Every finding on record at Hegg Memorial Health Center

Based on observation, staff interview, and policy review the facility failed to prepare food in accordance with professional standards by not completing appropriate hand hygiene during meal service to prevent cross contamination and by placing serving utensils on contaminated surfaces then using them. The facility reported a census of 58 residents.Findings include:A continuous observation on 11/5/25 at 9:01 AM of Staff A, [NAME] revealed pureed ham placed in food processor, ham processed, 3 metal steam table containers removed from shelf, containers placed on the table top, ham measured into each container, scoop placed in measuring cup, metal steam table containers placed in oven, green handled scoop removed from drawer, scoop placed on the metal counter where metal steam table containers were previously, pureed asparagus placed in processor, pureed asparagus removed from processor and placed in a measuring cup, obtained 3 metal steam table containers from the shelf, green scoop pushed to the right side of the metal table top, green scoop picked up, green scoop utilized for measuring asparagus into the metal steam table containers and metal containers placed in oven. A continuous observation on 11/5/25 at 11:43 AM revealed Staff B, Hostess applied gloves, lifted lunch tray with left hand off of serving counter, obtained a bag with a hamburger bun from right side counter on tray, used both gloved hands to remove the bun out of the bag, separated bun with both hands, obtained tongs, used tongs to obtain hamburger from steam table with right hand, right hand used to place bun on top of hamburger and removed gloves. On 11/5/25 at 12:38 PM Staff C, Certified Dietary Manager (CDM) stated she would expect when the hostess wore gloves they would be utilized for a single use and not touch anything besides the intended food item to prevent cross contamination. Staff C stated when preparing food in the kitchen she would expect a barrier would be placed to prevent cross contamination for utensils when the utensils are placed on a contaminated surface. Review of an undated policy titled, LTC Food Safety and Sanitation/Glove Use documented gloves would be worn when handling ready to eat foods to ensure that pathogens are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. Anytime a contaminated surface was touched, the gloves must be changed - washing hands after removing the gloves and before putting on a new pair. Review of an undated policy titled, Cross Contamination documented all foods shall be protected from contamination. All surfaces, counters, food carts, utensils, and equipment, which comes in contact with food shall be washed, rinsed and sanitized and air dried after each use.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notices were signed by residents and or the resident's responsible person when residents transferred out of the facility. The bed hold notice also failed to notify the amount per day the resident or representative agreed to pay for 2 of 2 residents reviewed (Residents #1and #8). The facility reported a census of 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented reentry to the facility for a short term hospital stay. Review of the Clinical Census report for Resident #1 revealed the following information: 1. 3/25/25- entered hospital 2. 3/29/25- end hospital 3. 8/21/25- entered hospital 4. 8/25/25- end hospital Review of the Progress Notes for Resident #1 revealed the following: 1. 3/25/25 at 1:30 AM, Resident admitted due to shortness of breath. 2. 8/21/25 at 10:39 AM, Resident sent to clinic and admitted due to shortness of breath and edema. Review of the Bed Hold Notice dated 3/25/25 for Resident #1 revealed verbal authorization from Resident #1's representative but lacked a resident or representative signature. The bed hold lacked the amount per day the resident or representative agreed to pay. Review of the Bed Hold Notice dated 8/21/25 for Resident #1 revealed verbal authorization from Resident #1's representative but lacked a resident or representative signature. The bed hold lacked the amount per day the resident or representative agreed to pay. In an interview on 11/06/25 at 9:06 AM, the Director of Nursing (DON) reported staff would now have the bed hold cost per day available for reference when completing the forms with residents and representatives. The DON also reported when a resident's representative gave verbal consent, the facility would now provide a written bed hold notice via mail and complete documentation in the resident's chart. 2. The MDS dated [DATE] documented Resident #8 had a BIMS of 0 indicating Resident #8 was rarely/never understood. Review of the Clinical Census report for Resident #8 revealed the following information: 1. 7/1/25- hospital 2. 7/8/25- active 3. 10/19/25- hospital 4. 10/27/25- active Review of the Progress Notes for Resident #21 revealed the following: 1. 7/8/25 at 5:32 PM, Resident admitted to the hospital for urinary tract infection / sepsis. 2. 10/27/25 at 1:22 AM, Resident admitted to the hospital for evaluation / treatment of seizure. Review of the Bed Hold Notice dated 7/1/25 for Resident #8 revealed verbal authorization from Resident #8's representative but lacked a resident or representative signature. The bed hold lacked the amount per day the resident or representative agreed to pay. Review of the Bed Hold Notice dated 10/19/25 for Resident #8 revealed verbal authorization from Resident #8's representative but lacked a resident or representative signature. The bed hold lacked the amount per day the resident or representative agreed to pay. On 11/5/25 at 2:00 PM a request to the DON for a policy on bed holds. Facility failed to provide a policy on bed holds.

