Every finding on record at Four Seasons Health Care Inc

Based on record review, review of professional reference, and staff interview, the facility failed to notify the physician of a change in condition for 2 of 3 sampled residents (Resident #2 and #3) with a decline in skin integrity. Failure to promptly notify the physician or provider of the change in skin condition limited their ability to make informed decisions regarding the residents' medical care.Findings includeKozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Carrying Out a Physician's Orders . The nurse is considered responsible for notifying the primary care provider of any significant changes in the client's condition.-Review of Resident #2's medical record occurred on 05/19/26. Diagnoses included left sided hemiplegia and hemiparesis (severe or complete loss of motor function and muscle weakness). The current care plan stated, I get sore areas on my legs and feet due to decrease circulation. I many times refuse to let staff remove my shoes and brace even at night. Staff places powder to the bottom of my left foot as I will allow them to. I do refuse on pm's [evenings] at times.Physician orders included: *10/17/25, Zeosorb-AF [antifungal] Powder 2% [percent] (Miconazole Nitrate) Apply to both feet topically every day shift every Mon [Monday], Fri [Friday] for Moisture associated excoriation. Apply on bath days. On 04/15/26 the provider increased the application to every day.*03/06/26, Zinc Oxide [barrier] Cream to Left Foot daily, one time a day for infection. The provider discontinued this order on 04/15/26. Skin evaluations or observations completed by a nurse stated the following:*04/03/26, three pin sized open areas to left plantar [sole] arch. No redness, drainage, swelling, or warmth noted. Patient verbalizes no pain.*04/08/26, Bottom Left Foot open area 0.9x1.4cm [centimeter]; bottom left foot blister 0.5x0.5cm; and left heel blister 0.5x0.5cm. Notes: Bottom upper center pink and peeling, no redness, swelling, drainage. Middle medial area- What appears to resemble a pocket of pus. Bottom of left heel- what appears to resemble a pocket of pus.The nurses' notes stated the following:*04/14/26 at 9:39 a.m., Informed [name of nurse] of residents left foot wound and need for assessment in morning huddle report. Wound was assessed and documented by [name of another nurse] on 4/8/26 and pus was noted. [Name of first nurse] stated she would follow up with provider [name of provider] about this situation.*04/15/26 at 7:32 a.m., Resident allowed staff to change socks, remove brace and apply schedule zinc cream to left foot. This writer observed multiple small open areas still remain, surrounding area is red and moderate amount of purulent drainage noted on residents sock. [Name of nurse] was present to assess left foot and will follow up with provider with assessment findings.*04/15/26 at 2:35 p.m., Discussion held with provider regarding moisture-associated skin concerns to resident's left foot. Following review, provider ordered discontinuation of zinc oxide cream and increased Zeasorb application to daily for improved moisture management.During an interview on 05/19/26 at 4:56 p.m., an administrative nurse (#1) agreed the nursing staff failed to notify the provider of Resident #2's change in skin condition until seven days later. -Review of Resident #3's medical record occurred on 05/19/26. The care plan stated, I am at risk for impaired skin integrity r/t [related to] diabetes and immobility. I would like to maintain skin integrity through review date.A nurses' note, dated 05/03/26 at 5:31 a.m., stated, While CNA [certified nurse aide] was transferring resident into bathroom with sit to stand lift, resident's hand got bumped against door frame of bathroom door. Resident received crescent shaped skin tear to the back of R [right] hand measuring 2 cm x 1 cm. Wound was cleaned with wound cleanser, steri strips applied and covered with foam dressing for protection.The record lacked evidence the staff notified the provider of Resident #3's skin tear.During an interview on 05/19/26 at 4:37 p.m., an administrative nurse (#1) agreed Resident #3's record lacked documentation staff notified the provider and stated she expected nursing staff to notify the provider of skin tears.

Based on record review, policy review, and staff interview, the facility failed to provide adequate supervision for 1 of 1 sampled resident (Resident #3) who sustained an injury during a sit-to-stand mechanical lift transfer. Failure to ensure supervision while transporting through a doorway with a stand lift resulted in a skin tear and placed the resident at risk of experiencing pain/discomfort and a more serious injury.Findings include:Review of the facility policy titled Policy and Procedure on Using the Sit to Stand Lifts occurred on 05/19/26. This undated policy stated, It is the policy of Four Seasons Healthcare Center to ensure that each resident is safely transferred using the Sit to Stand Lift.Review of Resident #3's medical record occurred on 05/19/26. The current care plan stated, I am at risk for impaired skin integrity r/t [related to] diabetes and immobility. I need assistance with my ADL's [activities of daily living] . I require assist of 1 staff and PAL Lift [type of sit-to-stand mechanical lift] . to move between surfaces.Nurses' notes stated the following:*05/03/26 at 5:31 a.m., While CNA [certified nurse aide] was transferring resident into bathroom with sit to stand lift, resident's hand got bumped against door frame of bathroom door. Resident received crescent shaped skin tear to the back of R [right] hand measuring 2 cm [centimeter] x 1 cm. Wound was cleaned with wound cleanser, steri strips applied and covered with foam dressing for protection.*05/03/26 at 6:40 a.m., Steri strips remain intact over skin tear back of right hand. Skin approximated. Resident reports area is tender, but no redness noted. Foam dressing applied.During an interview on 05/19/26 at 4:37 p.m., an administrative nurse (#1) stated Resident #3 had fragile skin and bumping into the door frame caused the skin tear.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, review of the Minimum Data Set (MDS) validation reports in Centers for Medicare and Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQies), and staff interview, the facility failed to ensure timely electronic data submission of required assessments for 8 of 13 sampled residents (Resident #3, #4, #8, #9, #15, #18, #19, and #22) with late assessments. Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.20.1), page 2-34, stated, . The MDS must be transmitted (submitted and accepted .) electronically no later than 14 calendar days after the MDS completion date . Page 5-1 stated, . All Medicare and/or Medicaid-certified nursing homes . must transmit required MDS data records to CMS' Assessment Submission and Processing (ASAP) system. Review of the validation reports in iQies identified no MDS assessments submitted to CMS by the facility since 11/21/25. Review of medical records occurred on all days of survey and identified the last MDS submitted to CMS for the following residents as: * Resident #3: Quarterly MDS, dated [DATE]* Resident #4: Significant Change MDS, dated [DATE]* Resident #8: Quarterly MDS, dated [DATE]* Resident #9: Annual MDS, dated [DATE]* Resident #15: Quarterly MDS, dated [DATE]* Resident #18: Quarterly MDS, dated [DATE]* Resident #19: Quarterly MDS, dated [DATE]* Resident #22: Quarterly MDS, dated [DATE] During an interview on the afternoon of 02/19/26, an administrative staff member (#1) confirmed the facility does not run validation reports.

Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 5 sampled resident (Resident #18) reviewed for Preadmission Screening and Resident Review (PASRR). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include:The Long-Term Care Facility RAI User's Manual, revised October 2025, pages A-30 through A-32, stated, . A1500: Preadmission Screening and Resident Review (PASRR) . Coding Instructions: . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . - Review of Resident #18's medical record occurred all days of survey. Diagnoses included anxiety, depression, and psychotic disorder. A Notice of PASRR Level II Outcome, dated 09/29/22, stated, . this evaluation has determined that you have a PASRR condition . The facility should mark yes for question A1500 on the Minimum Data Set . The annual MDS, dated [DATE], showed the facility failed to code Resident #18's diagnoses of serious mental illness. During an interview on 02/19/26 at 12:30 p.m., an administrative staff member (#1) confirmed coding issues within the MDS.

