Every finding on record at Hampton Oaks Health Campus

Based on interview and record review, the facility failed to ensure a resident (Resident B) was treated with dignity and respect for 1 of 3 residents reviewed for resident rights. Findings include:The clinical record for Resident B was reviewed on 6/3/26 at 2:06 p.m. The resident's diagnoses included, but were not limited to, anxiety (an emotion characterized by feelings of tension, worried thoughts and physical changes), agitation (state of severed restlessness, mental distress and excessive physical or emotional arousal), and dementia with behavioral disturbance (behavioral and psychological symptoms of dementia which encompasses non-cognitive changes like aggression and anxiety).The care plan, dated 8/13/24, indicated Resident B demonstrated physical aggressive and resistive behaviors towards the staff during hands on care. Interventions included, but were not limited to the following:-Staff will hold the resident's hands to guide, redirect and reassure during care,-Prior to turning on the light, explain that you are going to turn the light on before turning the light on and make sure the resident is awake and aware,-Two staff members during incontinent care, and-Approach resident in a calm and unhurried manor.The progress note, dated 5/14/26 at 5:44 a.m., indicated Resident B was combative during care.During a telephone interview, on 6/3/26 at 10:17 a.m., Certified Nursing Assistant (CNA) 2 indicated on 5/14/26, between 3:30 a.m. and 4:00 a.m., she (CNA 2) and CNA 3 had begun to provide care to Resident B. Everything was fine at first. Resident B then got mad and started flailing his arms. Normally they would walk away, but the resident and bed were wet, and they did not want to leave him soaked and naked. The resident had gotten ahold of CNA 2's pants and had pulled them down to her knees. CNA 2 took her hand and placed it over Resident B's hand to keep him from hitting her.During a telephone interview, on 6/3/26 at 10:37 a.m., CNA 3 indicated Resident B had refused care throughout the night. From the minute she (CNA 3) and CNA 2 turned on the light, Resident B was mad because they had woken him up. Resident B flailed his arms and, at times, his feet, the whole time. It was the last bed check, and she and CNA 2 continued to provide care while the resident was combative because Resident B had refused care all night and needed to be changed.During an interview, on 6/3/26 at 1:56 p.m., CNA 4 indicated if a resident was combative prior to care, staff should stop care, walk away and have another staff member reapproach. If a resident became combative during care, you should stop the care, then reapproach or have another staff member reapproach.On 6/3/26 at 12:34 p.m., the Executive Director provided a current, undated copy of the document titled Resident Rights. It included, but was not limited to, A facility must treat each resident with respect and dignity and care for each resident in a manner.that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.This deficient practice was corrected on 5/14/26, prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan which included the following: All staff were educated on resident abuse, resident rights, and care of an aggressive and combative resident (5/14/26); Alert and oriented residents were interviewed and skin sweeps were completed on all non-alert residents (5/14/26); All residents with aggression and combativeness were reviewed and care plans updated (5/14/26). This Citation relates to Intake 3016354,410 IAC (Indiana Authorization Code) 16.2-3.1-3(t)

Based on observation, interview and record review, the facility failed to ensure misappropriation of resident property did not occur for 6 of 6 residents reviewed for abuse. (Resident B, Resident C, Resident D, Resident E, Resident G and Resident F)Findings include:1.The clinical record for Resident B was reviewed on 12/17/25 at 3:05 p.m. The resident's diagnoses included, but were not limited to, dementia without behavioral disturbance, rheumatoid arthritis, chronic pain syndrome, depression and anxiety. The quarterly MDS (Minimum Data Set) assessment, dated 10/22/25, indicated intact cognition.The incident report, dated 9/30/25, indicated Resident B identified that her debit card was missing.During an interview, on 12/18/25 at 8:23 a.m., the resident indicated someone had taken her bank card and charged over $700.00 dollars on the account. The bank did return the money to her. She had not had any issues with missing items prior to the incident or after the incident. Resident B was observed with no signs of any psychosocial distress.During an interview, on 12/18/25 at 8:10 a.m., the Executive Director (ED) indicated there were 2 separate reportable reports filed. On 9/15/25, Resident C and Resident D reported missing money. The facility completed an investigation and refunded both residents the money. On 9/30/25, the family of Resident B called and notified the ED that Resident B's bank card was missing. The ED instructed the daughter to notify the police and to monitor Resident B's account. She received another call later in the day from the daughter who reported purchases had been made and where. The ED reported the information to the Detective, who then followed up. On 10/1/25, the Detective provided an image of the person who had used Resident B's bank card and the ED identified the employee as CNA 7. The ED and Detective planned to speak with CNA 7 on 10/2/25 when she was scheduled to work. On 10/2/25, at 6:00 a.m., the ED and Detective took CNA 7 to the ED's office to speak with her. CNA 7 admitted to the misappropriation of funds, CNA 7 told the Detective she had thrown away the bank cards that belonged to Resident B and Resident G. The only residents that were missing any money or bank cards resided on the 100 Hallway, which was the only hallway CNA 7 worked. The ED reviewed the facility video footage on the 100 Hallway for both incidents which led the ED to believe CNA 7 was the common denominator. During an interview on 12/18/25 at 10:01 a.m., the Detective assigned to the case indicated on 10/1/25, he had provided the ED with a photo taken at a store which coincided with the purchase made to Resident B's bank card. He showed the picture to the ED who confirmed it was a staff member from the facility. On 10/2/25, in the early morning, he interviewed CNA 7 with the Executive Director present. CNA 7 admitted to taking the quarters belonging to Resident C and the bank cards that belonged to Resident B and Resident G, but denied taking any other resident funds. CNA 7 reported, during the interview, that she had thrown the bank cards away. 2. The clinical record for Resident C was reviewed on 12/17/25 at 3:18 p.m. The residents' diagnoses included, but were not limited to, hypertensive heart disease, peripheral vascular disease and osteoarthritis. The 8/21/25 annual MDS assessment indicated intact cognition.The incident report, dated 9/30/25, indicated Resident C reported missing $75.00 in quarters and $70.00 dollars in cash. During an interview on 12/17/25 at 1:48 p.m., Resident C indicated he had money missing a while back which he reported. He had over $70 dollars in quarters, which he used for bingo, and $70 dollars in cash. The facility reimbursed the money and provided a lock box to keep his money in. Resident C was observed with no signs of any psychosocial distress. 3. The clinical record for Resident D was reviewed on 12/17/25 at 3:30 p.m. The residents' diagnoses included, but were not limited to, metabolic encephalopathy, Alzheimer's disease and dementia. The 10/15/25 quarterly MDS assessment indicated intact cognition.The incident report, dated 9/30/25, indicated Resident D reported missing $60.00 dollars in cash. During an interview, on 12/18/25 at 8:27 a.m., the resident indicated she had money that went missing while she was in the hospital. The facility reimbursed the missing $60 dollars. She had not had any issues with any missing money prior to the missing $60.00 dollars and had not had any issues since then. Resident D was observed with no signs of any psychosocial distress.The progress notes indicated the resident was sent to the hospital on 9/11/25 at 7:00 p.m. and returned to the facility on 9/13/25 at 8:45 p.m. 4. The clinical record for Resident E was reviewed on 12/17/25 at 3:45 p.m. The resident's diagnoses included, but were not limited to, systemic lupus, generalized anxiety, major depressive disorder and restless leg syndrome. The quarterly MDS assessment, dated 11/2/25, indicated intact cognition.The incident report, dated 9/30/25, indicated Resident E reported missing $200.00 dollars in cash. During an interview on 12/18/25 at 8:26 a.m., the resident indicated she did report missing $200 dollars a while back. The facility reimbursed her and put the money in a trust account for her. She had not had any issues of anything missing prior to the missing money nor after. Resident E was observed with no signs of any psychosocial distress. 5. The clinical record for Resident F was reviewed on 12/18/25 at 9:18 a.m. The residents' diagnoses included, but were not limited to, metabolic encephalopathy, diabetes, depression, anxiety and insomnia.The incident report, dated 9/30/25, indicated Resident F reported missing $20.00 dollars in quarters. During an interview on 12/18/25 at 8:20 a.m., the resident indicated she had reported $20 dollars in quarters missing. The facility reimbursed her the $20 dollars. She had not had any missing items prior to the missing money, and she had not had any issues since. 6. The clinical record for Resident G was reviewed on 12/18/25 at 9:33 a.m. The resident's diagnoses included, but were not limited to, Parkinson's disease, insomnia, major depressive disorder and generalized anxiety. The 11/13/25 quarterly MDS assessment indicated intact cognition.The incident report, dated 9/30/25, indicated Resident G reported a missing credit card.During an interview, on 12/17/25 at 2:18 p.m., the resident indicated her credit card had gone missing. The bank had reimbursed the charges to her; the facility took care of everything. That was the first time she had ever had anything missing. Resident G was observed with no signs of any psychosocial distress.The Past noncompliance began on 9/15/25. The deficient practice was corrected by 10/3/25 after the facility implemented a systemic plan that included the following actions: All staff were educated on resident rights and abuse with an emphasis on misappropriation of resident property (10/1/25); Psychosocial follow up was initiated on affected residents (10/2/25); Employee responsible was interviewed by detective and terminated (10/2/25); All families and residents were interviewed related to missing personal items or cash and encouraged to place cash in resident trust fund account or lock box (10/3/25); All alert and oriented residents were offered lock boxes that had declined previously (10/3/25). On 12/18/25 at 12:56 p.m., the Executive Director provided a current copy of the document titled Abuse and Neglect Procedural Guidelines dated 8/29/19. It included, but was not limited to, Purpose.has developed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse.Misappropriation of Property.the deliberate.wrongful.or permanent use of a resident's belongings or money without the resident's consent. This Citation relates to Intake 2631677 3.1-28(a)

Based on observation and interview, the facility failed to ensure the kitchen was maintained in a sanitary manner for 4 of 4 observations. This deficient practice had the potential to affect all 65 residents currently residing at the facility. Findings include: 1. During the initial tour of the kitchen on 1/2/24 between 9:10 a.m. and 9:40 a.m. while accompanied by the Director of Food Service, the following concerns were observed: - The shelf below the steamer had a dinner plate size brown puddle on it along with tan food particles. - The top of the dishwasher had a heavy soil of brown and yellow food crumbs and grease. - The grill slats had a heavy coat of dried black crust on them with black crumbs on the tray in front of the grill. The Director of Food Service indicated at this time that the cooks scraped it off after each time they used it. - The left side of the convection oven next to the grill had a heavy coat of yellow/brown grease and food particles. - The right side of the stove next to the grill and the left side of the stove next to the fryer had a heavy coat of yellow and brown grease and food particles. - The entire length of the metal strip of the range hood near the ceiling had a heavy coat of brown grease with gray dust stuck to it. - The shelf under the main prep counter in front of the stove had various small piece of food particles and spots on it. - The Walk-in fridge 2 condenser fan covers, the area surrounding the fans and the ceiling of the walk in had a 2 foot wide section that ran the entire length of the unit with a moderate coating of gray greasy dust. The entire length of silver electric cord to the light fixture above the entrance door was coated with a moderate amount of gray dust. The fans were running at this time and there were open boxes of various produce items on the shelves. - The fryer had a moderate amount of brown food particles in the oil. - The stove burners had a build up of brown food particles on them. 2. During the lunch meal observation in the kitchen on 1/2/24 between 11:20 a.m. and 12: 30 p.m., the following concerns were observed: - The same issues identified at 9:10 a.m. remained. - Inside the sandwich station, there was a moderate amount of brown and yellow food particles on the bottom shelf and the entire outside of the unit had streaks and brown food particles on it. - The toaster unit - there were brown crumbs on the top rack and a heavy build-up of black debris under the 2 chains that propelled the racks was able to be scraped with a paper towel. - Under the fryer and steamer was a piece of frozen fish and fried fish was observed on the steam table for lunch. 3. During a kitchen observation on 1/4/24 between 10:55 a.m. and 11:30 a.m., the following concerns were observed: - The same concerns identified on 1/2/24 at 9:10 a.m. and 11:10 a.m. remained. - The grill grates had a heavy build-up of black debris on them and there were black and yellow food particles in the tray in front of the grates. The Assistant Dietary Manager indicated at this time that the grill was last used the previous evening. - Although the brown puddle on the shelf below the steamer was gone, there was still multiple dried spots. - The piece of fish remained under the fryer along with 4 french fries under the fryer and stove floor. - The toaster remained with a black substance under the chains and a heavy build up of bread crumbs on the bottom ledge and under the toaster. - The front ledge of the range hood remained with heavy yellow/brown grease and the section of the hood below the filters between the stove, grill, and convection oven had a heavy coating of yellow/brown grease on it. - Although a Dietary Aide was observed sweeping the floor under the shelving racks, a creamer and plastic lid remained on the floor under the cereal and microwave counter. 4. During a kitchen observation on 1/8/24 at 1:10 p.m. with the Director and Assistant Director of Food Services, the following concerns were identified: - The same issues identified on 1/2/24 at 9:10 a.m. and 11:10 a.m. and on 1/4/24 at 10:55 a.m. remained. - The shelf under the steamer had multiple dried spots on it. - The sandwich station inside bottom cabinet remained the same. When the cover was lifted, there was yellow and brown food debris along the outside edge of the wells with wilted lettuce inside one of the wells. - The front ledge hood remains with heavy yellow/brown grease, the section of the hood below the filters between the stove, grill and convection oven remains with a heavy coating of yellow/brown grease. - The tops of the flour, sugar and bread crumb bins were soiled with a white powdery substance and the outside of the bins had dirt streaks on them. - The front of the steam table had dried water streaks down the entire front. - The outside of the prep sink had a heavy soil of brown/black dried food particles. - The wall behind the stove, grill and convection oven had a heavy build up of grease and food particles. - The fries and the piece of fish were now gone. During an interview on 1/8/24 at 1:23 p.m., the Assistant Director of Food Services indicated that Maintenance had an outside company who came in to clean the hood, but did not know how often or when the last time the company came in. Maintenance was responsible for cleaning the fans in the walk-in refrigerator. During an interview on 1/8/24 at 1:25 p.m., the Director of Food Services indicated the afternoon cooks and staff had more time to do the cleaning, some of the things, like the stove burners were left to them to do instead of the morning cooks. All the staff should be cleaning the sides of the stove and the convection oven. The cooks were supposed to strain the food crumbs from the oil after using it. During an interview on 1/8/24 at 1:30 p.m., the Maintenance Director indicated he cleaned the walk-in refrigerator fans every six months at the same time as the outside company came in to clean the range hood. They were due to come in this month and that he would take care of cleaning the fans when they came in. The receipt from the outside company indicated they were last in the facility on 7/9/23. On 1/9/24 at 9:00 a.m., the Director of Food Services presented a copy of the as-completed cleaning schedules, dated 12/31/23 to 1/6/24, for the cooks and dietary aides. Review of the schedules indicated the following tasks were signed off as being completed each day during this time period: a. AM Cook Cleaning Schedule: - Steamer - wipe down. - Fryer - wiped down and strained. - Charbroiler - grates clean, wiped down including hose. - Charbroiler Drip Tray emptied and relined with foil. - Toaster - clean and free of crumbs. - Convection ovens, including hose. - Back wall behind equipment. - Remove and clean range top burner covers. - Prep table clean - including bottom shelf. - Sweep and Mop floor - including under equipment. b. AM Aide Cleaning Schedule: - Dishwasher cleaned. c. PM Cook Cleaning Schedule: - Steamer - wipe down. - Fryer - wiped down and strained. - Charbroiler - grates clean, wiped down including hose. - Charbroiler Drip Tray emptied and relined with foil. - Convection ovens, including hose. - Back wall behind equipment. - Remove and clean range top burner covers. - Prep table clean - including bottom shelf. - Sweep and Mop floor - including under equipment. 3.1-21(i)(3)

