Every finding on record at Benedictine Living Community Mother of Mercy

Based on interview and document review, the facility failed to ensure a placed peripheral insertion central catheter (PICC) line was monitored and recorded in the medical record to ensure continuity of care in accordance with current standards of care for 1 of 1 resident (R1) reviewed for PICC care. R1 had a PICC line in place for over 30 days at the care center but the measurement from insertion to catheter hub (used to determine if the line is migrating) was not consistently tracked or recorded. This could delay identification of line migration or contribute to associated complications (i.e., thrombosis, vessel perforation, catheter dysfunction). Findings include: R1's (Hospital) Discharge summary, dated [DATE], identified R1 was hospitalized for over two weeks due to acute bacterial endocarditis (infection of the heart lining or valves) and urinary tract infection (UTI). R1 was seen by infectious disease (ID) and antibiotics were implemented. A PICC was placed and R1 was discharged to the care center with orders for intravenous (IV) antibiotics every 24 hours continuous. The summary included directions to change R1's PICC dressing weekly and as needed (PRN). R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 had intact cognition and demonstrated no delusional thinking. The MDS recorded R1 received intravenous (IV) medications while a resident at the care center. R1's progress note, dated 6/19/26, identified R1's PICC line dressing had been changed using sterile technique. The insertion site to catheter hub was listed as 4 centimeters (cm), and no signs of infection were identified. R1's care plan, last reviewed 7/9/26, identified R1's actual or potential problems along with goals for care and interventions to meet the goals. R1 had potential for an alteration in mood due to admission to the nursing home and using IV antibiotics. However, the care plan lacked any specific problem statement or what, if any, interventions were being completed specifically for the PICC line.R1's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated 6/2026, identified multiple orders to change R1's PICC line dressing every 7 days using sterile technique. When reviewed, the data identified the dressing was changed on 6/17/26, 6/19/26, 6/26/26, and 6/27/26. R1's MAR and TAR, dated 7/2026, identified again multiple orders to change R1's PICC line dressing. When reviewed, the data identified the dressing had been changed on 7/10/26. The PICC was then removed on 7/14/26. However, both months' MAR/TAR lacked any evidence of the PICC catheter being measured from insertion site to catheter hub to ensure no migration of the line. Further, R1's medical record was reviewed and lacked evidence any further measurement of the IV catheter had been completed after 6/19/26.On 7/15/26 at 10:39 a.m., R1 was interviewed in his room. R1 admitted to the care center from the hospital where he was found to have a bug in his urine (UTI) and needed IV antibiotics. R1 stated he had a PICC in place in his left inner arm until just yesterday (7/14) when it was removed. R1 stated he thought the nurses did a weekly dressing change on the device but was unsure if or how often the nurses were measuring the length of the catheter. R1 expressed no major concerns with his care at the center. When interviewed on 7/15/26 at 10:54 a.m., registered nurse (RN)-A stated they were currently assigned to R1 and had worked with him in the past. RN-A explained R1 had a PICC line in place until recently when it was removed, and they had never completed the dressing change on him specifically while he was at the care center. RN-A stated they were aware of the process to do a PICC line dressing change and explained it aloud. The process included removing the old dressing and then measuring the catheter length from insertion site to hub, and that measurement should be recorded in a progress note for tracking. RN-A stated nobody from the care center had ever told or directed them to do that, however, it was rather just what I am used to doing. RN-A stated the center had recently changed medical record (EMR) systems and the old system would have a prompt to record the length when recording the dressing change each time, however, the new system didn't have that, so it was up to the nurse to write it in the progress notes. When interviewed on 7/15/26 at 11:05 a.m., licensed practical nurse (LPN)-A stated they had worked with residents' using PICC lines before, and explained the RN usually changed the first PICC dressing after admission then the LPN could do it. LPN-A stated they check the site visually with each flush but if they had to do a dressing change, they'd have the unit manager help them and guide them doing it. LPN-A stated a catheter measurement should be done with each dressing change and recorded in the progress notes adding, You should. On 7/15/26 at 12:14 p.m., the director of nursing (DON) was interviewed and verified they had reviewed R1's medical record. DON explained that the prior EMR system (PointClickCare) had more data recorded to show the tracking and measurement of the PICC catheter. The new EMR was a bit different and didn't have an auto-populate question to be answered like the prior system did. R1's TAR had directions to monitor the PICC site but nothing specific to record the measurement for tracking purposes. DON stated that ideally a separate order in the MAR/TAR would be in place for the nurses to reference the last line measurement at quick glance and so it was easily accessible information. DON also acknowledged the lack of PICC information on the formal care plan and stated it should be included there. DON stated having the measurement tracked and information readily accessible was good to have so nurses can be aware if the line was migrating with each dressing change. It should be recorded in the progress notes under this new EMR system, and the facility was still trying to review multiple processes, like PICC line measurement, which had not directly converted when the EMR changed. The facility Central Venous Catheter Care and Dressing Changes policy, dated 7/9/26, identified general guidelines for line care including, 6. Measure the length of the external central vascular access device with each dressing change or if catheter dislodgement is suspected. Compare with the length documented at insertion. The policy outlined documentation to be completed which included the date/time of dressing change, location and objective description of the insertion site, and any complications. However, it did not outline how the external catheter measurement would be tracked or kept readily accessible for staff references.

Based on interview and document review the facility failed to implement interventions to reduce the risk of falls for 1 of 3 residents (R1) reviewed for accidents and supervision. R1's care plan directed bed mobility with assistance of two staff. On 5/4/26, R1 fell out of her bed while one staff provided cares without assistance. This resulted in R1's left hip fracture, pain, and fear. The immediate jeopardy (IJ) began on 5/4/26 when nursing assistant (NA)-A provided cares, including bed mobility, without the assistance of another staff person. R1's care plan, dated 4/28/26, directed assistance of two staff for bed mobility. The IJ was removed on 5/5/26 when the facility provided education to staff regarding following care plans, audits to monitor staff performance and policy review. The administrator, director of nursing (DON) and regional nurse were notified of the IJ on 6/4/26 at 1:10 p.m. The immediate jeopardy was corrected on 5/5/26 and the deficient practice corrected on 5/15/26 prior to the start of the survey and was therefore Past Noncompliance.Findings Include: R1's quarterly minimum data set (MDS), dated [DATE], indicated R1 had diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) due to cerebrovascular disease (condition affecting blood flow)affecting her non-dominant left side, cerebral infarction (stroke), anxiety and depression. She was dependent on staff for rolling side to side in bed. R1's care plan, dated 4/28/26, directed assistance from two staff for bed mobility. The care sheet, dated 5/4/26, directed assistance from two staff for bed mobility. A progress note, dated 5/4/26, indicated R1 had a fall at 7:45 p.m. when she was rolled to her side and fell out of bed. A progress note, dated 5/5/26, indicated R1 had a lot of pain related to her fall the prior evening and was receiving Tylenol for pain. A progress note, dated 5/6/26, indicated R1 was refusing to get out of bed due to severe pain rated 10/10. A progress note, dated 5/7/26, indicated R1 was sent to the hospital and had a left hip fracture. She did not have surgical repair and returned to the facility. R1 was prescribed Tramadol (an opioid pain medication) and Tylenol for pain. A hospital note dated 5/7/26, indicated R1 had a fall from bed and was diagnosed with a fracture of the left hip. An x-ray result, dated 5/7/26, indicated R1 had an acute sub capital femoral neck fracture (hip fracture where the break occurs at the junction below the femoral head and main neck of the thigh bone). A progress note, dated 5/7/26, indicated R1 returned to the facility with a diagnosis of left hip fracture. A progress note, dated 5/8/26, indicated R1's physician wrote an order for Tramadol for pain. A progress note, dated 5/8/26, indicated R1 remained in bed and rated pain of 5 -6/10. A progress note, dated 5/9/26, indicated R1 still had a lot of pain. A progress note, dated 5/11/25, indicated R1 reported pain 6-7/10 and remained in bed. A progress note, dated 5/13/26, indicated R1 complained of pain 5-7/10 and remained in bed. A progress note, dated 5/14/26, indicated R1 continued to report pain to left hip of 6-7/10 and stayed in bed. A provider note dated 5/27/26, indicated R1 had persistent left hip pain, worse with movement/rolling, at times severe. Tylenol provided minimal relief. During an interview on 6/3/26, at 12:30 p.m., R1 stated there was supposed to be two staff to provide her cares in bed. She stated NA-A assisted her to her right side; she fell between the bed and the wall, hitting the radiator, and landed on her belly. She was in a lot of pain and it was very, very traumatic. Since the incident she felt afraid during cares. She went to the hospital for an x-ray and learned her left hip was fractured. During an observation on 6/3/26, at 12:46 p.m., two staff transferred R1 from the commode to her bed via full body mechanical lift. R1 was observed to reach toward her left hip, wince, and say ouch. During an interview on 6/3/26, at 2:47 p.m., licensed practical nurse (LPN)-A stated R1 should have two staff to assist with all bed mobility. She stated she was not aware NA-A needed assistance on 5/4/26 until after the fall occurred. During an interview on 6/3/26, at 3:05 p.m., NA-A stated she was aware R1 required two staff for bed mobility but she proceeded without the assistance of another staff on 5/4/26 with R1 due to staff being occupied at the time and R1 becoming frustrated due to waiting. She stated she assisted R1 to roll onto her right side. R1's left leg went over too far and R1 fell to the floor from her bed, landing face down on the floor. She stated this could have been prevented. During an interview on 6/4/26, at 8:50 a.m., the director of nursing (DON) stated R1's bed mobility should have been performed as assist of two, as the care sheet directed and R1's fall from bed was preventable. During an interview on 6/4/26, at 9:04 a.m., the primary care physician (PCP) for R1 stated R1 has been less mobile than prior to her fall on 5/4/26. He stated pain was managed with Tylenol and Tramadol. The fall was likely preventable since the staff member was not following the care plan at the time of the incident. The past noncompliance immediate jeopardy began on 5/4/26. The immediate jeopardy was removed on 5/5/26 and the deficient practice corrected by 5/15/26 after the facility implemented a systemic plan that included the following actions:-Re-educated all staff on assistance with activities of daily living (ADL) and following care plans.-Reviewed the ADL policy and the fall policy.-Tested the staff to ensure understanding of the re-education.-The Quality Assessment Performance Improvement (QAPI) committee met and reviewed the incident on 5/27/26.-Reviewed and evaluated resident care plans for interventions to reduce the risk of falls.

Based on observation, interview and document review the facility failed to develop the care plan for 1 of 3 residents (R3) reviewed for care plans when R3's care sheet directed staff to transfer with a full body mechanical lift, but the staff transferred her with a mechanical standing lift.Findings include: During an observation on 6/3/26, at 3:40 p.m., nursing assistant (NA)-B and NA-C transferred R3 from her electric wheelchair to the tub chair using a mechanical standing lift. R3's care plan, dated 4/24/26, directed transfer status as assist of two, using a full body mechanical lift and large sling. R3's annual minimum data set (MDS), dated [DATE], indicated she had diagnoses of heart failure, critical illness polyneuropathy (debilitating complication of severe systemic disease in the intensive care unit) and muscle weakness. The care sheet for R3, dated 5/21/26, directed assistance of two with a full body mechanical lift and large sling. During an interview on 6/3/26, at 3:27 p.m., R3 stated the staff transferred her with a full body mechanical lift each morning and used the mechanical stand assist lift throughout the day. During an interview on 6/3/26, at 4:14 p.m., licensed practical nurse (LPN)-B stated care provided must follow the care plan. She stated R3 should always be transferred with the full body mechanical lift. During an interview on 6/3/26, at 4:19 p.m., NA-B stated the care sheets indicated care required for each resident. She stated the sheet directed to use a full body mechanical lift, but she was a stand assist lift as well. She stated it was important to know the care required for the residents' safety. During an interview on 6/3/26, at 4:26 p.m., NA-C stated the care sheets provided the information needed to care for each resident. The sheet says full body mechanical lift but that's not actually what it is. She started R3 transferred with the full body mechanical lift in the morning, and the stand assist lift the rest of the day. She stated the care sheets should be followed for people so they don't get hurt and they get the care they need. During an interview on 6/3/26, at 4:32 p.m., nurse manager (NM)-A stated care is directed through care sheets and R3 required assistance of two staff and a full body mechanical lift for all transfers at all times. During an interview on 6/3/26, at 4:48 p.m., the director of nursing (DON) stated the NA's should use the care sheets as they reflect the care plan and R3 should have been transferred with the full body mechanical lift at all times. During an interview on 6/4/26, at 8:50 a.m., the DON stated there was a recent change in record systems and it appeared there was a transcription error on the care sheets. The facility policy Comprehensive Assessment and Care Planning policy, dated 2017, directed all person-centered care plan interventions will be implemented by qualified personnel. Interventions may be communicated through the electronic health record, resident profile, assignment sheets, and/or verbal communication.

