Every finding on record at Denver Sunset Home

Based on record review, staff interview, and family interview, the facility failed to notify a resident representative of the risks and benefits of psychotropic medication use prior to administration of psychotropic medication, and failed to inform a resident representative of treatment alternatives to the medication prior to administration for 1 of 5 residents reviewed (Resident #5). The facility reported a census of 24 residents.Findings include: 1. Resident #5's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 6 out of 15, indicating severely impaired cognition. The MDS included diagnoses of dementia, depression, and peripheral vascular disease. Per this assessment, the resident took antidepressant medication. Review of the Physician Order dated 8/25/25 for the resident revealed, sertraline (antidepressant medication) 25 mg (milligram) by mouth daily for dementia with anxiety and major depressive disorder. Resident #5's Electronic Health Record (EHR) lacked documentation the facility notified the resident's representative in advance of the risks and benefits of the medication, treatment alternatives or other options, or to let them choose the option they preferred prior to administering the medication.Resident #5's Medication Administration Record (MAR) for August 2025 through March 2026 documented Resident #5 received sertraline daily since ordered in August. On 3/26/26 at 11:00 AM, the Administrator reported they facility didn't do a consent with the family for prior to giving. On 3/26/26 at 11:14 AM, the family representative reported the facility did not notify her of the risks and benefits of the medication, treatment alternatives or other options.

Based on observation, record review, and staff and resident interview, the facility failed to ensure a contracture of a resident's hand was addressed on the care plan for 1 of 1 resident reviewed for contractures (Resident #18). The facility reported a census of 24 residents. Findings include:Resident #18's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. The MDS documented he had an impairment to both upper and lower extremities on one side. The MDS included the diagnosis of a stroke. On 3/23/26 at 1:35 PM, observation of the resident's left hand noted severe contracture to left hand. The resident was unable to use the left hand. Resident #18 reported his hand had not worsened with the contracture. He reported therapy was trying to work with him, but it hurt and was uncomfortable so he made them stop. Resident #18's Physician Progress Note for a visit on 2/9/26 and on 6/6/24 revealed he had Dupuytren's contracture (contracture of one or multiple fingers towards the palm).Review of the care plan lacked any documentation of contracture to the hand and interventions. On 3/26/2026 at 9:40 AM, the Director of Nursing reported the contracture should have been on the care plan.

Based on record review, staff interview, and policy review the facility failed to create and implement upon admission a Baseline Care Plan for 1 of 6 residents reviewed (Resident #11). The facility also failed to implement Baseline Care Plans that included goals residents wanted to archive while living at the facility, significant diagnoses, and symptoms to monitor for, medications and significant medication side effects to monitor, and signatures that the resident and/or Power of Attorney (POA) were aware and agreed for 5 of 6 residents reviewed. The facility reported a census of 27 residents. Findings include: 48452 1. The MDS (Minimum Data Set) for Resident #11 dated 1/16/25, with an admitted [DATE], indicated the resident had diagnoses of coronary artery disease, renal failure, and depression. The orders tab of the resident's electronic health record (EHR) revealed the resident took Escitalopram (depression), Acetaminophen (pain), and Hydrocodone (pain). A Progress Note on 10/15/24 documented the resident also took Methocarbamol (muscle spasms) and Tramadol (pain) when he was admitted , for pain in his hips. During an interview with the Director of Nursing on 03/27/25 at 11:21 AM she reported she didn't know where to locate the Baseline Care Plan for Resident #11. It was not located in the resident's paper chart or in the electronic health record. 2. The EHR for Resident #126 included an admission record with an initial admitted [DATE]. It documented diagnoses of pulmonary fibrosis (scarring/thickening of lung tissue), chronic systolic heart failure (left ventricle weakens and can't pump blood effectively), and type 2 diabetes mellitus. The orders tab of the EHR included Acetaminophen (pain), Eliquis (anticoagulant), Lorazepam (anxiety), Citalopram (depression), and Lasix (diuretic). The Baseline Care Plan for Resident #126 did not include goals based on admission orders and the goals of the resident; a summary of medications and diagnoses; pain goals or interventions; mental health diagnoses, medications, or side effects; diabetic management; or monitoring for diuretic and anticoagulant symptoms and side effects. 3. The EHR for Resident #127 included an admission record with an initial admitted [DATE]. It included diagnoses of acute respiratory failure with hypoxia (lungs fail to deliver enough oxygen to the blood), major depressive disorder, anxiety disorder, and repeated falls. The orders tab of the EHR included Metformin (high blood sugar), Acetaminophen (pain), Gabapentin (pain), Hydrocodone (pain), Methenamine (UTI prevention), Lispro and Lantus (insulin), and Warfarin (anticoagulant). Progress Notes for Resident #127 documented falls 3/20/25 at 1:35 AM, 3/23/25 at 2:35 AM, and 3/26/25 at 3:15 AM. The Baseline Care Plan for Resident #127 did not include fall history, goals, or interventions; goals based on admission orders; resident goals; a summary of medications and diagnoses; pain goals, medications, or interventions; mental health diagnoses, medications, or side effects; diabetic and insulin management; discharge planning; or monitoring for anticoagulant symptoms and side effects. An interview with Resident #127 on 03/25/25 at 09:24 AM determined she hoped to go home. She did not think staff provided her with a copy of her Baseline Care Plan. 4. The EHR for Resident #128 included an admitted [DATE]. Their diagnoses included dementia, peripheral vascular disease, and transient cerebral ischemic attack (temporary interruption of blood flow to the brain). On 03/24/25 at 12:41 PM the surveyor observed a certified nurses aide (CNA) walk to a dining room table with the resident. The resident did not have a gait belt on. Another CNA came over to put one on her and explained that she needed it for safety. The first CNA said it wasn't on the resident's Care Plan or you better believe it would have been on her. The Baseline Care Plan for Resident #128 included a sentence that indicated the resident was up with one assist and her walker. It did not address the need for a gait belt; goals based on admission orders and resident goals; a summary of medications; pain goals or interventions; or monitoring for anticoagulant symptoms and side effects. 5. The Minimum Data Set (MDS) for Resident #12 documented diagnoses of fracture, anxiety, depression, and hypertension. The orders tab included Cyclobenzaprine (muscle relaxant), Acetaminophen (pain), Protriptyline (depression), and Lorazepam (anxiety). On 03/24/25 at 12:02 PM the surveyor observed the resident folded over in her wheelchair, head down on the table. The resident was not easily redirected by staff. The Baseline Care Plan for Resident #12 did not include mental health diagnoses, medications, behaviors, or side effects; goals based on admission orders and the goals of the resident; range of motion interventions; a summary of medications and diagnoses; or pain goals, medications, and interventions. During an interview on 03/25/25 at 11:14 AM Staff B, CNA stated Resident #12 had been there about 2 months. Since admission she had refused to talk or work with some staff. When asked about folding herself in her chair, Staff B stated she did that to avoid things. She thought the resident was using it as a coping mechanism, something she could control when she felt anxious. On 03/25/25 at 12:51 PM the DON corroborated Staff B's statement and added that family had reported a history of depression, possible PTSD, and electroshock therapy. Later that day, at 03:06 PM, the DON provided Baseline Care Plans for residents that consisted of a single sheet of paper. She confirmed they were the Baseline Care Plan for a resident until the Comprehensive Care Plan was completed, and stated they had until 7 days after the MDS was completed to finish them for a total of 21 days. She acknowledged the documents provided did not include diagnoses, medications, mental health information, behavior concerns, code status, signatures, involvement of the interdisciplinary team, or confirmation a copy had been given to the resident or responsible party. During a follow up interview on 03/27/25 at 11:21 AM the DON showed the surveyor a form the facility used to use for Baseline Care Plans that included most of the items missed on the current documents. She stated she didn't know why they stopped using them and thought they could start using them again. An undated facility policy titled Care Planning - Interdisciplinary Team documented baseline care plans would be posted at admission in the nurse's station until the comprehensive care plan was completed. The resident, resident's family, and/or the resident's legal representative were encouraged to participate in the development and revisions to the resident's care plan. The care planning/interdisciplinary team included the physician, registered nurse, dietary manager/dietician, social services, therapists, consultants, DON, charge nurse, nursing assistants, and others as appropriate to meet the needs of the resident.

Based on record review and staff interview the facility failed to provide Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123 at least two days before the end of a Medicare covered Part A stay for 1 of 3 residents reviewed (Resident #9). The facility reported a census of 27 residents. Findings include: Record review of Resident #9 NOMNC instructed her services would end on 10/28/2024, the form lacked documentation of family notification until it was signed on 10/30/24 indicating at least two days of notice was not provided. During an interview with the Administrator on 3/26/25 at 2:04 PM revealed there is no documentation of family notification for Resident #9 she can find prior to the 10/30/24 date. During an interview on 3/27/25 at 11:38 AM with the Director of Nursing (DON) revealed she knows she talked to Resident #9 family but did not document it anywhere.

