Every finding on record at Harmony Utica Ridge

Based on clinical record review, resident and staff interview, and facility policy review, the facility failed to use non-pharmacological interventions prior to the administration of a medication prescribed for anxiety which caused for 1 of 1 resident (Resident #8) reviewed for chemical restraints to experience hypersomnolence (excessive sleepiness). The facility reported a census of 91.Findings includeReview of Resident #8's Minimum Data Set (MDS) annual assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. The list of diagnoses included depression, adjustment disorder with mixed anxiety and depression, and insomnia.Review of Resident #8's Care Plan dated 10/09/24, revealed a Focus area to address Resident is at risk for pain related to diagnosis neuropathy and history of bilateral BKA (below knee amputation). Interventions included, in part:a. Encourage/Assist to reposition frequently to position of comfort. Initiated: 10/09/24.b. Implement non-pharmacological interventions massage, relaxation techniques, counseling, warm/cool compress, positioning as indicated. Initiated: 10/09/24.Review of the June 2026 Review of the June Medication Administration Record (MAR), revealed an order for: hydroxyzine HCL Oral Tablet 25 mg (milligrams). Give 25 mg by mouth every 12 hours as needed for anxiety for 14 days. Start date: 5/26/26. Further review revealed hydroxyzine 25 mg administered on 6/02/26 at 1:43 AM by Staff documented that on 06/02/2026 Staff A, Licensed Practical Nurse (LPN).During an interview on 06/04/2026 at 11:07 AM, Resident #8 stated that on the evening of 06/01/2026 into the morning of 06/02/2026 he was experienced pain and anxiety. Around 1:00 AM he requested staff assist him to move out of bed into his wheelchair, as he felt it would help with the pain and help calm him down. Resident #8 recalled he was told no by nursing staff and was instead offered medication. Resident #8 stated he did not know he had an as needed (PRN), and it was explained to him that his psychiatrist had prescribed the medication. Resident #8 stated he again asked to get out of bed, and a staff he identified as Staff A, LPN told him to take his medication first and if he was still wanting to get out of bed after it was working, she would assist him to his wheelchair. He noted he took the medication and he does not remember the rest of the evening. He woke up very late that day, after activities he had planned on participating in were over. Resident #8 explained he woke up groggy and felt distressed to he had slept so long.During an interview on 06/09/2026 at 08:48 AM, Staff A, LPN, stated she was made aware of Resident #8 wanting to get out of bed into his wheelchair in the evening, though she did not recall what time. She stated when she met with the resident he requested to get out of bed into his wheelchair, but she suggested he take his medication first and offered to help him into his wheelchair if it did not work. Staff A recalled Resident #8 reported not knowing he had a PRN medication available, and she had to talk him into taking it. She reported the medication as being effective. Staff A stated she had been made aware the next day the resident had a hyper somnolent episode (difficulty being roused and waking up). She reported she was unaware of the interventions in the Care Plan for Resident #8. Staff A added she had only been working at the facility for a few weeks at this time.During an interview on 06/04/2026 at 01:27 PM, Staff B, Assistant Director of Nursing (ADON), stated she had been informed the nurse [Staff A, LPN] suggested medication first instead of getting Resident #8 up into his chair at his request. The ADON acknowledged that the nurse should have attempted a non-pharmacological intervention first, especially when requested.During an interview on 6/08/2026 at 12:39 PM, the Director of Nursing (DON) stated the nurse [Staff A, LPN] failed to utilize non-pharmacological measures first. The DON stated she expected that non-pharmacological measures are utilized first and medications should be administered if those measures fail. The DON stated Staff A should have respected Resident #8's request to get up into his chair instead of resorting to medication.Review of a facility provided document titled One-on-One Inservice Record documented that on 06/02/2026 Staff A was provided with a corrective action. It stated On 06/01/2026 it was charted resident was having aggressive behaviors so PRN anxiety med was given. The document included instruction for the staff member to always utilize non-pharmacological measures first.Review of a facility provided document titled Behavior Management Guide, documented non-pharmacological interventions should be attempted prior to the use of any psychoactive medication.

Based on clinical record review, staff and resident interview, and facility policy review, the facility failed to document the outcome of weekly skin assessments and implement a new wound care order in a timely manner for 1 of 7 residents (Resident #1) reviewed for pressure ulcer care. The facility reported a census of 91.Findings include:Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below).Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions).Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI.Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI.Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur Review of Resident #1's Minimum Data Set (MDS) dated [DATE], indicated intact cognition based on a Brief Interview for Mental Status score (BIMS) score of 15 out 15. The list of diagnoses included heart failure, peripheral vascular disease, renal insufficiency (kidney failure), and multiple sclerosis. The MDS indicated the resident at risk for the development of pressure ulcers, and admitted with one stage 1 pressure ulcer. The MDS identified Resident #1 admitted after a short-term hospital stay on 4/07/26. fThe MDS dated [DATE] indicated Resident #1 discharged for a Short-Term General Hospitalization. During an interview on 05/28/2026 at 1:51 PM, Resident #1 stated she had issues waiting for staff members during her time at the facility. She stated staff were aware she had redness or an injury on her buttocks but they weren't treating it until days after the pain worsened. She stated the pain got worse after she was seen by a wound nurse, but she did not know the date. She said it was approximately a week after seeing the wound nurse that they began treating her buttocks.The Care Plan for Resident #1 dated 4/7/26, included a Focus area to address At risk for alteration in skin integrity related to impaired ADL (activities of daily living) function/mobility. Interventions included:a. Administer treatment per physician ordersb. Follow facility policies/protocols for prevention/treatment of skin breakdown. c. Observe skin condition with ADL care.Review of the admission summary dated [DATE] at 6:36 PM revealed, in part: Resident arrived into facility via ambulance x 2 attendants from [name of hospital redacted] .Surgical wound to back of neck/upper back measured and dressing reapplied.Redness noted to sacrum area, Tx (treatment) order obtained and performed. Resident refused weight, states she has lost a lot of weight recently but stated that movement caused her pain and she would like to wait on obtaining weight.Review of the admission Skin Evaluation-Non-Pressure Wound V2 dated 4/7/26, in the EHR revealed, in part: Section A: A. Resident has a skin alteration: Yes 1. Is this a NEW skin alteration: No. 4. Indicate where the skin alteration is located.Site: Sacrum. Type: Other. Length - 6 cm (centimeters) Width 4 cm. 6. Is there any drainage noted from the wound: No. 9. Is the resident experiencing pain: No. No other wounds noted on the evaluation. 1a. Narrative: Resident arrived into the facility with redness to this area. Tx (treatment) orders obtained from hospital and placed in [name of EHR redacted]. Review of the April 2026 Medication and Treatment Administration Record (MAR/TAR) revealed the following skin assessment orders:a. Skin assessment on admission and then weekly on Friday every evening shift. Start Date: 4/9/26. D/C Date (discontinue): 4/11/26.1. Documentation on April 2026 MAR/TAR indicated this order completed as scheduled.b. Body audit weekly Friday evening shift. Start Date: 4/10/26. D/C Date: 4/21/26.1. Documentation on April 2026 MAR/TAR indicated this order completed as scheduled.c. Weekly skin assessment update all skin -sheets full body audit every evening shift every Fri for skin assessment. Start Date: 4/24/26. D/C Date: 5/02/26.1. Documentation on April 2026 MAR/TAR indicated this order completed as scheduled.Review of facility documents titled Non-Pressure Skin Condition report revealed:a. For Site Location: Sacrum1. On 04/07/2026 - Measurement: Length (cm): 6 x 4 Width (cm) x Depth (cm): [blank]; Exudate: None.Wound Bed: Pink, pale tissue; Surrounding Skin: Normal for skin; Pain: No; Progress: Not changed; Treatment: Continue; Progress Note: MASD (moisture associated skin damage - inflammation, redness or erosion of skin prolonged by exposure to moisture or chemical irritants. 2. On 4/17/26 - Healed.b. For Site Location: Left gluteal cleft1. On 4/24/26 - Condition is: [no check box marked to indicate]. Measurement: Length (cm): 4 x 2 Width (cm x 0.5 depth; Characteristics: Partial Thickness; Exudate: None.Wound Bed: Dark pink/red tissue; Surrounding Skin: Normal for skin. Pain: No.During an interview on 06/03/2026 at 12:48 PM with the Director of Nursing (DON) stated it appeared there were not skin assessments documented from the 9th through the 15th. She stated she believed the wound assessments to be incomplete. The DON also stated the wound care NP orders were not started when they were ordered.A review of a HP Skin and Wound Note entered into the EHR on 4/19/26 by wound care provider revealed, in part: Date of Service: 4/15/26.Reason for visit: first evaluation of existing wound patient by new wound care team.Upon examination today, the patient presents with a surgical incision to her posterior neck that is closed. The patient also presents with an unstageable pressure injury to her sacrum and a pressure injury to her left buttock.Wound: 2 Location: Left buttock. Primary etiology (cause): Pressure ulcer/injury. Stage/Severity: Stage 3. Wound Status: First evaluation of existing wound by new provider.size 7 cm x 5 cm x0.1 cm.pain at rest: 3. Wound 3. Location: Sacrum. Primary etiology: Pressure ulcer/injury. State/Severity: Unstageable. Wound Status: First evaluation of existing wound by new provider.Size: 3.5 cm x4 cm x0.1 cm.WOUND TREATMENT.Wound #2 Left Buttock: Recommendations: 1. Cleanse with wound cleanser. 2. Apply hydrocolloid to base of the wound. 3. Secure with Leave open to air. 4. Change and PRN Every 3 days.Wound #3 Sacrum: Recommendations: 1. Cleanse with wound cleanser. 2. Apply hydrocolloid to base of the wound. 3. Secure with Leave open to air. 4. Change and PRN Every 3 daysReview of the April 2026 Medication and Treatment Administration Record (MAR/TAR) revealed the following wound treatment orders: a. Cleanse sacrum with soap and water, pat dry, apply zinc oxide Bid (twice daily), PRN (as needed) until healed. Two times a day for tx (treatment). Start Date: 4/8/26. D/C Date: 4/21/26.1. Documentation indicated this ordered administered twice daily from 4/8/26 through 4/19/26; for 4/20/26 administered for AM, blank for PM; and administered for AM on 4/21/26 before discontinued. b. Sacrum: cleanse w (with) NS (normal saline) or wound cleanser, apply hydrocolloid dressing and leave open to air. Every day shift every Mon, Wed, Fri for wound care. Start date: 4/22/26. D/C date: 5/2/26.1. Documentation indicated this ordered administered as scheduled. 2. Order also PRN and administered as a PRN on 4/24/26 [second time for day].c. Left buttocks: cleanse with NS or wound cleanser apply hydrocolloid dressing leave open to air every day shift Mon, Wed, Fri. Start Date: 4/22/26. D/C Date: 5/2/26. 1. Documentation indicated this ordered administered as scheduled. 2. Order also PRN and administered as a PRN on 4/24/26 [second time for day].d. Cleanse wound to L (left) gluteal cleft with NS, apply xeroform, cover with foam dressing, QD (daily), PRN until healed. Start Date: 4/24/26. D/C Date: 5/2/26.1. Documentation indicated this ordered administered as scheduled. During an interview on 06/03/2026 at 10:38 AM, the wound care provider Nurse Practitioner (NP) stated she first saw Resident #1 4/15/26. She stated she the resident's husband had informed her the resident had issues on her bottom, and upon her assessment discovered two pressure ulcers. The NP described an unstageable pressure ulcer on the sacral area, and a stage 3 on her left buttock. The NP stated she believed the resident was being seen by [name of community based wound clinic redacted]. The NP stated she put in her recommended orders on 4/19/26 because she had a significant backlog of residents and did not follow up with the resident after this. The NP stated it is unlikely the wounds appeared in the timeframe of the resident admission [DATE]] to 4/15/26 as these wounds happen longer than a few weeks. During an interview on 6/3/26 at 12:06 PM, Staff D, Licensed Practical Nurse (LPN) stated the wound care NP saw Resident #1 on 4/15/26, but did not make the order recommendations until 4/19/26. Staff D stated nothing had been done with the orders from the 19th until the 24th, when she put in the orders.During an interview on 06/03/2026 at 12:48 PM with the Director of Nursing (DON) stated the wound care NP orders were not started when they were ordered. During an interview on 06/03/2026 at 03:47 PM, Staff E, LPN, stated she does not remember the day Resident #1 admitted , but remembered she admitted with a surgical wound and a coccyx wound. Staff E stated she believed the coccyx wound was at least a Stage 2 when she admitted from the hospital. Staff E stated she completed wound treatments, but did not remember the order, and added maybe it was with soap and water. Staff E stated the documentation of the area being healed on 4/17/26 was a mistake. She stated the wound needed debridement on that date. During a second interview on 6/3/26 at 3:50 PM, the wound care provider NP stated the wounds would have had to be present on 4/7/26. She explained the area of note on the coccyx was about the size of quarter. It was unstageable and she feels it could have been missed if not digging for it. There was also a minor wound on her left gluteal fold. She believes it could have been mistaken for MASD. The NP stated the order to wash the area with soap and water was appropriate for wound care. She stated if she had come in on the 7th the wound would have been there before the 7th. The NP added her conversation with Resident #1's husband indicated he knew of the wound. The NP stated there is no way it wasn't there before the 7th. A review of the ERH revealed the following notes entered by the wound care NP:a. On 4/22/26 - Skin and Wound Note: Patient unable to be evaluated by skin and wound team today; patient at PT/OT (physical therapy/occupational therapy) during time of visit. Attempted x3.b. On 4/30/26 - Skin and Wound Note: Patient was unable to be evaluated by the skin and wound team today; patient at PT/OT during time of visit, surgeon following surgical incision, wound clinic following other wounds, signing off.During an interview on 06/04/2026 at 08:25 AM, the facility Advanced Registered Nurse Practitioner (ARNP) stated she examined the resident once and noted the wounds but did not document them. The ARNP stated she made recommendations to refer to the resident to the wound clinic.During an interview on 06/04/2026 at 09:12 AM, Staff F, Certified Nurse Aide (CNA), stated she remembered Resident #1, and she remembers she had a spot on her lower back when she entered, she believed this to be MASD. She stated it was the CNAs responsibility to report skin status changes to the nurses but she did not often work with Resident #1 and does not remember reporting anything.Review of a facility provided document titled Dressing change instructs staff members to follow physician's orders. It documented Step 1 as verify physician's orders.

Based on observation, clinical record review, facility policy review, and staff interviews, the facility failed to serve the correct portion size of the protein entree for 8 of 9 (Resident #1, #31, #43, #54, #77, #79, #89 and #96) residents with a mechanical soft diet order. The facility identified a census of 89 residents.Findings include:Review of the Week 1 Wednesday Noon Menu, approved by the Dietician directed to provide a 3- ounce (oz) portion of pork loin for the mechanical altered diet. The Diet Roster listed Resident #1, #31, #43, #54, #77, #79, #89 and #96 as receiving a mechanically altered diet. The Center for Medicare and Medicaid (CMS) Matrix provided by the facility listed Resident's #43 and #96 as having significant weight loss. During an observation of the Crow Creek Dining Room on 5/13/26 from the start of meal at 11:38 AM until 12:29 PM, Staff O, [NAME] used a #16 (2 Oz.) scoop to serve the ground pork loin to eight residents on the mechanical soft diet. During an interview on 5/13/26 at 12:56 PM, Staff O, [NAME] stated she used a #16 scoop for the ground pork loin. She thought it was a 2 oz scoop, but was not 100 percent sure. Staff O stated she didn't know if it was a correct portion of the mechanical soft meat, but it was the size of scoop they used to serve out the mechanical soft meat. During an interview on 5/13/26 at 1:38 PM the Certified Dietary Manager (CDM) reported she would expect the dietary staff to following the serving sizes on the menu. If there is significant weight loss, she would expect the full portion of each item to be served. During an interview on 5/13/26 at 3:04 PM, the facility Dietician explained she was told by the CDM the cook just pulled the wrong scoop size for serving the ground pork for the lunch meal. She had no knowledge the #16 scoop was used regularly to serve the ground meat and would have to check on that. The Dietician voiced the cook should have used the correct scoop according to the signed menu. Review of the facility policy Menus-Planning, Preparation, Services and Record-Keeping Policy revised 5/25 included Guidelines that menus are planned to meet the resident therapeutic diet requirements and nutritional parameters.

Based on observation, kitchen record review, facility policy review, the US Food Code (2017) and staff interviews, the facility failed to maintain clean and sanitary equipment in the main kitchen and in a kitchenette. The facility identified a census of 89 residents.Findings include:During the initial tour of the kitchen on 5/11/26 at 10:09 AM the following observations were made:a. A dried on black/brown substance 1.5 - 2 inches from the front of the stove running approximately 2.5-3-foot down the length of the stove. A dried on black/brown substance approximately 8-10 inches high in three areas and to the top of the stove backsplash in one area; all areas ran the entire length of the stove black splash. b. The walk-in cooler had 1-1.5 inches of a black substance running where the door seal connects to the cooler door around the entire cooler door frame and a build-up of a thick, black substance, along the cooler door threshold approximately four foot in length. c. A build-up of a black/brown/orange substance running approximately 4 feet down the front of the griddle.A revisit to the kitchen on 5/13/26 at 8:18 AM revealed:a. An approximate 24-inch dirty skillet positioned at the middle burner of the six-burner stove. A tacky, black/brown substance measuring approximately 1.5-2 inches came out from the front of the stove and ran the length of the stove approximately 2.5-3-foot. A large metal spoon lay on top of the black brown substance. A stuck down black/brown substance approximately 8-10 inches high in three areas and one area approximately 16 inches high to the back of the stove top ran the entire length of the backsplash. b. The walk-in cooler noted with 1-1.5 inches of a black substance along the entire door seal. The cooler door had a thick brown substance built up running the length of the cooler door threshold. c. A built-up of a black/brown/orange substance running approximately 4 feet down the front of the griddle. During an interview on 5/13/26 at 8:24 AM, the Certified Dietary Manager CDM) explained the Maintenance Director cleaned the cooler door seal and door threshold monthly. She didn't know if there was a checklist on the cleaning of the cooler door, but she would check. During an observation on 5/13/26 at 8:30 AM, the two-tier shelf underneath the coffee area with black/brown gritty circular rings throughout the first shelf with 15 clean coffee carafe stored upside down in direct contact with the gritty substance. The second shelf under the coffee area noted with a brown, stuck down, gritty substance saturated through a white non-slip matting throughout the second shelf with 8 pitchers stored upside down in direct contact with the dirty gritty substance. A review of the Weekly Cleaning List revealed the following:a. A deep clean of the stove and oven scheduled for a weekly cleaning. The Weekly Cleaning List dated 3/13/26 - 3/20/26 provided by the CDM showed Staff K, [NAME] signed off the Weekly deep clean of the stove X 2. b. The 3/13/26-3/20/26 Weekly Cleaning List directed to clean the coffee/area shelves weekly. Staff L, Dietary Aid signed the task as completed on 3/13/26. c. The 4/29/26 - 5/06/26 Weekly Cleaning List showed Staff K completed the deep clean of the stove/oven on 5/03/26 and Staff M, [NAME] completed the cleaning of the coffee area/shelves on 5/01/26. During an interview on 5/13/26 at 9:34 AM Staff M, [NAME] stated they don't really use the griddle that much, just mainly for making grilled cheese sandwiches at suppertime. The following observations were completed 5/13/26 at 11:10 AM in the Crow Creek Kitchenette:a. The steam table back inside supports had two inches of exposed rust by three inches of peeling paint and rust. The right side of the steam cart had approximately three inches of exposed metal with the paint off by three inches of peeling paint and a brown, white crumbly substance on the inside of the support. b. The front of the steam table had a 1-inch circular white crumbly substance ahead of the second steam well and various food crumbs on top of three of the four steam pan lids. c. A cart across from the steam table held a plate warmer unit which was surrounded by food crumbs on all sides. d. The wall across from the steam table observed with an approximate eight-inch open gash in the dry wall; 1-1.5 inches deep and three inches above the floor base cover. e. The front countertop by the condiment holder revealed five 1-centimeter (CM) areas of a red sticky substance stuck down on the counter. During an interview on 5/13/26 at 1:38 PM, the CDM looked at the stove and reported they usually do not have anything oil based when cooking or frying when using the stove. There is no grease trap. The CMS stated ideally, the staff should be addressing the grease built up on the stove, but it is probably hard to get off. During an interview on 5/13/26 at 2:15 PM, the CDM stated the build-up on the stove is carbon build up. They did get some of the grease build-up on the back splash cleaned up. Carbon buildup on a stove is a hard, black, charred residue caused by burnt food, polymerized grease, and carbonized oil from high-heat cooking or accumulated debris. It acts as a thermal barrier, causes uneven cooking, and cannot be cleaned with soap and water. Special cleaning agents are required. During an interview on 5/13/26 at 3:04 PM, the facility Dietician reported the CDM creates daily, weekly and monthly cleaning schedules as well as they contract cleaning for the kitchen. She doesn't know what they clean the stove with, but they haven't been able to get the carbon build up off the stove. The Dietician stated she believed the carbon build-up on the stove had been there a long time and they would have to hire someone to come in and clean the stove. She voiced even if the Maintenance Director cleaned the cooler door seal and floor threshold, the CDM should still direct how often it should be cleaned. On 5/13/26 at 3:31 PM the Administrator reported the Maintenance Director may have information regarding the walk-in cooler door in the TELS system. During an interview on 5/13/26 at 3:38 PM, the CDM reported the Weekly Cleaning List provided were the only cleaning list that she could find. She did not have any cleaning lists prior to 3/13/26 or since 5/06/26 to show staff had completed the kitchen cleaning. She completes random kitchen walk throughs and looks at the cleaning of the kitchen to monitor. She expects the staff to complete the cleaning according to the cleaning list. During an interview on 5/13/26 at 3:41 PM, the Maintenance Director reported the facility implemented the refrigerator/cooler door seal and threshold checks and cleaning today. He hadn't seen the actual verbiage come out but assumes he will check and clean weekly. Prior to today, he had nothing in his TELS or monitoring/cleaning that he was doing for it. During an interview on 5/14/26 at 7:24 AM, the CDM reported the facility does not have any cleaning lists for the smaller serving kitchenettes. The dietary staff are supposed to clean the area after they serve the meal and housekeeping mops the dining rooms floors. She completes walk-throughs of the areas daily. She inspected the Crow Creek dining room around 10:30 AM on 5/13/26 and didn't see anything. She didn't think anything had been put in for maintenance to fix the wall in the Crow Creek kitchenette. She expects the dietary staff to clean the kitchenettes after each meal. During an interview on 5/14/26 at 9:19 AM, the Administrator reported when she see gashes in the walls, she takes a picture of it and puts it in the TELS system for maintenance to repair it. Review of the facility policy titled Kitchen Sanitation and Cleanliness Policy revised 5/25, directed food service areas would be maintained in a clean and sanitary condition. The Procedure directed food service areas would be assessed on a periodic basis to develop and edit appropriate cleaning schedules for each area. Posted cleaning schedules would clearly communicate the location, frequency and may include the person responsible for the assigned area with a way to sign off the completion. The cleaning and sanitations tasks for the kitchen would be recorded by the person completing the task. The Dietary Manager or designee would be responsible for ensuring areas that require professional cleaning are completed on a periodic basis. The 2017 US Food Code under 4-6 Cleaning of Equipment and Utensils directs at 4-601.11 (B) food contact surfaces of cooking equipment shall be kept free of encrusted grease deposits and other soil accumulations; (C) nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, residue and other debris.

