Every finding on record at BHM Carrollton Opco LLC

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to protect one of three sampled residents' (R) (R1) rights to be free from physical and verbal abuse by a staff member when Certified Nursing Assistant (CNA) NN struck R1 while providing care. Findings include:Review of the facility's policy titled Abuse, Neglect, and Exploitation, revised 03/05/2024, included, It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Further review revealed the Definitions section included Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability.Review of the Facility Incident Report, dated 05/21/2026, revealed that the facility reported an allegation of physical/verbal abuse by CNA NN against R1 to the State Survey Agency (SSA).Review of the [Name] County Sheriff's Office Incident Report, dated 05/21/2026 at 5:00 AM, revealed the officer spoke with a family member of R1 and viewed video footage captured by a camera in R1's room. The report documented that the office witnessed CNA NN striking R1 in the face with the backside of his hand. The report documented that there were no injuries observed on R1's face at the time of the report. Review of the facility-provided Separation Notice revealed that CNA NN was terminated on 5/21/2026. The Reason for Separation section documented Abuse/Resident Rights. Review of the electronic medical record (EMR) revealed R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, metabolic encephalopathy, type 2 diabetes mellitus, bipolar disorder, major depressive disorder, anxiety disorder, atherosclerotic heart disease, chronic kidney disease, hypertension, hypothyroidism, chronic pain, insomnia, and generalized muscle weakness.Review of R1's quarterly Minimum Data Set (MDS) assessment, dated 03/04/2026, revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Section GG (Functional Abilities and Goals) revealed R1 required substantial to maximal assistance with activities of daily living (ADLs). Review of the care plan revealed a Focus initiated on 05/21/2026, of the resident had experienced abuse. The Goal was for the resident to have no indicators of psychosocial well-being problems. Interventions included assessing the resident for nonverbal signs of abuse, behavior monitoring, building relationships and trust with the resident, providing emotional support services as needed, and reporting any concerns the resident voices about care.Interview on 06/04/2026 at 11:00 AM with R1 revealed that CNA NN had slapped her and stated the incident occurred one time. R1 stated she felt alright now and felt safe in the facility. R1 stated she did not report the incident to facility staff at the time it occurred and instead called her son. R1 stated that her son observed the incident through a camera located in her room. Review of the Progress Notes for R1 revealed an entry dated 05/21/2026 at 12:24 PM that documented that a full assessment was conducted by the unit Manager, Registered Nurse (RN), and direct caregiver, Licensed Practical Nurse (LPN), Unit Nurse. No major injuries or acute distress were noted during the assessment. Review of the Progress Notes for R1 revealed an entry dated 05/22/2026 by the Nurse Practitioner (NP) that documented the chief complaint was for an evaluation following a reported incident of physical abuse by a facility care partner. The note documented that the resident reported no acute concerns, there was no obvious bruising or signs of trauma noted, and the resident was calm, and affect was appropriate. Review of the Progress Notes for R1 revealed an entry dated 05/22/2026 for a psychiatric evaluation. The assessment documented the resident reported being struck once in the face by a male staff member in her room. The follow-up recommendations were for staff to notify psychiatry services if the resident begins to exhibit signs of worsening mood, anxiety, confusion, or behaviors between visits. Interview on 06/04/2026 at 11:57 AM with the Director of Nursing (DON) revealed that R1's son presented the facility administration with video footage of the incident between 11:00 AM and 12:00 PM on 05/21/2026. After reviewing the video, facility leadership determined the allegation was reportable and initiated an abuse investigation. Interview on 06/04/2026 at 12:53 PM with the Administrator revealed that on 05/21/2026 at around 11:45 AM, R1's son and daughter-in-law arrived at the facility requesting a meeting. During the meeting, video footage was presented from a camera placed in R1's room. The video reportedly captured CNA NN providing care to R1 at around 5:00 AM on 05/21/2026. The Administrator stated that while the video did not clearly show physical contact, it captured CNA NN speaking to R1, and stating, turn, I do not like liars, followed by a visible flinch by the resident. Immediately afterward, R1 was heard stating, You better not ever hit me again, leading facility leadership to believe that CNA NN had physically struck the resident. The facility implemented the following corrective actions after becoming aware of the allegation on 05/21/2026:1. On 05/21/2026, the facility submitted an incident report to the State Survey Agency (SSA) and reported to the State CNA Registry.2. On 05/21/2026, CNA NN was removed from resident care duties pending investigation.3. On 05/21/2026, the facility notified local law enforcement. A police report was completed on 05/21/2026 at 3:00 PM. Case Number: 202605004835.4. On 05/21/2026, CNA NN was terminated from employment. 5. On 05/21/2026, a skin assessment was completed for R1, and no injuries were identified. 6. On 5/21/2026, the facility completed full head-to-toe skin assessments for all residents with a BIMS score below 10. No findings indicative of abuse, neglect, or unexplained injury were identified.7. On 5/21/2026, the facility conducted structured abuse screening interviews for all interviewable residents with BIMS scores above 10. No findings indicative of abuse, neglect, or unexplained injury were identified.8. On 05/22/2026, R1 received a psychiatric evaluation. 9. From 05/21/2026 through 06/02/2026, the facility provided abuse prevention education to all staff.10. On 05/21/2026, the facility conducted a Quality Assurance and Performance Improvement (QAPI) meeting to address the incident. The attendees included the Medical Director, Administrator, and DON.

Based on observations, staff interviews, and review of the facility's policy titled, Food Safety Requirements, the facility failed to store, handle, and serve food in a safe and sanitary manner by failing to: ensure expired food items were discarded; ensure food items were properly labeled and dated; properly store raw meat to prevent cross-contamination; maintain food storage areas in a clean condition; properly store food off the floor; ensure equipment and surfaces were maintained in a sanitary condition; and ensure meal tray carts were covered during transport. This deficient practice had the potential to affect all 94 residents who receive food orally by placing them at increased risk for foodborne illness, contamination, and infection.Findings included:A review of the facility's policy titled, Food Safety Requirements, revealed the policy, dated revised 1/4/2024, to read in part:Regarding food labeling, dating, and storage: Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded.Regarding raw meat storage and cross-contamination: Separating raw foods (e.g., beef, fish, lamb, pork, and poultry) from each other and storing raw meats on shelves below fruits, vegetables or other ready-to-eat foods so that meat juices do not drip onto these foods.Regarding food storage conditions: Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. and Dry food storage - keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and vents.Regarding ice machine sanitation: Cleaning and sanitizing the internal components of the ice machine according to the manufacturer's guidelines.Regarding food transport: Covering all foods when traveling a distance (i.e., down a hallway, to a different unit or floor).Regarding equipment sanitation: All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination.An initial brief kitchen tour was conducted on 4/7/2026 at 8:57 AM with the Dietary Kitchen Manager (DKM). The following concerns were identified:Dry Storage/Pantry:Observation conducted on 4/7/2026 at 9:00 AM of the dry storage/pantry revealed four (4) [NAME] Ready Care Thickened Orange Juice items with an expiration date of 2/2/2026, making them expired at the time of observation. Floor surfaces in the pantry were observed with heavy accumulation of food debris, dried food residue, and soiling beneath and around shelving units, indicating a lack of routine cleaning and sanitation of the area. Observation conducted on 4/7/2026 at 9:31 AM revealed an open bag of white bread that was not labeled with an open date or expiration date.Cooler:Observation of the cooler conducted on 4/7/2026 at 9:19 AM revealed six rolls of [NAME] Choice Ground Beef 77% Lean/23% Fat stored directly on top of a cardboard box without a leak-proof container to contain meat drippings during thawing. Additionally, a cardboard box containing additional ground beef that was thawing was observed with dark brown staining and dried liquid residue covering a large portion of the box exterior, also without a leak-proof container to contain meat drippings. Additionally, three onions were observed stored directly on the floor of the cooler without being placed on a shelf or in an appropriate container at the required minimum of six inches off the floor. The onions appeared partially peeled and deteriorated, with outer layers coming off. The cooler floor beneath and around the onions was observed with heavy accumulation of food debris, dried spills, yellow/orange residue, and scattered food particles, indicating a lack of routine cleaning. Additionally, unknown sliced deli meat was observed stored in an open, unsealed plastic bag without a date label, with the meat appearing brownish and discolored with dried, curled edges, inconsistent with fresh deli meat, suggesting the item had been stored open and exposed for an extended period. Additionally, a plastic container labeled Staff was observed stored on the cooler shelf, containing what appeared to be staff personal food items, including a head of lettuce and fruit cups, stored without proper date labels or identification on individual items.Freezer:Observation of the freezer conducted on 4/7/2026 at 9:27 AM revealed a box of frozen hamburger/meat patties with the interior bag open, unsealed, and unlabeled, leaving the frozen meat patties exposed and unprotected. Additionally, a box of frozen corn dogs was observed with the interior bag open, unsealed, and unlabeled, leaving the frozen corn dogs exposed and unprotected. Additionally, an unlabeled bag of chicken tenders and an unlabeled bag of raw chicken were observed.Ice Machine:Observation conducted on 4/7/2026 at 8:58 AM revealed the interior of the ice machine with a heavy accumulation of a black substance along the interior seams and corners of the machine.Dishware Storage:Observation conducted on 4/7/2026 at 9:53 AM revealed lids stored on top of the compartment sink on two storage mats in a wet nested condition. Multiple cups and lids were observed stacked and nested together while still wet. The storage mats beneath the cups and lids were observed with visible food debris, dried food residue, and particle accumulation, indicating the storage area was not being maintained in a clean and sanitary condition.Food Transport:Observation conducted on 4/8/2026 at 12:39 PM revealed a tray cart leaving the kitchen uncovered. Observation conducted on 4/8/2026 at 12:40 PM revealed a second tray cart leaving the kitchen uncovered. Observation conducted on 4/8/2026 at 12:50 PM revealed a third tray cart leaving the kitchen uncovered. Observation conducted on 4/8/2026 at 12:53 PM revealed a test tray cart leaving the kitchen uncovered.An interview conducted on 4/9/2026 at 9:54 AM with the DKM revealed the following regarding the identified concerns. Regarding food labeling, dating, and rotation, she stated the facility has a policy and that when the food truck is received, items are labeled with the delivery date and expiration date, and that when items are opened, staff are to label them with an open date and use-by date per a posted kitchen guide. She stated the DKM is responsible for ensuring all food items are labeled, dated, and rotated using a first-in, first-out (FIFO) method, and that she conducts daily audits of food storage areas. She stated that on the day of the survey, she was running late and went straight into the kitchen, which is why several items were found out of compliance. She stated her staff knows they are supposed to label items and that they are not doing so. She stated she expects that all food items are labeled, dated, rotated, and that expired items are discarded promptly. She stated a potential negative outcome is that food will expire more quickly if not rotated, and that residents could become sick or die from foodborne illness related to expired or outdated food.Regarding raw meat storage and cross-contamination prevention, she stated that meat should be stored in a solid, leak-proof container and not in a cardboard box, and that items should be labeled and dated. She stated she would take responsibility for the ground beef observed stored on cardboard without a drip-proof container. She stated her expectation is that meat be removed from boxes, placed in drip-proof containers, and labeled and dated. She stated that a potential negative outcome is that spillage, blood, and moisture could seep through the cardboard box, reach the floor, and potentially contact other food items, causing contamination.Regarding food storage conditions, she stated that food should not be stored on the floor and attributed the onions observed on the cooler floor to staff not following proper procedures. She stated her expectation is that all food items be covered, dated, and labeled, and that no items be stored on the floor. She stated that a potential negative outcome is that bugs will be attracted and the product will spoil more quickly, which would be harmful to residents.Regarding kitchen cleanliness and sanitation, she stated that floors are cleaned as needed and that the area underneath shelving is deep-cleaned once per week. She attributed the heavy accumulation of debris and residue observed in food storage areas to staff not completing their cleaning responsibilities. She stated her expectation is that all areas are kept clean at all times. She stated that a potential negative outcome is that bugs are attracted by food debris and that wet nesting grows bacteria, both of which are harmful to residents.Regarding the ice machine, she stated that the machine is cleaned monthly by the maintenance department and that she would be transitioning to a cleaning frequency of every two weeks. She identified the presence of the black substance as an oversight. She stated her expectation is that the machine be cleaned properly and that a potential negative outcome is sickness to residents.Regarding wet nesting of dishware, she stated that items are supposed to be fully dry before being stored. She acknowledged that wet nesting occurs when two items are stacked on top of each other while still wet and that this practice can grow bacteria. She stated her expectation is that all items are dry prior to being put away and that a potential negative outcome is harm to residents from bacterial growth.Regarding meal tray transport, she stated that tray carts should be covered when leaving the kitchen, that covers help keep food hot, and that covering serves as an extra layer of infection control. She attributed the uncovered tray carts to herself and stated that when she inherited the building, the standard for this practice was low. She stated she is responsible for ensuring tray carts are covered and that a potential negative outcome is an infection control risk during transport.Regarding staff personal food stored in the resident cooler, she stated the facility's policy does not permit staff food to be stored in resident refrigerators or storage areas. She acknowledged that a designated section for staff food had been historically maintained in the resident cooler. She stated her expectation going forward is that no personal food or beverages be stored in the resident's cooler and that staff food will be kept in the break room. She stated that a potential negative outcome is that staff may bring in food from unknown environments, which could contaminate resident food.An interview conducted on 4/9/2026 at 10:45 AM with the Administrator revealed the following. Regarding food labeling and dating, she stated that the DKM is responsible for ensuring all food items are labeled, dated, and rotated. She stated she believed items found out of compliance were taken out of their original packaging without being labeled, and that staff were not being adequately monitored. She stated that a potential negative outcome is that residents could become sick.Regarding cross-contamination and raw meat storage, she stated all kitchen staff are responsible for ensuring raw meats are stored and thawed appropriately. She stated her expectation is that raw meat be properly stored with a drip pan beneath it to prevent contamination of other foods. She attributed the observed deficiency to a dietary error in which staff did not consider the need for proper containment. She stated that a potential negative outcome is that residents could become sick.Regarding food storage conditions, she stated that all kitchen staff are responsible for maintaining proper food storage. She stated her expectation is that staff follow the proper cleaning schedule and that food is stored appropriately at all times. She stated the issue occurred because staff had been avoiding addressing ongoing problems. She stated that a potential negative outcome is that residents could become ill from unclean storage conditions.Regarding ice machine sanitation, she stated maintenance is on a rotating cleaning schedule and that the machine is cleaned every two weeks. She stated her expectation that the schedule be followed and that the machine be kept clean. She attributed the black substance observed to an oversight by maintenance. She stated that a potential negative outcome is that if mold gets into the ice, it will be distributed to residents and could make them sick.Regarding wet nesting of dishware, she stated that dietary staff are responsible for ensuring dishware is properly cleaned, dried, and stored. She stated her expectation is that staff follow the cleaning schedule and that no water be left standing, as it can cause waterborne illness to residents. She attributed the observation to carelessness by staff. She stated that a potential negative outcome is that residents could become sick.Regarding meal tray transport, she stated DKM is responsible for ensuring tray carts are covered during transport. She stated her expectation is that carts are fully covered at all times. She stated that a potential negative outcome is cross-contamination and infection control risk.Regarding staff food storage, she stated DKM is responsible for ensuring staff food is stored separately from resident food. She stated her expectation is that staff use the designated break room refrigerators. She attributed the staff food observed in the resident cooler to convenience and easy access. She stated that a potential negative outcome is failure to follow proper procedures, which could place residents at risk.

Based on observations, staff interviews, record review, and a review of the facility policy titled Routine Cleaning and Disinfection, the facility failed to maintain a safe, clean, and comfortable home-like environment related to dusty grayish buildup on packaged terminal air conditioner (PTAC) units in one of four halls (300 Hall).Findings included:During an observation on the 300 Hall on 4/7/2026 from 10:40 am until 11:40 am and on 4/8/2026 at 8:55 am, two rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) were observed with an excessive amount of dusty grayish buildup on PTAC units. During an interview on 4/8/2026 at 11:38 am, the Maintenance Director (MD) confirmed that the maintenance department services the PTAC units. He stated that he has one maintenance assistant tasked with cleaning the PTAC units throughout the facility, and cleaning the units should occur monthly. The MD verified that he does not implement any procedures in the electronic maintenance system. He utilizes a paper log.During an interview and observation conducted on 4/8/2026 at 11:41 am, Maintenance Assistant PP confirmed that room [ROOM NUMBER] and room [ROOM NUMBER] had a buildup of gray-like dust in the PTAC units. The MD confirmed the concerns and stated that cleaning will be done immediately. A review of facility documentation titled Maintenance Log (PTAC 2026) dated 1/7/2026 through 3/23/2026, the room number column and problem/concern column were blank; the maintenance signature was provided by Maintenance Assistant PP. A review of the policy titled Routine Cleaning and Disinfection dated 2/1/2024, revealed that routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Consulting Physician/Practitioner Orders and Provision of Quality of Care, the facility failed to provide treatment and care in accordance with professional standards of practice for two of 48 sampled resdients (R) (R2 and R48) related to ensuring that physician orders were in place to provide standard of care concerning: 1) catheter care, in that a physician order was not in place for indwelling Foley catheter and catheter care for R2 resulting in approximately 85 days of catheter care provided without a corresponding physician order; and 2) documentation and assessment of bowel movements and risk for bowel impaction for R48 resulting in the resident to be hospitalized for a 24-hour period for nausea and vomiting that was caused by a bowel impaction. These deficient practices had the potential to place residents at increased risk for catheter-associated urinary tract infection (UTI), catheter-related complications, undetected changes in bowel status, and adverse outcomes related to bowel impaction. Findings included: 1. During a review of the electronic medical record (EMR) revealed that resident R48 was admitted to the facility on [DATE], and pertinent diagnoses, including but not limited to cerebral vascular accident ischemic, atherosclerotic heart disease, type 2 diabeties, kidney disease, heart failure, anxiety, constipation, multiple sclerosis, vascular dementia, and major depressive disorder.During a review of R48's annual Minimum Data Set (MDS) assessment, a Brief Interview for Mental Status (BIMS) score of 13 was obtained, indicating R48 was cognitively intact in the 13-15 range. Section GG, functional status, revealed R48 was dependent for all activities of daily living (ADLs) except eating; she required set-up assistance. Section H-She was incontinent of bowel and bladder function. During the review of the care plan, it was revealed that there is no care planning for constipation. Medical records from the recent hospitalization have been requested. Review of the Physician's Orders for R48 included, but was not limited to, Macrobid cap 100mg one time daily, Cymbalta 60mg daily, Colace 100mg daily, Metformin 500mg twice daily, Senna tabs 8.6mg 2 tablets daily, Plavix 75mg daily, Polyethylene Glycol 3350 oral powder, 17 GM scoop, mix in water, given twice daily, starting on 4/4/2026, ordered during the hospital stay.During a review of the facility's policy titled Provisions of Quality of Care, revised 2/1/2024, section 1 revealed that each resident will be provided care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.An observation and interview on 4/7/2026 at 11:31 am with R48 revealed that she had returned from the hospital on 4/1/2026. She went for nausea and vomiting, but it was because she had not had a bowel movement in 3 weeks. She stated that they gave her an enema in the hospital, and she had a bowel movement, and her nausea improved. The resident was lying in bed, and the roommate was very vocal about R48 care. The resident responded to questions appropriately. She was dressed in street clothes and stated that she occasionally got out of bed with a mechanical lift. During an interview with R48 on 4/8/2026 at 2:51 pm, she revealed that she had an enema in the hospital and had a bowel movement, but she has not had a bowel movement since coming back to the facility. She states that her usual bowel movement routine is once a week. She denies abdominal pain; she says she has not had any abdominal pain in a long time. During an interview with the Director of Nursing (DON) on 4/9/2026 at 10:50 am, she revealed that she confirms that R48's hospitalization could have been prevented if the assessment had been more complete. She also attempted to review the CNA documentation, but the EMR system would not allow her to. She was unable to see when the residents' bowel movements were documented prior to her going to the hospital. The DON was able to pull up the week's documentation, and it was documented that the resident had several bowel movements since coming from the hospital. She states they gave her IV fluids, but ultimately the resident requested to go to the hospital.2. A review of the facility's policy titled Consulting Physician/Practitioner Orders revealed the policy, dated revised 2/14/2024, to read in part: The attending physician shall authenticate orders for the care and treatment of assigned residents.A record review of R2's electronic health record (EHR) revealed R2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. R2 had diagnoses including, but not limited to, cerebral infarction unspecified, Alzheimer's disease unspecified, encephalopathy unspecified, altered mental status unspecified, acute kidney failure unspecified, and chronic kidney disease stage 3A.A record review of R2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the following: Section C (Cognitive Patterns) documented that R2 was rarely or never understood. Section GG (Functional Abilities and Goals) documented functional limitations in the range of motion (ROM) with impairment on one side of the upper extremities and impairment on both sides of the lower extremities. Section GG further documented that R2 was dependent on eating, oral hygiene, toileting, showering and bathing, upper body dressing, lower body dressing, and putting on and taking off footwear, and required substantial to maximal assistance with personal hygiene. Section H (Bladder and Bowel) documented R2 had an indwelling urinary catheter, with urinary continence recorded as not rated, and bowel continence recorded as always continent. Section M (Skin Conditions) documented R2 had unhealed pressure ulcers, including two stage 3 pressure ulcers and one stage 4 pressure ulcer, and was receiving pressure ulcer and injury care with a pressure-reducing device for the bed. Section O (Special Treatments, Procedures, and Programs) documented that R2 was receiving hospice care.A record review of R2's care plan revealed an indwelling Foley catheter was initiated on 12/30/2025, with the documented reason being pressure ulcer and skin breakdown. The care plan identified goals for R2 to remain free from catheter-related trauma and to show no signs or symptoms of urinary tract infection (UTI) through the review date of 04/20/2026. Documented interventions included emptying the Foley catheter every shift and as needed, maintaining the Foley catheter strap in place at all times, providing Foley catheter care every shift, observing and documenting for pain or discomfort due to the catheter, and observing, recording, and reporting to the physician any signs or symptoms of urinary tract infection (UTI) including pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, urinary frequency, foul-smelling urine, fever, chills, altered mental status or behavior, and change in eating patterns.A record review of R2's Order Summary Report dated 4/7/2026 revealed the following active physician orders related to the indwelling Foley catheter, all with an order date and start date of 3/25/2026: Foley Catheter: Catheter care every shift and as needed (PRN) every shift, Foley Catheter: Foley Catheter 16 French (Fr) with 10 milliliter (ML) balloon to bedside bag, and Foley Catheter: May change Foley and as needed ( (PRN) every shift. The Order Summary Report revealed an active physician order with an order date and start date of 12/30/2025, which stated: For Your Information (FYI) Enhanced Barrier Precautions related to Indwelling Foley Catheter: Wear gown and gloves during high contact activities every shift for Indwelling Foley Catheter. No physician orders for catheter placement or catheter care were identified in the Order Summary Report before 3/25/2026, confirming that formal facility physician orders for catheter care were absent for approximately 85 days following the care plan initiation date of 12/30/2025.A record review of R2's Medication Administration Record (MAR) for the period of 12/29/2025 through 3/24/2026 revealed no physician orders for catheter placement or catheter care during that period. Record review of R2's MAR for the period of 3/01/2026 through 3/31/2026 revealed that the Foley catheter care every shift and as needed order reflected an entry of X, indicating not administered or not applicable, for days 1 through 24 of March 2026, with documentation of catheter care beginning on 3/25/2026 and continuing through 3/31/2026. The Foley catheter may change as needed order reflected the same pattern, with entries of X for days 1 through 24 and documentation beginning on 3/25/2026. Record review of the Enhanced Barrier Precautions order related to the indwelling Foley catheter revealed staff sign-offs every shift from 12/30/2025 through 3/31/2026, confirming that catheter care activities were being performed by staff throughout the entire period in which no corresponding facility physician order for catheter placement or catheter care existedA record review of the Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care Update Report dated 1/2/2026 revealed that the hospice plan of care, effective 1/1/2026, included an order for the hospice nurse to maintain the indwelling catheter 16 French (Fr)/10 cubic centimeter (cc) balloon and to change the catheter every four weeks or as needed, confirming the catheter was in place at the time of hospice admission on [DATE]. Record review of the Hospice IDG Comprehensive Assessment and Plan of Care Update Report dated 2/27/2026 revealed the Medical Social Worker (MSW) narrative stated R2 receives nourishment via feeding tube and has a catheter, confirming the catheter remained in place through at least 2/27/2026.A record review of a communication note dated 3/26/2026 at 5:26 PM revealed the following documentation: Resident daughter [NAME] notified of order placed by hospice Medical Doctor (MD) for foley catheter placement. Resident daughter verbalized understanding and has no concerns or questions at this time. This communication note confirmed that a formal order for catheter placement was entered on 3/25/2026.Interview conducted on 4/8/2026 at 1:19 PM with the Certified Nursing Assistant (CNA) GG revealed that she has been employed at the facility for approximately six months and is typically assigned to the 400 Hall, describing herself as familiar with R2. CAN GG revealed that when R2 first returned from the hospital around December 2025, that was when she first began providing catheter care to R2, and confirmed that to her knowledge, R2 has had a Foley catheter in place continuously since that time. CNA GG revealed that when documenting care in the facility's electronic health record (EHR) system, she selects the incontinence documentation option and records R2 as incontinence not rated due to indwelling catheter, confirming her ongoing awareness and consistent documentation of the catheter's presence throughout her time caring for R2.Interview conducted on 4/08/2026 at 1:24 PM with the Unit Manager Registered Nurse (RN) FF revealed that she has been employed at the facility since 03/22/2026 and confirmed that she is aware that R2 has an indwelling Foley catheter. After reviewing R2's physician orders, RN FF confirmed that R2's indwelling Foley catheter has been in place continuously since 12/30/2025 and that there was no physician order for catheter placement or catheter care until 03/25/2026. RN FF confirmed that she personally reviewed the discontinued orders to determine whether any prior catheter orders had been entered and subsequently discontinued, finding none. RN FF revealed that she was unable to provide an explanation as to why no formal physician order had been in place during those 85 days and confirmed that it was the Director of Nursing (DON) who identified the missing order and entered it into the system on 03/25/2026. The Unit Manager Registered Nurse (RN) revealed that based on her professional expertise as a RN, it was her clinical judgment that a physician order should have been in place in order for catheter placement and care to be provided, and she acknowledged that the absence of such an order during that period posed potential negative outcomes for R2, including but not limited to an increased risk for infection and other catheter-associated complications.An interview conducted on 4/8/2026 at 1:28 pm with the Director of Nursing (DON) revealed that she has been in the role for approximately 30 days and confirmed that R2 has an indwelling Foley catheter that was first placed when R2 returned from the hospital in December 2025. DON revealed that when asked about the absence of a formal facility physician order for catheter care on the Medication Administration Record (MAR) before 3/25/2026, representing approximately 85 days of catheter care provided without a physician order, she confirmed that she was the individual who identified the missing order and subsequently entered it into the system. DON revealed that during the time of R2's admission or readmission, the facility was utilizing agency nursing staff who did not capture all orders at that time, and that in her role as Assistant Director of Nursing (ADON) at that point, she was not conducting admission or readmission evaluations, which contributed to the order being missed during that process. DON revealed that she discovered the missing order while conducting a routine order review and that upon recognizing R2 had an indwelling Foley catheter with no corresponding physician order in the system, she entered the order on 03/25/2026. DON revealed that when asked about potential negative outcomes associated with a catheter being in place without a formal physician order, she acknowledged that R2 could have been at increased risk for a urinary tract infection (UTI) and other catheter-associated complications as a result of the missing order and the absence of a formal order-driven monitoring protocol during that period.An interview conducted on 04/09/2026 at 11:13 AM with the Administrator revealed that she stated R2 should have had a physician order and that when R2 returned from the hospital, that order should have been put in at that time. The Administrator stated it was a lack of informing the physician of the order, and stated that a lot of the time they have agency nurses and that they also have processes in place for orders, but was not sure how that was missed. The Administrator stated her expectation is that upon any resident's return from the hospital, they have orders for catheter care and for the catheter itself. The Administrator stated that potential negative outcomes associated with a catheter being in place without a formal physician order could cause re-infection and sepsis.