Based on observation, record review, and resident and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 3 of 13 sampled residents (Resident #3, #5, and #22). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care. Findings include: - Review of Resident #3's medical record occurred on all days of survey and identified a diagnosis of Parkinson's Disease. A physician's order, dated 10/18/23 and discontinued on 11/15/24, stated, Resting hand splint to L [left] hand daily. On in AM [morning] and off at HS [hour of sleep-bedtime] as nursing measure for left hand contracture. The current care plan stated, I need assistance with my ADL [activities of daily living] . Brace to my left hand and arm, On in am, off at hs. The facility failed to update Resident #3's care plan with discontinuation of the left hand and arm splint. During an interview on 02/19/26 at 12:30 p.m., an administrative nurse (#1) confirmed the facility failed to update Resident #3's care plan. - Review of Resident #5's medical record occurred on all days of survey. The current physician's orders identified Lasix (a diuretic medication) used for kidney disease. Resident #5's care plan failed to include problems, goals, and interventions for diuretic use. During an interview on 02/19/26 at 10:25 a.m., an administrative nurse (#4) confirmed Resident #5's care plan failed to address the use of diuretics. -Review of Resident #22's medical record occurred on all days of survey. Diagnoses included macular degeneration and bilateral cataracts. The current care plan stated, I am at risk for decrease in ADL due to weakness and impaired vision. A physician's consult report, dated 08/21/25, stated, . Eye screening and eye low vision testing; explained lamp use, ordered yellow fitover sunglasses, please encourage him to look just to the left of things, this gives him the best vision. Keep retina appointments as directed. RTC [return to clinic] to low vision clinic prn [as needed]. Observation on 02/17/26 at 4:47 p.m. showed Resident #22 in the activity room with a four-wheeled walker and two flashlights on the walker's seat. The resident voiced a concern regarding lack of vision in one eye and 95% [percent] gone in the other eye. During an interview on 02/18/26 at 5:35 p.m., an administrative nurse (#1) confirmed Resident #22's care plan lacked specific interventions recommended by the physician and the use of a flashlight by the resident.

Based on observation, record review, review of facility policy, review of manufacturer's instructions for use, and staff interview, the facility failed to ensure staff followed standards of care for 1 of 1 resident (Resident #3) observed for insulin administration. Failure to administer rapid acting insulin within the time specified by the manufacturer may result in a hypoglycemic (low blood sugar) reaction. Findings include:Review of the facility policy titled Timely Administration of Insulin occurred on 02/19/26. This undated policy stated, . Insulin administration will be coordinated with mealtimes . unless otherwise specified in the physician order . Administer insulin at appropriate times.Prescribing information for Insulin Aspart, found at https://www.novo-pi.com/insulinaspart, stated, . This product is NovoLog(R) (insulin aspart) . Insulin Aspart is rapid acting human insulin analog indicated to improve glycemic control in adults . Preparation and Administration Instructions . Inject Insulin Aspart subcutaneously within 5-10 minutes before a meal .Review of Resident #3's medical record occurred on 02/18/26. Diagnoses included diabetes mellitus. Observation on 02/18/26 at 11:30 a.m. showed a nurse (#2) administered 6 units of Insulin Aspart to Resident #3 per physician's order. When asked when the resident will have lunch the nurse replied, At noon. Staff assisted the resident to the dining room table at 11:44 a.m., at 12:08 p.m. an unidentified dietary aide assisted the resident to drink half a glass of unsweetened lemonade. The resident received the noon meal at 12:14 p.m., 44 minutes after receiving a rapid acting insulin. During an interview on 2/19/26 at 12:30 p.m., an administrative nurse (#1) stated she expected staff to administer a rapid acting insulin no sooner than 15 minutes prior to a meal.

Based on record review, review of facility policy, review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, and staff interview, the facility failed to offer the pneumococcal vaccine to 2 of 5 residents (Resident #4 and #22) reviewed for immunization status. Failure to offer the recommended pneumococcal conjugate vaccines (PCV) and pneumococcal polysaccharide vaccine (PPSV) to all residents, provide education to residents and their legal representatives, and document the administration or refusal has the potential for non-immunized residents to contract pneumonia and spread the infection to other residents, visitors, and staff. Findings include:Review of the facility policy titled Infection Prevention and Control Program occurred on 02/19/26. This policy, dated 01/02/25, stated, . Influenza and Pneumococcal Immunization: . b. Residents will be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or received the vaccines elsewhere. c. Education will be provided to the residents and/or representatives regarding the benefits and potential side effects of the immunizations prior to offering the vaccines. d. Residents will have the opportunity to refuse the immunizations. e. Documentation will reflect the education provided and details regarding whether or not the residents received the immunizations.Review of the CDC: Pneumococcal Vaccine Recommendations webpage https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, Clinical guidance for implementing pneumococcal vaccine recommendations for adults aged 19 years or greater, dated October 2024, stated, for adults aged 50 years or older who previously received the following vaccines:*PCV13 at any age and PPSV23 at age [less than] 65 years, CDC recommended: A single dose of PCV21 or PCV20 [more than or equal to] 5 years after the last pneumococcal vaccine dose. *PCV13 at any age and PPSV23 at age [more than or equal to] 65 years, CDC recommended: Shared clinical decision-making . of either a single dose of PCV21 or PCV20 . - Review of Resident #4's medical record occurred on 02/19/26 and identified the resident received the PCV13 and PPSV23 vaccines more than 5 years ago and the PPSV23 prior to age [AGE]. The record lacked evidence the facility assessed Resident #4's pneumococcal immunization status and offered the PCV21 or PCV 20 vaccine.- Review of Resident #22's medical record occurred on 02/19/26 and identified the resident received the PCV13 and PPSV23 vaccines more than 5 years ago after age [AGE]. The record lacked evidence the facility assessed Resident #22's pneumococcal immunization status, discussed further vaccination with the provider, or offered the PCV21 or PCV20 vaccine.The facility failed to follow the CDC recommendations for pneumococcal vaccine administration. During an interview on 02/19/26 at 12:50 p.m., an administrative nurse (#1) stated she was not aware if the facility offered the PCV 21 or PCV 20 vaccines to Residents #4 and #22.

Based on observation, review of facility policy, record review, and staff interviews, the facility failed to utilize appropriate assistive devices necessary to prevent accidents and/or injury for 2 of 2 sampled residents (Resident #1 and #2) observed during mechanical lift transfers. Failure to assess for and utilize the correct sling sizes for residents during full body mechanical lift transfers placed the residents at risk for falls and/or injuries. Findings include:Review of the policy titled Policy and Procedure on Using the Hoyer Lift occurred on 12/29/25. This policy, dated December 2023, stated, . It is the policy of Four Seasons Healthcare Center to ensure that each resident is safely transferred using the Hoyer Lift. 1. Identify correct lift and sling for the resident .- Review of Resident #1's medical record occurred on 12/29/25. The current care plan stated, . I need the two person hoyer (full body mechanical) lift and two assist with transfer.Observation on 12/29/25 at 4:15 p.m. showed two certified nurse aides (CNAs) (#1 and #2) assisted Resident #1 from the recliner to the bed using a full body mechanical lift. The tag on the sling stated, Proactive with no size noted.- Review of Resident #2's medical record occurred on 12/29/25. The current care plan stated, . I use the hoyer lift and two assist with transfer.Observation on 12/29/25 at 3:45 p.m. showed two CNAs (#1 and #2) assisted Resident #2 from the bed to the wheelchair using a full body mechanical lift. Prior to the transfer, CNA (#2) stated he needed to go get a sling since there was not one in the resident's room. When the CNA returned, he stated, I could not find the one (sling) she normally uses. The tag on the sling brought into the room identified, Invacare and size large. During an interview on 12/29/25 at 4:48 p.m., when asked how staff know what size hoyer sling to use for each resident, the CNA (#1) stated, There is a list posted in the supply room. Review of the list posted in the supply room stated, Hoyer Sling Sizing Chart Medium: 99 to 210 pounds Large: 198 to 350 pounds X - Large: 270 to 600 pounds Weight capacity is between 450 to 600 poundsDuring an interview on 12/29/25 at 5:27 p.m., a CNA (#2) confirmed they did not use the correct sling when they transferred Resident #2 with the mechanical lift. During an interview on 12/29/25 at 5:15 p.m., an administrative nurse (#3) confirmed the facility had not assessed residents who require the full body mechanical lift for appropriate sling size. The facility failed to assess Residents #1 and #2 for the appropriate sling size and provide staff with information and education regarding appropriate sling size when utilizing the mechanical full body lift.