Based on observation, interview and document review, the facility failed to assess the independent use of an electric lift chair for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm when R1 attempted to self-transfer from the lift chair, fell, hit her head, and sustained a hematoma (a collection of blood in the tissues after an injury) and laceration of the forehead, sent to the emergency department (ED) for further evaluation, wound care, pain control, and received four stitches to the right forehead. R1 sustained an additional fall from a wheel chair, hit her head, sustained a hematoma to right lateral proximal (point of attachment) hip, sent to ED for further evaluation and pain control. The facility implemented corrective action, so the deficient practice was issued at past non-compliance.Findings include:R1's admission Minimum Data Set (MDS) dated [DATE], identified she was admitted on [DATE], from the hospital. R1 had difficulty heading in some environments (when a person spoke softly or setting was noisy), impaired vision (able to see large print, but not regular print in newspapers/books), severely impaired cognition with thinking and/or memory, and no behaviors. R1 was dependent upon staff for toileting, lower body dressing, substantial /maximal assistance needed with shower/bathes, personal hygiene, repositioning in bed, sit to stand, all transfers, and used manual wheelchair for mobility. She was always continent of bowel and bladder. Medical history included renal insufficiency, arthritis, osteoporosis (causes bones to become weak and brittle), macular degeneration (blurred or reduced central vision), and encephalopathy (is a change in how your brain function and/or dysfunction and can appear as confusion, disorientation, memory loss, personality changes, agitation or irritability, and can be temporary or permanent), and kyphosis (excessive rounding of the upper back and can cause back pain and stiffness).R1's provider orders from 4/15/26, through 4/21/26, identified: -Order date 4/15/26, Physical therapy (PT) and Occupational therapy (OT) to evaluate and treat. -Order date: 4/21/26, OT to perform cognitive testing. -Order date 4/21/26, Acetaminophen oral tablet 500 milligrams (mg). Give 1000 mg by mouth three times a day related to wedge compression fracture (a spinal fracture where the front of the vertebra collapses while the back stays intact, giving the bones a wedge or triangular shape with weakened bones from osteoporosis). -Order date 4/21/26, Acetaminophen oral tablet 500 mg. Give 500 mg by mouth every 24 hours as needed for pain.R1's Fall risk evaluation completed on 4/15/26 at 12:33 p.m., identified short term memory loss. Poor safety awareness (i.e. self-transfers, forget to lock wheelchair brakes), moderately impaired vision, unable to ambulate to chair, required assist of two to transfer, and had three or more health conditions and medications that would increase her risk factors. R1 was identified as a risk for falls. Nursing interventions/approaches: discussed with family/R1 importance and reminders to use call light prior to any transfers and help with activities of daily living (ADLs) to prevent falls.R1's care plan dated 4/28/26, identified:-R1 was deemed vulnerable due to risk for falls, history of falls, cognitive deficits, and poor impulsive control, and required assist with ADLs. Staff were expected to encourage resident/responsible part to address questions/concerns to staff and interdisciplinary team to discuss resident's status, well-being, and observe and document changes in mood, behavior, and routine. Date initiated 4/14/26. -R1 had potential for injury related osteoarthritis and wedge compression fracture to spine. He was ok to have power lift chair in room but without power function intact. Therapy deemed inappropriate to have full power function. Daughter gave verbal consent 4/20/26. Date initiated: 4/20/26.-R1 had self-care deficit related to encephalopathy (a broad term for any disease, damage, or malfunction of the brain that alters its function or structure and occurs when the brain is deprived of oxygen, exposed to toxins, or affected by an underlying illness and causes a change in mental state and/or behavior). Staff were instructed to transfer with physical assist of two staff and EZ aide and stay with her while on toilet. Date initiated 4/15/26. -R1 had potential for injury related to impaired mobility, incontinence of bowel and bladder, impaired cognition, antipsychotic/antianxiety/narcotic/diuretic medications, impaired vision/hearing, history of falls, fluctuating blood sugars, and limited range of motion (ROM). She was impulsive as evidenced by (AEB) did not consistently ask for help or use call light, poor safety awareness, self-transferred, self-toileted, and refused to wear shoes with transfers. Staff were directed to keep call light within reach and encourage to use it, lift recliner use not recommended, deemed inappropriate to have power lift chair function, remained in neutral position, and continue to monitor appropriateness. Date initiated: 4/15/26. Date revised 4/20/26. - R1 had impaired cognitive function related to difficulty making decisions, disorientation, forgetfulness, impaired decision making, periods of confusion, and unable to make safe decisions. Staff were directed to explain cares/procedures prior to beginning it in simple and few words, provide cues, reorientation, and reminders as needed. Date initiated 4/14/26. -R1 had a communication problem related to a hearing deficit and impaired (very poor) vision related to macular degeneration. Staff were directed to anticipate needs, allow adequate time to respond, and use simple, brief, consistent words/cues, and keep call light within reach. Date initiated 4/15/26.R1's care sheet dated 5/6/26, identified Ambulation: not at this time, pivot only, assist of one with two wheeled walker and gait belt for transfers. Had glasses, very poor vision, hard of hearing, and stay with resident while on toilet. Lift recliner not recommended. Do not prop feet in recliner, on chair/stool, place in be to elevate feet.R1's progress notes from 4/15/26 through 5/5/26, identified:-4/15/26 at 10:49 a.m., BIMS completed and showed cognitive impairment. Patient Health Questionnaire (PHQ9) (assessment for mental health/depression) completed with score of 3/30 (0-4 minimal depression/mood concerns). She stated had difficulty concentrating at times. -4/15/26 at 11:06 a.m., R1 was admitted to facility from a local hospital for weakness and encephalopathy, not ambulating at this time, transferred with assist of two, pivots with walker and gait belt. R1 was able to demonstrate success in using the bed remote, television remote, and call light to make needs known. She was oriented to person only and noted weakness to bilateral upper extremities upon admission. -4/15/26, and 4/16/26, Orientated to person only, impaired short-term memory, decision making, and confused. -4/17/26, at 11:51 a.m., Alert and orientated to situation only, impaired short-term memory/decision making, and confused. Pleasant but anxious mood. -4/17/26 at 11:56 a.m., Reported by daughter she became more confused and restless in the evenings. She refused medications last evening. Was reported she was up multiple times during the night, in and out of her recliner, bed, and unable to get comfortable. -4/18/26 at 9:03 a.m., Orientated to situation only, impaired decision-making ability/short term memory, and confused. She required assist of staff and EZ stand with transfers. Changes in mood, behaviors noted, and some anxiety. -4/18/26 at 3:41p.m., R1 was found on floor laying on right side beside recliner with legs and arms curled. Injuries: open skin tear to superior area of right temporal region with moderate to severe bleeding. Severe pain noted to right temporal area, she was unable to place numerical value of pain, increased with touch. Open area cleansed with normal saline (NS), active bleeding contained after application of 4 x 4 gauze sponge dressing applied. Stretch gauze wrapped around injury and secured with surgical tape. Provider and daughter notified. Non emergent emergency medical services (EMS) notified for transfer. -4/19/26 at 9:26 a.m., Fall follow-up (FU): laceration with stitches noted above right eyebrow, clean, dry and intact with no signs of bleeding or infection. Denied pain. She was lethargic but arousable. Monitored closely for safety at least every 30 minutes while in her room. -4/19/26 at 7:38 p.m., R1 remained pleasantly confused throughout shift. -4/20/26 at 9:26 a.m., Orientated to situation only, impaired short-term memory and decision-making ability, and confused. Unsteady gait, impaired balance and weakness, required supervision. Self-transfer resulted in a fall on 4/18/26. -4/20/26 at 1:31p.m., Writer called and updated daughter. Power cord taken out of R1's room due to PT and OT noted increased confusion. Daughter stated ok to have recliner remain in her room without power cord intact. -4/21/26 at 8:51 p.m., IDT reviewed fall on 4/20/26. Noted she had used a power lift chair at home prior to admission. She had a power lift chair in place and the surface she sat on prior to attempting to self-transfer. She used non-skid footwear, and her left knee gave out, sent to hospital, had laceration sutured, and no fractures were identified. R1 was noted to have increased confusion and decreased cognitive impairment during PT session today. Therapy and nursing decided R1 was not to have full function of the power to lift chair at this time. Writer removed power cord and updated daughter. No, as needed (PRN) medication use within 24 hours of fall and no acute changes in resident's condition prior to the fall. -4/21/26 at 9:15 p.m., New order from Nurse Practitioner (NP): Occupational therapy (OT) perform St. Louis University Mental Status (SLUMS) (a cognitive assessment tool designed to screen for signs of cognitive impairment in older adults, including various types of dementia, like Alzheimer's disease) for cognitive testing. -4/26/26 at 1:15 a.m., R1 anxious throughout shift, reported difficulty falling asleep and frequently activating her call light. -4/26/26 at 2:30 a.m., Writer followed up with continued anxiety and repeated call light use. Was determined R1 wanted her clothing to be placed back on. -4/27/26 at 10:11 a.m., Provider noted increased insomnia and anxiety concerns in the evenings/night. -4/27/26 at 7:59 p.m., New order Trazadone 25 milligrams (mg) by mouth at bedtime related to insomnia -4/28/26 at 9:56 a.m., Changes to mood and behavior noted. Lethargic due to little to no sleep. -5/1/26 at 1:35 a.m., R1 observed to be anxious during routine rounding. Refused to return to bed. Placed R1 in wheelchair and positioned her at nursing station at 1:00 a.m. and appeared calmer. Sent message to provider requested evaluation for possible anxiety medication. -5/1/26 at 12: 13 p.m., New orders: Hydroxyzine (antihistamine primarily used to treat short-term anxiety) 25 mg every 6 hours PRN times 14 days for anxiety and increased Trazadone to 50 mg every HS. -5/2/26 at 12:52 p.m., Changes in mood/behavior noted, lethargic due to poor sleep. -5/3/26 at 5:30 a.m., R1 went to sleep at about 10:15 p.m. and appeared to sleep through most of the night. -5/5/26 at 11:14 a.m., R1 complained of upper left thigh pain 10/10, holding/guarding it while tearful. Left extremity if more swollen with 2+ edema and when tried to extend it she quickly reacted in pain. Updated provider. -5/5/26 at 10:21 p.m., R1 returned from local hospital ED via ambulance. No evidence of bone injury or intracranial hemorrhage. Instructions: ice thigh, acetaminophen, and rest. -5/6/26 at 9:39 a.m., IDT reviewed fall and interviewed floor nurse that was present at time of fall. R1 was noted to have feet elevated in room due to her cognitive decline she may have attempted to use bedside tray table to assist with standing. New intervention: lay resident in bed to elevate feet versus using a stationary item and leaving in wheelchair. Physical therapy (PT) visits dated 4/15/27, through 5/8/26, identified:-4/15/26 at 5:30 p.m., PT Evaluation and Plan of Treatment identified: referral for PT was made due to recent hospital stay for acute encephalopathy and increased confusion. R1's prior living environment: she lived at home with others and reported she slept on the couch, lifting her legs into bed was difficult. R1's fall risk assessment identified that she felt unsteady when standing, walking, and afraid of falling. She had a fall 4/2025, with a fracture of the left pelvis and a fall 5/19/25, sustained first lumbar (the first bone at the top of the back) compression (vertebra in the spine collapses due to trauma, weakened bone density, or osteoporosis) fracture. R1 required skilled therapy to address lower extremity core strength, transfers, and ambulation, improve balance, and decrease risk for falls. Without skilled therapy R1 was at greater risk for falls, resulting in injury or hospitalization.-4/17/26, R1 was pleasant and cooperative. She reported pain and weakness in left lower extremity (LLE). -4/20/26, Nursing reported R1 fell out of her lift chair this morning and bumped her head. Good participation and motivation for transfers, exercises, balance and gait training. -4/21/26, R1 required a prolonged knee extension stretch due to tight hamstrings. She required frequent cueing and rest breaks throughout the session due to fatigue. -4/22/26, Good participation and motivation with transfers, exercise, balance, and gait training. She required rest breaks due to fatigue. -4/23/26, Required step by step extensive direction for mobility. -4/24/26, R1 started to have heavy eyelids and required cues for keeping eyes open and awake. Attempted gait training ambulation with FWW put unable to awaken. -4/30/26, R1 had limited strength and weakness in her bilaterally lower extremities (BLE) and limited knee extension left greater than right. -5/1/26, R1 was able to ambulate with two wheeled walker 8 feet and 15 feet contact guide assistance (CGA) (the caregiver must keep continuous, hands-on physical contact with the patient, usually on their gait belt or back, to provide physical support, maintain balance, and assist with coordination if they stumble). Complained of some left thigh pain followed by wheelchair at a slow pace with shuffling steps. -5/6/24, Attended care conference. R1 had a recent fall, likely due to self-transferring, went to ER, no fractures. -5/7/26, R1 was drowsy and did not sleep well last night. She had increased pain in her lower right extremity (RLE) due to recent fall. Staff nurse confirmed she had a large hematoma on right lateral thigh. R1 complained of increased pain, took small steps, and was very cautious due to fall. Tylenol given and bio freeze applied to right thigh for pain prior to therapy session with relief. -5/8/26, R1 reported right thigh pain where hematoma was, restricted movement, and unable to provide a pain scale number. OT visits from 4/16/26, through 5/7/26, identified:-4/16/26, OT Evaluation and Plan of Treatment, identified R1 was alert however oriented to person only and increased confusion noted from her baseline. She was able to follow directions with simple cueing. Stand pivot transfer (SPT) wheelchair to toilet with front wheeled walker (FWW) she required moderate assist of one to stand and cues for sequencing. Dependent on clothing management and peri cares. Barriers likely to impact discharge to next level: exacerbation of cognitive impairment. Patient characteristics that may impact treatment: lacked capacity for chronic disease management. R1 had a fall history in the past year with an injury: sacral fracture and lumbar compression fractures. She felt unsteady when standing and worried about falling. Lacked insight into condition and risk factors. Multiple medical conditions/history, and multiple medications. Followed one step directions usually with cues/prompts. Decision making ability for routine activities was severely impaired. Problem solving new situations, dependent. Memory: dependent. Safety awareness: lacked awareness/impaired. Upper extremity strength impaired bilaterally. Self-care function score 2 (score 0 to 12; 12 being the highest function). She required substantial/maximal assistance with toilet transfers. -4/16/26, R1 was alert and oriented to person only, increased confusion noted from her baseline and followed directions with simple cueing. Barrier impacting treatment: mental status. Required treatment modifications to overcome barriers: required maximum cues for sequencing tasks and orientation.-4/17/26, R1 required verbal and tactile cues/input throughout session to stay awake, alert, and for correct sequencing. -4/20/26 at 11:29 a.m., R1 was generally restless lying in bed upon arrival. Assisted to bathroom with moderate assist with maximum cues, and gait belt. She was somewhat limited by low vision and confusion. Changes identified: R1 required maximum cues for sequencing tasks, in combination with orientation times person only, and prompted concerns with use of power lift chair. Recommendations at this time was removal of power lift option and utilized adjustable angle bed for periods of rest versus power lift chair. Due to her short stature, her feet need to be elevated or else they will dangle risking sliding forward from chair. Collaborated with director of nursing (DON) and provided written communication of recommendations. -4/21/26, R1 participated with verbal and tactile cues for directions and placement possibly due to eyesight. -4/22/26, improved ADL engagement, able to ambulate 10 steps to toilet with maximum cues and rests/breaks due to fatigue. -4/23/26, R1 was pleasantly confused and willing to participate. R1 was administered SLUMS, identified a score of 4/30, and indicated dementia. [NAME] Cognitive Scale (ACL) (a standard measure of cognitive functioning) with a score of 3.6 (scores between 3.0 and 3.8 meant a person required someone to look after them and help with ADLs). It was recommended 24-hour supervision was provided and remove access to dangerous objects. -4/24/26, Worked to progress from EZ aid with two person assist to pivot transfers with FWW. Required step by step cues for technique with transfers. Recommendation: one assist with EZ aid transfers. -4/27/26, R1 required several rest periods due to maximum fatigue and frequent cueing.-5/2/26, R1 required cues to turn feet and process of completing stand pivot transfer (SPT). -5/4/26, R1 assisted to gym in wheelchair, falling asleep, attempted to arouse several minutes without success. Unable to complete OT due to sleepiness and decreased alertness when woken up. -5/5/26, R1 alert today and required extra time to process directives. -5/5/26, R1 had fall self-transferring yesterday, sent to emergency room (ER) for imaging, no fracture. Applied elevating footrests due to complaints of right/shortened hamstring/calve was tight due to increased sitting with knees at 90 degrees. -5/7/26, R1 trialed a lightweight manual wheelchair with low seat to the floor and was able to reach floor with feet to propel herself while in wheelchair. Facility 5-day report submitted on 4/24/26 at 3:04 p.m., identified R1 was placed in power lift recliner chair after lunch in full reclined position. She attempted to stand up and her leg gave out. She fell, hit her head, and cried out for help. Nursing assistance entered R1's room found a large pool of blood and recliner in a fully reclined position. The call light was found on the same side as the recliner R1 had fallen from, within reach. Licensed practical nurse (LPN) attempted to slow the bleeding, applied pressure, ice, while she called EMS. R1 required evaluation in ER and received four sutures. Clinical manager, registered nurse (RN) felt that R1 was appropriate to have the full power function at the time of admission, but the assessment was omitted during the admission process. Maintenance director (MD) was interviewed and noted the power lift chairs are standard items provided in resident rooms at time of admission. The morning after the fall RN completed the adaptive equipment assessment and deemed R1 as appropriate and updated care plan. That afternoon therapy was working with resident deemed her inappropriate due to level of cognition at the time of the assessment being completed. This report (allegation) was not verified as R1 had a power lift chair at home and the care plan was being followed at the time of the fall.R1's ED provider notes dated 4/18/26 at 3:54 p.m., identified: Chief complaint fall injury. She presented the ED via EMS from nursing home memory care unit for further evaluation of a head injury after a fall. Just shortly prior to arrival she attempted to get up out of her chair without assistance when she stated her left leg gave out causing her to fall to the ground. She did not lose consciousness. She had a right sided headache near the area of injury and bleeding was controlled. No changes in vision or hearing. Physical exam identified a frail elderly female with a laceration. Through secondary assessment a hematoma (a collection of blood trapped underneath the skin due to a blow to the head) to the right forehead was identified. Ofirmev (acetaminophen) 1 gram (g) administered via intravenously (IV) for pain and NS 0.9% 500 milligrams (ml) IV for dry mucus membranes. Family felt like her confusion might have been a little bit worse today than usual. The following tests were ordered: chest and pelvic x-rays (unchanged no acute findings), computed tomography (CT) (imagining that used x-ray techniques to create detailed images of the body) of the head/cervical/lumbar spine/thoracic (no acute abnormalities found), and urinalysis (negative results), and urine culture. Forehead laceration was repaired with four sutures (see separate procedure note). History suggests mechanical cause of the fall. discharged in stable condition back to nursing home via EMS.R1's right forehead laceration repair document dated 4/18/26 at 6:47 p.m., identified laceration length 2.5 centimeters (cm), anesthesia lidocaine topical application and local infiltration (Lidocaine 1% with epinephrine) 1 ml subcutaneously (SQ) were administered. Laceration was irrigated with normal saline and four nylon sutures and three steri strip were used to repair the site. Antibiotic ointment and non- adherent dressing were applied. Estimated blood loss 1 ml.R1's Physical Device Evaluation dated 4/20/26 at 10:16 a.m., identified device being assessed, power lift recliner. Current applicable medical conditions: cognitive deficit and arthritis. R1's specific medical symptoms that required use of device: [R1] used lift power recliner for limited mobility and elevate legs when sitting. This device was a therapeutic intervention to achieve proper body position, balance or alignment: yes. The resident's level of independence with device: [R1] was being assessed by therapy for independence with device and assisted by staff to transfer. This device was not for bed mobility. By checking the box (box checked), as the nurse, you attest to reviewing the risks and benefits with the resident/representative. Verbal consent was given by R1's daughter upon admission. The care plan addressed this device and the need to review the use of this device: yes.Skin Evaluation dated 4/22/26, identified new skin impairment: -Right face temple wound bruising 5 centimeters (cm) x 3.5 cm). -Other: right face temple wound 3 cm. Steri strips dry and intact. No signs and symptoms of infection noted.R1's SLUMS examination dated 4/22/26, identified a score of 4/30 (scoring: 25 -30 normal, 20 to 26 mild neurocognitive disorder, and 1 to 20 Dementia).Rehabilitation Communication document dated 4/20/26, identified: Subject: [R1]. Comments/Recommendations: Discontinue use of powerlift chair controls at this time due to cognitive decline and variability from her baseline. Recommending patient rest in adjustable bed to reduce fall risk. Contact Rehab Department with questions/concernsFacility incident report dated 5/5/26 at 2:23 p.m., identified resident hollering out, staff walked in with resident lying on her side with head towards door, beside table between her legs, unable to move due to hollering in pain. She complained of pain in back and legs. R1 had an unwitnessed fall and complained of head and back excruciating pain. Contributing factors: wet floor, furniture, gait imbalance, impaired memory, drowsy, confused, lethargic, weak, ambulation status: assist of two with device, agitation, restlessness, sleepiness, complained of dizziness/lightheadedness and headache. Sent to ED for evaluation.R1's ED provider notes dated 5/5/26 at 3:54 p.m. identified EMS reported she fell while transferring from her chair today, sustained injury with obvious deformity to left hip. EMS administered 50 micrograms (mcg) of Fentanyl (a narcotic analgesic used for serve pain) in route. Physical exam identified swelling over right lateral proximal hip consistent with a hematoma with painful ROM. She presented with multiple complaints of pain in multiple areas without significant traumatic injury other than the right thigh hematoma. X-ray of right/left femur, pelvis, and spine, no definite acute fracture and soft tissue swelling lateral to the proximal femur. MRI would be recommended to further evaluate nondisplaced femoral neck fracture give R1's degree of osteopenia and if unable to bear weight. CT of head was negative for hemorrhage. Normal Saline (sodium chloride 0.9%) was administered 1000 mg via IV (hydration), acetaminophen 650 mg, and tramadol 50 mg (pain management). Clinical impression and primary diagnosis: Confusion related to dehydration and constipation. discharged back to facility at 8:57 p.m.During an observation on 5/7/26 at 1:25 p.m. nursing assistant (NA)-A knocked on the door, entered her room and stated he came to assist her to the bathroom. NA-A sanitized hands placed a transfer belt around her waist and pulled it snug. He pushed her wheelchair into the bathroom, removed her footrests from wheelchair, pushed her up to the toilet, and instructed her to grab a hold of the bar, and counted to three. NA-A grabbed ahold of the transfer belt with his right hand and assisted her up to stand. R1 grunted when she stood up and stated not sure I could do this, unable to move her feet, pivoted, pants were pulled down by NA-A, and lowered herself down onto the toilet. R1 pointed at a large bruise located on her right outer thigh, color was black and blue with a small amount of yellow discoloration approximately six inches in diameter. NA-A assisted her up to stand, completed peri cares, and R1 pivoted until she was in front of the WC. NA-A pulled up her pants, lowered herself down onto the wheelchair and pushed her back over to the side of her bed. NA-A sanitized hands and exited the room. R1's recliner was placed approximately three feet away from the bed, no power cord was visible, the remote was located on the floor still attached to the chair. During an interview on 5/7/26 at 1:13 p.m., R1 sat in a low wheelchair in the doorway of her room, fully dressed with gripper socks and her feet on the footrests. She had a fading bruise located underneath her right eye and healed laceration located on right side of her forehead. R1 pushed the wheels on her wheelchair with her hands and backed herself up into her room. R1 stated she had fallen two times since she arrived at this facility, one time from the recliner and another time just recently She stated unsure how she fell, received a big bump and it hurt, pointed to under her right eye, pointed to left thigh, and the right upper outer thigh. R1 stated she did not sit in the recliner anymore was afraid of falling again, scared her when she hit her head quite hard, was bleeding and was taken to the hospital.During an interview on 5/7/26 at 2:27 p.m., NA-E stated R1 was forgetful and confused, would not have been safe to use a lift chair remote, unable to remember how to use it, tended to self-transfer, placed her at a high risk for falls.During an interview on 5/7/26 at 2:43 p.m., LPN-B stated R1 had impaired cognition and had not changed since admission. The admitting nurse and therapy would have been expected to assess R1 upon admission for safe use of the lift recliner prior to use. We do not know if the resident understands what the buttons are used for and could have placed them at risk for injuries/falls. R1 would have not been safe to use the remote to operate the lift chair safely due to impaired cognition. The remote should have been removed until assessment was completed. R1 self-transferred and not safe alone in room with the lift recliner electric remote or manual and placed her at risk for another fall/injury. The other day R1's daughter came to visit in the morning and asked if R1's feet could be elevated. The daughter placed R1's feet on a chair on top of a pillow while she sat in her wheelchair in her room and everything was fine. At 1:45 p.m. R1 was toileted, and feet placed back up on a chair in her room. At about 2:10 p.m. we heard someone hollering out and found R1 laying on the floor. LPN-B entered R1's room and noted the chair her feet were placed on was pushed across the floor and she was scared. R1 stated after fall she may have moved that chair, possibly grabbed the bedside table and fell onto the floor. R1 substantiated a large hematoma on the right outer thigh. Prior to this fall she complained about left leg could have been due to previous left hip replacement surgery. LPN-B stated she sent R1 to ER via ambulance, diagnosed her with a hematoma to right thigh and no fractures.During an interview on 5/8/26 at 8:40 a.m., family member (FM) stated R1's cognition/memory was poor when admitted to the facility from the hospital. Her memory varied from one day to the next and some days it was better than others. There was an electric lift chair in her room when admitted . R1 had an electric lift chair at home she used but someone was there with her most of the time with her. R1 was kind of out of it and needed cues to push the buttons. FM had bought a call light button off Amazon, and R1 used it most of the time, but there were times she forgot. R1 used the control for the lift chair, to use the call light, pushed the lift chair all the way up and FM thought she was going to fall out of it and another time she forgot to use call light again, was almost standing up by herself without assistance, really concerned her. FM stated she did not share that information with staff and was unaware if an assessment was completed on R1 upon admission regarding safe use of lift chair. FM stated she assumed therapy would determine if R1 would be safe in the lift recliner with a remote. Follow- up interview on 5/12/26 at 8:53 a.m., FM stated she did not remember being asked if she felt comfortable and safe with R1 using the remote to her lift recliner at the facility upon admission or after that. Risks and benefits were not explained for use of the lift chair independently. FM stated on 5/5/26, R1 was scared to be placed into the recliner after her fall. FM stated around 9:00 a.m. she placed R1's feet on a chair while she sat in her wheelchair about two feet away from her bed, the bedside table was placed between her and the bed, and call placed light on table or pinned to her. FM informed nurse working prior to leaving the facility that morning how she had left her mother in her room and nurse verbally acknowledged what she had said. After lunch that same day she received a phone call and informed R1 had fallen from her wheelchair and was currently on the floor. FM immediately went to facility, only lived a short distance away, arrived before paramedics got there. R1laid on the floor with head behind the door to her room and legs in front of the recliner. R1 was in pain crying and screaming. Staff had informed her the bedside table had been tipped over and laid over R1's legs when they found her. FM pointed out a bruise on R1's face more noticeable on the left outer forehead, purple in color approximately two inches by 1/2 inch, and stated she hit her head during this fall. R1 was sent into ER via ambulance. During an interview on 5/8/26 at 10:45 a.m., with maintenance director (MD) stated the lift chair recliners located in resident rooms have a power system to r