Based on record review, facility admission paperwork, Bed Hold records, Progress Notes, and staff interview the facility failed to notify a resident and their representative of the cost to hold their bed when the resident was transferred out of the facility for 1 of 1 residents reviewed for hospitalization (Resident #11). The facility reported a census of 27 residents. Findings include: The Minimum Data Set (MDS) for Resident #11 dated 01/16/25 included diagnoses of congestive heart failure, depression, and kidney disease and documented an admission date of 10/14/24. A document titled admission Agreement, signed by Resident #11's representative on 10/14/24, indicated that a resident temporarily absent from the facility for any reason would be charged the current base rate and for additional services. This was listed as $318 per day. A section titled Temporary Absences documented the facility shall provide written information to the resident specifying the duration of the bed hold and the facility's policies. The facility would then ask if the resident wanted to hold the bed. The facility provided Bed Hold documents for Resident #11 dated 11/6/24, 11/7/24, and 12/13/24. The documents indicated that, prior to transfer, the nurse needed to enter the date the current daily rate charge would start. The top of the form included documentation that requested the hospital give the form to the family or legal representative, and directed the family or legal representative to review the form, sign it, date it, and return to the facility. The Bed Hold forms dated 11/6/24 and 11/7/24 indicated a family representative gave verbal permission to hold the bed, documented the resident was at the facility using Medicare funding, and noted this insurance would not pay for Bed Hold days. The forms indicated the rate was listed at the bottom of the form. Neither document included the rate for the Bed Hold or indicated that the resident was notified of the policy. The Bed Hold form dated 12/13/24 documented the resident paid privately and that the current daily rate would be charged from the first day of absence until the date specified in writing or via the telephone. Staff indicated the resident gave verbal permission to hold the bed. The document did not include that the family representative was notified of the policy or provide the rate for holding the bed. Progress Notes dated 11/6/24 and 11/7/24 did not include information regarding Bed Hold policy or rates. Progress Note dated 12/13/24 documented resident wanted to hold the bed and did not include information regarding the Bed Hold policy or rate. A document titled Room Rate Schedule, effective 01/01/25 listed the daily room rates as semi-private, $312; private, $326; and super single private, $343. It did not include the rate on the admission Agreement. During an interview with the Administrator on 3/26/25 at 4:41 PM, she indicated they did not send the written Bed Hold notices to the resident representatives who gave verbal consent or provide a copy to the resident. She confirmed the daily rate was not provided a the time of transfer. At a second interview 03/27/25 at 09:08 AM the Administrator acknowledged the rate for the bed hold was not included on any forms sent to the hospital. She was not able to confirm a copy of the Bed Hold form was provided to the resident or family at the time of transfer. On 03/27/25 at 11:06 AM Staff A, Licensed Practical Nurse (LPN) stated the nurse who sent a resident to the hospital completed the Bed Hold form. She did not send the form to the hospital or the resident representative. She put it in the file for the Director of Nursing (DON). During an interview with the DON on 03/27/25 at 11:21 AM she stated if she was in the building she would complete the Bed Hold form, or the nurse sending the resident to the hospital would. She reported there was a time they sent the forms to the hospital but they didn't get them back so they stopped. They did not send them to the resident's responsible party.

Based on record review and staff interviews the facility failed to accurately code 1 of 2 residents Preadmission Screening and Resident Review (PASRR) on their annual Minimum Data Set (MDS) (Resident #1). The facility reported a census of 27 residents. Findings include: The MDS for Resident #1 dated 6/13/2024 documented he was not considered by the state as needing a Level II PASRR. Record review of Resident #1 PASRR dated 6/13/21 documented he required a Level II PASRR. During an interview with the Director of Nursing (DON) on 3/27/25 at 11:36 AM revealed she is not sure why she coded Resident #1 6/13/24 PASRR inaccurately she is aware he required a PASRR level II.

Based on observation, record review, staff interviews, and written education review, the facility failed to provide services that met professional standards regarding medication administration for 1 of 1 residents observed for insulin administration (Resident #5). The facility reported a census of 28 residents. Findings include: During the Medication Pass Task, an observation on 5/7/24 at 8:15 AM revealed Staff A, Licensed Practical Nurse (LPN) administered Resident #5's insulin. Staff A, LPN obtained a Humalog (insulin) flex pen from the medication cart, put a needle on the tip of the pen, primed the pen with 2 units then dialed up to 10 units and proceeded to administer the insulin. Staff A, LPN failed to keep the needle under the skin for a full count of 10 to ensure the full dose was injected before removing. During the same observation, Staff A, LPN obtained a Lantus (insulin) flex pen from the medication cart, put a needle on the tip of the pen, primed the pen with 2 units then dialed up to 20 units and proceeded to administer the insulin. Staff A, LPN failed to keep the needle under the skin for a full count of 10 to make sure the full dose was injected before removing. In an interview following the insulin injections on 5/7/24 at 8:15 AM, Staff A, LPN stated she was not aware of a need to leave the needle under the skin for several seconds after injecting but stated she would check on it with administration and report back. In an interview on 5/7/24 at 9:59 AM, Staff A, LPN stated she had checked and learned that she was to leave the needle injected under the skin for the count of 10 prior to removing the needle. She stated she had just learned this but would implement the practice from here on out. In an interview on 5/7/24 at 3:39 PM, the Director of Nursing (DON), stated it was the expectation the licensed staff ensure the insulin pen needle be left under the skin after injecting insulin from a flex pen for the full count of 10 before removing the needle from the skin to ensure all the insulin is administered. A facility provided care giver education titled How to Use an Insulin Pen stated after pushing the injection button down firmly to inject the insulin, count to 10 then pull the needle straight out of the skin.

Based on observations, interviews, and record review, the facility failed to obtain parameters for oxygen administration for 1 of 1 resident reviewed with oxygen (Resident #2). The facility reported a census of 28 residents. Findings include: On 5/6/24 at 1:58 p.m., Resident #2 was laying in his bed. He had oxygen on per nasal canula at 1 1/2 liters. His respirations were non-labored. On 5/8/24 at 9:57 a.m., Resident #2 was sitting in the common area. Respirations were non-labored. He was not receiving oxygen. A Doctor's Order dated 5/2/24, documented oxygen as needed for comfort. A Treatment Administration Record for May 2024, documented that this resident received oxygen on 5/3/24 and 5/7/24. It did not specify the liter flow. It lacked documentation of the oxygen he received on 5/6/24. On 5/8/24 at 3:03 p.m., the Director of Nursing (DON), stated that this resident's oxygen order should specify the liter flow. She verified it did not. She stated she would call the provider to see what her order was to be. When told the only criteria for when to apply oxygen was for comfort, no pulse oximetry checks (non-invasive test that measures oxygenation level in the blood) and that Resident #2 was receiving oxygen on 5/6/24 but this was not documented on the Treatment Administration Record, the DON acknowledged the concerns. On 5/9/24 at 8:45 a.m., the DON stated she talked with the provider who ordered the oxygen. The DON stated the provider thought this resident was actively dying at the time she wrote the order. The DON stated that the provider said she would be sure to clarify all oxygen orders in the future. An undated Oxygen Administration by Oxygen Concentrator policy, directed staff to administer oxygen to residents when insufficient oxygen is being carried by the blood to the tissues. The facility will administer oxygen to residents when prescribed by a physician to accomplish the following objectives: to relieve hypoxemia (oxygen tension in arterial blood below normal), to relieve hypoxia (insufficient amount of oxygen available to supply the body need), relieve congestion and respiratory distress, to relieve pain and discomfort, and to normalize rate, rhythm, depth, and quality of respirations.

Based on interview and record review, the facility failed to issue the bed hold policy to 2 out of 2 residents reviewed for recent hospitalization s (Resident #9 and Resident #21). The facility reported a census of 28 residents. Findings include: A Census Page for Resident #9, documented that Resident #9 had Hospital Paid Leave that started on 10/28/23. It documented that Resident #9 returned to the facility on [DATE]. A Census Page for Resident #21, documented that Resident #21 had Hospital Paid Leave on 7/13/23. It documented that Resident returned to the facility on [DATE]. On 5/7/24 at 12:19 p.m., the Assistant Director of Nursing (ADON), stated the facility did not issue the bed hold policy for Resident #9 or Resident #21 for their most recent hospitalization stays. A Bed Hold Prior To Transfer policy dated 1/2017, directed staff that prior to transferring a resident to the hospital, the facility will provide written information to the resident and/or resident representative regarding bed hold. The facility will provide to the resident or resident representative, written notice at the time of transfer to hospital Bed Hold information which specifies the duration of the Bed Hold.

Based on Record review and staff interview, the facility failed to issue Center for Medicare and Medicaid (CMS) form Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) 10055 for 2 of 3 residents (Resident #1 and #19) reviewed. The facility reported a census of 25. Findings include: As part of the survey process, surveyor asked for CMS form 10055 for 2 residents discharged from skilled services in the last 6 months. The facility was unable to provide the forms. During an interview on 1/18/23 at 11:49 AM the Administrator stated they did not have the forms. She stated we have looked and we do not have them, they are not there.