Based on observation, Electronic Health Record (EHR) review, document review, staff interview and policy review the facility failed to follow the menu and prepare food to meet the nutritional needs of the residents by not serving residents on International Dysphagia Diet Standardization Initiative (IDDSI) level 5 diet (minced and moist) the appropriate amount of meat according to the menu for 3 of 3 residents reviewed, (Residents #41, #43 and #52). The facility reported a census of 58 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #41 had a Brief Interview for Mental Status (BIMS) of 7 indicating severe cognitive impairment. Review of Resident #41's EHR dated 7/23/25 titled, Diet Orders documented an order for a regular diet with IDDSI 6 meat.2. The MDS dated [DATE] documented Resident #43 had a BIMS of 5 indicating severe cognitive impairment.Review of undated document, Texture Modifications documented Resident #43 was on a regular diet with minced/moist meats.Review of Resident #43's EHR dated 3/12/25 titled, Diet Orders documented an order for a regular diet with minced/moist meats.3. The MDS dated [DATE] documented Resident #52 had a BIMS of 15 indicating no cognitive impairment. Review of undated document, Texture Modifications documented Resident #52 was on a regular diet with minced/moist meats.Review of Resident #52's EHR dated 9/11/25 titled, Diet Orders documented an order for a regular diet with minced/moist meats.On 11/5/25 at 9:01 AM an observation revealed Staff A, [NAME] inserted 8 servings of ham into the food processor for the minced/moist diets. Staff A processed the ham, removed all ham into a measuring cup and measured out 4 cups.On 11/5/25 at 9:05 AM Staff A explained while reading the puree portions chart 4 cups of minced/moist meat divided between 8 servings would be a #8 scoop (black handled, 4oz., half a cup).Review of a document titled, Week 4 with Wednesday's meals documented on it given to Staff B, Hostess by Staff A indicated the mechanical soft diets or minced/moist meat diets were to have the black handled/#8 scoop utilized for their servings. A continuous observation on 11/5/25 at 11:25 AM - 12:15 PM through lunch service revealed Staff B, Hostess serve Resident #41, #43, and #52 minced/moist ham from a 3 ounce / green handle scoop. On 11/5/25 at 12:10 PM Staff B requested by phone 1 serving of pureed meat be brought down to the kitchenette. Staff C brought 1 serving of pureed ham to the kitchenette. On 11/5/25 at 12:38 PM the Staff C Certified Dietary Manager (CDM) asked Staff B if she had utilized the correct scoops for the ham. Staff B said the green scoop was utilized for the minced/moist meat. Staff C explained the green scoop was a 3 oz scoop used for the minced/moist ham and should have been served with the black handled 4 oz scoop. Staff C acknowledged the residents who received minced/moist meat during that meal did not receive the appropriate amount.On 11/5/25 at 2:31 PM the Director of Nursing (DON) said her expectation was the appropriate serving size scoop would have been utilized when serving residents their meals. On 11/6/25 at 8:45 AM Staff D, Registered Dietitian stated even with an observation being made by a surveyor she would expect the appropriate scoop size would be used during serving. Staff D explained that with the ham that was served at lunch on 11/5/25 she would expect all of the IDDSI 6 diets to have received minced/moist meat as well as the IDDSI 5 diets because ham is not as soft as other meats.Review of undated policy titled, Menus/Menu Substitutions documented the menus shall provide nutritionally adequate meals in a form acceptable to the resident's culture, likes and dislikes. A cycle menu of 5 weeks will be used and revised twice yearly to include seasonal items. Portion sizes will be included on the menu. All menus shall be approved by the dietitian.