Based on observation, interview, and record review, the facility failed to ensure food items were properly stored, labeled, dated and discarded properly. Additionally, the facility failed to ensure 1 refrigerator in the kitchen and 2 of 3-unit refrigerators were adequately monitored for temperature and food quality to reduce the risk of complications or illness. These findings had the potential to affect all 56 residents within the care center. Findings include: During initial walk-through observation and interview of the kitchen on 2/23/25 at 12:52 p.m., with licensed dietician (LD) the following was observed:In the walk-in cooler: an opened gallon sized plastic bag of hard salami lacked an open/expiration date/label;A white Styrofoam to-go container containing 5 squares of cheese cake lacked an open/expiration date/label;an open container of cole slaw approximately 1.5 quart sized lacked an open/expiration date/label;a silver rectangular dish approximately 12x6x8 inches containing fresh green beans was uncovered and lacked an open/expiration date/label;a silver rectangular dish approximately 12x6x8 inches containing sliced, cooked potatoes with a cream sauce lacked an open/expiration date/label;an open container of three bean salad approximately 1.5 quart sized lacked an open/expiration date/label. LD could not identify when the items were opened, placed in the cooler or when they were expired.In the walk-in freezer the following was observed:2 open cases of sweet potato fries were stored on the floor;1 open case of chicken and dumplings was stored on the floor;on the middle shelf on the right back corner 2 chicken patties in an open plastic bag were noted. The bag lacked an open/expiration date;a white uncovered container approximately 1.5 quarts of pureed berries was located on the top left shelf just inside the door.LD picked up the boxes from the floor, closed them and put them on the shelf and stated they were not supposed to be on the floor. LD could not identify when the chicken patties or puree were opened/expired.On a portable metal rack located just outside and around the corner of the walk-in cooler:a package of hamburger buns with quarter sized patches of mold visible through the package was noted.An open package of King's Hawaiian rolls with 3 rolls remaining lacked an open/expired date/label.an open package of hot dog buns with 10 buns remaining in the package had the date 2/9 written on the outside in black marker.LD could not identify if that was the open date or the expired date. LD could not identify how long bread was good after opening but later provided an answer of 4 days.Two tall single door freezer/refrigerator units located by entrance to dish room had a sheet of paper taped to the door titled February 2026 with numbered space to record freezer/refrigerator temps. The door on the left was a freezer, and the temp log was missing recorded temps for 2/12-2/21; the door on the right was a refrigerator and was missing all temp information for the month of February.The unit refrigerator temperature logs were reviewed from November 2025 through February 2026 for 3-unit refrigerators. The logs indicated the following:First floor unit refrigerator missing the following dates: November 2025-11/3, 11/10, 11/16,11/17,11/21,11/28; December 2025-12/1, 12/3, 12/9,12/10,12/11,12/18, 12/26 and 12/29; January 2026-1/12,1/16, 1/23; February 2026- 2/2, 2/6, 2/9, 2/16, and 2/19Second floor unit refrigerator missing the following dates: November 2025-11/1, 11/6, 11/7, 11/12, 11/14, 11/15, 11/16, 11/17, 11/19, 11/20, 11/23, 11/24, 11/26,11/29; December 2025- 12/6, 12/7, 12/8, 12/18, 12/20, 12/23, and 12/31; January 2026- 1/3, 1/6, 1/7, 1/9, 1/14, 1/18, 1/20, 1/24, 1/22, 1/28-1/31; February 2026- 2/3, 2/4, 2/5, 2/11, 2/12, 2/14, 2/15, 2/17, 2/18, and 2/19Third floor unit refrigerator missing the following dates: November 2025- 11/1, 11/2, 11/12, 11/15, 11/16, 11/18, 11/20, 11/28, 11/29 and 11/30; December 2025-12/8-14, 12/17, 12/19, 12/20, 12/22, 12/25-12/31; January 2026- 1/4, 1/5, 1/6, 1/8, 1/10, 1/11, 1/12, 1/18, 1/19, 1/23, 1/24, and 1/25; February 2026- 2/4, 2/7-2/12, 2/14, 2/14-2/18, 2/21, and 2/22During interview on 2/25/26 at 10:16 a.m., culinary services manager (CDM) stated all opened food containers, or any leftovers should be labeled with a use by date and or an open date. CDM acknowledged there was food in the walk-in cooler that lacked a label with these dates. CDM stated he expected all opened containers or leftovers to be labeled when they were put in the cooler. CDM stated this was important to reduce the potential of food born illnesses from undated food. CDM confirmed bread products were good for 4 days after opening and stated the bread bag should be dated when opened and any undated bread should be immediately thrown away. CDM went on to say when frozen foods were received, they were immediately placed in the freezer on the shelves and should never be stored on the floor. Additionally, CDM stated leftover food or open packages in the freezer would also need use by date or an open date. CDM confirmed the temp logs in the kitchen were missing many temperatures for the month of February and stated it was his expectation to record all refrigerator, and freezer temps every day both in the kitchen and in the resident units. CDM stated it was important to record the temps to know a refrigerator was cooling appropriately and to avoid spoiled food that could potentially be served to residents. Facility policy title Food Storage-Perishable with a last review date of August 2019 indicated all food items must be stored on shelving or drainage racks that allow the entire floor to be completely cleaned. The policy also indicated all prepared food stored in the refrigerator units should be in covered, seamless containers or otherwise suitably protected with used by date.

Based on interview and record review the facility failed to ensure Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) was given to residents whose Medicare part A services were ending for 2 of 3 residents (R73, R48) who were reviewed for NOMNC and ABN notices. Findings include:R73's admission Minimum Data Set, dated [DATE] indicated R73 admitted to facility 8/7/25, was cognitively intact and had the following diagnoses: Chronic respiratory failure, urinary tract infection, and high blood pressure.Review of R73's medical record indicated R73's last covered day of Medicare part A service was 9/8/25 and was discharged [DATE]. R73 did not require an ABN but did require a NOMNC, however the medical record lacked evidence of this.R48 admission Minimum Data Set, dated [DATE] indicated R48 was admitted to the facility on [DATE], was moderately cognitively impaired and had the following diagnoses: wedge compression fracture of vertebrae, cancer, coronary artery disease, and arthritis.Review of R48's medical record indicated R48's last covered day of Medicare part A services was 1/29/26 and he stayed in the facility. An ABN should have been issued, however the medical record lacked evidence of this. A NOMNC was issued to R48's daughter on 1/27/26.During interview on 2/26/26 at 12:44 p.m., social worker designee (SW) stated a NOMNC should be given to residents to notify potential non-covered Medicare services. SW stated an ABN should be given when a resident stays in the facility but no longer qualifies for Medicare Part A services. SW confirmed R73 had not received the NOMNC and R48 did not receive an ABN. SW stated it was the responsibility of SW to issue these notices in a timely manner so residents can decide about their care and their covered or non-covered benefits.During interview on 2/26/26 at 1:02 p.m., Administrator (Admin) stated any resident who was admitted under Medicare part A should be reviewed for ABN and NOMNC notices when services were to end. Admin confirmed neither R73 nor R48 had received the proper notices. Admin stated she expected staff to communicate with one another so the notices were issued prior to the end of the services covered. Admin stated it was primarily the responsibility of SW to issue the notices, but they may also be issued by therapy or nursing staff. Admin stated it was important to issue the notices prior to services ending so residents can make informed decisions about their care and potentially explore other options.Facility policy titled Medicare Beneficiary Notice with a last review date of 12/20/24 indicated the following: If the Medicare team determines there is no longer a need for daily skilled care under Part A, B or Medicare Advantage they must issue the Notice of Medicare Non-Coverage no later than 2 days before termination of all skilled services. When the beneficiary meets the technical requirements but does not need daily skilled services, part A services are ending and the beneficiary has days remaining and the beneficiary will remain in the facility or when the need for daily skilled service is no longer necessary, but they will receive Part B therapy services, issue the Skilled Nursing Facility Advanced Beneficiary Notice.

Based on record review, and interview, the facility failed to conduct care conferences for 1 of 2 residents (R27) reviewed for care planning. Findings include:R27's admission Minimum Data Set (MDS) dated [DATE], indicated R27 was admitted to the facility on [DATE], was cognitively intact and had the following diagnoses: hypertension (high blood pressure), arthritis, malnutrition, anxiety, bipolar disorder, and schizophrenia.During screening on 2/23/26 at 1:02 p.m., R27 stated they had no recollection of any care conferences being offered or conducted since they had been admitted to the facility.R27's medical record lacked any evidence a care conference was ever offered or conducted.On 2/26/25 at 0935 a.m., the social worker (SW) stated care conferences were expected to be completed with quarterly, and annual MDS or if there was a change in condition. The SW confirmed no care conference was ever offered or conducted for R27.On 2/26/26 at 1:12 p.m., the DON confirmed no care conference had been offered or conducted for R27, and the importance of conducting them to include the whole team in R27's care, review the chart, get the families involved and gain outside input for the resident and including the information in their care plan.The facility's Comprehensive Assessments and Care Planning Policy undated, indicated review of MDS assessments will be done every 3 months and as appropriate in preparation for Care planning.

Based on record review and interview the facility failed to ensure medications were available for administration per physician order for 1 of 1 resident (R64) reviewed for pharmaceutical services.Findings include:R64's undated face sheet, indicated R64 was admitted on [DATE] and was discharged on 6/5/26, and had the following diagnoses: acute respiratory failure( lungs are unable to move gases efficiently), diabetes (DM), vitamin D deficiency, hyperlipidemia (HLD) (high levels of fat in the blood stream), dementia, neurocognitive disorder with Lewy bodies(ND w/L) (a form of dementia), heart failure (the heart is pumping efficiently) (HF), asthma, ischemic cardiomyopathy (IC) (enlargement of the heart) benign prostatic hyperplasia (BPH) (enlarged prostrate), and a coronary angioplasty implant and graft (procedure use to open a blocked artery and keep it patent).The Order Recap report dated 2/25/26, included but is not limited to the following orders which were active when R64 was in residence at the facility:Amlodipine Besylate 10mg tablet- give 10 mg by mouth (po) in the morning for (HF)Empagliflozin 10mg tablet-give 10 mg po in the morning for ICMetformin 500mg tablet- give 500mg po twice a day (BID) for DMMirabegron 25 mg tablet- give 25 mg po in the morning for BPHRosuvastatin 40mg tablet-give 40mg po in the morning for HLDSertraline 75 mg tablet- give 75mg po in the morning for ND w/LTamsulosin 0.4mg tablet- give 0.4mg po at bedtime for BPHTorsemide 40mg tablet- give 40 mg po BID for (HF)R64's medication administration record (MAR) printed 2/25/26 at 11:10 a.m., indicated medication administrations in May 2025. The MAR indicated R64 did not receive the above listed medications from 5/23/25 through 5/28/25.R64's notice of Medicare Non-coverage dated 5/13/25, stated R64's insurance coverage would end on 5/14/25.R64's medical record also included the following progress notes during that time period:On 5/21/25 at 1:28 p.m., a progress note stated veterans affairs (VA) had been notified R64 no longer had any medical coverage with medications, and a list of medications was sent to the VA to get refills on medications.On 5/26/25 at 10:02 p.m., the progress note indicated the provider had been updated the resident had not been taking metformin and tamsulosin due to no supply.On 5/27/25 at 9:17a.m., the progress note indicated the facility had been in contact with the VA to get R64's medications refilled. The VA required more information and was awaiting a call back to fill the medications.On 5/28/25 at 8:27 a.m., the progress note stated guardian pharmacy had faxed over a list of medications with the cost of the medications.On 2/25/26 at 10:38 a.m., the registered nurse manager (RN)-A stated if they were to run out of medications they would reach out to the pharmacy, the provider, and wait for orders. The pharmacy would let them know if there were any concerns with insurance. RN-A stated they remembered R64 had come off of skilled care and no longer had coverage for medications. RN-A stated they had reached out to R64's legal guardian, who informed the facility R64 had Veteran affairs (VA) insurance. RN-A reached out to the VA and requested orders from the VA provider. Guardian pharmacy had also sent a list of cost for the medications to be filled. RN-A stated this whole process took a while to resolve with insurance, providers, and waiting for the medications to be approved through the VA.On 2/26/26 at 09:31 a.m., the consultant pharmacist (CP) stated they have an electronic portal they use to check the status of medication coverage, however, this system was not automatic, and issues or changes to coverage would only show up if they were looking at the medication for coverage, it does not automatically update them to changes. The CP stated for R64, in May of 2025, they had issued their medications on 5/5/25, some for a 17-day supply and some for a 25-day supply. The CP stated guardian pharmacy had faxed the facility on 5/23/25 when they became aware they needed to have signed orders from the provider to fill the medications. CP stated the only other communication they could locate was guardian pharmacy had sent over a list of cost for the medications on 5/28/25.On 2/26/26 at 11:57 the director of nursing (DON) and the Business Coordinator (BC) stated they had reviewed R64's insurance coverage and they had given notice of those changes which would occur on 5/14/25, but felt R64 had coverage during their whole stay, however were unable to clarify, if that was the case why the VA needed to be involved. The DON stated they had not been overseeing the building at that time and could not clarify exactly what had occurred.On 2/26/26 at 11:09 a.m., the administrator and the social worker (SW) confirmed there was no process in place at the time of the occurrence to notify the pharmacy of any coverage change for R64 on 5/14/25 and confirmed R64 went without their medications from 5/23/25-5/28/25. The administrator's expectation was the coverage changes would have been provided to the pharmacy to prevent the resident from going without his medications.On 2/26/26 at 1:12 p.m., the DON and the regional director of clinical services (REG) stated their expectation, when there was a change in insurance coverage, was it would be discussed during their interdisciplinary team meeting, then passed onto the RN manager to update the pharmacy. The DON confirmed R64 went without their medications from 5/23/25-5/28/25 and it was outside of their expectations. The DON stated the importance of providing residents with their prescribed medications because something could go wrong clinically.The facility policy Administering Medications copyright 2020, indicated medications are to be administered in accordance with the orders, and within their prescribed time.

Based on observation, interview and document review, the facility failed to properly sanitize a shared glucometer after use on 1 of 1 residents (R71), reviewed for blood sugar monitoring. Findings include:R71's quarterly minimum data set (MDS) dated [DATE], included R71 was cognitively intact. R71 had diagnosis of diabetes and anxiety disorder. R71's order summary report dated 2/26/26, included R71 received finger stick blood glucose checks every shift. During observation on 2/25/26 at 8:35 a.m., nursing student (NS)-A checked R71's blood glucose using a glucometer from the medication cart. NS-A used a [NAME] brand germicidal surface wipe to wipe down the glucometer for approximately 20 seconds and returned the glucometer to the drawer. During interview on 2/25/26 at 8:35 a.m., NS-A confirmed she had not allowed the proper contact time for disinfecting the glucometer. NS-A read the label on the germicidal wipes used to clean the glucometer to confirmed to allow surfaces to remain wet for 2 minutes. During interview on 2/25/26 at 9:44 a.m., nursing instructor (NI) stated she supervises all nursing students while they complete nursing tasks. NI confirmed she was supervising NS-A while she checked R71's blood glucose level. NI confirmed NS-A had not allowed proper contact time when disinfecting the glucometer after use. During interview on 2/25/26 at 9:54 a.m., infection preventionist (IP) stated all residents should have their own personal glucometers, however the facility did have a glucometer kept on the medication cart for a backup. IP stated the glucometer should have been disinfected according to the manufacturer's instructions. User manual for Assure Platinum blood glucose monito system including cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. The wipe should be used according to the product label. During interview on 2/26/26 at 11:31 a.m., director of nursing (DON) confirmed that all shared glucometers should be cleaned and disinfected between residents. All staff are educated upon hire, yearly and as needed. DON expected all nursing students to be supervised at all times when performing nursing tasks and should follow all facility policies. The [NAME] stated this was important to prevent the spread of blood borne illnesses. Facility stated they would follow user manual for disinfecting.

