.m. in the dining room without R19 feet touching the floor. At 11:40 a.m. she was observed with both feet on the floor, but her buttocks were forward in the chair and knees lower than hips. On 8/10/11 she was observed at 6:45 a.m. up in her wheelchair, her buttocks back in chair and her feet not touching the floor. At 8:40 a.m. R19 had slid forward in her wheelchair so her feet were touching the floor, but her pants were again pulled up in her groin area. At 10:40 a.m. she was observed propelling her wheel chair with her toes, scooting forward in chair. At 12:11 p.m. she was observed in the dining room with tips of her toes only touching the floor and slid forward in the wheelchair. The Clinical Coordinator Registered Nurse (RN)-B was interviewed on 8/10/11 at 8:40 a.m. and stated R19 might have a different cushion in her wheel chair for comfort and to prevent pressure ulcers. This may have caused her to be up too high so can not propel her wheelchair. RN-B would refer her to therapy for a seating evaluation. A "rehabilitation screening form" dated 8/10/11 included "Res (resident) is sitting too high, feet do not touch the ground properly. Reminder-she needs a pressure cushion in place." The Occupational Therapist (OT)-E was interviewed on 8/10/11 at 10:58 a.m. she stated it would be too hard for R19 to propel her wheelchair if her knees were not at 90 degrees. When she evaluated R19, her feet were off the floor and she was swinging them. OT-E would check into getting her a lower chair. Resident 63 (R63) was observed sitting in a rocking style geri-chair but was not positioned properly. R63 had [DIAGNOSES REDACTED]. Her quarterly Minimum Data Set ((MDS) dated [DATE] indicated she had short and long term memory deficits; required extensive to total assistance with all ADL's (activities of daily living), did not ambulate and could feed herself with set up/cueing. R63's plan of care dated 6/30/11 indicated she had a "specialized wheel chair, a rocking wheel chair," and "wheel chair for mobility, 1 assist to propel." Further it indicated "resident presents with [DIAGNOSES REDACTED]." R63 was observed on 8/8/11 from 4:55 p.m. to 5:52 p.m. at the dining table sitting in a rocking style wheel chair. She was leaning so far to the right that her back was leaning on the right arm rest. R63 head was tipped back not being supported. R63 had fed herself independently after NA-L handed each item to R63 to eat. Licensed Practical Nurse (LPN)-E; Nursing Assistants (NA)-L and NA-M were all in the dining room during this time and no one had attempted to reposition R63 so that she would be straight in her chair with her head support. R63 was again observed for dining on 8/9/11 at 11:40 a.m.; she ate her meal sitting sideways in her chair again with back leaning against right arm rest. Her feet were hanging between the foot rests of the chair, rather than on them. R63 was observed on 8/10/11 from 6:45 a.m. to 8:35 a.m. and had been brought to the dining room for the morning meal at 8:00 a.m. Throughout this time she was sitting slightly sideways, leaning against right arm rest, she fidgeted in the chair, stretching several times throughout the meal. NA-G and NA-K had been in the dining room throughout the meal and made no attempted to reposition R63. R63 was again observed during the noon meal at 12:12 p.m. sitting to the right with her right foot hanging between the foot pedals. On 8/11/11 at 8:00 a.m. R63 was sitting sideways in chair sleeping, her head was tilted back over the right arm rest. Occupational Therapist (OT)-E was interviewed on 8/10/11 along with Certified Occupational Therapy Assistant (COTA)-D at 11:10 a.m. They stated they had fit her for a high back wheel chair at one time, but R63 kept tipping it back so when a rocking style chair became available they gave it to her. They had not evaluated R63 in the rocking style chair for proper positioning or fit. Clinical Coordinator Registered Nurse (RN)-B was interviewed on 8/10/11 at 1:35 p.m. she was unaware R63 sat sideways in the rocking style chair. A "Mobility/wheelchair Assessment" dated 6/25/11 included "Resident does present with upright posture. Resident does present with occasional forward sliding and right lateral leaning. This is easily corrected with repositioning." Even though R63 sat sideways leaning to the right while in her wheel chair, causing feet to hang between the foot rests and did not provided head support. R63 was not assessed for proper wheelchair positioning in the chair provided to her and was not repositioned in her chair even though staff were observed in the dining room assisting R63 and other residents. Resident 59 (R59) was not properly positioned in her wheelchair. R59 had [DIAGNOSES REDACTED]. R59 quarterly minimum data set ((MDS) dated [DATE] identified R59 as being severely cognitively impaired, needed total assistance of staff for transfers and locomotion on and off the unit. The MDS also indicated R59 had functional impairment on her upper and lower extremities. R59 current plan of care dated 7/6/11 indicated R59 has "alteration in mobility related to cognitive impairment...inability to make purposeful movements of self or extremities without total assistance from staff... Resident presents with partial range of motion (ROM) to the upper and lower extremities..Resident does have kyphotic with inability to hyper-extend neck or extend back" the care plan also indicated R59 has a Rocking wheelchair to aid in positioning per therapy recommendations, needs assist of one to propel wheelchair to areas on unit and off the unit. On 4/14/10 R59 was screened by occupational therapy (OT) for a nursing concern of "resident legs do not stay on wheelchair pedals and often dangle. Could we get different pedals or something to support back of calves." Occupational therapy responded "foot pedals adjusted by physical therapy (PT) for better fit. Please inform PT if more changes are necessary." R59 has not been seen or referred to therapies since 4/14/2010. On 7/5/11 R59 had a mobility assessment completed and indicated "resident presents with appropriate wheelchair positioning at this time. Resident presents with use of a geri-chair and presents reclined with straight positioning. Resident does present with occasional right lateral leaning, staff intervene with pillow support as needed." R59 was observed on 8/8/11 at 4:14p.m. in the Library sitting with her husband in a "Rocking" wheelchair. R59 left foot was dangling between both footrests. R59's husband stated her feet are always off her foot rests and thought they could place a board under her feet so they stop slipping off. On 8/8/11 at 7:23 p.m., R59 was observed again in the library leaning to the right with her head was completely off her head rest. No pillows were noted in her wheelchair to support her from leaning. On 8/9/11 at 8:23a.m., R59 was observed in the dining room, R59 left foot was off her foot rest but her right foot was on R86's footrest who was sitting next to her at the table. Several minutes later R59 was wheeled out of the dinning room by Nursing Assistant (NA)-A. Both of R59 feet were dangling between the footrests. During interview on 8/9/11 at 7:51p.m., with NA-A stated that R59's feet keep coming off her footrests and we attempt to reposition them but they keep coming off. NA-A also stated that in the past month she has noted that R59 has been leaning to the right. R59 was observed on 8/10/11 at 11:35a.m., with the certified occupational therapist assistant (COTA)-A while seated in her wheelchair. The COTA-A stated R59 feet were not positioned properly on the footrests and her upper body has a slight lean towards the right. COTA-A stated this may be due to her hoyer sling and how staff get her up in her wheelchair. The calf supports R59 has on her wheelchair do not work since they don't touch the back of her legs. COTA-A will have nursing get an order so R59 can be screened for wheelchair positioning.