Based on clinical record review, observation and staff interviews, the facility failed to provide appropriate supervision, training, safety and follow the facility policy and manufacturer's instructions for use of a standing lift for 2 of 3 residents sampled, (Resident's #1 and #2). The facility identified a census of 26 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #1 dated 1/06/22 showed a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive loss. The Resident required extensive assistance of two staff for transfers and toileting; extensive assistance of one staff for dressing and personal hygiene. The MDS listed a diagnosis of unspecified dementia without behavioral disturbance, hypertension, diabetes mellitus, Non-Alzheimer ' s Dementia, [CONDITION(S)], spinal stenosis, foot drop; unspecified foot, and stiffness of the left hand, not elsewhere specified. A Morse Fall Scale dated 1/06/22 documented a score of 30. The Morse Fall Scale scoring system is as follows: 1.High Risk 45 and higher 2.Moderate Risk 25-44 3.Low Risk 0-24 The Care Plan with goal revision 1/15/22 documented Resident #1 required some increased assistance with activities of daily living (ADL's) related to generalized weakness in the upper and lower extremities. The Care Plan with a revised intervention on 6/10/21 directed the staff to use the standing lift with assist of two for all transfers. Hoyer (lift)as needed. An Event Report for Resident #1, completed by Staff A, Registered Nurse (RN) on 2/22/22 at 7:00 p.m. documented a witnessed fall/slip that occurred on second shift resulting in a fracture of the right leg. Resident #1 recorded vital signs temperature 97.8 degrees, pulse 69 beats per minute, respirations 20 breaths per minute and blood pressure 166/66. The Event Report documented the Provider had been notified 2/22/22 at 9:00 p.m. and the family had been notified of the incident 2/22/22 at 7:15 p.m. A Fall Scene Investigation Report dated 2/22/22 at 6:45 p.m. completed by Staff C on 2/22/22 at 9:00 p.m. documented the incident as an equipment malfunction, specifically the straps on the left (side of the lift) came off. The Resident had a fall to the floor in her room during a staff assisted transfer to her bed that had been witnessed by Staff A, Certified Nursing Assistant (C.N.A). The Fall Scene Investigation Report documented the Resident had been assisted per the care plan. The Fall Scene Investigation Report further documented Resident #1 did not exhibit any confusion, she was happy, transferring fine, standing well and following directions. The Fall Scene Investigation Report specified the root cause of the fall as the amount of assistance in effect and assistive/protective device. Staff C documented the root cause of the fall as the assistive device letting the straps loose and not having a second person to assist (with the transfer). An Emergency Department Report, dated 2/22/22 at 8:29 p.m. documented Resident #1 with a history of hypertension, diabetes mellitus, [CONDITION(S)], dementia presented to the emergency department for evaluation of right leg pain after staff reported they were getting the resident up with an easy stand and one of the straps dislodged which caused the knee to twist and bend and patient was then eased to the floor by staff. The Active Problem list included a diagnosis of tibial fracture 2/22/22. The Review of Systems for Musculoskeletal documented tenderness from the right hip down to the knee and right ankle. The final results of the x-ray for the tibia fibula (lower leg), impression, spiral fractures within the proximal fibular shaft and distal tibial shaft. Diffuse soft tissue swelling is seen throughout the calf surrounding the fibular and tibial fractures. Soft tissue swelling is also seen overlying the lateral malleolus (ankle bone). The Resident was provided with pain management and a long leg splint applied. admitted to the hospital for further workup and referral to an orthopedic surgeon. A Hospitalist History and Physical (H+P) date of service 2/22/22 at 10:16 p.m. documented a chief complaint of right shin pain after the twisting of her right leg. The H+P further documented the resident developed excruciating pain in her right lower leg after this episode. A right tibia and fibula x-ray showed a spiral fracture within the proximal fibular shaft and the distal tibial shaft. The Resident was given 25 micrograms (mcg) of intravenous [MEDICATION(S)] for pain. The assessment documented the right lower leg as tender to touch. Passive and active range of motion is painful. A handwritten statement, untitled, undated and unsigned documented the following: she (the resident) had either both legs or just her right give out, which caused the left strap of the standing lift to fall off. She (Staff A) was unsure of why it got loose because she had double-checked everything to make sure it was on tight and correct. Resident #1 kept holding her right hand on the stand as she was trying to lift her on either the bed or chair, both a foot away, but couldn't, so she made her (the resident) let go and lowered her to the ground. Resident #1 complained of her right leg hurting after and that was it. Staff A immediately called the nurse and put a pillow under her head. A Resident #1 2.22.22 titled document, unsigned, provided by the facility documented at approximately 7:00 p.m. on 2/22/22 Staff A, C.N.A., called Staff C to Resident #1's room. Upon entering the room, Staff C noted the resident laying on her right side with her feet on the sit to stand lift. Upon initial assessment, Resident #1's right leg appeared to be bent and rotated. Staff A informed Staff C the Resident did not hit her head. The resident lay in the same position and an ambulance was called. The Resident had been given a pillow and blanket for comfort as she lay on the floor. The Resident transferred to the hospital via ambulance at 7:15 p.m. and admitted to the hospital for a right leg spiral fracture within the proximal fibular shaft and distal tibial shaft. Staff A stated she had hooked the Resident up in the sit to stand lift and the Resident had been standing well. She changed her from the back and then somehow the left sling strap came off the knobs that the sling attaches to on the sit to stand lift. Resident #1 still had her right hand on the sit to stand (lift) and Staff A lowered her to the floor. The Document documented Staff A had been suspended from duty pending the investigation and transfer education for all nursing staff would be initiated. A Document signed by the DON on 2/23/22 documented she had completed a visual inspection of the standing lift on 2/23/22 and it appeared to be in good working order. She consulted maintenance and he stated that he continues to do monthly checks and they have been completed for February (2022). He had a checklist that he uses during the checks and maintenance would continue to the monthly checks. A Risk Management Statement/Interview Documentation Form completed by Staff A on 2/23/22 at 2:15 p.m. documented the following statement of events: Staff A had been putting Resident #1 to bed alone in her room. She had the standing lift hooked up correctly with the loops attached on two knobs secured tight and the middle strap attached and pulled tight. The Resident's feet and knees were aligned with the machine and correct. She had just lifted the resident to the appropriate height for her and locked the brakes (on the lift) and was standing behind the Resident. She had just taken off the Resident's brief and set it in the trash can behind her without leaving the resident. Staff A was not sure what happened, but it seemed like the Resident's right leg or both legs gave out and she started to fall. The left strap came unhooked from the machine. It happened so fast so she tried to keep the Resident up and transfer her to the bed, one foot away, but was unsuccessful. The middle strap got tucked under the Resident's chin, so Staff A unhooked it. The Resident had still been holding on the right side of the machine so she lowered the Resident to the ground and called another aide and the nurse. An undated, untimed, statement written by Staff B, C.N.A., documented Staff A had called her on the walkie to come to Resident #1's room very fast. Staff B ran out of the breakroom to the Resident's room. She saw Staff A standing over the Resident laying on the floor on her side. Staff B told Staff A to put a pillow over her head. Staff A called for the nurse. Staff B decided to just run and get the nurse so he would come faster in case he didn't hear the call. A Risk Management Statement/Interview Documentation Form completed by Staff C on 2/22/22, untimed, documented the following statement of events: Staff C had been called to Resident #1's room on the radio just before 7:00 p.m. As he walked down the hallway with the vital signs cart he saw Staff B come out of the room toward him stating, Resident #1 fell from the standing lift. Staff C asked Staff B to get a hoyer lift sling as he continued down the hall. Upon entering the room, the Resident was laying on the floor on her left side with a pillow under her head. Both feet had gripper socks on and were still on the standing lift platform. Staff C asked the Resident if she was ok and she replied, yes, but my leg really hurts. The resident described the pain as a 7-8 (on 1-10 scale). The Resident denied hitting her head. Resident #1 stated she had not been sure, she was kind of standing there, then started to fall, now she was here (floor). Staff C's initial assessment of the Resident's right foot was rotated externally and misaligned. He instructed the Resident not to move her legs. An Untitled, undated, untimed Document, signed by the Director of Nursing (DON), documented an investigation had been initiated on 2/22/22 at approximately 7:45 p.m. She spoke with Staff A who had assisted Resident #1. Staff A verbally explained the event in detail according to her statement. The DON had Staff A facetime her and show her exactly how the transfer went. There had not been a second C.N.A. during the transfer per the facility policy and resident plan of care. The sit to stand machines and slings were inspected on 2/23/22 and found to be in good working order. Skill checks started on 2/23/22 with employees for hoyer and sit to stand transfers with information reviewed with agency staff as coming on duty. Results of the investigation resulted from Staff A making a choice to transfer the resident by herself using the sit to stand machine and not follow the facility policy and procedure. Staff A stated she knew that she should have had another C.N.A. with her to transfer and made a poor choice to hurry the process. On 8/25/22 a review of Staff A's Temporary Nurse Aide Skills Competency Checklist had all skills typed into specific categories with a completion date of 6/03/20. On page 2 of the Competency Checklist Hoyer and Standing Lift were hand written in with the date 6/5/20 for skill completion. On 8/25/22 at approximately 3:00 p.m. the DON reported it had been a bad situation all the way around. She stated Staff A made a bad decision to not follow the facility policy to use two staff when using the lift and she knew better. She even admitted that she had made a bad decision and had not followed the policy and knew better. She would have expected her to follow the facility policy and use two people when using the standing lift for safety. The DON provided the Surveyor a Self-Identification and Correction Form. The Form documented the facility had taken the following action steps to correct the problem and determined the correction was completed on 2/25/22: 1. Addition to the pocket care plan for lifts 2. Staff/Agency education and skill check. 3. Employee no longer employed due to not following facility policy and procedure. A review completed on 8/29/22 of the facility C.N.A. Standing Lift and Hoyer lift Education revealed Staff Q, O, R, B and S completed their educational competency on 2/23/22. Staff T completed the education/competency on 3/3/22. Staff T had documentation on her Skill checklist which included to remind to double check the (sling) loops. A review of the current Employee Phone List, dated 6/20/22, provided by the facility, documented C.N.A.'s and Certified Medication Aides, Staff F, G, I, J, K and L as current employees. A review on 8/29/22 of the Mechanical Lift Sling Checklists, provided by the facility, documented the hoyer and standing lift slings inspections started monthly on 2/23/22 by the DON. During an interview on 8/29/22 at 9:51 a.m. the DON reported she did not realize until now that the C.N.A. Orientation Checklist did not specifically have the standing lift and hoyer lift skills listed. She reported she has now added the standing and hoyer lifts requiring assistance of two (staff) and to make sure to double check loop (placement) to the C.N.A. checklist. She stated it is expected as part of the daily nurse/C.N.A. shift report that each C.NA., including agency staff take a copy of the pocket care plan which lists each resident transfer assistance level. The pocket care plan documented the residents using mechanical lifts and specified two staff for transfer assistance. In bold printed at the top of the form documented all hoyer and sit to stand machine transfers assist of 2 and cover arms and legs to prevent injury! She reported she had checked and did not have any standing lift or hoyer lift training documentation for Staff F, G, I, J, K or L. She reported she had not been doing any lift audits prior to Resident #1's incident (2/22/22) as there had not been any need to but realizes she probably should have been doing audits. The DON verified she did not have any lift slings inspection documentation prior to 2/23/22. During an interview on 8/29/22 at 11:53 a.m. Staff A reported she no longer works at the facility. She had been hired as a temporary nursing assistant and then tested and became certified while still an employee at the facility. She did recall the incident with Resident #1. The Resident had been a standing lift assist of two for transfers. Staff A reported she didn't recall if she had been actually shown how to operate the lift by nursing management, but she got a briefing on it from some of the other C.N.A.'s that worked the floor there. That night there were 2 -3 other C.N.A's on shift, but they were all busy. The incident happened sometime between 7:00 - 8:00 p.m. Resident #1 wanted to go to bed and was crying. She used her walkie talkie and called out for help several times. She waited 15-20 minutes and no one came to help her. She had been told by other C.N.A's that they transfer Resident #1 in the lift by themselves from time to time. She hooked her up in the lift and made sure everything was correct. It seemed like the resident's left leg gave out when she stood her up in the lift, then the sling came off the Resident's left side. She did the best she could to try to lower her to the floor. The Resident's feet stayed on the footplate of the lift and she twisted when she fell to the floor. She called out for help on her walkie talkie several times. No one came so she put a pillow under her head and covered her up. She went and found the nurse and came right back. She stated she always double checks to be sure the loops are on right so she doesn't understand how it happened. She had it happen before where the loops were not on the attachment points of the lift but had always caught it and secured the straps before transfer. It happened 1 or 2 times before, but she had noticed it and corrected the loops so she never reported it to the DON. She didn't know it should be reported. Resident #1 was complaining of her right leg hurting. She reported the incident had been her fault. She should have waited and gotten a second person. She had seen other people use the lift by themselves, but she shouldn't have done that. Some agency staff used the lift by themselves, but she couldn't remember any specific names. She reported Resident #1 had been the last resident that she assisted. She finished her charting, then reported to the DON. She stayed in the facility for the last 30-40 minutes of her shift. During an interview on 8/29/22 at 12:19 p.m. Staff B, C.N.A. reported she recalled the evening that Resident #1 fell . She had been in the break room when Staff A called her on the walkie talkie to come to Resident #1's room right now. When she walked in Resident #1's room the Resident lay on her side on the floor. She had fallen off of the standing lift. Staff A stated she had transferred Resident #1 by herself and the resident fell out of the lift. Staff A asked Staff B to cover for her and say that she had been in the room helping her transfer Resident #1. Staff B stated Staff A begged her to cover for her but she refused. Staff B then reported Staff A asked her to help transfer the Resident into bed as if nothing had happened. Staff B stated she refused as she could clearly see the bone sticking out of Resident #1's leg. Her leg was broken. Staff B couldn't recall which side the resident had been laying on when she entered the room or which leg had been injured. She put a pillow under the Resident's head and covered her with a blanket and went to get the nurse. Staff B reported she contacted the DON right after she contacted the nurse. She informed the DON that Staff A had transferred the resident in the lift alone and tried to get her to cover it up. During a follow-up telephone interview on 8/29/22 at 1:58 p.m. Staff A reported she had been standing behind the resident as she had removed her brief to provide peri-cares when the left side of the standing sling came off the lift. The Resident still had the sling attached around her waist and had her right hand holding onto the lift. She slid down in the standing lift sling and the waist belt of the sling was below her chin. The resident's knees twisted but it happened so fast she didn't know which direction her knees went. She tried to put her knee under the resident to support her in the lift but couldn't. She didn't like the way the sling had gone up under her chin so she undid the buckle and tried to shift her over to the bed or the chair but couldn't so had to lower her to the floor, but she couldn't recall which side she lowered her to. During an interview on 8/29/22 2:23 p.m. Staff C reported he hadn't been in the room when it happened. He thought it had been Staff B that came up and told him that Staff A needed help in Resident #1's room as the Resident had fallen from the standing lift. When he entered the room Resident #1 lay on the floor toward her left side, but still slightly on her back. Her right foot lay positioned on the base of the standing lift and her left foot lay on the floor with her toes slightly under the base of the lift. Resident #1's left side of her sling had come unhooked from the lift. He could tell immediately that her right leg had rotation; was not aligned and had broken. He took her vital signs and instructed the staff not to move her. He called the ambulance so they could come splint her right leg before moving her. She screamed out in a lot of pain when they moved the lift. Her right foot laid on the foot rest up on the lift. Staff A said she had been transferring the Resident to bed, but the strap just popped off and the resident started to go to the side and she got behind her and had to take her to the floor. From his perspective the Resident went down on her left side her right foot to catch on the base of the lift, her body rotated and her foot did not causing the spiral injury. During an interview on 8/29/22 at 1:07 p.m. Staff O C.N.A. stated the facility policy is to use two staff for any type of standing lift transfer. She reported she had never seen any staff use the standing lift by themselves. During an interview on 8/29/22 at 1:47 p.m. Staff I and P, C.N.A.'s reported it has always been the policy since they have been at the facility that two staff are required for any type of mechanical lift transfers. Staff I and P had not seen or heard of other staff using the standing lifts alone. During an interview 8/29/22 at 3:13 p.m. with Staff M, Licensed Practical Nurse (LPN) reported ever since she has worked at the facility, the facility has required two staff assist with mechanical lifts. During an interview on 8/29/22 at 3:15 p.m. the DON reported regarding the incident Staff A could have potentially placed the sling loop wrong, she doesn't know and wasn't in the room to know that. However, if Staff A would have followed the facility policy to have a second staff person with her, that staff person may have seen something if the sling had not been attached right or may have been able to assist to lower the resident to the floor to prevent injury possibly. She would have expected Staff A to follow the facility policy and have two staff assist with the standing lift transfer. She reported she had looked for standing lift audit information prior to the 2/22/22 incident and could not find where any audits or recent training on the standing lift had been done. 2. The MDS Assessment for Resident #2 dated 6/23/22 showed a BIMS score of 99 with documented short/long term memory impairment with moderately impaired decision- making ability. The Resident required extensive assistance of two staff with transfer. The MDS listed a diagnosis of vascular dementia without behavioral disturbance, hypertension, Non-Alzheimer's Dementia, anxiety, depression and [CONDITION(S)]. The Care Plan, target date 10/02/22, documented the Resident required staff assistance to complete her activities of daily living (ADL's) related to her dementia, impaired mobility and weakness. The undated Care Plan intervention directed the staff to use the standing lift with assistance of two staff for all transfers. During an observation on 8/25/22 at 2:05 p.m. Staff D, C.N.A. placed a gray with green border standing lift sling behind Resident #2's back. Staff D placed the sling loop on the Resident's right side over the top of the attachment point of the lift arm, failing to secure or double check the sling loop seated into the attachment point. The sling loop on the Resident's left side seated properly into the attachment point on the lift arm. Staff E, C.N.A. locked the rear [NAME] wheels on the standing lift and utilized the lift control to start to stand the resident. As Resident #2 came up off the wheelchair seat the right-side sling loop popped securely into the attachment point base on the lift arm of the standing lift. Staff E unlocked the rear [NAME] wheels and widened the lift base legs. After completing peri-cares, Staff D and E transferred the resident into the recliner with the standing lift. Staff D and E failed to double check the sling loops were secured to the standing lift attachment points prior to operating the hand control to start the transfer. During an interview on 8/25/22 at 2:11 p.m. Staff D reported the green sling loop on the Resident's right side had not been fully placed onto the knob. She reported she heard the pop as the resident started to come out of the wheelchair. She should have double checked to be sure the lift sling loop had been placed correctly prior to starting the transfer. During an interview on 8/25/22 at 2:53 p.m. the DON reported the lift sling loop should have been fully around the hook on the standing lift prior to transfer. During an interview on 8/29/22 at 8:29 a.m. Staff N, Maintenance Assistant, reported he had been doing monthly maintenance checks on the standing lifts prior to the incident. He stated he had all the maintenance records in a book. He does the lift inspections and the DON completes the lift sling inspections. During an observation on 8/29/22 at 8:39 p.m. the Maintenance Assistant demonstrated the emergency stop on the Invacare Standing Lift that sat in Resident #2's bathroom. He stated the lift is their newer standing lift. He pulled up on the emergency stop at the base of the standing lift and the lift control failed to cease operation of the standing lift arm up and down. He continued to try to operate the emergency stop on the standing lift. The emergency stop failed to stop the lift from operation 3 out of 4 times during the demonstration. He reported there are rubber stoppers on the standing lifts that wear out. He stated he had contacted their supplier on 8/25/22 to check into getting more rubber stoppers for the lifts. The facility currently did not have any rubber stoppers in stock. He reported the emergency stop has to be pulled up really hard and held to stop the lift. Further observation revealed no emergency stop button on the lift hand controls. During an interview on 8/29/22 at 9:51 a.m. the DON reported she did not have any skills checklist regarding the standing lifts for Staff D and E. She had contacted agency staffing to see if they had any records of standing lift transfer education. She had been told, they do not do that type of training. That is taught in the C.N.A program. During an observation on 8/29/22 at approximately 9:55 a.m. the DON reported the Maintenance Assistant had not notified her of any issues regarding the standing lifts that day. The Surveyor notified the DON of the concerns with the standing lift in Resident #2's bathroom regarding the emergency stop demonstration by the Maintenance Assistant in failing to stop the operation of the lift. The DON reported they would take the lift out of use for safety. During an observation on 8/29/22 at 10:43 a.m. the standing lift remained in Resident #2's bathroom accessible for use. The Safely Using Mechanical Lifts Nursing Procedure, issue date 12/20/03, provided by the facility documented the following Policy: may utilize a mechanical lifts to enable staff to lift and move a resident safety, with as little effort as possible. The Procedure directed the following basic procedure: Nursing staff will follow the steps below when using mechanical lifts: 1.Assemble equipment (mechanical resident lift and sling). 2.Secure the assistance needed. Two persons required. 3.Wash hands. 4.Explain to the resident what you are going to do and how he/she can assist. Provide privacy. 5.Position chair next to the bed; if using a wheelchair, lock the brakes. 6.Slide the sling under the resident, by turning the resident from side to side. 7.Be sure all locks and straps are fastened securely and correctly and the base of lift is positioned correctly. 8.Explain to the resident what you will be doing. Have the resident fold arms across the chest and slowly raise the resident. 9.Have the assistant guide the resident's legs and lower the resident carefully into position in the chair. 10.Remove equipment and properly position and secure the resident in the chair. 11.Wash hands. 12.Report any unusual observations to the supervisor. The Invacare User Manual for the Stand-Up Patient Lift, model RPS350-s, page 18, section 4 Lifting the patient warnings included: 1. Do not exceed the maximum weight limitation of 350 pounds. Individuals that use the standing patient sling must be able to support the majority of their own weight, otherwise injury may occur. 2. Do not move the patient if the sling is not properly attached to the attachment points on the stand-up lift. Make sure that the sling is properly attached before lifting the patient. If any attachments are not properly in place, correct the problem. When the sling is elevated a few inches off the stationary surface and before moving the patient, check again to make sure the sling and all attachments are securely in place. If any problem is found, lower the patient back onto the stationary surface and correct the problem - otherwise, injury, or damage may occur. 3. Adjustments for safety and comfort should be made before moving the patient. 4. Invacare patient slings are made specifically for use with Invacare patient lifts. For the safety of the patient, do not intermix patient slings and patient lifts of different manufacturer's. 5. Standing slings - before lifting the patient, make sure the bottom edge of the standing sling is positioned on the lower back of the patient and the patient arms are outside the sling. 6. Transfer slings - before lifting the patient, make sure the bottom edge of the transfer sling is at the base of the spine and the patient's arms are outside of the sling. 7. Invacare does not recommend locking the rear casters of the stand-up lift when lifting and transferring the individual. Doing so could cause the lift to tip and endanger the patient and assistants. Invacare recommends that the rear casters be left unlocked during lifting and transferring procedures to allow the stand-up lift to stabilize itself when the patient is initially lifted from and transferred to a chair, bed or any stationary object. The User Manual documented the following procedure for lifting a patient: 1.Instruct the patient to hold onto the hand grips on both sides of the stand up lift. 2.Instruct the patient to lean back into the standing or transfer sling. 3.Ensure the following: a. The patient's knees are secure against the knee pad. b.The patient's feet are properly positioned on the foot plate. Slings: a. Standing slings - the bottom edge of the standing sling is positioned on the patient's lower back. b. Either sling style - the patient's arms are outside of the sling. c. The rear casters are unlocked. d. The legs are in the maximum open position. 4.If transferring from a wheelchair, lock the wheel locks on the wheelchair. 5. Press the Up arrow button on the hand control to raise the patient above the surface (bed, wheelchair or commode). The User Manual documented the following procedure for moving the patient: 1.Ensure the legs of the stand up lift are in the maximum open position. If not, press the open button on the hand control to open the legs to the maximum open position. 2.Move the stand-up lift away from the surface they were lift from. 3.Slowly move the patient to the desired surface. A review of the maintenance Safety Inspection Checklist for the Invacare standing lift identified a institutional inspection/adjust monthly should be performed. The lift arms and linkage is to be checked for the following: 1.Check all hardware and attachment points. 2.Inspect bolted joints of lift arms for wear. 3.Inspect to ensure that the lift arms are centered between the base legs. The Stand-up Patient Lift Manual, Section 7 Maintenance, Page 22, documented the following: slings used for institutional are to be checked each time it is used to ensure proper connection and patient safety. Inspect the sling material and straps for wear monthly. Detecting Wear and Damage: it is important to inspect all stressed parts, such as slings, lifting arm and any pivot for slings for signs of cracking, fraying, deformation or deterioration. Replace any defective parts IMMEDIATELY and ensure that the lift is not used until repairs are made.