Based on interview and document review, the facility failed to monitor and implement interventions for heart failure for 2 of 2 residents (R33, R43) reviewed. This resulted in actual harm to R33 who was re-hospitalized on exacerbation of heart failure. Findings include: R33's significant change Minimum Data Set (MDS) dated [DATE], indicated R33's diagnoses included dementia, chronic diastolic congestive heart failure (CHF), diabetes, phantom limb pain (from below knee amputation), and cellulitis (bacterial infection) of left lower limb. R33's cardiology clinic note dated 2/28/24, indicated R33 presented with her family member (FM)-B for a cardiology provider visit on 2/26/24. R33 had CHF with noted congestion in lungs and reported occasional shortness of breath and lower extremity edema. The cardiologist ordered furosemide (Lasix - a diuretic) 20mg daily as needed (PRN) for lung congestion and/or lower extremity (LE) edema related to CHF. However, R33's record lacked evidence a nurse had contacted the cardiologist to obtain more specific parameters for the administration of a PRN diuretic. Additionally, R33's record lacked evidence measures were initiated to monitor R33 for lung congestion and LE edema. During interview on 12/20/24 at 4:18 p.m., director of nursing (DON) stated the nurse was expected to update R33's care plan to ensure R33 was monitored for lung congestion and edema to trigger the nurse to administer the PRN Lasix as ordered. Additionally, because R33 had a diagnosis of CHF, the nurse was expected to ensure R33 was monitored for edema and weight gain to prevent CHF exacerbation. R33's progress note, dated 3/13/24 at 12:35 a.m., indicated R33 had left lower extremity (LLE) 2+ edema (moderate pitting), and the area below and behind the knee was taut. However, R33's record lacked evidence the nurse administered Lasix 20mg daily PRN for LE edema as ordered. Additionally, the record lacked evidence the provider had been notified. R33's weight summary, printed 12/18/24, indicated R33's weight was 199 pounds (lb) on 3/15/24, and 205 lb on 3/22/24, which indicated a weight gain of 6 pounds in a week. However, R33's record lacked evidence R33 had been assessed for lung congestion and/or LE edema to determine if PRN Lasix was indicated. Additionally, the record lacked evidence the provider had been notified of the weight gain. R33's pharmacist (PharmD) recommendations to providers dated 3/21/24, indicated an order for 'PRN Lasix 20mg to give for lung congestion or edema' had vague parameters that could lead to inconsistencies in administration. PharmD indicated the PRN Lasix had not been used since ordered on 2/26/24, and suggested the provider consider either discontinuing the PRN Lasix; or if the provider wished to continue the PRN Lasix, the order needed to include specific parameters for when to administer (e.g. Give for 5-lb weight gain in a week, 3-lb weight gain in a day). Subsequently, on 3/26/24, R33's primary care provider (PCP) placed a check mark in the agree box and signed the document, but the provider had not indicated if the PRN Lasix was to be discontinued or if it was to be continued with specific parameters. Further, R33's record lacked evidence the nurse had contacted the PCP and/or the cardiologist to clarify the PharmD recommendations. During interview on 12/20/24 at 4:18 p.m., DON acknowledged the provider's response to the PharmD recommendations dated 3/21/24 was unclear. DON verified PRN Lasix order had been discontinued by the nurse on 3/26/24. DON stated the PRN Lasix should not have been discontinued and the nurse should have contacted the provider to clarify the order. R33's medication administration record (MAR) dated March 2024, indicated R33's furosemide [Lasix] 20mg daily PRN for lung congestion and/or lower extremity edema was discontinued on 3/26/24. However, R33's chart lacked evidence of a signed physician order to discontinue Lasix 20mg daily PRN. R33's progress note dated 3/31/24 at 10:15 p.m., indicated R33's LLE had 3+ edema (deep pitting) and cracks on foot where swelling increased pressure. However, the nurse indicated will update provider on next doctor rounds. R33's record indicated the provider saw R33 on 4/4/24. R33's progress note dated late entry 4/12/24 at 10:05 a.m., indicated upon skin assessment resident found to have a few blood blisters on left shin. Current interventions included inspect skin PRN with cares, nurse to observe skin weekly, lift/do not slide resident, use assistive devices, and observe for signs/symptoms of infection and updated provider PRN. New intervention of lotion body daily PRN. However, R33's record lacked evidence the provider had been notified. R33's progress note dated 4/12/24 at 4:30 p.m., indicated two small blood blisters and two small opened blisters were found on R33's left calf, and occasional blistering of skin was related to edema. However, R33's record lacked evidence the provider had been notified. R33's progress note dated 4/16/24 at 3:30 p.m., indicated R33 was seen by the provider during rounds, and ordered increased bedtime (HS) dose of gabapentin (for pain), increase HS dose of Lyrica (for pain), and continue to monitor blood blisters on LLE. R33's weight summary for April 2024 through August 2024, indicated R33's weights were obtained 4/5/24, 4/12/24, 4/19/24, 5/10/24, 5/17/24, 6/1/24, 6/7/24, 6/14/24, 6/28/24, 7/5/24, 7/12/24, 7/19/24, 8/2/24, 8/9/24, and 8/26/24, with no significant weight gain noted. R33's order history, printed 12/18/24, indicated R33 received wound care for a right lower extremity (RLE) ulcer from 4/23/24 through 6/19/24, and an order for a wound clinic referral was placed 4/30/24. R33's progress note dated 8/12/24 at 5:21 a.m., indicated R33's 2nd, 3rd, and 4th toes on left foot were very red, not warm to touch, swollen, and R33 denied pain. However, R33's record lacked evidence the provider had been notified. R33's progress note dated 8/13/24 at 12:37 a.m., indicated R33 was noted to have bled through her sock and all R33's toes on left foot were swollen with dark purple discoloration extending to the top of R33's foot, with redness across top of foot. R33's 1st toe was largely swollen with the 2nd toe resting tightly against it. R33's 3rd toe was swollen to the point of skin breaking open on top of toe with peeling skin and resident cannot feel toes and cannot detect pain. The nurse indicated the unit manager was notified and R33 was added to provider rounds later that day. R33's progress note dated 8/13/24 at 12:58 a.m., indicated R33 had a 3cm x 3cm wound on the front of left calf and noted to have thick, purulent drainage (pus). R33's progress note dated 8/13/24 at 12:56 p.m., indicated R33 was seen by the provider for her LLE. The provider ordered Keflex (antibiotic) 500mg three times a day (TID) for 7 days, MRI for left foot to check for deeper infection, and labs drawn 8/15/24. R33's progress note dated 8/14/24 at 12:52 p.m., indicated R33 was transferred to the ED for increased redness and swelling in left foot. A subsequent progress note dated 8/14/24 at 6:20 p.m., indicated R33 was admitted to the hospital. R33's Hospital Orders Discharge Report dated 8/20/24, indicated R33 was hospitalized from 8/14/24 to 8/20/24 for multiple open wounds of LLE. The discharge orders instructed facility staff to call the physician for weight gain of 3 pounds or more over night or gain 5 pounds in a week. However, R33's record lacked evidence the weight monitoring order had been transcribed and implemented. During interview on 12/20/24 at 4:18 p.m., DON verified the 8/20/24 hospital discharge order to monitor R33's weight had not been completed. DON stated the nurse was expected to identify and follow the hospital weight monitoring order. R33's primary care provider (PCP) progress notes, dated 8/22/24, indicated R33 had a history of right partial lower extremity amputation below the knee in 2020 due to osteomyelitis, and had recently been hospitalized due to a wound on R33's left lower leg. R33's progress note dated 9/3/24 at 11:57 a.m., indicated R33 was seen on provider rounds and weights x1 week was ordered. However, R33's record lacked evidence the nurse clarified the order to obtain specific parameters for when to notify the physician. R33's subsequent PCP progress notes for 9/3/24, dated 9/4/24 at 8:10 a.m., indicated nursing staff were to monitor R33's weights 3 times weekly, and if weight increased the PCP would look at as needed dosing of diuretics or reinstitution of lower dose of Jardiance. However, R33's record lacked evidence the nurse identified the conflicting weight orders of weights x1 week and weights 3 times weekly, and R33's record lacked evidence the conflicting weight orders were clarified with the provider. During interview on 12/20/24 at 4:18 p.m., DON acknowledged the PCP progress notes for 9/3/24 directing the nursing staff to monitor weights 3 times weekly had not been completed. DON stated the nurse was expected to review the PCP progress notes and to have entered the order to monitor R33's weights 3 times weekly. Additionally, DON stated the nurse was expected to contact the provider to clarify any order discrepancies and ensure specific parameters were in place. R33's order history indicated an order for daily weights one time a day for 1 week was started 9/4/24 and ended on 9/11/24. R33's weight summary indicated the following weights for 9/4/24 through 9/11/24: 9/4 - no documented weight 9/5 - 201 lb 9/6 - no documented weight 9/7 - 200 lb 9/8 - 199 lb 9/9 - no documented weight 9/10 - 206.5 lb - gain of 7.5 lb in 2 days 9/11 - no documented weight However, R33's record lacked evidence the provider was notified of the weight gain of 7.5 lb from 9/8/24 through 9/10/24. Additionally, the record lacked evidence the nurse notified the provider, weights had not been obtained on 9/4/24, 9/6/24, 9/9/24, and 9/11/24. R33's record lacked evidence the order for weights 3 times weekly, as indicated on the 9/3/24 PCP progress notes were entered and implemented. R33's weight summary indicated R33's weight was 204 lb on 9/23/24, and 209 lb on 9/27/24, which indicated a weight gain of 5 lb in 4 days. R33's record lacked evidence the provider had been notified. R33's weight summary indicated R33's weight was 206 lb on 10/22/24, and 213 lb on 10/24/24, which indicated a weight gain of 7 lb in 2 days. R33's record lacked evidence the provider had been notified. R33's weight summary indicated R33's weight was 206.5 lb on 10/28/24, and 209.5 lb on 10/29/24, which indicated a weight gain of 3 lb in 1 day. R33's record lacked evidence the provider had been notified. R33's PCP progress notes, dated 10/30/24, indicated R33's continued to have LLE sores that were secondary to chronic edema of the area. R33's PCP progress notes, dated 11/5/24, indicated R33's active diagnoses included CHF, and cellulitis of the LLE. The PCP progress note further indicated, Cardiology has recommended Lasix 20 mg if she experiences a 2-pound weight gain. However, R33's record lacked evidence a nurse notified the provider that R33 did not have a current order for Lasix. R33's orthopedic visit note, dated 11/7/24, indicated the lesion at the front of R33's left leg was a result of swelling into the leg. R33's weight summary indicated R33's weight was 206.5 lb on 11/18/24, and 211 lb on 11/19/24, which indicated a weight gain of 4.5 lb in 1 day. R33's record lacked evidence the provider had been notified. During interview on 12/18/24 at 9:46 a.m., R33's family member (FM)-B stated a few weeks ago she spoke with the DON why R33 was not getting her PRN Lasix because she was concerned about the swelling in R33's legs. FM-B stated the DON told her the PRN Lasix had been discontinued on 3/26/24, and the DON later found the order had been discontinued based on a pharmacy recommendation. FM-B stated she had asked the cardiologist in February 2024 to prescribe something for R33's edema and thought R33 had been receiving the PRN Lasix since then. FM-B stated R33's family was concerned because R33 already had a leg amputated after her edema led to blisters and sores that became infected. FM-B stated she was concerned the same could happen to R33's LLE because the facility was not following physician orders. R33's Physician Fax Order, dated 12/4/24, indicated registered nurse (RN)-E requested an order for PRN Lasix as indicated on the cardiology clinic note dated 2/26/24, as R33 did not have the medication available, and family wanted it available. However, RN-E failed to provide any assessment information to support the request. On 12/5/24, R33's PCP subsequently wrote an order for Lasix 20mg daily PRN for 3 lb gain in a day or 5 lb gain in a week. During interview on 12/20/24 at 4:18 p.m., DON stated the 12/4/24 request to the provider for PRN Lasix was prompted after FM-B stated concern regarding R33's edema and asking why R33 was not receiving the PRN Lasix. DON stated after she determined the PRN Lasix had been discontinued on 3/26/24 and subsequently requested on order for PRN Lasix. Additionally, DON stated prior to FM-B bringing the concern to her, she absolutely would have expected a nurse to have identified the changes. R33's order history indicated an order for weight daily AM was started 11/28/24 and on 12/5/24, an order for Lasix 20mg every 24 hours as needed for edema; weight gain give if 3 lb gain in a day or 5 lb gain in a week was started. However, the nurse failed to ensure the weight daily AM order alerted the nurse of the specific parameters and PRN Lasix order. During interview on 12/20/24 at 4:18 p.m., DON stated the nurse was expected to have transcribed the order and/or verify the order to ensure the weight order was connected to the PRN Lasix order. R33's weight summary indicated the following weights for 12/5/24 to 12/18/24: 12/5 - 210.5 12/6 - 211 lb 12/7 - 211 lb 12/8 - 208 lb 12/9 - 212 lb 12/10 - no documented weight 12/11 - 212 lb 12/12 - 211 lb 12/13 - 211.5 lb 12/14 - 211 lb 12/15 - no documented weight 12/16 - 214.5 lb 12/17 - no documented weight 12/18 - 212 lb R33's weight summary indicated R33's weight was 208 lb on 12/8/24, and 212 lb on 12/9/24, which indicated a weight gain of 4 lb in 1 day. However, R33's MAR, dated December 2024, indicated PRN Lasix was not administered on 12/9/24 as ordered by the provider. During interview on 12/20/24 at 4:18 p.m., DON verified Lasix 20mg PRN had not been administered on 12/9/24. Additionally, DON verified R33 had a weight gain of 4 lbs in 1 day, from 12/8/24 to 12/9/24. DON stated the nurse was expected to administer the PRN Lasix because R33's weight gain met the parameters. R33's care plan, printed 12/18/24, indicated daily weight was initiated on 12/12/24. However, no information regarding the PRN Lasix was added to R33's care plan. R33's weight summary indicated R33's weight was 211 lb on 12/14/24, and 214.5 lb on 12/16/24, which indicated a weight gain of 3.5 lb in 2 days. However, R33's lacked evidence the nurse notified the provider R33's weight was not obtained on 12/15/24. During interview on 12/20/24 at 2:35 p.m., registered nurse (RN)-A verified she administered R33's medications on 12/16/24. RN-A stated R33's weight had not been taken on 12/15/24, so she looked at the weight from one week prior, and R33's weight on 12/9/24 was 212. RN-A stated she did not administer PRN Lasix to R33 on 12/16/24 because there was only a 2.5 lb gain in a week. RN-A stated the provider was not contacted for direction and the provider was not notified of the missed weight. Additionally, R33's record lacked evidence the nurse notified the provider R33's weights had not been obtained on 12/10/24 and 12/17/24. During interview on 12/20/24 at 4:18 p.m., DON stated the nurse was expected to reach out to the provider to notify weight missed and request advice. DON expected the nurse on the cart to ensure the daily weight was obtained. R33's progress note dated 12/19/24 at 12:18 a.m., indicated R33 had been admitted to the hospital telemetry unit for CHF, it was unclear if R33 had a hip fracture, but the hospital was dealing with the CHF at that time. R33's Hospital Emergency Department (ED) to Admission Notes, dated 12/19/24, indicated R33 presented to the ED on 12/18/24 with acute on chronic heart failure exacerbation, coming in for dieresis, and a fall injury. R33 was started on Lasix 40 mg intravenous (IV), with plan to increase as needed. On 12/19/24 at 8:23 a.m., FM-B stated she was with R33 in the ED on 12/18/24. In the ED, R33's LLE was really swollen, red, and R33 was unable to straighten her leg. FM-B stated R33 was given Lasix IV in the ED and R33's weight went down as a result. On 12/20/24 at 9:10 a.m., FM-B stated R33's weight was down and it was visible in R33's face, legs, and belly. FM-B stated R33 was given scheduled Lasix and would discharge from the hospital with an order for scheduled Lasix. On 12/19/24 at 12:20 p.m., the provider stated Lasix 20mg daily PRN for 3 lb gain in a day or 5 lb gain in a week was ordered for R33, and the facility was expected to obtain daily weights for such an order. R33 should have received PRN Lasix on 12/9/24 because of a one-day 4 lb increase, and the provider should have been notified. The provider expected to be notified if a daily weight was missed, and he was not aware daily weights were missed on 12/10, 12/15, and 12/17. The provider stated if the order was not followed, it could cause fluid retention leading to heart failure, shortness of breath, and possible hospitalization . Provider acknowledged R33 was currently hospitalized and stated if the PRN Lasix was administered per the specific parameters, the need for dieresis could have been avoided. On 12/19/24 at 3:01 p.m., nursing assistant (NA)-B stated R33 had LE swelling that varied in severity, they are normal, then big, then in between, and NA-B notified the nurse whenever R33's legs were bigger than the prior day. On 12/20/24 at 4:18 p.m., DON verified R33 was currently hospitalized and was admitted with diagnosis of acute exacerbation of CHF and fracture of the femur. DON acknowledged the facility failed to monitor R33's weights and administer PRN Lasix as ordered, and stated Absolutely, the need to admit for exacerbation could have been avoided. R43's quarterly minimum data set (MDS) dated [DATE] indicated R43 was admitted to facility on 8/8/23 and had the following diagnoses: acute on chronic congestive heart failure, hypertensive heart disease with heart failure, history of transient ischemic attack and cerebral infarct. The MDS further indicated R43 was cognitively intact. An order summary dated 11/20/24 indicated R43 had an order for furosemide oral tablet 20 mg twice daily related to acute on chronic congestive heart failure. The bottom of the document had a handwritten provider note indicating the following: D/C Lasix (furosemide); Bumex 1mg BID; Labs-TSH, BNP, BMP in 1.5 weeks. Weights MWF. DX: CHF. An unsigned order summary dated 12/20/24 indicated an order for Bumex 1mg tablet -give Bumex 1mg by mouth in the afternoon related to acute on chronic congestive heart failure, and Bumex 1mg tablet-give Bumex 2 mg by mouth in the morning for acute on chronic congestive heart failure. The order summary lacked a documented order for weights to be obtained on Monday, Wednesday and Friday as ordered on 11/20/24. R43's care plan with a last review date of 6/19/24 indicated a focus area of alteration in cardiac status related to diagnosis of hypertension (high pressure in the arteries that carry blood from the heart to the rest of the body), congestive heart failure (CHF) (a progressive disease that affects pumping action of the heart muscles), angina (a condition characterized by chest pain due to insufficient oxygen-rich blood reaching the heart muscle), atrial fibrillation (an irregular and often fast heartbeat) and deep vein thrombosis (a blood clot in a deep vein). Interventions included: administer oxygen as ordered; appointments with cardiology as directed; observe for signs and symptoms of CHF exacerbation including not limited to edema, shortness of breath, weight gain, adventitious lung sounds, cough, decreased oxygen saturations, weakness, increased heart rate, distended neck veins. The care plan also listed an intervention of obtaining weights as directed and update MD as ordered. Review of R43's documented weights indicated between 8/2/2024 through 8/30/24 seven out of thirteen opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Review of R43's documented weights indicated between 9/2/24 through 9/30/24 eight of thirteen opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Review of R43's documented weights indicated between 10/2/24 through 10/30/24 seven of thirteen opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Review of R43's documented weights indicated between 11/1/24 through 11/29/24 nine of thirteen opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Physician progress note dated 11/18/24 indicated R43 told provider she felt like she was gaining water weight and her legs felt tighter than usual. The note went on to indicate the R43's weight had increased from 261.5 on 11/1 to 265.5 on 11/11 to 268.5 on 11/18. The progress note confirmed R43's order to check weights MWF but were not getting done consistently. Physician progress note dated 11/24/24 indicated resident had a history of heart failure and had been seen a few times earlier in 2024 for the same issue. The note indicated R43's baseline weight was around 245 to 250 pounds, but she had been experiencing a gradual increase over the past few months. Review of R43's documented weights indicated between 12/2/24 through 12/16/24 three of seven opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Physician progress note dated 12/3/24 indicated R43 reported to the provider her weight was recorded once during week, despite being scheduled for weigh-in on Monday, Wednesday, and Friday. The provider indicated ongoing concerns and despite orders for weights 3 times weekly, nursing staff had only completed once weekly. During observation and interview on 12/16/24 at 09:57 a.m., R43 had pitting edema (swelling caused by excess fluid in the body's tissues that leaves an indentation when pressed) in both lower extremities. R43 stated she took diuretics (a medication to help move excess fluid and salt out of the body) daily and was supposed to be weighed three times weekly on Monday, Wednesday, and Friday before breakfast. R43 stated she was frequently weighed only once per week despite orders from her physician to be weighed three times. During interview on 12/20/24 at 3:15 p.m., licensed practical nurse (LPN)A stated residents with CHF should be monitored closely for weight increases as this could be a sign of fluid overload. LPN-A stated this would be completed by the certified nursing assistants (CNA) with morning cares. LPN-A went on to say she did not routinely follow up with CNAs to confirm scheduled weights were completed. During interview on 12/20/2024 at 4:11 p.m., director of nursing (DON) confirmed R43 had an order for weights three times weekly on Monday, Wednesday, and Friday and was missing documentation for more than half of scheduled weights over the past 5 months. DON stated when a physician orders scheduled weights, she expects nursing staff to follow the order, obtain the weight and if it is not completed staff should document the reason why and communicate any missed weights to the provider. DON stated this process was important for monitoring for signs/symptoms of heart failure and the purpose of the scheduled weights was to avoid an acute episode of heart failure. A policy was requested. However, not provided. 49654

Based on record review and interviews the facility failed to ensure the required staffing information was posted daily. This had the potential to affect all 57 residents residing in the facility and their visitors who may wish to view the information. Findings include: On 12/16/24 upon entrance the staff posting was observed to include liscensed staff and total hours worked. On 12/17/24 the staff posting included liscensed staff and total hours worked. Staff postings dated 11/17/24 through 12/20/24, lacked evidence of accurate postinging information as evidenced by lack of information regarding how many liscensed staff were working in the facility each day, how many hours worked, and the total hours of all liscensed staff working on the days listed above. On 12/20/24 at 2:01 p.m., the director of nursing stated the information on the staff postings was incorrect and there had been miscommunication. The information had been lost. On 12/20/24 at 2:08 p.m., the director of nursing and the HR manager (O)-F stated they would run a report through their charting system and then post the posting for Monday through Friday daily and would pre-post it for the weekend. Both the DON and O-F confirmed the information on the daily staffing sheets was incorrect and/or not there. It was not updated in person on the weekends, and they had not kept the information for the time frame requested. On 12/20/24 at 2:28 p.m., the DON stated their expectation was the staff posting to be updated and posted with correct information and was important to know how many licensed staff and residents are in the building, however did not indicate daily posting as required. The facility policy was requested and none was provided.