Based on observation, clinical record review, facility policy review, staff and resident interviews the facility failed to determine if 1 of 1 resident (Resident #4) with an inhaler at their bedside could safely self-administer the medication. The facility reported a census of 89 residents.Findings include:Review of Resident #4's Minimum Data Set (MDS) assessment, dated 4/16/26 revealed a Brief Interview for Mental Status (BIMS) with a result of 15 out of 15, which indicated intact cognition. The list of diagnoses in the MDS included stroke, atrial fibrillation (irregular heartbeat), and asthma.Review of Physician Orders revealed an order for ProAir RespiClick Inhalation Aerosol Powder Breath Activated 108 (90 Base) MCG/ACT (Albuterol Sulfate) inhaler to provide 2 puffs inhaled orally every 4 hours as needed for wheezing/SOB. Start Date: 3/2/26. Review of Resident #4's Care Plan, dated 5/2/25, revealed a Focus area to address Resident is at risk for ineffective breathing pattern r/t (related to) asthma. Interventions included, in part: Medications as ordered. Date Initiated: 5/5/25.During an observation on 5/13/26 at 7:53 AM, Resident #4 in her room, and had an inhaler (albuterol sulfate0 rested on her bedside table. Resident #4 stated she has had the inhaler at her bedside since last May [2025] and has been using the inhaler on her own. Staff E, Licensed Practical Nurse (LPN) also present and acknowledged the inhaler rested on the overbed table. Staff E stated she had not previously seen the inhaler in Resident #4's room. Staff E stated Resident #4 did not have an order to self-administer the inhaler. During an interview on 5/13/26 at 8:01 AM, the Director of Nursing (DON) confirmed Resident #4 didn't have an order to have medication at beside to self-administer.Review of the facility policy titled, Self-Administration of Medication revised June 2023 revealed the following:1. The Interdisciplinary team (IDT) will assign a staff to evaluate resident's ability to safely administer medication. A Self-Administration Evaluation Form will be filled out to determine capability. A return demonstration will be done to accurately evaluate resident's ability after teaching.2. The resident may store the medication at bedside if there is a physician order to keep it at bedside. The medication should be secured.3. The nurse on duty will document administration of medication in the MAR.4. The medication will be administered by the resident.5. The resident's ability to self-administer medication will be assessed by the facility to coincide with the MDS assessment or any notable change in status.

Based on clinical record review, Centers for Medicare and Medicaid Services (CMS) Long-term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual and staff interviews, the facility failed to ensure he Minimum Data Set (MDS) assessments coded accurately to reflect resident use of an indwelling catheter and use of an antidepressant and hypnotic for 2 of 2 resident (Resident #32 and Resident #83) reviewed. The facility reported a census of 89 residents.Findings Include: 1. Review of Resident #32's MDS assessment, dated 5/4/26, revealed an admission date of 4/29/26. The list of diagnoses included: neurogenic bladder (lose of control due to nerve damage); multiple sclerosis and depression. The MDS identified Resident #32 with no appliance (such as a catheter or ostomy). Review of a Hospitalist Progress Note, dated 4/27/27 revealed an Assessment/Plan section which included, in part: Neurogenic bladder MS on chronic foley catheter (name of an urinary catheter). Review of the electronic health record (EHR) revealed an Admission/readmission Assessment for the 4/29/26 admission. The assessment Bladder section identified Resident #32 with an indwelling urinary catheter with an insertion date of 4/24/26. Review of Physician Orders revealed an order for Foley Catheter 16 Fr (size) 10 ml [NAME] (a balloon filled with sterile water to keep the catheter from slipping out). During an interview on 5/13/26 at 10:09 AM, Staff D, MDS Coordinator stated she is responsible for completing the MDS Assessments. Staff D stated Resident #32 had an indwelling catheter and the MDS had been coded incorrectly. During an interview on 5/13/26 at 10:13 AM, the Director of Nursing (DON) stated the expectation is the MDS assessments are coded to accurately reflect the resident's condition. 2. Review of Resident #3's 4/27/26 MDS revealed a list of diagnoses which included depression. The Medications section of the MDS did not identify if Resident #3 is taking or there is an indication of the need for an antidepressant. Review of the Medication Administration Records for February, March and April 2026 revealed the following medications administered to Resident #3: a. Trazodone (an antidepressant that is also used off-label as a sedative-hypnotic) Give 25 mg (milligrams) by mouth at bedtime for insomnia. Start Date: 2/27/26. End Date: 3/1/26. b. Trazodone Give 25 mg by mouth at bedtime. Start Date: 3/2/26. End Date: 4/10/26 c. Trazodone Give 25 mg by mouth at bedtime. Start Date: 4/13/26. d. Mirtazapine (an antidepressant) 15 mg Give 1 tablet by mouth for depression. Start date: 4/11/26. D/C (discontinue) date: 4/13/26. During an interview on 5/13/26 at 10:45 AM, Staff D, MDS Coordinator reported she didn't see the antidepressant on Resident #3's medication orders. Staff D explained Trazodone is an antidepressant and Mirtazapine should have been coded as such on the MDS. Staff D reviewed the 4/27/26 MDS and stated she miscoded the MDS. She stated sometimes Trazodone is ordered for insomnia, but it should still be coded as an antidepressant on the MDS. Staff D stated she didn't know if the facility had an MDS policy, but she follows the RAI for coding the MDS. The CMS RAI Manual, Chapter 3, Section N, Page N-9 directed all high-risk drug class medications (including antidepressant medication) coded according to their pharmacological classification, not how the medications are used. The CMS LTC RAI User's Manual, October 2025, Version 1.20.1, Page 1-4 documented the RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require the assessment accurately reflects the resident's status. In an email correspondence dated 5/13/26 facility staff reported the facility did not have MDS policy, and follows the RAI manual in coding the MDS assessment.

Based on observation, clinical record review, facility policy review and staff interview the facility failed to provide complete shaving care for 2 out of 2 residents dependent residents (Resident#1 and Resident #67) reviewed for activities of daily living care. The facility reported a census of 89 residents.Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #1 dated 3/4/26, listed diagnoses of coronary artery disease and non-Alzheimer's dementia. The MDS Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicated a severe cognitive impairment. The MDS also reflected Resident#1 required partial/moderate assistance for personal hygiene, including shaving.The Care Plan for Resident#1 dated 02/20/2024, directed assistance of 1 staff for grooming.During an observation on 05/11/2026 at 12:16 PM, Resident#1 facial hair appeared unkempt with several days' growth. During an observation on 05/13/2026 at 7:50 AM, Resident #1 sat in his wheelchair at the nurse's station. His facial hair appeared long on both sides of his face and longer on his chin. During an observation 05/14/2026 at 7:44 AM, Resident #1 sat in the w/c in the hall outside the dining room. Resident #1 facial hair remained long and uneven. 2. The MDS assessment for Resident #67 dated 4/8/26, listed diagnoses of stroke, dementia, high blood pressure, and aphasia (inability or impaired ability to understand or produce speech). The BIMS score of 2 out of 15 indicated a severe cognitive impairment. The MDS assessed Resident #67 required partial/moderate assistance for personal hygiene, including shaving. The Care Plan for Resident #67 dated 2/21/24, directed for Dressing & Grooming the assist of 2 staff members to complete this ADL (activities of daily living such as shaving, nail care, brushing teeth, etc.). During an observation on 05/12/2026 at 9:20 AM, Resident #67 sat in his wheelchair, while in the hallway outside of the dining room. His facial hair appeared unkempt and about a quarter of an inch in length. During an observation on 05/12/2026 at 2:10 PM, Staff P, Certified Nursing Assistant (CNA) walked by Resident #67 and asked him when he was going to get a shave. During an observation on 05/13/2026 at 8:58 AM, Resident #67's facial hair continued to appear unkempt. During an observation on 05/14/2026 at 7:45 AM, Resident #67 in his room, dressed for the day and sat in his wheelchair. Resident $67's facial hair continued to appear unkempt on his face and neck. The facial hair appeared to be over a half inch in length.During an interview on 05/14/2026 at 8:52 AM, the Unit Manager/Infection Preventionist reported shaving is done as needed and every shower/bath day. At 8:55 AM, the Unit Manager checked on Resident #67 and the CNA present stated she needed to find the electric razor to shave the resident. During an interview on 05/14/2026 at 9:44 AM, the Director of Nursing (DON) reported she expected the residents are assisted with shaving at least on shower/bath days which is 2 times a week.Review of the facility policy titled Hygiene - Bathing/Shower dated 3/2024, directed staff to shave residents' facial area as needed.

Based on clinical record review, facility policy review, and staff interview, the facility failed to complete physician ordered treatments for 1 of 4 residents (Resident #4) reviewed for wound care. The facility failed to reported a census of 89 residents.Findings include: 1.Review of Resident #4's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS identified Resident #4 with the skin problem of moisture associated skin damage (often referred to as MASD, skin damage caused by prolonged exposure to moisture such as for example urine, or perspiration), with the need for treatments such as non-surgical dressings and ointments/medications. Review of Resident #4 Care Plan dated 5/2/25, revealed a Focus area which addressed At Risk for alteration in skin integrity related to impaired mobility, incontinence and DM (diabetes).MASD to groin, buttocks, perineum and abd (abdomen) folds. Will frequently refuse treatments, even after education & encouragement. Interventions included, in part:a. Administer treatments per physician orders.b. Apply barrier cream to peri area/buttocks/abdominal folds as needed.During an interview on 5/11/26 at 11:37 AM, Resident #4 stated treatments had been missed.Review of Physician Orders revealed the following:a. Abdomen: cleanse w/NS (with normal saline) normal saline, apply calcium alginate and secure with boarded gauze. Every day shift every Monday, Wed and Fri. Start Date: 5/1/26. Review of May 2026 Treatment Administration Record (TAR) revealed no documentation present on 5/4/26 to indicate if the treatment completed, held or refused. Review of Progress Notes found no documentation to explain further.b. Left buttocks: Cleanse with NS, apply foam dressing every day shift for MSAD. Start Date: 3/14/26. D/C (discontinue) date: 5/6/26. Review of the May 2026 TAR revealed no documentation present on 5/2/26 or 5/4/26 to indicate if the treatment completed, held or refused. Review of Progress Notes found no documentation to explain further.c. Right buttocks: Cleanse with NS, apply zinc oxide paste every day shift for MASD. Start Date: 5/1/26.Review of the May 2026 TAR revealed no documentation present on 5/4/26 to indicate if the treatment completed, held or refused. Review of Progress Notes found no documentation to explain further.d. Right labia: Clean with NS, apply zinc, leave open to air every day shift for wound care. Start Date; 5/1/26.Review of the May 2026 TAR revealed no documentation present on 5/4/26 to indicate if the treatment completed, held or refused. Review of Progress Notes found no documentation to explain further.e. Nystatin external powder 100,000 unit/GM: apply to groin topically every shift for rash. Start Date: 3/2/26.Review of the May 2026 TAR revealed no documentation present on 5/4/26 to indicate if the treatment completed, held or refused. Review of Progress Notes found no documentation to explain further.During an interview on 5/13/2026 at 10:06 AM, Staff E, Licensed Practical Nurse (LPN) stated when treatments are provided, they are documented in the electronic health record under the TAR. Staff E stated if a TAR box is left blank it means the treatment wasn't provided.During an interview 5/13/2026 at 1:08 PM, the Director of Nursing (DON) stated when a treatment is provided, it's documented on the TAR. If a resident would refuse a physician ordered treatment, the nurse would document the refusal on the TAR and note it in the Progress Notes. The DON reported if a box is left blank on the TAR, it meant the treatment wasn't completed. The DON verbalized the expectation is physicians' orders are followed with appropriated documentation in place.Review of the facility policy titled, Physician Orders/Transcription of Orders revised July 2023, directed, in part: Active orders should be followed and carried out as written/transcribed.

Based on observation, clinical record review and staff interview the facility failed to implement pressure reducing interventions per the wound nurse practitioner's recommendations for 1 of 2 (Resident #11) reviewed for pressure injuries. The facility identified a census of 89 residents.The CMS RAI Manual defines the following pressure injury (PI) (a pressure ulcer/injury is a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful) stages:Stage 1: Non-blanchable Erythema: Intact skin with persistent red/blue/purple discoloration; color does not blanch.Stage 2: Partial Thickness Loss: Shallow, open wound with red-pink bed (no slough) or a serum-filled blister.Stage 3: Full Thickness Skin Loss: Subcutaneous fat may be visible, but bone/muscle is not exposed; slough (moist, stringy, dead tissue) may be present.Stage 4: Full Thickness Tissue Loss: Exposed bone, tendon, or muscle; slough/eschar (dry, black dead tissue) and tunneling often present.Unstageable: Full-thickness loss where slough or eschar obscures the true depth, which is revealed to be Stage 3 or 4 upon removal.Deep Tissue Injury (DTI): Purple/maroon localized area of discolored intact skin or blood-filled blister.Findings include:Review of Resident #11's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated a moderate cognitive impairment. The list of diagnoses included stroke, coronary artery disease, diabetes, Non-Alzheimer's Dementia, anorexia, palliative care and an unstageable pressure ulcer to the left heel. The MDS indicated Resident #11 required partial to moderate assistance with positioning side to side in bed. The MDS documented the resident had an unhealed, unstageable PI and utilized a pressure reducing device for the bed, chair, pressure injury care, and application of dressings to the feet. The MDS identified Resident #11 received hospice care. The MDS listed the admission date as 4/6/26.A review of the admission Assessment, dated 4/6/26 identified Resident #11 with a Stage 3 PI on the right heel, which measured 2.5 cm (centimeters) by 1.1 cm to the right heel.Review of the Care Plan dated 4/6/26 revealed a Focus area to address At Risk for alteration in skin integrity related to pressure ulcer to the Left Heel Care Plan. Interventions included, in part:a. Pressure reducing device on bed.b. Pressure reducing deice on chair.A review of the electronic health record (EHR) Skin Evaluation Pressure Wound Assessments revealed;a. On 4/14/26.the left heel PI measured 2.5 cm in length (L) x 2 cm in width (W) by 0.1 cm in depth (D); stage three. The wound bed described as filled with slough. The Nurse Practitioner (NP) documented the area as a new area and recommended frequent repositioning and to use heel protectors.b. On 4/22/26.the left heel PI measuring 1.2 cm x 2.8 cm x 0.2 cm; stage three. The wound bed described as filled with slough. The NP recommended frequent repositioning, the use of heel protectors and to provide a medical grade honey with border gauze treatment.c. On 4/29/26.the left heel PI measured 1.4 cm x 2.8 cm x 0.2 cm; unstageable. The wound bed described as filled with slough. The NP recommended frequent repositioning, the use of heel protectors and a medical grade honey alginate border gauze treatment three times a week.d. On 5/5/26.the left heel PI measured 1.4 cm x 2.6 cm x 0.2 cm; unstageable and to continue the same recommendations as prior.Review of the electronic health record revealed a Skin and Wound Note entered by the NP on 4/19/26 at 10:48 PM: Upon exam Resident #11 presented with an unstageable PI to the left ankle. The NP recommended an alternating air mattress for pressure redistribution, ensure settings were maintained appropriate for the patient's needs and body habitus, and float heels while in bed with use of heel boots.During an interview on 05/11/2026 at 11:05 AM, Resident #11 stated they were treating an area to her heel. She lifted her left foot into while lying in bed on her back. She wore gripper booties on her feet. Further observation revealed two padded blue boots laying in a chair across from the foot of the bed. Resident #11 reported she had her gripper booties on and preferred to lay in bed. Resident #11 observed laying with her heels in direct contact with the mattress. The resident's bed did not have an air mattress.During an observation on 5/11/26 at 1:53 PM, Resident #11 in her room, in bed positioned on her left side. Two blue padded boots sat in a chair across from the foot of the resident's bed. The resident's bed did not have an air mattress. During an interview on 5/11/26 at 3:40 PM, Resident #11 reported the dressings on her left heel was changed one to two times per week. Resident #11 added or at that is what happened last week. During an observation on 5/11/26 at 4:05 PM, Staff H, Licensed Practical Nurse (LPN) and Staff F, Unit Manager, Registered Nurse (RN) completed scheduled wound care. Resident #11 bed continued to have an air mattress in place; and the blue padded boots remained on the chair across from the foot of the resident's bed.During an observation on 5/12/26 at 7:33 AM, Resident #11 sat on the edge of her bed, and wore gripper booties on her feet. The residents bed remained without an air mattress in place. During an interview on 05/12/2026 at 11:30 AM, the Hospice Case Manager stated the goal for Resident #11's left heel wound is to heal with no pain. During an interview on 5/12/26 at 11:55 AM, Staff F, RN stated the believed the goal was for Resident #11's PI to be free of pain but that would be the role of the NP to make that decision. Staff F stated the Wound NP sees Resident #11 weekly on Wednesdays and documented her visit notes in the EHR.During an interview on 5/12/2026 at 1:57 PM, Staff J, Certified Nursing Assistant stated heel protectors are to be used or a resident's feet should be positioned so their heels float on a pillow. Staff J stated heel protectors are offered to the resident when she lays in bed, and she used to refuse the blue boots. Staff J looked into Resident #11's room where she lay in bed on her back with no padded boots on her heels. When queried if she had offered Resident #11 the blue padded boots, Staff J stated she had not offered the blue boots to Resident #11 today. Staff J stated Resident #11 did not have an air mattress on her bed and as far as she knew she had only used a regular mattress. During an interview on 5/12/26 at 4:20 PM. Resident #11stated the staff do not offer her the padded boots when she lays down. The resident stated she tries to lay on her side because she doesn't want her heels to get worse. Resident #11 bed noted to not have an air mattress in place.During an observation on 5/13/26 at 7:15 AM, Resident #11 lay in bed on her back with her heels in direct contact with the mattress. The blue padded boots laid at the foot of the bed.During an interview on 5/13/26 at 11:25 AM, the NP stated as Resident #11 received hospice care, the goal is maintenance and prevent the heel wound from getting worse. The NP explained she first saw the wound about a month ago and it was unstageable. The NP stated she had recommended the heel boots and the air mattress. She explained the Resident can be non-adherent with using the boots but the staff should still offer them. When queried if Resident #11 should have an air mattress, the NP reported yes and thought hospice provided one to her. During an interview on 5/13/2026 at 3:53 PM Staff F, RN reported she thought Resident #11 had an air mattress on her bed. At 3:58 PM Staff F went to Resident #11's room and confirmed there was no air mattress in place. Staff F voiced it is her responsibility to monitor the wound care notes and ensure the wound interventions get implemented. Staff F added Hospice could also provide an air mattress for her. When queried if staff should offer her the padded boots when she lays down in bed, Staff F stated, yes and added the staff should offer the padded boots every time they lay the resident down. Staff F explained she needed to do a better job of checking the NP wound progress notes.During an interview on 5/13/26 at 4:16 PM, the Director of Nursing (DON) reported the air mattress should have gone in timelier and the CNA's should be offering the heel boots when she lays down. During an interview on 5/14/26 at 10:17 AM, the Administrator reported Resident #11 had a room change, and she had an air mattress on her bed but the bed was not moved with her. The Administrator stated the facility is implementing a room change checklist so that all safety interventions will go with the resident.The Physician Orders/Transcription of order Policy revised 7/2023 directed active orders should be followed and carried out as written/transcribed.

