Every finding on record at Braxton Healthcare Center

Based on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and comfortable environment designed to prevent the development and transmission of foodborne or environmental pathogens. Specifically, the facility allowed an air conditioning (AC) unit to malfunction and leak substantial amounts of water down a dining room wall, causing extensive damage, bubbling paint, and separation of wallboards and baseboards where residents eat. The facility also failed to provide a homelike environment for residents in their rooms. These failed practices had the potential to affect more than a limited number of residents. Facility Census: 61. Findings include:a) Dining Room Air Conditioner UnitsOn 08/03/26 at approximately 11:18 AM, a walking inspection of the main resident dining room was conducted. Three (3) separate AC units mounted on the dining room wall were observed with visible wiring exposed. One (1) AC unit was malfunctioning. Water was observed leaking and pouring directly down the wall from this unit. The lower wall panel and baseboards were visibly saturated, warped, and peeling away from the wall. Areas of paint beneath the AC units were bubbling, peeling, and flaking off the wall surface. The facility was using a bucket and towels placed on the floor to catch the water. On 08/04/26 at 11:38 AM, an interview was conducted with the dining room staff regarding the leaks and damage in the dining area. Activities Leader #27 acknowledged the leaks and the visible damage to the wallboards, baseboards, and paint and stated, I will clean this up. and 'I turned it off. referring to the air conditioner. On 08/04/26 at11:30 AM, Activities Leader #12 reported she was unsure how the AC unit had been leaking and stated, It wasn't last Tuesday.b) room [ROOM NUMBER] On 08/04/26 at 2:35 PM, during the initial resident interview process, the closet in room [ROOM NUMBER] was observed to be overflowing with items spilling out of the closet onto the floor past the closet door. Various items including a gait belt, a torn storage box, clothes and blankets were observed to be falling out of the closet. Nurse Aide #62 confirmed the closet door would not shut and items were spilling out of the closet for both residents in the room. When the nurse aide was asked how do you know which resident the items belong to, Nurse Aide #62 stated, We just know whose is whose. c) Interview with Administrator On 08/04/26 at 4:30 PM, the Administrator acknowledged the leaks and the visible damage to the wallboards, baseboards, and paint. The above findings were reviewed with the Director of Nursing, the Administrator and the Regional Director of Operations.

Based on record review, staff interview, and observation, the facility failed to ensure food was stored, prepared and served in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 61.Findings included: a) Food Storage: Dry Goods Policy The facility's policy and procedure for Food Storage: Dry Goods stated, 5. All packaged and canned food items will be kept clean, dry, and properly sealed. 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. b) Food Storage: Cold Foods Policy The facility's policy and procedure for Food Storage: Cold Foods stated, 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.c) Kitchen TourOn 08/03/26 at 10:35 AM, the Kitchen Investigation was initiated. The following items were found by the state surveyor and confirmed by the Account Manager throughout the tour:Reliance Brownie Mix- eleven (11) bags with no use by date. Reliance [NAME] Cake Mix- seven (7) bags with no use by date.Krusteaz Sweet Pancake Mix - no use by date.Rice Krispies - not labeled.Imperial food thickener - opened and not sealed - in a large bag and in a brown box.Creamy Style Hot Chocolate Mix - two packets opened and not dated.Celery - not sealed or labeled, brownish in color, in a plastic bag in a brown box. The Account Manager stated, I'll toss those immediately.Lettuce - Not labeled, not sealed and not dated.Whole strawberries - box opened, bag in box not sealed and not dated.Lemons - opened in a brown box, not sealed, no use by date, one (1) lemon with white, mold-like coloring.Frozen [NAME] House rolls - not sealed.Chocolate and vanilla ice cream containers x 2 were opened and not dated with ice cream dripping off the sides. The ice cream was removed by the Account Manager.No liner in handwashing sink trash can.Brown residue, crumbs, and paper were in the sink and around the sink area in the Dining Room. This was confirmed by Activities Leader #12.Ice Build-up in a Blue Bunny freezer chest. The ice cream and popsicles were not labeled or dated. The ice chest and ice cream were confirmed by the Account Manager 08/03/26 at 12:30 PM. The Account Manager stated, You are absolutely right.On 08/04/26 at 3:20 PM, the Nutrition Station was investigated. The following item was found: Rotisserie Chicken Salad - no opened or use by date. The item was confirmed by Nurse Aide #62.The above finding was reviewed with and acknowledged by the Director of Nursing, Administrator and Regional Director of Operations on 08/04/26 at 4:30 PM.

Based on record review, observation, resident interview, and staff interview, the facility failed to provide complete accurate and accessible medical records for residents in area of incorrect Diagnosis Report, inaccurate medication route, and POST form signature. Resident's #66, #10, #13, #32. Facility Census 61. Findings Included: a) Resident #66 During a record review, completed on 08/03/26, Resident #66's Diagnosis Report revealed the following: Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side. During an interview with Resident #66, on 08/04/26 at 2:20 PM, the resident reported that she had a stroke approximately two (2) years ago that affected the right side of her body and she does not have use of her right arm. During an interview on, 08/04/26 at 3:00 PM, Regional Director of Operations #86 acknowledged that the resident's care plan and diagnosis read, left side weakness that populated from the hospital discharge plan. The Administrator reported, at 3:09 PM, that nursing documented the correct side during intake. Therapy notes were populated over from orders and were incorrectly put in as a result from the hospital orders. Resident #66 was admitted on [DATE]. b) Resident #10 The facility failed to ensure an accurate medication route order for a resident with an order for nothing by mouth (NPO). The resident's order stated, NPO diet NPO texture, NPO consistency, for Nutrition. The resident's pharmacy order stated, FiberCon Tablet (calcium Polycarbophil) Give 1 tablet by mouth at bedtime for constipation. On 08/04/2026 at 4:24 PM, the Director of Nursing (DON) acknowledged the medication should be via the resident's feeding tube and confirmed the by mouth order for Fibercon and stated, I updated that for you. The finding was acknowledged and reviewed with the DON, the Administrator and the Regional Director of Operations on 08/05/26 at 4:40 PM. c) Resident #13 The facility failed to ensure a Patient/Patient Medical Power of Attorney (MPOA) representative/surrogate's signature on a Physician Orders for Scope of Treatment (POST) form was obtained as required in the 2026 POST Form Guidance. On 08/03/2026 at 2:21 PM, during resident #13's record review, the resident's POST form E: Signature was blank. The form stated, Patient/ Patient MPOA representative/surrogate signature (required). Verbal consent witnessed by two employees on 05/27/26 was documented with no evidence of the MPOA name, contact method, date, or time documented in the resident's medical record. On 08/04/26 at 12:37 PM, the Regional Director of Operations confirmed there was no signature on the Resident's POST form and that the resident's MPOA lives out of state. The Regional Director of Operations reported it did not have to be signed if verbal consent was obtained. The state surveyor reviewed the 2026 POST Form guidelines and reviewed with the Regional Director of Operation that a signature was required on the POST form. At 12:45 PM, the Regional Director of Operations stated, I'll have to see about that. No further information was provided through the completion of the survey process. The finding was acknowledged and reviewed with the DON, the Administrator and the Regional Director of Operations on 08/05/26 at 4:40 PM. d) Resident #32 The facility failed to ensure an order for oxygen therapy was written for a resident receiving oxygen therapy. On 08/03/2026 at 3:20 PM, the resident was observed receiving oxygen via a nasal cannula across his open mouth. The resident's concentrator was set to approximately 4.5-5 liters per minute. No order for oxygen was found on the resident's medical chart during a record review. On 08/03/26 at 4:00 PM, the DON acknowledged and confirmed the resident had a nasal cannula positioned across his mouth and the oxygen setting on the concentrator. The DON stated, Let me see if the orders are just not in there. At 4:20 PM, the DON confirmed there was no order on the resident's medical chart for the oxygen, but the order had been clarified. The facility's policy and procedure for Supplemental Oxygen using nasal Canula stated, Supplemental oxygen may be administered to residents via routes including through the use of nasal cannula at the order of physician or provider. The finding was acknowledged and reviewed with the DON, the Administrator and the Regional Director of Operations on 08/04/26 at 4:30 PM.

Based on resident interview and observation, the facility failed to ensure an environment that maintained or enhanced a resident's dignity during the dining experience. This failed practice had the potential to affect a limited number of residents. Facility Identifier: #30. Facility Census: 61. Findings included: a) Resident Rights Policy The facility's policy and procedure for Resident's Rights stated, Dignity: a state worthy of honor or respect; includes but not limited to speaking respectfully to resident, providing privacy for care and treatment, providing safe and secure housing, sanitary food and hydration; respecting resident choice and attending to needs in a timely fashion. b) Resident #30 On 08/03/26 at 12:05 PM, during the dining room observation, Resident #30 was not served her lunch at the same time as her lunch table mate. The majority of the residents in the dining room had been served except the last table in the back of the dining room. Resident #30 was seated at a table in the front of the dining room. The state surveyor asked the resident why she wasn't eating and the resident stated, They ain't never brought me anything. At 12:20 PM, Activities Leader #27 confirmed the resident did not have her tray until it was served at 12:20 PM and stated, They thought it was sent to the floor and they had to re-make her tray. c) On 08/05/26 at 4:40 PM, the above findings were reviewed with the Director of Nursing, Administrator and the Regional Director of Operations.