Based on record review and interview, the facility failed to ensure 5 of 6 residents or responsible parties were provided written notice of Transfer/Discharge upon transfer to an acute care facility. (Residents 9, 67, 21, 12, and 272) Findings include: 1. The record for Resident 9 was reviewed on 1/8/24 at 9:08 a.m. The diagnoses included, but were not limited to, altered mental status, hypertensive heart disease with heart failure, acute systolic (congestive) heart failure, fluid overload, and acute pulmonary edema. The Admission Minimum Data Set (MDS) assessment, dated 10/25/23, indicated the resident's cognition was severely impaired. A nurse's note, dated 10/21/23 at 1:55 p.m., indicated the resident had a change in condition with increased confusion and lethargy; Labored breathing, shortness of air, and flushed skin. Her colostomy was observed to have bright red tinged substances with a foul odor. The resident was unable to answer questions regarding pain or discomfort. The physician was notified and new orders were received to transfer the resident to the hospital emergency room . The family was made aware of the transfer. Documentation lacked to indicate the resident or the responsible party were given written notice upon the resident's transfer to the hospital, of the reasoning for the resident to be transferred to the hospital or which hospital she was going to. 2. The record for Resident 67 was reviewed on 1/3/24 at 1:46 p.m. The diagnoses included, but were not limited to, pain in left shoulder, generalized muscle weakness, abnormalities of gait and mobility, other symptoms and signs involving cognitive functions and awareness, and Alzheimer's disease. The Admission MDS assessment, dated 9/26/23, indicated the resident's cognition was severely impaired. The nurse's note, dated 10/6/23 at 8:01 p.m., indicated the resident had become very aggressive and combative during the shift with multiple requests to go home. All efforts at redirection failed. After the nurse then sat with the resident to give her time to vent her feelings and check for safety, she went back to the nurse's station to call the family to come in. The nurse then heard a loud noise from the resident's room and found the resident laying on her back. She then rolled to her side with her head resting on the bed frame and yelled to go home. Upon assessment, the resident indicated her back was hurting and began vomiting on herself. She further indicated she was unable to have the nurse touch her back and began having labored breathing and feeling dizzy. While another nurse was helping assess the resident, the resident vomited a second time and was combative. The physician was notified and gave new orders for the resident to be sent to a special hospital for evaluation and treatment. While EMS (Emergency Medical Services) was evaluating and assisting the resident to the stretcher, she vomited a third time. Family was notified of the event. Documentation lacked to indicate the resident or the responsible party were given written notice upon transfer to the hospital, of the reasoning for the resident to be transferred to the hospital or which hospital she was going to. During an interview on 1/5/24 at 1:53 p.m., the Regional Director of Clinical Operations indicated she was unable to locate a copy of the Notice of Transfer/Discharge for Resident 67. 3. The record for Resident 21 was reviewed on 1/4/24 at 9:22 a.m. The diagnoses included, but were not limited to, displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus with diabetic neuropathy, unspecified, age-related osteoporosis, unspecified fall, and other abnormalities of gait and mobility. The Quarterly MDS assessment, dated 8/18/23, indicated the resident was alert and oriented. The nurse's note, dated 10/11/23 at 4:00 p.m., indicated that while holding onto the bar in the bathroom in order to be transferred onto the toilet by the CNA (Certified Nurse Aide), the resident's left leg gave out and buckled. The CNA was unable to hold the resident up and the resident fell to the floor and landed on her left hip. The resident was assisted into bed and began to complain of left hip and knee pain. The physician, family and management were notified and new orders were received to obtain an X-ray of the left hip and knee and continue to monitor the resident. A nurse's note, dated 10/11/23 at 5:48 p.m., indicated the resident was in bed resting and administered pain medication as ordered. The X-ray results were pending. A nurse's note, dated 10/11/23 at 11:41 p.m., indicated the X-ray results showed an acute left intertrochanteric hip fracture. Physician was notified and gave an order to send the resident to the hospital. Family was called and informed. Documentation lacked to indicate the resident or the responsible party were given written notice upon transfer to the hospital, of the reasoning for the resident to be transferred to the hospital or which hospital she was going to. During an interview on 1/5/24 at 1:30 p.m. with LPN (Licensed Practical Nurse) 2, she indicated the face sheet, EMS transfer form, list of medications, a copy of the continuity of care form (CCD) and a copy of the Notice of Transfer/Discharge was put into the packet and sent with the resident to the hospital. She did not give the resident or the family a copy of the Notice of Transfer/Discharge. 34309 4. The record for Resident 12 was reviewed on 1/4/24 at 10:35 a.m. The diagnoses included, but were not limited to, senile degeneration of brain, cardiomegaly, chronic kidney disease stage, Alzheimer's disease with late onset, dementia, disorientation, osteoarthritis, fall, palliative care, sepsis, dementia with agitation, encephalopathy, history of falling, fracture of the neck of left femur. The Significant Change in Status MDS assessment, dated 11/17/23, indicated the resident's cognition was severely impaired. The nurse's note, dated 5/12/23 at 9:21 a.m., indicated the nurse was alerted that the resident was on his knees next to the bathroom door. The resident had a laceration to his forehead with complaints of right knee pain. Pressure and ice were applied to the area, and EMS was called. The record lacked documentation of a signed Transfer/Discharge form provided to the resident or representative. The nurse's note, dated 8/21/23 at 4:26 a.m., indicated EMS arrived at the facility and the resident was in severe pain. The local hospital did not have an orthopedic physician in house, so the resident was being taken to another hospital. The nurse's note, dated 8/21/23 at 4:40 a.m., indicated EMS had exited the facility with the resident and was transporting the resident to the other hospital. The record lacked documentation of a signed Transfer/Discharge form provided to the resident or representative. The nurse's note, dated 11/26/23 at 4:34 p.m., indicated a CNA alerted the nurse that the resident was vomiting. Vital signs were taken, and the resident had a temperature of 100.7 Fahrenheit. The resident had fallen with a head injury yesterday. The resident's pupils were evaluated, and the left pupil was in the twos and the right pupil was six (baseline). The hospice company was made aware of the situation and indicated they would send a nurse to evaluate the resident. The hospice nurse called and indicated she could not make it to the facility to assess the resident within a reasonable amount of time and the doctor gave orders to send the resident to ER to be evaluated and treated. EMS were called and a transport was requested. EMS transported the resident to a local hospital for evaluation and treatment. During an interview on 1/8/24 at 10:12 a.m., RN 1 indicated he sent a CCD sheet, the face sheet, physician's progress notes and the Transfer/Discharge form in a packet when a resident went out to the hospital. They had just started making up the packets to send with residents last year. During an interview on 1/8/23 at 9:25 a.m., the DHS (Director of Health Services) indicated she had no documentation of the Transfer/Discharge for the resident. 5. The record for Resident 272 was reviewed on 1/4/24 at 2:18 p.m. The diagnoses included but were not limited to, arthrodesis status, pulmonary embolism, discitis lumbar region, intervertebral disc displacement lumbar region, spinal stenosis, lumbar region with neurogenic claudication. The nurse's note, dated 10/20/23 at 7:40 a.m., indicated the resident had a change in his cognitive status. The resident had been up for breakfast, was talking, and went to the toilet. Approximately 15 minutes later, the resident was diaphoretic, had a heart rate in the 150s, and was not responding. 911 was called and the resident was transferred to the hospital. The Admission MDS assessment, dated 10/31/23, indicated the resident was cognitively intact. The record lacked documentation of a signed Transfer/Discharge form provided to the resident or representative. 3.1-12(a)(6)(A)

Based on record review and interview, the facility failed to ensure 5 of 6 residents or responsible parties were provided written notice of and signed the facility's bed hold policy upon transfer to an acute care facility. (Residents 9, 67, 21, 12, and 272) Findings include: 1. A nurse's note, dated 10/21/23 at 1:55 p.m., indicated Resident 9 was observed to have a change in condition with increased confusion and lethargy. The physician was notified and new orders were received to transfer the resident to the hospital emergency room . The family was made aware of the transfer. Documentation lacked the resident or the responsible party were given the facility's bed hold policy, the policy was explained to them, or had them sign a copy of it. The resident's diagnoses included, but were not limited to, altered mental status, hypertensive heart disease with heart failure, acute systolic (congestive) heart failure, fluid overload, and acute pulmonary edema. The Admission Minimum Data Set (MDS) assessment, dated 10/25/23, indicated the resident's cognition was severely impaired. 2. The nurse's note, dated 10/6/23 at 8:01 p.m., indicated Resident 67 had become very aggressive and combative during the shift with multiple requests to go home. The physician was notified and gave new orders for the resident to be sent to a hospital for evaluation and treatment. Documentation lacked to indicated the resident or the responsible party were given the facility's bed hold policy, the policy was explained to them, or had them sign a copy of it. The resident's diagnoses included, but were not limited to, generalized muscle weakness, abnormalities of gait and mobility, other symptoms and signs involving cognitive functions and awareness, and Alzheimer's disease. The Admission MDS assessment, dated 9/26/23, indicated the resident's cognition was severely impaired. 3. A nurse's note, dated 10/11/23 at 11:41 p.m., indicated Resident 21's X-ray results showed an acute left intertrochanteric hip fracture. The physician was notified and gave an order to send the resident to the hospital. Family was called and informed. Documentation lacked to indicate the resident or the responsible party were given the facility's bed hold policy, the policy was explained to them, or had them sign a copy of it. The resident's diagnoses included, but were not limited to, displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus with diabetic neuropathy, unspecified, age-related osteoporosis, unspecified fall, and other abnormalities of gait and mobility. The Quarterly MDS assessment, dated 8/18/23, indicated the resident was alert and oriented. During an interview on 1/5/24 at 1:30 p.m., LPN (Licensed Practical Nurse) 2 indicated a copy of the facility's bed hold policy was put into the packet and sent with the resident to the hospital. She did not give the resident or the family a copy of the Bed Hold policy or have them sign it. 34309 4. a. The nurse's note, dated 5/12/23 at 9:21 a.m., indicated the nurse was alerted that Resident 12 was on his knees next to the bathroom door. The resident had a laceration to his forehead with complaints of right knee pain. Pressure and ice were applied to the area and EMS was called. b. The nurse's note, dated 8/21/23 at 4:40 a.m., indicated EMS had exited the facility with the resident and was transporting the resident to the other hospital. c. The nurse's note, dated 11/26/23 at 4:34 p.m., indicated a CNA alerted the nurse that the resident was vomiting. Vital signs were taken, and the resident had a temperature of 100.7 Fahrenheit. The resident had fallen with a head injury yesterday. The resident's pupils were evaluated, and the left pupil was in the twos and the right pupil was six (baseline). The hospice company was made aware of the situation and indicated they would send a nurse to evaluate the resident. The hospice nurse called and indicated she could not make it to the facility to assess the resident within a reasonable amount of time and the doctor gave orders to send the resident to ER to be evaluated and treated. EMS were called and a transport was requested. EMS transported the resident to a local hospital for evaluation and treatment. The record lacked documentation of a signed Bed Hold form provided to the resident or the resident's representative for all the following resident transfer dates: 5/12, 8/21, and 11/26/23. The record for Resident 12 was reviewed on 1/4/24 at 10:35 a.m. The diagnoses included, but were not limited to, senile degeneration of brain, cardiomegaly, chronic kidney disease, Alzheimer's disease with late onset, dementia, disorientation, osteoarthritis, fall, palliative care, sepsis, dementia with agitation, encephalopathy, history of falling, fracture of the neck of left femur. The Significant Change in Status MDS assessment, dated 11/17/23, indicated the resident was severely cognitively impaired. During an interview on 1/8/23 at 9:25 a.m., the DHS provided a copy of the Bed Hold Notification form. There was no signature of receipt of the document. There was no documentation of the resident or representative receiving a copy of the Bed Hold Notification. During an interview on 1/8/24 at 10:12 a.m., RN 1 indicated he sent a CCD (continuity of care document) sheet and the Bed Hold policy, the face sheet, physician's progress notes and the Transfer/Discharge form in a packet when a resident went out to the hospital. They had just started making up the packets to send with residents last year. During an interview on 1/8/23 at 9:25 a.m., the DON indicated she had no documentation of the Bed Hold for the resident. 5. The nurse's note, dated 10/20/23 at 7:40 a.m., indicated Resident 272 had a change in his cognitive status. The resident had been up for breakfast, was talking, and went to toilet. Approximately 15 minutes later, the resident was diaphoretic, had a heart rate in the 150s, and was not responding. Emergency 911 was called and the resident was transferred to the hospital. The resident's diagnoses included, but were not limited to, arthrodesis status; pulmonary embolism; and discitis lumbar region, intervertebral disc displacement lumbar region, spinal stenosis, lumbar region with neurogenic claudication. The Admission MDS assessment, dated 10/31/23, indicated the resident was cognitively intact. The DHS provided a copy of the facility's Bed Hold Notification form for Resident 272 on 1/5/24 at 2:45 p.m. There was no documentation or signature by the resident or representative having received a copy of the Bed Hold Notification. During an interview on 1/5/24 at 1:35 p.m., RN 3 indicated the bed hold was signed by the resident if able or the family if they were present and given a copy. If the resident was not able to sign and no family was present, then just 2 nurses would sign the bed hold as witnesses. During an interview on 1/5/24 at 1:36 p.m., RN 4 indicated the bed hold policy would be signed by 2 nurses only if the resident was unable to sign or no family were present. During an interview on 1/5/24 at 1:40 p.m., LPN 5 indicated she had the resident if able or the family sign the bed hold policy when transferred to the hospital. During an interview on 1/5/24 at 1:53 p.m., the Regional Director of Clinical Operations indicated she had the DHS (Director of Health Services) implement an action plan on what to send with the resident to appointments and the hospital and what to have the resident or family sign. During interview on 1/5/24 also at 1:53 p.m., the DHS indicated she developed an action plan on 12/4/23. She had inserviced the nurses, on 12/5/23, related to the paperwork needed to accompany the resident when going to appointments or the hospital. This included having the resident or family sign the bed hold policy. She then did audits on those residents who went out to the hospital after 12/4/23 for compliance. The facility's current policy on Guidelines for Transfer and Discharge (Including AMA) included, but was not limited to, .Procedures: 5. Notice of Bed-Hold Policy and Readmission: .b. Before the facility transfers a resident to a hospital .Nursing staff or other designated staff member should provide written information to the resident and a family member or legal representative of the bed-hold and admission policies. c. In cases of emergency transfers, the notice of the bed-hold policy should be provided to the resident or resident's representative within 24 hours of the transfer .d. Social Services should review the documentation the following business day to assure written information was provided to the resident and a family member or legal representative of the bed-hold and admission policies. Notification of bed-Hold Policy and Readmission should be provided via certified mail in the event notification was not provided as part of the discharge process. The facility's current Bed Hold Policy - Policies and Procedures Revenue [NAME] and Collections included, but was not limited to, Policy: The campus will properly inform residents in advance or their option to make bed-hold payments as well as the amount of the facility's charge to hold a bed .Purpose: To establish a policy and procedure following a state and federal guidelines as iot pertains to resident notification and billing procedures for hospital leave therapeutic leave bed-hold . The Past noncompliance began on 12/4/23 and the deficient practice corrected by 1/4/24 after the facility implemented a systemic plan that included the following actions: The facility completed nurse education on the discharge process and Bed-Hold policy (12/5/23) and all residents transferred to the hospital after 12/4/23 were audited to ensure 100% compliance on transfers/discharges to the hospital. 3.1-12(a)(25) 3.1-12(a)(26)