Based on observation, clinical record review, manufacturer guidelines and staff interviews, the facility failed to use the correct size full-body mechanical lift sling based on resident weight during a transfer for 1 of 3 (Resident #67) reviewed for accidents. The facility reported a census of 89 residents.Findings include:Review of Resident #67's Minimum Data Set (MSD) assessment dated [DATE], revealed a list of diagnoses which included stroke, dementia, and aphasia (inability or impaired ability to understand or produce speech) The Brief Interview for Mental Status (BIMS) score of 2 out of 15 indicated a severe cognitive impairment. The MDS assessed Resident #67 dependent for chair to bed transfer. The MDS listed the resident's weight as 183 pounds.Review of Resident #67's Care Plan dated 2/21/24, revealed a Focus area to address Resident requires assistance with ADL's (activities of daily living). Interventions included, in part: Transferring: assist 2;1 with hoyer (hoyer is a brand name of a mechanical lift and also has become a genericized trademark for mechanical lifts) lift. Review of the electronic health record (ERH) revealed a Nutrition note entered on 4/14/26 at 8:41 AM with a Present weight: 183.5 # (pounds). During an observation on 05/13/2026 that started at 1:50 PM, Staff I, Certified Nurse Aide (CNA) and Staff R, CNA entered Resident #67's room, completed hand hygiene and put on gloves. Staff R placed a full body mesh sling with blue trim under Resident #67 in anticipation of a transfer. At 1:53 PM, Staff I and Staff R informed Resident #67 they needed to check and change him. They proceeded to hook the sling to the lift and as Staff I started the mechanical lift, the cushion under Resident #67 started to slide of the seat of the wheelchair. Resident #67 bottom appeared to go too far through the opening of the sling. Staff I verbalized the need to move Resident #67 back down into his wheelchair. As Staff I lowered Resident #67 into his wheelchair she pushed the cushion back into place. Staff R stated Resident #67 needed the sling placed better under his backside as tucked the sling under the resident. Staff I stated the sling is too big for Resident #67. On 05/13/2026 at 1:53 PM both of the CNAs hooked to the lift sling to the lift. The CNAs told Resident#67 they needed to check and change him. As Staff I lifted Resident #67 the cushion under him started to slide off the seat of the wheelchair (w/c). Resident #67 bottom appeared to go far through the opening of the sling. Staff I reported the need to put Resident#67 back down in the w/c. As Staff I lowered him into the w/c she pushed the cushion back in place on the seat in the w/c. Staff R reported Resident#67 needed the sling placed better under his backside as she tucked the sling under Resident#67. Staff I stated the sling 's too big for him. Staff R stated the sling is tucked under his bottom better and it's fine. Staff I raised Resident #67 in the full body lift. Staff I kept him over the wheelchair until high enough to get over the bed. Staff I moved him over the bed and lowered him onto the bed.During an interview on 05/13/2026 at 1:59 PM, Staff I, CNA stated the sling with blue trim is for heavy set residents. Staff I stated Resident #67 needed a sling with the green trim. Staff I stated there is nothing in the care plan or the record for Resident #67 that tells the staff the size of sling to use. Staff R, CNA explained they [CNA's] just know how big the slings and the residents are. Staff R added if they don't know what size sling to use, they go ask the Unit Manager. Staff R reported no one has fallen during any transfers from the lift. The tag on the blue trimmed lift sling failed to show a size of the sling.During an interview on 05/13/2026 at 2:58 PM, Staff F, Registered Nurse/Unit manager stated she knew the size of the sling because of the chart that hung in the room on the South wing on the 1st floor. Staff F went to the room and the referred to sling size chart was not present. Staff F stated she used to work as a CNA and the chart hung in the room. She reported none of the residents have fallen from any of the lifts in the past 2 years she's been here as a nurseDuring an interview on 05/13/2026 at 3:25 PM, the Director of Nursing (DON) stated the facility staff know to pick the sling by the size of the resident. She reported they look for the chart that tells them what color for the weight of the resident. Review of the mechanical lift manufacturer Sling Color/Size guide revealed a green sling should be used for the weight range of 154 - 264 lbs. (pounds). The guide listed the blue sling is for a weight range of 308 to 440 lbs.

Based on observation, clinical record review, facility policy review, resident and staff interviews, the facility failed to respond to a call light in a timely manner for 1 out of 4 residents (Resident 3#) reviewed for call lights. The facility reported a census of 89 residents.Findings include:Review of Resident #3's Minimum Data Set (MSD) assessment dated [DATE], revealed a list of diagnoses which included amputation, heart failure, and diabetes mellitus. The MDS listed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The MDS assessed Resident#3 needed supervision or touching assistance for chair/bed to chair transfers. Review of Residents #3 Care Plan, dated 10/9/2024, revealed a Focus area to address Resident requires assistance with ADL's (activities of daily living - grooming, transfers, etc). Interventions included, in part: Transferring: 1:1 slide board to complete this ADL, and Call light within reach.Review of Resident Council Minutes, dated 2/2026 indicated residents felt more staff are needed and that the Certified Nurse Aide (CNAs) need to follow through with what theyare doing. They will leave the room and not return.During an observation on 05/12/2026 that started at 2:40 PM, Resident#3's call light activated. Staff P, CNA went into the room asked what Resident #3 needed and turned the call light off. Staff P exited Resident#3's room, and informed Staff Q, CNA the call light had been turned off and what Resident #3 needed. At 2:53 PM, Resident #3 call light activated. The sound of banging came from the room.At 2:55 PM, Resident #3 called out hello. No facility staff in hallway. The call light remained on, with 15 minutes elapsed since activated.At 2:56 PM, banding coming from Resident #3's room heard. The call light remained activated.At 2:59 PM, banging again heard from Resident #3 room. The call light remained activated. At 3:00 PM, Resident #3 called out hello. No facility staff in hallway. The call light remained activated, with 20 minutes elapsed since activated.At 3:01 PM, Resident #3 called out hello and banging heard coming from the resident's room. No facility staff in hallway. The call light remained activated.At 3:03 PM, three facility staff stood at the nurse's station. Resident #3 call light remained activated.At 3:04 PM Staff Q, CNA exited another resident's room, and went into Resident #3's room. The call light turned off after 24 minutes elapsed since activated. At 3:05 PM, Resident #3 told Staff Q, CNA he's been waiting for help for the last 1/2 hour. At 3:11 PM, Staff Q, CNA opened the room door, Resident #3 exited the room and thanked the staff.During an interview on 05/13/2026 at 1:14 PM, Resident #3 stated he was upset yesterday when it took a half an hour for the staff to get him up for his scheduled activity. He reported the other residents were upset as well because he had the equipment for the activity. He reported Staff P, CNA went into his room shut off his light and told him Staff Q, CNA would help in a minute. Resident#3 reported after he waited 15 minutes for Staff Q he started banging his light and yelling for help. Resident #3 stated this happened to him at least 3 times a month. Resident#3 reported he's talked to the Unit Manager about the call lights when they take too long. Resident#3 confirmed he banged and called out for help to get the staffs attention. During an interview on 05/13/2026 1:32 PM Staff R, CNA stated the staff are expected to answer the call lights in 10-15 minutes. Staff R said the facility told them frequently get the lights. Staff R reported if nursing staff go get a call light, they are expected to meet the need of the resident. Staff R said the CNA who went in the room first needed to provide the care the resident needed.During an interview on 05/13/2026 at 3:21 PM, the Director of Nursing (DON) reported she expected call lights answered in 5 minutes which is the best, but 15 minutes is maximum. The DON explained if a CNA went in a resident's room and turned off the light they needed to meet the need of that resident, not turn off the light and tell another CNA to take care of the resident. Review of the facility policy titled, Call Light Policy dated 9/2023, revealed a Purpose statement which declared To ensure that there is a prompt response to the resident's call for assistance. The facility also ensures that the call system is in proper working order. The Procedure section directed, in part: Facility shall answer call lights in a timely manner. When answering a call light, respond to the requests. If immediate assistance cannot be provided and there is not an emergent need, call light may be turned off and resident informed that a staff member will be back to assist shortly.

Based on observations, clinical record review, facility policy review, and staff interviews, the facility staff failed to implement Enhanced Barrier Precautions when doing wound care for 1 of 4 residents (Resident #83) reviewed for infection control. The facility reported a census of 89 residents. Findings include:Review of Resident #83's Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated a severe cognitive impairment. The MDS listed diagnoses of non-Alzheimer's dementia, urinary tract infection, and pressure ulcer, stage 3. Review of Resident 83's Care Plan revealed the following Focus area's:a. At risk for alteration in skin integrity related to impaired mobility and diabetes mellitus. admitted with a stage 3 pressure injury lt (left) buttock. Interventions included, in part: Administer Treatment per physician orders. Date Initiated: 3/25/26.b. EBP (enhanced barrier precautions - an infection control practice used to prevent the spread of multi-drug resident organisms) related to: Pressure injury. Interventions included, in part: EBP Precautions: Staff to wear a gown and gloves while performing high-contact care activities (High Contact Care Activities to include: Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Caring for or using an indwelling medical device (central venous catheter/PICC, urinary catheter, feeding tube care, tracheostomy/ventilator care), Performing wound care) Date Initiated: 04/02/2026.During an observation on 5/11/26 at 1:38 PM, EBP and Contact Precautions signage posted on the door of Resident #83's room. During an observation on 5/12/26 at 4:23 PM, Staff A, Registered Nurse (RN) and Staff B, Certified Nursing Assistant (CNA) donned gloves and masks. Staff A also donned a gown. Staff B assisted in repositioning Resident #83, lower her pants and incontinent brief and held Resident #83 on her right side. Staff A performed the pressure area treatment. During an interview on 5/12/26 at 4:33 PM, Staff A, RN reported Resident #83 required EBP due to wound care. Staff A verbalized she was not sure if Staff B should have had a gown on. Staff A acknowledged Staff B should have donned a gown after reviewing the EBP and Contact Precaution signage on the door. During an interview on 5/12/26 at 4:34 PM, the Director of Nursing (DON) verbalized Resident #83 is on EBP precautions. The DON verbalized staff are to wear gloves and gowns when providing cares. Review of the Enhanced Barrier Precautions facility policy revised on March 2024 revealed the following:1.EBP will be used in conjunction with standard precautions for residents with any of the following (if/when Contact Precaution requirements are not in place):a. Infection or colonization with a Centers for Disease Control (CDC)-targeted Multi-Drug-Resistant Organisms (MDRO) when contact precautions do not otherwise apply;b. Wounds and/or indwelling medical devices (even if the resident is not known to be infected or colonized with a targeted MDRO)NOTE: Wounds generally include chronic wounds including but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. This would not include shorter-lasting wounds, such as skin breaks/tears covered with an adhesive bandage or similar dressing2. For residents whom EBP are indicate; gowns and gloves should be used during high contact resident care activities that provide opportunity for MDROs to be transferred to staff hands and clothing. High contact resident care activities include: Dressing, Bathing/Showering, Transferring, Providing hygiene, Changing linens. Changing briefs or assisting with toileting, Device care or use: central lines/PICC, urinary catheter, feeding tube, tracheostomy/ventilator, Wounds care: any skin opening requiring a dressing

Based on review of the Certification and Survey Enhanced Report (CASPER) from the Centers for Medicare & Medicaid Services (CMS), facility policy review, and staff interviews, the facility failed to ensure an effective QAPI program to address previously cited deficiencies which resulted in five deficiencies being re-cited during the current Health Recertification survey. The facility reported a census of 89 residents.Findings include:A review of the facilities 4/21/25 Statement of Deficiencies and Plan of Correction revealed the following citations: F641 (Accuracy of Assessments); F684 (Quality of Care); F689 (Free of Accident Hazards/Supervision/Devices); F812 (Food Procurement, Store/Prepare/Serve-Sanitary); F880 (Infection Prevention and Control)The Health Recertification survey completed on 5/14/26 resulted in the following citations: F641, F684, F689, F812, and F880.During an interview on 5/14/26 at 10:55 AM, the Administrator reported the facility worked on all previously cited deficiencies in the Quality Assurance Performance Improvement (QAPI) and all deficiencies continued to be ongoing and tracked for years.The facility provided a policy titled QAPI Plan dated 11/10/2025 included the administrator, as chair of the QAPI Committee is responsible and accountable for ensuring the QAPI:a. Is defined, implemented, maintained and address identified prioritiesb. Is sustained during transitionsc. Receives adequate resources to functiond. Identifies and prioritizes problems and opportunities that reflect organizational process, functions, and services provided to residents based on performance indictor data, resident, and staff input and other informatione. Corrective actions address gaps in systems and are evaluated for effectivenessThe policy also stated the QAPI Committee is responsible for:a. Identifying and prioritizing problems based on performance indicator datab. Including patient, patient representative, and staff input into the processc. Ensuring corrective actions are effectived. Analyzing QAPI program performance to identify and follow up on areas of concern or opportunities for improvement

Based on Payroll Based Journal (PBJ) review and staff interview, the facility failed to ensure accurate reporting of weekend staffing hours, resulting in a excessively low weekend staffing trigger for Quarter 1 2025 (October 1-December 31). The facility reported a census of 88 residents. Findings include: Review of the facility's PBJ report for Quarter 1 2025 (reported data from October 1-December 31 2024) revealed the facility triggered for excessively low weekend staffing for the time period. During an interview on 4/17/25 at 2:13 PM, the Administrator acknowledged they had not put agency hours in correctly. A facility policy to related to PBJ reporting requested. The facility reported they do not have such a policy.

Based on observations, staff interviews, and facility policy review, the facility failed to discard expired lettuce from refrigerator storage and failed to record evening meal temperatures for 3 of 7 days reviewed. The facility reported a census of 88 residents. Findings include: On [DATE] 10:15 AM, the walk in refrigerator contained trays with multiple pre-filled side salads, covered with plastic wrap, dated [DATE]. The walk-in refrigerator also contained a large plastic storage container, filled with shredded lettuce, dated [DATE], and labeled use by [DATE]. On [DATE] at 1:00 PM, the Dietary Manager entered walk-in refrigerator and confirmed the container of lettuce had expired on [DATE]. When queried if lettuce from expired container had been used for [DATE] lunch side salads, Dietary Manager stated, she did not know. Review of facility's meal temperature log, dated between [DATE] and [DATE], lacked record of temperatures for the food items served for evening meals on [DATE], [DATE], and [DATE]. On [DATE] at 1:05 PM, Dietary Manager revealed expectation of all dietary staff to record the food temperatures for each meal in the facility's meal temperature log. The Facility lacked policies related to food storage and expiration or monitoring food temperatures.

Based on clinical record review, facility policy review and staff interviews, the facility failed to notify the provider of a weight change of 3 pounds or more in one day as ordered for 1 of 1 resident (Resident #67) in sample reviewed. The facility reported a census of 88 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #67 scored an 8 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. The MDS listed diagnoses included: chronic systolic (congestive) heart failure; renal insufficiency, renal failure, ESRD (end stage renal disease), and non-Alzheimer's dementia. The MDS indicated the resident took a diuretic. Review of the Care Plan revealed a Focus area dated 5/6/24, for Resident #67 required the use of diuretic medication related to systolic CHF (congestive heart failure). The interventions dated 5/6/24 indicated to monitor for signs and symptoms of fluid defect and report to practitioner abnormal findings. The Care Plan revealed a Focus area dated 5/8/24, for Resident #67 had the potential/actual risk for altered nutritional status related to NAS (no salt added) therapeutic diet with 1800 ml (milliliter) FR (fluid restriction) for CHF, CAD (Coronary Artery Disease). The interventions dated 5/8/24 indicated to monitor weights; and notification to MD/RD (medical provider/registered dietician) of significant weight change. Review of Physician Orders revealed in part: Daily weights notify provider of weight gain of 3 lb (pounds) in one day or 5 lbs in one week, or a loss of 3 lbs in one day. State Date: 9/10/24. Review of the document titled Weight Summary, dated 4/16/25 revealed Resident #67 had a weight change of 3 pounds in one day on the following dates: The Review of the Weights revealed the following dates the resident had a weight change of 3 pounds for more in one day: a. 3/3/25 at 6:39 AM: 286.0 lbs to 3/4/25 at 11:14 AM: 291.2 lbs, gain of 5.2 lbs b. 3/16/25 at 7:03 AM: 287.4 lbs to 3/17/25 at 6:14 AM: 284.0 lbs, loss of 3.4 lbs c. 3/19/25 at 6:56 AM: 282.8 lbs to 3/20/25 at 9:33 AM: 288.8 lbs, gain of 6 lbs d. 4/3/25 at 6:48 AM: 288.0 lbs to 4/4/25 at 1:21 PM: 292.0 lbs, gain of 4 lbs e. 4/5/25 at 1:59 PM: 292.0 lbs to 4/6/25 at 6:14 AM: 287.8 lbs, loss of 4.2 lbs f. 4/7/25 at 6:23 AM: 286.8 lbs to 4/8/25 at 6:17 AM: 283.8 lbs, loss of 3 lbs g. 4/8/25 at 6:17 AM: 283.8 lbs to 4/9/25 at 7:32 AM: 287.0 lbs, gain of 3.2 lbs h. 4/13/25 at 7:04 AM: 284.6 lbs to 4/14/25 at 10:40 AM: 288.8 lbs, gain of 4.2 lbs Review of the electronic health record revealed a lack of provider notification for the weight fluctuation which resulted in a gain of 3 pounds in one day, and a loss of 3 lbs in one day. During an interview on 4/17/25 at 10:17 AM, Staff L, LPN (Licensed Practical Nurse) queried on Resident #67 weight change order, stated she text the doctor when Resident #67 had a weight loss of more than 3 pounds. Staff L stated she didn't document in the progress notes when she notified the provider because she ran all the time checking on the residents and she may of failed in that aspect. When asked to provide the text messages, Staff L stated she deleted the messages after the provider responded back to her. During an interview on 4/17/25 at 10:39 AM, Staff M, LPN queried about the order to notify the provider if Resident #67 had a 3 pound weight change, stated she notified the provider and documented a progress note in Resident #67 file. During an interview on 4/17/25 at 12:33 PM, Staff O, RN (Registered Nurse) Unit Manager queried where notification to the provider was located and Staff O stated in a progress note or on paperwork submitted to the provider. During an interview on 4/17/25 at 2:34 PM, the Director of Nursing stated if there is a weight change over 3 pounds stated staff should be notifying the doctor after first reweighing the resident. The DON stated the Unit Manager should be auditing and educating staff. The DON stated she educated using the same scale and notification to the provider in the daily meetings. Review of the facility policy titled Physician Orders/Transcription of Orders, dated 7/2023 revealed Procedure section: #9. Active Orders should be followed and carried out as written/transcribed Review of the facility policy titled Notification for Change of Condition, dated 6/2023 revealed Procedure section: #1. The facility must immediately inform the resident, consult with the resident's physician .when there is: b. A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions, or clinical complications). c. A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment).

Based on clinical record review and staff interview, the facility failed to ensure timely completion of quarterly Minimum Data Set (MDS) assessments for 4 of 4 residents reviewed for quarterly MDS timeliness (Resident #1, Resident #10, Resident #34, Resident #61). The facility reported a census of 88 residents. Findings include: 1. Review of the quarterly MDS assessment for Resident #1, Assessment Reference Date (ARD) 3/5/25, revealed the assessment completed on 3/31/25. 2. Review of the quarterly MDS assessment for Resident #10, ARD 3/5/25, revealed the assessment completed on 3/27/25. 3. Review of the quarterly MDS assessment for Resident #34, ARD 1/22/25, revealed the assessment completed on 2/6/25. 4. Review of the quarterly MDS assessment for Resident #61, ARD 2/19/25, revealed the assessment completed on 3/6/25. On 4/17/25 at 3:31 PM, Staff J, MDS Coordinator explained infection control responsibilities had taken quite a bit of their time, and explained they should have asked for help. On 4/17/25 at 3:58 PM, the facility's Director of Nursing (DON) acknowledged timeliness of the quarterlies had been recognized as a concern, and further explained assessments should be getting done within that week. A facility policy to address MDS requested, and the facility explained they did not have a policy.