Based on observation, interview, and record review, the facility failed to ensure appropriate safety interventions were implemented and followed for one of 48 sampled residents (R) (R11) by failure to ensure the resident wore a smoking apron while smoking. This deficient practice placed the resident at risk for burns and other accident hazards related to smoking injuries.Findings included:A review of facility policy titled Protocol: Smoking, undated, revealed in the designated smoking area section, fire extinguishers/smoking blanket will be available in designated smoking areas. Smoke-Free Facility -Grandfathered in Policy Acknowledgement provided dating 4/9/2026.A review of R11's electronic medical record (EMR) revealed the resident was initially admitted to the facility on [DATE] with diagnoses of intracapsular fracture of the right femur, chronic obstructive pulmonary disease, dementia, major depressive disorder, acute respiratory failure, and contracture of the right ankle.A review of R11's EMR titled Smoker Screen, dated 8/4/2025, indicated the resident requires a protective assistive device while smoking (i.e., smoking jacket or apron).A review of R11's Minimum Data Set (MDS) assessment revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, which revealed the resident was cognitively intact.A review of the care plan R11 smokes and is at risk for burns and other injuries. Interventions: Advise her & family not to keep cigarettes or lighters in her room & all smoking supplies are to be kept at the nurses' station. Assist her to & from the smoking area during assigned times as/if needed. Assure that she will always be supervised during smoking times. Inform the family when she is low on cigarettes. Inform her of smoking location & times. Monitor skin & clothing for burn areas. Smoking assessments to be completed quarterly as long as she continues to smoke. Weekly room safety checks for smoking supplies.An observation on 4/7/2026 at 10:02 AM revealed R11 going outside to the designated smoking area with the Activities Assistant with Certified Medication Aide (CMA)2. R11 did not have on a smoking apron. Signage posted with smoke break times of 10:00 am, 1:00 pm, 4:00 pm, and 6:00 pm.An observation on 4/7/2026 at 10:00 am revealed R11 smoking in the designated area without a smoking apron, with a staff member supervising.An observation on 4/8/2026 at 10:00 am revealed R11 smoking in the designated area without a smoking apron, with a staff member supervisingAn observation on 4/9/2026 at 10:01 am revealed the resident being escorted via wheelchair to the designated smoking area by Activities Assistant MM. She applied a smoking apron to the resident, provided a cigarette, and lit it for her. Two fire extinguishers were observed in the smoking area.An interview with Activities Assistant NN on 4/8/2026 at 2:02 pm revealed that R11 has not worn a smoking vest due to the facility not having one. Activities Assistant NN, a few months ago (August 2025, September 2025), observed ashes fall on the resident's clothes, burn a hole, but it was not reported nor was it documented. Later stated she didn't see the ashes fall on the pants, but noticed a burn hole on her pants and assumed it was from smoking.An interview with Activities Assistant MM on 4/9/2026 at 10:01 am revealed her taking R11 out for her smoke break. Activities Assistant MM stated that cigarettes are retrieved from a locked nurses' cart for Hall A. Today was the first day that R11 was observed and required to wear a smoking apron. She stated that she was not aware that a smoking vest was required (nor did the facility have one) and confirmed that she lights the cigarette for the resident. Activities Assistant MM states she had not received any education on smoking since she was hired in 2021.An interview with the Director of Nursing (DON) on 4/8/2026 at 12:05 pm revealed the facility is designated as a non-smoking environment, except for one resident who has been grandfathered in for smoking privileges. The DON stated that staff are expected to supervise residents during smoking and assist with lighting cigarettes. Residents are required to extinguish cigarettes in the ashtray. Additionally, the DON indicated that the facility's smoking policy and procedures will be reevaluated. Regional Registered Nurse (RN) CC and Regional RN DD were also present during the interview.

Based on observations, record review, staff interviews, and review of the facility policies titled Oxygen Administration and Oxygen Concentrator, the facility failed to ensure that three of 11 sampled residents (R) (R45, R104, and R56) received respiratory care as ordered related to oxygen therapy and a Bilevel Positive Airway Pressure (BIPAP) machine.Findings included:1. During an observation on 4/7/2026 at 11:41 am and on 4/8/2026 at 8:55 am, R45 was observed receiving oxygen therapy via a nasal canula at the flow rate of between 3.0 and 3.5 liters (L). In addition, the oxygen concentrator filter was observed to have a gray-like dust build-up. During an observation and interview on 4/8/2026, at 9:52 am, Registered Nurse (RN) BB confirmed the concentrator filter had a considerable accumulation of dust-like particles. RN BB stated that R45 has been diagnosed with chronic obstructive pulmonary disease (COPD), which includes symptoms of shortness of breath and hypoxia. She stated that the concentrator filters should not contain dust, but she will verify the flow rate and provide further information. RN BB mentioned the nurses on the night shift are supposed to check and clean the oxygen equipment, and that unclean filters could cause respiratory distress. At 10:11 am, RN BB clarified that the Maintenance Director and third-party providers are to clean the respiratory equipment. A review of the electronic medical record (EMR) revealed that R45 was admitted to the facility on [DATE] with diagnoses including, but not limited to, chronic respiratory failure with hypoxia, paroxysmal atrial fibrillation, gastro-esophageal reflux disease without esophagitis, and COPD. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that R45 presented with a Brief Interview for Mental Status (BIMS) score of eight, indicating that R45 presents with moderate cognitive impairment. The assessment further revealed that R45 was receiving oxygen therapy. A review of the physician's revision order dated 8/18/2025 for R45 revealed oxygen 2L per minute via a nasal cannula continuously with exertion and sleep. A review of the care plan initiated 3/28/2025 revealed that R45 was receiving oxygen therapy with interventions including, but not limited to, monitoring and documenting side effects and effectiveness, and providing oxygen therapy at 2L via the nasal canula as ordered by the physician. 2. During an observation and interview on 4/7/2026 at 12:41 pm, R104's BiPAP (Bilevel Positive Airway Pressure) machine didn't have a filter. During an interview, R104 stated that the mask was never sanitized. RN FF was the manager of the unit, and she stated that a third-party provider was expected to configure the machine settings. However, the third-party provider only delivered several machines, and she was uncertain about specific residents assigned to each machine. She confirmed that the BIPAP machine does not contain a filter and that there are no filters available in stock for weekly replacements, as necessary. A review of the EMR revealed that R104 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including, but not limited to, acute and chronic respiratory failure, chronic obstructive pulmonary disease, type 2 diabetes, anxiety, polyneuropathy, atherosclerotic heart disease, opioid dependence, chronic pain syndrome, and fracture of the first thoracic vertebra. A review of the MDS assessment dated [DATE] revealed that R104 presented with a BIMS score of 14, indicating that the resident was cognitively intact. A review of the care plan dated 3/9/2026 revealed that R104 was diagnosed with COPD and was using my BIPAP machine. It was noted that the BIPAP should be used as ordered, listing parameters; assess and document respiratory rate, heart rate, oxygen requirements, and lungs sounds as needed; clean mask and tubing per manufacturers guidelines; connect the filter and tubing to the device and the mask as needed (usually used at night for 8 to 10 hours; and plug device into a power source or use the detachable battery as needed. A review of the physicians' orders revealed that R104 was ordered to require BiPap at night, to start at the hour of sleep following setting parameters; place oxygen tubing and nebulizer in a bag when not in use; and change bag, oxygen tubing, nebulizer mask, water, and date weekly. A review of the progress note dated 4/8/2026 documented, resident's oxygen concentrator filter was heavily soiled with dust, and the oxygen flow rate was set at 3.5L/min. The RN entered the resident's room to assess the patient, reviewed the current oxygen order in the MAR (Medication Administration Record), and adjusted the oxygen flow rate to the prescribed 2L/min. The oxygen concentrator was replaced with a clean, properly functioning unit. During an interview on 4/8/2026 at 2:07 pm, R104 stated that the settings, the mask, and tubing had not been changed for his BiPAP machine. He confirmed that the oxygen tubing and mask were not stored in bags when not in use. He stated that the mask has never been replaced or cleaned. An observation revealed that the BiPAP machine still did not have a filter. During an interview on 4/9/2026 at 10:50 am, the Director of Nursing (DON) stated that she expected that the residents using BiPAP machines would have the necessary filters and supplies. During an observation on 4/9/2026 at 11:56 am, R104's BiPAP machine still did not have a filter. 3. A review of the EMR for R56 revealed he was admitted to the facility on [DATE] with a diagnosis that included, but was not limited to, centrilobular emphysema. A review of the most recent MDS assessment, dated 1/8/2026, documented that R56 had a BIMS score of 12, indicating that the resident had intact cognition and was receiving oxygen therapy. A review of the care plan for R56 revealed a care plan dated 4/18/2024 that documented the resident required oxygen as ordered/needed related to the disease process, with interventions that include giving oxygen therapy as ordered by the physician. A review of the physician order dated 7/25/2024 revealed an order for oxygen at 2L via nasal cannula to keep peripheral capillary oxygen saturation (Sp02) above 92% every morning and at bedtime; place the oxygen tubing in a bag when not in use; and change and date the oxygen tubing and water bottle every night shift, every Wednesday. An observation on 4/7/2026 at 10:07 am revealed R56's oxygen concentrator had gray fuzzy material covering the back filter of the machine, and the oxygen level on the concentrator was set to 3.5L. An observation on 4/8/2026 at 9:00 am revealed R56's concentrator set at 3.5L of oxygen and grey fuzzy material covering the vent. An observation on 4/9/2026 at 9:30 am revealed R56 was not in the room, and the oxygen tubing was lying on the bed, not in a bag. An observation on 4/9/2026 at 9:53 am with the RN FF confirmed that the concentrator had grey material covering the back, and she stated that it needed to be cleaned. She revealed that she was not sure who was responsible for cleaning the machine. She confirmed the oxygen setting to be 3.5L. An interview on 4/9/2026 at 9:15 am with Licensed Practical Nurse (LPN) JJ revealed that it is the nurse's responsibility to check the oxygen tubing and rate. When the resident returns to the room if they are out, the nurse would be the one to reset the oxygen. She stated that when you turn the concentrator off, the rate should remain the same as it was prior to turning it off. An interview on 4/9/2026 at 10:03 am with the Unit Manager/RN FF revealed that oxygen is always checked by a nurse. She stated the nurse will set the rate and make changes per the physician's orders.

Based on observation, record review, and staff interviews, the facility failed to ensure the medication rate was less than 5 percent (%) related to four errors with thirty-two opportunities. The medication error rate was 12.5%.Findings included:During an observation on 4/8/2026 at 7:50 am, Registered Nurse (RN) FF was observed administering R2 scheduled 9:00 am medications through her gastrostomy tube (G-tube). RN FF prepared two medications; three were scheduled at this time. The 325 milligrams (mg) aspirin enteric coated (EC) could not be crushed, and a non-EC aspirin was not available. RN FF confirmed that she did notify the Director of Nursing (DON), and that a new order was obtained for a chewable aspirin that was given late.During an observation on 4/8/2026 at 8:23 am, Licensed Practical Nurse (LPN) AA was in 300 Hall. LPN AA was observed obtaining medication for R23. Three medications for R23 were unavailable: Bumex (diuretic), metoprolol (blood pressure), and citalopram (antidepressant). LPN AA stated that it looks like the medications had been ordered prior. Overflow medications were checked. R23's blood pressure was obtained (131/82). LPN AA reported to the Unit Manager that these medications were unavailable. Two of the medications (Bumex, citalopram) were pulled from the Pyxis (an automated medication dispensing cabinet) at 3:25 pm, which were due at 9:00 am.During an observation on 4/8/2026 at 8:00 am, LPN QQ was delivering medication to R23; the medication had already been obtained, and the nurse was in the resident's room. The medications that were missing from the medication pass yesterday at 9:00 am were also missing during this observation. The nurse reported this to the Unit Manager, and she obtained the medications from the Pyxis this am promptly. Residents Blood Pressure was 152/60, and pulse was 88.During an interview on 4/9/2026 at 10:09 am, LPN HH revealed that if she were missing medications for one of her residents, she would first re-order them through the computer. She would then check the overflow, and if the medication was not there, she would pull from the Pyxis. She would not wait until her med pass was finished; she would go immediately and try to obtain.During an interview on 4/9/2026 at 8:20 am, the Unit Manager/Registered Nurse (RN) BB revealed that when medications are missing, it should be brought to her attention, and she or the nurse would call the pharmacy, check the overflow, or obtain from the Pyxis. She stated that she pulled R23's medication from the pyxis, and they were given. Receipt shows pulled from Pixis at 3:24 pm (medication was due at 9:00 am) and Bumex, one of the medications missing, was ordered to be given twice a day. Metoprolol was not given on 4/7/2026.During an interview on 4/9/2026 at 10:23 am, the Administrator revealed that she expects that if any medications are missing from the med-pass, it should be reported to the DON, and they should be ordered and pulled from the Pyxis for timely delivery. She stated pharmacy should also be called. If unavailable, obtain the medication, and the physician should be called.A review of the facility policy titled Unavailable Medications, dated 2/14/2024, revealed that the facility shall use uniform guidelines for unavailable medications and that a STAT supply of commonly used medications is maintained in-house for the timely initiation of medications. It was noted that the facility staff would notify the physician of the inability to obtain medication upon notification or awareness that medication is not available.

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Hand Hygiene, the facility failed to perform hand hygiene when performing resident care, including Foley catheter care and wound care, for one of 48 sampled residents (R) (R2). This deficient practice had the potential to cause the spread of infection to other areas of the residents' bodies and infection to staff.Findings included:During a review of the electronic medical record (EMR), it was revealed that resident R2 was admitted to the facility on [DATE], and pertinent diagnoses, including but not limited to Cerebral infarction, type 2 diabetes, chronic kidney disease, atherosclerotic heart disease, depression, bipolar disorder, and schizoaffective disorder.During a review of R2's quarterly Minimum Data Set (MDS) assessment, it was revealed that a Brief Interview for Mental Status (BIMS) score was not attempted, which indicated R2 was severely cognitively impaired; that R2 is dependent on staff for all activities of daily living (ADL) care; that R2 has a Foley catheter; and that R2 is incontinent of bowel.During a review of R2's care plan, it was indicated that there was a risk of skin breakdown; has an indwelling catheter, pressure ulcer, and skin breakdown.A review of the current Physician's Orders for R2 included, but was not limited to: Foley catheter care every shift and PRN; Wound care to the sacrum: cleanse with NS, pat dry, apply a collagen sheet and calcium alginate to the wound bed, and cover with an island gauze dressing daily. An observation and interview on 4/8/2026 at 10:27 am with Licensed Practical Nurse (LPN) KK performing wound care on R2 revealed LPN KK donned a gown, washed her hands with soap and water, and collected the dressing supplies. She reentered the room with the wound care supplies, placed them on R2's bedside table, and then washed her hands with soap and water. She donned clean gloves, set up a clean field on the resident's bedside table, and arranged the wound care supplies. She then removed her gloves and donned clean gloves. (no hand hygiene) She removed the resident's brief, removed the old dressing and packing material, cleaned the sacral wound with sterile normal saline-damp gauze, removed her dirty gloves, donned clean gloves (no hand hygiene), and cleaned the wound again with normal saline-damp gauze. She then opened a calcium alginate dressing, stopped, removed her dirty gloves, and donned clean gloves (no hand hygiene performed). She then placed a 2x2 square of collagen and covered that with calcium alginate, but the calcium alginate fell to the bed, so she removed her dirty gloves (no hand hygiene), went to the treatment cart, and obtained more calcium alginate. She then washed her hands with soap and water, donned clean gloves, opened the dressing material, and placed the wound, covering it with a bordered dressing. The LPN did not bring in a biohazard bag; she used the small resident trash bag, gathered it, and took it out to the large receptacle. LPNKK stated she felt she had done everything correctly, but when breaks in hand hygiene were pointed out, she realized the mistake and stated she was nervous.An observation made on 4/8/2026 at 10:40 am of Certified Nursing Assistant (CNA) GG performing Foley catheter care on R2 revealed that the CNA GG washed her hands with soap and water in the resident's bathroom and then donned her gown and gloves. While the resident was on her left side, the CNA, using disposable wipes, cleaned the resident's rectal area, which had a small amount of bowel movement present. The CNA then took a clean disposable wipe and went as far up as she could, wiping the catheter tubing downward from the meatus. (She did not perform hand hygiene and changed her gloves before doing this.) The foley tubing is lying behind the resident rather than over a leg and is not secured with a securement device. There is no privacy cover on the urine bag. The CNA then rolls the resident on her back and, using a clean disposable wipe, wipes the resident's labia 3 times from front to back. (She did not perform hand hygiene and did not don clean gloves) The CNA then removed her dirty gloves and washed her hands with soap and water. She disposed of the wipes and gown in the appropriate receptacle. The CNA required prompting to turn the resident and perform care from the resident's front. CNA GG stated that she was nervous and could not remember how to properly perform Foley catheter care.During a review of the facility's policy titled Hand Hygiene revised 2/1/2024, section, Policy explanation and compliance guidelines #2 revealed Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the hand hygiene table. #6a states: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene before donning them and immediately after removing them. The hand hygiene table in the hand hygiene section includes the following: Hand hygiene should be performed when handling contaminated objects, before applying personal protective equipment (PPE), and after removing PPE, including gloves. Before and after handling clean or soiled dressings, linens, and during resident care, moving from a contaminated body site to a clean body site. During an interview with the Registered Nurse RN FF unit manager for the 400 wing on 4/8/2026 at 11:13 am, it was revealed /confirmed that she has been here for 3 weeks, but she expects that cath care should be performed every time the resident is cleaned and should start at the meatus and extend down the tubing. The labia area should be cleaned from front to back using a clean part of the cloth each wipe. She confirmed that she is aware that many of the staff require education on infection control.During an interview with the DON (who has been in this position for one month) on 4/8/2026 at 12:43 pm, it was revealed/confirmed that the DON expects to perform Foley care properly. And do wound care properly. She confirms that the staff needs education and plans to conduct a skills check-off in the coming months.During a review of the facility's policy titled Catheter Care dated 11/5/2025, further review of sections: Female #8 and #10; revealed #8 Gently separate the labia to expose the urinary meatus, and #10 use a new part of the cloth or a different cloth for each side.

Based on observation, record review, staff interviews, and the facility policy titled Restorative Nursing Program, the facility failed to provide restorative services for one of three sampled residents (R) (R86) related to splinting and range of motion (ROM) services.Findings included:During an observation on 4/7/2026 at 8:30 am, R86 was observed resting in bed with her left hand resting on her stomach. Her hand was closed and appeared to be contracted. No splint was observed.During an observation on 4/8/2026 at 10:30 am, R86 was observed in a reclining chair near the nursing station. Her left hand was contracted, and she was holding it on her lap. No splint was observed.During an observation on 4/9/2026 at 2:00 pm, R86 was observed in a reclining chair. Her left hand was in her lap. The left hand was closed in toward her palm, her fingernails were pressing into skin, and her wrist was turned inward. No splint was observed. A review of the electronic medical record (EMR) revealed that R86 was admitted to the facility on [DATE] with diagnoses including, but not limited to, neurocognitive disorder with Lewy bodies, a history of falls, and osteoarthritis.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R86 had no limited ROM of the upper extremities and was not receiving skilled therapy or restorative services.A review of the admission Nursing Evaluation dated 9/3/2025 revealed that R86 had no contractures on admission to the facility.A review of the Joint Range of Motion Screen dated 3/2/2026 revealed R86 had full ROM in the upper wrist and fingers on the right and left side.A review of the care plan dated 1/23/2026 revealed that R86 had no plan of care related to contracture prevention/management or restorative ROM services.During an observation on 4/9/2026 at 3:15 pm, the Director of Nursing (DON), Regional Registered Nurse CC, and Regional Registered Nurse DD all confirmed that R86's left wrist was contracted. During this observation, the resident had no splint, hand roll, or contracture management devices in place.During a telephone interview on 4/9/2026 at 2:30 pm, the Physician for R86 revealed that if the resident had contractures, he had no recall of being notified. He stated the facility should have restorative nursing and skilled therapy to guide him on recommendations. He stated that if a resident had contractures, he would have documented those findings in his physical exam notes.

Based on record review, staff interviews, and review of the facility policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, the facility failed to protect one of 14 sampled residents (R) (R3) right to be free from sexual abuse from R5. This deficient practice created the potential for R3 and other residents to experience further potential abuse. Findings include:Review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, reviewed 9/2024, read, in pertinent part, It is the policy of the facility to prevent abuse.1. Review of R3's admission Record, dated 9/9/2025 and found in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included dementia and type 2 diabetes. Review of R3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/8/2025 and found in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated R3 was severely cognitively impaired. Review of R3's Progress Notes, dated 6/24/2025 at 3:34 am, and found in the EMR under the Notes tab, indicated CNA [Certified Nurse Aide] reported to nurse resident from room [ROOM NUMBER]B [R5] got up and went into female resident and was being touched by male resident on her leg and trying to pull her cover down. CNA redirected resident [R5] back to his room.2. Review of R5's admission Record, dated 9/9/2025 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included vascular dementia, chronic kidney disease, and type two diabetes. Review of R5's quarterly MDS with an ARD of 6/19/2025 and found in the EMR under the MDS tab, revealed a BIMS score of four out of 15, which indicated R5 was severely cognitively impaired.Review of R5's Progress Notes, dated 6/24/2025 at 3:10 am and found in the EMR under the Notes tab, revealed CNA reported to nurse resident got up and went into room [ROOM NUMBER]A and was touching the female [R3] in bed A on her leg and trying to pull her cover down. CNA redirected resident [R5] back to his room.Review of the facility's investigation records, provided by the facility, related to the 6/24/2025 incident during which R5 touched R3 inappropriately on her leg and was trying to remove her covers, and revealed that the facility substantiated that R5 was in R3's room and inappropriately touching R3's upper thigh while trying to remove her bed covers. During an interview on 9/8/2025 at 1:20 pm, the Director of Nursing (DON) confirmed that it had been substantiated that R5 went into R3's room and inappropriately touched her on her thigh while trying to remove her covers during the incident on 6/24/2025. During an interview with the Administrator and DON on 9/9/2025, at 1:15 pm, both confirmed their expectation was that residents in the facility would remain free from abuse.