Based on interview and record review, the facility failed to ensure an allegation of misappropriation of resident funds was reported to the State Agency for 1 of 3 resident's reviewed for reporting of alleged violations. (Resident 40) Findings include: The clinical record for Resident 40 was reviewed on 12/14/22 at 1:00 p.m. The diagnosis included, but was not limited to, depression. The Annual MDS Assessment, dated 9/8/22, indicated the resident was cognitively intact. During an interview on 12/13/22 at 2:06 p.m., Resident 40 indicated two to three months ago someone had taken his wallet out of his drawer and taken the money out of it and then put the wallet back. He told everyone about it and they all said they would keep an eye out, but nothing came of it. He didn't have a lock on his drawer prior, but after the incident happened the maintenance man put a lock on his drawer. He recalled talking to the Executive Director (ED) and one of the aides about it missing. The facility did not replace his money. The concern log, provided on 12/16/22 at 8:00 a.m., by the ED indicated the resident reported a concern on 9/15/22. The nature of the concern was lost property. The resident was missing $65 from his wallet. The resident stated he knew about a month prior he had $65 in his wallet. He had two twenty dollar bills, two ten dollar bills, and one five dollar bill. On 9/15/22, he looked in his wallet and the money wasn't there. He could not pinpoint when it came up missing, but knew it was in his wallet a month prior. The resolution indicated a lock was put on the resident's drawer so he could lock his money up. The facility offered for him to open an account with the business office but he wanted to lock his money up in his room and understood the risks of keeping it there. The facility offered to go buy him the things he needed to compensate for the money he lost but the resident stated he did not need anything, he just liked to have money on hand. The resident's family member was going to bring him $25. The Executive Director discussed the issue and ensured the resident had a way to secure his money and discussed again with him the resident trust. During an interview on 12/15/22 at 2:07 p.m., the ED indicated she did recall the resident saying he was missing money. He had gotten a birthday card. He didn't put it in his bank account with the facility. It had been several months. They could not replace the money. A State reportable for the resident's allegation of missing funds could not be provided by the facility when requested on 12/16/22 at 12:05 p.m. During an interview on 12/16/22 at 12:06 p.m., the ED indicated she had not been reporting every time the resident's said they had missing property. They verified to make sure they didn't have anyone else missing anything. With Resident 40, they asked other residents and no one else had complaints of any money missing. She talked with the staff on the floor to see if they knew if he had money. Nobody was aware of any money that he had. She did not report the resident's allegation. The Reportable Event Guidelines policy, provided on 12/16/22 at 9:00 a.m. by the ED, included, but was not limited to, Procedures . 1. Occurrences to be reported include . d. Misappropriation of funds . 2. The campus shall complete the appropriate 'State Reporting Form' and send to the State Agency within the time set forth in state and federal guidelines . 3.1-28(c)

Based on observation, record review, and interview, the facility failed to ensure adequate monitoring of fluid status, including daily weights (Residents 3, 36, and 2) and application of compression hose (Resident 3) for 3 of 4 residents reviewed for fluid/hydration status. Findings include: 1. The clinical record for Resident 3 was reviewed on 12/14/22 at 1:58 p.m. The diagnoses included, but were not limited to, hypertensive heart disease with heart failure, chronic diastolic CHF (congestive heart failure), and atrial fibrillation. The care plan, initiated on 7/11/22 and last revised on 11/10/22, indicated the resident had potential for complications related to CHF. The interventions included, but were not limited to, weight as ordered, observe for and report complications as needed. The Physician's note, dated 8/11/22 at 8:56 p.m., indicated the resident had worsening leg edema. A chest x-ray was consistent with pulmonary congestion. She had acute on chronic CHF and was started on lasix 40 mg daily. The physician's order, dated 10/17/22, indicated to obtain the residents weight upon waking for accurate documentation daily between 6:00 a.m. and 12:00 p.m. The order did not specify any parameters for physician notification. The review of the November TAR (Treatment Administration Record) for the resident's daily weight documentation indicated the following: -On 11/11/22 the resident's weight was not obtained and it was not documented why. -On 11/13/22 the resident weighed 188.2 lbs. -On 11/14/22 the resident weighed 192 lbs, which was a 3.8 lbs increase in weight in a day. There was no documentation of notification to the physician of the gain. The IDT note, date 11/21/22 at 9:00 a.m., indicated the resident had an increase in edema and a productive cough. She was COVID and flu tested and was negative. She had just recently recovered from COVID a little over 30 days ago. The IDT note, dated 11/26/22 at 3:03 p.m., indicated the resident had 4+ (plus) edema to the bilateral lower extremities and feet. The physician was notified with new orders to give Lasix 40 mg (milligrams) twice daily for one week. The physician's order, dated 11/28/22, indicated to apply TED (compression) hose to the resident's bilateral lower extremities every morning and remove at bedtime. The review of the December TAR (Treatment Administration Record) for the resident's daily weight documentation indicated the following: -On 12/2/22 the resident weighed 193.8. -On 12/3/22 the resident weighed 197.8 lbs which was a 4 lb weight gain with no documentation of physician notification. -On 12/7/22 the resident weighed 198.4 lbs. -On 12/8/22 the resident weighed 202.4 lbs which was a 4 lb weight gain with no documentation of physician notification. -On 12/13/22 the resident weighed 200 lbs. -On 12/14/22 the resident weighed 205 lbs which was a 5 lb weight gain with no documentation of physician notification. During an observation on 12/16/22 at 11:09 a.m., Resident 3 was sitting up in her wheelchair wearing jeans and socks. Her legs were very edematous with the swelling extending over the cuffs of her socks. She did not have any compression hose in place. The review of the TAR indicated RN 5 had marked the resident's order for compression hose as applied on the morning of 12/16/22. On 12/15/22 they were marked as not applied due to the item being unavailable. During an interview on 12/16/22 at 11:14 a.m., RN 5 indicated they had ordered the resident compression hose but they were the wrong size and they had ordered them again. They had been putting the large on her but they were too tight on her calves. She requested the extra large be ordered earlier last week. She did not have it documented anywhere. She did not know when the last the last time she recalled putting the compression hose on the resident was. She attempted the day prior and the resident hollered they were too tight and painful. She may have documented they were applied that morning, but she did not attempt to apply them because of the previous interaction with her the day prior. It could take a week or longer to get the hose in. She talked to supply about ordering them, she requested it from them a week ago. She did not talk to anyone yesterday when she went to apply them and she had not seen any boxes come in. The central supply and laundry room were toured with the DON (Director of Nursing), on 12/16/22 at 11:20 a.m. There were no extra large compression hose available. During an interview on 12/16/22 at 11:23 a.m., QMA (Qualified Medication Aide) 6 indicated she was in charge of ordering supplies and she had not been asked to order any extra large compression hose and was not aware Resident 3 needed a pair. When she ordered them they could be in usually within one day. During an interview on 12/19/22 at 11:17 a.m., RN 5 indicated for a resident with an order for daily weights she would notify the physician of a weight gain of 3 lbs. within a day or 5 lbs in a week. That was the typical standard. If she noticed a weight gain she would notify the DON, get ahold of the doctor, and see if they had any orders. 2. The clinical record for Resident 36 was reviewed on 12/15/22 at 10:05 a.m. The diagnoses included, but were not limited to, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease and chronic diastolic CHF. The physician's order, dated 5/4/22, indicated to obtain a weight on the resident once daily between 6::00 a.m. and 2:00 p.m. The order lacked documentation of any parameters for physician notification. The care plan, initiated on 5/12/22 and last revised on 12/8/22, indicated the resident had chronic kidney disease related to renal failure. The interventions included, but were not limited to, assess for fluid excess which included weight gain and monitor weight per order. The review of the May TAR (Treatment Administration Record) for the resident's daily weights indicated the following: -On 5/7/22 the resident weight 215 lbs. -On 5/8/22 the resident weighed 220 lbs, which was a 5 lb. weight gain. There was no documentation of physician notification of the gain. -On 5/10/22 the resident weighed 225 lbs. There was no documentation of physician notification of the gain. -On 5/13/22 the resident's weight was not obtained. -On 5/14/22 the resident weighed 229.2 lbs. There was no documentation of physician notification of the gain. The review of the June TAR for the resident's daily weights indicated the following: -On 6/1/22 the resident weighed 213.4 lbs. -On 6/2/22 the resident weighed 218 lbs, which was a 4.6 lb weight gain. There was no documentation of physician notification of the gain. -On 6/5/22 the resident weighed 216.2 lbs. -On 6/6/22 the resident weighed 220.6 lbs, which was a 4.4 lb weight gain. There was no documentation of physician notification of the gain. -On 6/14/22 the resident weighed 210.4 lbs. -On 6/15/22 the resident weighed 214.2 lbs, which was a 3.8 lb weight gain. There was no documentation of physician notification of the gain. -On 6/24/22 the resident weighed 211 lbs. -On 6/25/22 the resident weighed 221.2 lbs, which was a 10.2 lb weight gain. A nurse's note, dated 6/25/22 at 12:16 a.m., indicated the resident had 4+ edema to her right leg and 2+ edema to her left leg. The physician was notified that her medication were not helping with her edema, however the note did not indicated the physician was notified of the resident's weight gain. The review of the July TAR for the resident's daily weights indicated the following: -On 7/3/22 the resident weighed 208.4 lbs. -On 7/4/22 the resident weighed 212.8 lbs., which was a 4.4 lb weight gain. There was no documentation of physician notification of the gain. The review of the August TAR for the resident's daily weights indicated the following: -On 8/6/22 the resident weighed 207.8 lbs. -On 8/7/22 the resident weighed 214.4 lbs, which was a 3.6 lb gain. There was no documentation of physician notification of the gain. -On 8/10/22 the resident weighed 212.8 lbs. -On 8/11/22 the resident weighed 215.8 lbs, which was a 3 lbs weight gain. There was no documentation of physician notification of the gain. The review of the September TAR for the resident's daily weights indicated the following: -On 9/13/22 the resident weighed 213.1 lbs. -On 9/14/22 the resident weighed 217.8 lbs, which was a 4.7 lb weight gain. There was no documentation of physician notification of the gain. -On 9/28/22 the resident weighed 213.5 lbs. -On 9/29/22 the resident weighed 219.2 lbs, which was a 5.7 lb weight gain. There was no documentation of physician notification of the gain. The review of the November TAR for the resident's daily weights indicated the following: -On 11/18/22 the resident weighed 214.2 lbs. -On 11/19/22 the resident weighed 218 lbs, which was a 3.8 lb weight gain. There was no documentation of physician notification of the gain. -On 11/20/22 the resident weighed 217 lbs. -On 11/21/22 the resident weighed 220 lbs, which was a 3 lb weight gain. There was no documentation of physician notification of the gain. -On 11/24/22 the resident's weight was not obtained. 3. The clinical record for Resident 2 was reviewed on 12/13/22 at 11:08 a.m. The diagnoses included, but were not limited to, hypertensive heart disease with heart failure, acute on chronic diastolic CHF, atrial fibrillation, cardiomegaly, hypokalemia, hypomagnesemia, and presence of cardiac pacemaker. The care plan, initiated on 1/7/21 and last revised on 8/15/22, indicated the resident was at risk for malnutrition. Interventions included, but were not limited to, obtain weight as ordered by the physician. The physician's note, dated 9/9/22 at 11:48 a.m., indicated the resident was started on minoxidil for her hypertension. The nurse's note, dated 9/20/22 at 12:13 p.m., indicated the resident was weaker than normal and required assist of 2 for transfers. Her heartrate was running between 74-124. The physician was notified related to the resident being on the new order for minoxidil but she indicated that would not be the cause. She referred the resident to her cardiologist. The BMP result, dated 9/12/22, indicated the resident's potassium was 3.6 mmol/L (millimole per liter) (normal value 3.5 to 5.1). The BMP results, dated 10/5/22, indicated the resident potassium was low at 3.3 mmol/L (normal value 3.5 - 5.1) The nurse's note, dated 10/7/22 at 12:25 a.m., indicated the nurse entered the resident's room and found her talking about a skeleton and laughing to herself. She was having involuntary muscle movements and erratic breathing. Her oxygen was 85% (percent) on room air, her blood pressure was 176/95, and her heartrate was 110. The physician was notified of the resident's condition along with her recent lab values. The physician gave no new orders and indicated to monitor the resident's condition and notify her if it worsened. The nurse's note, dated 10/7/22 at 10:00 a.m., indicated the resident was not acting right, was having difficulty taking medications and shortness of air. She had edema to her upper extremities, bilateral arms, face and neck. Her blood pressure was 170/80, her pulse was 116. The physician ordered to send the resident to the hospital. The nurse's note, dated 10/8/22 at 9:04 p.m., indicated the resident was admitted for observation related to a CHF exacerbation, hypomagnesemia, and hypokalemia. Electrolytes being replaced and and the resident was pleasant at that time. The hospital discharge summary, dated 10/10/22, indicated the resident was admitted to the hospital on 10/7/22 for congestive heart failure, chest pain, and hypomagnesemia. The resident was returning to the facility from the hospital in stable condition with instruction to return to the hospital if symptoms reoccurred. The resident was instructed to weigh herself daily every morning when she got up before she ate. She was to call her doctor when she had a gain of more than 2 lbs in a day or 5 lbs in a week. The nurse's note, dated 10/10/22 at 11:20 a.m., indicated the resident returned to the facility. The nurse's note, dated 10/12/22 at 12:11 a.m., indicated the resident did not seem right. She was in bed with eyes closed and having involuntary jerky arm movements and saying things that didn't make any sense. When asked what her name was and where she was, the resident would just laugh or say something that made no sense. The residents blood pressure was 132/75 and he heart rate was 110. She didn't seem short of air or have any trouble breathing but was very jerky and having what seemed like involuntary muscle spasms in her arms and body. The physician was notified in detail of the resident's current status and said that since she was not in pain or discomfort to just monitor the resident. The nurse's note, dated 10/12/22 at 4:20 a.m., indicated the resident was still having involuntary jerking movements of the face and extremities. She seemed very anxious and was breathing a little more heavy than earlier. When asked if she was in pain the resident said she was hurting all over and in her right arm and shoulder. She seemed to have not gotten any better and maybe even worse than last time The physician was notified and ordered to send the resident to the hospital. The nurse's note, dated 10/12/22 at 7:56 p.m., indicated the emergency room nurse reported the resident's potassium level was 2.7 They were replacing her potassium and were going to recheck her levels soon to see if she needed more. The hospital discharge summary, dated 10/16/22, indicated the resident presented to the hospital from the nursing facility with altered mental status. Her assessment and plan indicated she likely had worsening congestive heart failure, hypokalemia, and hypomagnesemia. The heart failure discharge care plan and goals indicated, Weight yourself every morning on the same scale when you get up -- before you eat but after you use the bathroom . write down your weight every day on a chart so that you can keep track of it . She was to call her doctor when she had a gain of more than 2 lbs in a day or 5 lbs in a week. The clinical record lacked documentation of any daily weights or any physician's orders for daily weights upon the resident's return to the facility on [DATE]. During an interview on 12/19/22 at 11:30 a.m., RN 7 indicated if a resident had a gain of more than 5 lbs in a day they would notify the physician. If it was more than 8 to 10 lbs they would reweigh the resident to be certain and then would definitely notify the physician. That was a standard of what to do. If a resident had an order for compression hose and they did not have the right size, he would talk to QMA 6 and get the right size ordered for them. During an interview on 12/19/22 at 12:06 p.m., Resident 3 and Resident 2's physician indicated for CHF patients she did not have standards for weight monitoring. With someone with daily weights, if she ordered daily weight she would give an order for parameters. If a resident had a weight change she would say 5 lbs a day she was sure they would notify her. During an interview on 12/19/22 at 11:38 a.m., the DON indicated if they saw a significant weight change she would expect staff to reweigh the resident and ensure it was an accurate weight. Typically the physician ordered weight parameters. In her own standard she would say if a resident had a weight gain greater than 5 lbs, if they had reweighed and assessed the resident, she would notify the physician. She was not sure offhand why they did not continue the daily weights on Resident 2 upon her return from the hospital. Guidance titled Managing Heart Failure Symptoms was obtained from the American Heart Association website on 12/18/22. The guidance included, but was not limited to, . Your healthcare team will tell you which heart failure symptoms you should track. The most common symptoms to track are . Daily weight Many people are first alerted to worsening heart failure when they notice a weight gain of more than two or three pounds in a 24-hour period or more than five pounds in a week .It's a good idea to track your weight and check in with your doctor if you notice sudden changes. Make sure you know the amount of weight gain your healthcare provider considers to be a problem for you . The Guidelines for Weight Tracking policy, provided on 12/16/22 at 9:00 a.m. by the ED, included, but was not limited to, . Purpose . To ensure resident weight is monitored for weight gain and/or loss to prevent complications arising from compromised nutrition/hydration . 7. Resident's who have a weight that seem out of normal range shall be re-weighed to determine the accuracy of the original weight . 3.1-46(a)(1)