Based on staff interview and clinical record review, the facility failed to ensure accuracy of Section N, Medications, on the Minimum Data Set (MDS) assessment for 2 of 5 residents reviewed for unnecessary medications (Resident #26, Resident #34). The facility reported a census of 88 residents. Findings include: 1. Review of the MDS assessment dated [DATE], revealed Resident #34 scored 14 out of 15 on a Brief Interview for Mental Status (BIMS) which indicated intact cognition, and revealed the resident took antiplatelet medication. Review of the resident's January 2025 Medication Administration Record (MAR) lacked administration of antiplatelet medication. During an interview on 4/17/25 at 3:35 PM, Staff J, MDS Coordinator shown Resident #34's MAR, queried if resident on antiplatelets, and Staff J confirmed no. 47336 2. The MDS assessment dated [DATE], revealed Resident #26 scored a 5 out of 15 on the BIMS exam, which indicated cognition severely impaired. The MDS indicated the resident took a diuretic. Review of the Physician Orders did not list a diuretic order for Resident #26. During an interview on 4/17/25 at 10:51 AM, Staff J, MDS Coordinator queried if Resident #26 accurately coded for use of a diuretic. Staff J reviewed the medical record and stated she didn't know why she coded it because Resident #26 didn't take a diuretic. During an interview on 4/17/25 at 2:36 PM, the Director of Nursing stated she didn't see Resident #26 prescribed a diuretic. The DON stated Staff J probably made a coding mistake. The DON stated she expected the MDS to be on time, correct, and coded correctly. Per email from the Administrator on 4/21/25 at 8:42 AM, the facility does not have a policy for MDS accuracy.

Based on clinical record review, facility policy review, and staff interviews, the facility failed to include dialysis services and use of an anticoagulant in the Care Plan for 2 of 3 (Resident #3 and Resident # 83). The facility reported a census of 88 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] identified Resident #3 as cognitively intact with a BIMS (Brief Interview for Mental Status) of 13 out of 15. The MDS list of diagnoses included: fluid overload, coronary artery disease, and renal insufficiency requiring dialysis. Section O, Special Treatments, Procedures and Programs identified Resident #3 received dialysis services while a resident. Review of the Admission Record revealed Resident #3 admitted to the facility on [DATE]. Review of Progress Notes revealed an Alert Note entered on 3/18/25 at 3:53 AM, which documented Resident #3 readmitted to the facility on [DATE] after a hospitalization . Review of the Order Summary Report dated 4/17/25, revealed an order for [Dialysis provider name and phone number redacted] M-F-W (Monday-Wednesday-Friday) @ 12:00pm, arrival @ 11:40 am, pick up 11:20 am, every day and evening shift every Mon, Wed, Fri for monitoring. Start Date: 3/17/25. Review of the Care Plan revealed a lack of Focus areas and Interventions related to address Resident #3's dialysis services. During an interview on 4/17/25 at 10:24 AM, Staff C, Registered Nurse (RN) reported Resident #3 goes to dialysis three times a week. Staff C stated dialysis services should be in the residents Care Plan. During an interview on 4/17/25 at 2:43 PM, the Director of Nursing (DON) reported Resident #3 received dialysis three times a week. The DON stated this service should be included in the Care Plan. 2. The MDS dated [DATE], identified Resident #83 as cognitively intact with a BIMS of 15 out of 15. The MDS list of diagnoses included: atrial fibrillation (an abnormal heart rhythm), heart failure and hip fracture. The MDS identified Resident #83 prescribed an anticoagulant (a blood thinner). Review of the Admission Record revealed Resident #83 admitted to the facility on [DATE]. Review of Order Summary Report dated 4/15/25, revealed an order for Rivaroxaban (medication classified as an anticoagulant or blood thinner) Oral Tablet 20 MG .Give 1 tablet by mouth at bedtime and did not have orders for any antibiotics. Start Date: 1/25/25 Review of the Care Plan revealed a lack of a Focus area and related Interventions to address the use of an anticoagulant. During an interview on 4/16/25 at 11:32 AM, Staff C, RN reported any nurse can update the Care Plans. Staff C stated residents prescribed an anticoagulant should have them included in the Care Plan. During an interview on 4/17/25 at 2:43 PM, the DON reported Resident #83 should have the orders for the anticoagulant ordered addressed in her Care Plan. Review of the facility policy titled Care Plan Policy, revised March 2025 included a Purpose statement, which declared To ensure that all care plans including baseline care plans are in conjunction with the federal regulations including a baseline care plan to be completed within 48 hours of admission and a comprehensive care plan developed after the comprehensive assessment of a resident. The Procedure section directed, in part: #4. After the comprehensive assessment (state/federal-required MDS) is completed, the facility will put in place person-centered care plans outlining care for the resident.

Based on observation, staff and resident interview, clinical record review, and facility policy review, the facility failed to follow physician orders for treatment of left lower leg surgical site for 1 of 3 residents (Resident #87) reviewed for non-pressure injuries, when staff used an alternate treatment application to wound site during observation of wound care. The facility reported a census of 88 residents. Findings include: The Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The MDS identified surgical wounds and diagnosis of encounter for orthopedic aftercare. Resident #87 required surgical wound care, application of ointment or medication and application of non-sterile dressings. The Care Plan, dated 3/22/25, revealed Resident #87 had been at risk for alterations in skin integrity due to recent surgeries, resulting in open surgical wounds of left below the knee amputation with intervention to administer treatment per physician orders. The Treatment Administration Record (TAR), dated April 2025, revealed the following treatment orders: 1. Vashe Wound Cleanser External Solution 0.033%, with instructions to apply to left below the knee amputation topically every day and evening shift for skin care. Order initiated 3/27/25 and directed to be held between 4/17/25 and 4/19/25. 2. Cleanse left below the knee amputation site with normal saline, apply Vashe moistened gauze to wound bed, cover with padded dressing and secure with gauze wrap (Kerlix) and tape, initiated 3/27/25, with instructions to change dressing twice daily and as needed (PRN). 3. Cleanse left below the knee amputation site with normal saline, cover wound with gauze moistened with normal saline, apply padded dressing and secure with gauze wrap (Kerlix) and tape, with instructions to change dressing twice daily for wound care. Order initiated 4/17/25 and discontinued 4/17/25. 4. Cleanse left below the knee amputation site with with normal saline, cover wound with gauze moistened with Vashe, apply padded dressing and secure with gauze wrap (Kerlix) and tape, with instructions to change dressing two times a day for wound care. Order start date 4/18/25. On 4/17/25 at 11:16 AM, Staff Q, Registered Nurse (RN), performed wound cares to Resident #87's left lower extremity amputation site. Staff Q removed old dressing and cleansed wound site with normal saline. Resident #87 reported that the Vashe treatment had not been used for the past 3 days and stated Xeroform (gauze dressing impregnated with petrolatum and often contains 3% bismuth tribromo phenate) was utilized instead. Staff Q applied Xeroform to left lower leg amputation site, covered with padded dressing and secured with gauze wrap and tape. On 4/17/25 at 2:33 PM, Staff Q, Registered Nurse (RN), revealed the process for treatment order change included documentation of Vashe treatment refused by Resident #87 and Provider notification of refusal, with request for a new order of the Xeroform from Provider. Staff Q reported nursing staff should document treatment changes in the Nursing Progress Notes. On 4/17/25 at 3:58 PM, Director of Nursing (DON) informed that nursing staff had been unable to find Vashe treatment prior to Resident #87's left lower extremity amputation site dressing change. DON revealed expectation of nursing staff to follow physician treatment orders and notify physician if treatment is refused. A review of the facility policy titled: Physician Orders/Transcription of Orders dated as last reviewed on July 2023 had documentation of the following procedure: a. Physician orders will be received by a licensed nurse, therapist or dietitian. b. Orders may be received through written communication in the resident ' s chart, verbally, or per phone, via fax or electronically entered in PCC (Point Click Care, the electronic medical record software). c. When receiving a verbal or telephone order, the order should be repeated back to the Physician/Nurse Practitioner/Physician Assistant to assure accuracy. d. The order should be entered into the resident ' s medical record exactly as it was stated/written by the MD/NP/PA. e. If for any reason, the physician is not available or cannot be reached by the nurse, the facility appointed Medical Director may be contacted for orders. f. Medication and treatment orders will be entered into the electronic medical administration record or electronic treatment administration record accordingly. g. Active orders should be followed and carried out as written/transcribed.

Based on observation, clinical record review, resident, family and staff interviews, the facility failed to provide a wound assessment and intervention for 1 of 3 residents reviewed (Resident #16). A bandage over a wound to the right buttocks on Resident #16 was identified by nursing staff on [DATE] without prior documentation and without provider notification for a treatment order. Resident #16 required hospitalization on [DATE] for sepsis, an infected wound, Methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli (E.coli) and a Urinary Tract Infection (UTI). Resident #16 expired on [DATE]. This deficient practice resulted in an Immediate Jeopardy to the health and safety of residents who resided at the facility. The facility identified a census of 89 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of [DATE] on [DATE] at 10:00 AM. The facility staff removed the Immediate Jeopardy on [DATE] by implementing the following actions: 1. Nurse education re-initiated on [DATE] to be completed 100% for all nurses prior to their next scheduled shift on skin practice guidelines that include direction on how to identify skin areas and wound care/dressing change, and Medical Director and family notification. 2. Baseline audit of skin on current patients in house on ,d+[DATE]//2024. 3. Nursing education on skin preventative measures including repositioning on [DATE]. The scope lowered from J to G at the time of the survey. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #16 revealed diagnoses of Parkinson's, anxiety and depression. The MDS listed the Brief Interview for Mental Status (BIMS) score as 15 out of 15 indicating intact cognition. The MDS revealed Resident #16 had limited Range of Motion (ROM) in both upper and lower extremity, and dependent upon staff for toileting, dressing and bed positioning. The MDS assessed the resident at risk for pressure ulcers, and lacked to identify a pressure ulcer yet identified an application of a non-surgical dressing. The Care Plan for Resident #16 directed staff to encourage frequent repositioning, use assistive devices as needed and administer treatment as per the physician orders. During an interview on [DATE] at 1:43 p.m., Resident #16's daughter stated she had seen her mother on [DATE] and Staff D, Licensed Practical Nurse (LPN) applied a dressing to her mother's right buttocks. When she asked to see it, the nurse informed her it was just a surface wound. The daughter stated a week later, she received a call from Staff F, LPN who stated the wound needed to be seen by the wound nurse, then a week later her mother needed to be seen at a wound clinic. The daughter stated she called the wound clinic and reported to the facility that the earliest appointment was in a week. During a visit on [DATE], staff informed the daughter, Resident #16's blood pressure was low, she had been feeling sick but it was due to waxing of floor and they moved her to a different room. The daughter stated the facility called her on [DATE] to ask if her mother could be treated at the hospital, I said yes absolutely. The daughter said the emergency room physician showed her the wound was a 5 centimeter, tunneling, infected wound and transferred her mother to the intensive care unit for 4 days. The Treatment Administration Record dated [DATE] documented the following treatment orders: a. Right gluteal crease - cleanse with Normal Saline (NS), apply xeroform and cover with a foam dressing 3 x weekly and as needed (PRN) every day shift on Tuesday, Thursday and Saturday for wound care. With an order start date of [DATE], and discontinuation date of [DATE]. c. Right buttock- cleanse with NS, apply slightly moistened Hydrofera Blue (wound product to provide protection and address bacteria and yeast), cover with foam dressing every day shift, every other day for wound care. With an order start date of [DATE], and discontinuation date of [DATE]. A review of Progress Notes for Resident #16 revealed: a. Lack of documentation on [DATE] of a wound. b. On [DATE] at 2 p.m. An open area to the right buttocks measured 4.5 cm x 3 cm x 0.5 cm and the left inner gluteal cleft measuring 3 cm x 2 cm x 0.1 cm. c. Resident had no pain, no drainage, the site was cleansed, xeroform and foam applied. d. The wound nurse was notified. e. The doctor and the Power of Attorney (POA) were notified. A review of the clinical record revealed documentation for Resident #16 by the Certified Nursing Assistant (CNA) staff, dated [DATE] thorough [DATE], titled Positioning Resident Offered or Repositioned within every 2 hours. The documentation lacked entries for multiple shifts. During an interview on [DATE] at 7:22 AM. Staff F, LPN stated she had worked in the facility for [AGE] years. Staff F stated she found the dressing to Resident #16's right buttocks and did not see the wound on [DATE] when she applied a dressing to the wound below it. It's frustrating, it doesn't take much to document it and get a treatment. Staff F stated she reported the new wound on [DATE] to the physician, POA and the wound nurse. The facility provided a document titled Harmony Statement which involved Resident #16 that revealed: a. Person interviewed was Staff D, Licensed Practical Nurse (LPN) b. Person conducting interview was the Director of Nursing (DON) c. Date of incident [DATE] d. Date of interview [DATE] e. On [DATE] at 5:15 PM., a skin assessment was completed. The daughter was at bedside. All open areas treated per physician orders, no new open areas were noted. f. Signed by Staff D, LPN on [DATE] and the DON. The facility provided a document titled Harmony Statement which involved Resident #16 that revealed: a. Person interviewed was Staff F, LPN. b. Person conducting the interview is not identified. c. Date of incident [DATE] d. Date of interview [DATE] e. On [DATE], Staff F stated she went in to do the a left ischial (bony area on bottom of pelvis, often called a sit bone) treatment for Resident #16 and found a foam dressing on Resident #16's right buttocks. The wound was measured, completed skin sheet, notified provider, and obtained an order. Staff F notified the daughter and wound nurse. Staff F stated she did not recall previous skin assessments or noticing this area. f. Signed by Staff F, LPN and the DON. A review of documents referred to as skin sheets for Resident #16 related to the right gluteal crease revealed: a. Initial observation on [DATE] lacked documentation. b. [DATE] measurement 1.5 cm x 1.0 cm x 0.1 cm, partial thickness, surrounding skin reddened. New order for Xeroform dressing, change 3 times a week and as needed (PRN). c. [DATE] measurement 2.4 cm x 1 cm skin intact, reddened, and continued the treatment. d. [DATE] measurement 2.4 cm x 1 cm x 0.1 cm partial thickness, reddened and excoriated. e. [DATE] lacked an assessment. f. [DATE] measurement 3 cm x 1.2 cm normal for skin, and continued the treatment. g. [DATE] measurement 3 cm x 1 cm pink, pale tissue, and continued the treatment. h. [DATE] the wound was resolved. A review of skin sheets for Resident #16 right buttocks area revealed: a. Initial observation on [DATE] measurement 4.5 cm x 3 cm x 0.5 cm partial thickness, wound bed had slough (moist yellow or gray necrotic tissue), and a treatment order for Xeroform. b. [DATE] measurement 4.5 cm x 3.1 cm x 0.4 cm partial thickness, and the wound bed had slough. During an interview on [DATE] at 10:09 AM Staff H, Wound Nurse, stated she had assessed a wound for Resident #16 on [DATE] right buttock with an odor that did not resolve with cleaning, therefore she notified Resident #16's daughter as she needed an appointment with the wound clinic. During an interview on [DATE] at 11:43 a.m. Staff D, LPN stated he is an agency nurse serving the facility for 3 years and had met Resident #16 a few times. Staff D stated on [DATE] Resident #16's daughter was present in the room when he placed a treatment to her right bottom. Staff D stated the daughter asked about the need for the wound clinic, and he reported it's not bad and not for me to decide and the wound nurse see's people there. Staff D stated the wound was pink, smaller than a quarter, cleaned it, placed Xeroform (type of gauze dressing) on it and checked it off in the TAR. Staff D stated he did not remember documenting it. A hospital document titled ED Triage Notes dated [DATE] revealed: a. Patient presented with Altered Mental Status (AMS), diagnosed with UTI, started antibiotic, facility admits to some fevers and increased confusion and tachycardia (fast heart rate). b. No Tylenol or ibuprofen given for fever 101.8 before arrival. c. Oxygen saturation (oxygen in blood) 88% (normal ,d+[DATE]%) placed on 2 liters of oxygen. d. Admit diagnosis Infected pressure ulcer, Stage IV, septic shock, UTI with indwelling catheter, elevated lactic acid level and hypotension (low blood pressure). e. Critical lab values, admitted to ICU for heart monitoring, hypotension and sepsis. A Hospital document titled Wound Care Initial Consultation Note dated [DATE] for Resident #16 revealed: a. Evaluation of complex wound/ulcer. b. admitted on [DATE] for Sepsis. c. Right ischial ulcer, unstageable, boggy to touch, drained a large amount of dark purulent (thick milky or yellows fluid) foul odorous drainage, and measured 4.5 cm x 5 cm x 1.5 cm. d. Wound culture was obtained. e. Left ischial, Stage 3 pressure ulcer, scant amount of serosanguineous (blood with serum) drainage, measured 1.5 cm x 2 cm x 0.1 cm. f. Treatment order. g. Follow up with the wound center upon discharge. During an interview on [DATE] at 8:12 AM, the DON stated she expected nursing staff to make weekly assessments of wounds, follow physician orders when treating wounds, turn and reposition residents frequently. The State of Iowa Certificate of Death for Resident #16 dated [DATE] revealed the immediate cause of death was due to non-healing pressure ulcerations.