Based on interview and record review the facility failed to conduct and document a comprehensive facility-wide assessment which included all of the necessary components to provide adequate care and services to the residents in the facility. The deficient practice had the potential to affect all 57 residents in the facility. Findings include: During the entrance conference on 12/16/24 at 9:19 a.m., the team leader requested the facility assessment to be provided within four hours of entrance. Subsequent requests were made on 12/19/24 and 12/20/24. On 12/20/24 at 6:11 p.m., the administrator sent an email to the survey team containing the document titled Facility Assessment Tool 12-2024. Review of the entire document with an assessment date of 9/5/2024, indicated the assessment lacked important components to ensure the facility identified all the resources necessary to care for and provide services to their residents. The provided document had some sections filled out and others left blank. The missing components included but were not limited to: 1) The facility's information such as name of the facility, names of current leadership and management, medical director. 2) The quality assurance teams input or participation in the facility assessment formation or update. 3) List of personal or person from whom the information was gathered, or if resident or family member input was taken into account when the assessment was created. 4) A contingency staffing plan. 5) Staff Competencies and skill sets. 6) Health information technology resources. On 12/20/24 at 5:54 p.m., the administrator confirmed they were responsible for writing and creating the facility assessment. Their expectation was its completion should have been verified while they worked on their emergency preparedness program. It was important to complete a facility assessment to help guide staffing needs, equipment, and resident care needs. A facility assessment Policy was request and none was provided.

Based on interview and document review the facility failed to maintain a Quality Assurance Assessment/ Quality Assurance and Performance Improvement (QAA/QAPI) program that was effective in identifying, assessing, performing, developing and implementing appropriate plans of action to assure clinical care, quality of care, resident rights and services were identified to maintain acceptable levels of performance. Furthermore, the facility failed to conduct ongoing quality assessment and assurance activities, develop, and implement appropriate plans of action to correct repeated quality deficiencies identified during the survey the facility was aware of or should have been aware of which had the potential to adversely affect all 57 residents which resided in the facility. Findings include: See F552: The facility failed to ensure changes in medication were communicated to residents (R33) and or resident representative infringing on the resident's right to be informed. See F625: The facility failed to provide a written notice of a bed-hold at the time of transfer for hospitalization s as required. See F684: The facility failed to monitor and implement interventions for heart failure. This resulted in actual harm to R33 who was re-hospitalized on exacerbation of heart failure. See F838: The facility failed to conduct and document a comprehensive facility-wide assessment which included all of the necessary components to provide adequate care and services to the residents in the facility. See F880: The facility failed to ensure appropriate hand hygiene during medication pass and while handling soiled clothing to reduce the risk of infection. The facility's QAPI meeting minutes for the past 12 months were requested, however the facility only provided Quality Assurance and Assessment (QAA)/Quality Assessment and Performance Improvement meeting agenda dated October 17th, 2024. The meeting agenda did not identify previous recertification survey results. The meeting agenda identified the current performance improvement project (PIP) as meds not available on electronic medication administration record (EMAR). During interview on 12/20/24 at 4:11 p.m., the director of nursing (DON) stated she was aware of ongoing issues of quality of care and specifically concerns of staff obtaining and documenting resident weights. DON stated she had identified the issue in October 2024, however failed to provide staff education or training until two months later on 12/20/24. During interview on 12/20/24 at 5:42 p.m. the administrator stated the facility held monthly QAA meetings and quarterly QAPI meetings, however no monthly QAA meeting minutes were provided, and only one QAPI meeting agenda dated 10/17/24 was provided. The administrator stated the facilities current PIP included weights, skin audits, staffing and medication administration, however the provided QAPI agenda lacked evidence of the reported PIP projects. Undated facility policy titled Quality Assurance and Performance Improvement (QAPI) Program identified the objections of the QAPI program as: 1. Provide a means to measure current and potential indicators for outcomes of care and quality of life. 2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. 3. Reinforce and build upon effective systems and processes related to the delivery of quality care and services. 4. Establish systems through which to monitor and evaluate corrective actions.

Based on interview and document review, the facility failed to ensure changes in medication were communicated to 1 of 1 residents (R33) reviewed for notification of change in medications. Findings include: R33's significant change Minimum Data Set (MDS) dated [DATE], indicated diagnoses included dementia, chronic diastolic congestive heart failure (CHF), atrial fibrillation (irregular heartbeat), peripheral neuropathy (nerve damage), and diabetes. R33's cardiology clinic note dated 2/28/24, indicated R33 presented with family member (FM)-B for a cardiology provider visit on 2/26/24. R33 had CHF with noted congestion in lungs and reported occasional shortness of breath and lower extremity edema. R33 needed to follow up with the cardiologist in one year, or sooner as needed. On 2/26/24, the cardiologist ordered furosemide (Lasix) 20mg daily as needed (PRN) for lung congestion and/or lower extremity edema related to CHF. R33's progress note dated 3/26/24 at 3:24 p.m., indicated Pharmacist recommendation of PRN Lasix 20 mg to give for 'lung congestion or edema'. If it is to continue, please add specific parameters for when to administer Lasix 20 mg QD PRN. i.e give for 5# weight gain in a week, 3# in a day, or give for 3+ BLE (Bilateral Lower Extremity), etc. This was reviewed and agreed to by PA. However, the progress note did not indicate what the provider agreed upon. R33's medication administration record (MAR) dated March 2024, indicated R33's furosemide 20mg daily PRN for lung congestion and/or lower extremity edema was discontinued on 3/26/24. However, R33's chart lacked evidence R33's representative had been notified of the change in medication. On 12/18/24 at 9:46 a.m., FM-B stated she brought R33 to the cardiologist in February of 2024 and a PRN order for Lasix was provided for lower extremity edema related to CHF. On 12/12/24, FM-B brought R33 for a prosthetic diagnostic fitting. Because R33 experienced an increase in edema, they were unable to apply the prosthetic. Upon return to facility, FM-B inquired about the PRN Lasix. The director of nursing (DON) informed FM-B the PRN Lasix had been discontinued on 3/26/24. FM-B stated the facility had not notified her of this medication change nor would not have agreed to discontinue the Lasix On 12/20/24 at 4:18 p.m., DON confirmed progress notes failed to indicate R33's family had been notified the PRN Lasix had been discontinued. DON stated FM-B should have been made aware of the change to medications. It was important to communicate medication changes to residents and their family to ensure coordination of care. The facility's Change in a Resident's Condition or Status Policy, revised 2/2021, indicated the facility would promptly notify the resident/representative of any changes in medical care or nursing treatments.

Based on interview and document review, the facility failed to ensure advanced directives for emergency care and treatment were accurately reflected in all areas of the medical chart to ensure resident wishes would be implemented correctly in an emergent situation for 1 of 24 residents (R13) reviewed for advanced directives. Findings include: R13's admission Minimum Data Set (MDS) dated [DATE], indicated R13 admitted [DATE], was moderately cognitively impaired and had the following diagnoses: hypertension (HTN) (high blood pressure), arthritis, osteoporosis (bones becomes weak and brittle), and asthma. R13's Provider Orders for Life-Sustaining Treatment (POLST) dated 10/17/24, indicated R13's resuscitation wishes were Do Not Attempt Resuscitation/DNR. The document was signed by R13's Heath care agent, and the Physician's assistant. On 12/16/24 R13's resuscitation status in the electronic medical record (EMR) banner was FULL CODE. On 12/16/24 at 12:12 p.m., the registered nurse manager (RN)-D stated upon admission the nurse would review resuscitation options with the resident or family member, fill out the paper form and have the resident or family member sign off. The physician would review and sign, then the facility would upload it to the EMR. RN-D stated in an instance where they found someone unresponsive, staff would call for help, check the banner in the EMR, and proceed with the residents wishes. RN-D reviewed R13's current code status and stated R13 was a full code, RN-D checked R13's POLST. RN-D stated the orders and the POLST did not match. RN-D got up, and left. RN-D returned shortly and stated if the instance of finding orders that do not match, they would clarify them immediately as she just had done and updated the resident's medical record. RN-D stated when checking a resuscitation status, staff would always check the banner of the EMR, and then verify with the POLST. On 12/16/24 at 1:21 p.m., the director of nursing (DON) expected resuscitation orders were reviewed by the nurse upon admission, with the resident or resident family. A POLST form was initiated and a provider signed off. The DON stated their expectation if a resident was found unresponsive, was the staff would review the code status on the EMR banner and verify with the POLST. The DON confirmed the EMR banner and POLST form did not match prior to survey start on 12/16/24. In this instance the DON's expectation was staff would verify the order and update when/if needed, and the POLST was the most current information On 12/19/24, R13's EMR indicated a physician order for Full Code dated 10/16/24 and discontinued on 12/16/24. Physician order for DNR dated 12/16/24 and care plan was revised to include DNR on 12/17/24. Changes to the EMR were noted to have been made after survey entrance. The facility's Advanced directive policy dated 2001, indicated if the resident or representative indicates the resident does not have an established advance directive, the facility will offer assistance in establishing advanced directives.

Based on interview and document review, the facility failed to notify and consult provider for 2 of 2 residents (R33, R43) reviewed for heart failure monitoring. Findings include: R33's significant change Minimum Data Set (MDS) dated [DATE], indicated diagnoses included dementia, chronic diastolic congestive heart failure (CHF), atrial fibrillation (irregular heartbeat), peripheral neuropathy (nerve damage), and diabetes. R33's Physician Fax Order Form dated 12/4/24, indicated an order for Lasix (a diuretic) 20mg daily as needed (PRN) for 3-pound (lb.) gain in a day or 5-lb. gain in a week. R33's weight summary and/or treatment administration record (TAR), printed 12/18/24, indicated the following daily weights from 12/5/24 to 12/18/24: 12/18 - 212 12/17 - no weight indicated 12/16 - 214.5 12/15 - 211 12/14 - 211 12/13 - 211.5 12/12 - 211 12/11 - 212 12/10 - no weight indicated 12/9 - 212 12/8 - 208 12/7 - 211 12/6 - 211 12/5 - 210.5 R33's weight summary and/or TAR, printed 12/18/24, indicated R33 had a 3.5-lbs weight gain from 12/15/24 to 12/16/24 and a 4-lbs weight gain from 12/8/24 to 12/9/24 R33's medication administration record (MAR), printed 12/18/24, indicated Lasix 20mg daily PRN had not been administered 12/16/14 or 12/9/24 as ordered for weight gain. On 12/19/24 at 2:20 p.m., registered nurse (RN)-A confirmed R33 had an order for daily weights and to give Lasix 20mg daily PRN for 3-lb gain in a day or 5-lb. gain in a week. RN-A confirmed Lasix 20mg had not been administered to R33 on 12/16/24 nor 12/9/24 as ordered. R43's quarterly minimum data set (MDS) dated [DATE] indicated R43 was admitted to facility on 8/8/23 and had the following diagnoses: acute on chronic congestive heart failure, hypertensive heart disease with heart failure, history of transient ischemic attack and cerebral infarct. The MDS further indicated R43 was cognitively intact. R43's care plan with a last review date of 6/19/24 indicated a focus area of alteration in cardiac status related to diagnosis of hypertension (high pressure in the arteries that carry blood from the heart to the rest of the body), congestive heart failure (CHF)(a progressive disease that affects pumping action of the heart muscles), angina (a condition characterized by chest pain due to insufficient oxygen-rich blood reaching the heart muscle), atrial fibrillation (an irregular and often fast heartbeat) and deep vein thrombosis (a blood clot in a deep vein). Interventions included: administer oxygen as ordered; appointments with cardiology as directed; observe for signs and symptoms of CHF exacerbation including not limited to edema, shortness of breath, weight gain, adventitious lung sounds, cough, decreased oxygen saturations, weakness, increased heart rate, distended neck veins. The care plan indicated obtain weights as directed and update MD as ordered. An order summary dated 11/20/24 indicated R43 had an order for furosemide oral tablet 20 mg twice daily related to acute on chronic congestive heart failure. The bottom of the document had a handwritten provider note indicating the following: D/C Lasix (furosemide); Bumex 1mg BID; Labs-TSH, BNP, BMP in 1.5 weeks. Weights MWF. DX: CHF. An unsigned order summary dated 12/20/24 indicated an order for Bumex 1mg tablet -give Bumex 1mg by mouth in the afternoon related to acute on chronic congestive heart failure, and Bumex 1mg tablet-give Bumex 2mg by mouth in the morning for acute on chronic congestive heart failure. The order summary lacked a documented order for weights to be obtained on Monday, Wednesday and Friday as ordered on 11/20/24. Review of R43's documented weights indicated between 8/2/2024 through 8/30/24 seven out of thirteen opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Review of R43's documented weights indicated between 9/2/24 through 9/30/24 eight of thirteen opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Review of R43's documented weights indicated between 10/2/24 through 10/30/24 seven of thirteen opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Review of R43's documented weights indicated between 11/1/24 through 11/29/24 nine of thirteen opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Physician progress note dated 11/18/24 indicated R43 told provider she felt like she was gaining water weight and her legs felt tighter than usual. The note went on to indicate R43's weight had increased from 261.5 on 11/1 to 265.5 on 11/11 to 268.5 on 11/18. The progress note confirmed R43's order to check weights MWF but were not getting done consistently. Physician progress note dated 11/24/24 indicated resident had a history of heart failure and had been seen a few times earlier in 2024 for the same issue. The note indicated R43's baseline weight was around 245 to 250 pounds, but she had been experiencing a gradual increase over the past few months. Review of R43's documented weights indicated between 12/2/24 through 12/16/24 three of seven opportunities for weight were missed. The record lacked evidence of provider notification of the missed weights. Physician progress note dated 12/3/24 indicated R43 reported to the provider her weight was recorded once during week, despite being scheduled for weigh-in on Monday, Wednesday, and Friday. The provider indicated ongoing concerns and despite orders for weights 3 times weekly, nursing staff had only completed once weekly. During interview on 12/20/2024 at 4:11 p.m., director of nursing (DON) confirmed R43 had an order for weights three times weekly on Monday, Wednesday, and Friday. DON stated nursing staff is responsible for obtaining, documenting, and communicating any concerns for residents with an order for scheduled weights. DON stated if a scheduled weight was not performed the nursing staff should notify the physician. Further, DON confirmed R33 had not received PRN Lasix on 12/16/24 nor 12/9/24, as indicated by R33's weight gain. DON stated nurses were expected to administer the Lasix 20mg PRN if R33 had a weight gain that met the physician ordered parameters. DON further stated if a weight had been missed, nurses were expected to reach out to the provider to notify and request direction. DON stated this process was important for maintaining resident health and to avoid an acute episode of heart failure. The facility's Change in a Resident's Condition or Status Policy, revised 2/2021, indicated the facility promptly notified the resident attending physician of changes in resident's medical/mental condition and/or status. 49654 Findings include:

Based on interview and document review, the facility failed to provide a written notice of a bed-hold at the time of transfer for two hospitalization s for 1 of 2 residents (R33) reviewed for hospitalization . Findings include: R33's significant change Minimum Data Set (MDS) dated [DATE], indicated diagnoses included dementia, chronic diastolic congestive heart failure (CHF), atrial fibrillation (irregular heartbeat), peripheral neuropathy (nerve damage), and diabetes. R33's progress note dated 8/14/24 at 12:52 p.m., indicated R33 was transferred via ambulance to the hospital for increased redness and swelling in the left foot, and a verbal bed-hold was received from FM-B. R33's progress note dated 8/14/24 at 6:20 p.m., indicated R33 was admitted to the hospital for intravenous (IV) antibiotic treatment. A subsequent progress noted dated 8/20/24 at 11:57 p.m., indicated R33 returned from the hospital. R33's Bed-hold Policy form, dated 8/14/24, indicated a bed-hold telephone consent was obtained verbally from R33's family member (FM)-B. The form was signed and dated by the registered nurse (RN) on 8/14/24. However, R33's record lacked evidence a written bed-hold notice was received by the resident/representative at the time of transfer. R33's progress note dated 12/18/24 at 11:57 p.m., indicated R33 was transferred via ambulance to the hospital for increased pain and change in transfers, a verbal bed-hold from the POA (power of attorney) was noted, and orders/MAR were sent. R33's progress note dated 12/19/24 at 5:06 a.m., indicated R33 was admitted to the hospital Telemetry unit for congestive heart failure (CHF) and possible hip fracture. On 12/19/24 at 8:23 a.m., FM-B stated she gave a verbal consent for a bed-hold on 12/18/24. FM-B stated the family had questions regarding the policy and potential costs but had not received a written copy from the facility, nor was a copy sent with R33's information provided by the facility for the hospital at the time of transfer. On 12/20/24 at 10:56 a.m., social services designee (SS)-A, stated the nurses were trained to review the Bed-hold Policy with the resident/responsible party at the time of transfer, and obtain verbal consent or a signature on the form. A copy of evidence a written bed-hold notice was received by the resident/representative at the time of transfer for 8/14/24 was requested. However, SS-A only provided a copy of the telephone consent from 8/14/24. On 12/20/24 at 4:18 p.m., director of nursing (DON) verified evidence a written bed-hold notice was received by the resident/representative at the time of transfer for 8/14/24 and 12/18/24 were not stated written bed-hold information needed to be provided at the time of transfer, or with 24 hours for emergent transfers. The DON expected staff to have the Bed-hold Policy signed by the resident/representative at the time of transfer or send a copy of the Bed-hold Policy with the resident at the time of transfer. If a signature was not obtained by the resident/representative at the time of transfer, the DON expected social services (SS) or the nurse manager to follow-up until a signed form was obtained. DON stated written bed-hold information was important, so residents/representatives understood their rights and what a bed-hold entailed. On 12/23/24 at 5:18 p.m., the facility provided a copy of R33's Therapeutic Leave of Absence Day (Bed-hold Policy) form which indicated a bed-hold telephone consent was obtained from R33's family member (FM)-B. The form was signed and dated by the registered nurse (RN) on 12/18/24. However, R33's record lacked evidence a written bed-hold notice was received by the resident/representative at the time of transfer. The facility's Bed-Holds and Returns Policy, revised 10/2022, indicated residents/representatives were provided written information regarding the bed-hold policies, which addressed holding or reserving a resident's bed during periods of absence at the time of transfer or, if the transfer was an emergency, within 24 hours.

Based on interview and document review, the facility failed to complete and transmit a discharge return not anticipated Minimum Data Set (MDS) for 2 of 2 residents (R25, R48) reviewed for transmission of resident assessment. Findings include: R25's significant change MDS dated [DATE], included an admitted [DATE]. R25 was cognitively intact with a primary diagnosis of osteoarthritis of the right hip (the tissue of the joint breaks down over time) with joint replacement. R25's facility assessment titled Post Discharge Plan of Care dated 6/21/24, included a discharge date of [DATE]. Assessment included R25 participated in the discharge plan. R25's medical record lacked evidence a discharge MDS was completed. R48's admission MDS dated [DATE], included an admitted [DATE]. R48 was cognitively intact with a primary diagnosis of hyponatremia (low sodium level). R48's progress note dated 9/5/24, included R48 left the facility and stated she would not be returning. Facility noted a Minnesota Adult Abuse Reporting Center (MAARC) report was filed. R48's progress noted dated 9/6/24, included R48 returned to the facility to collect belongings and medication. R48's medical record lacked evidence a discharge MDS was completed. During interview on 12/20/24 at 11:21 a.m., MDS registered nurse (RN)-A confirmed she completed MDS assessments for the facility. RN-A worked offsite and relied on the facility to update her when residents admitted , discharged , or had a significant change. RN-A confirmed a discharge MDS was not completed for both R25 and R48. RN-A thought this may have been due her not being updated on the discharge and noted young staff and frequent turn over of leadership. During interview on 12/20/24 at 2:23 p.m., director of nursing (DON) stated she had not had a lot to do with MDS completion and submission since she started in October. She stated there was a leadership email group that should be updated whenever someone was admitted , transferred to the hospital or discharged . The MDS nurse should have been on this email group and should have received updates. The DON stated it was important to submit complete and accurate MDS data in a timely manner to document and bill correctly. Policy for MDS submissions requested and not provided.