Based on record review and interview, the facility failed to ensure appropriate social services follow-up and monitoring resident with a feeling of hopelessness and stating they were better off dead for 1 of 5 residents reviewed for social services. (Resident 43) Findings include: The clinical record for Resident 43 was reviewed on 12/13/22 at 1:38 p.m. The diagnoses included, but were not limited to, major depressive disorder, anxiety disorder and altered mental status. The 5-Day MDS (Minimum Data Set) assessment, dated 11/17/22, indicated the resident was moderately cognitively intact. The care plan, dated 11/29/22 and revised on 12/12/22, indicated the resident had a history of a traumatic experience or event. She had experienced the recent death of a child. Interventions included, but were not limited to, assist the resident to identify and avoid triggers from the traumatic experience, provide supportive contacts to the resident as needed, offer the resident choices in daily routine and involve the resident in the plan of care, offer psychiatric and supportive services to the resident and/or the resident representative, and observe for signs and symptoms of re-traumatization (examples given included anxiety, avoidance, depression, disassociation, intrusive thoughts, new or worsening behaviors, and sleep disturbances.) The Social Services note, dated 11/29/22 at 3:48 p.m., indicated the resident came to the social service office to talk and she voiced that she felt like she wanted to go home, but she knew she needed help right now, and the Social Service Director (SSD) explained to the resident about some different options, including assisted living with Medicaid waiver and the facility wasn't going to keep her here against her will. The resident indicated she wanted to give it a little bit longer because she said she loved it at the facility, and it was just a hard adjustment. The resident was open to speaking with talk therapy and have psychiatric care follow her as she felt she may need some medicines adjusted. She did feel anxious at times, and she did feel depressed. The resident indicated her family member committed suicide less than a year ago and that, along with her health issues had affected her. The nurse's note, dated 12/2/22 at 1:32 p.m., indicated the resident was tearful during the am while staff assisted her to the bathroom. Stating so many things were wrong, and she felt out of sorts, and wanted to go home but she knew she couldn't. The resident indicated she was having a tough morning. Staff encouraged the resident to utilize call light for assistance to help avoid falls. The IDT (Interdisciplinary Team) note, dated 12/10/22 at 3:35 p.m., indicated the resident was assessed with depression symptoms on 12-8-22, and was currently receiving Duloxetine 60 mg po (oral) daily for depression. She was not wanting to participate in her usual routine of going dining room. She was staying in bed more and showed no interest. Staff would continue to monitor the resident's mood state and keep the physician aware. The nurse's note, dated 12/10/22 at 8:46 p.m., indicated the resident had been crying most of the shift. The resident's roommate came to the nurse and stated the resident was telling her that she didn't want to be alive anymore and that she wished she could just die. The nurse went in to talk to the resident and asked the resident what was bothering her. The resident indicated she was upset over her family members recent death and that her whole life was gone because she had no more children, and her sister was moving away. The resident was very distraught during the conversation and was stating that she wasn't doing good at the facility and that she felt like she was failing. She was assured that her progress was improving day by day, and the resident calmed down after the conversation and thanked the nurse for talking to her. The clinical record lacked documentation of any psychosocial follow-up by the SSD. During an interview on 12/15/22 at 2:47 p.m., the SSD (Social Service Director) indicated she did a mood assessment for MDS on 12/13/22. She did not see a follow-up for the incident on 12/10/22 when the resident expressed, she wanted to die. There should have been a follow-up with the resident. The nurse should have reached out to the Director of Nursing or the physician. The resident had not seen psychiatric services since 12/3/22. She indicated she did not know if anyone was informed about the incident or not. The policy stated the incident should be reported to the director and a social service follow-up. She would be informed at the morning staff meeting about the incident. During an interview on 12/16/22 at 9:32 a.m., the DON (Director of Nursing) indicated when a resident expressed statements like they want to die they would make sure the resident was safe and interview the resident to see if they had a plan. If the resident had a plan staff would sit with the resident one on one. The resident did not express she had a plan. The nurse would inform the DON of the incident. She indicated the weekend supervisor checked on the resident on 12/11/22 and the incident was discussed in the morning meeting on Monday. She indicated she was not sure when Social Service should follow-up with the resident. Psychiatric services and the therapist would see the resident every 2 weeks. She indicated she heard the resident's son did not commit suicide. Social service follow-up would be in morning meetings every day and they would do weekly clinically at-risk meetings and a follow-up would be done then. The Director of Social Services Job Description, provided on 12/14/22 at 11:00 a.m., indicated the Duties and Responsibilities of the Director of Social Services included, but were not limited to, . 4. Reviews and revises care plans and assessments as necessary . 9. Ensure that social service progress notes are informative and descriptive of the services provide and of the resident's response to the service . The Guidelines for Suicide Threats Policy, provided on 12/14/22 at 11:00 a.m., by the Executive Director, included, but was not limited to, . 1. Resident threats of suicide should be taken seriously and must be reported immediately to the charge nurse . 2. The charge nurse shall notify the resident's attending physician, the Director of Health Services, Director of Social Services, and resident representative of such threats . 8. Social Service staff shall be consulted to discuss the incidents with the resident and provide ongoing assistance to prevent further occurrences of suicidal thoughts . 3.1-34(a)

Based on observation, record review, and interview, the facility failed to monitor for skin changes, follow physician's orders and interventions to prevent the development and worsening of pressure ulcers for 2 of 3 residents reviewed for pressure ulcers. (Residents 47 and 27) Findings include: 1. The clinical record for Resident 47 was reviewed on 10/12/21 at 2:01 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (Minimum Data Set) Quarterly assessment, dated 9/17/21, indicated the resident was cognitively intact. The care plan, dated 1/31/20 and revised on 9/21/21, indicated the resident was at risk for skin breakdown related to decreased mobility, history of pressure ulcer to right knee, multiple comorbidities, and [CONDITION(S)]. The interventions included, but were not limited to avoid shearing skin during positioning, turning, and transferring. Conduct weekly skin assessments. Pay particular attention to bony prominences. Encourage and assist to turn and reposition for comfort and as needed. Float heels as needed. Keep linens clean and dry. Keep resident as clean and dry as possible. The care plan, dated 9/7/21 and revised on 10/6/21, indicated the resident had a pressure ulcer to the left left outer heel, which developed an infection on 9/29/21 and an antibiotic was initiated. The interventions included, but were not limited to, a pressure relieving boot to the left heel while in bed. Observe and report signs of infection, such as localized pain, redness, swelling, tenderness, drainage, odor, and fever. Treatment per MD (Medical Doctor) order and notify the MD if the treatment was not effective. The physician's order, dated 4/30/21, indicated to perform a weekly skin assessment once a day on Mondays. The Comprehensive Metabolic Panel, dated 5/4/21, indicated an [MEDICATION(S)] level of 2.6 g/dL (grams per deciliter). The normal value was specified as 3.5-5.5 g/dL. The September 2021 TAR (Treatment Administration Record), , dated 9/6/21, the skin assessment indicated no new skin areas. The Pressure, Stasis, Diabetic Wound Event, dated 9/7/21 lacked any documentation. The Wound Management Detail Report, dated 9/7/21, indicated the resident had a new stage 3 pressure ulcer to the left outer heel. The wound measured 1.1 cm (centimeters) long by 1 cm wide by 0.1 cm deep. The wound was 90% covered with granulation tissue and 10% slough. The wound had irregular wound edges with [CONDITION(S)] (redness) and blanchable surrounding skin. The nurse's note, dated 9/9/21 at 11:31 a.m., indicated the purpose of the review was to evaluate the status as to the resident's wound that was identified on 9/7/21. The resident was admitted to the facility on [DATE]. The stage 3 wound location was the left heel. The current treatment orders were to cleanse the wound with cleanser or normal saline, apply skin prep, cut to size collagen dressing and cover with foam dressing every 3 days. Supplements were ProStat and a multivitamin. The resident was noted to have a new Stage 3 pressure area to the left outer heel. The area measured 1.1 cm by 1 cm by 0.1 cm with 90% granulation tissue and 10% slough per wound nurse. A new intervention of a pressure relieving boot while in bed was put into place. The physician's order, dated 9/9/21, indicated to apply a pressure relieving boot to left foot while in bed, three times daily. The September 2021 TAR for pressure relieving boot to left heel while in bed, starting 9/9/21 thru 9/30/21, indicated by an X the resident was not wearing a pressure relieving boot. The Wound Management Detail Report, dated 09/15/21, indicated the pressure ulcer to the left outer heel was unstageable with slough and/or eschar. The wound measured 2 cm long by 3.5 cm wide with necrotic tissue. There was light serosanguineous (pale red to pink, thin and watery) exudate. The Wound Management Detail Report, dated 9/22/21 indicated the wound measured 6 cm long by 4 cm wide. The wound culture, dated 9/27/21, of the left heel resulted with a heavy growth of pseudomonas aeruginosa. Probable staphylococcus aureus. The Wound Management Detail Report, dated 9/29/21, indicated the wound measured 4 cm long by 6.3 cm wide. There was light serous (clear, amber, thin and watery) exudate. The wound had 100% slough and/or eschar. The nurse's note, dated 9/29/21 at 8:20 p.m., indicated the final wound culture results of the left heel were sent to the MD. New orders to start [MEDICATION(S)] 500 mg (milligrams) every day for 10 days. The Wound Healing Center note, dated 10/5/21, indicated the Stage 3 pressure ulcer to the left posterior heel measured 7 cm x 3.5 cm x 0.2 cm. There was moderate serosanguineous exudate. The color was black with bright red, macerated surrounding skin. There was a mild odor. The eschar covered 76-100%. During the visit, the wound was cleansed/irrigated to remove the bio film devitalized tissue. A topical anesthetic was applied. The wound was debrided and a primary dressing was applied to the wound using collagen dressing. A foam dressing was applied and secured with a rolled gauze. A follow up visit was scheduled for 10/12/21. The Wound Management Detail Report, dated 10/6/21, indicated the wound measured 3.5 cm long by 7 cm wide. There was necrotic tissue presented with 25% slough and 75% eschar. The nurse's note, dated 10/10/21 at 5:15 a.m., indicated the resident completed a round of [MEDICATION(S)] 500 mg po (by mouth) daily x 10 days for left heel infection. To continue with current POC (Plan Of Care), monitor the area with treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Management Detail Report, dated 10/13/21, indicated the wound measured 4.9 cm long by 7.5 cm wide. The physician's order, dated 10/13/21, indicated to cleanse the wound to left heel with mild soap and water, pat dry, apply collagen dressing cover with ABD (absorbent sterile dressing), and secure with kerlix every other day. During an observation, on 10/15/21 at 9:12 a.m., RN 4 removed the dressing from the left heel. The rolled gauze around the heel and ankle was undated. There was a small amount of sanguineous drainage on the rolled gauze. The ABD pad had a moderate amount of serosanguinous and brown drainage. The RN indicated at this time it was brown, due to the medication. She cleansed the wound with mild soap and applied the collagen dressing, soaked in sterile solution, to the wound. She covered the collagen dressing with an ABD pad and wrapped it with a rolled gauze. The RN measured the wound at 7.6 cm long x 5.5 cm wide. She was unable to gauge a depth due to the necrotic tissue. The wound was observed to have 60% brown necrotic tissue, 30% tan slough with exposed muscle, and 10% granulation. There was no exposed bone. On 10/15/21 a left leg scan was performed to rule out vascular disease. The results indicated no stenosis was present. During an interview, on 10/15/21 at 9:12 a.m., the resident indicated he didn't have a boot applied during the night. He never had one. The facility talked about putting pillows under his calves, but never did it. He would wear a shoe during the day, which was snug fitting. During an interview, on 10/15/21 at 9:13 a.m., RN 4 indicated the dressing to the left heel was changed every other day. The resident had the first visit to the wound care center on 10/5/21 and was assessed. On the second visit to the wound care center on 10/12/21, the resident's left leg had an arterial doppler and ABI (Ankle Brachial Index) performed. The doctor also performed a wound culture. She indicated a mild soap was used to cleanse the wound. The collagen dressing was moistened with a sterile solution and placed on the wound. An ABD pad was applied, then was wrapped in the rolled gauze. During an interview, on 10/18/21 at 1:08 p.m., the ED (Executive Director) indicated the resident was independent and could turn and reposition himself. He can voice any skin concerns. He had an air mattress prior to the development of the pressure ulcer to the heel. During an observation and interview, on 10/18/21 at 1:11 p.m., with the DON (Director of Nursing) searched the resident's room and indicated she could not locate a pressure relieving boot in the room. She asked the resident if he used one at night and he indicated he did not. She asked if one was placed on him at night and he indicated he had never had one. When asked if pillows were used under the calves to float the heels, he indicated no pillows were placed under his calves, he just wore his wound dressing and socks. He just placed 2 pillows under his head and the other pillow was placed in his recliner. During an interview, on 10/18/21 at 1:14 p.m., CNA (Certified Nursing Aide) 5 indicated she hadn't worked with resident for a couple of weeks, but had never seen a boot in the resident's room. During an interview, on 10/18/21 at 1:20 p.m., the ED indicated the shower sheets should be marked with any new or existing skin areas. It was just for their use though. During an interview, on 10/18/21 at 1:42 p.m., the Regional Director of Clinical Operations 6, indicated when a resident had [CONDITION(S)] in one wound, standard precautions were used and they would make sure there was no cross contamination to another wound. The ED indicated the resident was also educated on infection prevention. During an interview, on 10/19/21 at 10:00 a.m., LPN (Licensed Practical Nurse) 7 indicated she had not noted a boot on the resident's foot or a pillow under the calf, when the resident was assisted to transfer out of bed that morning. During an interview, on 10/19/21 at 10:59 a.m., the DON indicated she found the resident's boots in the supply room. He should have had the boots on when in bed. Preventatively, the staff would perform skin checks, use preventative treatments, and skin prep. They would also check the shoes, but she was unsure if that was the problem. It was hard to say if the wound should have been found before it was a stage 3, because they develop quickly. 2. The clinical record for Resident 27 was reviewed on 10/15/21 at 8:54 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS (Minimum Data Set) assessment, dated 9/1/21, indicated the resident was cognitively intact, required extensive assistance of two staff members with bed mobility and transfers, was occasionally incontinent of urine and frequently incontinent of bowel, was at risk of developing pressure ulcers, did not have any pressure ulcers upon admission, and skin and ulcer/injury treatments included pressure reducing device for chair and bed, application of nonsurgical dressings, and ointments/medications. The Admission Observation, dated 8/27/21, indicated the resident had skin impairments and a wound event would be completed. The skin tear/laceration skin event, dated 8/27/21, indicated upon admission the resident had a skin tear to the right posterior calf measuring 3 cm x 2 cm, which was shallow and had a treatment in place. The clinical record did not identify any other wounds or issues with skin integrity upon admission. The care plan, initiated on 9/8/21, indicated the resident was at risk for skin breakdown related to incontinence and a skin tear. Interventions included, but were not limited to, avoid shearing skin during positioning, turning, and transferring, conduct weekly skin observation. Pay particular observation to bony prominences, encourage and assist to turn and reposition for comfort and as needed, float heels as needed, keep linens clean and dry, keep resident as clean and dry as possible. Minimize skin exposure to moisture, pressure reducing cushion to chair, pressure reducing mattress to bed, use lifting device as needed for mobility, use moisture barrier product to perineal area as needed. The review of the MAR (Medication Administration Record) for September, indicated a skin assessment was conducted on 9/10/21 and no new areas of skin impairment were identified. The shower sheet, dated 9/11/21, indicated no new areas were identified. The clinical record lacked documentation of any nursing or clinical notes or of the identification of any new redness, blisters, or other compromised skin integrity between 9/8/21 and 9/12/21. The nursing note, dated 9/13/21 at 4:45 a.m., indicated a CNA had informed the nurse of a skin tear to the resident's coccyx and upon examination the nurse observed a 5 cm by 1 cm wound which was light yellow, non-blanchable, and had a red border around it. The site was cleaned and a foam dressing was placed. The Wound Management Detail report, dated 9/13/21, indicated the resident had the following new wounds: a. A new unstageable pressure ulcer to the coccyx, measuring 3.5 cm in length by 1 cm in width, which was 10% granulation and 90% slough with irregular wound edges and [CONDITION(S)] (redness) surrounding the wound. b. A new unstageable pressure ulcer to the left heel, measuring 6.1 cm in length by 3.5 cm in length with 50% eschar tissue. c. A new unstageable pressure ulcer to the right heel, measuring 4.5 cm in length by 9 cm in width, which was described as closed/resurfaced. The wound pictures, dated 9/14/21 showed the following: a. Coccyx Wound- The resident's coccyx was observed to have an open area with irregular borders. The wound bed at the top portion was covered in tan/yellow slough, with a another, shallow area below it which had a pink/white wound bed. There was a sticker above the wound, dated 9/14/21, which indicated the resident's first initial and last name, a location of coccyx, and measurements of 3.5 x 1. b. Left Heel Wound- The left heel was observed to have a large, open area, with an indeterminate depth, which appeared to be a dark colored crater. There was a thin band of white around the edge of the wound, and then a larger area of intact, darkened area surrounding the wound and encompassing the bottom of the heel. There was a sticker above the wound, dated 9/14 which indicated the resident's first initial and last name, a location of left heel, and measurements of 6.1 by 3.5. c. Right Heel Wound- The right heel was observed to have a large, dark maroon area encompassing the resident's heel. There was a sticker above the wound, dated 9/14/21, which indicated the resident's first initial and last name, a location of right heel, and measurements of 4.5 x 9. d. Left Buttocks Wound- The resident's left buttocks was observed to have a very shallow wound with irregular edges and a bright pink wound bed. There was a sticker above the wound, dated 9/14/21, which indicated the resident's first initial and last name, a location of left buttocks, and measurements of 1.3 x 1.3. The treatment orders, initiated on 9/14/21, included the following: Cleanse coccyx with normal saline or wound cleanser, apply skin prep to peri wound, santyl to wound bed, and cover with foam dressing daily. Monitor for signs of infection until resolved. Cleanse the right heel open area with normal saline or wound cleanser, apply skin prep,a foam dressing, and wrap with a rolled gauze every 3 days. The order was discontinued on 9/30/21. Cleanse the left heel with with wound cleanser or normal saline, apply skin prep to peri-wound and apply [MEDICATION(S)] to wound bed, apply foam dressing and wrap with rolled gauze. Change every 3 days. The order was discontinued on 9/17/21. The physician's note, dated 9/16/21 at 6:41 p.m., indicated the resident was seen related to his pressure ulcers, and wound care was following. The note did not indicate any statement of unavoidability or any new recommendations. No new orders were written at this time. On 9/17/21, the wound treatment order for the left heel was changed to cleanse wound with wound cleanser, apply skin prep to periwound and blister, apply Dakin's moistened gauze to wound bed, cover with rolled gauze daily. Monitor for signs and symptoms of infection until resolved. The order was discontinued on 9/30/21. The wound management detail report, dated 9/22/21, the wound to the coccyx was reclassified as a stage 3, and now measured 3 cm in length by 1 cm in width with 75% granulation and 25% slough and was noted to be improving. The wound to the left heel was now 100% eschar and had increased in size to 7 cm in length by 4 cm in width. The wound to the right heel was unchanged. The nursing note, dated 9/22/21 at 12:40 p.m., indicated the DON (Director of Nursing) spoke with [CONDITION(S)] related to the resident's condition and pressure ulcers. The [CONDITION(S)] nurse indicated they had been worried about the resident's condition for a few weeks and had been keeping a close eye on him. Their physician felt he was not doing well and didn't believe he would make it much longer. The physician's note, dated 9/27/21 at 6:42 p.m., indicated the resident was having increasing pain in his foot, was unable to bear weight with physical therapy due to pain and nursing staff were concerned about the resident's progressive disability. The left heel had a 4 cm necrotic and malodorous ulcer which was dark maroon to black base and non blanching dark maroon to black [CONDITION(S)] down the lateral foot. His pre [MEDICATION(S)] was 2.5. His medical burden was becoming insurmountable and care of his foot ulcer would need to include arterial status as well as consideration for possible concomitant streamlets, however evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . His nutritional statistics were poor and not likely to improve. His prognosis was poor. The physician recommended consideration for end of life care and comfort measures only, including cessation of [CONDITION(S)] as a reasonable option. The Wound Management Detail report, dated 9/29/21, indicated the following: a. The wound to the coccyx measured 3 cm in length, by 1 cm in width, with 75% granulation tissue, 25% slough. b. The wound to the left heel measured 6 cm in length, by 5 cm in width, with 10% slough and 90% eschar. b. The wound to the right heel measured 4.2 cm in length, by 6 cm in width, with 25% slough, and 75% eschar. The Wound Management Detail report, dated 10/6/21, indicated the following: a. The wound to the coccyx was improving and measured 1.2 cm in length by 0.2 cm in width, by 0.1 cm in depth, with 100% epithelial tissue. b. The wound to the left heel increased in size to 7 cm in length by 6 cm in width, and remained at 100% necrotic tissue. c. The wound to the right heel measured 4 cm in length, by 8 cm in width, and was 100% necrotic tissue. On 9/30/21, the wound treatment order was updated to cleanse both the right and the left heel wounds with wound cleanser, apply skin prep to periwound and blister, apply Dakin's moistened gauze to wound bed, cover with rolled gauze daily. Monitor for signs and symptoms of infection until resolved During an interview, on 10/13/21 at 11:41 a.m., the ED (Executive Director) indicated the physician felt the resident's wounds were arterial in nature and the wounds had already started to tunnel shortly within being found. During an interview, on 10/14/21 at 10:44 a.m., the facility's RN 4 indicated the resident did not have pressure injuries when he admitted , but was at risk for developing them due to his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The first time she saw them, the left heel was worse than the right, and it looked like a DTI (deep tissue injury) on the right. The left was more severe, it had a circle shaped area with necrotic tissue around it, and what looked like a deep tissue injury. She could not answer how long they had been developed before they were identified. With his conditions she was not sure how rapidly it would have developed. During an interview, on 10/14/21 at 11:12 a.m., the resident's physician indicated he was the primary care doctor for the resident. He had been caring for the resident's wounds, since he had been at the facility and he had seen him 2 or 3 times. The left heel looked like a giant arterial ulcer. It had black eschar at the base, was severely painful, and had some purpuric changes down the foot to the toe that goes along with arterial insufficiency. The coccyx looked more just like pressure skin changes. He would not know how to define unavoidable. He wasn't sure how long the resident had been at the facility, but he would expect it to take weeks, more than a month for the wounds to get to the point they were at when he saw the resident on 9/16/21. During an interview, on 10/14/21 at 1:14 p.m., the Regional Director of Clinical Operations indicated staff should be inspecting heels when they turn the resident or float their heels. Pressure Ulcer Staging (Redefined in 2016), was retrieved on 10/21/21 from the NPIAP (National Pressure Injury Advisory Panel) website. The staging guidance included, but was not limited to, Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes . This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface . The Guidelines for Pressure Prevention policy, last revised 05/10/17, provided on 10/19/21 at 11:45 a.m. by the ED, included but was not limited to, . Procedures . Care plan interventions shall be implemented based on risk factors identified in the nursing assessment. Interventions may include but not be limited to: Hygiene . Inspect the skin daily during care for signs of breakdown or changes to the skin . 3.1-40(a)(1) 3.1-40(a)(2) 3.1-40(a)(3)