Based on medical record review, family and staff interview and facility failed to supervise and ensure a compromised resident (left sided weakness/paralysis) was safe from accidents when turned in bed, and the result was the subdural hematoma and death. (Resident #14). The facility reported a census of 99 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 2/22/24 at 1:50 PM. The IJ began on 2/20/24. Facility staff removed the Immediate Jeopardy on 2/22/24 at 4:34 PM by completing the following; a. At the direction of the center Quality Assessment and Assurance (QA&A) Committee, an investigation was initiated which included interviewing employees and interviewing like residents residing in the center beginning 2/20/24. b. A QAA meeting was held to review the incident and gather information on 2/20/24 and an addition QAA meeting was held on 2/21/24 to review and determine immediate action necessary and performance improvement plan. Like Residents identified as those residing in the facility. c. Care Plans for all in house residents were reviewed to validate Activities of Daily Living (ADL) assistance including transfers, bed mobility and fall prevention starting on 2/20/24 and completed 2/22/24. d. System Revisions: 1. Education to nursing staff was initiated immediately 2/20/24 to include fall care path/prevention, change in condition, bed making (occupied bed), and repositioning. 2. Education completed with all nursing staff on 2/21/24 and will be ongoing and completed prior to the staff's next working shift. e. Monitoring: 1. The Director of Nursing or designee will complete audits weekly times 4 weeks to validate bed positioning and cares in bed are completed in accordance with Care Plan/Kardex. 2. The Director of Nursing or designee will complete daily audits Monday - Friday times 4 weeks to validate compliance with fall care path and preventative measures. 3. The Administrator or designee will complete weekly audits times 4 weeks to validate nursing staff understanding of the education provided. 4. Concerns or trends from monitoring will be forwarded to QAA for further review. The scope lowered from J to D at the time of the survey. Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #14 as mildly cognitively impaired with a Brief Interview for Mental Status (BIMS) of 10 and had the following diagnoses: Coronary Artery Disease, Heart Failure and End-Stage Renal Disease which required hemodialysis. The MDS also identified Resident #14 required substantial/maximal assistance with toileting, and to be totally dependent on staff for showers, putting on and taking off footwear, lower body dressing and walking. On 12/19/23, the Care Plan identified Resident #14 with the problem of being at risk for falls and directed staff to: a. Assist the resident with ambulation and transfers as needed b. Keep the bed in a low position On 12/20/23, the Care Plan identified Resident #14 with the problem that he required assistance with ADLs, and directed staff to assist with bathing with the assist of one to two staff A review of the facility Incident Report dated 2/20/24 at 5:05 AM had documentation of the following: a. Incident Description: Staff Nurse was called to the room by the Certified Nurses Aide (CNA) that the resident rolled off the bed during incontinent care. The resident was found in a prone position on arrival to the room. Emesis noted. General assessment done. Skin tear and abrasion to right elbow. First aid given and the resident was cleaned. Assisted to a sitting position and used a mechanical lift transfer back to the bed with assist x 2. Neuro checks started. b. Physician notified of increasing blood pressure, advised to send the resident out to the hospital. Facility on call staff notified of the transfer. c. Resident #15's family member notified of the hospital transfer on 2/20/24 at 6:20 AM d. Immediate action taken: Nurse instructed the CNA to always ask for help during incontinent care. e. Injuries observed at time of incident: Abrasion and skin tear to the right elbow A review of the Medication Administration Record revealed the following: a. Apixaban 2.5 milligrams (mg) by mouth two times a day for anticoagulation (blood thinner) (signed out twice daily from 2/1/24 to 2/19/24) b. Glucose monitoring before meals and at bedtime - last documented blood glucose at 8:00 PM was 139. Blood sugars documented at 7:00 AM had an average of 99. A review of the facility Progress Notes had documentation of the following: a. On 2/20/24 at 5:15 AM. The Nurse was called to the room by the CNA. The resident was found in a prone position with emesis noted. (the resident vomited) There was a skin tear and abrasion noted to the right elbow. Assisted back to bed using a Hoyer with assist of two. Neuro checks started. The physician was notified of increased blood pressure and gave orders to send the resident to the hospital. The resident's family was notified of the hospital transfer. The note did not have documentation that the resident hit his head on the nightstand. b. The next entry was documented after 5:15 AM, 45 minutes later at 6:00 AM. Resident #14's blood pressure 157/87 Pulse 77 Respirations 16. Oxygen saturation was 98%. A neurological check was initiated. c. At 6:02 AM, the resident was observed having seizures lasting up to 45 seconds. The physician was notified of the increased blood pressure and seizure activity. A review of the Facility Neurological Evaluation Flow Sheet had documentation of the following: 2/20/24 at 5:15 AM Alert, pupils equal and reactive, right upper limb movement marked as Yes, no documentation for left upper limb. Blood Pressure (BP) 172/84 (Heart Rate (HR) 94, Pulse Ox 94%, Temperature (Temp) 97.2, Respiratory rate (Resp rate) 22 2nd and last check on 2/20 at 5:45 AM Level of consciousness - all were marked as no for alert, lethargic, semi-comatose and comatose. Pupils equal and reactive, no documentation of both arms being assessed for movement BP 241/102 HR 156 Pulse Ox 92%, Temp 97.8 Resp rate 28 A review of the Emergency Medical Services (EMS) Patient Care Report dated 2/20/24 had documentation of the following: Injury occurred at 5:05 AM Call received at 6:10 AM Enroute: 6:14 AM At scene: 6:18 AM Transport0: 6:34 AM At destination: 6:41 AM A review of the Hospital Emergency Department Physician Notes dated 2/20/24 at 6:50 AM had documentation of the following: a. EMS reported Resident #14 was being cleaned up by staff when he rolled out of bed, smacking his head on the floor. Fall was a 2 1/2 foot drop and he is on blood thinners. The last Eliquis dose was given 2/19/24 before bedtime. b. Glucose level was 59 mg/dL (Normal range should be between 70 to 100 mg/dL) c. The head Computerized Tomography a series of x-ray images (CT) completed 2/20/24 at 7:03 AM revealed a large left subdural hematoma (a pool of clotted blood that pools in a body space) which measured up to 5.6 centimeters (cm). d. 2/20/24 at 7:34 AM patient's son now at bedside, confirmed Do Not Resuscitate (DNR) with son. e. 2/20/24 9:34 AM time of death In an interview on 2/21/24 at 5:15 PM, Resident #14's family member reported the nurse said Resident #14 hit his head on the nightstand, he was found face down on the floor and had bad hemorrhaging. He did not get sent to the hospital for at least 45 minutes or an hour. He had a huge bump right above his left eye. In an interview on 2/21/24 at 2:50 PM, Staff G, Licensed Practical Nurse (LPN) reported the following: a. On 2/20/24 at 5:04 AM, Staff Q, CNA screamed out in the hallway. She said she was trying to change Resident #14's depends and he had bowel movement (BM) on his hands. She was by herself in the room. b. When Staff G arrived to the room, Resident #13 was lying face down on the floor next to the bedside table. The bottom part of the bed was about 2 feet from the floor. There was a little blood on his right elbow where he had an abrasion and skin tear. Staff G did not see any bleeding from the head. c. Resident #14 initially was responsive to his name and his eyes were open. Then Resident #14 did not respond to any stimuli. d. Staff G, Staff Q and Staff R, CNA's used a mechanical lift to transfer the resident back to bed. e. Staff G checked Resident #14's blood pressure which was 170/80. Staff G left the room at 5:20 AM to finish up his medication pass. f. Staff G returned to Resident #14's room at 5:35 AM later to check him again. His respirations were 28 breaths per minute and his blood pressure was 240. She could not remember the exact number. Staff G left the room and asked Staff S, CMA to stay with Resident #13. g. At 5:50 AM, Staff G witnessed Resident #14 having a seizure while the resident was in bed. The seizure lasted 45 seconds. He could not recall if Resident #14 hit his head on the nightstand, however, when he checked the resident a second time, he did notice a little contusion to the left side of his skull. Staff G called 911, then paramedics arrived and transported Resident #14 to the hospital. In an interview on 2/22/24 at 8:36 AM to 8:54 AM, Staff Q, CNA reported the following: a. On 2/20/24, she provided incontinent cares that morning after Resident #14 had a BM. No one else was in the room helping her. The top of the bed was at about her hips (her height was 5 feet 1 inch). b. Staff Q started to turn Resident #14 and he rolled off the bead. She tried to catch him, but could not stop him from falling. Resident #14 then became unresponsive and she yelled out for help. c. The resident was face down on the floor. He had a small amount of bleeding from his elbow but could not recall which one. d. When Staff G, the nurse entered the room, she told him what happened. Then Staff R, CNA came into the room. e. Staff G, Staff R and Staff Q lifted Resident #14 off the floor without using a mechanical lift. Staff G lifted Resident #14's upper body, Staff Q and Staff R lifted each leg and transferred him to the bed. f. Resident #14 was care planned for one assist with bed mobility and two for transfers. g. The paramedics took Resident #14 to the hospital after 6:00 AM In an interview on 2/22/24 at 10:01 AM, Staff S, CMA/CNA reported the following: a. At 6:05 AM, Staff G, LPN was on the phone and told Staff S to check on Resident #14. b. No one was in the room at 6:07 AM and Resident #14 was biting his tongue. His eyes were open, but he did not respond when she called his name. Staff S left the room, he was still biting his tongue, to check where she was scheduled. c. Then Staff S reported the EMTs arrived at 6:11 AM to take Resident #14 to the hospital. In an interview on 2/22/24 at 10:15 AM, Staff F, LPN reported the following: a. At 6:10 AM Staff G, LPN said he would be sending Resident #14 out so Staff F went to check on him. Resident was lying in bed using accessory muscles to breathe. b. At 6:18 AM the paramedics were there. The nurse did not say anything about the resident hitting his head on the nightstand before falling on the floor. c. Staff F was at the nurse's station when Staff G told the family he had rolled off the bed, but did not say anything about the nurse was telling the family there were two people in the room when they were changing him, he rolled off the bed and landed on his face He did not say anything about Resident #14 hitting his head on the nightstand before hitting the floor. d. If a resident has a seizure and biting his tongue, we should put them on their side. Put a pillow under the head. The resident should not be left alone if they are biting their tongue. e. The incident could have been prevented if another staff member stood on the other side of the bed, that person could have prevented him from rolling off the bed. In an interview on 2/22/24 at 11:56 AM, the Director of Nursing (DON) reported the following: a. She would have expected the staff to transfer Resident #14 off the floor using a mechanical lift. b. The bottom of the bed frame was approximately 2 feet from the floor. c. The incident potentially could have been avoided if there were two staff present, or if the bed had been positioned lower. In an interview on 2/28/24 at 9:30 AM to 10:04 AM, the Administrator reported the following: a. She felt like if another staff member were on the other side of the bed, it possibly could have been avoided. The facility did not utilize side rails as they are a risk hazard. b. She would expect the nurse to document after the fall a full assessment, vital signs, range of motion, neuros, level of pain, the abrasion to his elbow should also have been charted. c. If the resident had a seizure, the staff member should stay with the resident. d. She would have expected the staff to use a mechanical lift to transfer Resident #14 back to bed from the floor. A review of the Facility Policy titled: Fall Occurrence dated as last reviewed November 2023 had documentation of the following: a. Residents will be assessed by a licensed nurse prior to being moved after a fall b. Neurological assessment will be initiated for unwitnessed falls and/or falls that are witnessed and resident hits their head. c. Documentation and monitoring will be monitored for 72 hours post fall.

Based on record review, family and staff interviews the facility failed to safely transfer a resident with a mechanical lift for 1 of 3 residents reviewed (Resident #1) resulting in an injury to the resident. The facility identified a census of 77 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] showed the required extensive to total assistance of two staff for all cares, bed mobility, transfers and toileting. The resident did not ambulate. The assessment showed the resident had a Brief Interview for Mental Status (BIMS) of 12 indicating the resident had mildly impaired cognitive skills. The MDS also identified the resident with [DIAGNOSES REDACTED]. The Care Plan initiated on 5/19/14 showed the resident with a self care deficit related to assistance with bed mobility, transferring, and toileting. The Care Plan noted a [DIAGNOSES REDACTED]. The Care Plan with an initiation date of 3/21/16 also had an intervention directing staff may have Hoyer pad in wheelchair per patient request. Noted an intervention dated 4/11/17 the resident prefers Hoyer sling to stay under patient while in wheelchair. The Care Plan failed to provide any recommendations for using a Sara Lift (mechanical stand lift). The Urinary Incontinence Care Plan directed staff to use a Hoyer Lift for toileting upon resident request. The last Physical Therapy (PT) evaluation the facility provided dated 4/18/17 indicated the resident was total dependence for transfers without attempts to initiate, resident utilized a Hoyer Lift prior to evaluation and currently. On 3/23/21 at 2:30 p.m., the Administrator provided a Hospital Note from PT dated 11/2/20 stating a reason not to provide additional therapy and states per prior PT evaluation this year Resident #1 is a long term care resident and has used a mechanical Hoyer lift for transfers for approximately 5 years. The Kardex (Reference Nursing Staff utilize) with a date as of 2/16/21 directed the staff to provide 2:1 assist with transfers using mechanical lift. Resident may have Hoyer pad in wheelchair per request. Please use toileting sling with Hoyer to allow patient to use toilet upon resident's request. The Nurse Progress Notes for Resident #1 dated 2/12/21 at 7:31 p.m. documented resident states I fell in the bathroom today after 4:00 p.m. and I am having pain on my right arm and shoulder. The Nurse spoke with the Certified Nursing Assistants (CNA's) who transferred the resident and they stated no fall occurred for the resident during the transfer. The Progress Notes failed to document the type of mechanical lift utilized for the resident. An X-ray report dated 2/12/21 at 10:10 p.m. documented suggestion of an acute moderately displaced [MEDICAL CONDITION] right humerus surgical neck with moderate angulation; recommend surgical consultation. The Nurse Progress Note dated 2/12/21 10:47 p.m., Resident #1 up in wheelchair and is able to make needs known. Noted purplish bruising to right upper arm and purplish bruise to right upper shin. Moderate swelling top right wrist. X-ray report concludes acute moderate displacement to proximal right humerus. Medical doctor notified of x-ray report and will arrange for surgical consult on Monday. Pain medication administered and positioned for comfort. The Nurse Progress Note dated 2/13/21 at 1:18 p.m., stated Resident #1 continues on post fall neuro check and within normal limits. Resident #1 has complained of right arm pain and as needed medication was administered per order. Bruising to upper right arm and breast present. Range of motion altered in right upper extremity. During an interview on 3/22/21 at 3:00 p.m. with staff B, Certified Nursing Assistant (CNA) stated she assisted Staff A, CNA on 2/12/21 to transfer Resident #1 with the Sara Lift in the bathroom. Nothing unusual was noted with the transfer. The Kardex in Point of Care (electronic charting record) has the transfer status listed. Staff B, CNA stated it will depend on the resident and if the Kardex says to use a mechanical lift we can use a Hoyer Lift or Sara Lift. The CNA determines at the time of the transfer which one to use. During an interview on 3/22/21 at 4:00 p.m., Staff A, CNA stated they used a Sara Lift to transfer Resident #1 on 2/12/21 and she was a resident who could use a Hoyer Lift or a Sara Lift. The staff verify the transfer status on the Kardex. During an interview on 3/22/21 at 4:25 p.m., Staff C, CNA stated the resident transfer status is on the Kardex in the Resident Profile of Point of Care. If the Kardex states mechanical lift, a CNA should ask the nurse and never make the decision of which type of lift to utilize. It should say Hoyer or Sara Lift, all types of lifts should be on the Kardex for transfer status. Staff C remarked that Resident #1 was a Hoyer Lift and had been for some time. Resident #1 was not able to bear weight. During an interview on 3/22/21 at 4:35 p.m., Staff D, Licensed Practical Nurse (LPN) stated the Care Plan should specify if resident is a Hoyer Lift or a Sara Lift and a CNA should never make the decision on their own which one to use. Staff D reported Resident #1's transfer status was a Hoyer Lift due to she was dead weight. Staff D stated that at any time helping another CNA to transfer the resident it was with a Hoyer. During an interview on 3/23/21, the Rehabilitation Director stated the last PT evaluation was 4/18/17 for Resident #1 and has not been seen since her status was unchanged to warrant services from therapy. The last evaluation stated her transfer status was dependent, required max assist and with total dependence of a Hoyer Lift. During an interview on 3/23/21 at 8:30 a.m., Staff E, CNA reported the Care Plan will state if a resident is a Hoyer or Sara Lift. Staff E stated that Resident #1 was a Hoyer Lift and never transferred with a Sara Lift. She was a Hoyer Lift and it said it on the Care Plan. Staff E remarked if the Care Plan said only mechanical lift, she would clarify this with a Supervisor before using a different lift. During an interview on 3/23/21 at 8:45 a.m. with Staff F, CNA stated the facility provided education regarding mechanical lifts. She stated they teach the Kardex tells staff how to transfer a resident and it will always differentiate if a Sara Lift and a Hoyer Lift is to be utilized. If it stated only mechanical lift, Staff F would ask the nurse to clarify and no residents here vary from one lift or the other we use the lift it states on the Care Plan. During an interview on 3/23/21 at 9:00 a.m., Staff G, Registered Nurse (RN), Unit Manager states the staff look at the Kardex on the computer for transfer status, this comes from Therapy and is updated by the Nurse Manager. If it states transfer with a mechanical lift could mean a Hoyer Lift or a Sara Lift but staff need to clarify with the Nurse. Resident #1 was a Hoyer Lift. Staff G reported would not use a Sara Lift for the resident, we have slings available for the Hoyer Lift to use on the toilet. During an interview on 3/23/21 at 1:25 p.m., Staff H, CNA stated a resident's transfer status is always on the Kardex and will specify if should use a Hoyer or Sara Lift. Resident #1 was a Hoyer Lift, as not able to bear weight and Staff H reported would never use a Sara Lift to transfer her. During an interview on 3/23/21 at 2:15 p.m., Staff I, LPN stated he was the nurse on duty when Resident #1 stated she fell . Staff I went to the room and Resident #1 said she fell while being transferred in the bathroom. Staff I questioned the CNA and they said they did not drop her from the lift. Staff I then asked the resident again and she would not let Staff I assess her. Staff I did report the resident was an assist of 2 with a Hoyer Lift and had a Hoyer sling in her room and used the Hoyer all the time. During an interview with a family member on 3/23/21 at 11:00 p.m., the family member stated Resident #1 not able to bear weight. She had been using a Hoyer Lift since she moved to a room downstairs at the facility about 5 years ago. During an interview on 3/23/21 at 2:30 p.m., the Director of Nursing (DON) stated she would expect a resident be a Hoyer transfer if this is what PT recommends. The DON also stated would expect the Unit Managers to know the residents transfer status and update the Care Plan/Kardex accordingly. During an interview on 3/23/21 at 4:30 p.m., the Administrator states the Care Plan should document which type of lift should be used for a resident and staff should follow the Care Plan for which lift to use. The facility provided a policy titled Transfer: Bed-Chair/Wheelchair dated 1/2011 which noted for transfers requiring mechanical lift, please refer to manufacturer guidelines for use. The facility provided a policy titled Mechanical Lift last updated 4/2019 directing staff to verify transfer assist needed per Kardex. Obtain additional assistance and needed equipment as indicated. Use of a mechanical lift requires a second caregiver. The undated Instruction Manual for the Sara Lift 3000 states in the Patient/Resident assessment section of the safety instructions recommend that facilities establish regular assessment routines. Caregivers should assess each resident/patient according to the following criteria prior to use: a. Patient/Resident sits in a wheelchair. b. Patient/Resident is able to partially bear weight on at least one leg. c. If the Patient/Resident does not meet these criteria an alternative equipment /system shall be used.

Based on record review and interview, the facility failed to assess and evaluate a resident's significant weight loss and implement interventions to prevent further loss for 1 of 3 residents reviewed with a weight loss (Resident #2). The facility reported a census of 85 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool, dated [DATE], listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance of 1 staff for personal hygiene, walking, and bathing, and extensive assistance of 2 staff for bed mobility, transfers, dressing, and toilet use. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. An [DATE] History and Physical report stated the resident presented to the Emergency Department with bilateral (pertaining to both sides of the body) [MEDICAL CONDITION] and listed the resident's weight as 122.98 lbs (pounds). The resident's facility Admission Record Report stated the resident had a hospital stay from [DATE]-[DATE] and initially admitted to the facility on [DATE]. The Weights and Vitals Summary listed an [DATE] weight of 124.4 lbs. A Progress Note, dated [DATE], stated the resident admitted to the facility following a hip replacement and planned to discharge to home following her stay. The note stated the resident was in good spirits. A facility Progress Note, dated [DATE], stated the resident discharged to the hospital due to vomiting and respiratory distress. A Hospital Dietician Report, dated [DATE], stated the resident had lost 4.2 lbs. from her stated weight and reported it was not significant but clinically relevant. The note stated the resident was receptive to trying Ensure [MEDICATION NAME] chocolate (a dietary supplement) and stated the resident would return to the facility with dietary supplements ,[DATE] times per day. The note stated the facility Dietician should follow. A facility Progress Note, dated [DATE], stated the resident readmitted to the facility after a hospitalization . The Weights and Vitals Summary listed an [DATE] weight of 115 lbs. This calculated as a 7.56% loss from the resident's weight of 124.4 lbs prior to the hospitalization on [DATE]. A [DATE] Nutrition Assessment, completed by the facility dietician, listed the resident's weight as 112 lbs. It stated the resident was underweight for an older adult and consumed ,[DATE]% of meals. The assessment stated the resident did not like the food choices offered and the lack of salt was affecting her food intake. The notes stated the resident's was on a No Added Salt (NAS) diet and requested a regular diet. The note stated the Dietician obtained an order for [REDACTED]. An Order Audit Report listed a [DATE] order for a magic cup three times per day. The facility lacked documentation of a magic cup initiated on [DATE] when the Dietician stated the resident agreed to it. The resident's [DATE] Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A [DATE] the Nurse Practitioner report directed staff to continue the resident's NAS diet. The Order Summary Report with a list of active orders as of [DATE], listed an order for [REDACTED]. The Weights and Vitals Summary listed a [DATE] weight of 101.1 lbs, calculated as a 12.09% loss from the resident's readmission weight of 115 lbs on [DATE] and an 18.73% loss from the resident's original admission weight on [DATE]. The Weights and Vitals Summary listed a [DATE] weight of 95.4 lbs, calculated as a 17.04% loss from the resident's readmission weight of 115 lbs on [DATE] and a 23.3% loss from the the resident's original admission weight on [DATE]. An untitled Physician's Progress Note, dated [DATE], stated the resident's had lost 20 lbs since her initial admission. The note stated the resident reported she had a decline in her appetite since being at the facility but had not been taking her antidepressant. The note also stated the resident had chronic diarrhea several times per day and was usually on [MEDICATION NAME] (an antidiarrheal). The note stated the physician would restart the resident's [MEDICATION NAME] and antidepressant. The facility lacked documentation of physician and family notification of the resident's weight loss between the resident's readmission on [DATE] and [DATE] when the physician noted the weight loss. The facility lacked documentation of an additional intervention carried out aside from the magic cup initiated on [DATE] and the multivitamin on [DATE]. The facility lacked documentation of whether or not the resident consumed the magic cup and lacked documentation of ongoing assessments of the resident's weight or an evaluation as to whether the magic cup was effective. The Weights and Vitals Summary included the following weights (in lbs): [DATE]: 124.4 [DATE]: 114 Resident was in the hospital from [DATE]-[DATE] [DATE]: 115 [DATE]: 114.6 [DATE]: 110.6 [DATE]: 110.6 [DATE]: 103 [DATE]: 102.6 [DATE]: 100.8 [DATE]: 101.1 [DATE]: 98.6 [DATE]: 98.8 [DATE]: 99 [DATE]: 98.6 [DATE]: 98.9 [DATE]: 97.1 [DATE]: 95.4 [DATE]: 94.8 [DATE]: 94.2 [DATE]: 99 [DATE]: 94.8 [DATE]: 94.4 [DATE]: 94.2 [DATE]: 93.4 [DATE]: 93 [DATE]: 93.2 A [DATE] Progress Note stated the family requested to discharge the patient to home on [DATE]. A [DATE] Progress Note stated the resident tested positive for COVID-19. A [DATE] Progress Note stated the family requested a Hospice evaluation. The resident's [DATE] Documentation Survey Report v2 lacked documentation staff offered the resident fluids on the following 6:00 a.m.-2:00 p.m. shifts: [DATE] and [DATE] and on the following 2:00 p.m.-10:00 p.m. shifts: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The report documented the resident did not consume any of her meals from [DATE]-[DATE]. The facility had documentation the resident's Advanced Registered Nurse Practitioner (ARNP) aware the resident was not eating according to the [DATE] ARNP Progress Note. The facility lacked further documentation of provider notification the resident was not eating from [DATE] until the time the resident was sent to the emergency roiagnom on [DATE]. An Emergency Department Report, dated [DATE], stated the resident admitted to the ER due to [MEDICAL CONDITION] (inadequate oxygen in the blood) and [MEDICAL CONDITION](low blood pressure). The note stated the resident had dry, cracked oral mucous membranes and her labs were consistent with acute kidney injury likely secondary to dehydration. A [DATE] Progress Note stated the resident returned from the hospital. A [DATE] Progress Note stated the resident expired at the facility at 6:10 p.m. Care Plan entries, dated [DATE], stated the resident would experience no significant weight change and included the following interventions: a. Vitamin and mineral supplements. b. Honor food preferences. c. Supplements (dietary). d. Report intolerance to current diet. e. Review weights and notify the physician and responsible party of significant weight change. f. Snacks per resident preference. The Care Plan lacked additional resident centered, specific interventions based on the residents likes and dislikes to assist the resident in maintaining or gaining weight. The facility policy Weight Measurement, dated ,[DATE], directed staff to compare weights to the previous weight and review discrepancies with the nurse. The policy stated discrepancies were considered to be 5 lbs if the patient was over 100 lbs. The policy directed staff to notify the physician and the responsible party of the weight loss and stated the dietician would evaluate and document in the nutrition progress notes. The untitled facility policy regarding Care Plans, dated 2013, stated the facility would create a Comprehensive Care Plan to include individualized interventions which focused on specific risk factors. The facility policy Change in Condition, dated ,[DATE], stated the facility must immediately inform the resident, the resident's physician, and the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status. During an interview on [DATE] at 2:32 p.m., the Director of Nursing (DON) stated she could not locate any additional dietary interventions for Resident #2 other than a magic cup. She stated a weight loss would trigger if it occurred in a 30 day time period. She stated it would not trigger for a shorter period of time. When the surveyor asked if the facility could miss a weight loss due to this, she stated potentially. During an interview on [DATE] at 3:30 p.m., the Registered Dietician stated if a resident had an ,[DATE] pound weight loss in a week, it should trigger. She stated though that weight changes were triggered for the period of 1 month and 6 months and may not trigger for a shorter period of time. She stated she completed Resident #2's initial assessment but did not complete any follow up. During an interview on [DATE] at 7:45 a.m., the Registered Dietician stated she completed the resident's assessment on [DATE] and liberalized the diet, started a magic cup, and recommended a multivitamin. On [DATE], she continued those interventions. She stated on [DATE], she already had interventions in place. She stated the unit managers would let her know of weight losses and stated unless someone told her of more of a weight loss, she would not have followed up. She stated the resident told her ,[DATE] lbs was her usual weight. She stated they would notify the physician of a weight loss if it triggered for the period of 1 month or 6 months. She stated they may not inform the physician of a weight loss in a shorter period of time. She stated with Resident #2, the month period hadn't passed yet. During an interview on [DATE] at 9:28 a.m., Staff P, Physician, stated if a resident's weight decreased from 115 lbs-101 lbs in a period of a week, she would want the facility to notify her. She stated with weight loss, they may start an appetite stimulant. If the facility tried a supplement and it wasn't working or the resident did not like it, she would expect them to try something different. If a magic cup was the intervention, she would want the facility to evaluate whether or not it was effective. She stated if a resident returned from the hospital with a weight loss, the facility should monitor the weight even more closely During an interview on [DATE] at 9:52 a.m., the Food Service Director stated the facility Dietician assessed weight loss. She stated the Dietician discussed the resident's preferences of food. She stated she wasn't provided a list of weight losses in the facility. During an interview on [DATE] at 10:30 a.m., Staff Q, Licensed Practical Nurse (LPN) stated she would want to know if a resident's weight decreased from 115 lbs to 101 lbs in 1 week. She stated if this happened, she would let the Dietician and the physician know and would start giving snacks and Ensure (a dietary supplement). During an interview on [DATE] at 10:58 a.m., Staff F, Registered Nurse (RN) stated the facility Dietician flagged residents with weight loss. She stated if a resident's weight decreased from 115 lbs to 101 lbs in a period of a week, they should notify the physician. During a interview on [DATE] at 8:05 a.m., Staff D RN/Nurse Manager stated if a resident's weight decreased from 115 lbs to 101 lbs in a week and the weight was accurate, he would expect staff to notify the doctor and the Dietician for supplements. He stated they would notify the family and inquire if the resident had any comfort foods. He stated staff should evaluate the effectiveness of an intervention such as a magic cup. During an interview on [DATE] at 8:54 a.m., Staff M RN/Nurse Manager stated if a resident had a weight loss, she would let the Dietician and the physician know. She would want to figure out the reason, possibly the resident had food preferences and the family could bring in food. She stated the Certified Nursing Assistants (CNA's) weighed the resident and it was the nurses' responsibility to look at the previous weight to see if there was a change and if so to notify the physician. She stated if a resident's weight decreased from 115 lbs to 110 lbs in 1 week, she would speak to the physician to determine the root cause. She stated she wasn't sure if staff monitored interventions such as a magic cup to see if residents consumed them. She stated if a resident had a weight loss during a hospital stay, this would be a trigger to keep an eye on the resident's weight. During an interview on [DATE] at 10:43 a.m., the DON stated the Dietician monitored weights on a 30 day basis and was not sure about weight losses which occurred in a shorter period of time. When the surveyor asked whether the facility should notify the physician if a resident's weight decreased from 115 lbs to 101 lbs in the period of a week, she stated she was not sure how that worked outside of the 30 day time frame and stated she would check the facility policy and get back to the surveyor. During subsequent email correspondence on [DATE] at 1:49 p.m., the DON wrote that the facility followed the regulatory guidelines for a notification of a 5% weight loss in 30 days.