Based on observation, interview and record review the facility failed to ensure that staff practiced safe transfer techniques for 1 of 2 residents. Resident #5 required the use of the mechanical lift for transfers and staff used a sling that was 2-sizes larger than the manufacturer recommended size for her weight. The resident had a decline in condition which changed her ability to tolerate the mechanical lift transfer. The facility reported a census of 55 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #5 had a Brief Interview for Mental Status (BIMS) score of 0 (severe cognitive deficit). She was totally dependent on staff for sit to lying, chair to bed transfers and toileting. Resident #5 was frequently incontinent of urine and bowel and had diagnosis that included; anemia, heart failure, Diabetes Mellitus, malnutrition and anxiety disorder. The Care Plan last reviewed on 9/27/24, showed that Resident #5 was totally dependent on staff to assist with Activities of Daily Living. She transferred with the use of a total lift with 2 staff and used wheel chair for mobility. The resident was admitted to hospice services on 6/14/24. She could be forgetful and confused, had difficulty making herself be understood, sometimes, did not understand others. She had chronic pain. On 11/18/24 at 11:13 AM, Resident #5 was in her wheel chair near the table in the dining room, with her head hanging down into her chest. At 11:57 AM, her head was still down and a staff member was sitting next to her trying to encourage her to take bites and drink. The resident occasionally opened her mouth, she did not speak and did not reach for food or drink. On 11/18/24 at 12:14 PM, Resident #5 was in the whirlpool room sitting in the tub. Her head was hanging down in her chest, she did not respond or speak. The resident had a bruise on left shoulder. Staff F, Licensed Practical Nurse (LPN) said they thought that the bruise was from the sling used with the mechanical lift. She said that Resident #5 had a recent significant decline is health. An Incident Report dated 11/20/24 at 10:35 AM, showed that Resident #5 had a new bruise on posterior shoulder that measured 2.5 centimeters (cm) x 7 cm and one on the left upper outer arm 2 cm x 3.2 cm. The type of injury was defined as a skin tear. The documentation lacked description of the bruising or possible cause. In an observation on 11/19/24 at 7:20 AM, Resident #5 was in bed sleeping on her back. Staff A Certified Nurse Aide (CNA) and Staff B, CNA woke her up and explained that they would be getting her dressed for the day. They assisted her to sit on the side of her bed with Staff A lifting her upper body, and Staff B swinging her legs around so her feet landed on the floor. The resident did not open her eyes or say anything. As she tried to sit up, she leaned over to the left and Staff B held her up in the seated position. Staff A grabbed a mechanical lift sling that was on the shelf, and the two CNA's put the sling around her back, tucked the leg straps under her legs, and placed her arms on the outside of the sling. When Staff A hooked the sling to the lift, the padding on the upper part of the sling (designed to support the arms during transfers) landed parallel to the resident's forearms and her armpits rested on the fabric of the sling. She continued to lean to the left and she was not able to sit up. As the lift raised up in the air and Staff A moved the machine toward the bathroom, it was discovered that the bottom of the sling was at the middle of her back, and the leg straps were just above her knees. The weight of the resident rested in her armpits and the back of her knees. She was then lowered to the toilet. At 7:35 AM, Staff C, Certified Medication Aide (CMA) came into the room to apply a lotion while Resident #5 was on the toilet. The resident continued to lean further to the left and Staff B tried to hold her head up. Her left arm was hanging down alongside the toilet and her right shoulder hyperextended back as she slid further down in the sling. At 7:37 AM staff engaged the mechanical lift and hoisted her back off of the toilet. From the middle of her back (from the bottom of the sling) to just above the back of her knees (the leg straps) her body was unprotected and hung down while Staff A and Staff B applied a clean brief. At 7:38 AM, they moved her out of the bathroom and into the wheel chair. Upon further inspection, it was discovered that the sling used for Resident #5 was an extra-large. According to the Sling User Guide dated March of 2005, it was recommended that an extra-large sling would be used for resident in the weight range of 264-352 pounds. (According to the electronic chart, Resident #5 weighed 150 pounds) On 11/19/24 at 7:40, Staff D, LPN and Staff E, Registered Nurse (RN) looked at the sling that staff had used to transfer the resident and explained that it was a special design used for toileting. Staff E stated that they were going to get a different sling since the resident had a decline and she wasn't sitting up any longer. On 11/19/24 at 7:59 AM Staff C CMA said that at one point the resident was able to sit up during transfer but she had gotten much weaker. The resident was mostly incontinent and hadn't been using in the toilet so the toileting sling probably was not the best option for her. She said that the padding on the sling was to help support and protect the arms and she hadn't noticed the position of the padding when the resident was on the toilet. On 11/20/24 at 12:31 PM, the Director of Nursing (DON) said that the nurses used the sling chart with weights to determine size of sling to use but there was not a specific assessment form for determining appropriate sling size. On 11/21/24 at 8:32 AM, the DON stated that when the CNA's saw that Resident #5 was different on 11/19/23, they should have notified the nurse so she could have done a complete assessment before transferring the resident to the toilet. According to the Arjo Sling User Guide: dated March of 2005, Using the correct sling for each patient was an essential element of safe patient handling. A sling that was the wrong size of a body fit for the patient created discomfort and increased the risk of injury. Indications of a badly fitted or wrongly sized sling included; 1. leg support of the sling digging into the back of the patient's knees with the sling clips/loops several inches above the front of the patient's thighs (sling may be too large). 2. The sling must adequately support the head 3. The patient's buttocks were not slipping through the sling aperture. It was not advised to use the toileting sling with residents that were flaccid as they could slip through the commode hole. The sling should be fitted with the top of the patients head as a guide to positioning. Both of the resident's arms should be positioned outside the sling, over the padded areas but under the head support straps. According to facility policy titled dated 11/5/05, the facility would provide a safe work environment for resident care areas by providing and requiring the use of safety materials, equipment and training designed to prevent personal and resident injury. The staff were accountable for utilizing proper body mechanics, lifting techniques and resident safety.