Based on record review, and interview, the facility failed to develop and implement appropriate fall interventions for 1 of 4 residents reviewed for accidents. (Resident 30) Findings include: The clinical record for Resident 30 was reviewed on 10/15/21 at 2:15 p.m. Diagnoses included, but were not limited to, fracture of right femur, [CONDITION(S)] and [CONDITION(S)] following cerebral infarctions affecting right dominant side, pain in right leg, muscle weakness, lack of coordination, cognitive communication deficit, and unsteadiness on feet. The Annual MDS (Minimum Data Set) assessment, dated 5/26/21, indicated the resident was cognitively intact, required extensive assistance of 2+ staff members with bed mobility, toileting, personal hygiene, and transfers, did not have a toileting program in place, was frequently incontinent with 7 or more episodes of urinary incontinence but at least one episode of continent voiding, and was frequently incontinent of bowel with 2 or more episodes of bowel incontinence but at least one continent bowel movement. The care plan, dated 12/05/18, indicated the resident was at risk for falling related to a history of a craniotomy and [CONDITION(S)], decreased mobility, incontinence, and weakness. Interventions included, but were not limited to, encourage resident to assume standing position slowly, keep personal items and frequently used items within reach, provide nonskid footwear, and ensure the floor is free of liquids and foreign objects, which all began on 12/5/18, and transfer with a full body lift, which began on 1/9/21. The nursing note, dated 8/13/21 at 6:00 a.m., indicated the resident was found by a CNA (Certified Nursing Aide) laying next to the bed. The resident stated she needed to go to the bathroom so she was getting up and fell . She landed on her right knee, but her left leg was hurting. There were no visible signs of injury. The nursing note, dated 8/13/21 at 12:17 p.m., indicated the resident complained of right knee and hip pain and the physician had ordered x-rays. The IDT (Interdisciplinary Team) note, dated 8/13/21 at 12:56 p.m., indicated the IDT had reviewed the recent fall event. The resident was found laying next to the bed and had indicated she was trying to get up and go to the bathroom when she fell . The resident was non-ambulatory and incontinent of bowel and bladder. She complained of knee pain. The physician and family were notified of the fall. The only new fall intervention listed was to have therapy evaluate the resident. The nursing note, dated 8/13/21 at 8:00 p.m., indicated the x-ray reported no fractures. The resident's care plan for risk for falling was updated with a new intervention for therapy to evaluate, but did not include any other new interventions. The nursing note, dated 8/24/21 at 1:25 p.m., indicated the resident was complaining of severe pain in her right knee, related to her past fall. She had bruising around her knee and it was swollen. The physician was notified and ordered another x-ray. The nursing note, dated 8/25/21 at 8:06 p.m., indicated the resident had age-indeterminate distal femoral fracture medially, potential recent or acute fracture. The physician was notified and ordered to send the resident to the hospital. The nursing note, dated 8/26/21 at 2:00 a.m., indicated the resident returned from the hospital. She had an immobilizer in place to the right knee and had orders to follow up with ortho in seven days. The PT (Physical Therapy) Therapist Progress and Discharge Summary, dated 9/3/21, indicated the resident had been on therapy caseload from 8/16/21 to 9/3/21. Therapy had assisted with positioning to accomodate her right knee immobilizer and worked towards goals of the resident being able to tolerate sitting in her wheelchair to participate in meals. The clinical record lacked documentation of any new fall interventions to address the resident's toileting status or attempts to self transfer. During an interview, on 10/12/21 at 2:42 p.m., Resident 30 indicated she had fallen and broke her leg when she was trying to go to the bathroom. She had pressed her light and waited 45 minutes and couldn't get anyone to help her, so she tried to go on her own and fell . During the same interview, the resident indicated she could walk and stand, but staff told her she could not. During an interview, on 10/18/21 at 10:10 a.m., Nurse Aide 8 indicated the resident was incontinent. At times the resident thought she could still walk and would ask to use the restroom, but they could not put her on the toilet because she was a hoyer lift. She had not ever offered the resident a bed pan. During an interview, on 10/18/21 at 10:17 a.m., CNA 9 indicated the resident was incontinent and required a hoyer lift. She did not believe the resident had ever had a toileting program or schedule. During an interview, on 10/18/21 at 1:57 p.m., the DON (Director of Nursing) indicated the resident often forgot she was incontinent and would ask to use the restroom. She often forgot she could not walk, but she could use a bed pan. She did not know if they had her on a toileting program. If the resident was getting up to go to the bathroom when she fell , she would consider interventions such as checking to see if her urine needed checked, checking on her more frequently, increase toileting frequency. She didn't know why they chose therapy as an intervention, she could see how it may not keep a fall from happening again, and strengthening wouldn't be a realistic intervention as the resident had been immobile and had not walked in a long time. Interventions should be related to the cause of the fall. When she looked at a fall, she looked at what was happening prior to the fall and see if anything was clinically going on. During an interview, on 10/18/21 at 2:12 p.m., the ED (Executive Director) indicated the resident had believed she could go to the bathroom from the day she got to the facility. She thought she could walk, even though she was non-ambulatory. During an interview, on 10/19/21 at 1:41 p.m., Physical Therapist 10 indicated she was familiar with the resident. She had worked with her the last time she was on caseload. She fell out of bed and she was having some right knee pain. She initially evaluated her for the knee pain and to see if there was anything she could do with the transfers and positioning. Her focus was on the acute pain as the result of the fall, and not interventions to prevent another fall. During an interview, on 10/19/21 at 2:06 p.m., the DON indicated the only thing she found was the intervention for therapy to evaluate. There were no other interventions identified at that time. When a fall occurred the IDT got together and discussed the fall, what happened, the root cause, and an intervention, and decisions on new interventions were based on the root cause. During an interview, on 10/19/21 at 2:11 p.m., the ED indicated the therapy evaluation was the only intervention the former DON had put into place. There were no other interventions put into place at that time. The Falls Management Program Guidelines policy, last revised 5/31/17, provided on 10/18/21 at 2:50 p.m., by the DON, included but was not limited to, [Name of Facility] strives to maintain a hazard free environment, mitigate fall risk factors and implement preventative measures . 2. Should the resident experience a fall the attending nurse shall complete the 'Fall Event' This includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce the risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and appropriateness of the interventions . 5. The resident care plan should be updated to reflect any new or change in interventions . 3.1-45(a)