Based on observation, record review, and staff, physician, Police, First Responder and Medical Examiner interviews, the facility failed to provide care in accordance to Physician order [REDACTED].#10). The facility reported a census of 92 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated [DATE] revealed Resident #10 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident scored 11 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that indicated cognitive impairment, without symptoms of [MEDICAL CONDITION], and required extensive assistance of at least 1 staff to reposition in bed, transfer to and from bed and chair, ambulation, dressing, toileting and personal hygiene. Physician order [REDACTED]. a. Continuous oxygen administered via nasal cannula (NC) at 4 liters per minute. b. [MEDICATION NAME] (a beta agonist medication that dilates the airways) 20 micrograms in 2 milliliters administered via nebulizer twice a day. c. [MEDICATION NAME] (a corticosteroid medication that reduces swelling of the airways) 0.5 milligrams in 2 milliliters administered via nebulizer twice a day. d. [MEDICATION NAME] 0.5 milligrams with [MEDICATION NAME] 2.5 milligrams (both [MEDICATION NAME][MEDICATION NAME] medications and when combined, referenced as Duo-Neb) in 3 milliliters solution administered via nebulizer every 4 hours while awake. e. [MEDICATION NAME] 2.5 milligrams in 3 milliliters solution administered via nebulizer every 6 hours as needed. f. Trilogy machine (a ventilator that accommodated Bi-Pap and C-Pap settings, that provides volume and pressure control through a mask applied to the nose and mouth) ensure oxygen bled in to the tubing, mask applied at hour of sleep in the evening, removed in the morning. A risk for respiratory impairment related to aspiration problems initiated on the Nursing Care Plan on [DATE] identified a goal to maintain a patent airway for Resident #10 and directed staff to implement the following to achieve the goal: a. Encourage deep breathing exercises. b. Evaluate lung sounds and vital signs as needed. c. Obtain pulse oximetry and report abnormal findings to the physician. d. Administer medications per physician orders. e. Elevate the head of the bed. f. Administer oxygen per physician orders. A Physician/Nurse Practitioner Progress Note dated [DATE] revealed the resident was oxygen dependent, breath sounds diminished to auscultation with cough productive of thick yellow sputum, directed the continued administration of antibiotics, oxygen, breathing treatments, Trilogy, and instruct resident to cough and deep breath at intervals during the day. Review of the resident's Medication Administration Record [REDACTED].m Further review showed the medication administered by Staff B, Registered Nurse (RN), at 1:02 a.m. and 5:37 a.m. on [DATE]. The MAR indicated [REDACTED]. Documentation of oxygen saturation levels revealed (normal value 95 to 100 percent on room air)the following levels: a. On [DATE] at 8:13 p.m., 99 percent with oxygen via NC. b. On [DATE] at 8:15 a.m., 96 percent with oxygen via NC. c. On [DATE] at 1:43 a.m., 88 percent with oxygen per Bi-Pap (Trilogy). d. On [DATE] at 8:00 a.m., 95 percent with oxygen via NC. e. On [DATE] at 12:45 p.m., 94 percent with oxygen via NC. f. On [DATE] at 4:09 p.m., 94 percent with oxygen via NC. g. On [DATE] at 1:34 a.m., 93 percent with oxygen via Bi-Pap. h. On [DATE] at 4:49 p.m., 97 percent with oxygen via NC. i. On [DATE] at 1:48 a.m., 89 percent with oxygen via Bi-Pap. j. On [DATE] at 4:41 p.m., 98 percent with oxygen via NC. k. On [DATE] at 6:51 p.m., 91 percent on room air. l. On [DATE] at 3:38 p.m., 98 percent with oxygen via NC. A Nurse's Note dated [DATE] at 7:22 a.m., transcribed by Staff A, Licensed Practical Nurse (LPN) stated 2 Certified Nursing Assistants (CNA's) found the resident unresponsive in the room. A Fireman in the room noticed the resident didn't look good, came out of the room and yelled the resident required CPR. The Fireman returned to the room and started compressions with facility staff assisting. The resident's time of death recorded at 7:49 a.m., and the spouse notified of the resident's death. The Facility's Self-Reported Incident described at approximately 7:00 a.m. on [DATE], the nurse that cared for the resident's room-mate realized the nebulizer treatment was completed, removed nebulizer (mask) and replaced the NC at 4 liters. At approximately 7:20 a.m. the resident observed unresponsive and CPR initiated with the resident expiring at 7:49 a.m. at the facility. Investigation by facility in progress as death was unexpected, Medical Examiner to complete an autopsy and toxicology. The facility's Medication and Treatment Administration Guidelines policy, updated ,[DATE], directed staff to complete the following: a. Medications were administered in accordance with standards of practice and state specific and federal guidelines. b. Medications were administered in accordance with the rights of medication administration that included right patient, right medication, right dose, right route, right time and right clinical indication. c. Medications that were not administered according to Physician order [REDACTED]. The facility's Oxygen Administration policy last reviewed ,[DATE] directed staff: a. Verify physician's orders [REDACTED].>b. When concentrator used, plug the power cord into the outlet, turn unit on and set flow meter to correct flow rate, and ensure that exhaust filters are clean and unblocked. c. When administered by NC, direct prongs toward floor of nostrils, hook cannula tubing behind ears and under chin, and slide adjuster upward under chin to secure cannula in place. The facility's Respiratory Nebulizer Mist Therapy policy, revised ,[DATE], directed staff: a. Verify physician's orders [REDACTED].>b. Verify that aerosol unit is off and plug power cord into electrical outlet. c. Connect one end of tubing to nebulizer and other end to aerosol unit air outlet. d. Fill nebulizer with prescribed medication. e. Connect mask to tubing. f. Apply mask to resident face. Verify nebulizer is held upright at all times to maintain prescribed medication in chamber. g. Switch aerosol unit on and direct resident to inhale mist slowly and deeply. h. Continue until prescribed medication has been aerosolized from chamber. i. Switch aerosol unit off when treatment completed. j. Assess lung fields and heart rate, document any changes. k. Rinse excess mist and medication from nebulizer and mask. l. Store dried nebulizer and mask in separate, labeled plastic bag. The Nurse Supervisor Job Description dated as last reviewed ,[DATE], described nursing responsibilities that included: a. Administers medications and treatments timely and according to facility policy. b. Receives, transcribes and carries out physician orders. c. Documents medications and treatments per facility policy. d. Documents in Nurse's Notes any exceptions to resident condition. A One-On-One Inservice Record form completed by the Administrator and Director of Nursing (DON), dated [DATE] revealed Staff B administered a 4:00 a.m. scheduled medication at 5:37 a.m Staff B instructed medications should be administered within an hour before or after the scheduled time and if the resident was asleep at 4:00 a.m. the nurse should have documented asleep. Also if the medication requested at 5:30 a.m., the nurse should have documented the as needed medication administered at that time. A statement obtained from Staff B, RN, via phone on [DATE] 15 1:32 p.m., recorded by the Administrator and DON stated: On his night shift that concluded at 6:00 a.m. on [DATE], Resident #10 had no issues and slept through the night with his Trilogy on. The nebulizer treatment was applied between 5:30 a.m. and 5:45 a.m., at that time, the Trilogy mask was removed, nebulizer mask applied, he could not remember if oxygen via NC was applied but that would have been part of his normal process. At that time the resident was alert and asked for water. He could not recall if the nebulizer treatment was removed prior to the time he left the facility. Observations on [DATE] revealed: a. At 7:38 a.m., Staff C, RN, started administration of an ordered Duo-Neb nebulizer treatment to Resident #1. The nurse remained at the resident's bedside, the medication administration was completed at 7:43 a.m., then the nurse washed the nebulizer tubing and placed it in a plastic bag stored in the resident's room. b. At 1:27 p.m., Staff D, LPN, started administration of an ordered Duo-Neb nebulizer treatment to Resident #2. The nurse remained at the resident's bedside, the medication administration was completed at 1:35 p.m., then the nurse washed the nebulizer tubing and placed it in a plastic bag stored in the resident's room. Staff interviews revealed: On [DATE] at 7:16 p.m., Staff E, RN, stated she worked the day shift (6:00 a.m. to 2:00 p.m.) on [DATE], between 6:45 a.m. and 7:00 a.m. as she provided care to Resident #10's room mate (Resident #11), she heard the nebulizer and saw the nebulizer mask on Resident #10 with the treatment completed. She noted the oxygen not on the resident, the cannula tubing laid over the overbed table connected to the concentrator and not on the resident. She stated the resident's color was dusky (dark blue-purple) as she removed the nebulizer mask and applied the oxygen via NC. When the ambulance arrived for Resident #11, she could not recall if Resident #10's skin was warm or cool, and the resident did not respond as she applied the oxygen (per ambulance report, arrived at the resident's room at 6:53 a.m. on [DATE]). Staff E stated she had cared for Resident #10 before, he was oxygen dependent, she always administered his nebulizer treatments via mask applied over his oxygen cannula, and removed the mask when the treatment was completed, after about 10 to 12 minutes. On [DATE] at 1:14 p.m., Staff A, LPN, stated she was assigned to the resident on the [DATE] day shift. Staff B, RN, stated he had just given the resident's breathing treatment and didn't communicate anything unusual in his change of shift report to her and she hadn't seen or assessed the resident yet. Sometime between 7:00 a.m. and 7:30 a.m. a Fireman said the resident required CPR and as she assisted with CPR, the resident felt cool but not cold. On [DATE] at 2:50 p.m., Staff F, CNA, stated the resident was assigned to her on the [DATE] day shift. That morning she noticed the privacy curtain partially pulled between the resident's in the room and she hadn't entered the room but could tell the resident was in bed. Staff F reported she couldn't see if his oxygen was on or not and hadn't seen the resident until she went in the room to get him up with Staff G, CNA, and at that time the Fireman in his room said the resident didn't look good. On [DATE] at 12:46 p.m., Staff G, CNA, stated on [DATE] after the ambulance left with Resident #11, he went with Staff F, CNA, to get Resident #10 up, a fireman in the room said he didn't look good. Staff G reported they tried and couldn't wake the resident, the fireman yelled for staff to respond and started CPR (the ambulance left the facility with Resident #11 at 7:18 a.m. per ambulance record). On [DATE] at 9:56 a.m., Staff H, Emergency Medical Technician (EMT) and a Fireman from the local fire department stated on [DATE] after the ambulance loaded Resident #11 for transport, he returned to the room around 7:22 a.m. and thought the resident didn't look good, the resident didn't respond when staff tried to wake him, he felt for a pulse, couldn't find one and called out to staff for help with CPR. Staff H could not recall if the resident had oxygen on, and didn't think he removed oxygen when he started CPR. The resident felt a little cool, he checked for lividity (discoloration of the skin due to the settling and pooling of blood) but didn't find it, his legs looked discolored. At the end of CPR the resident had lividity on his thighs. On [DATE] at 10:14 a.m., Staff I, Paramedic/Fireman stated he hadn't noticed the resident until they left with the room mate (Resident #11) and thought it was odd that the resident had not responded to the commotion in the room. Staff I reported he thought maybe his face looked pale, and did not recall oxygen on the resident but not absolutely certain of that. On [DATE] at 12:56 p.m., Staff J, Police Detective with the local police department stated he was called to the facility on [DATE] at 8:15 a.m. for a suspicious death, evidence was collected from the resident's room, there was an ongoing investigation that may result in charges, subpoenas had been issued, the County Medical Examiner's office was involved and an autopsy would be completed. On [DATE] at 12:38 p.m., Staff K, County Medical Examiner and physician, stated the resident's death was suspicious and an autopsy was underway that morning, the resident was oxygen dependent and knew there was a period of time that oxygen was not administered prior to his death. She had conferred with the resident's spouse who reported the resident required 5 to 6 liters of oxygen per minute prior to his admission to the facility, and consented to the autopsy. On [DATE] at 3:04 p.m., Staff L, the resident's Pulmonology Physician of record, stated the resident was oxygen dependent with advanced [MEDICAL CONDITIONS], required the Trilogy respirator at night due to advanced disease beyond Bi-Pap or C-Pap support. Staff L stated if the resident had a nebulizer mask left over his mouth and nose for an hour and 15 minutes, without oxygen administered, his oxygen level would have dropped and could have caused his [MEDICAL CONDITION] and death. On [DATE] at 9:41 a.m., Staff M, CNA, stated when she worked the night shift from 10:00 p.m. on [DATE] to 6:00 a.m. on [DATE], the resident used his call light more than usual and able to communicate his needs. Staff M reported he didn't sleep well, hadn't asked for any pain medication, was scheduled for a breathing treatment at 4:00 a.m. but didn't see the nurse go in his room and not sure if he got it. She completed incontinence care of the resident at 4:45 a.m., the resident had his C-Pap mask on, and when she last checked on him at approximately 5:00 a.m., he still had the C-Pap mask on, in bed and asleep. On [DATE] at 7:12 a.m., Staff N, RN, stated she had cared for the resident, the resident needed the oxygen and administered his nebulizer treatments with oxygen on under the nebulizer mask. On the night shift, the resident wore the Trilogy mask with oxygen connected to it, to administer a nebulizer at that time the nurse had to remove the Trilogy mask, disconnect the oxygen tubing from the concentrator, attach the NC tubing to the concentrator and apply NC to the resident, then apply the nebulizer mask over the oxygen. On [DATE] at 8:19 p.m., Staff O, LPN, stated the resident was oxygen dependent, she administered his nebulizer treatments via mask with oxygen administered per NC under it, the resident said he didn't like the Trilogy mask, his oxygen saturation was 87 to 88 percent when the Trilogy mask was on with oxygen bled into the line as ordered, and saturations higher when oxygen administered via NC. On [DATE] at 1:40 p.m., Staff D, LPN, stated she stayed with a resident when nebulizer treatments were administered, unless there was an order for [REDACTED]. On [DATE] at 1:31 p.m., the DON and Administrator could not answer if the nurse was required to stay with the resident through nebulizer administration and stated their policy/procedure did not really say. The DON thought there was a Medication Self-Administration Policy, but hadn't considered it as required for nebulizer treatments as many residents were alert and participative with the treatment. The Administrator stated when they questioned Staff B about the events on [DATE] and why the nebulizer wasn't administered until 5:35 a.m., the staff reported he was running behind. The Administrator stated when she went to the resident's room to look at the equipment and investigate the incident on the morning of [DATE], the police had already removed the items as evidence. On [DATE] at 1:25 p.m., the DON stated she expected nurses to administer all medications and treatments as ordered by the physician unless contraindicated and should then seek clarification from the prescriptive physician. On [DATE] at 3:22 p.m., Staff B, RN, refused an interview without legal representation. As of 4:30 p.m. on [DATE] and after repeated requests, the staff member's attorney had not made arrangements for an interview with the Iowa Department of Inspections & Appeals (DIA) or the local police department. On [DATE], the State Agency informed the facility of the Immediate Jeopardy situation found at the facility. On [DATE] the facility abated the Immediate Jeopardy. The facility provided education to the Nursing Staff on proper administration of Nebulizer treatments with continuous oxygen.