Based on observation, staff interview and resident interview, the facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of a stroke. Resident #66. Facility Census 61. Findings include: a) Resident #66 On 08/03/26, review of Resident #66's care plan revealed the following: Page 10, Focus: Resident had an ADL self care performance deficit related to impaired mobility, weakness to left side following CVA. Date Initiated 08/01/26. Date Revised 08/03/26. It was noted the resident required assistance with setup/cleanup for eating and oral hygiene and was totally dependent for toileting hygiene, shower/bath, dressing, putting on and taking off footwear and personal hygiene. During an interview with Resident #66, completed on 08/04/26 at 2:20 PM, the resident reported that she had a stroke approximately two (2) years ago that affected the right side of her body and she did not have use of her right arm. During an interview on 08/04/26 at 3:00 PM, Regional Director of Operations #86 acknowledged the resident's care plan and orders read left side weakness that populated from the hospital discharge plan. The Administrator reported, at 3:09 PM, that nursing documented the correct side during intake. Therapy notes are populated over from orders and were incorrectly put in as a result from the hospital orders. Resident was admitted on [DATE].

Based on record review and staff interview, the facility failed to ensure a resident's care plan was revised for aspiration precautions and compensatory swallowing strategies. Compensatory swallow strategies are temporary adjustments like posture changes and swallowing maneuvers used to make eating safer. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #64. Facility Census: 61.Findings included: a) On 08/05/26, a review of Resident #64's care plan was completed secondary to the resident's history of dysphagia, risk of aspiration, recommended swallowing precautions and compensatory techniques and a mechanically altered diet level. The resident's diet order stated, Regular diet Dys Adv texture, thin liquids consistency, Food in bowls, 2-handles cups at bedside for hydration per resident request. The resident's care plan was reviewed for safe swallowing strategies, compensatory swallowing strategies to increase safety of oral diet, reflux precautions and aspiration precautions. No interventions to maximize safety of swallow were documented in the resident's care plan to decrease risk of aspiration. b) The resident care plan stated, Resident #64 is at risk for potential nutritional problem r/t High BMI/healthy for advanced age, vit def, GERD, Iron deficiency anemia, Parkinson's, chronic pain, dysphagia, hypothyroidism, impaired vision, HTN, COPD, dementia - mechanically altered diet, -Use of adaptive equipment, -At risk for malnutrition per MNA, and -supplemental use. c) On 08/05/26 at 9:30 AM, the Minimum Data Set (MDS) Coordinator, Registered Nurse #51, acknowledged and confirmed there were no swallowing precautions. safe swallowing strategies or aspiration precautions in the resident's plan of care. The MDS Coordinator stated, No, just provide assistance with meals.

Based on record review, observation, staff interview, and resident interview, the facility failed to ensure a resident received proper treatment and assistive devices to maintain hearing abilities. This was true for one (1) of five (5) residents reviewed under the communication/sensory pathway throughout the Long-Term Care Survey Process. Resident Identifier: #42. Facility Census: 61.Findings included: a) Resident #42 On 08/03/2026 at 2:25 PM, Resident #42 appeared to be very hard of hearing. The resident reported he did not have a hearing aid at this time. he reported he had four (4) broken, but he would like another one. Resident #42 stated, I guess I'll try again. b) Care Plan The resident's care plan stated, The resident has a communication problem r/t [related to]hearing impairment, wears hearing aid in left ear. Resident needs assistance at times with understanding written material.c) Interview with Social Worker On 08/04/2026 at 12:30 PM, the Social Worker was interviewed regarding the resident's hearing aids. The Social Worker stated, Resident #42 had several pairs of hearing aids and that he has gone through many. The Social Worker reported the resident had been seen by 360 Audiology, but was not sure if the resident had an appointment. d) Interview with Medical Record Coordinator #52 On 08/05/26 at 2:55 PM, Medical Record Coordinator #52 was interviewed and reported the resident had an in-house consultation with 360 Audiology on 04/30/26 and a pocket talker was recommended. The facility was working on getting payment for the assistive listening device. e) Review of Hearing Exam Details The 360 Care Hearing Exam, completed on 04/30/26, reported a severe to profound sensorineural hearing loss and speech discrimination could not be tested due to severity of loss. Amplification options were discussed and a pocket talker was agreed upon during the visit. f) Interview with Business Office Manager On 08/05/26 at 3:00 PM, the Business Office Manager (BOM) was interviewed via phone. The BOM acknowledged the payment was not sent out for the pocket talker and it would be sent out as soon as possible. The BOM reported she had been in contact with the resident's power of attorney and that the power of attorney thought the facility should replace the hearing aids, but there had been no grievance filed. The BOM stated. That's on me. I should have followed up. g) Interview with Administrative Staff The above findings were reviewed with the Director of Nursing, the Administrator and the Regional Director of Operations on 08/05/26 at 4:40 PM. The Administrator reported the pocket talker had been ordered.

Based on record review, staff interview, and observation, the facility failed to ensure a resident's call light was in reach while the resident was in bed. This failed practice had the potential to affect more than a limited number of residents. Resident Identifier: #32. Facility Census: 61. Findings included: a) Resident #32 On 08/03/26, during the initial patient interview process, Resident #32's call light was observed to be laying across the resident's bedside table and was not in reach. The resident's call light placement was observed to be out of reach at 2:30 PM, 3:20 PM and 4:00 PM on this date. On 08/02/26 at 4:00 PM, the Director of Nursing (DON) confirmed the resident had a significant change in condition with a decreased level of responsiveness and reported that this change in condition had happened before to the resident. The DON confirmed the call light was not in reach and placed the call light within the resident's reach. On 08/04/26 at 4:30 PM, the above findings were reviewed and acknowledged by the DON, Administrator, and the Regional Director of Operations.

Based on record review, staff interview, and observation, the facility failed to ensure menus were followed as posted for the dining room and on resident tray cards. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #18, #54, #14, #61, #8 and #52. Facility Census: 61. Findings included: a) Posted Lunch Menu On 08/03/26, the facility's posted lunch menu included: Hamburger Steak with Grilled OnionsMashed PotatoesCornRollChocolate Pudding Parfait On 08/03/26 at 12:10 PM, Licensed Practical Nurse (LPN) #16 confirmed there were no grilled onions per posted menu and as listed on the resident's tray cards for the following residents: Resident #18, Resident #54, Resident #14, Resident #61, Resident #8 and Resident #52. The menu extension given stated that grilled onions were to be served with the hamburger steak for the dinner meal. On 08/04/26 at 1:45 PM, the Account Manager confirmed onions were on the menu for yesterday and reported they had a substitute driver and the truck was delayed. The Account Manager reported they did not have enough onions for everyone and the residents in the dining room did not receive them. b) Resident #61 Resident #61's tray card stated, COTTAGE CHEESE-1/2 CUP. The resident did not receive cottage cheese. LPN #16 confirmed the resident food and tray card and then stated, Just needs cottage cheese. The above findings were reviewed with and acknowledged by the Director of Nursing, the Administrator and the Regional Director of Operations on 08/04/26 at 4:30 PM.

Based on observation and staff interview the facility failed to promote a dignified dining experience. These were random opportunities for discovery. Resident identifiers: #1, #3, #6, #8, #9, #14, #20, #24, #26, #38, #61 and #62. Facility Census: #65 Findings Include a) Resident #8 and #62 On 04/21/25 beginning at 11:15 AM during observation of the noon meal in the dining room it was observed that staff were not distributing meals to all residents seated together at an individual table. Resident #8 and #62 were sitting together at a table in the dining room. Resident #62 was served their meal at 11:25 AM. Resident #8 did not received a meal. Staff continued serving meals at various tables throughout the dining room. At 11:50 AM Resident #8 left the dining room. At 11:58 AM it was confirmed with Licensed Practical Nurse #82 that Resident #8 had left without a meal. b) Resident #6, #26 and #61 On 04/21/25 beginning at 11:15 AM during observation of the noon meal in the dining room it was observed that staff were not distributing meals to all residents seated together at an individual table. Resident #6, #26 and #61 were sitting together at a table in the dining room. Resident #26 received their meal at 11:27 AM. Resident #61 received their meal at 11:46 AM (nineteen (19) minutes later). Resident #6 received their meal at 11:50 AM (twenty three (23) minutes later). Staff continued serving meals at various tables throughout the dining room before returning to their table to serve each resident. c) Resident #14 and #20 On 04/21/25 beginning at 11:15 AM during observation of the noon meal in the dining room it was observed that staff were not distributing meals to all residents seated together at an individual table. Resident #14 and #20 were sitting together at a table in the dining room. Resident #20 received their meal at 11:30 AM. Staff continued serving meals at various tables throughout the dining room during this time. Resident #14 received their meal at 11:40 AM (ten (10) minutes later). The above observations was confirmed with the Administrator on 04/21/25 at 11:58 AM. d) Resident #3 On 04/21/25 at 1:18 PM it was observed that Licensed Practical Nurse #85 was standing to assist Resident #3 with their noon meal while the resident was in her bed. The nurse was notified that she could not stand to assist the resident. She replied she was not aware. On 04/21/25 at 1:35 PM the findings were confirmed with the Administrator. 49467 e) Resident #24 and #9 At approximately 12:20 PM on 04/22/2025, Licensed Practical Nurse (LPN) #82 was observed going into the room where Residents #24 and #9 reside, to check on Resident #24. Upon entering the room, LPN #82 did not knock on the door or announce himself. When he entered the room, he started to shut the door. As the door was almost shut, LPN #82 reached back around to the outside of the door and then knocked, after he was already in the room, conversing with the Resident #24. At approximately 12:40 PM on 4/22/2025, LPN #82 was observed going back into the same room, both residents present, and did not knock again. LPN #82 entered the room, went to the bedside of Resident #24 and, upon realizing he did not knock, reached outside and knocked on the doorframe. LPN #82 was interviewed after leaving the room at approximately 12:45 PM and confirmed he did not knock before entering the room either time. 49751 f) Resident #38 and Resident #1 On 04/21/25 at 11:35AM Residnet #1 was observed setting at the dining room table with Resident #38. Further observation showed Resident #1 was served their tray at 11:40 AM. At approximatly 11:45 AM the table beside Resident #1 and #38 were served their trays. On 04/21/25 11:50 PM Resident #38 was served 10 minutes after Resident #1 An interview with the Administrator on 04/21/25 at 12:10 PM Confirmed Resident #38 should have been served before serving another table.