Based on review of a FRI, record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #2) who experienced unwanted sexual contact from another resident (Resident #1). Failure to protect Resident #2 from sexual abuse placed this resident and all residents at risk for psychosocial harm and mental and emotional distress.During the on-site FRI investigation survey, the survey team consulted the State Survey Agency (SSA) and determined noncompliance with regulatory requirements existed on 08/23/25. On 09/15/25, the SSA consulted with Centers for Medicare and Medicaid (CMS) Regional Office and determined an Immediate Jeopardy (IJ) situation existed on 08/23/25. The facility failed to protect Resident #2 from sexual abuse. *On 09/16/25 at 1:19 p.m., the survey team notified the administrator (#1) and Director of Nursing (DON) (#2) of the IJ situation, provided the IJ template, and requested the facility's removal plan for the IJ.*On 09/17/25 at 9:00 a.m., the SSA reviewed and accepted the removal plan. *On 09/24/25 at 5:00 p.m., the survey team verified the implementation of the removal plan as of 08/23/25 and the IJ removal. The deficient practice remained at a scope and severity of a G following the removal of the IJ. The facility completed the following steps to remove the immediacy and correct the deficient practice: *Implemented individualized care plan interventions including behavioral interventions for residents who exhibit sexual behaviors to reduce the threat or occurrence of incidents that may not be consensual between two residents. Updated Resident #2's care plan interventions to include her behavior of disrobing and hourly behavior monitoring. Updated Resident #1's care plan at the time of the incident to include monitoring of whereabouts and safety. Additional plans included referral and treatment for hypersexuality. *Completed chart audits for all resident who scored a Brief Interview of Mental Status (BIMS) lower than 12 to identify if sexual abuse occurred. Interviewed all residents identified as interviewable regarding any safety concerns. *Implemented 1:1 supervision for Resident #1 if he displays sexual intentions towards any residents.*Immediate implementation of the revised facility abuse/neglect policy to redefine sexual abuse as nonconsensual sexual contact of any type with a resident. *Implemented a policy and procedure to provide a provision of intermediate 1:1 care, to include a staff calling tree, as well as a weekend on call rotation of department managers who will be available to assist with 1:1 care should the need arise.*Educated all staff on 09/19/25. Off duty staff will be educated prior to their next shift. Education included the updated policy and procedure and 1:1 supervision as needed. Findings include:Review of the facility policy titled Abuse and Neglect occurred on 08/28/25. This policy, dated 05/13/19, stated, All residents have the right to be free from verbal, sexual, physical, and mental abuse . Residents must not be subjected to abuse by anyone, including . other residents . Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault .Review of Resident #1's medical record occurred on 08/28/25. Diagnoses included dementia. The Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment. Review of Resident #2's medical record occurred on 08/28/25. Diagnoses included dementia. The MDS, dated [DATE], identified severe cognitive impairment. The initial FRI report, received by the SA on 08/25/25 at 11:28 a.m., identified nonconsensual sexual contact between Resident #1 and #2 occurred on 08/23/25. After the third occurrence, the facility initiated one to one (1:1) supervision for Resident #1.The facility's final investigation report, dated 08/25/25, stated, . At approximately 1315 [1:15 p.m.] on August 23, 2025, in the resident lounge area, a staff member found [Resident #1] with his face in the breast area of [Resident #2]. When the staff member asked [Resident #1] what he was doing, he stated, 'I was just talking to her.' [Resident #2] was removed from the lounge area and taken to a location closer to the nurse's station for observation. [Resident #1] was redirected to his room and counseled that this behavior was inappropriate. at 1330 [1:30 p.m.], [Resident #1] was again observed by staff kissing this female resident on the mouth in the lounge area. Noted that [Resident #2] exhibits wander behaviors, and per her normal, routinely strolls into the lounge frequently and back out. This area has the ability for monitoring over the facility camera system. At 1330 [1:30 p.m.] [Resident #2] again removed from the lounge area and into the nurses station for safety. While staff were attending to other residents, [Resident #1] sought out [Resident #2] and at 1345 [1:45 p.m.] was observed touching [Resident #2] inappropriately. [Resident #1] was again immediately redirected to his room. Staff continued monitoring both residents following the series of incidents.During an interview on the afternoon of 08/28/25, an administrative nurse (#1) reported both residents remain on hourly checks, and no further interactions have occurred.The Facility failed to protect Resident #2 from inappropriate and unwanted sexual contact from Resident #1 and the sexual contact continued two more times before the facility implemented 1:1 supervision.

Based on record review, review of facility policy, and staff interview, the facility failed to provide necessary care and services for 1 of 1 closed record resident (Resident #28) reviewed. Failure to assess, monitor and implement interventions in response to Resident #28's decline in condition may have contributed to the resident's death. Findings include: Review of the facility policy titled Vital Signs occurred on 10/30/24. This policy, dated 12/12/23, stated, . 'Vital signs' are indicators of health status, including temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and pain. Vital signs shall be obtained at least in the following circumstances: . When the resident's general condition changes. When a resident reports nonspecific symptoms of physical distress (e.g., [example] feeling 'funny' or 'different'). Acceptable ranges for adults: . Oxygen saturation: > [greater than] 90% [percent]. Review of Resident #28's medical record occurred on 10/30/24. Diagnoses included chronic obstructive pulmonary disease (COPD), pulmonary fibrosis (damaged lung tissue), and congestive heart failure (CHF). The baseline care plan identified the resident as independent with bed mobility, transfers, walking, toileting and eating, assistance of one with locomotion grooming/hygiene and bathing and oxygen use at two liters per minute. The care plan also stated the resident, Wants to do as much as possible for himself but feels weak so at least offer assist and supervise. The medical record identified Resident #28 admitted [DATE]. The record lacked documentation in the nurse progress notes for August 30, 31, and September 1, 2024. The nurse progress notes dated 09/02/24 stated the following: * At 4:06 p.m. Note Text: Vitals completed. O2 [oxygen] sat [saturation] 81% at 3 liters. Resident has normal respirations at 20 per minute and non labored. and denies shortness of breath. * At 6:22 p.m. Note Text: Resident states he is not feeling well. Vitals are stable and has no fever. O2 sat 89%. It is warm in his room so fan is moved to blow on him per his request. The nurse progress notes dated 09/03/24 stated the following: * At 3:20 a.m. Note Text: Resident told this nurse he is dying and can't eat because it's too hard to breathe. This nurse mentioned Hospice and resident stated, 'That is a great idea because I am definitely dying.' This nurse will pass message on to the day nurse. * At 6:50 a.m. Note Text: Called [family member's name], the president's [sic] son and informed him of his dad's condition. Resident is having SOB [short of breath]. Poor appetite. He said he did not eat or drink for four days. [Resident #28] asked for the nurse's opinion. Informed will consult with the provider and get back to him. Called [Resident #28's son] again but went to his voice. Left message that his dad is on his way to the emergency. Left phone number to call back. * At 7:30 a.m. Note Text: Called the [name of clinic] and spoke with [name of physician] nurse, [name of nurse] Informed her that the resident is having SOB and had not been eating or drinking. [name of nurse] said she will check with [name of physician] and call back. [Name of physician] called and ordered ER [emergency room ] transfer for evaluation. Resident sent to the ER via ambulance 0820 [8:20 a.m.]. * At 8:00 a.m. COMMUNICATION - with Physician* Situation: SOB. Accessory muscle for breathing. Background: Poor appetite. SOB. Oxygen 2L [liters] NC [nasal cannula]. Assessment (RN) [registered nurse]/Appearance (LPN) [licensed practical nurse]: BP [blood pressure] 98/62, P [pulse]-96, r[respirations]- 28, Oxygen 82, T[temperature]-97.3. Recommendations [sic]: Send to ER via Ambulance to [name of town]. * At 8:20 a.m. Transfer to Hospital Summary* Note Text: Resident had been experiencing SOB and poor appetite. Complained of pain as well but said 'pain is a lesser evil. I can't breathe' [name of physician] ordered ER transfer for evaluation. * At 8:21 a.m. Note Text: Report given to the ER nurse. Resident on his way in Ambulance to the ER. * At 9:25 a.m. Note Text: [name of person], Nurse from the [name of town] Hospital called and reported that the patient passed away today at 0908 [9:08 a.m.]. Family notified per the nurse. During an interview the morning of 10/30/24, an administrative nurse (#2) confirmed the medical record lacked nurse progress notes for August 30, 31, and September 1, 2024. The medical record lacked documentation or evidence of the following; * An assessment, treatment interventions, and/or symptom management interventions, and/or physician notification on 09/02/24 at 4:06 p.m., when the resident was on three liters of oxygen with an oxygen saturation of 81% and again at 6:22 p.m. (almost two and a half hours later), when the resident's oxygen saturation was 89%. * Vital signs or assessment of resident condition from 09/02/24 at 6:22 p.m. until 09/03/24 at 3:20 a.m. (almost nine hours later) when the resident reported to nurse he is dying and can't eat because it's too hard to breathe. * Physician notification of a change in resident condition when Resident #28 first reported difficulty breathing and statements of dying on 09/03/24 at 3:20 a.m. until four hours later at 7:30 a.m. when the facility first contacted the physician's clinic. The facility failed to promptly identify and intervene for an acute change in a resident's condition resulting in an actual decline in health status, delayed treatment, and a negative outcome.