Based on observation, policy review and staff interview, the facility failed to cover desserts served to all residents being served in their rooms. The facility reported a census of 28. Findings include: During an interview on 9/14/21 at 12:17 PM, the Food Service Supervisor (FSS) stated all residents were eating in their rooms at this time. During an observation of the meal trays being delivered to residents 9/14/21 at 12:17 PM, the cake noted to be in bowls covered with a plastic lid. The lid rested on top of the cake and did not cover the sides of the cake as it was being transported through the halls. During an observation of meal service on 9/15/21 at 11:38 AM, chocolate cream pie was placed on trays going out to residents being served in their room covered with plastic lids. The lids rested on top of the pie and did not cover the sides of the pie as it was being transported through the halls. During an observation on 9/20/21 at 12:15, noted multiple trays of dessert bowls with bars all covered with a lid. The lid rested on top of the bar and did not cover the bar as it was being transported through the halls. During an interview on 9/20/21 at 12:53 PM, Staff C, Certified Nursing Assistant (CNA) assisting a resident to eat in her room. Staff C stated both residents in that room received the bar for dessert. She stated the desert bowl was covered with the plastic lid. During an interview on 9/20/21 at 2:20 PM, the FSS stated the plastic lids are to cover the dessert and stated they didn't use plastic wrap because it would smash the dessert. She acknowledged the lid did not completely cover the dessert and stated she would look into other options. Review of the undated policy titled Meal Tray Service, documented all food items shall be covered. Review or the Long Term Care (LTC) Survey Pathway from the Centers for Medicare and Medicaid Services (CMS) website accessed on 9/20/21 at 1:46 PM, Federal Tag 812 states food is to be covered during transportation and distribution to residents.