Based on interview and document review, the facility failed to revise the comprehensive care plan for 2 of 2 residents (R33, R43) reviewed for heart failure. Findings include: R33's significant change Minimum Data Set (MDS) dated [DATE], indicated R33 was admitted to facility on 9/15/23 and had the following diagnoses: chronic diastolic congestive heart failure (CHF), atrial fibrillation (A-Fib), chronic obstructive pulmonary disease (COPD), and diabetes. The MDS further indicated R33 was cognitively intact. R33's care plan with a last review date of 6/19/24, indicated a focus area of alteration in respiratory status related to diagnoses of COPD, sleep apnea, CHF, chronic bronchitis, and resident experienced shortness of breath (SOB) with exertion. Interventions were listed to administer medications/nebulizers as ordered and observe for effectiveness/side effects; observe for SOB, dyspnea (labored breathing), cyanosis (blue skin), change in mentation (mental function), anxiety, restlessness, air hunger, and document if these occurred; utilize CPAP per physician order. The care plan also listed an intervention of licensed nurse to observe skin weekly. Additionally, an intervention of daily weights was added on 12/12/24. R33's cardiology clinic note dated 2/28/24, indicated R33 presented with her family member (FM)-B for a cardiology provider visit on 2/26/24. R33 had CHF with noted congestion in lungs and reported occasional shortness of breath and lower extremity edema. The cardiologist ordered furosemide (Lasix - a diuretic) 20mg daily as needed (PRN) for lung congestion and/or lower extremity (LE) edema related to CHF. However, R33's record lacked evidence a nurse had contacted the cardiologist to obtain more specific parameters for the administration of a PRN diuretic. Additionally, R33's record lacked evidence measures were initiated to monitor R33 for lung congestion and LE edema. R33's order history, printed 12/18/24, indicated R33 had an order for furosemide oral tablet 20mg daily as needed for lung congestion and/or lower extremity edema was started on 2/28/24. However, R33's care plan had not been updated to include interventions to monitor for lung congestion and LE edema. R33's Hospital Orders Discharge Report dated 8/20/24, indicated R33 was hospitalized from 8/14/24 to 8/20/24. The discharge orders instructed facility staff to call the physician for weight gain of 3 pounds or more over night or gain 5 pounds in a week. However, R33's record lacked evidence the weight monitoring order had been transcribed and implemented. Additionally, R33's care plan had not been updated to include interventions to monitor for weight gain. R33's progress note dated 9/3/24 at 11:57 a.m., indicated R33 was seen on provider rounds and weights x 1 week was ordered. However, R33's care plan had not been updated to include interventions to monitor weights. R33's PCP progress notes for 9/3/24, dated 9/4/24 at 8:10 a.m., indicated R33's Jardiance was to be discontinued to help with R33's urinary concerns, and because CHF was a chronic concern, nursing staff would monitor weights 3 times weekly, and if weight increased the provider would consider ordering a diuretic or restart a lower dose of Jardiance. However, R33's care plan had not been updated to include interventions to monitor weights or signs/symptoms of CHF exacerbation. R43's quarterly minimum data set (MDS) dated [DATE] indicated R43 was admitted to facility on 8/8/23 and had the following diagnoses: acute on chronic congestive heart failure, hypertensive heart disease with heart failure, history of transient ischemic attack and cerebral infarct. The MDS further indicated R43 was cognitively intact. R43's care plan with a last review date of 6/19/24 indicated a focus area of alteration in cardiac status related to diagnosis of hypertension (high pressure in the arteries that carry blood from the heart to the rest of the body), congestive heart failure (CHF) (a progressive disease that affects pumping action of the heart muscles), angina (a condition characterized by chest pain due to insufficient oxygen-rich blood reaching the heart muscle), atrial fibrillation (an irregular and often fast heartbeat) and deep vein thrombosis (a blood clot in a deep vein). Interventions were listed as administer oxygen as ordered; appointments with cardiology as directed; observe for signs and symptoms of CHF exacerbation including but not limited to edema, shortness of breath, weight gain, adventitious lung sounds, cough, decreased oxygen saturations, weakness, increased heart rate, distended neck veins. The care plan also listed an intervention of obtaining weights as directed and update MD as ordered. An order summary dated 11/20/24, indicated R43 had an order for furosemide oral tablet 20 mg twice daily related to acute on chronic congestive heart failure. The bottom of the document had a handwritten provider note indicating the following: D/C Lasix(furosemide); Bumex 1mg BID; Labs-TSH, BNP, BMP in 1.5 weeks. Weights MWF. DX: CHF. R43 physician note dated 11/21/24, indicated resident had 'a history of heart failure and had been seen a few times earlier this year for the same issue. Resident baseline weight was around 245 to 250 pounds, but she has been experiencing a gradual increase over the past few months. Her most recent weight, recorded three days ago, was 268 pounds. This morning, her weight was recorded as 265.5 pounds. Resident believed her weight gain is due to fluid retention, as her legs feel tight'. R43 physician note dated 12/3/24, indicated resident reported her weight was recorded once during week, despite being scheduled for weigh-in on Monday, Wednesday, and Friday. The provider indicated ongoing concerns and despite orders for weights 3 times weekly, nursing staff had only completed once weekly and weight was up to 268. During interview on 12/20/2024, at 4:11 p.m., director of nursing (DON) confirmed R33 had a history of CHF exacerbation and expected nurses to implement interventions to monitor weights and edema. Additionally, nurses were expected to review and update resident care plans when they review orders, provider notes, and hospital discharge orders. Further, DON stated R43 had an order for weights three times weekly on Monday, Wednesday, and Friday. DON also confirmed the order was not carried over to the care plan as written. DON stated nursing staff is responsible for creating the care plan based on assessments of each resident and physician's orders. DON stated this process was important for maintaining resident health and for staff to have a clear directive and plan to prevent an acute exacerbation of heart failure. During interview on 12/20/24 at 4:18 p.m., director of nursing (DON) A policy was requested, but not provided. 49654

Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene for 2 of 4 staff observed for medication pass. Further, the facility failed to ensure 1 of 1 staff consistently followed infection control standards of practice for handling soiled clothing to reduce the risk of infection. This practice had the potential to affect all 57 residents, staff, and visitors. Findings include: During observation on 12/19/24 at 7:51 a.m., registered nurse (RN)-C was preparing and administering medications for a resident. RN-C prepared medication in medication cup, locked the medication cart, went to resident in common area and handed medication cup to the resident who took medications independently. RN-C returned to the cart, picked up a new medication cup off of a stack of medication cups, pulled up information for a new resident on computer and unlocked medication cart to retrieve medications. RN-C did not wash hands with soap and water or utilize alcohol-based hand sanitizer during this process. During interview on 12/19/24 at 7:54 a.m., RN-C stated she always utilized alcohol-based hand sanitizer when passing medications. She stated she was going to throw away the medication cups and utilize alcohol-based hand sanitizer before preparing the next resident's medications. During observation on 12/19/24 at 11:49 a.m., licensed practical nurse (LPN)-A completed a blood sugar check utilizing a glucometer stored in the resident's room. LPN-A utilized alcohol-based hand sanitizer, applied gloves, cleansed resident's finger, and completed blood sugar check appropriately. LPN-A disposed of supplies and removed gloves. LPN-A did not wash hands with soap and water or utilize alcohol-based hand sanitizer after removing gloves. LPN-A then drew up insulin, applied gloves, cleansed administration site, and gave insulin correctly. LPN-A disposed of supplies and removed gloves. LPN-A did not wash hands with soap and water or utilize alcohol-based hand sanitizer after removing gloves. LPN-A then picked up a new medication up and pulled up information to administer medication to a different resident without washing hands. During interview on 12/19/24 at 11:50 a.m., LPN-A stated she should have utilized alcohol-based hand sanitizer between residents and after completing tasks, but she forgot. During interview on 12/20/24 at 11:32 a.m., director of nursing (DON) stated she expected staff to utilize alcohol-based hand sanitizer between each resident and before and after tasks while passing medications. She stated this was important to reduce infection. Facility policy titled Medication Administration dated April 2019, included staff will follow established infection control procedures, including handwashing, for medication administration. On 12/19/24 at 8:06 a.m., nursing assistant (NA)-A was observed holding a pair of dark blue, plaid, flannel pants as she walked down the 2nd floor hallway, past the nurse station, and into the tub room. However, NA-A was observed to to be wearing gloves and the clothing was not secured in a bag. On 12/19/24 at 8:07 a.m., NA-A confirmed the soiled clothing should have been placed in a bag before the item was removed from the resident's room and brought to the tub room. NA-A did not confirm nor deny wearing gloves. On 12/20/24 at 1:25 p.m., infection preventionist (IP) stated staff were expected to have soiled items bagged and gloves on when handling soiled clothing/linens. IP stated soiled items needed to be contained, and gloves worn as a protective barrier, to prevent the spread of infection. Policy requested, but not provided by facility. 44645 49035

Based on observation, interview and document review, the facility failed to provide medically related social services for 1 of 1 residents (R23) who expressed desire to be moved to another facility. The failed practice resulted in psychosocial harm when the facility failed to follow up on recommendations R23 be assisted in finding alternate placement at a lower level of care (LOC). Findings include: R23's face sheet printed 2/17/23, indicated R23's diagnoses included Friedrich's ataxia (causes difficulty walking, loss of sensation in arms and legs and impaired speech). R23's quarterly Minimum Data Set, dated dated dated [DATE], indicated R23 was able to communicate needs and cognition was intact. R23 required physical assistance from staff with transfers, grooming, bathing, repositioning, and toileting. R23's care plan, revision date 11/8/22, indicate R23 wished to remain in the facility for long term care (LTC). R23 requested to be asked about returning to the community only with comprehensive assessments. No active discharge planning was in place at time of revision. Associated Clinic of Psychology (ACP) note dated 7/27/22, recommended R23 would benefit from a level of care (LOC) to enable him to thrive and not just survive. ACP note dated 10/5/22, directed again consider a different level of care due to [23's] age and socialization needs. ACP note dated 12/6/22, directed please consider a group home or other living environment as this is too restrictive LOC for this client [R23]. Progress note dated 12/9/22, noted ACP visit: plan/recommendations: please consider a group home or other living environment as this is too restrictive a LOC for this client. Additional progress notes reviewed 10/1/22-2/14/23, no other notes found to indicate attempts were made to find alternate placement for R23. On 2/13/23, at 1:08 p.m. R23 was crying and voiced his desire to live in an environment with people closer to his age and cognitive level. R23 reported no facility staff have talked with him about other living options or discharge. On 2/16/23, at 1:55 p.m. R23 was observed crying as he stated no other residents in the facility were on the same cognitive level as he was, its like being with a bunch of three-year-olds. R23 voiced concern he would be treated as a three-year-old as his condition continued to decline. Further, facility staff had not asked R23 how he felt about living at the facility, its not that good. On 2/16/23, at 2:13 p.m. nurse manager (NM)-C indicated she knew she needed to read provider notes, including ACP notes and document the visit in R23's progress notes, but was not aware she needed to follow up on recommendations. She was not aware R23 desired to live in a less restrictive environment and had not talked with R23 about how living in the facility made him feel. On 2/17/23, at 9:17 a.m. director of nursing (DON) stated she had not asked R23 how he felt about living in the facility with others who were much older. R23's physical needs required the level of care provided by the facility. DON agreed there was potential to help R23 find a facility to meet his physical needs and also able to meet his socialization needs. DON expected the nurse manager to review ACP progress notes and follow up on recommendations that were made. DON confirmed, discharge planning was not started for R23. Facility policy, Discharge Planning dated 12/2021 indicated all residents will have assistance with discharge planning.

Based on interview and document review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (R1) who did not receive his anticoagulation medication. This deficient practice resulted in an immediate jeopardy situation (IJ) for R1 who suffered a [CONDITION(S)] ([CONDITION(S)]) and subsequent death as a result of the medication errors. The immediate jeopardy began on [DATE], when R1 did not receive his scheduled dose of [MEDICATION(S)] (an anticoagulant medication, prescribed to prevent blood clots). In addition, R1 had not received his scheduled [MEDICATION(S)] on [DATE], [DATE], [DATE], for a total of four days. On [DATE], R1 was found to have right sided flaccidity, was difficult to arouse, was sent to the hospital by ambulance and admitted with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The IJ was identified on [DATE]. The facility administrator and interim director of nursing (DON) were notified of the IJ on [DATE], at 3:07 p.m. The facility had identified the significant medication error, implemented corrective action to prevent recurrence by re-educating the staff involved and other licensed staff to ensure they understood the proper procedure for medication administration. In addition, the facility implemented a system to ensure medications were available for administration. The immediate jeopardy and the deficient practice was removed on [DATE], prior to the start of the survey, therefore, was issued at past noncompliance. Findings include: Review of R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's admission Care Area Assessment (CAA) dated [DATE], indicated R1 was admitted to the facility from home related to advanced dementia. The CAA revealed R1 had altered cognition, had a previous stroke with [CONDITION(S)] and required assistance with ADL's. The CAA identified R1 received [MEDICATION(S)], had chronic [CONDITION(S)] and had indicated he had right sided [CONDITION(S)]. Review of R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's emergency room (ER) note dated [DATE], identified the following: -emergency room history and physical (H&P) identified R1 presented to the emergency department with acute neurological deficit. Reports from emergency medical services (EMS) and the nursing home staff, at approximately 1:00 p.m. that day, R1 had a right sided facial droop, began to lean to the right and was not able to converse. The H&P revealed a stroke neurologist specialist was consulted regarding R1's condition. -emergency room medical decision making (MDM) note identified R1 presented with acute catastrophic neurological deficits and had severe right sided neglect. The MDM note revealed R1 had advanced imaging which revealed significant left-sided MCA (left middle cerebral artery) stroke. The note identified R1 was not a candidate for treatment, was placed on palliative care and admitted to the hospital. -emergency room diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's [CONDITION(S)] Diseases/Neurology progress note dated [DATE], identified R1's history of present illness (HPI) indicated R1 had [CONDITION(S)], had been off his anticoagulation medication and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The note revealed the hospital had been notified R1 had missed several doses of his [MEDICATION(S)], with his last possible dose on [DATE]. -assessment and plan identified R1 had an acute ischemic stroke, LMCA with cerebral [CONDITION(S)], left MCA thrombus (blood clot), ICA occlusion (internal carotid artery blockage) and left vertebral artery occlusion with presumed etiology (cause): [CONDITION(S)] with recent missed doses of [MEDICATION(S)]. Review of R1's State Agency (SA) report dated [DATE], identified R1 was sent to the hospital on [DATE], due to a change in condition. The report revealed R1's medical record identified he had not received his anticoagulation medication from [DATE], to [DATE]. The report identified facility staff directly involved with the incident had reported R1's anticoagulant medication had not been available. The report revealed facility staff indicated they had re-ordered the medication from the pharmacy and it had not been received. The SA report facility staff were educated on the following steps: updating the pharmacy, updating the provider, internal communication, and documentation. The report revealed an internal investigation was ongoing. Review of R1's progress note dated [DATE], identified R1 was drowsy, leaning to the right and could not be aroused. The note revealed R1 was sent to the emergency department by ambulance. -a note dated [DATE], revealed R1 passed away at the hospital with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on [DATE], at 10:20 a.m. licensed practical nurse (LPN)-A stated she had received education by text via the facility's communication system within the last few days regarding the six rights to safe medication administration, ensuring residents received their medications, managing pharmacy orders/delivery and notification to providers with a post test. LPN-A indicated she had received the education as a result of a significant medication error where R1 had not received his anticoagulation medication for several days, had a stroke and passed away. LPN-A stated she made sure she had all of the medications prescribed for the residents. She indicated when pharmacy delivered medications to the main level for the other floors, she would personally deliver the medications to the other units and placed in the medication cart with the residents' other medications. Further, LPN-A indicated if a medication was not available for the resident, she would contact the pharmacy and the provider for further instruction. During an interview on [DATE], at 10:41 a.m. registered nurse (RN)-A indicated she had recently received written education via text within the last few days regarding the six rights to safe medication administration, ensuring residents received their medications, managing pharmacy orders/delivery and notification to providers with a post test. RN-A indicated she had been working on [DATE], the day R1 was sent to the hospital with symptoms of an acute stroke. She stated R1 had a significant medication error as he had not received his [MEDICATION(S)] for four days, had a stroke and died in the hospital four days later. RN-A indicated she had received education and reminders to ensure resident medications were available. RN-A stated she was reminded of the steps to take when resident medications were not available, such as contacting the pharmacy and the resident's provider for further instructions. During an interview on [DATE], at 11:40 a.m. trained medication aid (TMA)-A stated she had recently received written education via text within the last few days regarding the six rights to safe medication administration, and notification to providers and licensed nursing staff of any missed medications. TMA-A stated a licensed nurse was required to receive medications from any of the pharmacies the facility used. TMA-A indicated she was provided education as a result of R1's significant medication error. She indicated R1 had not received his anticoagulation medication for several days, was hospitalized with a stroke and died . TMA-A indicated she had received skills assessment/competency for medication administration upon hire and on-line education annually. During a telephone interview on [DATE], at 11:57 a.m. the pharmacist identified the pharmacy received a fax request on [DATE], to refill R1's [MEDICATION(S)] from the nursing home R1 resided in. The pharmacist identified R1's [MEDICATION(S)] was sent to the facility on [DATE], at 8:00 p.m. The pharmacist indicated he had been unaware R1 was completely out of [MEDICATION(S)], or had missed any doses. He identified [MEDICATION(S)] had a half -life (the time it takes for a drug's active substance in your body to reduce by half) of ,d+[DATE] hours. The pharmacist identified, after missing a day's dose, R1 would have no longer been considered anticoagulated and would have placed him at an increased risk for a stroke. The pharmacist stated the missed doses of an anticoagulant would be considered a significant medication error with almost certain harmful consequences. During an interview on [DATE], at 12:33 p.m. the DON indicated R1 was sent to the hospital on [DATE], for symptoms of acute stroke. The DON stated she had reviewed R1's medical record and noted a significant medication error in which R1 had not received his scheduled [MEDICATION(S)] for four days prior to his stroke symptoms. The DON stated R1 had been admitted to the hospital on [DATE], and died on [DATE]. She stated upon review of R1's MAR, she identified four entries from three different staff, which identified R1's [MEDICATION(S)] was not available. The DON identified the following three staff: RN-B, LPN-B and TMA-B, had not administered R1's [MEDICATION(S)] as ordered, and all identified the medication was not available. The DON stated on [DATE], upon looking in the medication room of R1's unit, she had found R1's [MEDICATION(S)], which had been delivered on [DATE]. The DON confirmed she had provided education on safe medication administration, management of pharmacy deliveries, notification to providers of missed medications to the three identified staff, and to all other nursing staff who administered medications. The DON confirmed the education had been completed as of [DATE]. Further, the DON identified a facility-wide audit had been completed of all residents' medication administration records to review for additional medication errors. During a telephone interview on [DATE], at 12:48 p.m. R1's primary medical doctor (MD)-A stated he had not been made aware R1 had missed any doses of [MEDICATION(S)] and indicated he would have wanted to be informed of any missed doses so another plan could have been made. MD-A indicated R1 had a [CONDITION(S)] in the past, prior to his admission to the nursing home. He indicated R1 had been receiving anticoagulation medication for the past few years. MD-A stated if R1 hadn't received a dose of [MEDICATION(S)] after 24 hours from the prior dose, he would not have been considered anticoagulated and was at risk for a [CONDITION(S)]. MD-A indicated R1 had a significant medication error with unfortunate catastrophic consequences. During a telephone interview on [DATE], at 2:22 p.m. LPN-B stated she had been unable to administer R1's [MEDICATION(S)] on [DATE], and indicated the medication was not available. LPN-B confirmed she had not contacted R1's MD, nursing leadership or the pharmacy to notify them the medication was unavailable. LPN-B stated within the last few days, she received written and verbal education on the six rights of safe medication administration, dealing with pharmacy deliveries, and notification of any missing medications or medication errors. LPN-B indicated she was provided the education in response to R1's significant medication error in which he had suffered a stroke and had died . During a telephone interview on [DATE], at 2:32 p.m. RN-B stated she had noticed R1 was out of [MEDICATION(S)] on [DATE], and placed an order by fax to his pharmacy. RN-B confirmed R1 had not received his ordered [MEDICATION(S)] that day and confirmed she had not notified R1's MD he had not received the medication. RN-B stated within the last few days, she received written and verbal education on safe medication administration, management of pharmacy orders/deliveries and notification to residents' providers and families and communication with nursing team. RN-B stated she had completed post tests on the education and would be ensuring residents received their medications as prescribed. During a follow-up interview on [DATE], at 10:40 a.m. with the DON, she indicated she planned to meet with the three staff involved in the medication error to perform further education, skills assessment and would continue to perform audits of medication administration for all residents and nursing staff who passed medications. She stated she would also provide education on high-risk medication which had the potential for serious consequences with errors. The interim DON indicated she reviewed several facility policies and would be meeting with the facility medical director within the next week and the quality assurance team to review the significant medication error, to complete a root cause and to develop and implement processes to ensure safe medication administration. Further, she indicated there were plans to review the facility's process with pharmacy deliveries and communication within the facility's nursing and leadership team. Review of a facility policy titled, Medication Error - Long Term Care effective ,d+[DATE], identified it was the policy of the facility medication errors and good catches would have been reported and monitored. The policy revealed a detailed account of the incident would have been recorded and would include the following: date/time of the incident, medication, provider name, date, and time they were notified, notification to family/representative, any known or suspected contributing factors that led to the incident. In addition, the policy revealed any changes in the resident condition would have been immediately reported to the attending physician, DON, or RN on call. Review of a facility policy titled, Medication Guidelines - Long Term Care effective ,d+[DATE], identified medication administration guidelines which included: process for the six rights of medication administration; right resident, drug, dose, route, right time, and documentation. Review of a facility policy titled, Accepting Delivery of Medications effective ,d+[DATE], revealed all staff should follow a consistent procedure in accepting medications. The policy identified any errors noted in receiving medications should have been brought to the attention of the Pharmacist and director of nursing services. The past noncompliance immediate jeopardy began on [DATE]. The immediate jeopardy was removed, and the deficient practice was corrected on [DATE], after the facility implemented a systemic plan which included the following actions: -a facility wide audit of resident medication administration records was conducted for medication errors; two additional errors were found, and both were followed up on. -re-educated the employees directly involved with the significant medication error on the standards of practice for safe medication administration, management of pharmacy deliveries and orders, communication with providers and nursing team. -re-educated all facility licensed nursing staff and trained medication aids regarding standards of practice for safe medication administration, management of pharmacy deliveries and orders, communication with providers and nursing team. -implemented systemic changes to management of pharmacy deliveries to ensure receipt and accountability.