Based on review of the State Agency (SA) facility files, review of the facility Quality Assurance and Performance Improvement (QAPI) program, review of facility policy, survey findings, and staff interview, the facility failed to develop a QAPI process to evaluate and identify problems and opportunities to improve services/outcomes, decrease or prevent likelihood of problems or occurrence of adverse events, and ensure compliance with federal requirements. Findings include: Review of the facility policy titled QAPI Change Process occurred on 10/30/24. This policy, dated 10/02/24, stated, . The QAA [Quality Assessment and Assurance] Committee utilizes a systematic approach to performance improvement, including analysis of data, corrective action, and performance tracking. As corrective actions are taken, the committee continues to collect and analyze data to determine the effectiveness of any changes. Once actions are implemented, the facility continues to track performance to ensure that improvements are realized and sustained. Performance on the measures are discussed in QAA Committee meetings. Data is analyzed, and the process continues as appropriate. Review of the state agency files indicated the facility failed to maintain compliance at F625, F657, F684, F689, F812, and F880 as indicated by deficiencies cited during the last standard survey on 11/08/2023 and the comparative and extended Federal Monitoring Survey (FMS) on 12/04/23. Refer to F625, F657, F684, F689, F812, and F880 for specific findings. During an interview the morning of 10/30/24, administrative staff members (#1) and (#8) stated management staff monitor areas identified as needing improvement based on the previous survey results. Failure of the facility to effectively utilize QA resulted in continued noncompliance in the following: * F625 Notice Of Bed Hold Policy Before/upon Transfer * F657 Care Plan Timing And Revision * F684 Quality Of Care * F689 Free Of Accident Hazards/supervision/devices * F812 Food Procurement, store/prepare/serve-Sanitary * F880 Infection Prevention and Control

Based on observation, review of facility policy, and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment in multiple areas of the facility (supply room, laundry room, oxygen storage room, and resident rooms) observed during survey. Failure to maintain a safe, clean, comfortable, and sanitary environment and keep resident care equipment clean and properly stored does not provide a homelike area for residents or promote quality of life. Findings include: Review of the facility policy titled Oxygen Concentrator occurred on 10/30/24. This policy, dated 10/23/24, stated, . An 'oxygen concentrator' is a medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen. Keep concentrators covered when not in use. Care of the Concentrator . Nurse responsibilities . The main body cabinet should be dusted when needed . Observations during survey showed the following: - Clean Supply Room: * An oxygen concentrator with a layer of dust on the outside and filter. * Oxygen tubing and a mask attached to the concentrator laid on the floor beside the machine. A portable liquid oxygen tank and a nebulizer machine sat on the floor next to the concentrator. - Laundry room: * Visible dust/debris on a fan grate and blades blowing into the clean laundry area. - Oxygen storage room: * Two ceiling vents had a thick layer of dust accumulation. * Floor tiles cracked/broken and a visible layer of fine dirt along the perimeter of the floor. * Ceiling tiles with water leak marks. - Resident rooms: * Rooms on Unit A with scuff marks, chipped paint, and gouges/paint scratched off walls. * An overbed table in room B8 with an approximate two-inch strip of missing laminate along the entire front length of the table with wood exposed, and a large area of loose laminate on the right top side of the table. * The top of the oxygen concentrator in room B8 covered in dust. During an interview the afternoon of 10/29/24, a maintenance staff member (#10) confirmed the facility failed to have a process for identifying areas within the facility and/or resident rooms in need of cleaning or repairs. He/she reported being unaware of any resident room concerns. During an interview on 10/30/24 at 11:29 a.m., an administrative staff member (#1) stated he/she expected staff to clean/sanitize oxygen and nebulizer equipment removed from a resident's room prior to storage and dispose of items such as oxygen tubing and oxygen masks in the resident's room. 40488

Based on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 8 of 12 sampled residents (Resident #3, #4, #6, #11, #15, #20, #23, and #24). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION H - BLADDER AND BOWEL The Long-Term Care Facility RAI User's Manual, revised October 2024, page H-2, stated, . Check next to each appliance that was used at any time in the past 7 days. H0100A, indwelling catheter . - Review of Resident #4's medical record occurred on all days of survey. A nursing home recertification of care, dated 07/10/24, stated, Resident does not currently have a foley catheter in place. Observation on 10/28/24 at 3:30 p.m. showed no indwelling catheter present. Review of the MDS, dated [DATE], Section H0100A, indicated the presence of an indwelling catheter. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2024, page N-3, stated, . N0350: Insulin . Coding Instructions . Enter in Item N0350A, the number of days during the 7-day look-back period . that insulin injections were received. - Review of Resident #11's medical record occurred on all days of survey. The physician's orders included Insulin Glargine (used to control high blood sugar) in the evening for diabetes mellitus 2. The facility failed to code insulin use on the significant change in status MDS, dated [DATE]. The Long-Term Care Facility RAI User's Manual, revised October 2024, pages N-6 to N-8, stated, . Code all high-risk drug class medications according to their pharmacological classification . N0415: High-Risk Drug Classes . Coding Instructions . N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., [example] aspirin/extended release .) was taken by the resident at any time during the 7-day observation period. - Review of Resident #3's medical record occurred on all days of survey. The physician's orders included aspirin. The facility failed to code the antiplatelet medication on the quarterly MDS, dated [DATE]. - Review of Resident #6's medical record occurred on all days of survey. The physician's orders included aspirin. The facility failed to code the antiplatelet medication on the quarterly MDS, dated [DATE]. - Review of Resident #15's medical record occurred on all days of survey. The physician's orders included aspirin. The facility failed to code the antiplatelet medication on the annual MDS, dated [DATE]. - Review of Resident #20's medical record occurred on all days of survey. The physician's orders included aspirin. The facility failed to code the antiplatelet medication on the annual MDS, dated [DATE]. - Review of Resident #23's medical record occurred on all days of survey. The physician's orders included aspirin. The facility failed to code the antiplatelet medication on the quarterly MDS, dated [DATE]. - Review of Resident #24's medical record occurred on all days of survey. The physician's orders included aspirin. The facility failed to code the antiplatelet medication on the quarterly MDS, dated [DATE]. During interviews the morning of 10/30/24, an administrative nurse (#2) confirmed staff failed to code the MDSs correctly for Residents #3, #4, #6, #11, #15, #20, #23 and #24. 46963

Based on confidential resident interviews, the facility failed to ensure the availability of sufficient nursing staff to respond to residents' needs for 3 of 3 confidential residents (Residents A, B, and C). Failure to provide sufficient staffing for resident needs/assistance may negatively affect the residents' physical, mental, and psychosocial well-being. Findings include: During confidential interviews the morning of 10/30/24, Resident's A, B, and C (identified as interviewable by the resident's most recent Brief Interview for Mental Status (BIMS) score) stated the following: * Resident A - Not enough staff at night. The resident reported a wait time of 20-30 minutes about every night for toileting clean up assistance ever since I've been here [several weeks]. * Resident B - The facility is shorthanded. I need two people and they can't help me. So, I have to wait [until a second person is available]. My pad will be wet. I have to sit in it. I get sore. The resident stated this occurs after he/she receives evening cares and throughout the night. * Resident C - I wait 1-2 hours for my pain cream for my knees. The resident indicated the wait time for the pain cream occurs on all shifts The facility failed to provide sufficient staffing to meet the needs and assistance required by residents during the overnight shift.