Based on observation, family and staff interviews, the facility failed to ensure residents' dignity by failing to complete shaving 2 of 6 male residents observed (Residents #6 and #12). The facility reported a census of 28. Findings include: 1. During random observations of Resident #6, the following noted: a. On 9/14/21 at 2:03 PM, Resident #6 sitting in the living room area wearing a mask. Observation of the face and neck area around the mask showed the resident with unshaven facial hair. b. On 9/15/21 at 8:46 AM, the resident sitting in his room, fully dressed and finished with breakfast and not wearing a mask. Observation of the full face and neck area showed the resident with unshaven facial hair. c. On 9/16/21 at 10:38 AM, the resident sitting in his room fully dressed and finished with breakfast and not wearing a mask. Observation of the face and neck area around the mask showed the resident continued with unshaven facial hair. 2. During random observations of Resident #12, the following noted: a. On 9/14/21 at 2:10 PM, Resident #12 resting in bed and did not have a mask on. Observed the resident's full face and neck area with unshaven facial hair. b. On 9/15/21 at 8:47 AM, the resident sitting in his room, in his wheelchair fully dressed and not wearing a mask. Observation of the full face and neck area showed the resident with unshaven facial hair. c. On 9/16/21 at 10:39 AM, the resident sitting in his room, in his wheelchair fully dressed and not wearing a mask. Observation of the full face and neck showed the resident continued unshaven facial hair. During a family interview on 9/14/21 at 1:31 PM, the family member stated the resident does not get shaved as often as he should. The family member stated they often have to shave the resident when they visit. During an interview with the Director of Nursing (DON) on 9/20/21 at 10:31 AM, she stated she expects male residents to be shaved daily as part of Activities of Daily Living (ADL) cares.