Based on observation, record review and interview the facility failed to ensure respiratory signs and symptoms and outcome were monitored for 2 of 6 residents reviewed for respiratory symptoms. (Residents 10 and 36) Findings include: 1. During an observation, on 10/12/21 at 10:19 a.m., Resident 10 was observed with a congested cough. She spit mucous into a tissue and showed it to the CNA (Certified Nursing Aide). The resident appeared to have difficulty coughing up mucous. The clinical record for Resident 10 was reviewed on 10/19/21 at 1:40 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS (Miniminal Data Set) assessment, dated 7/26/21, indicated the resident was severely cognitively impaired. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The O2 (oxygen) Set - assess and observe for signs and symptoms of SOB while laying flat related to [CONDITION(S)] 3 times a day. Head of bed elevated to alleviate and reduce shortness of breath while lying flat 3 times a day. The care plan, dated 10/18/21, indicated the resident had a potential for complications, functional and cognitive status decline related to respiratory disease [CONDITION(S)]. Interventions included, medications as ordered, monitor lung sounds per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated 10/10/21 at 1:28 p.m., indicated the resident was sitting in her room and noted to be coughing up yellow colored [MEDICATION(S)]. She stated she had been coughing and it was keeping her up at night. The nurse's note, dated 10/11/21 at 4:45 p.m., indicated she refused to go to the dining room due to feeling poorly. The nurse's note, dated 10/12/21 at 9:08 a.m., the resident was having coughing spells with small amount of [MEDICATION(S)] expelled. The nurse's note,10/14/21 at 8:25 a.m., the resident was sitting in her wheel chair, in her room this morning, small cough noted and inhaler requested. The clinical record lacked documentation of monitoring of the resident's respiratory status and symptoms on the evening and night shift from the onset of symptoms, and any further monitoring on day shift for respiratory symptoms after 10/15/21. During an interview, 10/12/21 at 10:19 a.m, Resident 10 indicated she had been coughing a lot. She coughed so much last night she thought she would need to go to the hospital. She had been coughing up [MEDICATION(S)] and when she coughed she became short of breath. Her roommate indicated she was so worried about her, with that cough and congestion. During an interview, on 10/19/21 at 10:15 a.m., Resident 10 indicated she still had her congested cough and wheezing. The coughing and wheezing was worse in the early morning. She was not on oxygen at this time. Sometimes it would be hard for her to catch her breath. She was unable to sleep when she was coughing. Her cough would start getting worse in the late afternoon, nighttime and continue until early morning. The inhaler helped for a couple of hours and then stopped working. During an interview, on 10/19/21 at 10:30 a.m., RN 4 indicated when a resident had respiratory changes in condition, they would be monitored for at least 72 hours and beyond until the symptoms were resolved. The symptoms would be monitored and documented at least 1 time per shift and as needed. The shifts varied from 8 to 12 hours, so the resident should have at least 2 to 3 progress notes indicating respiratory monitoring. During an interview, on 10/19/21 at 10:50 a.m., QMA (Qualified Medication Aide) 11 indicated respiratory symptoms would be monitored until resolved. She received a report from the night shift about the resident's cough and what medications were given to the resident. 2. The clinical record for Resident 36 was reviewed on 10/19/21 at 1:33 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge MDS assessment, dated 1/4/21, indicated the resident was moderately cognitively impaired. The physician orders, included, but were not limited to, [MEDICATION(S)] tablet, 500 mg (milligrams) 1 tablet, oral daily x 7 days, once a day. Chest x-ray, 2 views, one time, with a start date of 7/23/21. The Change in Condition assessment note, dated 7/23/21 at 2:08 p.m., indicated the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note, dated 7/23/21, at 7:59 p.m., indicated the resident's CXR (chest x-ray) showed mild bibasilar atelectasis or infiltrates. The nurse's note, dated 7/31/21 at 8:41 a.m., resident continues ABT (antibiotics) for pneumonia, no adverse side effects. The clinical record lacked documentation for respiratory symptom monitoring for the night shift in the nurse's notes or the observation notes. During an interview, on 10/19/21 at 2:15 p.m., LPN (Licensed Practical Nurse) 7 indicated if a resident were having symptoms they would be move to transmission precautions and Covid tested immediately and monitored. During an interview on 10/19/21 at 1:25 p.m., the DON (Director of Nursing) indicated the respiratory monitoring for a resident with symptoms would be documented in the events and progress notes. On 10/19/21 at 2:11 p.m., the DON provided a copy of the Infection Prevention and Control Program, dated 11/10/17, which included, but was not limited to, .2. be. Surveillance activities to identify, investigate, control, and prevent the spread of infection. Infections shall be tracked per hall/unit, type of infection, and monitor lab reports, to identify organism(s).g. Monitor health status of resident (i.e., identifies those at risk for infection; reviews immunization status, ect.). 3.1-47(a)(6)

Based on record review and interview, the facility failed to ensure post-[CONDITION(S)] monitoring of a [CONDITION(S)] access site as ordered for 1 of 1 resident's reviewed for [CONDITION(S)]. (Resident 27) Findings include: The clinical record for Resident 27 was reviewed on 10/15/21 at 8:54 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan, initiated on 9/8/21, indicated the resident had renal failure resulting in a need for [CONDITION(S)]. Interventions included, but were not limited to, assess access site for signs of localized infection such as swelling, redness, pain or tenderness, heat at the area, purulent drainage, bloody/malodorous [MEDICATION(S)] and observe catheter site per orders. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .m The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The review of the September 2021 TAR (Treatment Administration Record) indicated the orders, scheduled for 6:00 a.m. to 2:00 p.m., to monitor the port for signs of infection, monitor the AV shunt for bruit and thrill, monitor the AV shunt for redness, swelling, signs of infection, pain, warmth, exudate, tenderness, numbness, and extremity swelling, and monitor the AV shunt to the left antecubital were documented as not completed, on the following days and times due to the resident being unavailable or at [CONDITION(S)], on 8/30/21 at 8:12 a.m., 9/10/21 at 6:28 a.m., 9/13/21 at 6:40 a.m., 09/15/21 at 6:38 a.m., 9/20/21 at 8:04 a.m., and 9/22/21 at 8:11 a.m. The [CONDITION(S)] Center Communication Form observations for August 30, and September 10, 13, 15, 20, and 22, 2021, lacked documentation of completion of the post-[CONDITION(S)] assessments, including monitoring of the access site. The section of the forms titled, Assessment upon return from [CONDITION(S)] were left blank. During an interview, on 10/19/21 at 11:10 a.m., RN 4 indicated they monitored [CONDITION(S)] patients access sites for bruit and thrill, bleeding from the site, signs of infection, like redness, warmth, and swelling. There was an order to monitor for those things and if they had anything they would document it under the progress notes. It was to be completed every shift, and she would monitor the site upon return from [CONDITION(S)]. During an interview, on 10/19/21 at 1:48 p.m., the DON (Director of Nursing) indicated the resident went to [CONDITION(S)] on Mondays, Wednesdays, and Fridays. He left around 5:45 a.m. and got back around 10:00 a.m. He would return before first shift ended. She would expect, upon return, for the post-[CONDITION(S)] assessment to be done. The port assessment and monitoring should be done daily and documented on the observation as well as in the MAR (Medication Administration Record). The Guidelines for [CONDITION(S)] policy, last revised 5/11/16, provided on 10/19/21 at 9:30 a.m. by the ED, included, but was not limited to, . 5. Upon return from the [CONDITION(S)] Provider the campus shall: a. Provide ongoing monitoring of the shunt site for signs of complication . 7. Monitor the AV fistula/graft/central venous catheter daily and document in resident medical record . 8. Monitor AV shunt daily for bruit and thrill . 3.1-37(a)

Based on record review and interview, the facility failed to ensure appropriate infection control practices were followed during the COVID-19 pandemic, related to testing of a symptomatic resident for 3 of 7 residents reviewed for infection control. (Residents 4, 10, and 36) Findings included: 1. The clinical record for Resident 4 was reviewed on 10/18/21 at 9:52 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Encourage social distancing and for resident to wear a mask when out of room and/or when staff care. The nurses note, dated 10/08/21 at 5:19 p.m., indicated the resident had a productive cough with sputum being thick and green, audible wheezing noted and lung sounds were diminished. The resident also had diarrhea and the resident stated that her chest felt tight. Mild confusion was also noted. The Nurse Practitioner ordered [MEDICATION(S)] nebulizer treatments TID (three times a day), [MEDICATION(S)] 500mg (milligrams) BID (twice daily) x (times) 10 days, Robitussin DM ([MEDICATION(S)]) 2 tsp (teaspoons) QID (four times a day) until cough was cleared up. The clinical documentation lacked orders to test the resident for COVID-19. The nursing note, dated 10/09/21 at 1:14 a.m., indicated the resident was resting in bed .Wheezing was audible and lungs sounds were diminished to all bases. The nursing note, dated 10/09/21 at 10:22 a.m., indicated the resident's cough and congestion continued with no signs of distress noted. The nursing note, dated 10/13/21 at 9:56 a.m., indicated the antibiotic was given as ordered with no side effects or cough. Remained afebrile with no complaints at this time. During an interview, on 10/18/21 at 9:00 a.m., the Administrator indicated the facility had not tested the residents for COVID-19 since May because they hadn't been in outbreak testing. During an interview, on 10/18/21 at 9:25 a.m., RN 3 indicated that if a resident was experiencing any type of symptom, such as cough or temperature, the facility would COVID test them. During an interview, on 10/18/21 at 9:30 a.m., the Director of Nursing (DON) indicated that whether vaccinated or not, the facility would COVID test the resident if they were showing any type of symptoms. During a second interview with the DON at 11:25 a.m., she indicated the Nurse Practitioner wanted to do the antibiotics instead of performing a COVID test, because she did not feel the symptoms were COVID related. 2. The clinical record for Resident 110 was reviewed on 10/13/21 at 1:52 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing note, dated 10/10/2021 at 1:28 p.m., indicated the resident was noted to be coughing up yellow colored [MEDICATION(S)]. She stated she had been coughing and it had been keeping her up at night. The MD (Medical Doctor) was notified and a 2 view CXR (chest x-ray) was ordered. The clinical record lacked documentation of any orders to test the resident for COVID-19. The nursing note, dated 10/11/2021 at 4:45 p.m., indicated no cough or congestion was noted, but the resident refused to go to the dining room due to feeling poorly. The CXR revealed no infiltrate and she was afebrile. The nurses note, dated 10/12/2021 at 9:08 a.m., indicated the resident was having coughing spells with a small amount of [MEDICATION(S)] expelled. During a interview with the DON, at 11:25 a.m., she indicated the Nurse Practitioner wanted to do the inhaler instead of performing a COVID test. She did not feel the symptoms were COVID related. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A second order was also noted for the following Obtain temperature and O2 BID and monitor for new onset or worsening s/s (signs/symptoms) of COVID-19: Fever greater than 100.0, chills, cough, nausea, vomiting, diarrhea, shortness of breath, fatigue, headache, muscle/body aches, congestion, runny nose, sore throat, and/or loss of taste or smell. Encourage social distancing and for resident to wear mask when out of room and/or when staff care. 3. The clinical record for Resident 36 was reviewed on 10/19/21 at 1:33 p.m. The diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge MDS assessment, dated 1/4/21, indicated the resident was moderately cognitively impaired. The Change in Condition assessment note, dated 7/23/21 at 2:08 p.m., resident noted to have a wet a cough. When lungs were listened to, crackles were heard in bilateral lung lobes. The nurse's note, dated 7/23/21 at 7:59 p.m., indicated the resident's CXR (chest x-ray) was received and showed mild bibasilar atelectasis or infiltrates. The clinical record lacked documentation of the resident being Covid -19 tested when the resident presented with respiratory symptoms. During an interview, on 10/19/21 at 2:15 p.m., LPN (Licensed Practical Nurse) 7 indicated if a resident was having symptoms they would be move to transmission precautions and Covid tested immediately and monitored. The CDC (Center for Disease Control) Guidance, titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, last updated on 9/10/21 indicated Testing: .Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a [CONDITION(S)] test as soon as possible . 3.1-18(b)

Based on observation, record review, and interview, the facility failed to ensure call lights were accessible for 5 of 58 residents observed. (Resident 2, 7, 36, 46, and 27). Findings include: 1. During an observation and interview, on 6/12/19 at 9:13 a.m., the call light was observed on the recliner behind Resident 2's chair, and out of reach. The resident indicated the call light was out of reach occasionally. The clinical record was reviewed on 6/17/19 at 8:37 a.m., the resident's [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) assessment, dated 5/21/19, indicated the resident was cognitively intact. The resident required extensive assistance for bed mobility, transfer, locomotion on or off unit, dressing, toilet use, and personal hygiene, and supervision for eating. The mobility device was a wheelchair. The current care plan, dated 1/22/18, for Resident 2 indicated the Resident is at risk for falling R/T (related to): hx (history) of falls, weak, mobility, meds, new environment. Interventions included, .Keep call light within reach . 2. During an observation and interview, on 6/14/19 at 2:03 p.m., Resident 7 was sitting in his recliner. The resident's call light was laying on the bed out of the residents reach. Resident 7 indicated he wanted the call light on his bedside table. So it would be within reach while he was in his recliner and he wanted the call light on his bed when he was in bed. The clinical record was reviewed on 6/13/19 at 1:41 p.m. The resident's [DIAGNOSES REDACTED]. The MDS Quarterly Review assessment, dated 3/15/19, indicated the resident was cognitively intact and required extensive assistance for bed mobility, transfer, supervision for walking in room, locomotion on unit, extensive assistance for dressing, eating, toilet use, and personal hygiene. The mobility device was a wheelchair. The Care Plan, dated 12/07/18, indicated the Resident is at risk for falling R/T: decreased mobility, [MEDICAL CONDITIONS]. Interventions included, .Keep call light within reach . During an interview, on 6/17/19 at 9:03 a.m., LPN (Licensed Practical Nurse) 7 indicated if the call lights were out of reach, she would place it near the resident, and educate the CNA about placing the call light near the resident. 3. Observations made during an interview on 6/12/19 at 8:59 a.m., Resident 36's call light was behind her, laying across her bedside dresser. The resident indicated she was unable to reach her call light. During an observation and interview, on 6/14/19 at 2:09 p.m., Resident 36's call light was behind her wheelchair and the resident was unable to reach it to call for help. The resident indicated, I don't know where my light is. I want to go to bed. A review of the clinical record, on 6/14/19 at 3:00 p.m., indicated the resident's [DIAGNOSES REDACTED]. A review of the annual MDS assessment, dated 5/3/19, indicated the resident was cognitively intact. The resident required extensive assistance of two staff members for activities of daily living. The plan care for Resident 36, dated 7/11/17, indicated the , . resident is at risk for falling .Keep call light in reach . During an interview, on 6/17/19 at 8:52 a.m., LPN 4 she indicated We are to put the call light next to the residents within reach. If they can't use a call light, we give them a soft pad. For the residents that can't use a call light or pad, we check on them every 2 hours and more often if needed. During an interview, on 6/17/19 at 8:54 a.m., CNA 12 indicated, We are supposed to put the residents call lights within reach of the residents. 4. An observation, on 6/14/19 at 2:05 p.m., of Resident 46 indicated the resident was lying in bed. Her call light was curled up on the floor, under the bed, where the resident could not reach it. An observation, on 6/17/19 at 8:40 a.m., of Resident 46 indicated the resident was lying in bed. Her call light was curled up on the floor, under the bed, where the resident could not reach it. During an interview, on 6/17/19 at 8:48 a.m., CNA 10 and CNA 13 both indicated the resident's call light should not be under the bed. The call light should be clipped to the resident's sheet or clothing and kept in reach at all times. The clinical record was reviewed on 6/17/19 at 1:40 p.m. The resident's [DIAGNOSES REDACTED]. The annual MDS assessment, dated 5/7/19, indicated the resident had moderate cognitive impairment, and required extensive assistance for personal hygiene, toilet use, and dressing. The care plan for Resident 46, dated 5/24/19, indicated the Resident is at risk for falling . Keep call light in reach . 5. An observation, on 6/17/19 at 8:42 p.m., of Resident 27 indicated the resident was sitting in her wheelchair by the window in her room. Her call light was sitting on the end table, across the room, out of the resident's reach. A fall mat was in place, which would have prevented the resident from being able to propel her wheelchair to access the call light. During an interview, on 6/17/19 at 8:50 a.m., CNA 10 and 13 indicated the resident could not have reached her call light with it being on the end table. The call light should have been clipped to the resident or her wheelchair and kept in reach at all times. The clinical record was reviewed, on 6/17/19 at 1:45 p.m., for Resident 27. The resident's [DIAGNOSES REDACTED]. The annual MDS assessment, dated 5/22/19, indicated the resident had moderate cognitive impairment, and required extensive assistance for bed mobility, transfers, locomotion, dressing, toileting, and personal hygiene. The care plan, dated 6/11/19, for Resident 27 indicated the Resident is at risk for falling . Keep call light in reach . During an interview, on 6/17/19 at 9:04 a.m., the DON (Director of Nursing) indicated call lights should be kept within reach of the residents at all times and CNAs should check every two hours to ensure they are in reach. The Guidelines for Answering Call Lights Procedure, dated 5/11/16, indicated, 16. If nothing else is needed, return the call light to within reach of the resident . 3.1-19(u)