Based on observation, review of facility policy, and staff interview, the facility failed to prepare and store food in a sanitary manner in 1 of 1 kitchen and 1 of 2 resident refrigerators (main lobby). Failure to ensure proper concentration of sanitizer solution, apply an identifying label and an open date on food items brought into the facility, and ensure cleanliness in a resident refrigerator has the potential to affect food quality/preparation and may result in the spread of foodborne illness to residents, staff, and visitors. Findings include: Review of the facility policy titled Food Storage occurred on [DATE]. This undated policy stated, . Food will be stored in an area that is clean . and free from contaminates. Scoops must be provided for bulk foods (such as sugar, flour, spices). Scoops are not to be stored in food . but are kept covered in a protected area near the containers. Review of the facility policy titled Resource: Food Safety for Your Loved One occurred on [DATE]. This undated policy stated, If you plan to bring food into the facility . please be sure that the food is handled safely. Food or beverages should be labeled and dated to monitor for food safety . Foods in unmarked or unlabeled containers should be marked with the current date the food item was stored . - Observations on [DATE] during the kitchen tour showed the following: * A metal scoop in the flour bin. * An unlabeled, undated shaker containing a liquid located inside a reach-in cooler in the kitchen. A dietary staff member (#6) identified the container contained milk and oatmeal and belonged to a staff person. * An unidentified dietary staff member tested the sanitizer concentration in a bucket used to wipe down resident dining room tables. The results showed out-of-range (high). The test strips showed an expiration date of [DATE]. - Observation on the morning of [DATE] showed dried liquid substances on two shelves inside a refrigerator located in the main lobby used to store foods brought in by family. During an interview on [DATE] at 10:38 a.m., the dietary manager (#8) stated she expected scoops for bulk foods be placed outside the storage bins in protective containers, all staff foods brought into the facility be labeled, dated, and stored away from resident foods, and verified the sanitizer test strips expired and may have altered the test results of the sanitizer bucket water.

Based on record review, review of facility policy, and staff interview, the facility failed to provide the resident or the resident's representative a written bed hold notice at the time of the transfer or if an emergency, within 24 hours for 1 of 2 sampled residents (Resident #23) reviewed for hospital transfers. Failure to provide a written copy of the bed hold notice in a timely manner does not allow the resident and/or their representative to make an informed decision regarding their rights. Findings include: Review of the facility policy titled Bed Hold Notice Upon Transfer occurred on 10/30/24. This policy, dated 12/12/23, stated, . Before a resident is transferred to the hospital . the facility will provide to the resident and/or the resident representative written information that specifies . The duration of the state bed-hold policy . The reserved bed payment policy . The facility policies regarding bed-hold periods . Conditions upon which the resident would return to the facility . In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies . Review of Resident #23's medical record occurred on all days of survey and identified a hospital transfer occurred on 06/30/24. The medical record identified the facility provided the resident and/or representative with a written bed hold notice on 07/08/24, eight days after the transfer. During an interview on 10/29/24 at 10:15 a.m., an administrative staff member (#3) confirmed staff provided the required bed hold notice to the resident and/or their representative eight days after the resident was transferred to the hospital.

Based on record review, review of the North Dakota Provider Manual Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 1 sampled resident (Resident #8) reviewed for PASARR. Failure to complete a change in status assessment with a newly diagnosed mental illness may result in the delivery of care and services that are inconsistent with the resident's needs. Findings include: The North Dakota PASARR Provider Manual, revised December 2020, page 13, stated, . Change in Status Process . Whenever the following events occur, nursing facility staff must contact [the contracted agency] to update the Level I screen for determination of whether a first time or updated Level II evaluation must be performed. These situations suggest that a significant change in status has occurred: . If an individual with MI, ID, and/or RC [mental illness, intellectual disability, and conditions related to intellectual disability referred to in regulatory language as related conditions or RC] was not identified at the Level I screen process, and that condition later emerged or was discovered. Review of Resident #8's medical record occurred on all days of survey and identified the following; * PASARR completed on 08/13/21. * Progress note, dated 09/22/24, . communication with physician . updated on resident's delusion's [sic] and hallucinations that he has been having over the last month or more. * Progress note, dated 09/24/24, . communication with physician . Recommendations: New orders received and observed by fax from [name of physician] . increase Quetiapine [antipsychotic medication] to 37.5 mg [milligram] in PM [evening]. The record lacked evidence facility staff completed a PASARR related to the new diagnoses of delusions and hallucinations. During an interview on 10/29/24 at 1:32 p.m., a social services staff member (#3) confirmed the facility failed to complete a change in status Level 1 screen for Resident #8.

Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 3 of 12 sampled residents (Resident #4, #10, and #23). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care. Findings include: Review of the facility policy titled Comprehensive Care Plans occurred on 10/30/24. This policy, dated 10/29/24, stated, . The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS [Minimum Data Set] assessment. - Review of Resident #4's medical record occurred on all days of survey. A nursing home recertification of care, dated 07/10/24, stated, Resident does not currently have a foley catheter in place. Observation on 10/28/24 at 3:30 p.m. failed to identify the presence of an indwelling catheter. The current care plan stated, . I have an indwelling catheter . During an interview on 10/30/24 at 11:56 a.m., an administrative nurse (#2) confirmed staff failed to revise Resident #4's care plan following the removal of the foley catheter. - Review of Resident #10's medical record occurred on all days of survey. A physician order, dated 07/29/24, included Eliquis (an anticoagulant medication) five milligrams (mg) two times a day. The current care plan stated, . Staff will monitor me for any bleeding problems that may be due to Plavix (an antiplatelet medication) use. - Review of Resident #23's medical record occurred on all days of survey and identified warfarin [an anticoagulant medication] discontinued on 05/01/24. The care plan stated, . Staff will do PT/INR (a blood test done for people on warfarin) checks as ordered, and change Coumadin [warfarin] dose as directed. The facility staff failed to review and revise Resident #10 and #23's care plans following medication changes. 46963

Based on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 resident (Resident #14) observed receiving a topical medication. Failure to administer topical medications according to physician orders may result in adverse outcomes for the resident. Findings include: Review of the facility policy titled Medication Administration occurred on 10/30/24. This policy, dated 05/15/24, stated . Medications are administered . as ordered by the physician and in accordance with professional standards of practice . administer medication as ordered in accordance with manufacturer specifications . Skidmore-Roth's Mosby's 2023 NURSING DRUG REFERENCE, 36th Edition eTEXT, 2023, Elsevier Inc., pages 365-367, stated, . diclofenac sodium [Voltaren] . Topical gel route . Use only for osteoarthritis, mild to moderate pain . use dosing card to measure . Observations during medication pass on 10/28/24 at 10:00 a.m. showed a staff nurse (#4) removed a box of Voltaren gel from the medication cart and carried the box into Resident #14's room. The nurse (#4) dispensed an undetermined amount of the gel from the tube into his/her gloved hand and applied the gel up and down the resident's left arm and partial left shoulder. The nurse (#4) dispensed another undetermined amount of the gel into the same gloved hand and applied the gel starting at the resident's right upper arm, down to the right wrist, and then onto the right back shoulder area. Review of Resident #14's medical record occurred on all days of survey. Physician's orders, dated 03/24/22, identified . Voltaren Gel . Apply to shoulder and knees topically two times a day for OA [osteoarthritis] 2 grams for shoulders and 4 grams for knees . and . Voltaren Gel . Apply to affected areas topically every 24 hours as needed for pain 2 grams for shoulders and 4 grams for knees . The nurse (#4) failed to measure the correct dose of Voltaren gel and apply as ordered. During an interview on 10/30/24 at 11:29 a.m., an administrative staff member (#1) agreed the nurse (#4) failed to follow the provider orders for accurately measuring and applying the medication.