Based on record review and interviews, the facility failed to act upon a change of condition for one of 28 sampled residents (R) (263) related to low blood sugar, which resulted in being transferred to the hospital for treatment. This failure to provide quick intervention led to harm being identified on 12/29/2023, when R263's blood sugar went so low, to the point where the resident was unresponsive and slow to respond to the emergency use of Glucagon intramuscular when administered at the facility. R263 had to be transferred to the emergency room (ER). Findings included: 1. A review of the electronic medical record (EMR) revealed that R263 had been admitted to the facility on [DATE] with the diagnosis of type 2 diabetes mellitus. A review of R263's quarterly Minimum Data Set (MDS) assessment with an assessment Reference Date (ARD) of 12/6/2023 indicated a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated R263 was severely cognitively impaired. R263 was also coded as taking Hypoglycemic medication, insulin, while a resident at the facility. A review of R263's care plan revealed a care plan dated 10/20/2023 which indicated, I have a diagnosis of Diabetes Mellitus [sic]. Interventions were Diabetes medication as ordered by doctor [sic]. Monitor/document for side effects and effectiveness . Monitor/document/report PRN [as needed] any s/s [signs/symptoms] of hypoglycemia: Sweating, Tremor, Increased heart rate (Tachycardia), Pallor, Nervousness, Confusion, slurred speech, lack of coordination, Staggering gait [sic]. A review of R263's Blood Sugars revealed documentation on 12/29/2023 at 10:04 am of having a blood sugar reading of 45 milligrams per deciliter (mg/dl). The EMR was reviewed in its entirety, and no documentation of the nurses' response to the low blood sugar was identified. A review of the facility's undated Blood Sugar Protocol indicated, If BS [blood sugar] < [less than]60 and asymptomatic, treat with 15 mg [milligrams] of oral glucose. If symptomatic (confusion and/or inability to swallow), treat with IM [intramuscular] Glucagon 1 mg. Recheck BS in 1 hour. If BS > [greater than] 60, continue to monitor. If BS still <60 notify MD [medical doctor] [sic]. A review of the progress notes dated 12/29/2023 at 12:05 pm, written by the Nurse Practitioner (NP)1 indicated, .Patient seen for nurse reports of lethargy. Patients are noted to be unresponsive. Glucose level 39, nurse reports unknown last baseline, reports patient was not able to take meds [medicines] this am d/t [due to] lethargy. Oral glucose was attempted, but the patient was too unresponsive. Glucagon IM given; patient still poorly responsive . Gen: Unresponsive, diaphoretic . Resp [Respirations]: Irregular breathing . Hypoglycemia unawareness due to type 1 diabetes mellitus, unknown down time, poorly responsive to glucagon. Send to ER for full eval [evaluation] . A review of the hospital records revealed [R263] was found unresponsive at [name of nursing facility] this morning and noted to be hypoglycemic with blood glucose of 30. EMS [Emergency Medical Services] was called, she [R263] received glucagon and D50 with improvement to 67 and improvement in mentation. She [R263] presented to the ED [emergency department] and a recurrent episode of hypoglycemia after initial improvement, and this improved again with dextrose and juice . During an interview on 3/18/2025 at 2:24 pm, Licensed Practical Nurse (LPN)1 stated, I must have done something because that [blood sugar] is too low. I must have forgotten to document it. During an interview on 3/21/2025 at 3:00 pm, NP1 stated, That was a while ago, and I don't remember anything except what I had documented. During an interview on 3/21/2025 at 4:30 pm, the Interim Director of Nursing (DON) stated, I would expect the nurses to follow the Blood Sugar Protocol if they obtained a low blood sugar and notify the doctor of what had occurred and what treatment had to be given.

Based on observation, interview, and facility policy review, the facility failed to keep the kitchen's two convection ovens, deep fat fryer, steamer, storage shelves, large manual can opener, and the main dining room's ice machine and microwave oven clean and sanitized. Additionally, the dietary staff failed to label, date, and/or cover food and beverages stored in the kitchen. This failure had the potential to create an environment for food-borne illnesses, which could affect 101 residents who consumed food prepared from the facility's kitchen. Findings included: A review of the facility's policy titled Sanitation dated October 2008 indicated Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation 1. All kitchens, kitchen area and dining areas shall be kept clean . 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions . 12. Ice machines and ice storage containers shall be drained, cleaned, and sanitized per manufacturer's instructions and facility policy . A review of the facility's policy titled Dating and Labeling Policy dated 04/05/24 indicated, Policy: The kitchen will ensure food safety by maintaining proper dates and labels on all goods and ready-to-eat food products. Procedure: . 2. Label products in storage with the date the package was opened . 4. Ready-to-eat foods must be dated with a 72-hour use-by date and discarded when they expire. 7. Keep all storage areas clean and dry . 1. An observation during the initial kitchen inspection on 3/16/2025 from 7:55 am to 8:25 am revealed the following unclean food preparation and storage equipment: a. The kitchen's two convection ovens had a heavy accumulation of dried and burned food substances on their inner cooking compartments. The doors on both convection ovens also had brown substances on them. b. Both sides of the kitchen's deep fat fryer had a heavy accumulation of a yellow-colored gritty substance, and grease was encrusted on both exterior sides of the deep fryer. c. A shelving unit above the kitchen's two-compartment sink was unclean with a heavy accumulation of dried substances. Food storage containers and lids were stored directly on this unclean shelf. d. The kitchen's steamer had dried food substances and loose debris around the exterior of the steamer's door and on its top. e. Six shelving units in the kitchen's walk-in refrigerator were unclean with accumulated dried substances. f. The kitchen's large manual can opener had dried and sticky substances on its blade and table base attachment. During an interview on 3/16/2025 at 9:00 am, the Dietary Manager (DM) confirmed that the kitchen's convection ovens, deep fat fryer, steamer, large manual can opener, and shelving units were unclean, that were observed during the initial kitchen inspection. The DM stated that the dietary staff were to follow the kitchen's cleaning schedule and keep all kitchen equipment clean. 2. An observation during the initial kitchen inspection on 3/16/2025 from 7:55 am to 8:25 am revealed the following concerns with food storage: a. An observation of the kitchen's walk-in refrigerator revealed the following stored food and beverages were unlabeled and/or undated: one large pan of Sheppard's pie, one large pan of cooked broccoli, 10 cups of juice, 15 ham sandwiches, one 32 ounce opened package of ham slices, one opened package of shredded cheese that was not closed, and one opened bag of lettuce that was not closed. b. Observation of the kitchen's bread storage racks revealed three opened and undated packages of hamburger buns. c. Observation of the kitchen's food storage bins revealed an open 25-pound bag of flour that was stored completely uncovered. During an interview on 3/16/2025 at 9:00 am, the DM confirmed the undated, unlabeled, and/or uncovered food that was observed stored in the kitchen's walk-in refrigerator, bread storage racks, and food storage bins that were observed during the initial kitchen inspection. The DM stated that food should be labeled, dated, and covered when stored by staff. 3. An observation on 3/16/2025 at 8:35 am of the facility's ice machine that was located just outside the kitchen, revealed its interior had a black mold-like substance that could be wiped away with a paper towel. During an interview on 3/16/2025 at 8:55 am, the Administrator confirmed the interior of the ice machine was unclean with a black substance. The Administrator stated that the ice machine should be cleaned by maintenance every month. 4. An observation on 3/16/2025 at 8:35 am of the microwave oven located in the facility's main dining room, just outside the kitchen, revealed the microwave's inner cooking compartment had a heavy accumulation of dried food spills and loose food debris. During an interview on 3/16/2025 at 8:55 am, the Administrator confirmed the microwave oven in the facility's main dining room was unclean. The Administrator stated that the microwave was utilized by staff to heat resident food and should be cleaned as needed by the staff. 5. An observation on 3/16/2025 at 9:10 am of food stored in the kitchen's walk-in freezer, with the DM present, revealed that two large bags of frozen potato cakes, one large box of biscuits, and one large box of chicken tenderloins were stored open and unprotected from possible contamination. During an interview on 3/16/2025 at 9:10 am, the DM confirmed the opened potato cakes, biscuits, and chicken tenderloins were stored in the kitchen's walk-in freezer. The DM stated that food should be completely covered when stored by staff.

Based on observation and interview, the facility failed to ensure that the soiled and clean sides of the laundry room were in good repair. Specifically, the facility failed to repair a gap under the exterior door that opens into the soiled laundry area; failed to repair broken wallboard with exposed insulation; failed to clean the air vents in the soiled side of the laundry that had debris build up; the doorless opening between the sorting area and the room with the washing machines was trimmed with unfinished molding, rendering the surface uncleanable; the floor where the washing machine was located had heavy debris build up; reusable rubber gloves were on the floor in the drying area; and the floor (standing) fan had heavy debris build-up on the fan grate. This deficient practice had the potential for the clean linen for all residents to be contaminated. Findings included: During an observation and interview on 3/18/2025 at 8:47 am with the Laundry Supervisor and the Infection Preventionist (IP) nurse revealed the following: 1. A three-fourth-inch gap under the exterior door that opens into the soiled laundry area, where items are sorted before washing, had a broken wallboard about five feet from the floor to the ceiling with exposed insulation around the missing and broken wallboard. Three pillows were stacked on top of a bin and resting against the insulation. The air vents in the room had debris built up and exposed steel beams. 2. The doorless opening between the sorting area and the room with the washing machines was trimmed with unfinished molding, rendering the surface uncleanable. 3. The floor where the washing machine was located had heavy debris built up on the horizontal surfaces, including the floor and the plastic crates supporting the buckets of laundry chemicals. There were reusable rubber gloves on the floor behind a bucket of chemicals, which was next to the washing machine. 4. In the drying area, the floor (standing) fan had heavy debris buildup on the fan grate. During an interview on 3/20/2025 at 10:11 am, the Laundry Supervisor confirmed the laundry area was in need of repair, and the standing floor fan should be cleaned before being used in the clean laundry area.

Based on observation, interview, record review, and facility policy review, the facility failed to serve food that was palatable and hot to four of seven residents (R) (R22, R77, R83, and R105) reviewed. Findings included: A review of the facility's undated policy titled Assistance with Meals indicated, . All foods shall be held at a temperature of 136 degrees or above until served. Cold foods shall be held at 40 degrees or below until served. Nursing and Dietary Services will establish procedures such that the delivery of food to serving areas accommodates this requirement. A review of the facility's policy titled, Food Temperatures and Test Tray Audits dated 04/05/24, indicated, Policy Test trays will be audited periodically to ensure that food temperatures, food quality, and overall dining experience are at optimal levels. Procedure . 11. Minimum temperatures at the time of service are defined below: a. Soups >[above]135 degrees F [Fahrenheit]. b. Milk & Milk Products < [below] 45 degrees F., Cold Entrees < 55 degrees F., Hot Entrees > 135 degrees F., Starches > 135 degrees F., Hot Vegetables > 135 degrees F., Cold Desserts (pudding/gelatin) < 55 degrees F., Cold Beverages < 55 degrees F., Hot beverages > 140 degrees F. 1. A review of R22's electronic medical record (EMR) revealed a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/2024 indicated a Brief Interview for Mental Status (BIMS) score of 14 of 15, which indicated the resident was cognitively intact. During an interview on 3/17/2025 at 9:35 am, R22 stated she ate her meals in her room, and the food served at meals was not hot. R22 specified that she would prefer her food to be served hot. 2. A review of R77's quarterly MDS assessment with an ARD of 12/26/2024 revealed a BIMS score of 15 of 15, which indicated the resident was cognitively intact. During an interview on 3/16/2025 at 1:35 pm, R77 stated the food served at meals lacked seasoning and was not hot. R77 specified that the hot food she was served at breakfast was cold. 3. A review of R83's quarterly MDS assessment with an ARD of 1/1/2025 revealed a BIMS score of 15 of 15, which indicated the resident was cognitively intact. During an interview on 3/16/2025 at 1:10 pm, R83 stated she ate her meals in her room, and the food she was served was cold, especially at breakfast. R83 stated that the hot food she was served at other meals was cold, too. 4. A review of R105's EMR revealed a quarterly MDS with an ARD of 1/24/2025 located under the MDS tab, revealed a BIMS score of 14 of 15, which indicated the resident was cognitively intact. During an interview on 3/16/2025 at 12:55 pm, R105 stated he ate his meals in his room, and when his meals were served, his food was cold. R105 specified that at breakfast, he was served cold eggs and cold breakfast meat. In response to resident complaints about food, a test tray was requested to be sent to the facility's 400 hallway during the breakfast meal on 3/18/2025. An observation revealed that before the meal tray cart, which contained the test tray, left the kitchen at 8:02 am, resident meals were observed being served on unheated plates, and food temperatures were at acceptable levels of 140 degrees Fahrenheit (F) and above on the kitchen tray line. The meal trays were placed on an open tray cart that was covered, but the cart had no heating element and was delivered to the 400 hallway at 8:04 am. The last resident breakfast tray was served on the 400 hallway on 3/18/2025 at 8:29 am. At this time, the food on the test tray was sampled in the presence of Licensed Practical Nurse (LPN)2. Tasting of the food revealed the following: a. The scrambled eggs tasted cold. LPN2 also tasted the scrambled eggs and confirmed that the eggs were cold. b. The grits served tasted cold and had begun to congeal on the plate. LPN2 also tasted the grits and confirmed that the grits were cold. During an interview on 3/18/2025 at 8:45 am, the Dietary Manager (DM) confirmed that residents' breakfast meals on 3/18/2025 were served on unheated plates. The DM stated the kitchen had a plate warmer, but staff were currently not using it because the suction cup the staff used to get the plates out of the warmer was broken. The DM explained that the kitchen also had insulated plate holders available to help keep the plate and food hot, but the staff did not use them at this meal.

Based on the record review and interviews, the facility failed to investigate a fall for one of three residents (R) (R70) reviewed for falls. This failure had the potential for the fall not to be investigated thoroughly, and allowed R70 to experience another fall. Findings included: A review of the electronic medical record revealed that R70 was admitted to the facility on [DATE] with the diagnosis of Huntington's Disease. A review of R70's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/8/2024 indicated R70 had short-term and long-term memory loss and was severely impaired in cognitive skills for daily decision-making. R70 was coded as being independent in bed mobility. A review of R70's care plan dated 1/25/2024 revealed that R70 was at risk for falls related to Huntington's Disease with Chorea and decreased mobility. The interventions indicated, .Educate the me/my family/caregiver about safety reminders and what to do if a fall occurs [sic] . A review of R70's nursing progress note EMR revealed on 9/28/2024 at 4:16 am, CNA [certified nursing assistant] changing resident and when rolled her to her side, resident slid off the edge of the bed onto the floor. ROM [range of motion] within normal limits for this resident. No S/Sx [signs/symptoms] pain observed . During an interview on 3/20/2025 at 5:25 pm, the Assistant Director of Nursing (ADON) stated, I did the investigation report for this fall. I filled it out by reading over the note that the nurse documented. The ADON provided a copy of this report. The ADON was then asked if she had taken statements from the CNA and the nurse who was working when this fall occurred. The ADON stated, No, I didn't. I wasn't aware that I needed to do that.

Based on record review, staff interview, and a review of the facility policy titled Resident Self-Administration of Medication, the facility failed to ensure that one of 28 sampled residents (R) (R89) was assessed for self-administration of medications before medications were left at the bedside. This failure had the potential for the residents to overmedicate themselves or for medications to be accessed by other residents. Findings included: A review of the facility's policy titled Resident Self-Administration of Medication and dated November 2017 revealed that if the resident desires to self-administer medications, an assessment will be conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. A review of the Electronic Medical Record (EMR) revealed that R89 was admitted to the facility on [DATE] with the diagnosis of dementia, anxiety disorder, hypertension, and major depressive disorder. A review of R89's quarterly Minimum Data Set (MDS) assessment, an Assessment Reference Date (ARD) of 9/17/2024, revealed R89 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated R89 was severely cognitively impaired. A review of R89's physician orders revealed there were no orders for R89 to be allowed to self-administer medications. A review of R89's care plan revealed that there was no plan of care developed for R89 to be allowed to self-administer medications. During an interview on 3/20/2025 at 10:30 am, the Assistant Director of Nursing (ADON) stated, Her [R89] sister brought a cup of pills to my office [on 9/27/2024] and stated that she found them on the nightstand in her sister's [R89] room. The ADON was asked if R89 was able to self-administer her medications, and the ADON confirmed that R89 was not able to self-administer her medications.

Based on record review and interviews, the facility failed to notify one of 28 sampled resident's (R) (R89) responsible party (RP) of a new medication order before the administration of the medication to the resident. This failure had the potential for R89 to be administered with medication that the RP may not want the resident to receive. Findings included: A review of the Electronic Medical Record (EMR) revealed that R89 was admitted to the facility on [DATE] with the diagnoses of dementia and anxiety disorder. A review of R89's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 5/17/2024, coded R89 as having a Brief Interview for Mental Status (BIMS) score of zero out of 15, which indicated R89 was severely cognitively impaired. A review of R89's physician orders revealed an order dated 8/8/2024 for Naltrexone 50 mg (milligrams), give one tablet by mouth one time a day for OCD (obsessive-compulsive disorder) related behaviors. A review of R89's psychotherapy summary dated 8/7/2024 stated, Recommendations . Start Naltrexone 50 mg QD [every day] for OCD . A review of R89's nursing progress notes revealed no documentation of R89's RP being notified of Naltrexone being started for OCD related behaviors. During an interview on 3/20/2025 at 3:30 pm, the Assistant Director of Nursing (ADON) stated, I did not notice that the nurse who signed the order for Naltrexone did not notify the RP until I made a note in the resident's record on 8/26/2024. The ADON confirmed the nurse should have notified the resident's RP of the new medication and documented it in the medical record. During an interview on 3/20/2025 at 5:00 pm, the Interim Director of Nursing (IDON) confirmed that when a new medication is ordered, the resident's RP should be notified by the nurse that is working on the shift when it was ordered.

Based on record review, interviews, and review of facility policy titled Abuse Prevention Program, the facility failed to ensure one of three sampled residents (R) (R33) reviewed for abuse was free from abuse. This failure had the potential for psychosocial impairment from being physically abused by another resident. Findings included: A review of the facility's policy titled Abuse Prevention Program, with a revised date of May 2023, indicated, As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone, including . other residents. Physical Abuse includes, but is not limited to, hitting, slapping, pinching, and kicking . A review of the electronic medical record (EMR) revealed R33 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, anxiety disorder, bipolar disorder, and depression A review of R33's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 1/1/2025 revealed a Brief Interview for Mental Status (BIMS) score of six out of 15, indicating R33 was severely impaired with diagnosis of metabolic encephalopathy, coronary artery disease, anxiety disorder, bipolar disorder, and depression. A review of the facility's investigation revealed that on 2/19/2025, R33 and R10 were involved in a physical altercation, hitting each other in the arm. A review of the skin assessment dated [DATE] revealed that both R33 and R10 had no redness, no discoloration, and no open areas as a result of the incident. During an interview on 3/20/2025 at 1:04 pm, the Assistant Director of Nurses (ADON) stated that residents were immediately separated. Then R33 was moved to the 300 Hall, in a room without a roommate, to prevent further interactions with R10. During an interview on 3/20/2025 at 1:44 pm, the Social Service Director (SSD) stated that she spoke with R33 and R10 regarding the incident, and both blamed each other.

Based on record review, interviews, and a review of the facility policies titled Abuse, Neglect and Exploitation and Abuse Prevention Program, the facility failed to ensure allegations of abuse were reported to the facility's abuse coordinator/administrator promptly for one of four residents (R) (R62) with allegations of abuse. The facility failed to notify the State Agency (SA) promptly. This deficient practice placed the resident at risk for uninvestigated abuse allegations. Findings included: A review of the facility's policy titled Abuse, Neglect and Exploitation dated December 2017 indicated, .staff to report abuse to the abuse coordinator/administrator immediately when a resident reports an allegation of abuse, and an investigation is to begin immediately . A review of the facility policy titled Abuse Prevention Program, revised May 2023, indicated, .the abuse coordinator will report allegations or suspected abuse . immediately to .State Survey and Certification agency . A review of R62's Electronic Medical Record (EMR) revealed an admitted [DATE] with diagnoses of dementia and anxiety. A review of the annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 9/19/2024 revealed a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated R62 cognition was severely impaired. A review of the facility' investigation document indicated that R62 reported to an agency Licensed Practical Nurse (LPN) 3 on 6/29/2024 around 12:00 am and 12:13 am, that Something ain't right, I feel like I've been raped. A review of the facility's Facility Incident Follow-Up Investigation Report revealed the SA was notified on 7/2/2024. During an interview on 3/20/2025 at 10:49 am, the Regional Nurse confirmed that the SA was not notified promptly.