Based upon record review and staff interview, the facility failed to complete SNF ABN, Form CMS-10055 and send to the resident or resident's representative in a timely manner. This was true for 1 (one) of 3 (three) residents reviewed during the annual survey process. Resident identifier: #20. Facility census: 65 Findings included: a) Resident #20 Upon entering the survey on 04/21/25, the facility completed the Beneficiary Notices of residents discharged within the last six months form. From this, three(3) residents were selected to review for required notifications. Resident #20, who was discharged on [DATE], but remained in the facility. SNF-ABN Form was not completed until the surveyor requested the SNF Beneficiary Notification Review form be completed during the annual survey process. Notice was not provided to the resident or resident's representative until 04/21/25. On 04/23/25, at approximately 1:35 PM, in discussion with the NHA, NHA stated the facility had discovered this failure during, an audit of ABNs.

Based upon record review and staff interview, the Facility failed to ensure preadmission screening and resident review (PASARR) was updated and completed with new diagnoses of Dementia (Non-Alzheimer's) and Alzheimer's . This was true for one (1) of five (5) residents reviewed. Resident identifier: #38. Facility censes: 65. Findings included: a) Resident #38 The resident's PASARR was initially completed on 10/07/24 by the facility. In Section III, MI/MR Assessment, the current diagnoses was marked for major depression. No other selections were marked in this section. The Resident had current diagnoses of: Major Depressive Disorder Anxiety Disorder Vascular Dementia with mood disturbance The last MDS Assessment was completed on 04/18/25. A review of Section I, Active Diagnoses documented: Alzheimer's Disease Non-Alzheimer's Dementia Anxiety Disorder Depression (other than Bi-polar) The PASARR should have been updated when the diagnoses of dementia and Alzheimer's were added for the resident. The resident's record was reviewed with the NHA on 04/23/25 at approximately 12:10 PM. When asked why the PASARR had not been updated, NHA asked if it had to be updated for a diagnosis of anxiety. Surveyor responded that some facilities will include anxiety disorder under other, but the diagnoses of Dementia and Alzaheimer's should have triggered a new PASARR to be completed.

Based on record review and staff interview, the facility failed to ensure Residents #24 and #53's care plans included sensory and one (1) on one (1) activities, even though the residents were receiving them. This was true for two (2) of 21 resident care plans reviewed during the survey process. Resident identifiers: #24, #53. Facility census: 65. Findings include: a) Resident #24 During review of Resident #24's activity participation records on 04/22/25, it was noted during the last 30 days, the resident had received one (1) on one (1) activities six (6) times during this period. The resident received one (1) on one (1) activities for the following days: -03/27/25 -03/28/25 -04/09/25 -04/12/25 -04/16/25 -04/18/25 During review of the same activities records, it was noted the resident received sensory activities 12 times. Resident #24 received sensory activities on the following days: -03/26/25 -03/30/25 -03/31/25 -04/01/25 -04/07/25 -04/08/25 -04/10/25 -04/11/25 -04/14/25 -04/20/25 -04/21/25 -04/22/25 During review of Resident #24's care plan, it was determined the care plan did not include one (1) on one (1) or sensory activities. Resident #24's care plan reads as follows: Goal- (Resident #24's name) is dependent on staff for activities, cognitive stimulation or social interaction, due to cardiac disease. Date initiated: 04/20/24. Revision: 04/20/24 Focus- Resident will participate activities of choice through review date. Date initiated: 04/20/24. Revision on: 04/16/25. Target date: 07/04/25. Interventions/Tasks (All initiated on 4/20/2024) -Assist with transport to activities as needed. -Assure that the activities are compatible with the resident's physical and cognitive capabilities. -Encourage attendance to entertainment programs, large and small group activities, volunteer demonstrations and religious activities. -Interview to determine resident's activity preferences. -Invite resident to scheduled activities. -Offer technology of interest i.e. laptop, internet access, tablets, etc. -Provide schedule of activities available. During an interview with the Activities Director (AD) on 4/23/2025 at approximately 9:45 AM, she confirmed Resident #24 was on the schedule for one (1) on one (1) and sensory activities for the department. The AD also confirmed the omission of the two from his care plan. 49751 b) Resident #53 Record review completed on 04/22/25 at 9:01 AM on Resident #53's activities revealed the following; Care Plan Focus [NAME] is self-directed for activities in and out of room daily. Date Initiated: 04/03/2024 Revision on: 07/17/2024 Goal Resident will participate in activities of choice through review date. Date Initiated: 04/03/2024 Revision on: 04/15/2025 Target Date: 07/03/2025 Interventions Assist with transport to activities as needed Date Initiated: 04/03/2024 Assure that the activities are compatible with resident's physical and cognitive capabilities. Date Initiated: 04/03/2024 Encourage attendance to entertainment programs, small group acclivities, volunteer demonstrations and religious activities Date Initiated: 04/03/2024 Revision on: 04/03/2024 Interview to determine residents activity preferences Date Initiated: 04/03/2024 Invite resident to scheduled activities. Date Initiated: 04/03/2024 Provide a schedule of activities available. Date Initiated: 04/03/2024 Provide activity materials of interest, i.e. library books, word puzzles, magazines Date Initiated: 04/03/2024 Further record review revealed the activity preference state weekly one (1) on ones (1), however was not in the careplan to receive one (1) on one (1) activities. During an interview on 04/22/25 at 1:30 PM with the Administrator and Activity Director (AD) who confirmed residents receiving one (1) on one (1) activities should be in Resident #54's care plan.

Based on record review and staff interview, the facility failed to accurately document the completion of behavior monitoring for Resident #18. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the survey process. Resident identifier: 18. Facility census: 65. Findings include: A) Resident #18 During a review of Resident #18's behavior monitoring record for the last 90 days, on 04/22/25, it was determined no behavior monitoring was conducted on March 29th, 2025 on day shift, April 8th, 2025 on day shift, and April 14th, 2025 on day shift. On 4/23/2025 at approximately 11:30 AM, an interview was conducted with the Director of Nursing (DON), she confirmed the behavior monitoring was missing. However, the DON was able to supply CNA documentation with behavior monitoring taking place on the aforementioned days. The DON stated It's expected the nurses will complete their documentation appropriately when referring to the missing dates on the Behavior Monitoring record.