1. Based on observation, record review, and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 1 of 3 sampled residents (Resident #11) observed during a gait belt transfer. Failure to utilize a gait belt during transfers placed the resident at risk for falls and/or injury. Findings include: Review of the policy titled Use of Gait Belt occurred on 10/30/24. This policy, dated 04/04/24, stated, . It is the policy . to use gait belts with residents that cannot independently ambulate or transfer for the purpose of resident and staff safety. Observation on 10/28/24 at 10:44 a.m. showed a licensed nurse (#4) assisted Resident #11 to stand up from a sitting position by placing her arm under the resident's arm. The nurse failed to utilize a gait belt during the transfer. Review of Resident #11's medical record occurred on all days of survey and identified repeated falls. The care plan, dated 07/20/23, stated, . Staff will assist me with transfer and locomotion . 2. Based on observation, record review, review of a facility incident report, and staff interview, the facility failed to ensure the safety of 1 of 1 resident (Resident #20) who ingested non-toxic craft paint. Failure to ensure craft paint is secured in a locked cabinet placed Resident #20's safety and health at risk. Findings include: Review of the policy titled Supplies & Equipment occurred on 10/30/24. This policy, dated 07/10/19, stated . When not in use, supplies and equipment are stored in designated activity storage. Review of Resident #20's medical record occurred on all days of survey and included diagnoses of dementia, restlessness, agitation, and wandering. A progress note dated 08/03/24, stated, . Resident was found with a battle [sic] of craft paint on his arms, mouth, and pant [sic]. The nurse was not sure of how much the resident might have consumed. resident [sic] tongue and teeth were all blue from the paint. Nurse called the on-call provider who gave an order to send resident to the ER for evaluation. Review of the facility's incident report, dated 08/03/24, stated, . Storage of Paint: . The cabinet door does have a key to unlock it hanging beside it and staff are aware that it needs to be always locked. Keeping any liquids that could potentially be drank by a resident with altered mental status out of reach and in a locked cabinet, cupboard, or room. Observation on 10/29/24 at 1:11 p.m., with an administrative nurse (#1) showed the activities supply cabinet unlocked. The administrative nurse (#1) confirmed the cabinet should be locked.

Based on record review, review of the facility reported investigation, review of facility policies, review of personnel records, and staff interview, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell out of a mechanical lift. Failure to follow the nursing care plan resulted in Resident #1's fall, which caused pain, bruising and fractures. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Safe Resident Handling/Transfers occurred on 08/30/23. This policy, revised 04/10/23, stated, .residents are handled and transferred safely to prevent or minimize risks for injury. Compliance Guidelines:. 10. Two staff members must be utilized when transferring residents with a mechanical lift (Hoyer). Review of Resident #1's medical record occurred on 08/30/23 and include the diagnoses of chronic pain, disorders of bone density, and adjustment disorder with depressed mood. Review of Resident #1's care plan stated, .I am at risk for falls due to body control problems, cognitive loss.I need two staff to assist me to transfer with hoyer lift. Facility reported the incident to the state agency and immediately started their investigation. The facility's investigation report, dated 08/14/23, included the following documentation: Time line of events: * 08/14/23 at 6:56 a.m. Administrative staff member (#1) spoke with CNA (#2) who found Resident #1. The CNA stated Between 6:15 and 6:30 a.m. knocked on [resident room number] to get hoyer lift (door was shut). When I entered curtain was partially pulled. [resident name] bed was empty and wheel chair was empty. [resident] was in the other bed in the room that had no sheets or pillows. (stripped clean) [resident] head was in the middle of the bed one leg cramed [sig] to the footboard and the other leg was over the footboard. Pants and brief was down by [resident] thighs. Sling was under resident but not crossed through the legs. When [CNA #2] walked in and seen [resident] in the other bed I asked 'why is she over here?' [CNA #5] said 'cause [resident] was sliding so [CNA #5] hurried and put [resident] here.' Then finished helping her out of the bed and into the wheel chair. Resident was complaining of leg pain so [CNA #2] told MA #4 and nurse #3 right away. The [MA #4] looked at the leg/ankle then noticed the swelling. * 08/14/23 at 6:58 a.m. Administrative nurse (#1) interviewed CNA (#5). CNA (#5) said he/she was transferring Resident #1 with the Hoyer lift on his/her own and almost lost [resident name]. * 08/14/23 at 7:10 a.m. Nurse (#3) notified [name of community hospital] that Resident #1 would be coming to the ER [emergency room ] to be assessed. Message left for Resident #1's family member. * 08/14/23 at 2:00 p.m. Nursing staff met for huddle in training room. Reviewed policies and procedures on mechanical lifts, safe transfers and residents care plans. * 08/14/23 at 7:19 p.m. Resident #1 having increased pain with transfers. Provider notified and orders received. * 08/15/23 at 9:15 a.m. Resident #1 taken to [name of community hospital] and then later transferred to [name of higher level of care hospital] During an interview on 08/30/23 at 11:00 a.m. administrative staff member (#1) stated she expects facility staff to follow care plans, care cards and policies and procedures. Based on the following information, non compliance at F689 is considered past non-compliance. The facility implemented corrective actions for the deficient practice by: *The facility completed an investigation with interviews of staff present on 08/14/23. *The investigation showed the CNA (#5), failed to follow policies and procedures on mechanical lifts and failed to follow the resident's care plan. *The facility suspended CNA (#5) pending the investigation and notified the state agency. The facility addressed the deficient practise and implemented systemic changes to ensure the deficient practice does not recur by: Educated all nursing staff on the following policies and procedures: *Safe Resident Handling/Transfers *Using the Hoyer lift *Using the Standing lift *Abuse and Neglect *Fall Prevention Program *Informing the Quality Assurance committee and implementing audits. The surveyor determined a deficient practice existed on 08/14/23. The facility implemented corrective action on 08/14/23 and completed nursing education by 08/15/23.