Based on clinical record review, document review and staff interviews, the facility failed to ensure the code status matched in all locations for 1 of 16 residents reviewed (Resident #20). The facility reported a census of 28. Findings include: Review of Resident #20's Electronic Health Record (EHR) on [DATE], showed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's paper chart on [DATE], showed a document from a local Hospice provider for the resident stating no interventions will be made in the event of a cardiac or respiratory arrest. The document was signed by the resident's legally responsible party. A review of the Full Code List posted in the Nurses Station, showed the resident not on the list for residents wanting CPR in the event of cardio or pulmonary arrest. During an interview on [DATE] at 7:56 AM, Staff I, Registered Nurse (RN) stated he would first look in the resident's EHR for their code status, unless at the Nurse's Station, and then if at the Nurse's Station, would look at the Full Code List posted on the wall. During an interview on [DATE] at 8:05 AM, the Director of Nursing (DON) stated she expected the code status to match in the EHR, the paper documents in the resident's paper chart and the list on the wall in the Nurse's Station.

Based on clinical records review, policy review and staff interview, the facility failed to ensure accurate assessment of influenza and pneumococcal vaccination status on the Minimum Data Set (MDS) Assessment for 1 of 5 residents sampled (Resident #20). The facility identified a census of 28 residents. Findings include: The Admission Minimum Data Set (MDS) Assessment for Resident #20, dated 12/14/20, showed an entry date of 12/7/20 and a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive loss. The MDS listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS listed the influenza vaccination received outside of the facility and the pneumococcal vaccination offered and declined. The MDS documented the resident as not receiving Hospice services. A Hand Off Report from the hospital, dated 12/7/20, on page 3, under Immunizations, documented there is no immunization history on file for this patient. The MDS assessment dated [DATE] showed a BIMS score of 6 indicating a severe cognitive loss. The MDS listed a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS listed the influenza vaccination received outside of the facility and the pneumococcal vaccination offered and declined. The MDS documented the resident as not receiving Hospice care. A review of the electronic Immunization Record and Nurses' Notes dated 12/7/20 to 9/15/21 lacked documentation of influenza and pneumococcal vaccination status, as well as any family/medical power of attorney contact regarding immunizations. On 9/15/21 at 10:26 a.m. the Director of Nursing, (DON), reported she did not have vaccination information regarding the influenza and pneumococcal status for the resident. The DON stated the resident had been on Skilled Care and gone on and off Hospice care. It must have been missed when the resident came off of Hospice care. The DON reported she talked with a family member on 9/14/21 regarding vaccination status and the family member reported she had no information regarding immunizations and to check with the physician's office. The DON reported the facility checked with the physician office and as of 9/15/21 the physician office had no record that the resident had up to date immunizations for influenza or pneumococcal. The DON stated again, it must have been missed. During an interview on 9/20/21 at approximately 11:30 a.m. the DON reported she does work on the MDS records. She reported regarding Resident #20 she thought they had just asked the resident or family about his vaccination status and then coded the MDS. She stated they normally check the hospital records, check the physician office records and interview the resident or family regarding flu and pneumococcal vaccinations. The Influenza and Pneumococcal Vaccine Policy, revised 10/28/2019, provided by the facility documented during the flu season, October 1 through March 31st, with the guidance of the Medical Director the Home will educate and offer a flu vaccine to all residents. It will be documented in the resident's medical record if the vaccine is accepted or declined. The charge nurse will follow-up for any type of reaction. The Policy directed the pneumococcal vaccines are administered throughout the year. A vaccination history is obtained and if the vaccination history is unknown the resident may receive the vaccine. One re-vaccination is recommended in 5 years for persons with renal disease or if the resident is older than 65 and the first dose was given prior to age 65 and 5 years or more have lapsed. Information is sent out to the resident/family yearly if applicable or upon admission to educate and offer the pneumococcal and influenza vaccine. This will be documented in the immunization record if accepted or declined and follow-up will be completed. The Primary Care Physician/Hospice and resident family member/Medical Power of Attorney will be consulted for consent for residents that are near end of life or receiving hospice services for influenza and/or pneumococcal vaccines. The MDS Policy, revised 4/10/21, provided by the facility, directed the Home completes the MDS and Care Plans according to the directions outlined in the Resident Assessment Instrument (RAI). The Assessment Policy, dated 7/15/99, documented the Home will develop and maintain a comprehensive, accurate assessment of each resident's functional capacity. Under Comprehensive Assessment (MDS) the Policy directed no later than 14 days of the resident's admission, staff will complete a comprehensive assessment of the resident's needs, following guidelines established by the federal and stat regulatory agencies. All departments responsible for resident care (i.e. nursing, dietary, activities, and the Administrator) will conduct comprehensive assessments. The Comprehensive Assessment includes, but is not limited to: a. Medically defined conditions and prior medical history. b. Special treatments or procedures. c. Drug therapies. The Policy specified Certification that each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 October 2019, Chapter 3, page O-8 lists the following steps to assessment to code O-0250 Influenza vaccination: a. Review the resident's medical record to determine whether an influenza vaccine was received in the facility for this year's influenza vaccination season. If vaccination status is unknown, proceed to the next step. b. Ask the resident if he or she received an influenza vaccine outside of the facility for this year's influenza vaccination season. If vaccination status is still unknown, proceed to the next step. c. If the resident is unable to answer, then ask the same question of the responsible party/legal guardian and/or primary care physician. If influenza vaccination status is still unknown, proceed to the next step. d. If influenza vaccination status cannot be determined, administer the influenza vaccine to the resident according to standards of clinical practice. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 October 2019, Chapter 3, page O-11 lists the following steps to assessment to code O-0300 Pneumococcal vaccination: a. Review the resident's medical record to determine whether any pneumococcal vaccines have been received. If vaccination status is unknown, proceed to the next step. b. Ask the resident if he or she received any pneumococcal vaccines outside of the facility. If vaccination status is still unknown, proceed to the next step. c. If the resident is unable to answer, ask the same question of the responsible party/legal guardian and/or primary care physician. If vaccination status is still unknown, proceed to the next step. d. If pneumococcal vaccination status cannot be determined, administer the recommended vaccine(s) to the resident, according to the standards of clinical practice. If the resident has had a severe allergic reaction to a pneumococcal vaccine or its components, the vaccine should not be administered. If the resident has a moderate to severe acute illness, the vaccine should be administered after the illness. If the resident has a minor illness (e.g., a cold) check with the resident's physician before administering the vaccine.