Based on record review, staff interview, and a review of the facility's policy titled Care Plans, the facility failed to develop and implement a comprehensive care plan for two of 28 sampled residents (R) (R44 and R263). This failure had the potential for R44 to not receive the appropriate treatment needed, and R263 did not have the newly identified pressure ulcer treatment ordered to prevent the area from becoming larger. Findings included: A review of the facility's policy Care Plans, Comprehensive Person-Centered dated September 2023 stated, .Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 1. A review of the electronic medical record (EMR) revealed that R44 had been admitted to the facility on [DATE] with the diagnosis of dementia. A review of R44's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 11/21/2024 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated that R44 was moderately cognitively impaired. A review of R44's care plan revealed there was no documentation of a dementia care plan that had been developed for R44. During an interview on 3/19/2025 at 2:45 pm, Licensed Practical Nurse (LPN)5 stated, I don't see where a care plan was developed for dementia for this resident. I think it got overlooked because the resident had a high BIMS score, and the nurse doing the MDS failed to look back at the diagnosis. LPN5 stated that R44 should have a care plan for dementia. 2. A review of the EMR revealed that R263 was admitted to the facility on [DATE] with the diagnoses of dementia and type 2 diabetes mellitus. A review of R263's quarterly MDS assessment with an ARD of 12/6/2023 indicated a BIMS score of four out of 15, which indicated R263 was severely cognitively impaired. R263 was also coded as being at risk for developing pressure ulcers/injuries. A review of R263's Change of Condition form dated 12/25/2023 revealed, During a brief change, sacral wound found. Wound measured and cleansed. AG [Silver] applied to the wound bed. Covered with foam dressing [sic]. The on-call physician was informed of the wound on 12/25/2023 at 2:05 am. The measurements of the sacral wound were documented as being 2.0 inches long; .5 inches wide, depth shallow [sic]. A review of R263's care plan revealed no documentation of a care plan for the newly identified sacral wound found and documented on 12/25/2023. During an interview on 3/19/2025 at 2:45 pm, LPN5 confirmed that the resident's care plan should reflect anything that is going on with that particular resident.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that supervision to prevent accidents and/or an environment free of hazards was provided for five residents (R) (R#8, R#10, R#21, R#30, and R#48) of nine sampled residents reviewed for accidents. This failure caused actual harm, when R#8 sustained a fracture while being transported in her Broda chair. In addition, fall interventions such as non-skid strips designed to prevent accidents were not in place. Staff failed to provide the sufficient amount of supervision/assistance during a transfer. Hazardous substances were left within access of a confused resident. Findings included: 1. Review of a policy provided by the facility titled Hazardous Areas, Devices and Equipment dated July 2017, revealed All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. A hazard is defined as anything in the environment that has the potential to cause injury or illness.Examples of environmental hazards include but are not limited to.Equipment and devices that are left unattended or are malfunctioning.Devices and equipment that are improperly used. Review of a document provided by the facility titled Job Description for Activity Aides (AA) dated as reviewed with AA2, 8/23/19 indicated Report all unsafe/hazardous condition equipment immediately. Observation of R#8 on 3/29/22 at 3:28 p.m. revealed the resident was in bed in her room. The resident was unable to be interviewed, due to her cognitive status. During this observation, a Broda chair (reclining, movable chair) with leg rests attached to the chair was noted in the resident's room. Review of R#8's undated Admission Record in the Electronic Medical Record (EMR) revealed R#8 was admitted to the facility on [DATE]. The resident had diagnoses including Alzheimer's disease with late onset, unspecified protein-calorie malnutrition, and a contracture of the right ankle. Review of R#8's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/7/21 revealed staff could not complete a Brief Interview for Mental Status (BIMS) score to determine cognition, and R#8 had short- and long-term memory problems. The assessment indicated R#8 the resident required extensive assistance with bed mobility with one staff member and was totally dependent on two staff for transfers. The assessment indicated R#8 was dependent on staff for locomotion. Review of R#8's EMR care plan, located under the Care Plan tab and dated 5/8/21, revealed R#8 required total assistance from staff with all activities of daily living related to her diagnoses of Alzheimer's disease with dementia, depression, [CONDITION(S)], and [CONDITION(S)]. Per the care plan, the resident required a Broda chair for positioning, initiated 10/27/20. Review of the health status Progress Notes located under the Prog [Progress] Note tab and dated 4/29/21, revealed R#8 sustained an accident three days earlier on 4/26/21. Specifically, the progress note stated Charge nurse reported to Risk Manager, on 4/29/2021 at 0700, that resident presents with discoloration, to left lower extremity. Vital signs initiated and within normal limits. Resident resting peacefully in bed, no physical signs or symptoms of pain observed. Skin assessment performed: [CONDITION(S)], heat, and discoloration to left lower extremity, noted. Resident's lateral, left, foot and ankle has [sic] blue/purple discoloration present, with pitting [CONDITION(S)]. Lateral, posterior portion of resident's calf and patella, has blue/purple discoloration, heat, and mild [CONDITION(S)] present. Resident is able to [sic] wiggle toes and move foot, without physical signs of pain. Passive ROM [range of motion] performed, with no difficulty or crepitus noted, but resident presents with facial grimacing and moaning, upon palpation of left lower extremity.NP [Nurse Practitioner], notified, and provided orders for stat x-ray. RP [Responsible Party] .notified. RP reports that when resident was rolled away, from visit, on 4/26/2021, her left foot, was noted to be dragging under her Broda Chair. RP reports that staff immediately corrected resident's positioning, and that her foot was under the chair, for less that [sic] 20 seconds. Activities Aide confirmed that she corrected resident's positioning. Resident was provided with PRN [as needed] Tylenol 650 mg [milligrams], PO [per mouth]. X-ray resulted and revealed fracture of left proximal lateral tibia, with 11 mm [millimeters] displacement. NP notified and ordered resident to be sent to ER [emergency room ], for further evaluation and treatment. RP notified of X-ray results and order to send resident to ER. RP verbalized understanding and stated that 'accidents happen'. Review of a document provided by the facility titled Skin Condition, dated 4/29/21, reiterated the same information as the health status progress note. Review of the hospital x-ray results dated 4/29/21 indicated R#8 sustained a minimally displaced fracture of the lateral proximal tibia with a subtle medial tibial plateau compression fracture. R#8 also sustained a nondisplaced proximal fibular head/neck fracture. R#8 required no surgery, and the hospital notes indicated the resident had generalized osteopenia. R#8 was readmitted back to the facility from the hospital on 5/3/21. Review of R#8's EMR current care plan, located under Care Plan tab and dated 4/29/21, revealed that, after this accident, a new intervention to recline R#8 in her Broda chair prior to transport. There was no mention in the current care plan to ensure the leg rests were on the Broda chair prior to transport. Review of a document provided by the facility titled Teachable Moment dated 4/29/21 indicated the Activity Director (AD) met with AA2 and wrote When transporting residents to and from visits check resident legs and arms to make sure up and inside w/c [wheelchair] before pushing them to and from the room. This document was signed by the AD and AA2. A review of a document provided by the facility titled Physical Therapy Plan of Care, dated 5/4/21 indicated R#8 sustained a left tibial plateau fracture due to the resident's left foot being caught under a Broda chair. The therapy plan indicated R#8 was unable to hold her legs up while seated in the Broda chair and the resident was dependent on all aspects of care. A telephone interview was conducted on 3/29/22 at 3:24 p.m. with AA2, who confirmed that while she was transporting R#8, the resident's left foot went under the Broda chair. AA2 stated that when this occurred, she lifted the chair and moved the resident's left foot out from under the Broda chair. AA2 stated that R#8's Broda chair did not have leg rests attached at the time of the incident, and that R#8 could lift her legs upon command. During an interview on 3/29/22 at 3:36 p.m., the Director of Rehabilitation stated a pad was placed across both footrests as a response to the 4/29/21 identification of the incident with injury. The Director of Rehabilitation stated this was to prevent R#8's feet from slipping through. The Director of Rehabilitation stated she was not aware R#8's Broda chair did not have leg rests attached at the time of the incident. The Director of Rehabilitation was asked to provide any additional training that therapy may have provided AA2 after the incident. No information was provided by the end of the survey. During an interview on 3/30/22 at 8:25 a.m., the AD stated AA2 alerted her to R#8's left foot being pulled under the Broda chair. The AD stated she would have reported any body part being caught in a piece of equipment and left the resident until nursing could come and assess the resident. During an interview on 3/30/22 at 9:49 a.m., the Risk Manager (RM) stated in the ideal world, AA2 should have notified nursing before moving R#8's foot from under her Broda chair, and the resident should not have been moved until an assessment was completed. The RM stated she did not remember speaking with AA2 and stated never took note of the footrests and if they were on or off the Broda chair. During an interview on 3/30/22 at 12:12 p.m., the Administrator stated it was her understanding that R#8 had her left toe touching the ground/floor and was pushed by AA2. The Administrator stated it was concerning to learn AA2 lifted the Broda chair to release R#8's foot from under the Broda chair. The Administrator stated she would have expected AA2 to have alerted nursing to the incident so nursing could have assessed R#8. 2. Review of the facility's undated policy titled Activities of Daily Living [ADL], Supporting directs Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance. Review of R#48's Admission Record located in the Profile tab of EMR revealed R#48 was admitted to the facility on [DATE] for long term care. Review of R#48's quarterly MDS, with an ARD of 1/12/22, documented the resident had a BIMS score of 9, which indicated the resident had moderate cognitive impairment. The MDS documented R#48 required the extensive assistance of two people for transfers. Review of R#48's active Care Plan located in the Care Plan tab in the EMR identified R#48 was at risk for falls related to weakness and altered cognition. The care plan also noted the resident had self-care deficits related to overall generalized weakness, required staff assistance with activities of daily living (ADL) functioning, and is at risk for functional declines. Although the 1/12/22 MDS identified that the resident required extensive assistance of two persons for transfers, the care plan called for assist with transfers of one staff with the use of a gait belt. Review of the undated plan of care (POC) Kardex (Certified Nurse's Aide (CNA) Care Plan) provided by the Director of Nursing (DON) on 3/30/22 at 4:00 p.m. and identified as current, revealed there was no information on staff requirements for transfer. During an observation on 3/30/22 at 7:35 a.m., AA1, who is also a Temporary Nurse's Aide (TNA), was at R#48's bedside and had finished washing and dressing the resident. AA1 instructed the resident to sit at the side of the bed and informed her she would help her transfer her to the wheelchair. R#48 rocked her body forward and backward, stood up with bent knees, was shaky and sat back down on the bed and was slightly short of breath and mouth breathing. The resident did this several times and said she was too weak and asked AA1 to get someone to help her with the transfer. AA1 told her to try one more time and the resident told AA1 to turn around and draped her whole body on AA1 and placed her arms around AA1's waist as they both pivoted. As R#48 stood, still slightly shaky, AA1 turned around and hooked R#48's left arm under her armpit. During this transfer, she did not use a gait belt and performed the stand pivot transfer with only one staff. During an interview on 3/30/22 at 7:45 a.m., AA1 did not know the resident's transfer status and was unable to locate R#48's POC/Kardex. During an interview on 3/31/22 at 11:15 a.m., the DON stated that AA1 should have viewed the Kardex for R#48 prior to transferring the resident and should have used a gait belt to perform a safe transfer. The DON was asked about the MDS assessment which stated the resident need the extensive assistance of two staff for transfer. The DON acknowledged in order to perform a safe transfer, the information from the MDS assessment should be followed, and she did not know why the recommendations were not on the care plan or Kardex. The DON summoned MDS2 to join the interview. During an interview on 3/31/22 at 11:20 a.m., MDS2, confirmed that she was responsible for maintaining the accuracy of R#48's care plan, and it should have been updated for a two-person transfer after the resident was readmitted from the hospital on 1/7/22. 3. Review of R#30's undated Admission Record located in the Electronic Medical Record (EMR) under the Resident tab indicated he was originally admitted on [DATE] with type 2 diabetes mellitus with diabetic [CONDITION(S)]. Review of R#30's quarterly MDS, with an ARD of 1/29/22, revealed the resident had a BIMS of 14, indicating the resident was cognitively intact. Per this MDS, the resident required extensive of one person assistance for toileting. Review of R#30's Care Plan, revised on 3/17/22 and located in the EMR under the Care Plan tab, revealed he was at risk for falls related to [CONDITION(S)] and daily [CONDITION(S)] medications. Per the care plan, the resident had a history of falls, including on 7/13/18, 7/25/19, and 2/2/22. Care plan approaches to prevent accidents included non-skid strips on the floor at bedside, which were to be installed and maintained as of 3/20/15. Observation on 3/28/22 at 2:58 p.m. revealed R#30 did not have non-skid strips next to his bed as indicated on his care plan. Interview on 3/29/22 at 2:40 p.m. with R#30 confirmed he had non-skid strips in his restroom, but not next to his bed. Observation on 3/29/22 at 3:24 p.m. with the MDS Coordinator (MDSC) confirmed that non-skid strips were not in place as indicated on the care plan. In addition, during this observation, a puddle of fluid was noted on the resident's floor under the bedside table by the survey team and confirmed by the MDSC. The MDSC stated that although there were two non-skid strips in front of R#30's commode, there were none next to his bed, and she would notify the maintenance director for installation. During this interview, the MDSC stated that no one had noticed, prior to surveyor intervention, that the non-skid strips were not in place. Review of the facility's policy titled Falls and Fall Risk, Managing, revised March 2018 included Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. Review of the facility's policy titled Fall Risk Assessment revised March 2018 included Policy Statement: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Review of the facility's policy titled Safety and Supervision of Residents revised July 2017 included .Individualized, Resident-Centered Approach to Safety .4d Ensuring that interventions are implemented .5b Evaluating the effectiveness of interventions; 5c Modifying or replacing interventions as needed. 4. Review of R#10's Face Sheet located in the EMR under the Clinical tab, indicated R#10 was admitted on [DATE] with diagnoses including congestive heart failure (CHF), chronic respiratory failure with [CONDITION(S)], and chronic obstructive pulmonary disease ([CONDITION(S)]). Review of R#10's progress notes, located in the EMR under the Progress Note tab, revealed R#10 had a history of falls, including falls on 12/7/21, 12/9/21, 1/12/22 and 1/15/22. Review of R#10's quarterly MDS, with an ARD of 12/10/21, revealed the facility assessed R#10 to have a BIMS score of 12, indicating R#10 had moderately impaired cognition. R#10's functional status included the need for limited assistance with bed mobility, extensive assistance with transfers and toileting and supervision with dressing. Review of R#10's Care Plan last revised on 3/19/22 and located in the EMR under the Care Plan tab, revealed a Focus area stating that R#10 is at risk for falls due to [CONDITION(S)], CHF, stage III chronic kidney disease, generalized weakness, [CONDITION(S)], lower extremity [CONDITION(S)] [swelling] .Goal: [R#10's] falls will be minimized thru management of risk factors thru next review. The Interventions/Tasks listed in the care plan included 10/14/20 Non-skid strips to be placed in bathroom due to safety .5/12/21 Strips at bedside and in front of commode due to: Room change. Observation on 3/30/22 at 10:25 a.m. in R#10's bathroom revealed there were no non-skid strips placed on the floor. During an interview on 3/30/22 at 10:20 a.m. with R#10, he stated he has fallen several times. R#10 stated that the non-skid strips that are on the floor beside his bed keep his feet from slipping when he is getting in and out of bed. R#10 was unsure whether there were non-skid strips on the floor in his bathroom. Interview with the DON on 3/31/22 at 2:35 p.m. revealed that the resident had changed rooms, indicating that the non-skid strips had not followed him to his new bathroom. 5. Review of a policy provided by the facility titled Hazardous Areas, Devices and Equipment dated July 2017, revealed, Identification of Hazards. Access to toxic chemicals. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. Review of R#21's undated Admission Record in the EMR revealed R#21 was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbances. Review of R#21's quarterly MDS with an ARD of 1/19/22 revealed R#21 had a BIMS score of 8, which revealed the resident was moderately cognitively impaired. Review of R#21's current care plan located under Care Plan tab revealed the resident was at risk for alteration in cognition related to dementia. The care plan indicated R#21's cognition varies throughout the day and seemed clearer in the morning. During an observation on 3/28/22 at 12:19 p.m., R#21 was observed to have a bottle of nail polish remover on the windowsill above her wall heater/cooler. During an additional observation on 3/30/22 at 9:01 a.m., upon entry to R#21's room, the nail polish remover was still placed on the windowsill above her wall heater/cooler. The temperature for the heater was set at 75 degrees Fahrenheit (F). The Social Services Director (SSD) was present and grabbed the bottle of nail polish remover, stating R#21 was not to have this in her room. Observation of the bottle of nail polish remover revealed it was labeled, Warning: Extremely Flammable Keep Away From Flame and Storage: Do Not Store Near Fire, Flame or Heat.

Based on observation, interview, record review, review of Centers for Medicare and Medicaid (CMS) guidance, and policy review, the facility failed to ensure that one resident (R) (R#48) of three residents reviewed for pressure sores who was at risk for pressure ulcer development did not develop a pressure ulcer and received the treatment needed to promote healing. R#48 was readmitted to the facility post hospitalization on [DATE] with skin issues which deteriorated to a Stage III pressure ulcer with signs of infection. The facility failed to conduct weekly assessments, change treatments when the pressure ulcer did not respond, and did not provide treatment in a manner designed to promote healing. This deficient practice harmed the resident and caused localized infection, tissue loss, and pain. Findings include: Review of the facility's Administrative Policy and Procedure titled Pressure Injury Prevention and Management, dated May 2018, revealed that, Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device .Licensed nurses will conduct a skin assessment on all residents upon admission/readmission, weekly, and as needed. Findings will be documented in the medical record . Assessments of pressure injuries will be performed by a licensed nurse and documented in the medical record. Interventions for Prevention and to Promote Healing: a. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury . c. Evidenced-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present . i. Treatment decisions will be based on the characteristics of the wound, including the stage, size, amount of exudate, and presence of pain, infection, or non-viable tissue. Per CMS's RAI Version 3.0 Manual, Section M1040: Other Ulcers, Wounds and Skin Problems states, Definition Moisture Associated Skin Damage is superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration .M1040H Moisture Associated Skin Damage (MASD). MASD is also referred to as maceration and includes incontinence-associated [CONDITION(S)], intertriginous [CONDITION(S)], peri wound moisture-associated [CONDITION(S)], and peristomal moisture-associated [CONDITION(S)]. Moisture exposure and MASD are risk factors for pressure ulcer/injury development. Provision of optimal skin care and early identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . MASD without skin erosion is characterized by red/bright red color (hyperpigmentation), and the surrounding skin may be white (hypopigmentation). The skin damage is usually blanchable and diffuse and has irregular edges. Inflammation of the skin may also be present. MASD with skin erosion has superficial/partial thickness skin loss and may have hyper or hypopigmentation; the tissue is blanchable and diffuse and has irregular edges. Inflammation of the skin may also be present. Necrosis is not found in MASD. If pressure and moisture are both present, code the skin damage as a pressure ulcer/injury in M0300. If there is tissue damage extending into the subcutaneous tissue or deeper and/or necrosis is present, code the skin damage as a pressure ulcer in M0300. Review of R#48's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R#48 was admitted to the facility on [DATE] for long term care. Review of R#48's discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/3/22 revealed R#48 had an unplanned discharge to the hospital and was expected to return. At the time of the transfer to the hospital, the resident had no skin problems. Review of R#48's Admission Nursing Evaluation dated 1/7/22 under the Assessments tab in the EMR and documented by Licensed Practical Nurse (LPN)1 revealed the resident was readmitted from the hospital. Review of the evaluation completed upon readmission to the facility revealed that LPN1 documented the resident had skin issues upon re-admission; however, there was no documented evaluation of the skin issues (i.e. no description of the skin issue, including type of issue, location, physical appearance including size, color, and stage, if appropriate.) Review of R#48's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/12/22 documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, which indicated the resident had moderate cognitive impairment. The MDS documented the resident was at risk for developing pressure ulcers, had MASD, and required the use of pressure reducing devices for the bed and chair and application of ointments. Although the 1/12/22 MDS documented the present of MASD, review of R#48's clinical record revealed that there was no documentation in the EMR from 1/7/22 to 1/12/22 of the presence of MASD. Review of a 1/17/22 nursing Progress Note in the Progress Notes tab in the EMR revealed the resident had a 3 cm [centimeter] breakdown area on the right buttock located near the sacrum area. Cleaned wound, applied [MEDICATION(S)] to the area, and dressed with border dressing. There was no further evaluation that included complete measurements and identification of the wound. In addition to the skin breakdown to right buttock/sacrum, review of R#48's Skin/Wound Note dated 1/20/22 by the Wound Care Nurse (WCN) revealed the resident also had, excoriation to left ischium 3 x 4 cm. area clean with NSS [normal saline solution], and duoderm [occlusive, waterproof dressing for dry to lightly exuding wounds] dressing applied. Excoriation to sacral area 2 x 2 cm. area clean with NSS, pat dry, [MEDICATION(S)] applied. Resident denies discomfort. Resident place on [Wound Physician] list for evaluation. Although the facility policy called for weekly skin assessments, there was no further documentation of the left ischium site wound or evidence that the wound was resolved. Treatment orders remained active as of the date of the survey and were administered per the Medication/Treatment Administration Records. Review of the Wound Physician (WP) Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 1/28/22 revealed that R#48 now had a full thickness wound of the right buttock that measured 3 cm length (L) x 3 cm width (W) x 0.1 cm. depth (D) with light serous exudate with 30% slough (a mass of dead tissue separating from an ulcer) and 70% granulation (pink tissue containing new connective tissue that is part of the healing process). The physician performed a surgical debridement to 2.7 cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissues were removed at a depth of 0.1 cm and healthy bleeding tissue. The WP diagnosed MASD with a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 21 days. This estimate is made with an 80% degree of certainty. Although facility policy called for weekly skin assessments, review of the EMR revealed no evidence of wound evaluations in the EMR from 1/28/22 until 2/15/22 by either the Wound Physician or licensed nursing staff. Review of the Wound Physician (WP) Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 2/15/22 documented a full thickness wound of right buttock measuring 4 cm L x 3 cm W x 0.1 cm. D with moderate serous drainage, 30% slough, and 70% granulation. The summary documented there was no change in the wound progression. The WP documented that he surgically excise [sic] 3.6 cm of devitalized tissue including slough, biofilm [a thin, slimy film of bacteria that adheres to a surface] and non-viable subcutaneous fat and surrounding connective tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. Treatment Alginate Calcium w/silver with border dressing. Review of the WP Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 2/21/22 documented that the visit for that day was rescheduled and there was no wound evaluation documented by either the Wound Care Physician or licensed nursing staff in the EMR until 2/28/22 Review of the WP Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 2/28/22 documented a full thickness wound of right buttock healing MASD 5 cm x 3 cm x 0.1 cm with moderate serous drainage, 30% slough, and 70% granulation. There was no change in the wound progression. The WP surgically excised 4.5 cm of devitalized tissue including slough, biofilm and non-viable subcutaneous fat and surrounding connective tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. Although there was no progression in wound healing, the treatment was not changed and the orders for the Alginate Calcium with silver dressing continued. There were no wound evaluations, per facility policy, from 3/1/22 to 3/17/22 documented in the EMR by either the Wound Care Physician or licensed nursing staff. Review of the WP Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 3/18/22 documented the full thickness right buttock wound measured 5 cm x 5 x 0.1 cm with moderate serous drainage, 30% slough, and 70% granulation with no change in the wound progression. The WP surgically excised 7.5 cm of devitalized tissue including slough, biofilm and non-viable muscle and surrounding fascial fibers were removed at a depth of 0.5 cm and healthy bleeding tissue was observed. Review of orders revealed that the wound treatment remained unchanged, even though the physician documented that there was no change in wound progression. Review of the WP Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 3/21/22 documented a full thickness right buttock wound that measured 3.0 cm x 4.0 x 0.1 with moderate serous drainage, 30% slough, and 70% granulation and improved for the wound progression. The WP excised 3.6 cm of devitalized tissue including slough, biofilm and non-viable muscle and surrounding fascial fibers were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. Review of the WP Wound Evaluation & Management Summary located in the Miscellaneous tab in the EMR dated 3/28/22 documented the full thickness right buttock wound measured 4 cm. x 4 cm. x 0.1 cm with moderate serous drainage, 30% slough, and 70% granulation with no change in the wound progression. The WP surgically excise [sic] 4.8 cm of devitalized tissue including slough, biofilm and non-viable muscle and surrounding fascial fibers were removed at a depth of 0.8 cm and healthy bleeding tissue was observed. There was no evidence of consideration of changes to the wound treatment, which had been in place for six weeks, and had not been effective in promoting healing of the wound. Review of each WP Wound Evaluation & Management Summary located in the Miscellaneous tab documented the Coordination of Care as Data and history pertinent to this patient's care were obtained via Nursing Staff, Patient. This patient's care was discussed with another health care provider Nursing Staff Member during this visit. Review of each of these records revealed the Wound Physician only evaluated the right buttock (sacral) wound. There was no evidence that either the Wound Physician or licensed nursing evaluated, on an ongoing basis, the left ischial wound, even though treatment had been ordered and administered since 1/17/22. As part of the survey, wound care was observed. Review of R#48's active Clinical Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, review of R48's active Clinical Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 3/29/22 at 8:55 a.m., the Wound Care Nurse (WCN) entered R#48's room to perform wound care. LPN/MDS Coordinator 2 was present to assist. After gathering supplies consisting of sterile water, calcium alginate dressing, clean 4 x 4 dressings, and a composite island dressing, the WCN removed the resident's brief. Although review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of the full thickness right buttock (sacral) wound, which was depressed with denuded skin in the center revealed it was the approximate size of a half dollar with yellow and brown/black slough and was surrounded by a large pink/red peri wound. During the observation at 9:12 a.m., the WCN acknowledged that there was no dressing on the wound, stating that that the dressings probably fell off and the CNAs should have informed the nurse so the dressings could have been immediately replaced. The WCN used sterile 4 x 4 dressings soaked in the sterile water to cleanse the outer peri wound area; however, the nurse did not cleanse/irrigate the center of the wound bed. During the task, R#48 said Ow, and acknowledged the wound was painful. R#48 then told the WCN to finish the wound care without pain medication, stating she would be all right. The WCN placed one DermaGinate (a primary dressing for wounds with moderate to heavy exudate such as pressure injuries, diabetic ulcers, post-operative wounds, leg ulcers, donor sites, lacerations, and abrasions.) 2 x 2 sterile dressing flat on top of the peri wound. Observation revealed the nurse failed to use her hands to depress the dressing on the center of the wound bed to make contact then covered it with the composite island dressing (wound covers that combine physically distinct components into a single product to provide multiple functions such as a bacterial barrier, absorption, and adhesion.) During an interview on 3/29/22 at 9:24 a.m., the WCN initially stated that she cleansed the wound with normal saline and applied the calcium alginate as the physician ordered. However, when the WCN checked the supplies in the treatment cart which only contained sterile water containers, she acknowledged that she used sterile water because that's what we have. She confirmed that the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The WCN acknowledged that center of the wound was deeper and stated she did not irrigate the center of the wound because the Wound Physician did not give orders to perform wound irrigation. During an interview on 3/30/22 at 3:35 p.m., the Director of Nursing (DON) expressed the belief that R#48 did not have a pressure ulcer, stating that the resident had MASD and that R#48 was being treated and evaluated weekly in accordance with facility policy by a Wound Physician and the facility's WCN. During an interview on 3/30/22 at 5:33 p.m., R#48's Nurse Practitioner (NP) stated that she leaves the weekly evaluations to the WP. The NP stated that she had never performed an examination of the resident's wounds and stated that if the WP was not available to perform the weekly evaluation, then the WCN should perform the weekly evaluation. During an interview on 3/30/22 at 5:16 p.m., the WP stated that generally he evaluates and treats residents with wounds weekly. The WP stated that he could not remember the exact reasons that some of his evaluations were not weekly; however, he recalled one time his car broke down. The physician stated that it was the facility's responsibility to ensure that weekly wound measurements were done. The wound physician confirmed that he had debrided the sacral wound several times due to necrotic tissue and that the wound was a full thickness wound whose origin was MASD, adding that he last evaluated and debrided the wound on 3/28/22. When asked about the current status of the wound as MASD versus pressure ulcer in accordance with definitions in the MDS 3.0 Manual, he acknowledged It was probably an oversight on my part, adding that he generally does not vary terminology from the origin of the wound. When asked about wound care, the physician stated the wound required cleansing with normal saline or wound cleanser and that the calcium alginate dressing needs to contact the wound base to be effective. The physician confirmed that incorrect wound treatments could impede healing of the sacral wound. An additional observation and interview of R#48's wounds was conducted at bedside on 3/31/22 at 10:05 a.m. The DON was present with the WCN for the wound treatment at the request of the surveyor. The WCN removed the resident's brief and there was a composite dressing on the right/buttock and a Duoderm dressing on the left ischium. The DON inquired about the two separate dressings and the WCN stated that the Duoderm on the left ischium was scheduled for changing every three days. When the WCN removed the dressing from the right buttock wound at 10:09 a.m., the DON acknowledged that she could see the depth of the wound. The DON instructed the WCN to clean the wound and measure the length, width and depth of the wound and check for undermining. During the observation, the WCN measured the wound as 5.0 x 5.0 cm. During this observation, the DON had to instruct the WCN on the correct way to measure the depth with at sterile cotton applicator and to measure the deepest portion of the wound; the WCN did not perform this correctly during the observation and had to make several attempts with oversight by the DON to perform the task correctly. In addition, the DON had to instruct he WCN to measure and correctly identify the area(s) of undermining in the wound. During an interview on 3/31/22 at 10:34 a.m., the DON acknowledged that the sacral wound looked different from the WP report documented on 3/28/22, and stated she doubted the WP's documentation was accurate. The DON confirmed that the resident's sacral wound had deteriorated. The DON also confirmed that the current treatment order directed cleansing the wound with NS in accordance with wound treatment guidelines and she was not aware the facility did not have the normal saline in the facility until staff informed her on 3/29/22 after surveyor intervention. The DON stated the WCN would update the wound documentation and she would contact the WP and obtain treatment orders based on the discovery of the condition of the sacral wound during the observation. Review of R#48's Weekly Wound Report located in the Assessments tab in the EMR dated 3/31/22 at 11:56 a.m., revealed the WCN documented the right buttock wound was acquired on 1/7/22 and had MASD that was unchanged with slough present and 1 cm of undermining, serous fluid with an odor present that measured 5.5 cm x 5.0 cm x 2.5 cm depth. Per the report, infection was suspected, the resident had pain associated with the wound and the treatment was changed to Dakin's solution (antiseptic that kills most forms of bacteria and viruses) wet to dry dressing daily for 30 days and [MEDICATION(S)] (antibiotic) 500 milligrams (mg) tabs crushed daily to wound bed, for 10 days. No location of the undermining was documented. During a concurrent record review and interview on 3/31/22 at 3:49 p.m. with the DON, the DON stated that she had not viewed the 3/31/22 11:56 a.m. Weekly Wound Report documented by the WCN. The DON stated that the WCN was responsible to ensure weekly documentation of both the sacral and left ischial wound. Upon review of the current documentation in the EMR, the DON confirmed the sacral wound that started as MASD had now progressed to a full thickness loss of skin and was a pressure ulcer. The DON also reviewed the 1/7/22 Nursing Skin Assessment and stated that all admitting nurses were required to perform a full skin assessment and document a full evaluation of any existing skin issues. The DON confirmed that this was not done for R#48 upon re-admission on 1/7/22. At the direction of the DON, the WCN joined the interview and stated that she documented the wound as MASD because she did not think she could change the WP's assessment. The DON then instructed the WCN to correct her documentation and acknowledged to the surveyor that the wound documentation was inaccurate, based on the current observation of a Stage III worsening pressure ulcer with slough and odor present.