Based on record review, review of facility policy, review of facility's fall investigation report, and staff interview, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 1 of 1 sampled resident (Resident #4) who fell out of a mechanical lift. Failure to communicate nursing assessments which identified the resident required more assistance with transfers and failure to re-evaluate transfer methods resulted in Resident #4's fall, which caused pain, bruising, and a fracture. Findings include: Review of the facility policy titled POLICY AND PROCEDURE ON USING PAL LIFT occurred on 03/27/23. This policy, dated 10/01/22, stated, POLICY: It is the policy . to ensure that each resident is safely transferred using the PAL [mechanical sit-to stand lift] Lift. PROCEDURE: The PAL Lift is used on residents who are able to use their hands to hang onto the handles and who are able to stand on their legs. When using the PAL Lift, the following will be completed: . OT [occupational therapy] /PT [Physical Therapy] to evaluate for any concerns on PAL Lift transfers. PAL Lifts should never be used on residents who cannot hang onto the PAL Lift handles or who cannot or can no longer stand up using their legs. If a resident can no longer stand using their legs, or they are not able to hang onto the handles for whatever reason, the Hoyer Lift [mechanical full-body lift] may need to be used. This change will be determined by the Charge nurse, Director of Nursing, or OT/PT. PAL Lifts may be utilized by one caregiver unless otherwise care planned. Review of Resident #4's medical record occurred on 03/27/23 and identified multiple sclerosis, muscle spasms, bladder cancer (on Hospice), and a proximal humerus fracture [a break of the shoulder at the top of the upper arm bone]. Review of Resident #4's Hospice Notes identified the following: * 03/07/23 (11 days prior to Resident #4's fall from the mechanical sit-to-stand lift) Functional: patient continues to require sit to stand lift for all transfers. Was utilizing hoyer lift on admit but then graduated to sit to stand. However, patient noted to have increased difficulty with sit to stand lift transfer as she continue (sic) to attempt to lay back during transfer and required physical assistance from staff to stand up straight. Patient also noted in past month to have decreased ability to bear weight on legs during transfer. Patient continues to be extensive assist with feeding, bathing, toileting and dressing.* 03/14/23 . Patient . apprears very fatigued. during assessment. Staff to continue monitoring safety with sit to stand lift transfers. A quarterly Minimum Data Set (MDS) dated [DATE] (six days prior to Resident #4's fall from the mechanical sit-to-stand lift) identified Resident #4 required extensive assist of two persons with transfers. Review of Resident #4's care plan and the CNA (certified nurse aide) care card, prior to the fall on 03/18/23, identified the following: Care Plan: I can again be transferred with the PAL lift and one assist. Staff will use the hoyer lift if I become weak and am unable to stand well. CNA Care Card: Assist x 1 with PAL Resident #4's nurses' notes identified the following: * 03/18/23 at 2:30 p.m., Incident Note . Staff reported she was hooked up to the Pal lift and while they were trying to transfer her, she started to not stand well and they had to lower her to the floor. She denies any injury. This nurse did move all of her limbs and she did not complain of pain. She did not hit her head. Family and hospice both notified of fall, and we will go back to hoyer lift for transfers. * 03/18/23 at 6:54 p.m., Pain Note . Resident displayed grimace and stated ouch. This writer and aide palpated extremities to see where and how resident reacted. Resident unable to verbalize where pain was located. movement to upper R) [right] arm shoulder area resident held breath, squeezed eyes shut, clenched teeth. Resident does have pain to R) arm/shoulder area. Son agrees area looks and feels swollen. This writer noted shoulder area is swollen, no bruising, slightly warm. Unknown if swelling is related to arthritis or injury from fall. This writer will touch base with Hospice for further instructions. * 03/18/23 at 9:13 p.m., Health Status Note . Sling to R) arm in place, resident tolerated applying sling well. Cold pack applied for 20 minutes. Light bruising is now starting to show up to upper R) bicep. * 03/19/23 at 9:40 a.m., Post Fall Note . Resident has been sleepy this morning after receiving prn Morphine during the night for right shoulder pain. No bruising noted to upper area of right shoulder. Edema present in scapula area, no pain on palpitation of site. Staff education given on supporting arm with sling, use of Hoyer lift for all transfers, and to tell nurse if increased pain is noted from resident. * 03/20/23 at 8:34 a.m., Post Fall Note - Late entry: Resident has bruising to right bicep from incident/fall that occurred on Saturday. Area has edema present and is tender to touch. Poor range of motion where sling was under her shoulder. Resident does grimace with movement of arm. Hospice nurse does plan to see resident today . Sling in place to immobilize area as suggested by . Hospice. Staff did report pain with turning this am with cares and advised to use 2 staff with increased pain. Resident has morphine sulfate concentrate solution for pain as needed every hour that can be given. * 03/21/23 at 9:45 a.m., Health Status Note . This nurse heard resident yelling out in pain and went in to check on resident, travel CNA [certified nurse aide] was in her room assisting resident to get AM [morning] cares done and up for the day. This nurse noted large blue/purple bruise on lower front of shoulder around the underneath. Resident vocalized pain and face grimacing noted. Another CNA came to assist resident, resident was unable to lift arm more than 1 inch off of bed. MS [morphine sulfate] was given for shoulder pain . PC [phone call] made to hospice requesting clarification to what type of immobilization device they were wanting to use on resident. Hospice nurse stated she would call MD [medical doctor] to get clarification and ordered MS to be scheduled QID [four times a day] while awake. * 03/21/23 at 12:32 p.m., Health Status Note . Order received to schedule MS and for OT to eval [evaluate] resident for an immobilizing device for right arm, hospice is to use their own therapy contact, hospice ordered x-ray to be done and will be done at . clinic tomorrow AM. * 03/22/23 at 9:54 a.m., Health Status Note . Staff assist x2 . this morning with AM cares. Resident grimaced and vocalized signs and sx [symptoms] of pain with arm movements. MS is provided for pain management. * 03/22/23 at 1:20 p.m., COMMUNICATION - with Family . Resident's daughter, [name] called to talk to DON regarding findings from appointment . [Daughter] voiced the provider talked to her to let her know that resident had a break right below the shoulder and that they were looking at setting up a consultation with orthopedics. Review of the radiology report, dated 03/22/23, stated, Indication: Shoulder Injury. Impression: Acute comminuted proximal humerus fracture . Review of Resident #4's Medication Administration Record (MAR) from March 1-27, 2023, identified Resident #4 received Morphine Sulfate 2 mg on the following dates and times: 03/18/23 at 7:59 p.m. 03/19/23 at 12:00 am, 5:12 p.m. and 10:33 p.m. 03/20/23 at 4:42 a.m. 03/21/23 to 03/27/23 - four times a day Resident #4 did not require any morphine sulfate prior to 03/18/23. An investigation report, dated 03/23/23, stated, Investigation Report: Sit to Stand Incident/Fall. [name of nurse] called to speak with DON about an incident/fall that occurred while resident was in the lift. Resident was strapped into the lift per policy as stated by staff, resident's knees buckled and arms went up (chicken winged) putting pressure on her upper arms and under her shoulders. [Name of nurse] requested we change how we transfer the resident from a sit to stand to a Hoyer lift for safety. [name of nurse] notified the Primary care physician via fax, verbally told Hospice, and called the Family about incident. An Incident Review Quality Assurance Form, signed by the DON and Administrator on 03/23/23, stated, Transfer in progress when she [Resident #4] started to not stand properly and staff at (sic) to lower her. Results of investigation: Sit to stand lift policy and procedure followed by CNA. Family was aware of resident not standing well with lift at all times per Hospice prior to fall, declined use of hoyer for resident dignity. No abuse or neglect found by staff and family. Review of Hospice notes and the facility nurses' notes prior to the fall failed to identify communication to family about changing transfer method from a sit-to-stand lift to a Hoyer lift. An interview with a nursing staff member (#1) occurred on 03/27/23 at 12:56 p.m. When asked how the resident was transferred prior to the fall, the staff member stated she was transferred with the sit-to-stand lift with one person, but at times she was transferred with a Hoyer lift. The staff member (#1) stated the way of transferring was always changing. An interview with a certified nurse aide (CNA) (#4) occurred on 03/27/23 at 1:11 p.m. The CNA stated Resident #4 was a sit-to-stand lift transfer with one person prior to her fall, but states the resident was getting weaker at that time. During an interview on 03/27/23 at 1:42 p.m., a CNA (#3) stated Resident #4 was a sit-to-stand lift transfer with one person prior to her fall, but that sometimes it went back and forth between a sit-to-stand lift and a Hoyer lift. The CNA stated she talks with the charge nurse if they change the type of mechanical lift transfer. An interview with a CNA (#2), who transferred Resident #4 when she fell out of the lift, occurred on 03/27/23 at 2:00 p.m. The CNA stated she was transferring Resident #4 from the wheelchair to her bed with the sit-to-stand lift. Resident #4 was not able to hold onto the handlebars of the lift and the resident refused to stand up. The resident ended up hanging with her arms over the lift belt, slid out of the sling, and she helped the resident to the floor. The CNA stated she was instructed to transfer Resident #4 with the sit-to-stand lift. During an interview on 03/27/23 at 4:40 p.m., an administrative nurse (#5) stated Resident #4's care plan, at the time of the fall, stated if the resident is weak, staff should use the Hoyer lift, but the nurse has to make that judgement, not the CNA.The nurse (#5) stated Therapy completes an assessment to determine assistance requirements. Review of therapy notes identified physical therapy staff last evaluated Resident #4 on 09/09/21 (18 months ago) and stated Reviewed transfers with facility. Res.[resident] is a standing with one and that is appropriate. The Hospice note from 03/07/23 identified Resident #4 was having difficulty with the sit-to- stand lift and in the past month had decreased ability to bear weight during transfer. The MDS note, dated 03/12/13 identified Resident #4 required extensive assist of two persons for transfers. The facility failed to implement interventions based on these assessments and change the plan of care for staff to safely transfer Resident #4. Based on the PAL lift policy, the PAL lift should not be used for residents who cannot hang on to the handles or can no longer stand up and a Hoyer lift may need to be used. A change in type of lift should be evaluated by the charge nurse, DON, or OT/PT. The facility staff failed to communicate nursing assessments and re-evaluate transfer methods when Resident #4 had a decreased ability to bear weight, which resulted in a fall, pain, bruising, and fracture.