Based on record review and interview, the facility failed to ensure fluid restriction orders were followed, the care plan was updated for noncompliance, and the physician was notified of a noncompliance for 1 of 2 residents reviewed for [MEDICAL TREATMENT]. (Resident 32) Findings include: During the review of the clinical record on 6/14/19 at 1:51 p.m., Resident 32's [DIAGNOSES REDACTED]. The review, on 6/14/19 at 2:46 p.m., of the care plan dated 6/11/19, indicated the Resident has [MEDICAL CONDITION] resulting in need for [MEDICAL TREATMENT] . Resident will be free from complications associated with [MEDICAL TREATMENT] . Diet and fluid restriction per orders . The care plan lacked documentation for noncompliance with fluid restriction. The current physician's orders [REDACTED]. The Nutrition Quarterly Assessment note, dated 5/7/19, indicated the resident had been placed on a 1000 mL per day fluid restriction due to increased fluid retention and need for additional [MEDICAL TREATMENT] treatments required. The review of the Intake & Out take Report, indicated between the dates of 5/7/19 and 6/17/19, the resident went over her fluid restriction limit for 20 of the 44 days by an average of 483 mL in excess fluids per day. The clinical record lacked documentation of physician's notification. During an interview, on 6/17/19 at 10:26 a.m., CNA (Certified Nursing Aide) 10 indicated the resident was not on a fluid restriction. During an interview, on 6/17/19 at 10:29 a.m., LPN (Licensed Practical 7 indicated, She (Resident 32) gets 1000 mLs a day. I give her 120 mLs with medications. With meals she gets 240 mLs with breakfast and lunch and 180 mLs for dinner. She does very well with it. She's alert and oriented and she doesn't complain about it. During an interview, on 6/17/19 at 10:31 a.m., CNA 11 indicated, She's (Resident 32) on a fluid restriction. Every once in a while she asks for extra, but she knows what she's allowed . During an interview, on 6/17/19 at 10:36 a.m., the DON (Director of Nursing) indicated, I actually was looking at that the other day. [MEDICAL TREATMENT] placed her on a restriction because they're only allowed to remove so much . She was pushing that limit of being over what they could take off of her. They said on Wednesdays she still was having issues. They can't remove the restriction . A couple weeks ago I had to intervene because she was giving the staff problems as far as taking the cup out of her room . I feel like she tries to, but I feel like there's some days where she is non-compliant. I feel like on some days she drinks what she wants to drink, and other days she cuts back . I didn't document a note about contacting [MEDICAL TREATMENT] and letting the doctor know . I think in some instances it could probably be a documentation issue, but not all. I know on some days that she probably is going over. During an interview, on 6/17/19 at 10:57 a.m., Clinical Support indicated, They should have notified the physician if she was going over her fluid restriction and it wouldn't hurt to have a progress note put in when she goes over. The Guidelines for Fluid Restriction Policy and Procedure, dated 5/11/16, provided on 6/17/19, included, but was not limited to, . Purpose . To ensure fluids are provided within the physician order [REDACTED]. Should the resident and/or responsible party chose (SIC) not to comply with the recommended fluid restriction a Self Determination of Care should be completed explaining the risk(s) of noncompliance . If the resident and/or responsible party continues to refuse recommended care intervention after the risk(s) have been explained an order should be obtained to discontinue the fluid restriction . 3.1-37(a)

Based on record review and interview, the facility failed to ensure the development of a care plan and the follow up monitoring by the physician for 1 of 6 residents reviewed for psychosocial well-being. (Resident 7). Findings include: The clinical record was reviewed on 6/13/19 at 1:41 p.m. Resident 7's [DIAGNOSES REDACTED]. The review of Resident 7's care plans lacked documentation of suicidal ideation's and depression. The Nursing note, dated 12/6/18 at 2:44 a.m., indicated cnas (Certified Nursing Aide), qma (Qualified Medication Aide) and nurses been in with resident several times this shift with resident stating he wants to die and wasting my time hanging his bottle feed (Enteral Nutrition) and he wished he had a gun to shoot himself. staff has sat with resident and been in and out of room numerous times all eve (evening) . will continue to monitor. A Nursing note, dated 12/17/18 at 6:34 p.m., indicated .New orders rec'd (received) and noted for social services talk therapist to talk to resident r/t (related to) talking of wishing death and suicidal thoughts. The Social Service note, dated 3/4/19 at 1:44 p.m., indicated Therapy approached writer to let aware that res.(Resident) was refusing therapy today, saying that he wished he were dead and if he had a knife then he would end himself. Writer went to speak with res and res. stated he has lived for [AGE] years and that is long enough, he is never going to get over this sickness. Res stated he needed writer to get him a knife so he could end it. Nursing aware and doing 15 min checks on res. D.O.N. (Director of Nursing) went to speak with res and res also told her that he needed a knife so that he could slit his wrist. POA (Power of Attorney) called and agreeable to send to . (psychiatric hospital) for evaluation. The Nursing note, dated 3/5/19 at 12:32 a.m., indicated EMS (Emergency Medical services) just showed up and took this resident to . (psychiatric hospital) via (by way of) stretcher/ambulance 2 EMS personnell (sic) . The Nursing note, dated 3/13/19 at 9:40 p.m., indicated (Recorded as Late Entry on 3/14/19 at 4:12 a.m.) This resident return back from . (psychiatric hospital) at this time via ambulance with 2 ems personnell (sic) . The Nursing note, dated 5/29/19 at 1:19 p.m., indicated This nurse contacted MD (physician's name) in regards to resident feeling more 'depressed and homesick'. This nurse asked resident if he had any thoughts of harmfing (sic) himself or suicide; resident denied any of those thoughts. No new orders at this time. awaiting MD response. A review, on 6/14/19 at 11:05 a.m., of the Resident Mood Interview by the Social Services Director on 12/5/18 and 12/25/18, indicated the resident was, feeling down, depressed or hopeless nearly every day, feeling bad about himself, or letting self or others down for several days. Continue current plan of care. On 2/4/19 the Mood Interview was not completed. On 3/15/19 the Interview indicated Feeling down, depressed or hopeless, half or more of the days. On 6/14/19 at 11:22 a.m., the review of the New/Worsening Behaviors Event occurrence on 12/4/18 at 9:40 a.m., completed by RN 5 indicated, Res stating that he doesn't want to live anymore. States that he wished he had a gun because he would kill himself.Resident informed and included (to the extent possible) of change in Plan of Care. A review, on 6/14/19 at 11:33 a.m., of the physician's orders [REDACTED]. Effective 3/14/2019 may see PRN (As Needed) psychologies. During an interview, on 6/17/19 at 8:43 a.m., the MDS (Minimum Data Set) Coordinator indicated, she was not aware the resident had [MEDICAL CONDITION]. The care plan for [MEDICAL CONDITION] would be developed by Social Services. We did the nursing side of the care plans. On 6/17/19 at 9:05 a.m., during an interview with LPN (Licensed Practical Nurse) 4 indicated the resident was sent out to psychiatric hospital for depression, quality of life,and eating. He did not have orders to monitor for depression or suicidal ideation. She could not locate a care plan for mood. If Psychiatric staff saw him, they would document in the Progress Notes. During an interview on 6/17/19 at 9:12 a.m., the DON indicated the resident was seen by Psych right after re-admission from the psychiatric hospital. The physician does not like for Psychiatric staff to follow his residents. On 6/17/19 at 9:17 a.m., during an interview, the Social Service Director indicated she did not have a care plan for suicidal ideation for the resident. She stated she was the person to develop the care plan for behavioral issues. During an interview on 6/17/19 at 11:12 a.m., the Social Service Director indicated the resident had never mentioned feeling down, depressed, or suicidal. It was the nurses, he had talked to about feelings of depression and suicide. During an interview on 6/18/19 at 8:40 a.m., the DON indicated the Social Service Director would be the person who would develop the care plans for psychiatric issues. The physician did not like to use psychiatric consults and preferred to address those issues himself. She acknowledged the physician had not evaluated the resident on documented assessments for psychiatric issues. The review of the Comprehensive Care Plan Guideline dated 5/22/18, included, but was not limited to, .b. Care plan interventions should be reflective of risk area(s) or disease processes that impact the individual resident. c. Should new identified areas of concern arise during the resident's stay, they should be addressed on the care plan . The review of the current Behavior Planning and Intervention procedure, indicated, but was not limited to, .a .10. Obtain a mental health or neurological consult to provide specific pharmological treatment for [REDACTED].d .6. establish coping skills groups to help residents who are more cognitively intact resolve problems and cope with the stresses of life in the campus . 3.1-43(a)(1)

Based on interview and record review, the facility failed to ensure the physician was notified of a two hour delay for hospital transportation of a resident (Resident B) with clinical changes for 1 of 3 residents reviewed for physician notification. Findings include: The clinical record for Resident B was reviewed on 3/8/19 at 10:57 a.m. [DIAGNOSES REDACTED]. The progress note, dated 1/9/19 at 3:54 p.m., indicated Resident B continued with a temperature of 101.4, hot to touch, jerking of the extremities, moist lung sounds, and spitting up thick sputum. The physician was notified with a new order to send the resident to the hospital for evaluation. EMS (emergency medical services) was called and EMS notified LPN (Licensed Practical Nurse) 4 it would be a couple of hours before they could get there due to making another run. LPN 4 notified the family and the Executive Director of the delay. The clinical record lacked documentation of physician notification related to the delay in transportation to the hospital for evaluation. During an interview on 3/11/19 at 11:16 a.m., LPN 5 indicated the physician should be notified if there would be a two hour delay in transportation for a hospital evaluation. This Federal tag relates to Complaint IN 572 3.1-37

Based on observation and interview, the facility failed to provide privacy during direct care and meet the resident's needs related to toileting for 5 of 11 residents reviewed for resident rights. (Residents 3, 36, 19, 4, and 37). Findings include: 1. During an observation, on 07/13/18 at 09:53 a.m., LPN (Licensed Practical Nurse) 1 with the assistance of CNA (Certified Nursing Aide) 7 provided pressure ulcer dressing care to the coccyx for Resident 3. The resident's door was shut. The window blinds and the bathroom door were left open. The resident's pants were lowered and the brief was unfastened. The resident was rolled onto her right side with her buttocks pointing toward the window. Wound care was provided with the old dressing being removed and a new dressing applied. CNA 7 performed perineal care for the resident with the blinds still open. The clinical record was reviewed for Resident 3. The quarterly MDS (Minimum Data Set) assessment, dated 03/06/18, indicated the resident's cognition was severely impaired. The resident required extensive assistance of two physical staff members for personal care. 2. During an observation, on 07/13/18 at 02:02 p.m., CNA 7 and CNA 8 provided indwelling urinary catheter care for Resident 36. The entry door was left open. The privacy curtains were left open the length of the foot of the bed, from the intersection of the tracks to the window. The clinical record was reviewed for Resident 36. The annual MDS assessment, dated 05/14/18, indicated the resident's cognition was moderately impaired. The resident required extensive assistance of two physical staff members for personal care. On 07/16/18 at 10:58 a.m., during an interview Resident 36 indicated she would not like for anyone to see her naked, except for the staff, who provide care and/or if someone would have came into her room while she was receiving care. On 07/17/18 at 01:55 p.m., during an interview CNA 9 indicated for resident's privacy she would pull the privacy curtains, close the blinds, close the entry door, and cover the resident. This would be done for all residents care. During an interview, on 07/17/18 at 02:40 p.m., the DON (Director of Nursing) indicated the staff should close the door and pull the privacy curtain, if not in a private room. The window blinds should also be closed. The review of the current Urinary Catheter Care policy, provided on 07/12/18 at 10:10 am. by the Administrator, indicated, but was not limited to, .Prior to beginning the procedure .close the room entrance door .Pull the privacy curtain .Close drapes/lower shades/close blinds, as applicable . 3. During an interview, on 07/18/18 at 01:00 p.m., Resident 19 indicated Takes maybe an hour to answer the call light. I frequently wet myself waiting for them and then lay in it. Review of the Quarterly MDS (Minimum Data Set) assessment, dated 04/18/18, indicated Resident 19 was frequently incontinent. The resident was alert and oriented with intact cognition and required extensive assistance of two physical staff members for toileting. The resident's [DIAGNOSES REDACTED]. 4. During an interview, on 07/18/18 at 01:05 p.m., with Resident 4 and a family member, the resident indicated Takes 30 to 60 minutes for them to answer call lights for me to go to the bathroom. The family member indicated, (resident) has called her after waiting so long for them to answer the call light will call the facility for them to go check on her. She has had accidents where she wet herself because she has waited so long . Review of the Quarterly MDS, dated [DATE], indicated Resident 4 was frequently incontinent. The resident was alert and oriented with intact cognition and required extensive assistance of one physical staff member for toileting The resident's [DIAGNOSES REDACTED]. 5. During an interview, on 07/18/18 at 01:45 p.m., Resident 37 indicated Takes a long time for them to answer the call light. I drink coffee which goes right through me and I get back to my room around 08:00 a.m. It sometimes could be almost lunch time before they may take me to the bathroom. I have soiled myself because of it. Review of the annual MDS, dated [DATE], indicated the resident was occasionally incontinent. The resident was alert and oriented with intact cognition and required extensive assistance of two physical staff members for toileting. The resident's [DIAGNOSES REDACTED]. 3.1-3(a) 3.1-3(t)

Based on interview and record review, the facility failed to ensure the physician and family were notified of a change in the resident's abnormal blood sugar level. This deficient practice affected 1 of 5 residents reviewed for change in condition. (Resident 56). Findings include: A review of the clinical record for Resident 56, on 7/17/18 at 09:46 a.m., indicated the resident's [DIAGNOSES REDACTED]. On 7/18/18 at 10:18 a.m., a review of the physician's orders [REDACTED]. For a BS of less than 50 MG (Milligrams)/DL (Deciliters) and unresponsive or unable to swallow nursing staff were to administer 1 mg (milligram) of [MEDICATION NAME] IM (Intramuscular). The resident should awaken within a couple of minutes. If the resident continues to be unresponsive nursing staff should administer an additional 1 mg [MEDICATION NAME] IM and call emergency assistance immediately. On 7/18/18 at 10:22 a.m., a review of the progress note, dated 5/11/2018, indicated this nurse was alerted by CRCA (Certified Resident Care Assistant) that resident not acting right and very diaphoretic. Resident was found to have B/S (Blood Sugar) of 29. [MEDICATION NAME] shot given per [DIAGNOSES REDACTED] order. resident rechecked after 10 min and B/S was 119. Resident also ate a couple peanut butter crackers. will continue to monitor resident through night. During a review of Resident 56's clinical record, on 7/18/18 at 10:22 a.m., the record lacked documentation indicating the facility notified the physician and or the resident's family of the change in the resident's condition. During an interview, on 7/18/18 at 10:54 a.m., LPN 1 indicated If we have a resident with a low blood sugar, we have orders for a [MEDICATION NAME] shot and we can also give them food. We always notify the doctor and recheck the blood sugar. On 7/18/18 at 11:06 a.m., during an interview with QMA (Qualified Medication Aide) 2 she indicated If I have a resident that has a low blood sugar, I will go and inform my nurse. I can give the resident orange juice if they are alert and responsive. I know the nurse can give them [MEDICATION NAME] and if the blood sugar was below 50 we are to hold the insulin and notify the doctor. On 7/18/18 at 2:14 p.m., during an interview with DNS (Director of Nursing Services) she indicated I could not find any documentation where the nurse called the doctor for resident 56's blood sugar being 29. On 7/18/218 at 2:49 p.m., the DNS presented a copy of the facility's current policy titled Notification of Change in Condition. Review of this policy included, but was not limited to, .To ensure appropriate individuals are notified of change in condition. The facility must inform the resident, consult with the resident's physician and if known notify the resident's legal representative when: A significant change in the resident's physical, mental or psychosocial status 3.1-5(a)(2)(a)