Based on clinical record review, Manual/Electric Portable Patient Lift instruction review, Nurse/Physician Communication Record review, facility investigation summary review, Employee Statement of Events form review, hospital Discharge Summary review, General Facility Orientation Checklist review, MayoClinic.org review, and staff interview, the facility failed to provide safe mechanical lift transfer, related to certified nursing assistant (CNA) staffs' failure to ensure the Maxilift legs were in the maximum open position during the transfer of one (1) resident (#1), who received Coumadin anticoagulant drug therapy and who required transfer via mechanical lift, of eight (8) sampled residents who were transferred via mechanical lift, on the total survey sample of eighteen (18) residents. Resident #1 received Coumadin anticoagulant drug therapy and required transfer via Maxilift. During Resident #1's Maxilift transfer from the bed to the wheelchair by CNA staff on [DATE], these CNA staff failed to ensure that the Maxilift legs were in the maximum open position, as specified by the manufacturer to ensure safety. During this transfer, the Maxilift tilted and Resident #1 was tapped on the forehead. The CNA staff notified the licensed nurse of this incident and the nurse assessed Resident #1 at that time, but then failed to inform the nursing staff of the following shift of this incident to ensure continued monitoring of Resident #1's status. Licensed nursing staff then failed to monitor the status of Resident #1, and on [DATE], she experienced a significant change in status, including vomiting, difficulty with breathing, an elevated body temperature of 100.5 degrees Fahrenheit (F), an elevated pulse rate of 132 beats per minute, and a low blood oxygen saturation level of 83 percent. Resident #1 was transferred to the hospital, diagnosed with [REDACTED]. After Resident #1 expired, the hospital physician documented the Primary [DIAGNOSES REDACTED]. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on [DATE] at 2:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE] (the date Resident #1 was tapped on the forehead during transfer when a Maxilift tipped after staffs' failure to ensure the lift legs were extended to the maximum open position, per manufacturer's specifications), continued through [DATE], and was removed on [DATE]. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on [DATE]. On [DATE], CNA staff failed to ensure the Maxilift legs were extended to the maximum open position, and Resident #1 was tapped on the forehead by the lift. On [DATE], Resident #1 experienced vomiting and difficulty with breathing, an had an elevated body temperature, elevated pulse rate, and a low blood oxygen saturation level, was transferred to the hospital, admitted to the Intensive Care Unit (ICU), and expired on [DATE]. During an interview with the facility's Maintenance Director conducted on [DATE] at 3:30 p.m., the Maintenance Director stated that if the legs of the Maxilift were not extended to maximum open position, the Maxilift could fall over. During an interview with the DON conducted on [DATE] at 4:00 p.m., the DON acknowledged that a Maxilift could fall over if the legs were not extended. An allegation of jeopardy removal was received on [DATE]. Based on the corrective plans which had been developed and implemented by the facility on [DATE], the immediacy of the deficient practice was determined to have been removed on [DATE]. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of monitoring, via both supervisory and management level staff oversight, of direct care staffs' compliance with mechanical lift safety, and physician notification and the monitoring of resident status, in accordance with facility policies and practices. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's policies and practices related to the transfer of residents utilizing mechanical lifts, and related to resident monitoring and physician notification. Resident records were reviewed to ensure that resident plans of care accurately reflected the transfer status and requirements of residents. Findings include: Review of the manufacturer's Manual/Electric Portable Patient Lift instructions for mechanical lift use revealed the following manufacturer's specifications: - In the section entitled Transferring to a Wheelchair, the manufacturer's instructions contained a warning indicating that the legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. The Manual indicated that if it was necessary to close the legs of the lift for maneuvering under a bed, to close the legs of the lift only as long as it took to position the lift over the resident and lift the resident off the surface of the bed. When the legs of the lift were no longer under the bed, the lift legs were to returned to the maximum open position. Record review for Resident #1 revealed an Admission Minimum Data Set (MDS) assessment having an Assessment Reference Date of [DATE] which documented a facility Entry Date of [DATE]. Section I - Active [DIAGNOSES REDACTED].#1 had [DIAGNOSES REDACTED]. Section G - Functional Status of this MDS documented that Resident #1 had been totally dependent and required the assistance of two-plus staff persons for transfer, and had utilized a wheelchair as a mobility device during the look-back period. Section K - Swallowing/Nutritional Status documented Resident #1 to have a weight of 282 pounds. The admission [DATE] physician's orders [REDACTED].#1 specified that the resident's medication regimen include the anticoagulant warfarin (Coumadin) 5 milligrams (mgs) daily for Coronary Artery Disease. The Laboratory section of this physician's orders [REDACTED]. A laboratory report dated [DATE] (the day after Resident #1's [DATE] facility admission), conducted per this physician's laboratory test order, revealed Resident #1 to have a Protime result of 22.4 seconds and an INR result of 2.03 at that time. A Resident Lift/Mobility Evaluation assessment form for Resident #1, dated as having been completed on the resident's [DATE] facility admitted , documented that the resident required assistance with transfers, as also indicated on the [DATE] MDS assessment referenced above. This Resident Lift/Mobility Evaluation assessment also documented Resident #1 to be dependent and to be a candidate for mechanical lift use. A Health Status Note (HSN) of [DATE] timed at 6:48 a.m. for Resident #1 noted that the resident required the assistance of two persons with a Maxilift for transfers, and a HSN of [DATE] timed at 7:29 a.m. again noted Resident #1's need for transfer via Maxilift and the assistance of two-plus staff persons. However, further review of Resident #1's clinical record revealed that, despite the resident's need for Maxilift transfer, there was no evidence to indicate that the facility put into place any specific steps or instructions to be used by direct care staff while transferring the resident using the Maxilift, to thus ensure the resident's safety. An HSN of [DATE] timed at 6:12 a.m. for Resident #1 then referenced that the resident had no complaints of pain to the brow area, and documented that staff would continue to monitor the resident's status. Review of a Nurse/Physician Communication Record (N/PCR) form dated [DATE] for Resident #1 revealed that on that date at 5:00 a.m., Resident #1 was being transferred with the Maxilift and the assistance of four (4) staff persons. This N/PCR form documented that during the transfer, Resident #1 leaned forward and slightly bumped her brow area on the padded Maxilift handle, resulting in no injury and no complaints of pain. This N/PCR form also documented that assessment at that time revealed Resident #1 to have normal vital signs, including a body temperature of 97.2 degrees F, a pulse of 78 beats per minute, a respiratory rate of 20 respirations per minute, and systolic/diastolic blood pressure readings of 132 and 74 millimeters of mercury (mm/Hg), respectively, and documented that the physician had been notified. An HSN of [DATE] timed at 3:05 p.m. for Resident #1 documented that the resident voiced no complaints, and documented normal vital signs which included a body temperature of 98.4 degrees F, a pulse of 67 beats per minute, a respiratory rate of 19, and systolic and diastolic blood pressure readings of 111 and 64 mm/Hg, respectively. An HSN of [DATE] timed at 10:01 p.m. documented assessment revealed Resident #1 to have no complaint of pain or discomfort, and also revealed no discoloration to the resident's brow. An HSN of [DATE] timed at 12:22 a.m. documented that Resident #1 denied any discomfort, and also documented normal vital sign readings which included a body temperature of 98.2 degrees F, a pulse rate of 74 beats per minute, and systolic/diastolic blood pressure readings of 139 and 82, respectively. A subsequent HSN of [DATE] timed at 12:07 a.m. documented continuing monitoring of Resident #1, who was documented as being alert and oriented and to have no complaint of pain or discomfort, and a HSN of [DATE] timed at 9:52 p.m. documented that Resident #1 remained alert and oriented with no noted distress. In addition, a HSN of [DATE] timed at 5:42 p.m. for Resident #1 documented that assessment at that time revealed the resident to have no noted distress. Further review of Resident #1's clinical record revealed no evidence of additional assessment and monitoring of the resident's status until a HSN dated [DATE] and timed at 11:24 p.m. (three days after the resident monitoring documented in the [DATE], 5:42 p.m. HSN referenced above). This [DATE], 11:24 p.m. HSN documented that Resident #1 awakened upon calling and had normal vital sign readings which included a body temperature of 98.6 degrees F, a respiratory rate of 20 per minute, systolic/diastolic blood pressure readings of 122 and 80, respectively, and a pulse rate of 90 beats per minute. The next HSN for Resident #1 was dated [DATE] and timed at 1:09 a.m., and documented that the resident was alert and oriented, and documented vital sign readings which included a body temperature of 98.1 degrees F. However, a subsequent HSN of [DATE] timed at 12:20 p.m. for Resident #1 documented that the body temperature had dropped to 97.7 degrees F, and that the resident stated she did not feel well, was a little short of breath, refused to get out of bed, and refused breakfast and lunch. A HSN of [DATE] timed at 2:15 p.m. for Resident #1 then documented that the resident was still complaining of not feeling well and had a body temperature of 97.6 degrees F, and documented that the resident had bruised areas of the left jaw and left eye. A N/PCR form dated [DATE] for Resident #1 documented that a facsimile was sent to the resident's physician which identified a discoloration measuring 2.5 centimeters (cms) by 2.5 cms below the resident's eye. This N/PCR also indicated that Resident #1's family was concerned with the bruising due to Coumadin use, and documented that the family was requesting PT and INR laboratory tests. A HSN of [DATE] at 9:09 p.m. for Resident #1 documented the facsimile to the physician regarding the discoloration and the family's request for a PT/INR. A Physician's Telephone Orders form of [DATE] for Resident #1 documented that the physician had responded to the request for PT and INR laboratory tests and had ordered that both a PT and an INR be performed. A laboratory report for Resident #1 of [DATE], timed as having been collected at 3:25 a.m., documented a high PT result of greater than 75 seconds (Reference Range, 11 to 15 seconds), and an elevated INR result of greater than 8.50. A hand-written notation on this laboratory report documented that the physician was notified of these PT/INR laboratory test results. A Physician's Telephone Orders form of [DATE] for Resident #1 specified to hold the resident's Coumadin drug therapy for five (5) days. The resident's [DATE] Medication Record documented that Resident #1's Coumadin dose was held as ordered on [DATE]. A HSN of [DATE] timed at 3:59 p.m. for Resident #1 documented vital signs which included a body temperature of 97.2 degrees F, a pulse rate of 77 beats per minute, and a normal blood oxygen saturation level of 93 percent. (The website MayoClinic.org indicated that a blood oxygen saturation of 90 to 100 could be considered normal, and a level below 90 percent was considered to be low, thus representing hypoxemia) However, a subsequent HSN of [DATE] timed at 12:31 a.m. for Resident #1 documented that at 4:30 p.m. (on [DATE]), the nurse was called to the resident's room by CNA staff, and noted that the resident had vomited and was struggling for breath. This HSN documented assessment at that time revealed Resident #1's body temperature to have increased to 100.5 degrees F, the pulse to have increased to 132 beats per minute, and the blood oxygen saturation level to have declined to 83 percent (compared to a body temperature of 97.2 degrees F, a pulse rate of 77 beats per minute, and a blood oxygen saturation of 93 percent as documented in the [DATE], 3:59 p.m. HSN referenced above). This HSN documented that the physician was paged and an order was received to send Resident #1 to the hospital emergency room (ER), and documented that Emergency Medical Services 911 was called to transport the resident to the hospital. A notation in this [DATE], 12:31 a.m. HSN documented that at 11:10 p.m. (on [DATE]), facility staff called the hospital and had received notice that Resident #1 had been admitted to the hospital with [REDACTED]. The hospital Discharge Summary (DS) related to Resident #1's hospital transfer of [DATE] documented that the resident had been brought to the hospital ER with Altered Mental Status. This DS documented, in the Brief Admitting History of Present Illness section, that a computerized tomography scan revealed Resident #1 to have a Subdural Hematoma. The Course In Hospital By Section portion of this hospital DS documented that Resident #1 had been admitted to the hospital but that her condition continued to decline, she began exhibiting seizure-type activity, and continued to have an elevated temperature. Keppra antiseizure drug therapy was initiated for Resident #1, but her condition began to worsen clinically with sepsis, and she was therefore transferred to the ICU for further monitoring. In the ICU, Resident #1 continued to have seizures, and exhibited [DIAGNOSES REDACTED] despite being on a benzodiazepine drip and a Propofol drip, and despite an increase in the dose of Keppra. The condition of Resident #1 was documented as continuing to worsen, and she passed away on [DATE]. Further review of this hospital DS revealed the Primary [DIAGNOSES REDACTED]. Additional review of the hospital DS referenced above revealed an amendment dated [DATE], and electronically signed by the hospital physician on [DATE], which documented that upon further review of the ER notes, the physician had noted documentation indicating that nursing facility staff had stated that Resident #1 had been hit on the head by a "triangle" while still in the facility. The physician documented that he assumed this meant that Resident #1 had been hit with a trapeze bar. The physician further documented that the Primary [DIAGNOSES REDACTED]. Review of facility investigative documents revealed a [DATE] investigation summary (IS) representing the facility's investigation into Resident #1 having been diagnosed with [REDACTED]. This IS documented the hospital had notified the facility that Resident #1's family had informed hospital staff that before hospital transfer, the resident had been hit in the head by a lift which had malfunctioned in the skilled nursing facility. The hospital employee informed facility staff that Resident #1's family alleged that this incident involving the resident being struck in the head with the lift had resulted in the Subdural Hematoma. The IS documented that prior to Resident #1's admission to the hospital, Resident #1's family had inquired about the resident having a discoloration on her head, and that the resident was observed to have a discoloration to the left side of her head. Staffing sheets were reviewed and staff members were interviewed, with the investigation then revealing that Resident #1 had bumped her forehead on the Maxilift on [DATE]. The incident had occurred on the 3rd shift while two (2) staff members (Certified Nursing Assistant (CNA) "BB" and CNA "CC")were transferring Resident #1 from the bed to the wheelchair with the 450 Maxilift. During this transfer, Resident #1 had been guided into her wheelchair which was sitting at a slant due to the size of the chair. The lift tilted due to movement of Resident #1 causing a shifting in the distribution of the resident's weight. As the Maxilift began to tilt, one of the staff members fell and pushed the lift over with her shoulder, and the lift bar tapped the resident in the middle of her forehead. The charge nurse (Licensed Practical Nurse (LPN) "AA") was informed of the incident involving Resident #1, assessed the resident and found no injury, and again checked the resident before shift change. The Conclusion section of the IS referenced above acknowledged that Resident #1 was bumped by the lift, revealing no initial signs of injury; however, the charge nurse got busy providing care to another resident and did not follow-up with Resident #1's family. This section of the IS also documented that physician notification occurred only when Resident #1 later experienced a change in condition. A written statement documented on an Employee Statements of Events form was provided by CNA "BB" as part of the facility's investigation into the [DATE] incident during which Resident #1 was tapped on the forehead by the Maxilift during transfer. In this written statement, CNA "BB" documented that she and CNA "CC" entered the resident's room around 6:30 a.m. to dress Resident #1 and to prepare her for breakfast. CNA "BB" indicated that during the process of transferring Resident #1 with the Maxilift, Resident #1's wheelchair was positioned at a slant due to the large size of the chair. CNA "BB" indicated that after Resident #1 was positioned in the wheelchair, the Maxilift tilted and landed on CNA "BB"'s right side/arm. CNA "BB" further documented at the time of the incident, she was positioned by the Maxilift, and CNA "CC" was at the back of Resident #1's chair. In an additional written statement, also documented on an Employee Statement of Events form, obtained from CNA "BB" as part of the facility's investigation, CNA "BB" further indicated that during the [DATE] incident during the transfer of Resident #1, the Maxilift had tilted over due to the position and the weight on the lift. CNA "BB" indicated that during the incident, the "swing part" of the lift tapped Resident #1 on the forehead. A written statement dated [DATE], and documented on an Employee Statement of Events form, was provided by CNA "CC" as part of the facility's investigation into the [DATE] involving Resident #1. In this written statement, CNA "CC" indicated that on the date of the incident, she and CNA "BB" were transferring the resident from the bed to the wheelchair with the 450 Maxilift. CNA "CC" indicated that after Resident #1 was seated in her wheelchair, the weight of the resident caused the lift to tilt over. CNA "CC" indicated that Resident #1 was secure in her wheelchair at the time but was tapped on the top of her forehead during the incident. CNA "CC" indicated that she and CNA "BB" then reported the incident to LPN "AA". Additionally, a written statement dated [DATE], and documented on an Employee Statement of Events form, was provided by LPN "AA" as part of the facility's investigation regarding the [DATE] incident involving Resident #1's Maxilift transfer. In this written statement, LPN "AA" indicated that on [DATE], she had been called to the resident's room by the CNAs. LPN "AA" indicated that as the CNAs were transferring Resident #1 from the bed to her wheelchair and as the resident was seated in her wheelchair, the lift started to tilt. LPN "AA" indicated that one CNA pushed the lift back upright with her shoulder, and the top of the lift bumped the middle top of the resident's forehead. LPN "AA" indicated she assessed Resident #1 at that time, and later conducted a recheck of the resident, and noted no mark, bump, or discoloration. LPN "AA" further indicated that she had intended to file a facility report and to notify the doctor of the [DATE] incident involving Resident #1 at the time of the incident. However, review of Resident #1's clinical record revealed no documented evidence of any reference to the [DATE] incident when Resident #1, who received daily Coumadin anticoagulant drug therapy, was tapped on the forehead during Maxilift transfer, or any evidence of monitoring of the resident's status, related to her having been tapped on the forehead on [DATE]. Additional record review for Resident #1, to include review of a HSN of [DATE] at 11:24 p.m., subsequent HSNs of [DATE] at 1:09 a.m., 12:20 p.m., 2:15 p.m., and 9:09 p.m., of [DATE] at 12:16 a.m. and 3:59 p.m., and of the final HSN of [DATE] at 12:31 a.m., revealed no evidence of a reference to Resident #1 having been tapped on the forehead with the Maxilift on [DATE], or of any monitoring of the resident's status related to that incident. The [DATE] Medication Record for Resident #1 documented that the resident had received daily 5 mg doses of the anticoagulant warfarin during the period of time from [DATE], when the resident was tapped on the forehead during MaxiLift transfer, through [DATE] (after which Coumadin was discontinued via the [DATE] Physician's Telephone Orders form referenced). However, as indicated above, there was no evidence of ongoing licensed nursing staff monitoring of Resident #1 related to the [DATE] incident during which she was tapped on the forehead during Maxilift transfer, from [DATE] through [DATE], when she was transferred to the hospital due to a significant change in status. During an interview with the Administrator conducted on [DATE] at 12:45 p.m., the Administrator acknowledged that LPN "AA" failed to document any reference to the [DATE] incident involving Resident #1 being tapped on the forehead with the Maxilift, failed to notify the physician of the incident, and failed to file the required incident report to ensure that nursing staff of subsequent shifts were informed of the incident to ensure the ongoing monitoring of the status of Resident #1. During a later telephone interview with the Administrator conducted on [DATE] at 09:05 a.m., the Administrator again acknowledged that LPN "AA" failed document a report of the [DATE] incident involving Resident #1 being tapped on the forehead to inform other nursing staff of the incident, and also failed to verbally inform other licensed nursing staff of this incident. The Administrator also acknowledged the failure of licensed nursing staff who worked on the dates following [DATE] to monitor Resident #1, related to her having been tapped on the forehead, due to LPN "AA"'s failure to pass along information regarding the incident. In addition, during interview with the DON conducted on [DATE] at 11:00 a.m., the DON was questioned about the facility's investigation into the [DATE] incident during which Resident #1 was tapped on the forehead as the Maxilift tilted during transfer. The DON stated that the facility had concluded that during the Maxilift transfer, the legs of the lift were not extended as required for stability, and that this had resulted in the lift tilting and tapping Resident #1 on the forehead. During the [DATE], 9:05 a.m. interview referenced above, the Administrator also acknowledged that the facility had concluded that on [DATE], when the Maxilift had tilted and tapped Resident #1 on the forehead, staff had failed to ensure that the lift legs were in the maximum open position, and the lift had tilted during the transfer. Review of a facility In-Service Summary and Attendance Record dated [DATE] revealed that on that date, the facility had conducted in-service training related to falls and mechanical lift safety, including the use of mechanical lifting devices. Review of the Attendance Record for this [DATE] in-service revealed that CNA "BB" had been in attendance. In addition, review of a Nursing Competency evaluation form of [DATE], used to evaluate CNA competency for mechanical lifting devices, revealed that during the competency evaluation, CNA "BB" had accurately verbalized that when using an adjustable base lift, the lift legs must be in the maximum opened/locked position before lifting the resident. CNA "BB" had also demonstrated how to open and close the lift base legs. A General Facility Orientation Checklist dated ,[DATE]-,[DATE] for CNA "CC" documented she was newly hired on [DATE]. The Individual Competency Validation Record portion of this General Facility Orientation Checklist documented that CNA "CC" received lift safety training regarding mechanical lifts, full-bed lifts, and Pneumatic lifts as part of her orientation process. In addition, review of a Nursing Competency evaluation form of [DATE], related to CNA competency for mechanical lifting devices, revealed that during the competency evaluation, CNA "CC" had accurately verbalized that when using an adjustable base lift, the lift legs must be in the maximum opened/locked position before lifting the resident. CNA "CC" had also demonstrated how to open and close the lift base legs. However, as indicated in both the [DATE], 11:00 a.m. DON interview and the [DATE], 9:05 a.m. Administrator interview referenced above, both acknowledged that on [DATE], when the Maxilift tilted and tapped Resident #1 on the forehead, these CNA staff had failed to ensure the lift legs were in the maximum open position, and the lift had tilted during the transfer. Based on the above, Resident #1 received Coumadin anticoagulant drug therapy and was transferred using a Maxilift. Resident #1 was being transferred via Maxilift on [DATE] after CNA staff had failed to ensure that Maxilift legs were in the maximum open position to ensure safety (specified by manufacturer's instructions, as referenced above). During this transfer, Resident #1 was tapped on the forehead by the lift when the lift tilted. LPN "AA" was immediately informed of this incident involving Resident #1, but the nurse failed to inform additional licensed nursing staff of the incident. Licensed nursing staff then failed to monitor Resident #1's status following this [DATE] incident involving Resident #1 being tapped on the forehead by the lift, and she continued to receive Coumadin anticoagulant therapy. On [DATE], nursing staff noted Resident #1 to have vomited, to have an elevated body temperature of 100.5 degrees F, an elevated pulse of 132 beats per minute, and a low blood oxygen saturation level of 83 percent. Resident #1 was transferred to the hospital and expired on [DATE], having [DIAGNOSES REDACTED]. The facility presented a Credible Allegation of Jeopardy Removal (CAJR) on [DATE], and it was determined that the immediate jeopardy was removed on [DATE], at which time the facility had implemented the following interventions: 1. On [DATE], the facility sent a report to the State Survey Agency regarding the incident involving Resident #1 being tapped on the forehead during lift transfer. 2. On [DATE], the Administrator and DON reviewed the policies and practices for mechanical lift safety and incident reporting. The lift safety policy specified that when staff are using a mechanical lift, two staff members should always be present, and the legs of the lift are to be opened all the way and locked, to ensure resident safety during transfer. The practice related to the reporting of resident incidents specified for staff to assess the resident immediately and to notify the physician and family, and routine monitoring of resident status and condition is to be conducted after the occurrence of an incident. The 24 Hour Report Book is used by the Charge Nurse to communicate, from one shift to the next, the need for resident monitoring after an incident. This review of the current policies determined no policy revisions were necessary. 3. On [DATE], a Life Safety Monitoring Tool was created to be used by the Staff Development Coordinator, Restorative Nurse, or designated Charge Nurse to monitor CNA staff while utilizing mechanical lifts to transfer residents. This newly developed procedure specifies a monitoring schedule to be used by these supervisory staff members calling for observation of sampled CNA staff performing resident lift transfers on one (1) hall per week; CNA staff on all four (4) facility halls will be observed by month-end. The results of these audits will be submitted to the DON for review. In addition, the facility implemented a new procedure by which the DON will conduct observations of selected CNA staff during mechanical lift transfer to further assess compliance with safety. 4. On [DATE], the facility developed and implemented a new procedure by which the licensed nursing staff member on duty the shift during which a resident experiences an incident will document this incident in the 24 Hour Report Book, and will communicate this information verbally to the licensed nursing staff member of the next shift. The licensed nursing staff member of the on-coming shift will then verify, via review of the 24 Hour Report Book, that this information has been documented, and will initial to indicate this review. The 24 Hour Report Book is reviewed daily in morning meetings by the Unit Manager, who then follows up to ensure licensed nursing staff conformance with these policies and practices. 5. On [DATE], the facility developed and implemented a procedure by which the Administrator/DON will conduct a monthly audit of selected resident clinical records to monitor for compliance with facility policies and practices related to physician notification and family notification of incidents, the required documentation of these incidents, and the monitoring of residents after incidents. These audits will be documented on the Chart Audit Tool. 6. On [DATE], the Maintenance Director completed an inspection of all facility lifts for mechanical defects. This inspection included the Maxilift utilized during the [DATE] incident involving Resident #1, with the insp