Based on medical record review and staff interview, the facility failed to provide evidence a resident's representative was provided a written Notice of Transfer/Discharge when a resident was discharged from the facility. This was true for five (5) of five (5) residents reviewed for hospitalization s in the long-term care survey process. Resident identifiers: #1, #39, #48, #23, and #52. Facility census: 54. Findings included: a) Resident #1 A medical record review completed on 07/11/23 at 8:56 AM, identified the following details: -Resident #1 was transferred to the hospital on 4/26/23. -There was no evidence of a Notice of Transfer/Discharge being provided to resident and/or resident's representative. During an interview on 07/11/23 at 12:02 PM, the Administrator reported the facility had no evidence a Notice of Transfer/Discharge had been issued. The Administrator went on to explain the notice had been part of the old form and the facility had not identified the fact that it did not carry over to the new form the facility was using since switching ownership. b) Resident #39 A medical record review completed on 07/11/23 at 8:36 AM, identified Resident #39 had experienced two (2) hospitalization s. The first hospitalization was on 04/28/23. The second hospitalization was on 05/07/23. -When Resident #39 was transferred to the hospital on 04/28/23 there was no evidence of a Notice of Transfer/Discharge being provided to resident and/or resident's representative. -When Resident #39 was transferred to the hospital on 05/07/23 there was no evidence of a Notice of Transfer/Discharge being provided to resident and /or resident's representative. During an interview on 07/11/23 at 12:02 PM, the Administrator reported the facility had no evidence a Notice of Transfer/Discharge had been issued. The Administrator went on to explain the notice had been part of the old form and the facility had not identified the fact that it did not carry over to the new form the facility was using since switching ownership. c) Resident #48 A medical record review completed on 07/11/23 at 8:36 AM, identified the following details: -Resident #48 was transferred to the hospital on 06/05/23. -There was no evidence of a Notice of Transfer/Discharge being provided to resident and/or resident's representative. During an interview, on 07/11/23 at 12:02 PM, the Administrator reported the facility had no evidence a Notice of Transfer/Discharge had been issued. The Administrator went on to explain the notice had been part of the old form and the facility had not identified the fact that it did not carry over to the new form the facility was using since switching ownership. d) Resident #52 Review of Resident #52's medical record showed the resident was transferred to the hospital on 5/25/23 due to mental status changes. The medical record did not contain a transfer notice to notify the resident's representative in writing of the reason for the transfer and how to appeal the decision if desired. During an interview on 07/11/23 at 12:02 PM, the Administrator confirmed a transfer notice had not been provided to Resident #52's representative on 05/25/23. No further information was provided through the completion of the survey process. e) Resident #23 Review of Resident #23's medical record showed the resident was transferred to the hospital on 5/13/23 due to mental status changes and low oxygen saturation. The medical record did not contain a transfer notice to notify the resident's representative in writing of the reason for the transfer and how to appeal the decision if desired. During an interview on 07/11/23 at 12:02 PM, the Administrator confirmed a transfer notice had not been provided to Resident #23's representative on 05/13/23. No further information was provided through the completion of the survey process. 43340

Based on medical record review and staff interview, the facility failed to provide evidence residents and/or resident representatives were provided written Bed Hold Notice when transferred from the facility to the hospital. Additionally, the facility had no evidence a written notice of bed hold was reviewed with residents / resident representatives upon admission. This was true for five (5) of five (5) residents reviewed for hospitalization s in the long-term care survey process. Resident identifiers: #1, #39, #48, #23, and #52. Facility census: 54. Findings Included: a) Resident #1 A medical record review completed on 07/11/23 at 8:56 AM, identified the following details: -Resident #1 was transferred to the hospital on 4/26/23. -There was no evidence of a written bed hold notice being provided to resident and/or resident's representative. -Additionally, there was no evidence the bed hold policy had been discussed and shared with resident and/or resident's representative upon admission to the facility. During an interview on 07/11/23 at 11:33 AM, the Administrator reported, We don't issue a written bed hold notice if our census is below 62 because we're not able to charge for the bed hold. The Administrator acknowledged the practice failed to address in writing if the resident's bed was going to be held or not. During a second interview on 07/12/23 at 8:03 AM, the Administrator explained, We verbally explain upon admission that if our census is high enough, we will charge for a bed hold. The Administrator went on to say the facility does not provide a written copy of the facility's bed hold when a resident is admitted to the facility. b) Resident #39 A medical record review completed on 07/11/23 at 8:36 AM, identified Resident #39 had experienced two (2) hospitalization s. The first hospitalization was on 04/28/23. The second hospitalization was on 05/07/23. -When Resident #39 was transferred to the hospital on 04/28/23 there was no evidence of a written bed hold notice being provided to resident and/or resident's representative. -When Resident #39 was transferred to the hospital on 05/07/23 there was no evidence of a written bed hold notice being provided to resident and/or resident's representative. -Additionally, there was no evidence the bed hold policy had been discussed and shared with resident and/or resident's representative upon admission to the facility. During an interview on 07/11/23 at 11:33 AM, the Administrator reported, We don't issue a written bed hold notice if our census is below 62 because we're not able to charge for the bed hold. The Administrator acknowledged the practice failed to address in writing if the resident's bed was going to be held or not. During a second interview on 07/12/23 at 8:03 AM, the Administrator explained, We verbally explain upon admission that if our census is high enough, we will charge for a bed hold. The Administrator went on to say the facility does not provide a written copy of the facility's bed hold when a resident is admitted to the facility. c) Resident #48 A medical record review completed on 07/11/23 at 8:36 AM, identified the following details: -Resident #48 was transferred to the hospital on 06/05/23. -There was no evidence of a written bed hold notice being provided to resident and/or resident's representative. -Additionally, there was no evidence the bed hold policy had been discussed and shared with resident and/or resident's representative upon admission to the facility. During an interview on 07/11/23 at 11:33 AM, the Administrator reported, We don't issue a written bed hold notice if our census is below 62 because we're not able to charge for the bed hold. The Administrator acknowledged the practice failed to address in writing if the resident's bed was going to be held or not. During a second interview on 07/12/23 at 8:03 AM, the Administrator explained, We verbally explain upon admission that if our census is high enough, we will charge for a bed hold. The Administrator went on to say the facility does not provide a written copy of the facility's bed hold when a resident is admitted to the facility. d) Resident #52 Review of Resident #52's medical record showed the resident was transferred to the hospital on 5/25/23 due to mental status changes. The medical record did not contain a bed hold notice given to the resident's representative upon hospital transfer. During an interview on 07/11/23 at 11:35 AM, the Administrator stated the resident received an automatic bed hold due to the facility's census and a bed hold notice had not been provided to Resident #52's representative on 05/25/23. e) Resident #23 Review of Resident #23's medical record showed the resident was transferred to the hospital on 5/13/23 due to mental status changes and low oxygen saturation. The medical record did not contain a bed hold notice given to the resident's representative upon hospital transfer. During an interview on 07/11/23 at 11:35 AM, the Administrator stated the resident received an automatic bed hold due to the facility's census and a bed hold notice had not been provided to Resident #23's representative on 05/13/23. No further information was provided through the completion of the survey process.

Based on observation and staff interview, the facility failed to ensure medications were stored under proper temperatures, in accordance with current accepted professional practices and manufacturer's instruction for storage. This was true for one (1) of one (1) medication storage rooms inspected. Facility census: 54. Findings included: a) Policy Review A review of the policy, titled: Storage of Medications, effective date of 09/01/2020, under Section J., noted the medication storage conditions were to be monitored on a monthly basis by the consultant pharmacist, pharmacy designee, or facility staff and corrective action taken if problems were identified. Under the section, labeled; Temperature, under sub-section C. showed Medications requiring refrigeration were to be kept in a refrigerator at temperatures between 36 degrees Fahrenheit (F) and 46 degrees F. b) Medication Storage Room Inspection An observation of the Medication Room, on 07/11/23 at 10:30 AM , revealed a medication refrigerator temperature log showing a temperature recorded for 07/05/23 to be 51.9 degrees Fahrenheit (F). The medication refrigerator contained two (2) Bivalent Covid 19 vaccines with the label to store between 38-46 degrees F. One(1) of the Bivalent Covid 19 vaccines was dated as delivered from pharmacy on 05/16/23 and the second Bivalent Covid 19 vaccine was dated as delivered on 06/22/23. The dates on the packages were verified, through interview with Licensed Practical Nurse (LPN) #66. LPN #66, at this time stated both vaccines should have been discarded, per policy, when staff noted the temperature had dropped below the temperature ranges for storage of those vaccines. LPN stated further, the vaccines remained in the refrigerator and would be available for use. Further review of the medication refrigerator logs showed additional dates in which the vaccines were being stored in the refrigerator and the temperatures exceeded the temperature storage requirement of 38-46 degrees F: On 06/23/23, the medication refrigerator temperature was recorded at 48.6 degrees F. On 06/25/23, the medication refrigerator temperature was recorded at 54.8 degrees F. On 07/07/23, the medication refrigerator temperature was recorded at 47.4 degrees F. An interview, with the Assistant Director of Nursing (ADON), on 07/11/23 at 11:50 AM, revealed the medication storage should have been maintained in accordance to Centers for Disease Control (CDC) and manufacturers guidelines of Pfizer bivalent vaccine of storing the vaccine between 2 C and 8 C (36 F and 46 F) and verified the faciility had failed to do so. An interview with the Administrator, on 07/12/23 at 11:16 AM, revealed prior to the change of ownership, the Smart Sense program would email temperatures outside the limits to the Director of Nursing (DON) and Infection Preventionist, however, since 04/15/23, Smart Sense has not emailed the DON. Additionally, there was no evidence, the designated person, as noted in the policy, took corrective action when problems were identified with temperature ranges being identified outside the accepted guidelines.

Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility did not properly dispose of personal protective equipment (PPE) after use. This deficient had the potential to affect more than a limited number of residents. Additionally, the facility failed to ensure the infection surveillance line listing was accurate and complete for two (2) of three (3) residents reviewed for antibiotics. Resident identifiers: #212 and #24. Facility census: 54. Findings included: a1) Resident #212 - personal protective equipment disposal Review of Resident #212's physician's orders showed the resident was on Enhanced Barrier Precautions due to a history of multi-drug resistant organisms. During observation of Resident #212's room on 07/11/23 at 11:48 AM, used isolation gowns were noted to be overflowing from the trash can and onto the floor. This practice could contaminate the floor, which could potentially allow anyone who walked through the room or the resident who used a wheelchair in the room to transfer infectious agents to other areas of the facility. During an interview on 07/11/23 at 11:50 AM, the Corporate Registered Nurse confirmed used isolation gowns were overflowing from the trash can onto the floor in Resident #212's room. She stated she would have the gowns picked up. a2) Resident #212 - infection surveillance Review of Resident #212's physicians orders showed the resident was currently on the antibiotic Cefazolin intravenously for a septic knee. The resident had been receiving this medication since admission on 07/04/23. The facility's infection surveillance line listing reported Resident #212 developed an upper respiratory tract infection on 07/10/23 and the resident was on enhanced barrier precautions. The line listing did not report the resident was receiving intravenous antibiotics for a septic knee. During an interview on 07/12/23 at 1:04 PM, the Director of Nursing (DON) confirmed the facility's surveillance line listing did not document Resident #212 was receiving intravenous antibiotics for a septic knee. b) Resident #24 Review of Resident #24's physicians orders showed the resident received the antibiotic Augmentin for pneumonia for five (5) days beginning on his admission on 06/18/23. The facility's infection surveillance line listing did not document Resident #24's antibiotic treatment for pneumonia. During an interview on 07/12/23 at 1:04 PM, the DON confirmed the facility's surveillance line listing did not document Resident #24 had received antibiotic treatment for pneumonia.

Based on observation and staff interview, the facility failed to preserve the resident's dignity by not changing his clothing when it was soiled with food. Resident Identifier: #19. Facility census: 54. Findings included: a) Resident #19 On 07/11/23 at 12:20 PM, Resident #19 was observed being fed by a staff member. On 07/11/23 at 12:55 PM, Resident #19 was observed sitting in a wheelchair in the hallway outside of his room. The resident's shirt was soiled with food. On 07/11/23 at 2:15 PM, Resident #19 was observed to still be sitting in a wheelchair in the hallway outside of his room. The resident was wearing the same shirt soiled with food. On 07/11/23 at 2:18 PM, the Director of Nursing acknowledged Resident #19 had food spilled on his shirt. She stated she would change the resident's shirt. No further information was provided through the completion of the survey process.

Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (1) of 18 resident rooms observed during the long-term care survey process. Resident identifier: #39. Facility census: 54. Findings included: a) Resident #39 During the initial tour of the facility on 07/10/23 at 1:33 PM, the following issue was identified: -The left side of Resident #39's bed was against the wall. It was immediately visible that the wall was in poor repair. There were many, multiple long scratches approximately 12 inches in length and spanning approximately 16 inches across the wall that was just above where the mattress on the bed was positioned. These scratches had removed the paint from the wall. Additionally, there was a circular hole with the approximate circumference size of a racquetball that was below the scratches. The Director of Nursing at 1:30 PM on 07/11/23 observed the above-mentioned concerns and stated the damage to the wall was from the bed scraping against the wall and that she believed a work order may have been put in to correct the issue. The Administrator produced a Wall Repair/Painting Action Plan dated 05/17/23 that addressed all needed repairs throughout the facility. The Administrator acknowledged that Resident #39 had returned from the hospital on 05/10/23 at which time the left side of her bed was placed against the wall at the request of resident's Medical Power of Attorney. The wall repair list was made the next week. The Administrator confirmed the above issues failed to provide a homelike environment to Resident #39. The Administrator also confirmed she was unaware of the hole in the wall. The Administrator stated the facility should have prioritized that particular repair and she would make sure it got done promptly.