Based on interview and record review, the facility failed to follow physician orders [REDACTED]. This deficient practice affected 1 of 5 residents reviewed for nursing services. (Resident 56). Findings include: A review of the clinical record for Resident 56, on 7/17/18 at 09:46 a.m., indicated the resident [DIAGNOSES REDACTED]. On 7/18/18 at 10:18 a.m., a review of the physician's orders [REDACTED].[MEDICATION NAME] (insulin [MEDICATION NAME]) Insulin Pen; 100 units/ml (milliliter) (3ml); amt:(amount) 60 units; subcutaneous Special instruction: 60 units q (every) hs (bedtime) subq (subcutaneously). A review of the progress notes, on 7/18/18 at 10:33 a.m., indicated bs (blood sugar) 132 at h.s. (bedtime) [MEDICATION NAME] held. 3rd shift nurse aware of no insulin being given. On 7/18/18 at 10:34 a.m., a progress note review, dated 2/20/2019 at 09:49 a.m., indicated Spoke with (Doctor's name) r/t (related to) residents BS levels DR (doctor) stated not to hold insulin unless she is first called, continue same dose of insulin, cont (continue) to monitor BS per orders will f/u with any changes. On 7/18/18 at 10:54 a.m., during an interview with LPN 1, she indicated our sliding scale is 60 and below, we notify the doctor and explain why we want to hold the insulin and if it is o.k. (okay). During an interview with the DNS (Director of Nursing Services), on 7/18/18 at 1:15 p.m., she indicated If we have a low blood sugar or want to hold the residents insulin, we will call the doctor first. If we have parameters, we will use those and call the doctor. On 7/18/18 at 9:52 a.m., the DNS presented a copy of the facility's current policy titled Guidelines for Hyper/[DIAGNOSES REDACTED]. Review of this policy at this time included, but was not limited to .All residents diagnosed with [REDACTED].Resident with specific orders will be followed as written . 3.1-35(g)(1)

Based on interview and record review, the facility failed to provide suctioning and proper oxygenation for a resident (Resident B) with a [MEDICAL CONDITION] in an emergency situation which resulted in hospitalization with subsequent death for 1 of 1 resident reviewed for [MEDICAL CONDITION] care. The Immediate Jeopardy began on 5/8/18 at 6:00 p.m. when a resident, with a [MEDICAL CONDITION], was in respiratory distress and the facility failed to provide suctioning and proper oxygenation in an emergency situation. The Administrator, Director of Health Services, and the Regional Campus Support were notified of the Immediate Jeopardy on 6/21/18 at 4:33 p.m. Findings include: The clinical record for Resident B was reviewed on 6/21/18 at 11:10 a.m. [DIAGNOSES REDACTED]. The admission observation, dated 5/8/18 at 4:07 p.m., indicated Resident B was admitted with a [MEDICAL CONDITION] and had diminished lung sounds. The physician order, dated 5/8/18, indicated the resident was to receive oxygen at 2 liters per minute with 28% humidification per [MEDICAL CONDITION] mask continuously. The vital signs report indicated the resident's oxygen saturation was 94% at 4:07 p.m. The vital signs report indicated the resident's oxygen saturation was 94% at 5:41 p.m. The progress note, dated 5/8/18 at 5:45 p.m., indicated the medical supply vendor arrived and set up humidification to oxygen. The progress note, dated 5/8/18 at 6:00 p.m., indicated the nurse walked into the resident's room to find the resident struggling for air. The oxygen tubing was checked and hooked up properly. The resident's oxygen saturation was 52% and the nurse summoned for help. A second oxygen concentrator was brought into the room, and oxygen was administered to the [MEDICAL CONDITION] and face mask. At 6:15 p.m., the resident's oxygen saturation was at 49%; staff continued to work with the resident and 911 was called. At 6:20 p.m., the resident's oxygen saturation was 58%; EMS (emergency medical services) arrived and took over oxygen delivery. At the time of transfer, the resident's oxygen saturation was at 91%. During an interview, on 6/21/18 at 2:01 p.m., LPN (Licensed Practical Nurse) 4 indicated the resident arrived at the facility around 4:00 p.m. and was lethargic. The resident was switched over to the facility oxygen with humidification per [MEDICAL CONDITION]. The medical supply vendor arrived and hooked the resident up to a different humidified oxygen machine. LPN 4 went back to make sure the resident was hooked up appropriately. Around 6:00 p.m., LPN 4 went back to the resident's room. The resident was pulling on his oxygen tubing and trying to sit up, at which time she summoned for help. LPN 4 retrieved another oxygen concentrator thinking maybe the original concentrator was not working and 911 was called. When EMS arrived they took over resident care. LPN 4 indicated she did not suction the resident due to she never heard the resident gurgling. If the resident had a plug, she would of suctioned the resident, but she was not sure what a plug sounded like. During an interview, on 6/21/18 at 3:00 p.m., the Director of Nursing indicated they did not have an emergency [MEDICAL CONDITION] policy. During an interview, on 6/22/18 at 1:55 p.m., MSV (Medical Supply Vendor) 5 indicated, on 5/8/18, he was sent to deliver [MEDICAL CONDITION] mask supplies and an air compressor to the nursing home. He did not go in Resident B's room to check and see if the equipment was set up. He only looked into the room to make sure the resident had the supplies that were needed. The EMS Patient Care Report, dated 5/8/18 at 6:33 p.m., indicated upon arrival to the resident's room there were several nurses in the room with a male patient who appeared lethargic and in distress. Staff advised the patient was admitted today and seemed fine upon admission. Shortly after the family had left, staff found the patient lethargic with oxygen saturation in the 60's. The patient had a [MEDICAL CONDITION] and normally received humidified oxygen via (per) [MEDICAL CONDITION] mask. Staff were trying to deliver oxygen via [MEDICAL CONDITION] mask and NRB (non rebreather) at 5 LPM (liters per minute). While adjusting oxygen delivery, (EMS) noted the patient's concentrator was not delivering oxygen. The patient was placed on 15 LPM over his [MEDICAL CONDITION] and continued to be pale and somewhat lethargic. With the increased oxygen he (Resident B) began to improve. During an interview, on 6/19/18 at 3:22 p.m., EMS Supervisor 6 indicated, upon arriving on scene, the resident was observed to be in respiratory distress. He had signs of panicking with gasping breaths. The resident had one mask over his [MEDICAL CONDITION], not hooked up to any oxygen tubing or other attachments, and a second mask over his mouth attached to oxygen tubing with the oxygen not turned on. Both masks were removed, a new mask was placed over the [MEDICAL CONDITION] with high flow oxygen administered, and the resident's breathing and oxygen saturation improved. The Hospital 1 emergency department note, dated 5/8/18 at 6:45 p.m., indicated the resident was admitted to the nursing home today, was found hypoxic with oxygen saturation in the 70's with difficulty breathing, and EMS reported the nursing home oxygen concentrator did not seem to be working. Upon (Resident B's) arrival the oxygen saturation was in the 70's. Respiratory therapy suctioned the [MEDICAL CONDITION] and was able to get his oxygen saturation in the 90's on 100% oxygen per [MEDICAL CONDITION] with a nasal cannula. Respiratory therapy had to suction the resident's airway multiple times in order to keep his oxygen saturation up in the 90's. Hospital 1's discharge summary, dated 5/8/18 at 11:28 p.m., included, but was not limited to, Discharge Problem .acute .chronic [MEDICAL CONDITION] with [MEDICAL CONDITION] .condition .serious The resident was stabilized at Hospital 1 and transferred to Hospital 2. The Hospital 2 history and physical, dated 5/9/18, indicated the resident was admitted for acute hypoxic [MEDICAL CONDITION] secondary to pneumonia and mucous plugging (build up of thick mucous inside the [MEDICAL CONDITION]). The Hospital 2 discharge summary, dated 5/12/18, indicated the resident was at the nursing home for several hours before he developed a mucus plug. The Hospital 2 preliminary cause of death report, dated 5/12/18 at 3:08 p.m., indicated [MEDICAL CONDITION]. The Immediate Jeopardy that began on 5/8/18 was removed on 5/9/18. when the facility completed staff education on suctioning/[MEDICAL CONDITION] care, and/or use of oxygen, 100% audit on respiratory equipment, and an audit on admissions from 5/8/18 to current to ensure there were no new admissions admitted with a [MEDICAL CONDITION]. The Immediate Jeopardy was removed on 5/9/2018 but noncompliance remained at the lower scope and severity of isolated, no actual harm with potential for more than minimal harm that was not immediate jeopardy because not all staff had been educated on suctioning/[MEDICAL CONDITION] care, and/or use of oxygen. This Federal tag relates to Complaint IN 918 3.1-47(a)(4)(5)(6)

Based on observation, record review and interview, the facility failed to ensure staff followed manufacturer's instructions designed to ensure a sling for a mechanical lift to transfer dependent residents was securely in place prior to transferring residents, from bed to wheelchair, which resulted in one dependent resident falling out of the lifted sling to the floor and sustaining a fracture, for 2 of 3 residents (Residents "B" and "C") reviewed who required the use of a mechanical lift for transfers in the sample of 3. Finding includes: 1. The record of Resident "B" was reviewed on 6/10/13 at 11:45 a.m. Resident "B" was originally admitted to the facility on [DATE]. A 5/23/13 "[DIAGNOSES REDACTED]. Review of Resident B's 1/23/12 Care Plan indicated the resident had osteoporosis and staff were to provide assistance with all transfers using a mechanical lift. A 3/13/13 Fall Risk Care plan (updated 5/22/13 and 5/29/13) indicated the resident was at risk for falls/injury and required the use of a mechanical lift for transfers. A nurse's note dated 5/22/13 at 6:15 p.m. indicated the nurse answered a Certified Nurse Assistant (CNA) verbal call for a nurse. The nurse entered Resident B's room and found Resident B on the floor laying across the mechanical lift's legs with the resident on her right side and head against the wall. The nurse's note indicated, "CNAs told this nurse that res (resident) fell out of the (mechanical lift)." The note further indicated the nurse assessed the resident and found "red place on (right) side of head. Looks like (resident) hit head on (mechanical lift) leg, bruising on the (right) side of stomach, (right) hip (and) when asked to move (extremities) (resident) couldn't move (left) shoulder. (Resident) stated (left) arm hurts so bad. Upon inspection there was a knot on (resident's) arm and it looked twisted...called MD (Medical Doctor) to send (resident) to (hospital) for (evaluation) and (treatment). Family present during fall and assessment. Family also request (resident) be sent to (hospital). Called 911." A 5/22/13 Fall Circumstance, Assessment and Intervention report, provided by the facility on 6/10/2013 at 11:50 am, indicated the resident fell out of the mechanical lift during transfer. The report further indicated the root cause was "Cloth hook was not on metal securely when sling elevated. Resident fell from sling." The facility incident report summary, provided with the above Fall Intervention report indicated "resident had fallen during a routine transfer...a strap on the upper left corner of lift pad slipped from the metal hook unexpectedly, resulting in the fall...(resident family) states that post fall, she noticed the left strap 'not attached' to the upper left hook." The summary further indicated that CNA #1 stated "they had hooked all four of the straps on to the lift. The resident was almost all of the way up in the lift when (CNA #1) heard a popping noise and resident fell ." The summary further indicated the lift sling pad was inspected and "showed no signs of weakness." The mechanical lift was inspected "per manufacturer and was functioning properly. Caregivers placed the straps on the hooks, but not securely." An incident intervention summary indicated "All staff were educated with proper (mechanical lift) procedure. Staff were able to demonstrate correct procedure with (mechanical lift) transfer...before lifting resident, staff always checks hooks of sling for proper placement and body alignment." Staff lists with signatures were attached with the summary and included manufacturer's instructions for proper use of the lift. Review of the manufacturer's training material attached to the training documentation, on 6/10/2013 at 12:15 pm, indicated the same "warning" on pages which were numbered 30, 32, 35, and 36. That warning stated "When the sling is elevated a few inches off the surface of the bed and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any attachments are NOT properly in place, lower the patient back onto the stationary surface and correct the problem-otherwise injury or damage could occur." Interview with CNA #1 on 6/10/2013 at 2:25 pm, who was present during the transfer on 5/22/13, could not confirm that the above check occurred, or that the CNA had been trained specifically on that step. The CNA indicated she had been trained in her "CNA clinicals" on use of the lift and had watched her facility orientation trainer use the lift prior to her using the lift. "She didn't instruct me; I just knew from clinicals." When asked to describe the steps when using a mechanical lift, the CNA stated "make sure the loops are pulled all the way down before we start." She did not indicate the straps were to be inspected for proper connection to the hooks once the resident had been slightly lifted. When asked to describe what occurred on 5/22/2013 the CNA stated "I hooked the right side. CNA #2 did the left (side), we started to lift her up. I was behind her to grab (the sling) from the back to move her to the bed." The CNA indicated she heard a pop and the resident fell . Interview with CNA #2 on 6/10/2013 at 2:10 pm indicated she had assisted with securing the straps during the transfer of Resident B on 5/22/13. CNA #2 indicated she then began operating the lift's remote and began lifting Resident B while CNA #1 was behind the resident's wheelchair assisting with the lift. CNA #2 did not indicate during the interview that they checked to make sure that the sling was properly connected to the hooks of the swivel bar once the resident had been slightly raised off of the surface. CNA #2 indicated they were trained to check the straps before operating the remote "but now I check more frequently and watch the hook and straps" during operation. Interview with Resident B's family member/guardian on 5/22/13 at 3:57 pm indicated the guardian was present in the room when the lift was being operated. The guardian stated the lift's strap "let loose and my sister fell forward to the side out of the sling." The guardian indicated two CNA's were present and operating the lift when the incident occurred. The guardian stated the two CNA's "were conversing with each other as they were hooking the lift up. They started lifting and they were still talking with each other when the strap let loose." The family member did not indicate that she observed the CNA's specifically check the connection of the straps to the bar once the resident was slightly off the surface. 2. During observation on 6/10/13 at 1:57 pm CNA's #4 and #5 were observed using a mechanical lift to transfer Resident C from a wheelchair to bed. During this time, staff were not observed to check the sling after it was slightly elevated a few inches off the surface of the bed and before moving the resident, to make sure that the sling was properly connected to the hooks of the swivel bar. Interview with the Director of Health Services (DHS) on 6/10/13 at 2:50 pm indicated she responded to the facility after the accident and inspected the lift. The DHS stated the sling "had all the straps intact and there was no wear or tear." The DHS demonstrated with a lift that when the straps are properly hooked, the weight being lifted prevents the strap from moving up the hook, remaining securely on the lift until the weight is released. The DHS visually demonstrated if the strap is only partially over the hook, applied weight could cause it to pull free of the hook. The DHS described the procedures to be followed when transferring residents with the lift and she did not indicate that there was to be a recheck of the straps connected securely once the resident is slightly lifted off the surface. Interview with the Assistant Director of Nursing (ADON) on 6/10/13 at 3:00 pm indicated she provided training to staff as part of her job duties. When interviewed regarding the procedures for transferring a resident using a mechanical lift, the ADON did not indicate that checking to ensure connections were secure once the resident was slightly lifted off of the surface was a step involved in using the lift. This Federal tag relates to Complaint IN 562. 3.1-45(a)(2)