Based on clinical record review and staff interview, the facility failed to ensure the involvement of the Quality Assessment and Assurance (QA) Committee in the development of a corrective action plan formulated in response to an incident involving a mechanical lift transfer for Resident #1. During a Maxilift transfer on [DATE], staff failed to place the Maxilift legs in the maximum open position, the Maxilift tilted and Resident #1 was tapped on the forehead. Licensed nursing staff failed to provide ongoing monitoring of the status of Resident #1 after this incident, and on [DATE], the resident experienced difficulty breathing, an elevated body temperature and pulse rate, and a low blood oxygen saturation, was transferred to the hospital, admitted to the Intensive Care Unit (ICU), and expired on [DATE]. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on [DATE] at 2:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE] (the date Resident #1 was tapped on the forehead during transfer when a Maxilift tipped after staffs' failure to ensure the lift legs were extended to the maximum open position, per manufacturer's specifications), continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Jeopardy Removal related to the immediate jeopardy on [DATE]. During an interview conducted on [DATE] at 1:00 p.m., the Administrator acknowledged the [DATE] incident during which Resident #1 had been tapped on the forehead during Maxilift transfer, and that a corrective action plan was developed after this incident; however, the Administrator indicated the QA Committee was made aware of this corrective action plan related to Resident #1's incident only after the development of the plan. An allegation of jeopardy removal was received on [DATE]. Based on the corrective plans which had been developed and implemented by the facility on [DATE], the immediacy of the deficient practice was determined to have been removed on [DATE]. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of monitoring, via both supervisory and management level staff oversight, direct care staffs' compliance with mechanical lift safety, and physician notification and the monitoring of resident status, in accordance with facility policies and practices. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's policies and practices related to the transfer of residents utilizing mechanical lifts, and related to resident monitoring and physician notification. Resident records were reviewed to ensure that resident plans of care accurately reflected the transfer status and requirements of residents. Findings include: Cross refer to F323. Based on record review and staff interview, the facility failed to ensure safe mechanical lift transfer for one (1) resident (#1), who received [MEDICATION NAME] anticoagulant therapy, on the survey sample of eighteen (18) residents. During Maxilift transfer of Resident #1 on [DATE], staff failed to ensure that the Maxilift legs were in the maximum open position, the Maxilift tilted and Resident #1 was tapped on the forehead. Licensed nursing staff failed to then monitor the status of Resident #1 on an ongoing basis related to this incident, and on [DATE], Resident #1 experienced a significant change in condition, was transferred to the hospital and admitted to the ICU, and expired on [DATE]. After Resident #1 expired, the hospital physician documented the Primary [DIAGNOSES REDACTED]. An interview was conducted with the Administrator on [DATE] at 1:00 p.m. related to the facility's QA Committee. During this interview, the Administrator was questioned about the QA Committee's review of the [DATE] incident involving Resident #1 being tapped on the forehead during Maxilift transfer after facility staff had failed to extend the lift legs to the maximum open position, as specified by the manufacturer. The Administrator was also questioned about the QA Committee's involvement in the formulation of the corrective action plan which was developed by the facility in response to the [DATE] incident involving Resident #1. During this interview, the Administrator indicated that upon learning of Resident #1 having been admitted to hospital with a Subdural Hematoma, the facility immediately initiated an investigation and learned of the incident (which occurred on [DATE]) around [DATE]. A corrective action plan was developed by facility management staff. This corrective action plan involved the review of the current facility policies regarding mechanical lift transfers and the processes utilized by licensed nursing staff to provide necessary and ongoing monitoring of resident status after incidents. The corrective action plan also involved the development and implementation of new procedures to be used by supervisory staff and management staff to assess direct care staff's ongoing compliance related to resident mechanical lift transfers and the monitoring of resident status. In addition, the plan involved the in-service training of nursing staff regarding the facility's policies and procedures related to lift transfers and resident monitoring. However, during the interview, the Administrator acknowledged that the corrective action plan was developed and implemented by facility management staff, but that the incident involving Resident #1 was not presented to the QA Committee for discussion until the Committee met on [DATE]. There was no evidence to indicate that the QA Committee had reviewed, evaluated, or approved the corrective action plan, which had been developed and implemented by facility administrative staff and which included procedural changes and staff training, prior to the implementation of the plan. The facility presented a Credible Allegation of Jeopardy Removal (CAJR) on [DATE], and it was determined that the immediate jeopardy was removed on [DATE], at which time the facility had implemented the following interventions: 1. On [DATE], the facility sent a report to the State Survey Agency regarding the incident involving Resident #1 being tapped on the forehead during lift transfer. 2. On [DATE], the Administrator and DON reviewed the policies and practices for mechanical lift safety and incident reporting. The lift safety policy specified that when staff are using a mechanical lift, two staff members should always be present, and the legs of the lift are to be opened all the way and locked, to ensure resident safety during transfer. The practice related to the reporting of resident incidents specified for staff to assess the resident immediately and to notify the physician and family, and routine monitoring of resident status and condition is to be conducted after the occurrence of an incident. The 24 Hour Report Book is used by the Charge Nurse to communicate, from one shift to the next, the need for resident monitoring after an incident. This review of the current policies determined no policy revisions were necessary. 3. On [DATE], a Life Safety Monitoring Tool was created to be used by the Staff Development Coordinator, Restorative Nurse, or designated Charge Nurse to monitor CNA staff while utilizing mechanical lifts to transfer residents. This newly developed procedure specifies a monitoring schedule to be used by these supervisory staff members calling for observation of sampled CNA staff performing resident lift transfers on one (1) hall per week; CNA staff on all four (4) facility halls will be observed by month-end. The results of these audits will be submitted to the DON for review. In addition, the facility implemented a new procedure by which the DON will conduct observations of selected CNA staff during mechanical lift transfer to further assess compliance with safety. 4. On [DATE], the facility developed and implemented a new procedure by which the licensed nursing staff member on duty the shift during which a resident experiences an incident will document this incident in the 24 Hour Report Book, and will communicate this information verbally to the licensed nursing staff member of the next shift. The licensed nursing staff member of the on-coming shift will then verify, via review of the 24 Hour Report Book, that this information has been documented, and will initial to indicate this review. The 24 Hour Report Book is reviewed daily in morning meetings by the Unit Manager, who then follows up to ensure licensed nursing staff conformance with these policies and practices. 5. On [DATE], the facility developed and implemented a procedure by which the Administrator/DON will conduct a monthly audit of selected resident clinical records to monitor for compliance with facility policies and practices related to physician notification and family notification of incidents, the required documentation of these incidents, and the monitoring of residents after incidents. These audits will be documented on the Chart Audit Tool. 6. On [DATE], the Maintenance Director completed an inspection of all facility lifts for mechanical defects. This inspection included the Maxilift utilized during the [DATE] incident involving Resident #1, with the inspection of the lift hardware, swivel bars, base and casters revealing no mechanical defects or issues. Inspection of a total of six (6) Maxilifts and two (2) Sara lifts revealed no evidence of mechanical defects. 7. On [DATE], the facility completed staff-in service training, which had been initiated on [DATE], to provide training to licensed nursing staff and certified nursing assistant staff related to the facility's policies and practices related to mechanical lift use and safety, physician and family notification of resident incidents, and the monitoring of residents after the occurrence of incidents. This in-service training also addressed the facility's new procedure involving the use of the Life Safety Monitoring Tool to be used by facility supervisory staff to conduct routine observations and monitoring of CNA staff during mechanical lift transfers to assess compliance with facility policies and procedures. This training also addressed the new procedure involving the licensed staff end-of-shift review of the 24 Hour Report Book. By [DATE], all licensed nursing staff (four registered nurses and twenty-two LPNs) and all certified nursing staff (sixty-nine CNAs) had received this training. 8. On [DATE], the facility developed and implemented a new procedure by which the results of supervisory staff monitoring of mechanical lift transfers, via the Lift Safety Monitoring Tool, and the DON audit of this Lift Safety Monitoring Tool procedure, as well as the monthly DON audit, via the Chart Audit Tool, of staff compliance with physician/family notification and resident monitoring, will be submitted to the facility's Quality Assurance (QA) Committee for the Committee's review. The QA Committee review will review and analyze the data collected as a result of the Monthly Lift Check Audit Tool and Chart Audit Tool, to assess facility staffs' understanding of, and compliance with, facility policies and procedures, and to identify the potential need for policy revision or additional staff training. The QA Committee met on [DATE] to begin this process of review. During the abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On [DATE], it was confirmed by review of the State Complaint Incident and Tracking System that the facility had reported, as indicated in Step #1 of the CAJR referenced above, the [DATE] incident involving Resident #1 being tapped on the head during transfer, with noted subsequent discoloration. This report was documented in the State System as an Entity Reported Incident dated [DATE]. - On [DATE], Administrator interview and policy/practice review confirmed, as indicated in Step #2 of the CAJR referenced above, the facility's policy for lift safety to require the presence of two staff during lift transfers, and to require that the legs of the lift are to be opened all the way and locked, to ensure resident safety during transfers. Residents are to be immediately assessed and monitored after an incident, and the physician and family are to be notified after the occurrence of an incident. The 24 Hour Report Book is used for shift-to-shift communication, including the need for resident monitoring after an incident. - On [DATE], policy and document review confirmed the establishment of a new practice, as indicated in Step #3 of the CAJR referenced above, involving the use of the Life Safety Monitoring Tool to document supervisory staff monitoring of CNA staff while conducting resident lift transfers. The Staff Development Coordinator/Restorative Nurse/Charge Nurse will observe CNA staff during lift transfers, observing sampled CNA staff on one (1) hall per week, and on all four (4) facility halls by month-end. - On [DATE], policy and practice review and Administrator interview confirmed a new procedure, as indicated in Step #4 of the CAJR referenced above, specifying that licensed nursing staff on duty when a resident experiences an incident will document this incident in the 24 Hour Report Book and verbally inform licensed nursing staff of the next shift. Licensed nursing staff of the on-coming shift will review the 24 Hour Report Book to ensure documentation has been completed. - On [DATE], policy review confirmed a new procedure, as indicated in Step #5 of the CAJR referenced above, specifying that the Administrator/DON conduct monthly audits of resident records to assess staff compliance with policies and practices related to physician/family notification, incident documentation, and resident monitoring. - On [DATE], it was confirmed by review of the Monthly Lift Checks and Mechanical Lifting Device Maintenance Checklist forms that the Maintenance Director had completed an inspection of the Maxilift utilized during the [DATE] incident involving Resident #1, and of all additional mechanical lifts used in the facility. Documentation indicated that this inspection by the Maintenance Director had revealed no evidence of mechanical defects or issues, as indicated in Step #6 of the CAJR referenced above. - On [DATE], review of facility in-service records confirmed in-service training, as indicated in Step #7 of the CAJR referenced above, related to policies/practices for mechanical lift use, physician/family notification, and resident monitoring. This training included the Life Safety Monitoring Tool and routine observations of CNA staff during mechanical lift transfers, and the licensed staff shift reviews of the 24 Hour Report Book. As of [DATE], the facility's four registered nurses, twenty-two LPNs, and sixty-nine CNAs had received this training. - On [DATE], Administrator interview and procedure review confirmed the new procedure, as indicated in Step #8 of the CAJR referenced above, requiring that the results of supervisory staff mechanical lift transfer monitoring via the Lift Safety Monitoring Tool, of DON audits of this Tool, and of DON audits of staff compliance with physician/family notification and resident monitoring via the Monitoring Tool, will be submitted to the facility's Quality Assurance (QA) Committee for review. Based on these corrective actions which had been developed and implemented by the facility as outlined above, it was determined that the immediacy of the deficient practice had been removed on [DATE]; however, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On [DATE], a new procedure was created by which the Staff Development Coordinator/Restorative Nurse/Charge Nurse would monitor CNA staff during mechanical lift transfers, with observations to be on one (1) hall per week, and involving all four (4) facility halls by month-end. This monitoring is to be documented on the Life Safety Monitoring Tool, and the results of are to be submitted to the DON for review. In addition, a new procedure of [DATE] specifies that licensed nursing staff of a shift during which a resident experiences an incident would document this incident in the 24 Hour Report Book and also communicate verbally to licensed nursing staff of the next shift, who would then review of the 24 Hour Report Book to verify documented evidence of the incident. The 24 Hour Report Book will be reviewed in daily morning meetings by the Unit Manager. The Administrator/DON will conduct a monthly audit of selected resident clinical records to monitor for compliance with these practices related to physician notification/family notification, and incident documentation, with the audits documented a new Chart Audit Tool. Another new procedure, also implemented on [DATE], indicated that the results of supervisory mechanical lift transfer monitoring, per the Lift Safety Monitoring Tool, the DON audit of this Lift Safety Monitoring Tool, and the monthly DON audit using the Chart Audit Tool of staff compliance with physician/family notification and resident monitoring, will be submitted to the facility's Quality Assurance (QA) Committee for the Committee's review. The QA Committee met on [DATE] initiate this process. However, facility staffs' ongoing compliance with the newly established and implemented practices involving supervisory staff monitoring of direct-care staff during resident mechanical lift transfers could not be fully assessed as of the exit date of this abbreviated survey and will need to be evaluated at a future time. Additionally, staff compliance with the newly established procedures specifying management staff audits of resident records to ensure licensed nursing staff compliance with the relaying of critical information regarding resident incidents, to therefore ensure subsequent ongoing resident monitoring, could not be fully assessed at the time of survey exit, and will need future evaluation. Therefore, the noncompliance continues, with the scope and severity of the deficiency reduced to the "D" level.