Based on interview and document review, the facility failed to provide medically related social services to 1 of 1 residents (R40). The failed practice caused R40 psychological harm, in that R40 experienced ongoing anxiety and frustration when she was not allowed to fulfill her duties as R54's legal guardian. Findings include: R40's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/20/21, indicated a Brief Interview of Mental Status (BIMS) score of 15, which indicated she was cognitively intact, and a Personal Health Questionnaire, 9th version (PHQ-9) score of 0, indicating no depression present. R40's quarterly MDS assessment with an ARD of 7/16/21, indicated a BIMS score of 15, and a PHQ-9 score of 4, which indicated minimal depression present. R40's post-hospitalization re-admission MDS with an ARD of 9/27/21, indicated a BIMS of 15 and a PHQ-9 score of 0. A significant change of condition MDS with an ARD of 10/20/21, also indicated a BIMS of 15 and a PHQ-9 score of four. Specifically, on the 10/20/21, PHQ-9, R40 reported feeling down, depressed, and hopeless at least once; and that she had failed or let her family down at least half of the time. R40's guardianship documents provided by the facility, and a second identical set provided by R40, indicated R40 was appointed co-guardian of R54 on 11/21/18, along with another individual; and again, with a new co-guardian appointed on 09/28/21. Review of the floor plan and census list provided by the facility on 11/15/21, indicated R40 and R46 (R40's husband) lived on the first floor of the facility and R54 lived on the second floor. In an interview on 11/15/21, at 2:51 p.m. R40 became tearful when asked about her treatment in the facility. R40 reported that she had a sister, R54, who had suffered an [CONDITION(S)] [CONDITION(S)] at birth and functioned at a cognitive level comparable to a 5-year-old, who also resided in the facility. R40 stated that she and her husband (R46) had been R54's co-guardians for over [AGE] years. R40 stated that when R46 was diagnosed with dementia, she obtained a new co-guardian. R40 stated that beginning in January 2021, following a hospital stay in which R40 experienced some [CONDITION(S)], the facility had stopped allowing her to make decisions on R54's behalf or participate in R54's plan of care. R40 stated that the facility cited various reasons as to why they were implementing those restrictions, including the [CONDITION(S)] she experienced while acutely ill, an assertion that R40 was interfering in R54's care, and R40's visual deficits. R40 reported that the facility did not inform her that they were utilizing the co-guardian to make decisions, and the co-guardian did not open financial mail which placed both R40 and R54 at risk of not having a funding source for the nursing home. R40 stated that, on her own, she hired an attorney and went back to court to establish a new co-guardian for R54. The new co-guardian was a third sister, family member (FM)1. In continued interview with R40 on 11/15/21, at 2:51 p.m. R40 stated her most pressing concern was moving R54 to the same floor as she and R46, as when the facility implemented visitation restrictions necessary for COVID-19 outbreaks, they limited residents to the floor where they each lived. R40 stated she understood why the facility had to implement these restrictions, but it meant there were extended periods of time when R54 did not have any family contact. R40 stated she had started making these requests many months ago, because in 2020 the family ended up spending both Thanksgiving and Christmas apart. R40 stated that she was becoming increasingly distressed and frustrated as the holidays approached again, because if there was another COVID-19 outbreak they might be separated for yet another holiday. R40 stated that also important, but to a lesser degree, was that she had made specific care plan requests for approaches and effective communication with R54. R40 stated that the facility refused to implement these approaches. R40 stated that she had spoken with the facility's administrator, director of nursing (DON) and social workers regarding these concerns, but they told her what happened to R54 was not your concern. R40s stated that she had involved the Ombudsman as an advocate in the situation, and the Ombudsman agreed with all R40's concerns; but the facility refused to act upon the Ombudsman's recommendations. R40 stated that the Ombudsman had offered to help her find alternative placement for the family, but none of them wanted to do that. R40 stated that they had chosen this facility because it was affiliated with their faith and had daily spiritual support. In an interview on 11/16/21 at 12:13 p.m., R40 stated FM1, who was R54's co-guardian, was in another state with one of their brothers, who was on hospice care and nearing the end of his life. R40 stated that the facility was waiting for FM1 to return before moving R54 to the same floor as R40 and R46. R40 stated that the facility felt this was because FM1 did not agree with the room move, but the facility's perceptions were incorrect. R40 stated, That's a blatant lie. [FM1] wants [R54] moved to be with [R46] and me. I have fought this for so many months. It's all I think about. In an interview on 11/16/21, at 1:24 p.m. the director of social services (DSS) stated she was aware of R40's status as R54's legal guardian, which the DSS stated meant R40 had the authority to make health care and placement decisions on R54's behalf. The DSS stated that a year or so ago R40 was hospitalized , and it was determined she had a cognitive deficit at that time. The DSS stated that R40 agreed to have a co-guardian for R54 at that time, then became upset when the co-guardian did not make the care decisions R40 felt were appropriate, such as moving R54 to the first floor, and did not follow through with information requests to secure Medicaid. The DSS stated that the facility felt R40 was not making decisions based on R54's best interests, so the facility had refused to honor R40's requests they felt violated R54's rights. The DSS stated that R40's visual deficit made it difficult for her to be independent and combined with her cognitive deficits impaired her ability to serve as R54's guardian. The DSS stated that after R40's hospitalization in January 2021, her cognition seems to have cleared and could not cite evidence of a current cognitive deficit. The DSS was unable to state how R40's visual deficit impacted her ability to fulfill her duties as R54's legal guardian. The DSS stated that FM1, who was R54's co-guardian, agreed with the facility's assessment that R40 was not making decisions in R54's best interest and wanted to talk to R54 before anything was changed. The DSS stated that after making this known to facility staff, FM1 went on vacation or something, and left without doing anything about it. There's nothing we can do until she comes back, and she didn't tell us when that was going to be. The DSS stated that the Ombudsman was involved and supported the facility's decision to delay moving R54 until FM1 returned and spoke to R54 independently. In an interview on 11/16/21, at 2:36 p.m., social worker (SW)-1 stated she was familiar with R40 and knew that R40 was R54's guardian. SW1 stated that R40 was manipulative and controlling towards R54. When asked for details of this assessment, SW1 stated that R40 had seen staff serving R54 both chocolate milk and hot chocolate prior to a meal and told staff to offer R54 one or the other until she had been presented with her meal, though staff knew R54 liked both items. SW1 stated that based on these types of interactions, the facility had determined R40 was making inappropriate decisions for R54. SW1 also stated that R40 had cognitive deficits which interfered with her ability to serve as R54's guardian. SW1 stated that the facility had not notified either R40's physician of their concern with her cognition or notified the court that they were concerned with R40's ability to carry out her court-appointed duties as guardian. In an interivew on 11/16/21, at 5:54 p.m., the ombudsman stated R40 had contacted her to ask her to advocate for R54 and R40. The Ombudsman stated she understood the facility was concerned with the decisions R40 was making but encouraged the facility to defer to R40 as R54's guardian. The Ombudsman stated that R54's current co-guardian (FM1) was in support of the decisions R40 was making and recommended to the facility that they follow those wishes. The Ombudsman stated she was not confident that the facility planned to listen to R40 and FM1. The Ombudsman stated that she had not noticed any obvious cognitive deficits for R40 during their interactions. When asked in an interview on 11/16/21, at 6:26 p.m. R40 stated that there was no disagreement between her and FM1 as far as the request for R54 to move nearer to her or the input she had for R54's care. R40 stated, Please call [FM1] and ask her. I don't know why they [the facility] has been so gruesome in their treatment of me. R54 expressed concern that facility leadership, specifically the DON and administrator, would retaliate against her for reporting to the survey team by further restricting her access to R54. In an interview with registered nurse (RN) nurse manager 2 on 11/17/21, at 8:20 a.m., she stated that she was the unit manager for the first floor, where R40 and R46 resided. RN Nurse Manager 2 stated that she was aware that R40 was R54's guardian and the facility's concern with her making decisions on R54's behalf. RN Nurse Manager 2 described R40 as forgetting things that happened when she was sick, and a couple of other things like that but had not been concerned with R40's cognition to the point that she felt they needed to notify the physician for further work-up. RN Nurse Manager 2 stated, I said months ago that they should just move her [R54] down here, but for some reason they just don't want to. In an interview on 11/17/21, at 12:21 p.m., R40's physician (MD) stated R40 had not been diagnosed with a cognitive deficit. The MD stated that a year ago R40 had experienced a [CONDITION(S)] during a hospitalization but had since cleared and returned to baseline. The MD stated that R40 did not have a cognitive deficit, or any other deficits, which would preclude her from fulfilling her duties as guardian. The MD stated he knew R40 had been R54's guardian for decades and there had never been any concerns brought to his attention. The MD stated that he was aware of the conflict R40 had had with the facility regarding this issue. The MD stated, [R40] has depression and anxiety at baseline and this hasn't helped, that's for sure. In my opinion you pick your battles carefully and why they picked this one is beyond me. In an interview on 11/17/21, at 12:55 p.m. the DSS and SW1 both stated the facility did not have a policy on the provision of medically-related social services. In an interview on 11/17/21, at 1:28 p.m. the administrator stated he was aware R40 was the legal guardian for R54. When asked about a guardian's role, the administrator stated, If a resident has an assigned guardian, we would have to basically honor their wishes, if the request was reasonable and the guardian was competent to ask for those things. The administrator stated that he would have to defer to clinical to determine if requests were reasonable, and to legal to determine if a guardian was competent to make requests. The administrator described R40 as being very domineering, citing again the example with hot chocolate and chocolate milk SW1 had previously mentioned. The administrator verified the facility lacked a policy on the provision of medically related social services. In an interview on 11/17/21, at 4:12 p.m. FM1 confirmed that R40 had been R54's guardian for at least [AGE] years. FM1 stated, I defer to [R40] completely. I could tell in the last meeting we had that they were not going to move [R54] even though both [R40] and I thought it was fine. Even though they said they talked to [R54] I just don't trust that they are asking her [R54, regarding the room move] in a way she understands. I have known [R40] and [R46] to make wise and loving decisions for [R54]. I defer completely. FM1 described the facility's failure to allow R40 to fulfill her duties as guardian as, Hard on her. Very hard. I think she's started to feel some of the staff are dismissive and rude. It's caused her a lot of anxiety, a lot of worry. An interview with R40 on11/17/21 at 4:46 PM revealed, You can't imagine what I have been through over the past year. The facility has tried to convince so many people I'm incapacitated. They have abused me with this, I can't deny that. There's no one I could talk to. R40 stated that she had been told by the social workers, nurses, and Administrator that it was the DON who would ultimately make the decision about whether to allow her to fulfill her duties as R54's legal guardian. In an interview on 11/17/21, at 5:42 p.m. the DON stated she had stepped into her current role a month and a half ago but was familiar with the situation due to her previous position at the facility. The DON stated that she presumed the social workers and administrator were overseeing their concerns and she had concentrated on clinical issues rather than psychosocial ones. The DON stated that she was horrified to learn that R40 was feeling ignored and abused by the situation. The DON stated, I've known [R40] for a long time. As far as I'm concerned, we can move [R54] any time. I've thought that since the beginning, but by the time I became the DON everyone had their heels dug in against the move, so I haven't been able to make it happen.

Based on interview and document review, the facility failed to ensure 1 of 3 residents (R1) was free from the use of physical restraint when staff placed a broom in the spokes and behind R1's wheelchair, restraining her movement. This resulted in actual psychosocial harm when R1 became tearful and agitated over a number of weeks when this practice was in place. Findings include: R1's quarterly minimal data set (MDS) dated [DATE], indicated R1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of MDS, indicated R1 required extensive assist of one staff with activities of daily living (ADL's) which included bed mobility, transfers, and locomotion on and off unit. In addition, MDS identified R1 was noted to wander. The facility report number 5 dated 2/23/21, at 7:39 p.m. indicated licensed practical nurse (LPN)-A noted there was a broom lying on the floor behind R1's wheelchair. LPN-A removed the broom and three nursing assistants were questioned and stated, it was done all the time on that shift because table mate became upset if resident left. LPN-A then reported incident to director of nursing (DON). The facility investigation dated 2/26/21, at 12:55 p.m. indicated nursing assistant (NA)-A stated, I have done it [placed the broom under R1's wheelchair]. I will own up to it. It was never to be mean to her [R1]. Further, NA-A indicated R1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . NA-A indicated the broom is removed from under R1's wheelchair as soon as she [R1] is done eating. In addition, NA-A stated staff have been utilizing the use of the broom to restrain the resident for sporadically for maybe two months. When asked what other staff had placed the broom under R1's wheelchair, NA-A stated NA-B, activities assistant (AA)-A, and possibly NA-E. When asked what other staff were aware of using the broom to restrain R1, NA-A stated several staff, but would not directly name any staff, other than LPN-B. On 3/2/21, at 11:05 a.m. R1 was seated in her wheelchair in the first floor dining room. R1 was placed in a circle with 10 other residents, who were participating in group exercise. R1 appeared to be positioned well and comfortable. On 3/3/21, at 8:02 a.m. R1 was seated in her wheelchair in the first floor dining room. R1 appeared comfortable and was smiling while unidentified staff member assisted with breakfast meal. On 3/2/21, at 11:11 a.m. registered nurse (RN)- A indicated she heard about an incident that involved NA-A who placed a broom behind R1's wheelchair. Further, RN-A stated staff should have reported the incident right away and the NA-A placed the broom there because R1 wanders. However, RN-A indicated R1 does not display any behaviors or go into other resident's room, intrude, or exit seek but R1 enjoys self-propelling in the wheelchair. On 3/2/21, at 11:21 a.m. DON indicated R1 does not have any behaviors and does not wander. Further, DON stated, My personal opinion is it was for convenience since [R1] has no behaviors and I am not tolerating it. I am not dealing with this so she [NA-A] is terminated. On 3/2/21, at 11:57 a.m. LPN-A indicated they were the floor nurse on 2/23/21, and was in the dining room assisting another resident when LPN-A overheard an unknown staff member say [R1] is upset because she can't move. LPN-A then stated she heard R1 sobbing. Further, LPN-A indicated after assisting with settling R1 down, LPN-A spoke with the staff members working about the inappropriateness and there is no reason to keep [R1] at the table. LPN-A indicated R1 does wander, but has not been noted to go into other resident rooms or exit seek. In addition, when LPN-A questioned the floor staff on reasoning for the broom, staff indicated it was due to wanting R1 to eat and another reason was table mates would become upset if R1 left the table. However, LPN-A indicated both of these reasons were not valid. LPN-A then reported the incident to the DON. On 3/2/21, at 12:43 a.m. NA-C indicated R1 does not display any behaviors but does move around a lot in the wheelchair but has not witnessed R1 going into other resident rooms or exit seek. Further, NA-C stated they have never put the broom under R1's wheelchair, but NA-C has noticed the broom there before. On 3/2/21, at 12:51 p.m. NA-D indicated R1 wanders but does not enter other resident rooms or exit seek. Further, NA-D stated, [R1] is not endangering herself when up and down the halls nor is R1 endangering other people. NA-D indicated NA-D has seen the broom under R1's chair and NA-A will place the broom under the chair more than others, and NA-A does it for convenience so R1 stays at the table. However, NA-D indicated NA-D did not place the broom under R1's wheelchair because I [NA-D] know it is wrong. Further, NA-D stated, It [placing the broom under the wheelchair] is wrong because [R1] is not allowed to move, it's not protecting her dignity, [R1] seems to be in distress and not like it, [R1] will cry, groan and moan acting like [R1] is trying to move but can't so [R1] will make tiny screeches. On 3/2/21, at 1:08 p.m. NA-E confirmed NA-E has noticed a broom under R1's wheelchair but had not placed it there. NA-E indicated, Staff were using it as brakes so [R1] stays at the dinner table because [R1] likes to wander. However, NA-E indicated R1 does not disrupt others when wandering and does not exit seek. Further, NA-E confirmed R1 cannot remove the broom under the wheelchair themselves, and R1 will try to push back from the table and has began crying and being in distress due to not being able to move. When asked what staff do when R1 begins to cry, NA-E stated, we try to distract her [R1] and comfort her [R1]. If [R1] becomes tearful and it is too much then we [staff] will remove it. Review of video surveillance camera showed on 2/9/21, at 5:32 p.m. NA-E removed the broom from under R1's wheelchair and placed the broom in the corner of the dining room. In addition, on 2/23/21, at 4:57 p.m. NA-E sat next to R1 in the dining room as NA-B placed the broom under R1's wheelchair. On 2/23/21, at R1 was attempting to reach broom under R1's wheelchair and NA-E repositioned the broom and NA-E was then noted to attempt to console R1. In addition, NA-E indicated since this incident, there have been two online training's on abuse and restraints assigned for staff to complete, however NA-E stated, we have a couple weeks to complete them, I will work before I complete them because I work today (3/2/21). On 3/2/21, at 1:23 p.m. dietary aide (DA)-A indicated R1 does not display any behaviors in the dining room, but R1 will wander and does not like to sit still. DA-A denied seeing a broom under R1's chair. On 3/2/21, at 1:29 p.m. family member (FM)-A indicated they were made aware of the incident with the broom being put under R1's wheelchair. FM-A stated the facility reported R1 would become very upset because she likes to move. They [staff] got [R1] back to [R1's] room and relaxed and not upset anymore. In addition, FM-A indicated FM-A was very disappointed. On 3/2/21, at 1:36 p.m. DA-A called back surveyor and stated DA-A did recall seeing a broom placed under R1's wheelchair. DA-A recalled seeing R1 sobbing when the broom was under R1's wheelchair, but was unable to identify a staff member who placed it there. Review of video surveillance camera on 2/23/21, at 5:09 p.m. DA-A was noted to watch NA-C remove the broom from under R1's wheelchair and NA-E attempting to console R1. On 3/2/21, at 2:20 p.m. activities assistant (AA)-A stated, to be honest when they [staff] were doing it [placing the broom]. I never looked at it as a restraint. R1 likes to roam and it was a way for R1 to eat. AA-A stated that AA-A has seen NA-A and NA-B both place the broom under R1's wheelchair. Further, AA-A stated that they themselves have placed the broom under R1's wheelchair because NA-A had directed them to do so. In addition, AA-A stated R1 was not able to move once the broom is placed under the wheelchair and R1 would begin to cry. On 3/2/21, at 2:34 p.m. LPN-B indicated R1 will self-propel around the unit in R1's wheelchair but does not endanger self or others. LPN-B indicated that she has not seen a broom under R1's wheelchair at any point. However, review of the facility surveillance camera footage reveals LPN-B removing the broom from under R1's wheelchair on 2/22/21, at 5:32 p.m. On 3/2/21, at 2:51 p.m. NA-B indicated R1 self-propelled the halls in wheelchair, but R1 does not endanger self or others. Further, NA-B stated R1 tended to get emotional and would cry when staff talk to R1. R1 wanted to remain in R1's wheelchair and wouldn't remain at the table in the dining room. NA-B indicated NA-B then placed a broom behind R1's wheelchair as unknown staff did a few weeks back. LPN-A then approached NA-B after R1 begun crying from not being able to move wheelchair away from dining room table, and informed NA-B placing the broom there is considered a restraint. On 3/3/21, at 8:38 a.m. trained medication assistant (TMA)-A stated, I think it's part of [R1's] condition all of a sudden she is happy and then starts crying. Sometimes R1 will be sitting at the supper table and all of a sudden tears will stream down. Further, TMA-A indicated TMA-A has noticed a broom under R1's wheelchair in the dining room and stated it has aggravated me, but [R1] was not physically hurt, I know the other parts are [R1's] emotional state. In addition, TMA-A stated R1 is unable to reach the broom stick when placed under the wheelchair due to limited mobility, but [R1] gets frustrated because [R1] can't move. [R1] would cry and you could see it on [R1's] face and [R1's] expressions are sad, worried, and fear like [R1] has that scared look. Then the girls [staff] just keep her at the table and the food comes. It is so very sad. On 3/3/21, at 12:08 p.m. DON indicated she was made aware of the incident on 2/23/21, when RN-A called. Further, DON stated, I had to think a little, it's a restraint and I need to report it. DON indicated NA-A put the broom under R1's chair for convenience. In addition, when asked about the effect it had on R1, DON stated at the moment it did have an effect on her, but not a [MEDICATION(S)] one. [R1] would cry and wanted to get away. My concern was there was not a tip bar on [R1's] wheelchair so there was a potential for harm. As we looked at the video, this went on for at least a month, they [staff] all should know better. DON further indicated two online training's (abuse and restraints) were assigned for staff to complete within two weeks, and stated, I have already started to do the coaching forms [for employees involved] but I am not calling them in for this. I have about 8-9 people and I will meet with them the next time they work. Facility policy titled, Mother of Mercy Senior Living dated 2/25/21, indicated, The purpose of these physical restraint guidelines are to assist each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Further review of policy, defined physical restraint as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. In addition, convenience is defined as any action taken by the facility to control a resident's behaviors or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest. The policy indicated guidelines that direct staff when to utilize the use of a restraint.