Based on observation, clinical record review, document review and staff interviews, the facility failed to assess 1 of 3 residents (Resident #17) for bruises to the right calf and serve the physician ordered diet for 1 of 2 residents (Resident #17) sampled for nutritional services. The facility identified a census of 28 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment, dated 7/22/21, for Resident #17 showed a short/long-term memory impairment with severely impaired decision making. The resident required extensive assistance with bed mobility, transfer, dressing, eating, toileting, total staff assist with personal hygiene and received a mechanically altered diet. The MDS listed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident received 7 days of anticoagulant medication therapy. A Telephone Order, dated and signed by the Provider on 4/30/21, documented a order to provide higher calorie super cereal, add in peanut butter, and a larger serving of milk and juice at meals. A Change of Diet Slip, dated 4/30/21 provided by the Food Service Supervisor, documented the new diet order as a pureed diet with honey thick liquids, double protein, higher calorie with super cereal, add in peanut butter, and large serving of milk and juice at meals. The Dietary Card, undated, provided by the Food Service Supervisor, documented Resident #17 received a pureed diet, honey thicken liquids, 2 x protein. The Dietary Card listed the resident to receive juice and milk at breakfast, lunch and dinner. The Dietary card lacked direction to the staff of the ounces, milliliters, or serving size of the glasses to be provided for the milk and juice. A Diet Sheet, undated, provided to the surveyors on 9/14/21 listed Resident #17 diet with the date 4/30/21 as pureed, double portion protein, honey liquids, magic cup as a supplement, super cereal at breakfast and peanut butter. The Diet Sheet failed to list or direct Dietary Staff on the larger size of juice and milk at all meals. The Care Plan, with an intervention dated 4/22/21, directed the staff to provide a large serving of milk and/or juice at meals. The Nutritional Assessment, dated 7/22/21, completed by the Consulting Dietician, documented supplemental food as increased calorie super cereal at breakfast, large milk/juice at meals. The Nutritional Progress Note, dated 7/22/21, written by the Consulting Dietician documented the resident's diet as pureed, honey thick liquids, double protein, increased calorie, super cereal, large milk or juice at meals. A Medication Review Report, signed by the Provider on 8/5/21, documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 9/14/21 at 12:14 p.m. Resident #17 sat upright in the Geri Chair in the room being assisted with her fluids by Staff A, Certified Nursing Assistant, (CNA). Staff A assisted the resident with a 6 ounce (oz.)/180 milliliters (ml) of milk and juice on her lunch tray. During an observation on 9/15/21 at 8:36 a.m. Staff B, Certified Medication Assistant, (CMA) and Staff C, CNA, performed hand hygiene and provided morning cares for Resident #17. Staff B rolled the resident over onto her left side to complete peri-cares. The Surveyor noted bruises to the back of the right calf with turning. The right outer lateral calf had a 1.5 inch x 1.5 inch circular light brown bruising present. The posterior upper calf had an approximate 3 inch x 2.5 inch purple bruise present with a 1.5 inch by 1.5 inch yellow bruising to the lower posterior calf. Staff B and Staff C assisted the resident up to a seated position on the edge of the bed to set up for a standing lift transfer. The residents right calf slide along the bed frame as the resident sat back on the bed prior to the staff positioning the standing lift harness for transfer. Observation on 9/15/21 at 9:26 a.m. revealed Resident #17 sitting upright in the Geri Chair in room eating breakfast with assistance by Staff A. The resident ate cereal mixed with peanut butter, apple sauce and her protein. Staff A assisted the resident with a small 4 oz. (120 ml) glass of honey thickened juice. The resident also had a 6 oz (180 ml) glass of milk on the tray. No large glasses of milk of juice were noted on the breakfast tray. The resident ate 100% of the served food and fluids from the meal. The Surveyor observed the breakfast tray prior to removal from room. The Meal Intake Log for 9/15/21 documented the resident consumed 100% of food and 300 ml of fluids for the breakfast meal. During an interview on 9/15/21 at 12:45 p.m., the Director of Nursing, (DON), reported they did not have any skin tracking sheets on Resident #17. The DON stated she expected the CNA's to report if a resident has significant bruising so that the nurse can do an assessment. She reported the CNA's had not reported in any bruising and she had not been made aware of any bruising to Resident #17's right calf therefore no assessment of the right calf had been completed. On 9/15/21 at 12:55 p.m. the resident sat in the Geri Chair in her room assisted by Staff D, Activity Director. The resident had a divided plate of pureed open face pork sandwich, double portion, mash potatoes and squash. Staff D assisted the resident with a 6 oz. (180 ml) glass of milk and a 4 oz. (120 ml) glass of juice. During a interview on 9/15/21 at 1:40 p.m., Staff E, Cook, reported the facilities small glasses are 4 ounce (120 ml). The larger glasses are 6 ounce (180 ml) glasses. She stated they have a few larger glasses, but every time they put those out, the larger glasses seem to disappear so they don't use them. Staff E proceeded to the cupboard and pulled a large glass out of the cupboard. She took the larger glass and measured water from the glass. The large glass measured 12 ounces (360 ml's). She reported the largest glass they usually serve out is the 6 ounce (180 ml) glass. On 9/15/21 at 3:34 p.m. the Consulting Dietician stated her understanding of the fluids for Resident #17 is they were going to give at least a 8 ounce glass of juice and milk at meals. She believes Resident #17 should be given the larger cup when reviewed. The kitchen does have 12 ounce cups. She stated some residents prefer larger or smaller cups of drinks. She didn't have other information pertaining to that and if physician ordered, she would expect it to be given. She said she would be at the facility on 9/16/21. During an interview on 9/16/21 at 10:23 a.m. the Dietary Supervisor reported when they received the dietary order for the large milk and juice at meals, they went from serving the 4 oz. (120 ml) glasses to the 6 oz. (180 ml) glasses. She verified the Diet Sheet did not address the large milk and juice per the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Dietary Supervisor stated the Dietary Cards are on the prep table and are out for use. She reported she could not verify that the cards are used during meal service all the time, but the cards are available along with the Diet Sheet. She stated they have a board that they use to communicate resident diet needs. She check the board with the surveyor at 10:26 a.m. A white, dry erase board listed Resident #17 name with honey (thickened liquids) written behind her name. The dry erase board did not direct staff to serve out a large milk, juice or direct a size of drinks to be served at meals. She reported she had just ordered larger glasses. During an interview on 9/16/21 at 11:06 a.m. with the Registered and Licensed Consulting Dietician, stated the Dietary Card does not specify the actual size of fluids to be given at the meal. Currently their largest glass is the 6 oz. (180 ml) glass. The staff should be serving out the milk and the juice in the 6 oz. (180 ml) glass. She reported they don't want resident's filling up on fluids and not being able to eat their meal. She stated she would expect the staff to follow the physician ordered diet and going forward the Dietary Manager will be writing the actual glass size required on the resident's Diet Card. On 9/20/21 at 9:15 a.m., the DON reported she would expect the staff to follow the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The Skin Care Program Policy, dated 5/1/09, provided by the facility under Skin Documentation directed the following: CNA's will observe all skin during bathing, and on a daily basis with cares and report changes to the Charge Nurse as follows: a. Any red area that doesn't disappear within 15 minutes or bruising needs to be reported to the nurse. b. All open areas will be reported to the nurse immediately. c. Any resident refusing inspection must be reported to the charge nurse. The Skin Care Program Policy under Skin Care Program Implementation directed the following when any skin issue that develops: a. Charge nurse will begin assessment/completed skin sheet/investigation and notify the DON and implement care plan interventions. b. Director of Nursing/designee will notify the Food Service Supervisor as needed. c. All skin concerns will be placed on the 24 hour sheet/communication sheet for staff to follow up on until healed. d. The nurse will observe skin conditions with ordered treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] e. Dietician will evaluate for appropriate nutritional interventions. The Skin Documentation Policy, undated, provided by the facility under bruises specified bruises would be documented on weekly on the Bruise Sheet until no longer visible. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's medical record shall include physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, clinical record review, policy review and staff interview, the facility failed to secure a catheter bag tubing up off the floor for proper infection control for 1 of 1 residents observed with a catheter (Resident #23) . The facility identified a census of 28 residents. Finding include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident required extensive assistance for toileting and limited assistance for personal hygiene. The MDS listed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The May and June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan, reviewed 9/3/21, identified a goal the resident would not develop complications from a Foley catheter use that would lead to hospitalization during the next quarter. The Care Plan directed the staff to provide catheter care twice a day and empty the drainage bag every shift and as needed. During an observation on 9/14/21 at 9:36 a.m., the resident sat upright in a chair in his room watching television. Approximately 10 inches of the catheter tubing lay directly on the floor running under the bedside table to the straight drainage bag which hung on the garbage can. On 9/14/21 at 1:17 p.m., the resident sat in the chair in his room watching television. The catheter bag tubing lay directly on the floor running under the bedside table to the straight drainage bag which hung from the garbage can. On 9/14/21 at 3:29 p.m. Staff F, CNA, washed hands, donned gloves and sat a graduate inside a plastic bag to empty the resident's catheter bag. Approximately 6 inches of the catheter tubing lay directly on the floor. Staff F removed the privacy cover from the catheter bag that hung from the garbage can and placed the privacy cover on the floor. Staff F cleansed the catheter port with an alcohol prep pad, picked up the catheter bag to suspend in the air and emptied the content of the bag into the graduate. Staff F hung the uncovered catheter bag on the side of the garbage can causing the port and bottom of the catheter bag to come into direct contact with the floor. Staff F then put the privacy cover from the floor under the catheter bag to prevent the contact from the floor. Staff F emptied the graduate into the toilet, removed her gloves, then picked up the dignity cover laying on the floor under the catheter bag and placed over the catheter bag and hung back on the garbage can. Staff F washed her hands and left the room. On 9/15/21 at 8:00 a.m. the resident sat in the chair in room watching television. Approximately 6 inches of the catheter tubing ran along the floor under the bedside table to the straight drainage bag suspended from the garbage can. On 9/16/21 at 10:43 a.m., Staff G, CNA reported she had received catheter care training by the facility. She reported the urinary drainage bag and tubing should never be on the floor as that would cause the catheter to become contaminated. On 9/16/21 at 10:50 a.m., Staff H, Licensed Practical Nurse, (LPN), reported the catheter bags and tubing should not be on the floor. She stated that is not proper catheter care. On 9/20/21 at 9:15 a.m., the Director of Nursing (DON) reported technically the catheter tubing should be up off the floor, but that is not always practical. She stated the catheter is a closed system so it really is the drainage bag that should be up off the floor. The Closed Drainage System Policy listed an objective that the Home will manage the closed drainage system to all for the continuous, bacteria-free drainage of the obstructed or paralyzed bladder. Under the Policy procedure, step 7 the procedure directed the following: a. Attach drainage bag to bed frame, below the level of the bladder-not touching the floor. b. Excess tubing should lay in an unobstructed coil, flat on the bed to allow free flow to the drainage bag. Tubing may be fastened to sheet with a safety pin. Avoid dependent loops of tubing between the catheter and the collection bag. c. Residents who use a wheelchair should have the drainage tubing and bag affixed to the wheelchair below the level of the bladder and off the floor (cloth bag cover should be utilized when residents are in the common areas). d. Ambulatory residents must be reminded not to raise the drainage bag higher than the level of the knees or bladder and not to step on the drainage tubing. The Policy lacked direction to keep the catheter tubing off the floor.