Based on clinical record review, Nurse/Physician Communication Record review, facility investigation summary review, Employee Statement of Events form review, hospital Discharge Summary review, National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules review, and staff interview, the facility failed to ensure that services were provided in accordance with professional standards of quality, regarding monitoring the status of one (1) resident (#1) who received [MEDICATION NAME] anticoagulant drug therapy and was tapped on the forehead during Maxilift transfer, and failed to ensure an initial plan of care for Resident #1 (a newly admitted resident) which instructed direct-care staff on Resident #1's use of the mechanical lift, on the total survey sample of eighteen (18) residents. During a Maxilift transfer on [DATE], Resident #1 was tapped on the forehead when the lift tilted. Although Licensed Practical Nurse (LPN) "AA" initially assessed Resident #1 for injury, the nurse failed to communicate relevant information to the attending physician and to other licensed nursing staff, as specified by standards of practice, to inform the physician and nursing staff of Resident #1 having been tapped on the forehead with the lift. Licensed nursing staff then failed to monitor the status of Resident #1, she continued to received daily [MEDICATION NAME] anticoagulant therapy, and on [DATE], she experienced vomiting, difficulty with breathing, an elevated body temperature of 100.5 degrees Fahrenheit (F), an elevated pulse rate of 132 beats per minute, and a low blood oxygen saturation level of 83 percent. Resident #1 was transferred to the hospital, admitted to the Intensive Care Unit (ICU) and had [DIAGNOSES REDACTED] while on benzodiazepine/Propofol drips and [MEDICATION NAME] anticonvulsant drug therapy, and expired on [DATE]. The physician documented Resident #1's Primary [DIAGNOSES REDACTED]. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on [DATE] at 2:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE] (the date Resident #1 was tapped on the forehead during transfer when a Maxilift tipped after staffs' failure to ensure the lift legs were extended to the maximum open position, per manufacturer's specifications), continued through [DATE], and was removed on [DATE]. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on [DATE]. During a [DATE], 9:05 a.m. telephone interview, the Administrator acknowledged nursing staffs' failure to monitor Resident #1 after the resident's [DATE] incident when she was tapped on forehead. An allegation of jeopardy removal was received on [DATE]. Based on the corrective plans which had been developed and implemented by the facility on [DATE], the immediacy of the deficient practice was determined to have been removed on [DATE]. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of monitoring, via both supervisory and management level staff oversight, of direct care staffs' compliance with mechanical lift safety, and physician notification and the monitoring of resident status, in accordance with facility policies and practices. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's policies and practices related to the transfer of residents utilizing mechanical lifts, and related to resident monitoring and physician notification. Resident records were reviewed to ensure that resident plans of care accurately reflected the transfer status and requirements of residents. Findings include: Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules revealed that the Model Nursing Administrative Rules specified in Chapter 2 - Standards of Nursing Practice, Section 2.3.2, Standards Related to Licensed Practical Nurse (LPN/VN) Responsibilities for Nursing Practice Implementation, Parts 2.3.2(k)(1) and (4), that the nurse communicates relevant and timely information with other health team members related to the status of the resident and the needs of the resident. Resident #1's Admission Minimum Data Set assessment of [DATE] documented an admission date of [DATE], and documented [DIAGNOSES REDACTED]. Section G-Functional Status documented that Resident #1 was totally dependent on two-plus persons for transfer. Resident #1's Resident Lift/Mobility Evaluation assessment of [DATE] indicated the resident's dependence on assistance with transfers and that the resident was a candidate for mechanical lift use. Additionally, Resident #1's [DATE] physician's orders [REDACTED]. Further record review for Resident #1 revealed that following the resident's facility admission on [DATE], as documented in the [DATE] MDS referenced above, the facility formulated an admission care plan, entitled Skin Risk Evaluation and Plan of Care, on [DATE] (developed prior to the Comprehensive Care Plan developed on [DATE]). However, even though Resident #1's [DATE] Resident Lift/Mobility Evaluation assessment referenced above indicated the resident was a candidate for mechanical lift use during transfers, review of the resident's admission care plan of [DATE] revealed that neither the use of the mechanical lift, nor Interventions to instruct staff on procedures to ensure the safe transfer of the resident with the mechanical lift, had been included on the admission care plan. During an interview with the MDS Coordinator conducted on [DATE] at 11:20 a.m., the MDS Coordinator acknowledged that Resident #1's use of a Maxilift during transfers had not been added to the resident's admission care plan when the plan was developed on [DATE]. A N/PCR form dated [DATE] for Resident #1 then documented that on [DATE], during transfer via Maxilift, Resident #1 leaned forward and slightly bumped her brow area on the padded Maxilift handle. This N/PCR documented that assessment of Resident #1 at that time revealed no injury. Further review of Resident #1's admission care plan referenced above revealed that it was only after this [DATE] incident involving Resident #1 leaning forward during transfer and bumping her head on the Maxilift handle that any reference to Maxilift use was added to the resident's admission care plan. The [DATE] addition to Resident #1's admission care plan regarding Maxilift use only referred to the [DATE] incident involving Resident #1 and the Maxilift. The only entry added in the Interventions section of Resident #1's admission care plan related to this [DATE] Maxilift incident was that the physician and responsible party were notified and that staff were to monitor Resident #1's brow area for injury. No admission care plan Interventions were added to instruct staff on the procedures to use while transferring Resident #1 using the Maxilift to ensure the safe transfer of the resident. Further clinical record review for Resident #1 revealed a Health Status Note (HSN) of [DATE] at at 12:20 p.m. which documented that the resident stated she did not feel well, was a little short of breath, and refused to get out of bed. A [DATE], 2:15 p.m. HSN then documented that Resident #1 continued to complain of not feeling well, and also documented bruised areas of the left jaw and eye. A [DATE] Nurse/Physician Communication Record (N/PCR) form for Resident #1 documented that a facsimile sent to the physician identified a 2.5 centimeter (cm) by 2.5 cm discoloration below the eye, referenced the resident's [MEDICATION NAME] use, and requested [MEDICATION NAME] Time and International Normalized Ratio (PT/INR) laboratory tests. A [DATE] Physician's Telephone Orders (PTO) form for Resident #1 specified orders for PT/INR laboratory tests. A [DATE] laboratory report revealed a high PT of greater than 75 seconds (Reference Range, ,[DATE] seconds) and a high INR of greater than 8.50, and a [DATE] PTO form specified to hold Resident #1's [MEDICATION NAME]. However, a [DATE], 12:31 a.m. HSN then documented that at 4:30 p.m. (on [DATE]), the nurse noted Resident #1 had vomited, was struggling for breath, and had an increased body temperature of 100.5 degrees F, a pulse of 132 beats/minute, and a blood oxygen saturation level of 83 percent. Resident #1's physician was paged, and an order was received for Resident #1's hospital transfer. Resident #1's hospital Discharge Summary (DS) documented that the resident had Altered Mental Status, with a computerized tomography scan revealing a Subdural Hematoma. Resident #1 had [MEDICAL CONDITION]-type activity, received [MEDICATION NAME] therapy and was transferred to ICU, but experienced [DIAGNOSES REDACTED] while receiving benzodiazepine/Propofol drips and an increased [MEDICATION NAME] dose. Per this DS, Resident #1 passed away on [DATE] with a Primary [DIAGNOSES REDACTED].#1's Primary [DIAGNOSES REDACTED]. A [DATE] facility investigation summary (IS) referenced Resident #1's Subdural Hematoma. This IS documented that prior to Resident #1's hospital admission, she was observed to have a discoloration to the left side of her head. Facility investigation revealed Resident #1 had bumped her forehead on the Maxilift on [DATE] while two staff (Certified Nursing Assistants (CNA) "BB" and "CC") were transferring her from bed to wheelchair via Maxilift. Resident #1 was placed in the wheelchair but she then moved causing a shift in weight distribution, the Maxilift tilted, and the lift bar tapped the resident in the middle of her forehead. This IS documented that the charge nurse (LPN "AA") was informed and assessed Resident #1 to have no injury. In a [DATE] written statement, documented on an Employee Statement of Events form and provided by LPN "AA" during the facility's investigation of the [DATE] incident involving Resident #1 being tapped on the forehead by the Maxilift, LPN "AA" acknowledged that on [DATE], upon being informed of the incident, she assessed Resident #1 and noted no injury, and indicated she had intended to file a facility report. However, record review for Resident #1's revealed no evidence to indicate that LPN "AA" documented the [DATE] incident when Resident #1 was tapped on the forehead as the Maxilift tilted, or informed the attending physician of the incident. There was also no evidence to indicate that LPN "AA" informed nursing staff of the oncoming shift of the [DATE] incident to ensure continued monitoring of Resident #1, who received [MEDICATION NAME], after she had been tapped on the head with the Maxilift. This was despite professional standards of practice, as reflected in the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules referenced above, which specified that the nurse would communicate relevant and timely information with other health team members related to the resident's status and needs. A [DATE], 11:24 p.m. HSN for Resident #1 (which was the first documented HSN after the [DATE] incident during which Resident #1 was tapped on the forehead during Maxilift transfer) documented the resident would awaken when called, and documented a body temperature of 98.6 degrees F, a heart rate of 90 beats/minute, a respiratory rate of 20 per minute, and a blood oxygen saturation of 92 percent. However, further record review for Resident #1, to include review of the [DATE], 11:24 p.m. HSN referenced above, and of subsequent HSNs of [DATE] at 1:09 a.m., 12:20 p.m., 2:15 p.m., and 9:09 p.m., of [DATE] at 12:16 a.m. and 3:59 p.m., and of [DATE] at 12:31 a.m., revealed no documented evidence to indicate that, during that period of time, LPN "AA" communicated information to other licensed nursing staff or the physician regarding the [DATE] incident involving Resident #1 being tapped on the forehead during lift transfer, as would be specified by professional standards of practice per the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules. Review of Resident #1's clinical record also revealed no evidence of continued monitoring by licensed nursing staff of Resident #1's status, related to her having been tapped on the forehead on [DATE] during lift transfer, from the time of the incident through her [DATE] hospital transfer due to a significant change in status. During a [DATE], 09:05 a.m. interview, the Administrator acknowledged that LPN "AA" failed to notify nursing staff of the oncoming shift of the [DATE] incident involving Resident #1, and acknowledged that nursing staff working on shifts following [DATE] then failed to monitor Resident #1 after she was tapped on the forehead. Based on the above, Resident #1 was totally dependent on staff for transfer, required the assistance of two-plus staff persons and the use of the Maxilift for transfer, and received [MEDICATION NAME] anticoagulant drug therapy daily. However, Resident #1 was tapped on the forehead when the Maxilift tilted during transfer from the bed to the wheelchair on [DATE], but LPN "AA" failed to then document a report of this incident or notify the physician of the incident. LPN "AA" also failed to inform licensed nursing staff of the oncoming shift of [DATE], or subsequent days, of this incident involving Resident #1 having been tapped on the forehead to ensure the ongoing monitoring of the resident's status, even though the resident received [MEDICATION NAME] anticoagulant drug therapy. LPN "AA" thus failed to ensure the provision of care for Resident #1 in conformance with professional standards of quality by failing to communicate information to the physician and other licensed nursing staff, regarding the status and needs of Resident #1 related to the [DATE] incident, as specified by the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules, Chapter 2 - Standards of Nursing Practice referenced above. Licensed nursing staff then failed to monitor Resident #1 from [DATE] through [DATE], as related to her after having been tapped on the forehead with the Maxilift on [DATE] while receiving [MEDICATION NAME] anticoagulant drug therapy. Resident #1 then experienced a significant change in status, including increased body temperature and pulse rate, and a decreased blood oxygen saturation level, was transported to the hospital, was diagnosed with [REDACTED]. Cross refer to F323 for more information regarding Resident #1. The facility presented a Credible Allegation of Jeopardy Removal (CAJR) on [DATE], and it was determined that the immediate jeopardy was removed on [DATE], at which time the facility had implemented the following interventions: 1. On [DATE], the facility sent a report to the State Survey Agency regarding the incident involving Resident #1 being tapped on the forehead during lift transfer. 2. On [DATE], the Administrator and DON reviewed the policies and practices for mechanical lift safety and incident reporting. The lift safety policy specified that when staff are using a mechanical lift, two staff members should always be present, and the legs of the lift are to be opened all the way and locked, to ensure resident safety during transfer. The practice related to the reporting of resident incidents specified for staff to assess the resident immediately and to notify the physician and family, and routine monitoring of resident status and condition is to be conducted after the occurrence of an incident. The 24 Hour Report Book is used by the Charge Nurse to communicate, from one shift to the next, the need for resident monitoring after an incident. This review of the current policies determined no policy revisions were necessary. 3. On [DATE], a Life Safety Monitoring Tool was created to be used by the Staff Development Coordinator, Restorative Nurse, or designated Charge Nurse to monitor CNA staff while utilizing mechanical lifts to transfer residents. This newly developed procedure specifies a monitoring schedule to be used by these supervisory staff members calling for observation of sampled CNA staff performing resident lift transfers on one (1) hall per week; CNA staff on all four (4) facility halls will be observed by month-end. The results of these audits will be submitted to the DON for review. In addition, the facility implemented a new procedure by which the DON will conduct observations of selected CNA staff during mechanical lift transfer to further assess compliance with safety. 4. On [DATE], the facility developed and implemented a new procedure by which the licensed nursing staff member on duty the shift during which a resident experiences an incident will document this incident in the 24 Hour Report Book, and will communicate this information verbally to the licensed nursing staff member of the next shift. The licensed nursing staff member of the on-coming shift will then verify, via review of the 24 Hour Report Book, that this information has been documented, and will initial to indicate this review. The 24 Hour Report Book is reviewed daily in morning meetings by the Unit Manager, who then follows up to ensure licensed nursing staff conformance with these policies and practices. 5. On [DATE], the facility developed and implemented a procedure by which the Administrator/DON will conduct a monthly audit of selected resident clinical records to monitor for compliance with facility policies and practices related to physician notification and family notification of incidents, the required documentation of these incidents, and the monitoring of residents after incidents. These audits will be documented on the Chart Audit Tool. 6. On [DATE], the Maintenance Director completed an inspection of all facility lifts for mechanical defects. This inspection included the Maxilift utilized during the [DATE] incident involving Resident #1, with the inspection of the lift hardware, swivel bars, base and casters revealing no mechanical defects or issues. Inspection of a total of six (6) Maxilifts and two (2) Sara lifts revealed no evidence of mechanical defects. 7. On [DATE], the facility completed staff-in service training, which had been initiated on [DATE], to provide training to licensed nursing staff and certified nursing assistant staff related to the facility's policies and practices related to mechanical lift use and safety, physician and family notification of resident incidents, and the monitoring of residents after the occurrence of incidents. This in-service training also addressed the facility's new procedure involving the use of the Life Safety Monitoring Tool to be used by facility supervisory staff to conduct routine observations and monitoring of CNA staff during mechanical lift transfers to assess compliance with facility policies and procedures. This training also addressed the new procedure involving the licensed staff end-of-shift review of the 24 Hour Report Book. By [DATE], all licensed nursing staff (four registered nurses and twenty-two LPNs) and all certified nursing staff (sixty-nine CNAs) had received this training. 8. On [DATE], the facility developed and implemented a new procedure by which the results of supervisory staff monitoring of mechanical lift transfers, via the Lift Safety Monitoring Tool, and the DON audit of this Lift Safety Monitoring Tool procedure, as well as the monthly DON audit, via the Chart Audit Tool, of staff compliance with physician/family notification and resident monitoring, will be submitted to the facility's Quality Assurance (QA) Committee for the Committee's review. The QA Committee review will review and analyze the data collected as a result of the Monthly Lift Check Audit Tool and Chart Audit Tool, to assess facility staffs' understanding of, and compliance with, facility policies and procedures, and to identify the potential need for policy revision or additional staff training. The QA Committee met on [DATE] to begin this process of review. During the abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On [DATE], it was confirmed by review of the State Complaint Incident and Tracking System that the facility had reported, as indicated in Step #1 of the CAJR referenced above, the [DATE] incident involving Resident #1 being tapped on the head during transfer, with noted subsequent discoloration. This report was documented in the State System as an Entity Reported Incident dated [DATE]. - On [DATE], Administrator interview and policy/practice review confirmed, as indicated in Step #2 of the CAJR referenced above, the facility's policy for lift safety to require the presence of two staff during lift transfers, and to require that the legs of the lift are to be opened all the way and locked, to ensure resident safety during transfers. Residents are to be immediately assessed and monitored after an incident, and the physician and family are to be notified after the occurrence of an incident. The 24 Hour Report Book is used for shift-to-shift communication, including the need for resident monitoring after an incident. - On [DATE], policy and document review confirmed the establishment of a new practice, as indicated in Step #3 of the CAJR referenced above, involving the use of the Life Safety Monitoring Tool to document supervisory staff monitoring of CNA staff while conducting resident lift transfers. The Staff Development Coordinator/Restorative Nurse/Charge Nurse will observe CNA staff during lift transfers, observing sampled CNA staff on one (1) hall per week, and on all four (4) facility halls by month-end. - On [DATE], policy and practice review and Administrator interview confirmed a new procedure, as indicated in Step #4 of the CAJR referenced above, specifying that licensed nursing staff on duty when a resident experiences an incident will document this incident in the 24 Hour Report Book and verbally inform licensed nursing staff of the next shift. Licensed nursing staff of the on-coming shift will review the 24 Hour Report Book to ensure documentation has been completed. - On [DATE], policy review confirmed a new procedure, as indicated in Step #5 of the CAJR referenced above, specifying that the Administrator/DON conduct monthly audits of resident records to assess staff compliance with policies and practices related to physician/family notification, incident documentation, and resident monitoring. - On [DATE], it was confirmed by review of the Monthly Lift Checks and Mechanical Lifting Device Maintenance Checklist forms that the Maintenance Director had completed an inspection of the Maxilift utilized during the [DATE] incident involving Resident #1, and of all additional mechanical lifts used in the facility. Documentation indicated that this inspection by the Maintenance Director had revealed no evidence of mechanical defects or issues, as indicated in Step #6 of the CAJR referenced above. - On [DATE], review of facility in-service records confirmed in-service training, as indicated in Step #7 of the CAJR referenced above, related to policies/practices for mechanical lift use, physician/family notification, and resident monitoring. This training included the Life Safety Monitoring Tool and routine observations of CNA staff during mechanical lift transfers, and the licensed staff shift reviews of the 24 Hour Report Book. As of [DATE], the facility's four registered nurses, twenty-two LPNs, and sixty-nine CNAs had received this training. - On [DATE], Administrator interview and procedure review confirmed the new procedure, as indicated in Step #8 of the CAJR referenced above, requiring that the results of supervisory staff mechanical lift transfer monitoring via the Lift Safety Monitoring Tool, of DON audits of this Tool, and of DON audits of staff compliance with physician/family notification and resident monitoring via the Monitoring Tool, will be submitted to the facility's Quality Assurance (QA) Committee for review. Based on these corrective actions which had been developed and implemented by the facility as outlined above, it was determined that the immediacy of the deficient practice had been removed on [DATE]; however, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On [DATE], a new procedure was created by which the Staff Development Coordinator/Restorative Nurse/Charge Nurse would monitor CNA staff during mechanical lift transfers, with observations to be on one (1) hall per week, and involving all four (4) facility halls by month-end. This monitoring is to be documented on the Life Safety Monitoring Tool, and the results of are to be submitted to the DON for review. In addition, a new procedure of [DATE] specifies that licensed nursing staff of a shift during which a resident experiences an incident would document this incident in the 24 Hour Report Book and also communicate verbally to licensed nursing staff of the next shift, who would then review of the 24 Hour Report Book to verify documented evidence of the incident. The 24 Hour Report Book will be reviewed in daily morning meetings by the Unit Manager. The Administrator/DON will conduct a monthly audit of selected resident clinical records to monitor for compliance with these practices related to physician notification/family notification, and incident documentation, with the audits documented a new Chart Audit Tool. Another new procedure, also implemented on [DATE], indicated that the results of supervisory mechanical lift transfer monitoring, per the Lift Safety Monitoring Tool, the DON audit of this Lift Safety Monitoring Tool, and the monthly DON audit using the Chart Audit Tool of staff compliance with physician/family notification and resident monitoring, will be submitted to the facility's Quality Assurance (QA) Committee for the Committee's review. The QA Committee met on [DATE] initiate this process. However, facility staffs' ongoing compliance with the newly established and implemented practices involving supervisory staff monitoring of direct-care staff during resident mechanical lift transfers could not be fully assessed as of the exit date of this abbreviated survey and will need to be evaluated at a future time. Additionally, staff compliance with the newly established procedures specifying management staff audits of resident records to ensure licensed nursing staff compliance with the relaying of critical information regarding resident incidents, to therefore ensure subsequent ongoing resident monitoring, could not be fully assessed at the time of survey exit, and will need future evaluation. Therefore, the noncompliance continues, with the scope and severity of the deficiency reduced to the "D" level.

Based on clinical record review, Nurse/Physician Communication Record form review, facility investigation summary review, hospital Discharge Summary review, MayoClinic.org review, and staff interview, the facility failed to immediately consult with the physician and notify the family member of an accident having the potential to require physician intervention for one (1) resident (#1) who received [MEDICATION NAME] anticoagulant drug therapy and who was tapped on the forehead during Maxilift transfer, of eight (8) sampled residents who required mechanical lift transfer, on the total survey sample of eighteen (18) residents. During a Maxilift transfer of Resident #1 on [DATE], the resident was tapped on the forehead as the lift tilted. Licensed Practical Nurse (LPN) "AA" assessed Resident #1 at the time of the incident, but failed to immediately consult with the physician and immediately notify Resident #1's family of this incident involving Resident #1 being tapped on the forehead during the lift transfer. On [DATE], Resident #1 then experienced vomiting, difficulty with breathing, an elevated body temperature of 100.5 degrees Fahrenheit (F), an elevated pulse rate of 132 beats per minute, and a low blood oxygen saturation level of 83 percent. Resident #1 was transferred to the hospital, diagnosed with [REDACTED]. After Resident #1's expiration, the Primary [DIAGNOSES REDACTED]. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on [DATE] at 2:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE] (the date Resident #1 was tapped on the forehead during transfer when a Maxilift tipped after staffs' failure to ensure the lift legs were extended to the maximum open position, per manufacturer's specifications), continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Jeopardy Removal related to the immediate jeopardy on [DATE]. Resident #1, who received [MEDICATION NAME] anticoagulant drug therapy, was tapped on the forehead during Maxilift transfer on [DATE]; however, nursing staff then failed to immediately consult with Resident #1's attending physician regarding this incident, thus failing to ensure the timely provision of care to the resident. Then, on [DATE], Resident #1 experienced vomiting, difficulty with breathing, elevated body temperature, elevated pulse rate, and a low blood oxygen saturation level. Resident #1 was transferred to the hospital, admitted to the Intensive Care Unit (ICU), experienced [DIAGNOSES REDACTED], and expired on [DATE], after which time the physician documented the Primary [DIAGNOSES REDACTED]. During an interview conducted on [DATE] at 4:00 p.m., the DON acknowledged facility staff's failure to immediately consult with Resident #1's physician, and the failure to immediately notify the family, of the [DATE] incident during which Resident #1 was tapped on the forehead during lift transfer. A Credible Allegation of Jeopardy Removal was received on [DATE]. Based on the corrective plans which had been developed and implemented by the facility on [DATE], the immediacy of the deficient practice was determined to have been removed on [DATE]. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of monitoring, via both supervisory and management level staff oversight, of direct care staffs' compliance with mechanical lift safety, physician/family notification, and the monitoring of resident status, in accordance with facility policies and practices. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's policies and practices related to the transfer of residents utilizing mechanical lifts, and related to resident monitoring and physician/family notification. Resident records were reviewed to ensure that resident plans of care accurately reflected the transfer status and requirements of residents. Findings include: Resident #1's [DATE] Admission Minimum Data Set (MDS) assessment documented diagnoses, in Section I-Active Diagnoses, including but not limited to [MEDICAL CONDITION] Fibrillation, Heart Failure, Hypertension, [MEDICAL CONDITION], Diabetes Mellitus, and [MEDICAL CONDITION]. Resident #1's [DATE] physician's orders [REDACTED]. Additional review of Resident #1's [DATE] MDS referenced above revealed that Section G - Functional Status documented Resident #1 had been totally dependent on two-plus staff for transfer during the look-back period. A Resident Lift/Mobility Evaluation form, completed on Resident #1's [DATE] admitted , indicated that she required staff assistance with transfers and was a candidate for a mechanical lift. A [DATE], 12:20 p.m. Health Status Note (HSN) documented Resident #1 stated she did not feel well, and documented shortness of breath and the resident's refusal to get out of bed. A [DATE], 2:15 p.m. HSN documented Resident #1 still complained of not feeling well and that she had bruised areas of the left jaw and eye. A [DATE] Nurse/Physician Communication Record form documented a facsimile sent to Resident #1's physician identified a 2.5 centimeter (cm) by 2.5 cm discoloration below the eye. A [DATE] Physician's Telephone Orders (PTO) form for Resident #1 ordered [MEDICATION NAME] (PT) and International Normalized Ratio (INR) laboratory tests, and a [DATE] laboratory report documented a high PT of greater than 75 seconds (Reference Range, ,[DATE]) and an elevated INR of greater than 8.50. A [DATE] PTO form specified to hold Resident #1's [MEDICATION NAME] drug therapy. However, a [DATE], 12:31 a.m. HSN documented that at 4:30 p.m. (on [DATE]), the nurse noted Resident #1 had vomited, was struggling for breath, had an elevated body temperature of 100.5 degrees F and pulse of 132 beats/minute, and noted a low blood oxygen saturation of 83 percent (per MayoClinic.org, blood oxygen saturation below 90 percent was low). A physician's orders [REDACTED].#1 to the hospital. A hospital Discharge Summary (DS) for Resident #1 documented that a computerized tomography scan revealed a Subdural Hematoma and that she was transferred to ICU. The hospital DS documented that Resident #1 exhibited [DIAGNOSES REDACTED] and received benzodiazepine/Propofol drips and [MEDICATION NAME] anticonvulsant therapy; however, Resident #1 passed away on [DATE] with [DIAGNOSES REDACTED]. In a [DATE] amendment to this DS, the physician documented that, upon discovery of documentation indicating Resident #1 had been hit on the head by a "triangle" in the facility, the Primary [DIAGNOSES REDACTED]. A [DATE] facility investigation summary (IS) for the facility's investigation into Resident #1's Subdural Hematoma documented that Resident #1's family had informed hospital staff that she was hit in the head by a lift in the nursing facility. The facility's investigation revealed Resident #1 had bumped her forehead during transfer on [DATE] when two certified nursing assistants were transferring her from bed to wheelchair with a Maxilift. During the transfer, the lift tilted and the lift bar tapped Resident #1 in the forehead. This IS documented the nurse (LPN "AA") was informed and assessed the resident, but did not notify the family of the incident until [DATE] (four days after Resident #1 had been tapped on the forehead with the lift). In addition, further review of Resident #1's record, to include review of HSNs of [DATE] at 11:24 p.m., [DATE] at 1:09 a.m., and [DATE] at 3:59 p.m., as well as the resident's final documented HSN of [DATE] at 12:31 a.m., revealed no evidence to indicate that Resident #1's attending physician was consulted on [DATE], when the resident was tapped on the forehead during Maxilift transfer, or after that date, up to and including the [DATE] date of the resident's hospital transfer. This was despite Resident #1 receiving [MEDICATION NAME] anticoagulant therapy during this period of time. During an interview conducted on [DATE] at 12:45 p.m., the Administrator acknowledged that LPN "AA" failed to notify the physician of the [DATE] incident during which Resident #1 was tapped on the forehead when the Maxilift tilted during transfer. Based on the above, despite Resident #1 receiving [MEDICATION NAME] anticoagulant drug therapy and being tapped on the forehead during transfer via Maxilift on [DATE], licensed nursing staff failed to immediately consult with the resident's physician and notify the family of this incident. Resident #1's family was notified of the incident on [DATE] (four days after the incident), but the physician was not consulted to make him aware of the incident when the resident was tapped on the forehead. On [DATE], Resident #1 vomited, had an elevated body temperature of 100.5 degrees F, an elevated pulse of 132 beats/minute, and a low blood oxygen saturation level of 83 percent. Resident #1 was transferred to the hospital and expired on [DATE] with [DIAGNOSES REDACTED]. Cross refer to F323 for more information regarding Resident #1. The facility presented a Credible Allegation of Jeopardy Removal (CAJR) on [DATE], and it was determined that the immediate jeopardy was removed on [DATE], at which time the facility had implemented the following interventions: 1. On [DATE], the facility sent a report to the State Survey Agency regarding the incident involving Resident #1 being tapped on the forehead during lift transfer. 2. On [DATE], the Administrator and DON reviewed the policies and practices for mechanical lift safety and incident reporting. The lift safety policy specified that when staff are using a mechanical lift, two staff members should always be present, and the legs of the lift are to be opened all the way and locked, to ensure resident safety during transfer. The practice related to the reporting of resident incidents specified for staff to assess the resident immediately and to notify the physician and family, and routine monitoring of resident status and condition is to be conducted after the occurrence of an incident. The 24 Hour Report Book is used by the Charge Nurse to communicate, from one shift to the next, the need for resident monitoring after an incident. This review of the current policies determined no policy revisions were necessary. 3. On [DATE], a Life Safety Monitoring Tool was created to be used by the Staff Development Coordinator, Restorative Nurse, or designated Charge Nurse to monitor CNA staff while utilizing mechanical lifts to transfer residents. This newly developed procedure specifies a monitoring schedule to be used by these supervisory staff members calling for observation of sampled CNA staff performing resident lift transfers on one (1) hall per week; CNA staff on all four (4) facility halls will be observed by month-end. The results of these audits will be submitted to the DON for review. In addition, the facility implemented a new procedure by which the DON will conduct observations of selected CNA staff during mechanical lift transfer to further assess compliance with safety. 4. On [DATE], the facility developed and implemented a new procedure by which the licensed nursing staff member on duty the shift during which a resident experiences an incident will document this incident in the 24 Hour Report Book, and will communicate this information verbally to the licensed nursing staff member of the next shift. The licensed nursing staff member of the on-coming shift will then verify, via review of the 24 Hour Report Book, that this information has been documented, and will initial to indicate this review. The 24 Hour Report Book is reviewed daily in morning meetings by the Unit Manager, who then follows up to ensure licensed nursing staff conformance with these policies and practices. 5. On [DATE], the facility developed and implemented a procedure by which the Administrator/DON will conduct a monthly audit of selected resident clinical records to monitor for compliance with facility policies and practices related to physician notification and family notification of incidents, the required documentation of these incidents, and the monitoring of residents after incidents. These audits will be documented on the Chart Audit Tool. 6. On [DATE], the Maintenance Director completed an inspection of all facility lifts for mechanical defects. This inspection included the Maxilift utilized during the [DATE] incident involving Resident #1, with the inspection of the lift hardware, swivel bars, base and casters revealing no mechanical defects or issues. Inspection of a total of six (6) Maxilifts and two (2) Sara lifts revealed no evidence of mechanical defects. 7. On [DATE], the facility completed staff-in service training, which had been initiated on [DATE], to provide training to licensed nursing staff and certified nursing assistant staff related to the facility's policies and practices related to mechanical lift use and safety, physician and family notification of resident incidents, and the monitoring of residents after the occurrence of incidents. This in-service training also addressed the facility's new procedure involving the use of the Life Safety Monitoring Tool to be used by facility supervisory staff to conduct routine observations and monitoring of CNA staff during mechanical lift transfers to assess compliance with facility policies and procedures. This training also addressed the new procedure involving the licensed staff end-of-shift review of the 24 Hour Report Book. By [DATE], all licensed nursing staff (four registered nurses and twenty-two LPNs) and all certified nursing staff (sixty-nine CNAs) had received this training. 8. On [DATE], the facility developed and implemented a new procedure by which the results of supervisory staff monitoring of mechanical lift transfers, via the Lift Safety Monitoring Tool, and the DON audit of this Lift Safety Monitoring Tool procedure, as well as the monthly DON audit, via the Chart Audit Tool, of staff compliance with physician/family notification and resident monitoring, will be submitted to the facility's Quality Assurance (QA) Committee for the Committee's review. The QA Committee review will review and analyze the data collected as a result of the Monthly Lift Check Audit Tool and Chart Audit Tool, to assess facility staffs' understanding of, and compliance with, facility policies and procedures, and to identify the potential need for policy revision or additional staff training. The QA Committee met on [DATE] to begin this process of review. During the abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On [DATE], it was confirmed by review of the State Complaint Incident and Tracking System that the facility had reported, as indicated in Step #1 of the CAJR referenced above, the [DATE] incident involving Resident #1 being tapped on the head during transfer, with noted subsequent discoloration. This report was documented in the State System as an Entity Reported Incident dated [DATE]. - On [DATE], Administrator interview and policy/practice review confirmed, as indicated in Step #2 of the CAJR referenced above, the facility's policy for lift safety to require the presence of two staff during lift transfers, and to require that the legs of the lift are to be opened all the way and locked, to ensure resident safety during transfers. Residents are to be immediately assessed and monitored after an incident, and the physician and family are to be notified after the occurrence of an incident. The 24 Hour Report Book is used for shift-to-shift communication, including the need for resident monitoring after an incident. - On [DATE], policy and document review confirmed the establishment of a new practice, as indicated in Step #3 of the CAJR referenced above, involving the use of the Life Safety Monitoring Tool to document supervisory staff monitoring of CNA staff while conducting resident lift transfers. The Staff Development Coordinator/Restorative Nurse/Charge Nurse will observe CNA staff during lift transfers, observing sampled CNA staff on one (1) hall per week, and on all four (4) facility halls by month-end. - On [DATE], policy and practice review and Administrator interview confirmed a new procedure, as indicated in Step #4 of the CAJR referenced above, specifying that licensed nursing staff on duty when a resident experiences an incident will document this incident in the 24 Hour Report Book and verbally inform licensed nursing staff of the next shift. Licensed nursing staff of the on-coming shift will review the 24 Hour Report Book to ensure documentation has been completed. - On [DATE], policy review confirmed a new procedure, as indicated in Step #5 of the CAJR referenced above, specifying that the Administrator/DON conduct monthly audits of resident records to assess staff compliance with policies and practices related to physician/family notification, incident documentation, and resident monitoring. - On [DATE], it was confirmed by review of the Monthly Lift Checks and Mechanical Lifting Device Maintenance Checklist forms that the Maintenance Director had completed an inspection of the Maxilift utilized during the [DATE] incident involving Resident #1, and of all additional mechanical lifts used in the facility. Documentation indicated that this inspection by the Maintenance Director had revealed no evidence of mechanical defects or issues, as indicated in Step #6 of the CAJR referenced above. - On [DATE], review of facility in-service records confirmed in-service training, as indicated in Step #7 of the CAJR referenced above, related to policies/practices for mechanical lift use, physician/family notification, and resident monitoring. This training included the Life Safety Monitoring Tool and routine observations of CNA staff during mechanical lift transfers, and the licensed staff shift reviews of the 24 Hour Report Book. As of [DATE], the facility's four registered nurses, twenty-two LPNs, and sixty-nine CNAs had received this training. - On [DATE], Administrator interview and procedure review confirmed the new procedure, as indicated in Step #8 of the CAJR referenced above, requiring that the results of supervisory staff mechanical lift transfer monitoring via the Lift Safety Monitoring Tool, of DON audits of this Tool, and of DON audits of staff compliance with physician/family notification and resident monitoring via the Monitoring Tool, will be submitted to the facility's Quality Assurance (QA) Committee for review. Based on these corrective actions which had been developed and implemented by the facility as outlined above, it was determined that the immediacy of the deficient practice had been removed on [DATE]; however, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On [DATE], a new procedure was created by which the Staff Development Coordinator/Restorative Nurse/Charge Nurse would monitor CNA staff during mechanical lift transfers, with observations to be on one (1) hall per week, and involving all four (4) facility halls by month-end. This monitoring is to be documented on the Life Safety Monitoring Tool, and the results of are to be submitted to the DON for review. In addition, a new procedure of [DATE] specifies that licensed nursing staff of a shift during which a resident experiences an incident would document this incident in the 24 Hour Report Book and also communicate verbally to licensed nursing staff of the next shift, who would then review of the 24 Hour Report Book to verify documented evidence of the incident. The 24 Hour Report Book will be reviewed in daily morning meetings by the Unit Manager. The Administrator/DON will conduct a monthly audit of selected resident clinical records to monitor for compliance with these practices related to physician notification/family notification, and incident documentation, with the audits documented a new Chart Audit Tool. Another new procedure, also implemented on [DATE], indicated that the results of supervisory mechanical lift transfer monitoring, per the Lift Safety Monitoring Tool, the DON audit of this Lift Safety Monitoring Tool, and the monthly DON audit using the Chart Audit Tool of staff compliance with physician/family notification and resident monitoring, will be submitted to the facility's Quality Assurance (QA) Committee for the Committee's review. The QA Committee met on [DATE] initiate this process. However, facility staffs' ongoing compliance with the newly established and implemented practices involving supervisory staff monitoring of direct-care staff during resident mechanical lift transfers could not be fully assessed as of the exit date of this abbreviated survey and will need to be evaluated at a future time. Additionally, staff compliance with the newly established procedures specifying management staff audits of resident records to ensure licensed nursing staff compliance with the relaying of critical information regarding resident incidents, to therefore ensure subsequent ongoing resident monitoring, could not be fully assessed at the time of survey exit, and will need future evaluation. Therefore, the noncompliance continues, with the scope and severity of the deficiency reduced to the "D" level.