I. Based on observations, record review, resident interviews, staff interviews, review of the Centers for Medicare and Medicaid State Operations Manual, and documentation provided by the facility, the facility failed to ensure the resident environment remained as free of accident hazards as possible. The facility also failed to ensure residents received needed supervision and assistance devices for safe transfer of residents requiring assistance for that activity. The facility had an ineffective program for assessing/implementing and reassessing residents after they had a functional status change in transfer ability. The facility also failed to implement an effective educational training program related to safe transfers with mechanical lifts and staff assisted transfers. This placed all residents who needed assistance with transfers in an immediate jeopardy situation. It had the potential to affect fifty-four (54) of sixty-one (61) residents residing in the facility who required transfer assistance. Residents #3, #30, and #66 were each observed being transferred by one (1) aide, although their care plans indicated they needed assistance of two (2) persons for transfers. Resident #26 received a suspected deep tissue injury (SDTI) as a result of being pinched by the lift pad during a full body lift transfer. The SDTI eventually became a Stage IV pressure ulcer. The improper use of the mechanical lift resulted in actual harm for Resident #26. Residents #78, #12, #5, and #60 were each identified as receiving skin tears and/or bruises during transfers using a mechanical lift. The immediate jeopardy situation began on 05/14/14 when Resident #3 slid out of the sit to stand mechanical lift while being transferred from her wheelchair to her bed. The resident was transferred by one (1) aide assisting the resident ,when there should have been two (2) aides assisting the resident with the transfer, as was identified in her care plan. The facility was notified of the immediate jeopardy at 10:49 a.m. on 05/22/14. A plan of correction (POC) was provided by the facility at 3:50 p.m. on 05/22/14. The POC was accepted at 4:06 p.m. on 05/22/14. The plan of correction indicated the facility would do the following: "1. The facility's policy for assessment of residents for safe transfers and use of lifts has been updated. 2. All direct caregivers on duty have received training on the following from the Maintenance Supervisor, Director of Nursing Services, and/or RN (registered nurse) assessment coordinator: a. How to identify the transfer requirements of a resident through the POC (plan of care) Care Plan Kardex. b. How to correctly use the full body lift to transfer a resident requiring full body lift. c. How to correctly use the sit to stand lift to transfer a resident requiring sit to stand lift. 3. Resident #3, #66, and #30 have all been screened for transfer requirements. Physician orders [REDACTED]. Direct caregivers have been re-educated on the transfer requirements of Resident #3, #66 and #30. 4. All other residents will be assessed for transfer requirements. Physician orders [REDACTED]. Direct caregivers will be re-educated on the transfer requirements of all other residents. This will be completed by 05/23/14. 5. The executive director will ensure immediate compliance with this abatement plan by 05/23/14. 6. Changes in the transfer status of residents will be communicated to direct care staff on duty through verbal notification by the Unit Charge Nurse at the time the change is made. Other direct care staff will be made aware of the change through review of the resident's plan of care and CNA Kardex. 7. The Clinical Care Supervisor or designee will monitor this process weekly for compliance." At 7:15 p.m. on 05/22/14, the survey team observed for compliance in the areas related to direct care givers on duty receiving training, Residents #3, #66, and #30 being reassessed for transfer ability using the new assessment tool, and the newly developed policy was reviewed. Residents #3, #66, and #30 were also observed being transferred and were transferred in accordance with their newly completed assessments and in accordance with their plan of care. The training of all direct care staff on duty was also verified at that time. The immediacy of this deficient practice was abated at 7:15 p.m. on 05/22/14; however, a deficient practice still remained, so the scope and severity was decreased from a "K" to a "G." Resident Identifiers: #3, #30, #66, #26, #78, #12, #5, and #60. Facility Census: 61. Findings Include: a) Resident #3 Review of Resident #3's medical record, on 05/21/14 at 5:00 p.m., revealed a nursing progress note dated 03/15/14. This note indicated the nurse aide (NA) reported to Employee #55, unit charge nurse/registered nurse (RN) that Resident #3 exhibited weakness and "shakiness" when being transferred with the sit to stand mechanical lift. This progress note indicated the following actions were taken: "This Nurse, (Employee #55) observed resident being transferred by staff with assist of sit to stand mechanical lift. Noted resident to have coarse tremors noted to upper extremities when grasping handles of lift. Resident does not attempt to put feet into designated foot pad area of lift. Staff assisted with placement of feet/legs. Resident c/o (complained of) pain in shoulders when being transferred with lift. Reports pain subsides after transfer complete." The outcome section of the note stated: "Spoke with OT (occupational therapy) staff regarding safety concerns with transfer utilizing sit to stand lift. She advises that OT services do not make recommendations concerning use of lifts, that this is a matter of safety to be determined by nursing staff. Reviewed matter with physician. N.O. (new order) received to transfer resident with as much assistance as required to ensure resident and staff safety. MPOA (medical power of attorney) aware and agreeable with plan of care." Employee #55, RN, wrote another progress note concerning Resident #3 on 03/16/14. This note indicated Resident #3 was upset about having to use the full body lift and she wanted to use the sit to stand mechanical lift. Employee #55 documented she told Resident #3 the new order was for her to be transferred with the amount of assistance necessary to ensure her safety. Resident then told Employee #55, "Well, I've never offered to fall in all the times I've been using that lift I'm not going to fall." Employee #55 then documented the following, "Again explained to resident that it was a safety concern because of noted weakness/tremors and difficulty maintaining standing position when being transferred, and that this presented a risk for fall. . . ." Employee #55 offered the resident the possibility to be referred to Physical therapy for strengthening exercises to which the resident replied, "Oh No. I can't do them exercises. My arms and legs are too weak. The (they) hurt my arms and legs." Employee #55 then reminded resident again that weakness is the reason the transfer orders were changed. The resident did not reply and propelled herself away from the nurses' station. There were no other progress notes, physician's orders [REDACTED].#3's transfer status until her fall on 05/14/14 from the sit to stand mechanical lift. The sit to stand lift was the lift identified as unsafe for transfers of this resident on 03/15/14. Resident #3 had an occurrence note dated 05/14/14. This note indicated Resident #3 had a fall on 05/14/14, sustaining a 5 cm (centimeters) X (by) 7 cm bruise to her outer right antecubital area with no swelling or open areas observed. There was an additional occurrence note dated 05/15/14, which discussed Resident #3's fall and indicated the equipment involved in the fall was the sit to stand lift. An occurrence follow-up note, dated 05/18/14, written as a follow up to the occurrence note on 05/14/14, indicated the intervention put into place to prevent reoccurrence was, "Resident to use full body lift for transfers." Additional occurrence follow-up notes dated 05/19/14, 05/20/14, and 05/21/14 indicated the interventions put into place to prevent reoccurrence were to educate staff on proper transfers. Review of the incident report regarding this fall revealed the resident slid off her bed onto the floor. Employees #25, a nurse aide (NA), stated, "While using sit to stand lift with resident, resident let go of hand handles of lift and lifted feet up and slid to the floor. Resident was over the bed at the time so she slid down side of bed." Employee #61, social services supervisor, provided additional documentation regarding Resident #3's fall on 05/14/14. She had written a note on a form titled, "Daily Contacts." This note stated, "Spoke with resident about fall which was reported to SW (social worker) earlier. Resident stated she was on the lift between beds and her hands slipped and she fell towards her bed. She stated it was no one's fault, 'it just happened.' She was not hurt. " On the same form titled, "Daily Contacts," dated 05/16/14, was an unsigned note, "SW (Social Worker), CCS (Clinical Care Supervisor), and DON (Director of Nurses) met to discuss occurrence. Order for full body lift to be obtained for resident safety. . . ." The resident's medical record contained a general patient note dated 05/18/14. This note indicated the resident was upset d/t (due to) having to use a full body lift. The nurse explained to the resident that for her safety, she would have to be transferred with the full body lift. The resident was noted to be unhappy with this decision. The resident's transfer status was not reassessed as a result of her being unhappy, and there was no indication the resident's transfer status was changed back to a sit to stand lift. Additionally there was no indication this matter was discussed with Resident #3's medical power of attorney (MPOA). Review of Resident #3's care plan revealed an intervention of, "Transfer Self-Performance: (Resident #3) requires assist of 2. (Resident #3) uses a sit to stand mechanical lift and is able to hold onto the lift while in operation. May Need Full Body Lift- Consult OT." This intervention was added to the care plan on 01/20/14, with a revision date of 03/12/14. Resident #3 had a physician's orders [REDACTED]." This order was discontinued on 03/15/14. Another order dated 03/15/14 was, "Transfer Order: Resident to be transferred with amount of assistance required to ensure resident /staff safety." This order was the current order at the time of this review. This order was not consistent with the resident's care plan or Kardex because neither was updated to reflect the changes identified in the physician orders [REDACTED]. Resident #3 was observed being transferred on 05/22/14 at 9:15 a.m. with a mechanical sit to stand lift. Employee #3, nurse aide (NA), was assisting the resident during the transfer. Employee #3 indicated she transferred Resident #3 by herself all the time because the resident was able to hold on to the lift and was not likely to fall. She stated she would have someone assist her if the resident was unable to hold on to the lift and was at risk for falling. Review of the in-service records related to lifts for Employee #3 on 05/23/14 at 1:00 p.m., found a form signed by Employee #3 dated 05/17/01, titled "Back Injury prevention program (BIPP) Resident Lifting/Transfer Policy." This form indicated the facility was a "No Lift" work place and had provided mechanical lifting equipment to achieve this goal. The form also indicated the following, ". . . it will be mandatory as of January 1, 2001 that no resident be lifted or transferred without the proper situation, any situation that in your judgment makes use of the equipment inappropriate." A Check-Off List, in the in-service records, for the correct usage of lifts, dated 07/19/11, indicated Employee #3 was in-serviced on all aspects of correctly using the lifts and gave a return demonstration on using the lift correctly. This was completed for the, "Hoyer Sit to stand 400 lbs. (pounds)," "Hoyer sit to stand 750 lbs." and "Hoyer Full Body 400 lbs." Employee #3 had also attended an in-service, dated 12/27/12, for training on sling/lift proper placement. Despite receiving in-service education on the correct way to use the lift, Employee #3 still transferred Resident #3 with the sit to stand lift in a manner that was not consistent with the resident's care plan. This observation, on 05/22/14, found Employee #3 transferring residents incorrectly. The education provided to this employee was ineffective as evidenced by her continuing to transfer residents via mechanical lift with only a one (1) person assist. When interviewed, the employee acknowledged she, "Did it all the time." On 05/22/14 at 10:52 a.m., Employee #25, the NA, who had transferred Resident #3 on 05/14/14, the night the resident had the fallen from the lift, was asked what had happened the night of the fall. Employee #25 stated she was assisting the resident to bed using the sit to stand lift with Resident #3. Employee #25 indicated she was the only staff member in the room at the time of the fall. She confirmed, she should have had another staff member with her when operating the lift, but did not go and ask anyone to help her because she was busy and did not want to make the resident wait to go to bed. She stated when she began lowering the resident to the bed, the resident let go of the handles, lifted up her feet, and began to slide to the floor. She stated the resident's arms were tangled in the lift sling and she had to raise the lift a little to get the resident's arms out of the sling. She stated she then went and got another NA and the Licensed Practical Nurse (LPN) to help her get the resident back to bed. When asked if she had ever been trained to use the lifts, Employee #25 indicated they had annual in-services, watched a slide show, and took a test regarding the use of lifts. She stated she did not recall the last time she had taken this in-service. She stated the DON or another RN would train them on the use of lifts. In-service records for lift training were reviewed and found Employee #25 signed a "Back Injury Prevention Program (BIPP) Resident Lifting/Transfer Policy" on 08/28/12. The policy also included that as of 11/15/05, two (2) persons be in attendance with all mechanical lifting episodes. According to the in-service records, Employee #25 also attended an in-service on "Full body slings," provided on 11/18/13 by Employee #53, the maintenance supervisor. At 12:45 p.m. on 05/22/14, Employee #64, NA, was asked if she was working the night of 05/14/14 when Resident #3 fell . She stated she did not know a lot about the fall, she was just told the resident had fallen by Employee #25. Employee #64 was asked if she ever worked with Resident #3. She confirmed she did. She was asked if she had ever had any problems with Resident #3 letting go of the lift or if she had any concerns about transferring Resident #3. She stated a few weeks before, Resident #3 had fallen from the lift. They had told the RN the resident was sliding, her legs were shaking, and her knees were buckling. She also indicated Resident #3 had also let go of the handles before with one hand. She stated if she would let go with both hands she would slide out of the lift. She stated when therapy reevaluated residents for the lifts, they did it in the morning when the residents were fresh, and not in the evening when they were tired. She stated she felt they needed to evaluate the residents in the evening when they were tired. She indicated they changed Resident #3 to a full body lift for about 2 (two) days, and then they switched her back to the sit to stand lift. Employee #64 was asked if she had been trained on the proper use of the mechanical lifts. She stated when she started to work at the