Based on clinical records review, policy review and staff interview, the facility failed to ensure influenza and pneumococcal vaccinations were up to date and offered for 1 of 5 residents sampled (Resident #20). The facility identified a census of 28 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed an entry date of 12/7/20 to the facility and a Brief Interview for Mental Status (BIMS) score of 6 indicating a severe cognitive loss. The MDS listed a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS listed the influenza vaccination had been received outside of the facility and the pneumococcal had been offered and declined. The MDS documented the resident as not receiving Hospice care. A Hand Off Report from the hospital, dated 12/7/20, on page 3, under Immunizations, documented there is no immunization history on file for this patient. A review of the Electronic Immunization Record and Nurses' Notes dated 12/7/20 to 9/15/21 lacked documentation of influenza and pneumococcal vaccination status. On 9/15/21 at 10:26 a.m. the Director of Nursing, (DON), reported she did not have vaccination information regarding the influenza and pneumococcal for the resident. She stated the resident had been on Skilled Care and gone on and off Hospice care and must have been missed when the resident came off of Hospice care. The DON reported she had talked with the family member on 9/14/21 regarding vaccination status and the family member reported she had no information regarding immunizations and to check with the physician's office. The DON reported the facility checked with the physician office and as of 9/15/21 the physician office had no record that the resident had up to date immunizations for influenza or pneumococcal. The DON stated again, it must have been missed. The Influenza and Pneumococcal Vaccine Policy, revised 10/28/2019, provided by the facility documented during the flu season, October 1 through March 31st, with the guidance of the Medical Director the Home will educate and offer a flu vaccine to all residents. It will be documented in the resident's medical record if the vaccine is accepted or declined. The charge nurse will follow-up for any type of reaction. The Policy directed the pneumococcal vaccines are administered throughout the year. A vaccination history is obtained and if the vaccination history is unknown the resident may receive the vaccine. One re-vaccination is recommended in 5 years for persons with renal disease or if the resident is older than 65 and the first dose was given prior to age 65 and 5 years or more have lapsed. Information is sent out to the resident/family yearly if applicable or upon admission to educate and offer the pneumococcal and influenza vaccine. This will be documented in the immunization record if accepted or declined and follow-up will be completed. The Primary Care Physician/Hospice and resident family member/Medical Power of Attorney will be consulted for consent for residents that are near end of life or receiving hospice services for influenza and/or pneumococcal vaccines.

Based on clinical record review, policy review, and staff interview, the facility failed to complete post-fall assessments for 3 of 3 sampled (Residents #3, #4, and #5). The facility reported a census of 26. Findings include: The undated Responding to a Fall procedure stated: provide follow-up assessments for the next 72 hours in order to identify any change in the resident's condition as a result of the fall. Neurological checks should be done, per facility policy, for any suspected head injury or unwitnessed fall involving a resident with a history of confusion. 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #3 had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairments. Resident #3 had [DIAGNOSES REDACTED]. The Event Report dated 5/11/20 at 12:45 p.m. revealed Resident #3 had an unwitnessed fall and sustained a abrasion to her right lower back. The Event Report dated 7/3/20 at 10:45 a.m. revealed Resident #3 had an unwitnessed fall without injury. Review of the Clinical Record revealed a lack of follow-up assessments 72 hours following both falls. 2. The MDS dated [DATE] documented Resident #5 had a BIMS score of 6 indicating severe cognitive impairment. Resident #5 had [DIAGNOSES REDACTED]. An Event Report dated 9/1/20 at 7:45 a.m. revealed Resident #5 had an unwitnessed fall without any injuries. Review of the Clinical Record revealed a lack of follow-up assessments for 72 hours following the fall. 3. The Minimum Data Set ((MDS) dated [DATE] documented Resident #4 had a BIMS score of 99 indicating inability to complete the interview. The staff assessment for mental status indicated moderately impaired cognitive skills. Resident #4 had [DIAGNOSES REDACTED]. An Event Report dated 6/24/20 at 7:30 a.m. revealed Resident #4 had an unwitnessed fall without any injuries. Review of the Clinical Record revealed a lack of assessments from 6/24/20 at 7:30 a.m. until 6/26/20 at 5:30 a.m. and from 6/26/20 at 5:30 a.m. until 6/27/20 at 8:45 a.m. The Progress Notes dated 6/29/20 at 9:33 a.m. documented Resident #4 had a faint yellow bruise, swelling, and pain to the right hip area. The staff notified the Advanced Registered Nurse Practitioner and received an order to obtain an x -ray of the right hip and pelvis. During an interview on 9/15/20 at 10:44 a.m., Staff A (Registered Nurse) stated that there is no set frequency or duration for post-fall assessments. The residents are assessed when they fall to determine if they hit their head and require neurological assessments. The position of resident #4 indicated no head trauma, and Resident #3 denied hitting head on 7/3/20 so neurological assessments were not completed. During an interview on 9/15/20 at 11:20 a.m., Staff B (Licensed Practical Nurse) stated routine neurological assessments are completed if the resident hits their head or there is uncertainty they hit their head. If neurological assessments are not completed, post-fall assessments are completed as needed. Resident #3 (5/11/20 fall) and Resident #5 denied hitting their heads at the time of their falls and had no bumps on their heads so neurological assessments were not completed. During an interview on 9/16/20 at 9:30 a.m. the Director of Nursing stated the expectation following the fall assessment at the time of the fall is to complete post-fall assessments if a concerns arise. Neurological assessment completion for unwitnessed falls depends on the resident's cognitive impairment, their position on the floor and any evidence of head injury. The Director of Nursing stated the facility's Responding to a Fall Procedure is vague and could use updating.

Based on observation, record review, staff and resident interview the facility failed to serve palatable food at an appropriate temperature for 1 of 1 meals observed. The facility reported a census of 29 residents. Findings include: During the initial tour of the facility on 12/2/19 at 11:35 a.m. Resident #12 reported the temperature of the food is not always consistent as some items on a plate will be hot and others will be cold. Review of the Spreadsheet Menu Record for week 3 shown Tuesday identified the noon meal with tomato cucumber salad, oven fried chicken and oven roasted red potatoes with chicken gravy. Observation on 12/3/19 at 12:10 p.m., Staff C, Dietary Cook checked food temperatures in the kitchen and revealed the following: a. Chicken at 202 degree Fahrenheit (*F). b. Gravy at 186 degree *F. c. Potatoes without skins at 186 degree *F. Observation on 12/3/19 at 12:41 p.m., Staff C, checked food temperatures immediately after all meals and room trays were served and revealed the following: a. Chicken at 162 degree *F. b. Gravy at 131 degree *F. c. Potatoes without skin at 92 degree *F. The surveyor tasted the potatoes on 12/3/19 at 12:43 p.m., noting they were cold and not palatable. During an interview on 12/3/19 at 2:30 p.m., Staff C revealed maintenance staff working on the air conditioning and were told it was hot in the kitchen and opened the vent over the serving area to increase the air blowing in the area. During an interview on 12/3/19 at 2:30 p.m., the Food Service Supervisor stated when working last week in the evening as a Cook, a resident told her the food was not hot. She checked post temperature on the food and did notice a drop. She reported unaware the vents had been changed over the serving area. Staff C reported foods should be kept above 135 degree *F for serving. Review of the facility's Food Temperature at Meal Times Policy updated 8/24/15 revealed if food is dished and served directly to residents in the dining room, hot foods or potentially hazardous food must be maintained at a minimum of 135 degrees *F.