Based on observation, clinical record review and staff interview, the facility failed to provide interventions to prevent and care for pressure ulcers for two of seven residents reviewed with pressure ulcers. (Resident #54 & #197) The facility census was 110 residents. Findings: 1. The Minimum Data Set (MDS) assessment completed 5/30/18, documented Resident #54 had [DIAGNOSES REDACTED]. The Stage III pressure ulcer measured 5.3 cm (centimeters) b 8.7 cm and depth of 0.1 cm. The care plan with the target date of 8/31/18 identified the resident with the problem of pressure wound to the right buttock related to impaired mobility, incontinence, Braden score of 14. It directed the staff to complete the following interventions: -Administer [MEDICATION NAME] per physician orders [REDACTED]. -Administer treatment per physician orders -Diet and supplements per physician orders -Encourage and assist as needed to turn and reposition, use sassiest devices as needed -Follow up care with physician as ordered -Obtain labs as ordered and report results to physician -Pressure reducing surface on bed and wheelchair -Report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etc. Notify physician as needed. -Use pillows and/or positioning devices as needed. A review of a pressure ulcer assessment completed in the electronic medical record on 5/25/18 at 1:57 p.m. identified the resident with a pressure wound to the right buttock with measurements of 6.0 cm by 9.0 cm by 0.1 cm. with no description of the appearance of the wound or surrounding skin edges. During observation on 6/25/18 at 11:16 a.m., the resident sat up in the chair in her room, talking on cell phone wearing non-skid shoes. At 12:18 p.m., the resident remained in the wheelchair wearing shoes to both feet. At 12:53 p.m., remained in the wheelchair in her room wearing shoes to both feet On 6/26/18 at 9:49 a.m., Staff L, registered nurse, RN and Staff X, certified nurse aide entered the resident's room to perform cares. Staff X removed the prevalon boots from the resident's feet. Staff L placed clean towel underneath the resident's gluteal folds, removed the dressing to the right gluteal fold which had moderate amount of serous drainage, the wound bed appeared large with red/pink granulation tissue, peri wound blanchable without odor, without tendon/muscle or bone exposed. The wound had no signs of infection noted. Staff L reported she needed to measure wound to area behind right ankle as it was a new area. The open area noted to the right Achilles appeared pale in color with scant amount of serous drainage. On 6/27/18 at 6:09 a.m., the resident was asleep in bed lying on their back without prevalon boots on and wore only gripper socks to her feet. On 6/28/18 at 7:20 a.m., the resident laid in bed on her left side without prevalon boots on at this time and only gripper socks to her feet without her heels floated. A review of a skin alteration record which should not be used for pressure ulcers identified an open area to the backside of the right ankle first identified on 6/26/18 with measurements of length of 1.8 cm width of 0.8 cm and depth of 0 cm. The wound had pale, pink tissue, scant amount of serous drainage and the surrounding skin with maceration - skin softening related to fluid and no pain at the site. A review of the progress notes dated 5/25/18 at 2:13 p.m., documented the right buttock pressure ulcer measured 6.0 cm by 9.0 cm and depth of 0.1 cm. with a large amount of yellow serous drainage, wound bed large red/pink granulation tissue with margins that were well defined and rolled, that the periwound to be blanchable , without odor or exposed tendon, muscle or bone. Recommendations for air mattress, roho cushion to chair Assessments had been completed weekly. An assessment dated [DATE] at 7:41 p.m., documented the wound measured 4.6 cm by 5.0 cm and depth of 0.1 cm with a moderate amount of yellow serous drainage, large red/pink granulation tissue, margins well defined with periwound that was blanchable and no odor or exposed tendon, muscle or bone. During an interview on 6/27/18 at 12:40 p.m., Staff G, CNA reported the resident had an open area to her bottom, and was care planned to not allow her to sit for long periods of time, usually after meals, she is supposed to lay down in bed. During interview on 6/27/18 at 1:17 p.m., Staff H, CNA reported the resident had a pressure sore to her bottom and was to lay down in bed after meals. During interview on 6/27/18 at 1:47 p.m., Staff L, RN reported the resident had a pressure ulcer to her right buttocks on admission. There was two on her left gluteal fold which was more from shearing. She also had an open area to the right Achilles which developed after she was admitted . She was care planned to be repositioned, when in bed she should have the prafo boots on, and should not be wearing any shoes until the Achilles wound heals. During interview on 6/28/18 at 7:28 a.m., Staff R, RN, Unit manager reported when residents have an open area to the feet or Achilles, the expectation would be to suspend the heels, or put heel protectors on as ordered. Staff R reported the resident had complained about the heel protectors and would not keep them on and that should have been care planned. 2. The MDS assessment completed 6/1/18, documented Resident #197 had [DIAGNOSES REDACTED]. The care plan with the target date of 9/2/18 identified the resident with the problem of pressure ulcers to the coccyx, right heel and right great toe and left great toe and directed the staff to: -Administer [MEDICATION NAME] as needed -Daily body audit -Friction reducing transfer surface -Incontinence management -Pain evaluation prior to treatment -Pressure redistributing support surface -Repositioning during activities of daily living -Skin barrier It also identified the resident with the problem of being at risk for alteration in skin integrity and directed the staff to: Elevate the heels as able Encourage the resident to lay down and not sit up for long periods her chair to prevent more pressure to the coccyx. A review of the nursing admission assessment completed 5/25/18 at 6:46 p.m. had documentation the resident had one pressure ulcer to the coccyx. physician progress notes [REDACTED]. physician progress notes [REDACTED]. Progress notes dated 5/29/18 at 11:09 a.m., documented the coccyx wound without measurements was blanchable and erythemic, without odor or appearance of tendon/muscle or bone. The left heel wound identified as Stage II measured 2.0 cm by 3.0 cm. Additional recommendations included heel protectors, floating heels on pillows while in bed. Assessments had been completed weekly. Progress notes dated 6/12/18 at 3:44 p.m., documented the residents left heel with measurements of 0.9 cm by 1.2 cm and depth of 0.1 cm. The wound had a small amount of serosanguinous drainage, the wound bed had large eschar and adherent slough noted with well-defined margins and blanchable, erythemic macerated periwound. No odors, tendon/muscle or bone exposed. It also identified the resident to have another new pressure ulcer to the left great toe with measurements of a length of 0.9 cm width of 0.9 cm and depth of 0.1 cm The wound had a large stable eschar with adherent slough noted, very small pink granulation noted around edges with well-defined margins and blanchable erythemic periwound. The wound to the coccyx had measurements with a length of 3.0 cm width of 2.0 cm and depth of 1.9 cm. The wound had a small amount of serosanguinous drainage, the wound bed had large adherent slough with small pink/pale granulation, margins had been well defined and the periwound blanchable. Progress notes date 6/26/18 at 8:21 p.m., documented the coccyx wound measured 2.5 cm by 1.6 cm and depth of 3.0 cm. The left heel wound measured 4.5 cm by 5.0 cm and depth of 0.1 cm. Observation on 6/26/18 at 6:21 a.m., Staff W, CNA removed the prevalon boots from resident's feet. Staff W transferred the resident and provided peri care after toileting the resident. Staff W did not place prevalon boots on the resident's feet prior to placing the resident's feet on the metal foot pedals while the resident only had gripper socks to her feet. At 7:34 a.m., the resident was sitting in the wheelchair in the dining room without prevalon boots on feet which only had gripper socks on and resting directly on metal foot pedals. Still no air mattress on bed. At 8:54 a.m., the resident sat in her wheelchair wearing only gripper socks on both feet on foot pedals without heels floated. At 9:02 a.m., Staff W checked the resident's vital signs and did not place prevalon boots on the resident's feet which remained with only gripper socks and not floated. At 9:30 a.m., the resident remained in up in her wheelchair without prevalon boots and both feet resting directly on metal foot pedals wearing only gripper socks to both feet without heels floated. At 10:34 a.m., the resident remained in the wheelchair with no boots on as planned. At 12:52 p.m., the prevalon boots sat on top of the table at the foot of the resident's bed. Staff Y, RN entered the room, washed hands, donned gloves and placed a clean towel under the resident's hip. Staff Y used the correct technique to remove the dressings from the wound to the coccyx which appeared pale pink with a moderate amount purulent drainage. The surrounding skin did not have signs of infection. Staff Y removed her gloves, used hand sanitizer, donned new gloves and measured the wound with a length of 2.5 cm by 1.6 cm and a depth of 3.0 cm Staff Y removed gloves, used hand sanitizer, donned new gloves then measured the first tunneling located at 11:00 as 1.6 cm The wound had a moderate amount of adherence slough in wound, the peri wound had been macerated, erythemic, but blanchable. Staff Y used the correct technique to cleanse the wound and dress it with hydrofoam. At 1:08 p.m., Staff Y used the correct technique to remove the dressing from the wound to the left great toe, cleanse the wound and measured it with a length of 0.9 cm width of 0.9 cm and depth of 0.1 cm with large adherence slough eschar noted and very small pink granulation noted. The peri wound was macerated and erythemic. Staff Y used the correct technique to apply a new silver alginate dressing and cover with a foam dressing. At 1:17 p.m., Staff Y used the correct technique to remove the dressing to the right great toe, cleanse the wound and measured it with a length of 0.9 cm width of 1.2 cm and depth of 0.1 cm. The wound had a large amount of adherence slough noted to wound, erythemic and the peri wound with some maceration. Staff Y used the correct technique to apply a new silver alginate dressing and cover with a foam dressing. At 1:25 p.m., Staff Y used the correct technique to remove the dressing to the right heel. The wound had large stable eschar noted to right heel, peri wound dry, slightly calloused, erythemic and blanchable without drainage. Staff Y measured the wound with a length of 4.3 cm width of 5.0 cm and depth of 0.1 cm. At 1:30 p.m., Staff Y used the correct technique to cleanse the wound and applied silver alginate, covered it with gauze and Kerlix and secured with tape and placed the prevalon boots to the resident's feet. During interview on 6/27/18 at 1:17 p.m., Staff H, CNA reported the resident had pressure ulcers to the coccyx and to her heels and care planned to have heel protector boots at all times, that she was to lay down after meals, elevate her feet and be repositioned every 2 hours. The only reason she would not have her heel protectors on would be if the aides forgot to place them on her. During interview on 6/27/18 at 1:39 p.m., Staff K, CNA reported the resident had been admitted with one large area to her coccyx and now had two open areas to each great toe and one open area to each heel. The right heel still had a black area. She was care planned for moon boots on her feet at all times, except during transfers or showers, lay her down after meals and after therapy and reposition her every 2 hours with a pillow underneath her coccyx. During interview on 6/27/18 at 1:47 p.m., Staff L, RN reported the resident had been admitted 3 weeks ago with open areas to both great toes, both heels and her sacrum. She is care planned to reposition frequently, should wear the prafo boots at all times. During interview on 6/28/18 at 7:28 a.m., Staff R, RN, unit manager reported the expectation for residents with open areas to the heels would be to suspend the heels, or put heel protectors on.

Based on clinical record review, resident and staff interviews, the facility failed to ensure one (1) of six (8) residents received adequate supervision during transfers to protect against hazards in the environment. Record review identified Resident #6 on a non-weight bearing status for her/his left arm and right leg due to recent injuries; and required 2 staff assistance for transfers with a Hoyer lift. On 7/29/16 staff transferred Resident #6 to a standing position using a Sara lift (sit to stand lift). Resident #6 reported after the staff lifted him/her to a standing position in the Sara lift, he/she felt a pop in his/her shoulder. Resident #6 sustained a dislocated left shoulder on 7/29/16 related to the improper transfers. The facility reported a census of 94 residents. Findings include: The initial Minimum Data Set ((MDS) dated [DATE] documented that Resident #6 had a BIMS (brief interview for mental status) of 15 which indicated intact cognition for daily decision making. The MDS indicated the resident required extensive assistance from two or more staff for activities of daily living. According to the MDS, the resident required the extensive assistance of two staff for transfers, dressing, personal hygiene and bed mobility. A balance during transition and walking test identified the resident as not steady and only able to stabilize with staff assistance when moving from a seated to standing position, moving on and off the toilet, and for surface to surface transfers. The MDS indicated the resident had occasional urinary incontinence. The MDS indicated the resident had [DIAGNOSES REDACTED]. The resident's care plan with a target date of 11/02/16 documented the resident at risk for falls related to right lower extremity cast, and non-weight bearing to right lower extremity. The care plan noted the resident at risk for complications due to musculoskeletal problems related to fracture of right tibia, gout, and dislocation of left shoulder. The staff were instructed to encourage to transfer and change position slowly, assist with bed mobility provide assistance to transfer and ambulate as needed, reinforce need to call for assistance, and therapy to reevaluate for slide board transfer. The CNA (certified nursing assistant) Tasks sheet (undated) instructed staff the resident required the following: the assistance of 2 staff for ADLs (activities of daily living), assist with bed mobility, keep cast on right leg clean and dry, uses slide board to get to wheelchair, toe touch weight bearing on left with brace, use bed pan until physical therapy able to get resident up and pivot turn or ambulate, brace to left leg at all times except during cares, left shoulder immobilizer on at all times, and no weight bearing to right leg and left arm. Progress notes dated 7/26/16 at 12:31 a.m., documented the resident admitted at 11:10 a.m. (7/25/16) from hospital following a fall from her/his motorized wheelchair on 7/22/16. Resident #6 had [DIAGNOSES REDACTED]. The resident is alert and oriented x 3 and transfers per Hoyer. Progress Notes dated 7/27/16 at 5:01 a.m. documented staff transferred Resident #6 per Hoyer. Resident #6 had been given as needed pain medication for left should and right leg pain. Resident #6 had a long leg cast on his/her right lower leg. At 8:37 p.m., staff documented Resident was assist of two with Hoyer for transfers and assist of 1 for ADLs. Resident continues with shoulder sling as ordered. Review of the resident's progress notes for 7/29/16 at 12:45 p.m. revealed Staff E, RN documented the resident had been assisted with two CNAs with slide board to transfer from chair to bed, the resident slid off of the board, lowered to left knee. The nurse documented the resident denied discomfort at the time, returned to bed with assistance and neuros, cognition and range of motion within normal limits. An addendum dated 8/2/16 to the fall on 7/29/16 revealed the resident had been working on slide board transfers with therapy. The resident request staff put him/her to bed with the slide board and the CNAs told the resident they were to use a mechanical lift but the resident insisted on using the slide board. During transfer the resident lost his/her balance and slid forward off the board and landed on his/her knees. The nurse completed an assessment and the resident had no new complains of pain. Staff the transferred the resident to bed using a Hoyer lift and two CNAs. Staff were educated to transfer the resident according to the Tasks list. The addendum noted the resident was educated that the staff must use a lift until cleared by therapy to use a slide board (to put the resident to bed). The Progress Notes dated 7/29/16, at 2:41 p.m. Staff F, RN documented late entry that the resident had been transferred to toilet with a mechanical lift and stated had significant left shoulder pain. The nurse notified of sudden onset of pain, Nurse Practitioner notified and order received for shoulder x-ray at bedside. The resident at high risk for shoulder dislocation related to previous injury. The Progress Notes dated 07/29/16 at 5:54 a.m. Staff H, RN documented the resident returned from emergency room per ambulance with immobilizer sling on right arm and shoulder. The Progress notes dated 7/29/16 at 8:10 p.m. Staff G, LPN documented received radiology report and physician notified. The resident sent to the emergency room with pain to the left shoulder, post fall. Review of the radiology report dated 07/29/16 revealed the results of the x-ray was the humerus (shoulder bone) is anteriorly and inferiorly dislocated with respect to the glenoid . The conclusion of the report stated anterior left shoulder dislocated . Review of the emergency department (ED) report dated 07/29/16 at 8:34 p.m. noted the resident had presented to the emergency department for a shoulder injury that occurred at 11:30 a.m. on the same day. The resident had stated he/she had been placed on a Sara Lift (Stand lift) to move from a seated to stand position. The resident reported he/she heard a pop from the left shoulder and felt pain. The resident had received an x-ray that showed a dislocation of the left shoulder. The chart review from the physician stated on 07/22/16 the resident had been seen and diagnosed with [REDACTED]. The physician notes dated 7/29/16 at 8:34 documented the following: At 8:34 p.m., the physician recommended reducing the shoulder and having the resident follow up with the physician in the office. At 9:31 p.m., the shoulder axillary view revealed the finding as follows: Redomonstrated is a commuted impacted fracture of the superior posterior aspects of the humeral head with multiple fracture fragments, similar to that seen on the prior exam. At 9:35 p.m., the resident still had complaints of pain and received more morphine. At 9: 46 p.m., the resident had good pulse and sensation after reduction attempt. At 9: 51 p.m., resident ' s shoulder is still dislocated, will attempt repeat reduction. At 10:20 p.m., resident had pain at 6 out of scale of 1-10. A second x-ray had been obtained after two attempted reduction of the injury which showed the dislocation almost completely reduced with mild residual anterior subluxation. Comminuted fractures seen in the head of the humerus. At 5:00 a.m., on 7/30/16, the physician discussed the computed tomography (CT) that shows reduced shoulder with large effusion and fracture. Resident had been resting and agrees to return to the nursing home. On 10/12/16 at 8:30 a.m. a telephone interview with Resident #6 he/she stated had placed the call light on for assistance to get help with toileting. The resident stated staff felt it would be faster to get the resident to the bathroom using a stand lift. The resident stated he/she had told the staff not to use the Sara lift (stand lift) because she/he had been non-weight bearing because of the right leg fracture and left shoulder fracture. Resident #6 reported the staff went ahead and used the stand lift and placed the sling around the resident ' s waist and began to lift him/her to a standing position when she/he felt a pop in the fractured shoulder and had a lot of pain. Resident #6 asked staff to put him/her down because of the pain. The resident stated he/she did have pain and the facility sent him/her out to the emergency department later in the evening for treatment and returned to the facility on [DATE]. Resident #6 stated he/she did not remember the staff ' s name but had been really upset with her. On 10/12/16 at 10:25 p.m. Staff F, RN stated the resident had been transferred by mechanical lift (Sara stand lift) to the bathroom. The resident had been non weight bearing because of a fractured leg. Staff F stated she does not know why the staff had transferred the resident with the stand lift (Sara) because of the non-weight bearing status. Staff F stated the staff was supposed to use a Hoyer lift for transfers for the resident. She stated the CNA Task list should indicate how the resident should be transferred. On 10/12/16 at 10:55 a.m. Staff J, CNA stated that earlier in the day after lunch Resident #6 told the staff that he/she could use the slide board for transfers. Staff J stated as the resident started to move from the wheelchair to the bed, he/she leaned forward and fell from the board down to his/her knees. Staff J stated they had a gait belt on the resident and did not pull but the resident just leaned forward. Staff J reported Resident #6 had been guided to the floor. Staff J reported the resident did not complain of pain at that time. Staff J stated later the same day (7/29/16), around 2:00 p.m. the resident had to use the bathroom. Staff J stated she decided to use the Sara stand lift, so placed the waist sling around the resident and stood the resident up and then into the bathroom. Staff J stated the resident seemed okay after the Sara lift transfer to the toilet. Staff J stated she left the resident on the toilet. Staff J stated when the resident placed the call light on, she asked another staff (Staff L) to assist her and they went back and placed the waist sling back on Resident #6. As they started to raise Resident #6 from the toilet the resident started to complain of his/her shoulder hurting. Staff J stated the resident already had a brace on the shoulder. Staff J stated when the resident complained the lowered the resident back down and rearranged the sling for the resident's comfort then completed the transfer to the resident's wheelchair. Staff J stated the resident did not complain again about the shoulder. Staff J stated one of the other CNAs told her they could use the Sara lift on the resident but could not recall who that staff person is. Staff J stated she did not look at the resident's task list to confirm they could use the stand lift (Sara lift). On 10/13/16 at 9:25 a.m. Staff L, CNA stated Staff J, CNA had called and asked her to assist with a transfer with Sara lift. Staff L stated Resident #6 had already been sitting on the toilet so she only helped to transfer Resident #6 from the toilet to a wheelchair. Staff L stated she assisted to buckle the resident into the waist sling then to the Sara lift. Staff L indicated Staff J did not identify who helped to put Resident #6 on the toilet. Staff L stated she had not helped to transfer with the slide board and did not know the resident had fallen earlier in the day. Staff L stated she had not worked with Resident #6 before so did not know him/her well. Staff L stated she did not know the resident had dislocated his/her shoulder during the transfer. On 10/12/16 at 11:20 a.m. Staff K, CNA stated that she had been assigned to care for Resident #6 on 07/29/16. She stated she had been on break when the resident fell from the slide board and had been informed of the incident by Staff J who had been covering for her. Staff K stated she had never used the Sara Lift on Resident #6 and stated she had been on break when the Sara lift transfer occurred. Staff K stated she did not tell Staff J how to transfer the resident but Staff J should have known since she had assisted with transfers for Resident #6 before. Staff K stated she did not know the resident had dislocated his/her shoulder again. Staff K said Staff J told her they had used the Sara lift to transfer the resident to the bathroom.