facility, the other aides would watch the new NAs use the lift to make sure they were doing it correctly. She stated, "We usually have an in-service in rotation once a year about the safety of the lifts." She stated a nurse would go over everything and would verbally discuss the lifts with the staff. When asked how many staff members need to be present when using a mechanical lift, she replied, "At least two (2)." When asked how she determined what type of assistance a resident needed with transfers, Employee #64 stated if it was a new resident, she would look at the Kardex. She stated if it was not a new resident, the nursing staff would give them report, and that was how they knew how to transfer their residents. She stated, "If we are off a few days, the other aides try to fill us in because it is like a whole new world after you are off a few days." She also stated it was always in the Kardex. She reported she would try to look at the Kardex at least once a week to see if anything had changed. Review of in-service records for lift training found Employee #64 signed a "Back Injury Prevention Program (BIPP) Resident Lifting/Transfer Policy" on 04/29/13. The policy included that as of 11/15/05, two (2) persons be in attendance with all mechanical lifting episodes. The facility was unable to provide any other in-service records for this employee. Employee #32, NA, was interviewed at 1:03 p.m. on 05/22/2014. Employee #32 stated she was working the night Resident #3 had fallen from the lift. She stated the only thing she did to assist with Resident #3 after she fell was to help the other aide and the LPN get the resident back in bed. She stated they should have used the lift to transfer her from the floor to the bed but they did not. She reports they just manually lifted the resident back to bed. Employee #32 stated she always had two (2) staff members present when she used a lift. She stated there would never be a time when it would be appropriate for just one (1) person to be present. Employee #32, when asked if she had been trained on the appropriate use of the lifts, stated her CNA (certified nursing assistant) instructor had trained her when she took the CNA class. She stated when she began to work here, the other aides would watch you and make sure you knew how to use the lifts. She stated she was not sure if she has attended any training or in-services on the use of lifts since she has been employed her. She did state, "I have missed a few in-services though." The facility was unable to locate any in-service records related to lifts for Employee #32. When asked how she knew how to transfer a resident, she stated she would look in the Kiosk, at the Kardex, or someone would tell you verbally if you had been off a few days. She stated she only looked at the Kardex when she needed to, such as when there was a new resident or if she would have a question about something. She stated if something changed with the current residents, the other staff would just tell you verbally. Employee #56, Licensed Practical Nurse (LPN), was interviewed at 3:14 p.m. on 05/22/14. She stated she was the nurse working the night Resident #3 fell from the lift. She stated, Employee #25 had come and got her and told her Resident #3 had fallen. She stated when she entered the room, the resident was on her buttock beside the bed with her legs fully extended and her feet were still resting on the foot base of the sit to stand lift. Employee #56 confirmed Employee #25 was the only aide assisting the resident with her transfer. She stated the aide should have had another aide assisting her. When asked how they transferred the resident from the floor to the bed, she stated she and two (2) other NAs picked the resident up and put her in the bed. She stated they should have used the other lift to get the resident from the floor to the bed, but they did not. The facility's policy titled "Subject: Lifts-Sit-To Stand, Hoyer (full body)," with a revision date of 11/11/10 was reviewed. This policy included, "Policy (Name of Facility) mission is to provide the safest way of transporting a resident to prevent harm to a resident and staff by way of the 2-types of lifts provided at the facility. The following procedures will be followed by the manufactures recommendations and the OSHA regulations. 1. Each resident will be evaluated upon admission by RN assessment within 24 hours of admission if resident requires a lift, by following check off list to determine which lift to use. 2. PT (Physical Therapy) will screen each resident for safety measures of using the proper lift ordered for the resident." In an interview the evening of 05/21/14, Employee #72, DON, was asked to provide a copy of the check off list mentioned in the policy and/or the assessments completed by PT regarding Resident #3. She stated there was not a check off list. She indicated nursing completed a head to toe assessment upon admission, but did not complete a check off list. She was unable to provide any documentation to suggest therapy had evaluated Resident #3 and determined it safe for her to use a sit to stand lift. b) Resident #30 During an interview with Employee #3, NA, at 8:40 a.m. on 05/22/14, she stated that they could use the lift with either one (1) aide or two (2). She indicated she reviewed the Kardex each morning and this was how she knew what assistance each resident needed for the transfers. She indicated if the resident was able to hold on to the handles and able to stand up once the lift assisted them up, she did not get another staff member to help with the transfer. She stated if the resident was not able to do this, then they have to notify the nurse. Resident #30 was observed being transferred at 9:08 a.m. on 05/22/14. Employee #3, NA transferred this resident using a sit to stand lift from the edge of her bed to her wheelchair. Employee #3 completed this transfer by herself. Review of Resident #30's medical record at 9:15 a.m. on 05/22/14, revealed a care plan intervention of, "Transfer Self-Performance: (resident name) requires extensive assist of 2 (two). May use sit to stand lift as needed for transfers. (Resident Name) uses 1/2 side rails and her wheelchair for balance and is able to stand and pivot. (Resident name) may use the sit to stand lift as needed for transfers, safety." This intervention was initiated on 12/13/13, revised on 01/03/14, and was the current care plan intervention at the time of this review. This care plan intervention was also noted on Resident #30's active Kardex at the time of this review. On 05/23/14, a review of the reportable incidents for the previous 12 months revealed a reportable incident dated 09/26/13 for Resident #30. This incident indicated Resident #30 was transferred via full body lift and bumped her forehead on the lift causing a reddened area. The facility completed an investigation into this incident and found that Employee #23 and Employee #86 were transferring Resident #30 using a full body lift on 09/26/13. The resident was instructed to fold her arms, but instead, grabbed the bar and bumped her forehead on the bar of the full body lift. Review of the incident report found it indicated the nurse, "Informed CNA's to be more careful during transfers and to watch placement of head during lift." This was a step taken to prevent reoccurrence. On 05/29/14 at 5:25 p.m., Employee #72, DON, was asked to provide evidence of the education provided to Employee #23 and Employee #86, but was unable to do so. She stated the education provided was verbal and was not documented anywhere. The medical record review revealed an order dated 09/16/13, which stated to use a full body lift for transfers. This order was discontinued on 09/30/13. Interview with Employee #73, Clinical Care Supervisor (CCS) Registered Nurse (RN) at 5:33 p.m. on 05/29/14, revealed the resident had to have a change in transfer orders because she had a [PROCEDURE] and was unable to use the sit to stand lift temporarily. She reported she was switched back to the sit to stand lift on 09/30/13. She stated at that time they did not have specific transfer orders and assessments, so it was just assumed when the full body lift order was discontinued, she would be transferred with the sit to stand lift when unable to tolerate the stand and pivot transfer. The facility was unable to provide an order for [REDACTED]. The next order, dated 05/22/14, and entered after the facility was notified of the immediate jeopardy situation, was for the resident to be transferred via stand and pivot with the assistance of two (2). The order indicated the resident was to be transferred via full body lift when unable to tolerate stand and pivot with assist of 2. This order was consistent with the Lift/Transfer Screening completed on 05/22/14 as a result of the immediate jeopardy. c) Resident #66 A review of the care plan, on 05/21/14 at 6:24 p.m., revealed Resident #66 required the extensive assistance of two (2) with transfers on/off the toilet. A review of the nursing assistant Kardex, on 05/21/14 at 6:30 p.m., revealed Resident #66 required the extensive assistance of two (2) for all transfers. In an interview, on 05/2214 at 9:20 a.m., with Employee #3 nursing assistant (NA), when asked what type of transfer assistance Resident #66 required, she stated she was required to check her resident every two (2) hours and assist her to the bathroom for toileting. She stated that she would transfer her with a gait belt from the wheelchair to the toilet. During an observation on 05/22/14 at 9:40 a.m., with Employee #72, the director of nursing (DON), Employee #5, nursing assistant (NA), transferred Resident #66 from the toilet to the wheelchair with the assistance of one (1) person and without a gait belt. On 05/22/14 at 9:40 a.m., Employee #3 (NA) and the DON read the Kardex on how Resident #66 was to be transferred. Employee #3 said the resident required the assistance of two (2) people for transfers. Employee #3 then admitted she did not transfer Resident #66 with two assistants and a gait belt on 05/22/14. During an interview with the DON, on 05/22/14 at 10:10 a.m., when asked whether the nursing assistant transferred this resident properly, she stated, "No." The DON agreed the nursing assistant should have transferred Resident #66 in accordance with the instructions on the Kardex. The DON stated the nursing assistant did not ask her to help with the transfer. On 05/22/14 at 10:40 a.m., the revised policy, dated March 2004, that addressed moving a resident from the bed to chair/chair to bed was reviewed. The policy instructed, if a resident could not stand alone staff were to use two (2) persons (one on each side), apply the gait belt on the resident, gently stand and turn the resident and sit him or her in the chair. d) Resident #26 Medical record review, on 05/21/14 at 2:30 p.m., revealed this resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Her admission comprehensive assessment indicated that she had a score a "15" on the Brief Interview for Mental Status (BIMS); which indicated the resident was cognitively intact During an interview with the resident, at 10:51 a.m. on 05/19/14, she stated, "The staff says my pressure ulcer is from a blood blister caused by being pinched by a lift pad during a transfer, although I don't know because I have no feeling from the waist down." A review of the nurses' notes for Resident #26, found an entry dated 11/28/13 at 9:00 a.m., that included, "Skin evaluation completed. Resident has no edema, rash, excoriation, skin tear, bruising or skin breakdown noted." Further review of nurses' notes revealed an "Occurrence" note entered on 12/01/13 at 4:07 p.m. by Employee #42, licensed practical nurse (LPN). The entry included, "bruising observed to left thigh (rear). Nursing Assessment: "purple bruising to left thigh 2cm (centimeters) in length x (by) 1cm width with blistered area in center, skin intact. Actions taken: "instruct staff to use caution with lift pads and report any further injuries." Treatment ordered: "None." Attending physician notified. Equipment involved: "full body lift pad." A note by Employee #39, LPN, on 12/02/13 at 10:00 a.m., included, "blister to back of left thigh is open. Attending physician notified and new orders received to cleanse the area with normal saline solution and 4x4 pad and then apply polysporin powder and cover with foam dressing daily for 7 (seven) days." In an initial pressure wound assessment, dated 12/08/13, Employee #52, RN, noted, "Unstageable pressure ulcer on left buttocks, the area measures 3cm in length and 2cm in width with a depth of 0.2 cm with eschar noted in wound bed and surrounding skin reddened." Additional notes were, "Resident is a quadriplegic and has no sensations down there. She was out to home on Thanksgiving Day and when she came back that evening she had a fluid filled blister noted. The blister has opened and there is eschar noted in the wound bed with peri-area pink and fragile." Review of the Wound Care Center notes revealed Resident #26 had a Stage IV (four) pressure ulcer located on the left ischial tuberosity. In an interview on 05/21/14 at 4:00 p.m., Employee #52, RN, was asked how the pressure ulcer occurred. She replied, "It was a blister that I think we had been watching for a few days prior to the initial pressure ulcer assessment which was completed on 12/08/14. I think the staff said the blister had ruptured when the resident's family took her home for Thanksgiving." When asked, "According to the facility wound protocol, what type of wound is a blister?" she stated, "A blister is a pressure ulcer." When asked whether the wound on the rear of the resident's left thigh and the wound on the left buttocks were the same or different areas, she said, "It is the same area." When asked, whether the wound care center's notes identifying the wound as located on the left ischial tuberosity, was this the same area the facility was calling the left buttock, she answered, "Yes." Employee #42, LPN, the nurse who completed the occurrence note on 12/01/13, was interviewed by telephone on 05/28/14 at 11:30 a.m. When asked what had happened to Resident #26 on 12/01/13, she said, "Two nursing assistants, (names of Employees #20 and #32) had used the full body lift to transfer Resident #26 from the chair to the bed. They noted a purple bruise with blistering present to left outer (rear) thigh area and then they notified me of the area." She was asked about the occurrence form statement, "the resident reported she thinks the metal bar in the lift pad could have caused it during transfer by pinching the skin." She stated, "Resident #26 did not have any feeling below her waist, she did not know how it happened. The two (2) nurse aides and I looked at the lift pad. There was a metal bar located at the bottom of the pad and it would hit her body in the area of the bruised blistered area during the transfers. We felt the resident's skin probably got pinch by the lift pad." When asked, whether the bruised, blistered area was noted prior to that time, she said, "No, not to my knowledge." A review of current comprehensive care plan revealed no interventions had been initiated since the injury on 12/01/13 involving the lift pad pinching her skin causing a suspected deep tissue injury. An interview with the director of nursing, Employee #72, on 05/27/14 at 2:00 p.m., confirmed the resident's care plan was not revised to include precautions with the use of lift pads during transfer. No actions had been initiated to prevent further injury involving the full body lift pad. e) Resident #78 Review of a reportable incident dated 09/13/13, at 3:42 p.m. on 05/27/14, revealed Resident #78 received a 9 cm (centimeter) skin tear to her right outer calf. This skin tear occurred on 09/06/13 when Employee #85 was transferring Resid