1. Based on observation, policy review, review of the Volaro Operator's Manual, record review, and staff interview, the facility failed to provide adequate assistance for 3 of 5 sampled residents (Resident #1, #4, and #6) observed during a sit-to-stand mechanical lift transfer. Failure to ensure proper use of the stand lift, and use the leg strap caused the residents unnecessary pain/discomfort and placed them at risk of possible injury. Findings include: Review of the facility policy titled POLICY AND PROCEDURE ON USING PAL [mechanical] LIFT occurred on 09/14/22. This policy, reviewed October 2021, stated, . POLICY . ensure that each resident is safely transferred using the pal lift. 1. All straps will be buckled unless resident specifically requests no straps. Review of the Volaro Operator's Manual occurred on 09/14/2022. These operator's instructions, stated, . ATTACHING SLING TO LIFT . have him hold onto the handle grips. attach the colored loops to the positive-locking J hooks. NOTE: Make sure you use the same colored loops on each J hook. - Review of Resident #1's medical record occurred on all days of survey and included the diagnoses of bursitis (inflammation) to right and left shoulders. The current care plan stated, I have . shoulder pain at all times. I am alert and able to report pain . I need assistance with my activities of daily living . I need the stand-up lift and one assist for transfer . Observation on 09/11/22 at 4:31 p.m. showed a certified nursing assistant (CNA) (#8) assisted Resident #1 out of the recliner using the sit to stand lift. The CNA applied the sling around the resident's abdomen, secured the buckle, attached the gray colored loops to the handle bars and not the J hooks, and told the resident to put her hands on the handle bars. Utilizing the lift, the CNA transferred the resident onto the toilet. During the transfer, the harness sling slid up the resident's back to the axilla area, and the resident leaned forward, causing the resident's elbows to bow outward above the shoulders. While lowering the resident onto the toilet and pulling the resident's pants down the resident stated, Oh I'm going down, I'm slipping and both of the resident's hands fell off the handle bars. The resident fell approximately 3 inches onto the toilet. The CNA left the sling loops connected to the handle bars while the resident used the toilet. When the resident finished, the CNA instructed the resident to place her hands on the square handle bar and attempted to lift the resident off the toilet. The resident stated, I'm slipping again, my arms, oh mercy. The CNA then lowered the resident to the toilet again. The CNA stated, Let's try using the blue loops, and changed the gray loops to the blue loops, attaching them again to the handle bar. The CNA attempted to lift the resident with the sit to stand. The resident stated, My arms and shoulders hurt, oh my arms, ouch (expletive) it hurts ouch ouch. The CNA lowered the resident to the toilet again and stated, Let's try a different lift that's not so hard on your arms and shoulders. The CNA called for assistance with the transfer and requested staff bring a different lift. At 4:45 p.m., a nurse (#16) entered the resident's room with a different sit to stand lift. Using the new lift, observation showed the nurse attached the loops to the correct hooks, secured the feet strap and proceeded to transfer the resident to her wheelchair. Once seated in the wheelchair the resident stated, Oh does that feel good. - Review of Resident #4's medical record occurred on all days of survey and included the diagnoses of [CONDITION(S)] and dementia. The current care plan stated, I have . shoulder pain at all times. I am alert and able to report pain . I need assistance with my activities of daily living . I need the Pal [sit to stand] lift and one assist with transfers. Observation on 09/11/22 at 4:16 p.m. showed a CNA (#8) used the sit to stand lift and transferred Resident #4 from her recliner to the toilet. The CNA applied the sling around the resident's abdomen, secured the buckle, attached the gray colored loops and not the J hooks, and told the resident to put her hands on the square handle bar. During the transfer, the harness sling slid up the resident's back to the axilla area, and the resident leaned forward, causing the resident's elbows to bow outward above the shoulders. When the resident finished using the toilet, the CNA attempted to lift the resident off the toilet. The resident stated, Oh boy, that hurts. The CNA then lowered the resident to the toilet again. The CNA changed from the gray loops to the blue loops, attaching them again to the handle bar. The CNA transferred the resident from the toilet to the wheelchair. Again during the transfer, the harness sling slid up the resident's back to the axilla area, and the resident leaned forward, causing the resident's elbows to bow outward above the shoulders. When the CNA was placing the resident in the wheelchair, the resident's buttocks were lower than the wheelchair and the CNA had to tip the wheelchair forward to get the resident seated. - Observation of care on 09/12/22 at 9:26 a.m. showed a CNA (#2) transferred Resident #6 from the toilet to his wheelchair using a sit to stand lift. As the CNA (#2) transferred the resident, observation showed the sling around Resident #6's torso loose, and the velcro strap not closed, the CNA (#2) failed to tighten the loose belt. As Resident #6 semi- squatted in the lift, his elbows rose almost level with his shoulders. The CNA (#2) failed to ensure the torso strap was fitted properly before transferring the resident, which may put him at risk for injury. During an interview on 09/12/22 at 2:30 p.m., an administrative nurse (#3) stated she expected staff to use the sit to stand lift correctly by securing the sling loops to the positive-locking J hooks (and not the handle bar) and using the leg straps at all times when transferring a resident. 2. Based on observation, record review, facility policy, and staff interview, the facility failed to ensure residents received adequate supervision and/or monitoring to prevent elopements from the facility for 1 of 1 sampled resident (Resident #19) coded for elopement. Failure to provide adequate supervision and monitoring may result in avoidable accidents and/or injury. Findings include: Review of the facility policy titled ELOPEMENT ASSESSMENT FOR NEW ADMITS occurred on 09/14/22. This policy, dated May 2020, stated, . POLICY . To ensure the safety of new residents on admission. 2. If resident is at high risk for elopement a Wanderguard will be placed. Review of Resident #19's medical record occurred on all days of the survey and identified an admitted [DATE]. The record included the diagnoses of cognitive communication deficits, [CONDITION(S)], [CONDITION(S)], and unspecified [CONDITION(S)]. The current care plan stated, . I have behaviors. I try to leave the building, I hit out at staff, am very paranoid. Staff needs to monitor me closely . I have tried to go out the window multiple times. Staff has a wanderguard on me to alert staff if I am trying to leave out the door. Staff monitors often to make sure I do not go out the window. I have removed the wanderguard so staff needs to try to reapply and check often to make sure that I still has this on. Review of Resident #19's electronic treatment record showed on 08/30/22 the facility discontinued monitoring the resident's wanderguard twice a day. Observations on all days of survey showed Resident #19 without a wanderguard. The admission Minimum Data set (MDS), dated [DATE] identified the resident wandered 1-3 times a week. Review of Resident #19's Risk Assessment, dated 07/19/22, indicated the resident scored a 9 out of 10 potential risk factors and was at risk for elopement. Nursing progress notes included the following: * 07/30/22 at 9:07 p.m., . Resident becomes more restless after family leaves. Resident is trying to exit out door 8 x 2 [attempted to exit out of door 8 twice]. * 07/31/22 at 6:31 a.m., . Resident is up in the hall early this am looking for her husband. Resident has her clothes packed up in boxes and folded on her bed. Other personal items also packed up. She is looking for [husband's name] to take her home. * 07/31/22 at 9:15 a.m., . Resident declined to allow staff to assist her with am cares until now. She has a couple staff only today that she is trusting. Increased delusions noted this morning . * 8/10/22 at 5:40 a.m., . Attempted Elopement. CNA was walking on the B wing hall way when she saw someone standing in front of the exit door in A wing. She notified writer through the walkie and writer ran after the resident. resident [sic] was pushing the door to go out and had also tried to push the automatic door button for the door to open. * 8/30/22 at 11:34 a.m., . Resident has shown no signs of elopement behaviors since initial admit, Resident has exhibited no behaviors. Current medication schedule has been working effectively for resident. During an interview on 09/14/22 at 10:00 a.m., an administrative staff member (#3) confirmed the facility failed to adequately assess the resident's current elopement risk and did not complete another risk assessment prior to removing her wanderguard.