Based on record review and staff interviews, the facility failed to ensure adequate supervision to prevent falls for one of four residents reviewed (Resident #1). The facility reported a census of 117 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 10/14/14 revealed Resident #1 with a BIMS (Brief Interview for Mental Status) score of 5 out of 15 that indicated Resident #1 as severely cognitively impaired. The MDS identified Resident #1 required extensive assist of 2 staff for bed mobility, transfers, and toilet use, extensive assist of 1 staff for dressing, and personal hygiene. The MDS documented Resident #1 always incontinent of bowel and bladder. The MDS listed Resident #1's [DIAGNOSES REDACTED]. The MDS identified the use of a wheelchair for mobility and documented Resident #1 had a fall since admission/entry to facility with no injury. Review of Resident #1's Care Plan with an initiation date of 10/1/14 revealed a Focus that included at risk for falls due to impaired balance/poor coordination, unsteady gait, slouches in wheelchair, potential medication effects, impaired cognition, and history of seizures. The care plan directed staff to place Resident#1's bed in a low position, have commonly used articles within easy reach, provide assist to transfer and ambulate as needed, implement use of preventive device dysom (anti-slip device), applied to the wheelchair, report development of pain, bruises, change in mental status, activity of daily living function, appetite, or neurological status per facility guidelines, therapy evaluation and treatment per orders. Review of the Progress Notes dated 10/17/14 at 2:16 a.m. revealed Staff B, RN (Registered Nurse) summoned to Resident #1's room by a CNA, that stated Resident #1 rolled out of the bed. Staff B documented observation of Resident #1 prone on the floor. Staff B documented the resident as unable to answer questions regarding pain. Staff B documented Resident #1 turned to back and lifted to bed by use of lift sheet and assist of four staff members. Staff B indicated Resident #1 to have 3 cm (centimeters) x 5 cm x 2 cm hematoma above left eye. Resident #1 stated right hip hurts (Noted in hospital documentation identified complaint of hip pain actually occurred on the left side). Resident#1s blood pressure noted to be elevated but not unusual for resident. Staff notified Resident #1's physician at 1:15 a.m. and received orders to transfer Resident #1 to the emergency room for further evaluation and treatment. Staff documented notification of Resident #1's family occurred. Staff documented transportation of Resident #1 to the emergency room via ambulance occurred at 2:05 a.m. Review of the Investigation Report with date of incident 10/17/14 12:15 a.m., indicated CNA (Certified Nurse Aide) Staff A providing incontinence care for Resident #1. Staff A rolled Resident #1 to side away from Staff A when the resident rolled to the floor. Resident #1struck his/her head resulting in a hematoma above the left eye. Resident #1 was assessed and assisted back to bed with a lift sheet and the assistance of four staff members. Staff notified the resident's physician and family. At 2:00 a.m. Resident #1 transferred via ambulance to the emergency room for further evaluation and treatment. Review of the CT scan of the head completed 10/17/14 at 2:37 a.m. indicated an impression of acute left subdural hematoma approximately 10 mm (millimeter) in thickness without mass effect, acute intraparenchymal hemorrhage of the right frontal lobe, and multifocal old infarcts including a massive old right MCA (Middle Cerebral Artery) infarct with encephalomalacia that appears similar to the prior study. Review of Resident #1's emergency room notes dated 10/17/14 at 2:33 a.m., revealed Resident #1 presents for evaluation of a left forehead hematoma and left hip pain after a fall tonight at the facility. Staff turned Resident #1 in bed when the resident rolled out of bed. The physician documentation discussed results with the resident's family and family requested aggressive treatment. If surgery is required the resident requires transfer to another hospital as this hospital does not have neurosurgery available. The emergency room documentation revealed Resident #1 transferred to another hospital on [DATE]. Review of the radiology report for Resident #1's pelvis film completed on 10/17/14 at 2:45 a.m. revealed a normal pelvic x-ray. No fracture noted. Review of Resident #1's history and physical of 10/17/14 at 1:17 p.m. from the second hospital revealed Resident #1suffered a fall at the facility and is admitted to the Neurosurgery service for observation of a post traumatic subdural hematoma and right-sided intraparenchymal hemorrhage. No further treatment modalities identified in the hospital record for Resident #1. Review of the facility investigation and witness statement for Staff A, CNA, completed on 10/17/14 revealed Staff A was assigned to care for Resident #1 on the evening of 10/16 -10/17/14. Staff A stated in the resident's room to check and change Resident #1 for incontinence of urine and bowel at 12:45 a.m. Staff A indicated she had to change Resident#1's incontinent brief and Staff A further indicated the last time Resident #1 was changed occurred at 10:30 p.m. Staff A stated she cleaned Resident #1 by herself and rolled Resident #1 in bed away from her as Staff A turned to grab cleaning supplies behind her. Staff A stated in the interview Resident #1 rolled off the opposite side of the bed onto the floor. Staff A acknowledged Resident #1 required assistance of two staff members for cares. Staff A stated she thought she could complete cares on her own, but Resident #1 kept holding onto the edge of the bed and pulling himself/herself over to the opposite side of the bed. Staff A indicated the bed position was not in the lowest position but in a standard height of most beds. Staff A stated she documented after the fact Resident #1 was 2 assist for bed mobility. Staff A reported she attempted to complete cares and bed mobility independently. Staff A indicated being aware of the procedure to check resident's task care plan prior to providing cares. Interview on 11/25/14 at 1:55 p.m., the DON (Director of Nursing) stated Resident #1 as identified for 2 assist with cares and staff have access to cares records required for residents. The DON stated the expectation for staff included to follow the care plan. According to the DON stated Staff A acknowledged only using one assist for Resident #1.The DON stated the facility as a side-rail free facility. Interview on 11/25/14 at 5:09 p.m., with Staff C CNA, identified she worked the shift when Resident #1 fell from the bed. Staff C indicated she has taken care of Resident #1 before and identified the resident as two assist with cares and bed mobility. Staff C stated Resident #1 as unable to move his/her left side and very limited movement on the right side. Staff C stated she was in the hall with the nurse and observed Staff A entering Resident #1's room. Staff C reported she was unaware the reason Staff A entered Resident#1's room. Staff C stated she was later alerted that Resident #1 fell out of bed. Staff C entered Resident #1's room to assist and identified Resident #1 on the floor, face down, located on his/her left side. Staff C stated she assisted three other staff members with a lift sheet to transfer Resident #1 back to bed following instruction from the nurse. Interview on 12/10/14 at 4:33 p.m., Staff B, RN (Registered Nurse) stated she was assigned to Resident #1 at the time of the fall. Staff B stated she was standing in hall by a medication cart when Staff A entered Resident #1's room. Staff B reported she entered another resident's room a few minutes later Staff A came to Staff B and informed her that Resident #1 fell out of bed. Staff B indicated Resident #1 as a two staff member assist and Staff members have access to the care information to identify the care needs of the resident's and staff are to follow that plan of care. Staff B assessed Resident #1and noted a hematoma to the head. Staff members assisted with transferring Resident #1 back to the bed and Staff B notified the resident's physician and family. Staff B stated not long after the fall Resident #1's hematoma increased in size and Staff B contacted the physician and received orders for Resident #1 to transfer via ambulance to the emergency room for evaluation and treatment. Staff B stated that facility as a side-rails free facility.

Based on observation, record review and staff interviews, the facility failed to appropriately assess and implement interventions for a resident (Resident #1) following a change of condition. The facility identified a census of 106 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 5/29/13. The MDS reflected Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident with a BIMS (Brief Interview for Mental Status) score of 4 out of 15. A score of 4 reflected a severe cognitive impairment. The MDS reflected Resident #1 required extensive assistance of one staff person for bed mobility, dressing, toilet use, and personal hygiene and limited assist of one staff member for transfers and ambulation in room and corridor, and supervision for ambulation in the unit and feeding assist. The MDS documented the resident used mobility devices of a walker and a wheelchair. The MDS further documented the resident's balance not steady, but able to stabilize without staff assistance. The MDS revealed the resident had no history of a fall in the past 6 months. The resident's Care Plan, with an initiated date of 5/22/13, informed staff that Resident #1 identified a focus of the resident being at risk for falls due to potential medication side effects, impaired cognition and the resident wanders. The interventions directed staff to: a) Administer Calcium and Vitamin D per protocol. b) Administer medications per physician's orders [REDACTED]. c) Encourage gripper socks or shoes when ambulating. d) Encourage to transfer and change positions slowly. e) Floor mat removed in room. f) Have commonly used articles within easy reach. g) Offer snacks when restless snacks or anxious. h) Provide assist for transfer and ambulate as needed. i) Report development of pain, bruises, change in mental status, and activity of daily living function, appetite, or neurological status per facility guidelines post fall. j) Therapy to evaluate resident's wheeled walker for appropriateness. Review of an Incident Report dated 8/29/13 at 10:00 p.m. revealed the resident observed to talking with staff. The resident stood up from the wheelchair and fell before the staff could get to the resident for assistance. The resident fell to floor, landing on his/her bottom. No injury documented. Review of the Progress Notes dated 8/29/13 at 11:16 p.m. revealed at 10:05 p.m. a nursing assistance notified this nurse to come to the end of the hall where the resident had fallen at 10:05 p.m. Resident had been talking to another resident when the resident stood up. The nursing assistance went to assist the resident, the resident lost balance and fell to floor landing on their bottom, before the staff could reach the resident. Nurse documented an assessment was performed and no injuries noted. The resident's physician and family notified of the incident. Review of the Progress Notes dated 8/30/13 at 4:42 a.m. revealed an assessment done post fall and the resident's vital signs within normal limits. Review of Progress Notes dated 8/30/13 at 1:29 p.m. revealed the resident continues on post fall vitals. Neurological and vital signs within normal limits and the resident denies pain. Review of Progress Notes dated 8/30/13 at 6:14 p.m. revealed the resident exhibiting left sided weakness and slurred speech, vital signs are as follows: temperature 97.8 degrees, blood pressure 157/63, pulse 70, and oxygen saturation of 98%. Resident's physician and family notified and resident transported to the emergency by a family member. Review of Progress notes dated 8/30/13 at 9:30 p.m. revealed the resident returned from the emergency room with no new orders. The note reflected the resident may have had a mild stroke; all tests came back within normal limits. Review of the MAR for the month of August revealed the resident did not receive any PRN (as needed) Tylenol for pain during the month. Review of the Progress Notes dated 9/3/13 at 11:42 p.m. documented an entry of change of condition of resident and revealed the resident crying and moaning before breakfast. When resident was asked what was wrong, the resident did not comprehend, but mentioned his/her back hurt so the nurse administered pain medication. The progress notes did not reflect an assessment had been performed. The resident ' s family member present at 11:00 a.m. and resident more agitated when family member arrived. The resident had pain when being moved. Therefore the family member requested resident be sent to the hospital. The nurse notified the resident's physician and the physician ordered the resident be sent to the emergency room for further evaluation and treatment. Review of the Facility's SBAR (Situation, background, assessment, and request)-v2 form dated 9/3/13 at 11:05 a.m. revealed the resident complained of pain but unable to indicate location. Resident is unable to bear weight to the lower extremities. Family member present and requested the resident be sent to the emergency room . The resident transferred to the emergency room for further evaluation and treatment. Review of the Progress Notes dated 9/3/13 at 8:55 p.m. revealed the hospital reported the resident admitted to the hospital with [REDACTED]. Interview on 11/21/13 at 10:50 a.m., the DON (Director of Nursing) stated the staff failed to do a fall post fall assessment on the resident per facility policy. No assessment between 8/30/13 at 6:14 p.m. until 8/31/13 at 8:53 a.m. and no assessment between 8/31/13 at 8:53 a.m. until 9/1/13 at 8:32 a.m. The DON stated two assessments were missed and should have been completed by the nursing staff according to the facility policy. The DON stated post fall assessments should be completed following a fall every shift for 72 hours and if any change in condition of resident staff should contact the resident's physician. On 11/20/13 at 10:14 a.m., a family member was interviewed and stated she called the facility on 9/1/13 to check on the resident. The family member stated she was told by the nurse that the resident doesn't want to walk and wants to sit in the wheel chair and complaining of back pain. The family member further stated the morning of 9/3/13 she came in to visit the resident in the morning and found the resident sitting in a wheelchair in the dining room. The family member stated the resident shook and she got a blanket for the resident. The family member stated the resident told her she would walk if she could. The family member reported she asked the staff to get the resident's walker to see if the resident would walk. The staff member stated when she lifted the resident's left foot off the wheel chair a few inches the resident screamed out in pain and moved his/her hand to the left hip area. The family member stated she told the staff that the resident has a fractured right hip and to call an ambulance to transport the resident to the emergency room . The family member stated she went to the emergency room with the resident and the resident was admitted to the hospital with [REDACTED]. The family member stated she was upset with the facility as they should have known something to be wrong with the resident prior to her telling them that she had a fracture to the left hip. Family member stated the resident is now living in another facility. On 11/20/13 at 1:11 p.m., Staff B, CNA (Certified Nurse Aide) was interviewed and stated she worked the day shift and 2nd shift (afternoon/evening) on 9/2/13 and was assigned to the resident. Staff B stated during the day shift the resident transferred per normal and able to bear weight. Staff B stated after supper he/she went to transfer the resident to bed and the resident moaned out in pain and not able to bear weight per normal. Staff B stated he/she reported this to the nurse and went and got Staff D to assist with transferring the resident to bed. Staff B stated later he/she went into the resident's room and while repositioning the resident, she/he moaned out in pain. Staff B stated she/he reported this again to the same nurse. Staff B reported he/she came into work the next morning and was assigned to care for the resident. Staff B stated he/she went to do cares for the resident and the resident appeared to be in more pain then last night; the resident moaning out louder with movement. Staff B stated she reported this to the nurse before getting the resident out of bed. Staff B stated the nurse went into the resident's room and told the Staff B to go ahead and get the resident up in the wheelchair and bring out for breakfast. Staff B stated it took two staff members to transfer the resident and the resident did not bear weight, which is not the norm for the resident. Staff B stated he/she felt something to be wrong with the resident, as it is not normal for the resident to moan out in pain with repositioning and transfer and not normal for the resident to not bear weight. Staff B reported being present when the resident's family member came into the facility. Staff B heard the nurse tell the family member the resident was in the wheelchair due to pain and the family member told the nurse she wanted the resident out of the wheelchair. Staff B stated the family member attempted to stand the resident up out of the wheel chair using the resident's walker. The resident moaned out in pain. Staff B stated the resident's family member started feeling around the resident's hip area and the resident would moan out in pain. Staff B stated the family member told the staff to call an ambulance for the resident to transfer the resident to the emergency room . Staff B stated the family member seemed to be upset over the resident's condition. Staff B further stated there had been no incident/fall since 8/29/13. On 11/20/13 at 1:34 p.m., Staff D, CNA, stated she/he worked days and 2nd shift on 9/2/13 and assisted to care for the resident. Staff D stated the resident to be normal during the day shift until after supper. Staff D reported she then helped Staff B transfer the resident to bed and the resident did not bear weight as normal during the transfer. Staff D stated she reported this to the nurse. Staff D stated later around 9:00 p.m. while doing cares and repositioning the resident in bed the resident again moaned out in pain and again Staff D stated he/she reported this to the nurse. Staff D reported the next day, 9/3/13; she worked the day shift and assisted in cares with the resident. Staff D stated while doing cares, while the resident in bed, the resident moaning out in pain. Staff D stated she reported this to the nurse prior to transferring the resident out of bed. Staff D stated the nurse came into the resident's room and after looking at the resident, told Staff D and Staff B to get the resident out of bed and into the wheel chair and bring the resident out for breakfast. Staff D reported the resident moaned out in pain and did not bear weight during the transfer. Staff D stated the resident ' s family member arrived to the facility sometime before lunch. The resident sat in the wheelchair in the hallway. The family member questioned why the resident sat in the wheelchair and Staff D informed the family member the resident was not up to ambulating. Staff D reported the family member asked him/her to assist with ambulating the resident to the dining room. Staff D stated she saw the family member attempt to stand the resident. The resident moaned out in pain and the family member sat the resident back down in the wheel chair. Staff D stated she then went and got the nurse supervisor, Staff C, to come and talk with the resident's family member regarding the resident's condition. Staff D stated she then went to the dining room to assist residents. Staff D stated she was concerned that something to be wrong with the resident due to the resident's change of condition in transferring, requiring more assist, and resident moaning out in pain; this is not normal for the resident. On 12/19/13 at 11:38 p.m. Staff E (licensed practical nurse) was interviewed by telephone. Staff E stated she had been assigned Resident #1 on 9/2/13. Staff E stated the CNA ' s had reported to her the resident did not bear weight, moaning out in pain and not her/his usual self. Staff E stated she checked on the resident at the supper time hour and could tell the resident as not himself/herself and voiced complaints of leg tenderness. Staff E stated she thought she had the nurse supervisor come and look at the resident. Staff E stated she could not recall if she gave the resident Tylenol or if she had called the physician or the family. Staff E stated the nursing assistants told her again that the resident could not bear weight and cried/moaned out in pain. Staff E stated she had not been aware the resident had a [MEDICAL CONDITION] until 9/4/13 when she returned to work. Staff E stated she did not report the resident ' s condition to the physician. On 12/23/13 at 1:39 p.m. Staff F (licensed practical nurse) was interviewed and stated she was assigned to the resident on 9/1/13. On 9/1/13, the resident was in the wheelchair and she asked the staff why the resident was in the wheelchair. Staff informed the nurse the resident had problems ambulating. Staff F stated she performed a post fall assessment and the resident appeared ok (alright). Staff F stated she administered Tylenol to the resident for general complaints of pain which would be normal for this resident. Staff F confirmed she did not contact the family or the physician. The MAR indicated [REDACTED]. The resident received Tylenol again on 9/3/13 for back pain by another nurse. The nurse did not assess a response to the medication. On 11/21/13 at 9:42 a.m., Staff C, Registered Nurse (RN) supervisor, was interviewed and stated she had not been aware of the resident's change of condition until 9/3/13 when the resident's family member came to the facility. Staff C stated CNA Staff D came to her that morning and reported the condition of the resident. Staff C stated she went to check on the resident the same time the family member came in. Staff C stated the resident did not bear weight and moaned out in pain. Staff C stated she told the family member something is wrong with the resident. Staff C stated the Nurse Practitioner (NP) was in the facility and Staff C wanted the NP to examine the resident and anticipated on sending the resident to the emergency room . Staff C stated prior to the NP examining the resident, the family member insisted on calling the ambulance to take the resident to the emergency room . Staff C stated she contacted the resident's physician and obtained order to send resident to the emergency room . Staff C stated she expected staff to immediately assess a resident with a change of condition, notify the physician, and family. Staff C stated when she saw the resident on 9/3/13; the resident had an obvious change in condition.

Based on observation, record review and resident and staff interviews, the facility failed to accommodate Resident #7 with choices and health care transfer needs and assist the attending physician with planning of the resident ' s needs. The sample consisted of 11 residents. The facility reported a census of 87 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 12/16/11 identified Resident #7 with the following Diagnoses: [REDACTED]. The care plan dated (as printed) 1/5/12 identified the resident with the following problems and interventions: a. Self care deficit as evidenced by [DIAGNOSES REDACTED]. The approach directed staff to transfer with the assist of two staff and with gait belt. The implementation date revealed to be 10/15/09. b. At risk for falls due to impaired balance. The approach directed staff to transfer with assist of two for all transfers and implementation on 8/21/10. c. Resistive/non compliant with the use of the lift for transfers. The approach directed the staff to leave and return later if the resident resisted care, praise/reward for demonstrating consistent desired/acceptable behavior, provide education about risks of not complying with therapeutic regimen. The interventions were implemented on 8/23/10. During an observation on 1/4/12 at 7:30 a.m., Staff B, Certified Nursing Assistant (CNA) and Staff F, CNA placed the sling to the Maxi Move lift under the resident. Staff F stated the resident, "really hates this because of the [MEDICAL CONDITION] arthritis", then Staff B pulled the straps between the resident's legs when the resident screamed, "It hurts! Something is digging in along the edge. Oh God! Oh Jesus! It hurts so much!" After both CNAs secured the sling to the lift and Staff B, operated the lift, the resident stated, "Ow! The edge of the strap is digging in", and pointed to his/her thighs. No attempt made to pad the sling with a pillowcase or towel (both were on top of the over bed table). After Staff B lowered the resident into the chair, he/she pulled the sling out from underneath the resident with a slightly rough motion when the resident stated, "Ow! That feels like rug burn!" An observation of the resident transfer on 1/5/12 at 8:00 a.m., revealed Staff G, CNA and Staff H, CNA used the Maxi Move lift while the resident moaned with facial grimaces of pain. When both nursing assistants removed the sling from underneath the resident, the resident stated, " That hurts, it's scraping across my leg; can you put some lotion right where that strap goes across"? On 1/4/12 at 8:02 a.m., Resident #7 was interviewed and reported, " It always hurts so much when they use the lift because I have arthritis in every bone of my body. It still hurts. Not everyone uses the lift and it's much better when they don't and use two people to move me." The resident rated his/her pain level at that time, 30 minutes after the lift was used to be 7 out of 10 on the pain scale (10 being the worst pain). On 1/5/12 at 8:10 a.m., Staff H, CNA, reported the resident as care planned to transfer with two people with a device (assumed it was the lift) and the resident did not like being transferred with the lift because always in pain when used. The DCD (Direct Care Director - nurse manager) decided it was safer for the resident to be transferred with the lift. The resident did much better when a two person transfer with a gait belt was used. On 1/5/12 at 8:18 a.m., the resident reported, "When they (facility) have me in that lift, it squeezes me so much it causes my pain to go up to a 10. I wish they wouldn't use it on me." In an interview on 1/5/12 at 11:45 a.m., Staff B, Registered Nurse, reported the MDS coordinator made the decisions as to what tasks were added to the care plan and did not involve the staff nurses. Staff B, also reported the resident had complained that he/she did not like the mechanical lift and initially the resident required two persons for transfers but physical therapy evaluated the resident and determined use of the mechanical lift as the safest transfer. Staff B reported attending the resident's care plan meetings but could not remember if the resident expressed any concerns with pain with the use of the mechanical lift. The resident did find transfers without the use of the mechanical lift more comfortable. In an interview on 1/5/12 at 3:15 p.m., the physician reported the resident should no longer transfer by the mechanical lift if the resident had severe pain. On 1/6/12 at 10:56 a.m., the interim Director of Nursing (DON) was interviewed and stated if the resident had severe pain with transfers with the mechanical lift, then she would expect the staff to stop using the mechanical lift. The DON stated if the resident complained the sling pinched, then she would expect staff to check and readjust it or pad it with a pillow or towel.