Based on medical record review and staff interview, the facility failed to ensure a resident who entered the facility without a pressure ulcer did not develop a pressure ulcer unless it was clinically unavoidable. Resident #26 developed a suspected deep tissue injury as a result of an incident during a transfer using a full body lift. The area subsequently evolved into a Stage IV pressure ulcer which constituted actual harm. Resident identifier: #26. Facility census: 61. Findings include: a) Resident #26 A review of the resident's medical records on 05/21/14 at 2:30 p.m., revealed this [AGE] year old female resident had [DIAGNOSES REDACTED]. The resident had lived in the facility since at least mid 2010. She was discharged return not anticipated on 10/03/13 to another nursing home or swingbed, and returned to the facility on same day, on 10/03/13. As the resident was discharged with return not anticipated, the comprehensive minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/10/13, was an admission assessment although the resident had resided in the building for over three (3) years. This assessment indicated she scored "15" on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. According to the assessment, the resident had no pressure ulcers, but was at risk of developing pressure ulcers. Further medical record review revealed a significant change in status MDS, with an ARD of 12/12/13, that identified the resident had an unhealed pressure ulcer at a Stage 1 or higher. Item M0300 F was coded as the resident having one (1) unstageable pressure ulcer present. Section S, the state specific section of the MDS indicated the resident had one (1) new in-house pressure acquired pressure ulcer, which had developed on the resident's left buttock during the last quarter. Additional review of the MDSs found in 2010, the resident had had a Stage IV pressure ulcer which had subsequently healed. Her annual MDS, with an ARD of 12/26/12, a Quarterly assessment with an ARD of 06/18/13, a significant change of status MDS with an ARD of 03/28/13, a Quarterly assessment with an ARD of 06/18/13, as well as the admission MDS of 10/10/13, all indicated the resident did not have pressure ulcers. The unstageable pressure ulcer identified on the significant change assessment with an ARD of 12/12/13,was the first time a pressure ulcer was coded for this resident in more than a year. At that time, the area was 3 cm (centimeters) long x 2 cm wide x 0.1 cm. deep, and the most severe tissue type was slough (Non-viable yellow, tan, gray, green or brown tissue), The resident was hospitalized from [DATE] to 02/27/14. On her next MDS, a Quarterly assessment with an ARD of 03/06/14, the area was coded as a Stage IV with granulation tissue and measured 4 cm x 2 cm x 2.9 cm.) Subsequent assessments, with ARDs of 03/12/14 and 03/27/14, reflected the area remained a Stage IV with granulation tissue measuring 4 cm x 2 cm x 2.9 cm. All of the assessments, with the exception of the 30-day MDS with an ARD of 03/27/14, identified the area had developed in-house. During an interview with the resident, at 10:51 a.m., on 05/19/14, she stated, "The staff says my pressure ulcer is from a blood blister caused by being pinched by a lift pad during a transfer, although I don't know because I have no feeling from the waist down." Review of the nurses' notes for Resident #26 found an entry on 11/28/13 at 9:00 a.m., "Skin evaluation completed. Resident has no [MEDICAL CONDITION], rash, excoriation, skin tear, bruising or skin breakdown noted." At 11:15 a.m. on 11/28/14, the resident went out of the facility with her family for Thanksgiving dinner. When she returned at 6:30 p.m., a nurse noted, "No distress noted." Further review of nurses' notes revealed a note, entered on 12/01/13 at 4:07 p.m. by Employee #42, licensed practical nurse (LPN). The documentation included: -- Type of nurse's note: Occurrence. -- Type of occurrence: "bruising observed to left thigh (rear)." -- Nursing Assessment: "purple bruising to left thigh 2 cm in length x 1 cm width with blistered area in center, skin intact. -- Actions taken: "instruct staff to use caution with lift pads and report any further injuries." -- Treatment ordered: "None." Attending physician notified. -- Equipment involved: " full body lift pad. " On 12/02/13 at 10:00 a.m., Employee #39, LPN, noted, "blister to back of left thigh is open. Attending physician notified and new orders received to cleanse the area with normal saline solution and 4 x 4 pad and then apply [MEDICATION NAME] powder and cover with foam dressing daily for 7 (seven) days." An initial pressure wound assessment, dated 12/08/13, completed by Employee #52, registered nurse (RN), noted, "Unstageable pressure ulcer on left buttocks, the area measures 3 cm (centimeters) in length and 2 cm in width with a depth of 0.2 cm with eschar noted in wound bed and surrounding skin reddened." Additional notes were, "Resident is a quadriplegic and has no sensations down there. She was out to home on Thanksgiving Day and when she came back that evening she had a fluid filled blister noted. The blister has opened and there is eschar noted in the wound bed with peri-area pink and fragile." Review of the Wound Care Center notes revealed Resident #26 had a Stage IV (four) pressure ulcer located on the left ischial tuberosity. In an interview with Employee #52, RN, on 05/21/14 at 4:00 p.m., when asked, how the pressure occurred, she said, "It was a blister that I think we had been watching for a few days prior to the initial pressure ulcer assessment which was completed on 12/08/14. I think the staff said the blister had ruptured when the resident's family took her home for Thanksgiving." When asked what type of wound a blister was considered according to the facility's protocol, she stated, "A blister is a pressure ulcer." The nurse was asked whether the the wound on the rear of the resident's left thigh and the wound on the left buttock were the same or different areas. She answered, "It is the same area." She was asked whether the area referred to in facility documentation as being on the left buttock was the same area the Wound Care Center's notes identified as located on the left ischial tuberosity. She answered, "Yes." In an interview with Employee #73, RN, the Clinical Care Supervisor on 05/22/14 at 7:00 p.m., was asked according to the occurrence report and the nurses' notes what type of wound did Resident #26 have documented on her left thigh/buttocks starting on 12/01/13. She stated, "It is a suspected deep tissue injury." When asked the location of the wound, she replied, "The wound is located on the resident's left ischial tuberosity." During a telephone interview on 05/28/14 at 11:30 a.m. with Employee #42, LPN, who completed the occurrence report on 12/01/13, the nurse was asked what had happened to Resident #26 on 12/01/13. She said, "Two nursing assistants, (Names of Employees #20 and #32) had used the full body lift to transfer Resident #26 from the chair to the bed. They noted a purple bruise with blistering present to left outer (rear) thigh area and then they notified me of the area." When asked about the portion of the occurrence form noting, "The resident reported she thinks the metal bar in the lift pad could have caused it during transfer by pinching the skin," she stated, "Resident #26 does not have any feeling below her waist, she did not know how it happened. The two (2) NA and I looked at the lift pad and there was a metal bar located at the bottom of the pad and it would hit her body in the area of the bruised, blistered area during the transfers and we felt the resident's skin probably got pinch by the lift pad." When asked whether the bruised, blistered area was noted prior that time, she said, "No, not to my knowledge." Review of the comprehensive care plan, dated 03/11/14, found no interventions in place to prevent the worsening and/or the development of further deep tissue injury/pressure ulcers. .