Based on clinical record review, Manual/Electric Portable Patient Lift instruction review, facility investigation summary review, Employee Statement of Events form review, hospital Discharge Summary review, MayoClinic.org review, and staff interview, the facility failed to provide care in a manner that prohibited neglect by failing to ensure safe mechanical lift transfer for one (1) resident (#1), and failing to ensure monitoring after Resident #1, who received [MEDICATION NAME] anticoagulant drug therapy, was tapped on the forehead during mechanical lift transfer, of eight (8) sampled residents who were transferred via mechanical lift, on the total survey sample of eighteen (18) residents. Resident #1, who received [MEDICATION NAME] anticoagulant drug therapy, was transferred from bed to wheelchair on [DATE]; however, certified nursing staff failed to ensure that the Maxilift legs were in the maximum open position to ensure safe transfer, and the Maxilift tilted and tapped Resident #1 on the forehead during transfer. The licensed nurse failed to notify the physician and inform nursing staff of the following shift of this incident involving Resident #1 being tapped on the forehead by the lift, and licensed nursing staff then failed to monitor the condition of Resident #1 related to the resident having been tapped on the forehead. On [DATE], Resident #1 experienced vomiting, difficulty with breathing, an elevated body temperature of 100.5 degrees Fahrenheit (F), an elevated pulse rate of 132 beats per minute, and a low blood oxygen saturation level of 83 percent. Resident #1 was transferred to the hospital, diagnosed with [REDACTED]. The hospital physician later documented the Primary [DIAGNOSES REDACTED]. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on [DATE] at 2:00 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on [DATE] (the date Resident #1 was tapped on the forehead during transfer when a Maxilift tipped after staffs' failure to ensure the lift legs were extended to the maximum open position, per manufacturer's specifications), continued through [DATE], and was removed on [DATE]. The facility implemented a Credible Allegation of Jeopardy Removal related to the immediate jeopardy on [DATE]. Resident #1, who received [MEDICATION NAME] anticoagulant therapy, was tapped on the forehead on [DATE] during Maxilift transfer after staff failed to utilize the mechanical lift as specified by the manufacturer. Licensed nursing staff then failed to ensure monitoring of Resident #1's status related to this incident, and on [DATE], she experienced vomiting, difficulty with breathing, an elevated body temperature, an elevated pulse rate, and a low blood oxygen saturation level, was transferred to the hospital, and expired on [DATE]. During interview on [DATE] at 12:45 p.m., the Administrator acknowledged that licensed nursing staff did not monitor Resident #1 on the days following the [DATE] incident involving Resident #1 being tapped on the forehead with the MaxiLift. During a subsequent, [DATE], 9:05 a.m. interview, the Administrator acknowledged the Maxilift tilted during Resident #1's [DATE] transfer due to staffs' failure to ensure the lift legs were in the maximum open position. An allegation of jeopardy removal was received on [DATE]. Based on the corrective plans which had been developed and implemented by the facility on [DATE], the immediacy of the deficient practice was determined to have been removed on [DATE]. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued the process of monitoring, via both supervisory and management level staff oversight, direct care staffs' compliance with mechanical lift safety, and physician notification and the monitoring of resident status, in accordance with facility policies and practices. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the facility's policies and practices related to the transfer of residents utilizing mechanical lifts, and related to resident monitoring and physician notification. Resident records were reviewed to ensure that resident plans of care accurately reflected the transfer status and requirements of residents. Findings include: Resident #1's [DATE] Admission Minimum Data Set assessment documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. A [DATE] Resident Lift/Mobility Evaluation documented Resident #1 required assistance with transfers and was a candidate for transfer via mechanical lift, and the [DATE] physician's orders [REDACTED]. A Health Status Note (HSN) of [DATE] at 2:15 p.m. documented that Resident #1 complained of not feeling well and had bruised areas of the left jaw and left eye. A [DATE] Nurse/Physician Communication Record (N/PCR) documented a facsimile to Resident #1's physician which noted a discoloration of 2.5 centimeters (cms) by 2.5 cms below the eye. This N/PCR indicated Resident #1's family request for [MEDICATION NAME] (PT) and International Normalized Ratio (INR) laboratory tests due to [MEDICATION NAME] use, and a [DATE] Physician's Telephone Orders form ordered PT/INR laboratory tests. A laboratory report for Resident #1 of [DATE] at 3:25 a.m. documented a PT result of greater than 75 seconds (Reference Range, 11 to 15 seconds), and an elevated INR result of greater than 8.50, with a notation indicating physician notification. A [DATE] Physician's Telephone Orders form specified to hold Resident #1's [MEDICATION NAME] for 5 days. A [DATE], 3:59 p.m. HSN documented Resident #1 to have normal vital signs at that time, including the body temperature of 97.2 degrees F, pulse of 77 beats/minute, and blood oxygen saturation level of 93 percent. (MayoClinic.org indicated blood oxygen saturation below 90 percent was low). But, a later [DATE], 12:31 a.m. HSN for Resident #1 documented that (on [DATE]) at 4:30 p.m., the body temperature had increased to 100.5 degrees F, the pulse had increased to 132 beats/minute, the blood oxygen saturation had decreased to 83 percent, and the resident had vomited and was struggling for breath. The physician, when paged, ordered Resident #1's transfer to the hospital. This [DATE], 12:31 a.m. HSN documented that at 11:10 p.m. (on [DATE]), the facility was notified of Resident #1's hospital admission with Altered Mental Status and a Subdural Hematoma. Resident #1's hospital Discharge Summary (DS) documented that the resident had Altered Mental Status, and a computerized tomography scan revealed a Subdural Hematoma. This hospital DS documented that after hospital admission, Resident #1's condition declined and she had [MEDICAL CONDITION]-type activity. [MEDICATION NAME] drug therapy was initiated and she was transferred to the ICU where she exhibited [DIAGNOSES REDACTED] while receiving benzodiazepine/Propofol drips, and after an increase in the [MEDICATION NAME] dose. This DS documented that Resident #1 passed away on [DATE], with the Primary [DIAGNOSES REDACTED].#1 had been hit on the head by a "triangle", and that Resident #1's Primary [DIAGNOSES REDACTED]. A [DATE] facility investigation summary (IS) referencing Resident #1 documented facility notification by hospital staff that Resident #1's family stated she had been hit in the head by a lift. The IS documented that while in the nursing facility, Resident #1 had a discoloration to the left side of the head, and that investigation revealed a [DATE] incident when Resident #1 was bumped on the forehead with a Maxilift. Two staff (Certified Nursing Assistant (CNA) "BB" and CNA "CC") were transferring Resident #1 via Maxilift to the wheelchair. After being placed in the wheelchair, Resident #1 moved and the lift tilted, one of the CNAs fell and pushed the lift over, and the lift bar tapped the resident on the forehead. The charge nurse (Licensed Practical Nurse (LPN) "AA") was informed, assessed Resident #1, and observed no injury. In a written statement of CNA "BB" documented on an Employee Statement of Events (ESE) form, CNA "BB" documented that on [DATE], she and CNA "CC" were transferring Resident #1 with the Maxilift, and after Resident #1 was in the wheelchair, the Maxilift tilted. CNA "BB" indicated, in another statement documented on an ESE form, that during Resident #1's transfer, the Maxilift tilted due to the position and the weight on the lift, and the "swing part" of the lift tapped Resident #1 on the forehead. During a [DATE], 9:05 a.m. interview with the Administrator, the Administrator stated that the investigation conducted by the facility had concluded that when the Maxilift tilted on [DATE] during the transfer of Resident #1 resulting in the resident being tapped on the forehead, staff had failed to position the lift legs in the maximum open position, and the lift had tilted. (The manufacturer's Manual/Electric Portable Patient Lift instructions specified that the legs of the Maxilift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety). In a written statement dated [DATE] documented on an ESE form, LPN "AA" indicated that on [DATE], after being informed by the CNAs Resident #1 had been bumped on the forehead during transfer via Maxilift, LPN "AA" assessed Resident #1 at that time, and also later in the shift, and noted no injury. However, further review of Resident #1's record revealed no evidence of monitoring of Resident #1's status by LPN "AA", or by any additional licensed nursing staff, on [DATE]. There was no documented evidence to indicate that LPN "AA" informed other licensed nursing staff, or the attending physician, of this incident involving Resident #1, who received daily [MEDICATION NAME] anticoagulant therapy, being tapped on the head during transfer during the 11:00 p.m. to 7:00 p.m. shift of [DATE] when the incident occurred. There was also no evidence to indicate that LPN "AA" informed the oncoming licensed nursing staff for the 7:00 a.m. to 3:00 p.m. shift on [DATE], or on subsequent dates, of this incident involving Resident #1 being tapped on the forehead during transfer. Further record review for Resident #1 revealed no documented evidence of any assessment or monitoring of the resident's status on [DATE]. A [DATE], 11:24 p.m. HSN for Resident #1 then documented assessment revealed a body temperature of 98.6 degrees F, a respiratory rate of 20 per minute, systolic/diastolic blood pressure readings of 122 and 80 respectively, and a pulse rate of 90 beats/minute. However, further record review for Resident #1, to include review of this [DATE], 11:24 p.m. HSN, revealed no evidence of a reference to Resident #1 having been tapped on the forehead during mechanical lift transfer on [DATE], or of any monitoring of Resident #1's status related to this incident, despite the resident receiving [MEDICATION NAME] anticoagulant therapy. Additionally, record review for Resident #1 revealed HSNs (subsequent to the [DATE], 11:24 p.m. HSN referenced above) of [DATE] at 1:09 a.m., [DATE] at 12:20 p.m., [DATE] at 2:15 p.m., [DATE] at 9:09 p.m., [DATE] at 12:16 a.m., and [DATE] at 3:59 p.m. which revealed no documented evidence of Resident #1 having been tapped on the forehead during Maxilift transfer on [DATE]. Record review, to include review of the HSNs referenced above, also revealed no evidence of licensed nursing staff monitoring of Resident #1's status from [DATE] through [DATE], related to her having been tapped on the forehead during the [DATE] Maxilift incident. As referenced above, Resident #1's final HSN of [DATE] at 12:31 a.m. did document that prior to hospital transfer on [DATE], assessment had revealed an elevated body temperature of 100.5 degrees F, an elevated pulse of 132 beats/minute, and a low blood oxygen saturation of 83 percent. However, further clinical record review, to include review of this [DATE], 12:31 a.m. HSN, continued to reveal no documented evidence of Resident #1 having been tapped on the forehead during lift transfer on [DATE], or evidence of any licensed nursing staff monitoring of the resident related to this incident. During interview on [DATE] at 12:45 p.m., the Administrator acknowledged that LPN "AA" failed to notify the physician of Resident #1 having been tapped on the forehead with the MaxiLift, and failed to ensure that licensed nursing staff of subsequent shifts were informed of the incident to ensure that the status of Resident #1 was monitored. Based on the above, Resident #1 required transfer via Maxilift and received [MEDICATION NAME] anticoagulant drug therapy. However, during a Maxilift transfer of Resident #1 on [DATE], facility staff failed to ensure that the Maxilift legs were in the maximum open position to ensure safety (as specified by manufacturer's instructions), the lift tilted, and the resident was tapped on the forehead with the lift. LPN "AA" was informed of this incident involving Resident #1 at the time of its occurrence, but failed to consult with the physician regarding the incident, and failed to inform additional licensed nursing staff of the incident. Facility licensed nursing staff then failed to monitor the status of Resident #1 following this [DATE] incident, related to her having been tapped on the forehead when the lift tilted during transfer, and she continued to receive daily [MEDICATION NAME] therapy. On [DATE], Resident #1 experienced a significant change in status, including an elevated body temperature of 100.5 degrees F, an elevated pulse of 132 beats/minute, and a low blood oxygen saturation level of 83 percent. Resident #1 was transferred to the hospital and expired on [DATE] with [DIAGNOSES REDACTED]. The facility's failure to inform the physician of the [DATE] incident involving Resident #1 being tapped on the forehead during lift transfer, and the failure of licensed nursing staff to ensure ongoing monitoring of Resident #1 related to this incident, represented neglect for this resident. Cross refer to F323 for more information regarding Resident #1. The facility presented a Credible Allegation of Jeopardy Removal (CAJR) on [DATE], and it was determined that the immediate jeopardy was removed on [DATE], at which time the facility had implemented the following interventions: 1. On [DATE], the facility sent a report to the State Survey Agency regarding the incident involving Resident #1 being tapped on the forehead during lift transfer. 2. On [DATE], the Administrator and DON reviewed the policies and practices for mechanical lift safety and incident reporting. The lift safety policy specified that when staff are using a mechanical lift, two staff members should always be present, and the legs of the lift are to be opened all the way and locked, to ensure resident safety during transfer. The practice related to the reporting of resident incidents specified for staff to assess the resident immediately and to notify the physician and family, and routine monitoring of resident status and condition is to be conducted after the occurrence of an incident. The 24 Hour Report Book is used by the Charge Nurse to communicate, from one shift to the next, the need for resident monitoring after an incident. This review of the current policies determined no policy revisions were necessary. 3. On [DATE], a Life Safety Monitoring Tool was created to be used by the Staff Development Coordinator, Restorative Nurse, or designated Charge Nurse to monitor CNA staff while utilizing mechanical lifts to transfer residents. This newly developed procedure specifies a monitoring schedule to be used by these supervisory staff members calling for observation of sampled CNA staff performing resident lift transfers on one (1) hall per week; CNA staff on all four (4) facility halls will be observed by month-end. The results of these audits will be submitted to the DON for review. In addition, the facility implemented a new procedure by which the DON will conduct observations of selected CNA staff during mechanical lift transfer to further assess compliance with safety. 4. On [DATE], the facility developed and implemented a new procedure by which the licensed nursing staff member on duty the shift during which a resident experiences an incident will document this incident in the 24 Hour Report Book, and will communicate this information verbally to the licensed nursing staff member of the next shift. The licensed nursing staff member of the on-coming shift will then verify, via review of the 24 Hour Report Book, that this information has been documented, and will initial to indicate this review. The 24 Hour Report Book is reviewed daily in morning meetings by the Unit Manager, who then follows up to ensure licensed nursing staff conformance with these policies and practices. 5. On [DATE], the facility developed and implemented a procedure by which the Administrator/DON will conduct a monthly audit of selected resident clinical records to monitor for compliance with facility policies and practices related to physician notification and family notification of incidents, the required documentation of these incidents, and the monitoring of residents after incidents. These audits will be documented on the Chart Audit Tool. 6. On [DATE], the Maintenance Director completed an inspection of all facility lifts for mechanical defects. This inspection included the Maxilift utilized during the [DATE] incident involving Resident #1, with the inspection of the lift hardware, swivel bars, base and casters revealing no mechanical defects or issues. Inspection of a total of six (6) Maxilifts and two (2) Sara lifts revealed no evidence of mechanical defects. 7. On [DATE], the facility completed staff-in service training, which had been initiated on [DATE], to provide training to licensed nursing staff and certified nursing assistant staff related to the facility's policies and practices related to mechanical lift use and safety, physician and family notification of resident incidents, and the monitoring of residents after the occurrence of incidents. This in-service training also addressed the facility's new procedure involving the use of the Life Safety Monitoring Tool to be used by facility supervisory staff to conduct routine observations and monitoring of CNA staff during mechanical lift transfers to assess compliance with facility policies and procedures. This training also addressed the new procedure involving the licensed staff end-of-shift review of the 24 Hour Report Book. By [DATE], all licensed nursing staff (four registered nurses and twenty-two LPNs) and all certified nursing staff (sixty-nine CNAs) had received this training. 8. On [DATE], the facility developed and implemented a new procedure by which the results of supervisory staff monitoring of mechanical lift transfers, via the Lift Safety Monitoring Tool, and the DON audit of this Lift Safety Monitoring Tool procedure, as well as the monthly DON audit, via the Chart Audit Tool, of staff compliance with physician/family notification and resident monitoring, will be submitted to the facility's Quality Assurance (QA) Committee for the Committee's review. The QA Committee review will review and analyze the data collected as a result of the Monthly Lift Check Audit Tool and Chart Audit Tool, to assess facility staffs' understanding of, and compliance with, facility policies and procedures, and to identify the potential need for policy revision or additional staff training. The QA Committee met on [DATE] to begin this process of review. During the abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On [DATE], it was confirmed by review of the State Complaint Incident and Tracking System that the facility had reported, as indicated in Step #1 of the CAJR referenced above, the [DATE] incident involving Resident #1 being tapped on the head during transfer, with noted subsequent discoloration. This report was documented in the State System as an Entity Reported Incident dated [DATE]. - On [DATE], Administrator interview and policy/practice review confirmed, as indicated in Step #2 of the CAJR referenced above, the facility's policy for lift safety to require the presence of two staff during lift transfers, and to require that the legs of the lift are to be opened all the way and locked, to ensure resident safety during transfers. Residents are to be immediately assessed and monitored after an incident, and the physician and family are to be notified after the occurrence of an incident. The 24 Hour Report Book is used for shift-to-shift communication, including the need for resident monitoring after an incident. - On [DATE], policy and document review confirmed the establishment of a new practice, as indicated in Step #3 of the CAJR referenced above, involving the use of the Life Safety Monitoring Tool to document supervisory staff monitoring of CNA staff while conducting resident lift transfers. The Staff Development Coordinator/Restorative Nurse/Charge Nurse will observe CNA staff during lift transfers, observing sampled CNA staff on one (1) hall per week, and on all four (4) facility halls by month-end. - On [DATE], policy and practice review and Administrator interview confirmed a new procedure, as indicated in Step #4 of the CAJR referenced above, specifying that licensed nursing staff on duty when a resident experiences an incident will document this incident in the 24 Hour Report Book and verbally inform licensed nursing staff of the next shift. Licensed nursing staff of the on-coming shift will review the 24 Hour Report Book to ensure documentation has been completed. - On [DATE], policy review confirmed a new procedure, as indicated in Step #5 of the CAJR referenced above, specifying that the Administrator/DON conduct monthly audits of resident records to assess staff compliance with policies and practices related to physician/family notification, incident documentation, and resident monitoring. - On [DATE], it was confirmed by review of the Monthly Lift Checks and Mechanical Lifting Device Maintenance Checklist forms that the Maintenance Director had completed an inspection of the Maxilift utilized during the [DATE] incident involving Resident #1, and of all additional mechanical lifts used in the facility. Documentation indicated that this inspection by the Maintenance Director had revealed no evidence of mechanical defects or issues, as indicated in Step #6 of the CAJR referenced above. - On [DATE], review of facility in-service records confirmed in-service training, as indicated in Step #7 of the CAJR referenced above, related to policies/practices for mechanical lift use, physician/family notification, and resident monitoring. This training included the Life Safety Monitoring Tool and routine observations of CNA staff during mechanical lift transfers, and the licensed staff shift reviews of the 24 Hour Report Book. As of [DATE], the facility's four registered nurses, twenty-two LPNs, and sixty-nine CNAs had received this training. - On [DATE], Administrator interview and procedure review confirmed the new procedure, as indicated in Step #8 of the CAJR referenced above, requiring that the results of supervisory staff mechanical lift transfer monitoring via the Lift Safety Monitoring Tool, of DON audits of this Tool, and of DON audits of staff compliance with physician/family notification and resident monitoring via the Monitoring Tool, will be submitted to the facility's Quality Assurance (QA) Committee for review. Based on these corrective actions which had been developed and implemented by the facility as outlined above, it was determined that the immediacy of the deficient practice had been removed on [DATE]; however, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On [DATE], a new procedure was created by which the Staff Development Coordinator/Restorative Nurse/Charge Nurse would monitor CNA staff during mechanical lift transfers, with observations to be on one (1) hall per week, and involving all four (4) facility halls by month-end. This monitoring is to be documented on the Life Safety Monitoring Tool, and the results of are to be submitted to the DON for review. In addition, a new procedure of [DATE] specifies that licensed nursing staff of a shift during which a resident experiences an incident would document this incident in the 24 Hour Report Book and also communicate verbally to licensed nursing staff of the next shift, who would then review of the 24 Hour Report Book to verify documented evidence of the incident. The 24 Hour Report Book will be reviewed in daily morning meetings by the Unit Manager. The Administrator/DON will conduct a monthly audit of selected resident clinical records to monitor for compliance with these practices related to physician notification/family notification, and incident documentation, with the audits documented a new Chart Audit Tool. Another new procedure, also implemented on [DATE], indicated that the results of supervisory mechanical lift transfer monitoring, per the Lift Safety Monitoring Tool, the DON audit of this Lift Safety Monitoring Tool, and the monthly DON audit using the Chart Audit Tool of staff compliance with physician/family notification and resident monitoring, will be submitted to the facility's Quality Assurance (QA) Committee for the Committee's review. The QA Committee met on [DATE] initiate this process. However, facility staffs' ongoing compliance with the newly established and implemented practices involving supervisory staff monitoring of direct-care staff during resident mechanical lift transfers could not be fully assessed as of the exit date of this abbreviated survey and will need to be evaluated at a future time. Additionally, staff compliance with the newly established procedures specifying management staff audits of resident records to ensure licensed nursing staff compliance with the relaying of critical information regarding resident incidents, to therefore ensure subsequent ongoing resident monitoring, could not be fully assessed at the time of survey exit, and will need future evaluation. Therefore, the noncompliance continues, with the scope and severity of the deficiency reduced to the "D" level.