Based on observation, interview and record review, the facility failed to followed manufacturer's instruction to ensure full body lift slings and stand lift harnesses were free of wear and tear and safe to use for transfers for 1 of 3 (R84) residents reviewed for accidents. This resulted in actual harm to R84, when a sling ripped during a transfer causing R84 to fall to the floor resulting in a laceration to the back of the head. In addition, the facility failed to assess the safety and risk of entrapment of side rails/grab bars for 1 of 3 residents (R6) reviewed for accidents. Findings include: R84's admission Minimum Data Set (MDS) assessment, dated 2/13/17, indicated R84 was totally dependent and required 2+ person physical assist for transfers. The Care Area Assessment (CAA), dated 2/14/17, indicated R84 had diagnoses, which included multiple sclerosis with quadriplegia. R84 was completely dependent for activities of daily living and mobility. R84 transferred with the assistance of two staff and an EZ (full body) lift for all transfers. R84's quarterly MDS dated 5//16/17, indicated moderate cognitive impairment. R84's care plan, last review date of 7/25/17, indicated R84 required assistance of 2 staff and an EZ lift for all transfers. The care plan indicated R84 had a witnessed fall on 7/6/17. On 7/7/17 an intervention to make sure the EZ lift sling was double looped at all times was added to R84's care plan. An Event Report, dated 7/6/17, indicated R84 fell from an EZ lift during a transfer from the bed to a wheelchair around 3:45 p.m. on 7/6/17. Two nursing assistants (unidentified) assisted with the transfer. While one nursing assistant assisted R84's feet/legs off the bed, a second nursing assistant maneuvered the lift. As soon as R84's feet were off of the bed, the sling loop ripped. The report lacked documentation identifying which of the sling's 4 loops ripped. R84 fell to the floor, hitting his head/upper body first. Several nurses responded. R84 was bleeding from the back of the head. R84 complained of pain to the back of the head, rating the pain 5 out of 10 (10 being the most severe pain). Staff called for emergent transportation around 4:00 p.m. Emergency services arrived around 4:10 p.m., and R84 was transported to the hospital at 4:14 p.m The facility's fall investigation, dated 7/12/17, identified two nursing assistants that will be identified as nursing assistant (NA)-G and nursing assistant (NA)-H. The investigation indicated the facility purchased the sling in November 2016 and following the fall, a representative (rep)-D from the EZ Way lift company came to the facility and inspected all the lift slings and stand harnesses with the director of nursing (DON). In addition, the investigation indicated It has been policy that both laundry and nursing staff inspect slings for any fraying or other problems. This policy has been followed. Policy changed so all lift transfers will be double looped. Hospital documentation, dated 7/6/17, indicated that R84 had head trauma after falling 4 feet from a lift. R84 reported pain to the back of the head. R84 had two curved lacerations measuring approximately 2.0 inches each in length on the left occipital (back of head) region and a subcutaneous hematoma (bruise) to the left parietal occipital (mid to lower back of head) region. The left lateral laceration was repaired with Dermabond (skin glue.) The right laceration was closed with 11 sutures. R84's progress notes, dated 7/6/17, indicated R84 returned the same day at 9:45 p.m During interview on 7/25/17, at 6:15 p.m. NA-G stated NA-H assisted with the transfer. NA-G stated he looked at the sling prior to use and did not see any rips or frays. NA-G stated both staff attached the four loop straps to the lift. NA-G stated he placed all three loops of the strap (triple looped) on the hook on the lift, stating only the shortest one is tight. NA-G was unsure which straps he attached to the lift and which straps NA-H attached. NA-H lifted R84 into the air. NA-G stated he believed all loop straps were attached to the lift. NA-G guided R84's feet off the bed, while NA-H moved the lift. NA-G stated the lift was about 4-5 feet from the bed, when one of the loops broke. NA-G stated he believed it was the top right loop strap. NA-G went on to say the loop thread ripped and R84 fell to the floor. During an interview on 7/26/17 at 11:34 am, the DON stated she responded to R84's room after the fall, and added, The aides told me the loop fell off. The DON brought out the sling used during the fall. The black loop (shortest of the 3 loops on the strap) on the upper left shoulder side was ripped at the stitching. The loop was open and no longer intact. There was no other wear, tear, or fraying on the sling. The sling was dated November 2015 (different from the fall investigation report that indicated a purchase date of November 2016). The DON stated slings are dated when they arrive at the facility, and it is unknown when the sling was put into use. The DON stated, We always check for fraying. The DON stated rep-D came out and they looked at all the slings and no slings were frayed. The DON further stated that two slings were older than 2 years and thrown out per rep-D's recommendation. The DON stated rep-D recommended to continue to examine the slings and make sure the slings are laundered properly. During an interview on 7/26/17, at 12:39 a.m., rep-D stated she came out to the facility after the fall. Rep-D looked at the sling with the ripped loop and sent a picture of the rip to EZ Way corporate staff, who thought the rip was unusual. Rep-D stated the wear of the sling at the site of the rip prior to the fall was not known. Rep-D stated she looked at other full body lift slings and stand lift harnesses while at the facility; however, could not guarantee she saw all the slings and harnesses at the facility. Rep-D stated she recommended a couple of stand lift harnesses be removed from use due to age. Rep-D recommended staff look at slings for wear and tear prior to each use. Rep-D stated EZ Way recommends slings are replaced after one year. Rep-D went on to say if the sling used during the fall was over a year old she would have recommended it to be replaced. During an interview on 7/26/17, at 2:47 p.m. and 7/27/17, at 8:44 a.m. registered nurse (RN)-G stated NA-H was pool staff at the time of the fall. RN-G stated she trains pool staff; however, does not provide training on the lifts to pool staff. Attached to the lifts was a policy, undated, titled EZ Lift Safety & Maintenance Checklist. #12 of the checklist directed: Check the entire sling for damage or wear, including the loops and stitching. If damage or wear is present, discard the sling and order a new one. It is recommended that slings be replaced after one year or if the sling shows any sign of damage. Hand written in was: checked by director of nursing. The policy indicated: It is the responsibility of the purchaser to ensure that regular maintenance inspection is conducted on the device by competent staff. Attached to the policy was a fill in check list form. #1 to #11 on the check list were filled in with monthly dates and initials. #1 through #11 referred to maintenance of the lift itself, which included checking bolts, cables, wheels, brakes, and for checking damaged, missing, or loose parts. #12 referred to checking the slings. #12 indicated: Checked by Director of Nursing-Slings. #12 was blank on all the check lists. These checklists contained several months of information with some dating back to 2016. During a follow-up interview on 7/27/17, at 12:43 p.m. the DON stated pool staff are given orientation on the unit by shadowing another aide. NA-H's competency with the lifts was based on his prior work history of [AGE] years working as a nursing assistant and having worked at the facility for 9 months without incident. The DON stated the rip in the sling was a result of a defective sling. She went on to state that prior to the fall it was policy for staff to check the slings for wear and tear prior to each use. The DON stated in relation to the manufactures recommendation to replace slings after one year it's a recommendation, it's not an absolute policy. The administrator joined the interview at the DON's request. The administrator reviewed the manufacturer's recommendations. The administrator stated if the facility's policy was to follow the manufacturer's instructions, the slings need to be replaced yearly. The DON stated due to the large number of older slings, she would inspect all slings by tomorrow and toss any worn slings or slings dated 2013 or older immediately. She stated she would order a few slings at a time and all slings will be under a year old in 90 days. The DON stated after the fall, notices were put up reminding staff to check the slings for wear and tear and not to use if wear or tear was present. In addition, the DON stated she had spoken with the laundry supervisor who told her she always checks for wear and tear of the slings. The DON went on to say she was unaware of the EZ lift checklist relating to the director of nursing checking the slings. A form provided by the facility identified 24 residents at the facility use a stand lift for transfers and 6 residents use a full body lift for transfers. Observations of the facility's full body lift slings and stand lift harnesses with the director of nursing on 7/27/17, between 3:07 p.m. and 3:54 p.m. revealed the following: -1st floor had 7 stand lift harnesses. 3 were not dated and had no wear or tear. 1 had a date of over a year old, with no wear and tear. 1, the DON stated the tag was old and worn and removed from use. The remaining 2 were less than a year old with no wear and tear. -1st floor: 7 full body slings. None of the 7 slings were dated. The DON stated 3 of the slings had fraying. DON stated 1 of the slings looked old and did not like the way one of the straps looked. The DON removed the 4 slings from use. -2nd floor: 4 stand lift harnesses. All 4 had dates of over a year old. 1 harness had no wear and tear. The DON identified 3 of the harnesses had fraying and removed the 3 harnesses from use. -2nd floor: 5 full body slings. 3 of the slings were not dated and showed no wear or tear. 1 had a date of over a year with no wear or tear. The DON identified 1 with fraying and removed the sling from use. -3rd floor: 7 stand lift harnesses. 2 had dates of over a year (4/13 and 3/14) with no wear or tear. The DON removed the 2 harnesses from use due to age. The DON removed 2 undated harnesses from use stating the harnesses looked old. The DON removed 1 undated harness from use stating the harness had fraying. 2 harnesses had dates of under a year with no wear and tear. 3 harnesses and 3 full body slings were located in the DON's office. These had been previously removed from first floor by the surveyor on 7/26/17, to investigate condition and age. 1 harness, dated 4/14, had no wear or tear. 1 harness, dated 4/14, had fraying. 1 harness, dated 4/13, had no wear or tear. 1 full body sling had a date over a year old, which the DON stated had no wear. 2 full body sling were undated, which the DON stated had wear. The DON removed the 3 harnesses and 3 full body slings from use. The DON stated after the fall, all the harnesses may not have been checked. During an interview on 7/27/17, at 8:53 a.m. when asked about checking for wear and tear. laundry aide (LA)-B stated she does not check the harnesses. During an interview on 7/24/17, at 1:46 p.m. both NA-I and NA-J stated they were aware of the fall and had received education after the fall to check the slings prior to use for fraying and rips, however, both NA-I and NA-J stated prior to the fall they did not check the slings. During interviews on 7/27/17, with 10 nursing assistants, all stated they now inspect the slings for wear and tear prior to use and would not use the sling if wear or tear was present. The facility's EZ Lift Training Guidelines procedure, dated 5/17/13, indicated a minimum of two staff are needed to operate the EZ lift. The guidelines lacked direction to check the sling for wear and tear. The facility's policy titled Mechanical Lift Transfers, dated 2008, indicated to Follow Manufacturer's Instructions. EZ Way manufacturer's manual for the full body and EZ Way stand lift included the following: The pre-operation check directed Before operating the unit, complete a maintenance safety check for loose nuts and bolts and damaged parts. Also, ensure the sling is not ripped, frayed, or showing signs of wear. EZ Way recommends all slings be replaced after one year, or at the first sign of wear. Additionally the manual indicated: water washing temperature, detergents and disinfectants, patient incontinence, frequency of use, types and weights of patients, etc., all have an impact on the life expectancy of each product. Because of these factors, the continued integrity of the product is not guaranteed. The user must therefore examine the product to ensure its integrity before each use. Users must accept full responsibility for checking the condition of all slings and harnesses before each and every use on a patient. SIDE RAILS R6's quarterly Minimum Data Set (MDS), dated [DATE], identified no cognitive deficit and indicated needing extensive assistance with bed mobility and transfers. R6's current physician orders [REDACTED]. A facility progress note dated 3/6/17, at 2:40 p.m. identified an annual review of R6's adaptive equipment, including bed rails, had been conducted. The note indicated R6 had bilateral quarter rails which were appropriate for her, as she was alert, oriented and could participate in bed mobility. The review lacked documentation of the extra grab bar. A facility progress note dated 6/5/17, at 6:47 p.m. identified a quarterly review of R6's adaptive equipment had been conducted. This review noted a grab bar on the left side of the bed, along with bilateral half rails that were used to promote R6's mobility. The review indicated the grab bar and side rails were appropriate for R6, since they did not restrain her and she has adequate upper body strength to push away from the rails. A Side Rail Consent Form, dated 5/30/17, was signed by R6's power of attorney (POA). The consent included the risks of side rail use attributing to strangulation, injury, and/or death. The consent further indicated the policy of this facility to use side rail(s) only after an assessment and care planning deem it appropriate, and further identified In all instances, the least restrictive device, which is effective, will be used. The consent identified a side rail assessment had been completed and maintenance had been notified. R6's care plan, dated 3/21/12, identified the need for assistance with bed mobility. The care plan further directed R6 needed limited to extensive assist of one to two staff, with more assistance needed when weak or tired. It noted R6 was able to participate in some turning/repositioning, using the bed rails, and She does have an extension to side rail that family wanted. R6's medical record lacked documentation of any assessment of entrapment risk or alternative to bed rails trialed. During observation on 7/26/17, at 9:41 a.m. R6 was sitting in her wheelchair. Nursing assistants (NA)-A and NA-B came into the room and transferred R6 from the wheelchair to the bathroom using a standing lift. During observation, bilateral side rails were noted on R6's bed, and on the left side about half way down the bed, a U shaped grab bar was noted. The grab bar was wide, taller than the side rails, and covered with black foam. The grab bar was also observed tucked under the mattress. When checked for for security of the rail connection to the bed, the grab bar was easily slid out from under the mattress, as the bar was not affixed or secured to the bed. During interview on 7/26/17, at 9:49 a.m. NA-A stated R6's family brought in the grab bar. NA-A stated R6 got out on the right side of the bed, so the grab bar was just for bed mobility with turning at night. NA-A stated R6 needed both the side rail and grab bar on the left side depending on how far down she was in the bed, further stating R6 would slide down in bed and they would boost her up, then she could use the side rail instead of the grab bar. NA-A reported R6 needed assistance with turning in bed and could not turn independently. During interview on 726/17, at 11:21 a.m. R6 stated she had used the grab bar at home and it was easier to hold herself. R6 denied any injury from using the grab bar; however, she denied being told the risks of using it, stating she was just told as long as it helps. During interview on 7/28/17, at 8:33 a.m. the director of maintenance (DM) observed the grab bar, stated it was way to wide, and measured the length and width of the grab bar. DM stated at the widest/tallest points for both width and length were 13 inches. DM stated he received an assessment from nursing to get the okay to put grab bars on the beds; however, further reported he had not seen the grab bar and had not put it on the bed. DM stated family probably brought it, stating yeah need to fix this, acknowledging the grab bar was unsafe because it was not affixed to the bed. The DM stated the facility never installed bars that weren't secured to the bed because of the risk of falling out. He further stated the facility did not measure rails or bars for entrapment, but used manufacture approved side rails with approved sizes. The DM reported (staff) know better. During interview on 7/28/17, at 11:09 a.m. registered nurse (RN)-F stated the grab bar was requested by R6's family, so when R6 slid down in bed, it was easier to reach the grab bar. RN-F stated R6 had an assessment, order and a consent for the grab bar, a process which had just been started a couple weeks ago. RN-F stated prior to that, there was no process for assessing grab bars. RN-F stated the assessment identified if the bar was a restraint and the safety of the resident to use the bar related to medication, falls, and behaviors. RN-F reported the assessment did not address entrapment; however, the consent did identify the risk of it. RN-F did not think the grab bar needed to be affixed to the bed stating R6's weight held it in place, and R6 pull the grab bar towards her, not pushing it away from the bed. During interview on 7/28/17, at 11:53 a.m. the director of nursing (DON) expected residents to be safe while using grab bars, wanting them to be alert and oriented. The DON stated she used to have a 4.5 inch block she would measure for entrapment, but still wanted residents to be safe even if the bars fell into the measurement recommendations. The DON stated the many different kinds of side rails at the facility makes me nuts, had recently assessed every side rail and grab bar in the facility, and had not found any that big. The DON reported she was not familiar with R6's grab bar; however, the safety of it not being affixed to the bed depended on why R6 used the grab bar. If R6 used it just to turn in bed then it was not an issue, further stating she did not see anything wrong with what they had now. A facility policy was requested but not provided.