Based on observation, facility policy, and staff interview, the facility failed to provide a process in which grievance may be anonymously submitted. The facility reported a census of 52 residents. Findings include: Tour of the facility's main lobby and each of the 3 neighborhoods on 9/25/23 at 2:31 PM lacked observation of posted information about how to file a grievance or how to file an anonymous grievance. In an Electronic Mail (email) on 9/26/23 at 4:40 PM, the Director of Nursing (DON) reported that no grievances were filed since the last survey (June 2022). In a concurrent facility tour, Grievance Policy review, and interview on 9/27/23 at 3:17 PM, the DON located a binder in the main lobby that contained 2 grievance forms and the grievance policy. Upon review of the Grievance Policy, the DON was unable to locate information about how residents or their representatives could file an anonymous grievance. In the same interview, the DON agreed that there was no way for residents or their representatives to know how to file an anonymous grievance. The Supporting the Right of Residents to Voice Grievances Policy last revised April 2023 revealed: 1. Residents, their legal representative and family have the right to express a grievance or complaint about care and services provided by this community. 2. Notification of the right to file grievances either orally or in writing (anonymously if so desired) will be posted in each household along with the contact information of the Grievance Official. The announcement will also state the reasonable expected time frame for completing the review of the grievance, the right to obtain a written decision regarding the grievance and the contact information of the State Agency, Quality Improvement Organization and State Long- Term Care Ombudsman program or protection and advocacy system. 3. As the acting Grievance Official the social services coordinator will oversee the grievance process, namely: leading any necessary investigations by the facility maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously. The Welcome to Whispering Heights Admission Booklet, with no date, revealed a section related to Grievance Policy with no information about how to file an anonymous grievance.

Based on observations and staff interviews the facility failed to ensure food was discarded after product expiration date. The facility identified a census of 52 residents. Findings include: An initial kitchen tour conducted on 9/25/23 at 1:12 p.m., during the initial tour of the kitchen revealed the following items ready for service in the pantry: a. Two boxes of pancake mix unopened with best by date of 9/11/23. b. One box of pancake mix with an open date of 9/21/23 and a best by date of 9/11/23. c. Mango sauce unopened with an expiration date of 2/23. Dietary Manager (DM) discarded the items immediately except for the Mango sauce as the food representative had just brought the item for the facility to try. Review of the facility provided policy titled Food Storage Guidelines undated revealed it is the policy to ensure safe, sanitary, quality food products as required in Food Code 2017 and Servsafe Essentials. Interview on 9/25/23 at 1:32 p.m., with the DM revealed the items should have been discarded and not in the pantry for use. The pancake mix that was opened after the expiration date should not have been used.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #1) reviewed for PASRR requirements. The facility reported a census of 52 residents. Findings include: The The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses depression, hypertension and Peripheral Vascular Disease (PVD)The MDS included a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the MDS dated [DATE] revealed an active diagnosis of depression. Review of the Long Term Care Recertification signed on 9/7/23 revealed a diagnoses of major depression in partial remission. Review of Resident #1 ' s active problems in her chart revealed a diagnosis of major depression in partial remission with first entered date of 11/26/17 and major depressive disorder, recurrent episode, mild with a first entered date of 10/25/22. Review of the PASRR Level 1 revealed the following information: a. Does the individual have any of the following major mental illnesses? The box was marked no b. Does the individual have any of the following mental disorders? Yes was marked with depression as mild or situational. Review of the clinical record revealed a exemption for PASRR dated 3/15/16 revealed Resident #1 PASRR Level 1 identification screen reviewed for a potential PASRR status change shows that further PASRR evaluation is not required at this time. The current PASRR dated remains valid for your stay at the nursing facility and should be transferred with you if you relocate. No further PASRR screening is required unless you experience a significant change in behavioral health needs or it is believed that your needs can be met in a less restrictive placement, such as in the community. Review of Resident #1 ' s chart lacked a follow-up and resubmission of a PASRR with the diagnosis of major depression. The facility does not have a PASRR policy. Interview on 9/27/23 at 9:47 a.m., with the Social Worker revealed she does not have the diagnosis of major depression on the current PASRR.

Based on clinical record, facility policy, and staff interview, the facility failed to accurately assess a wound for 1 of 1 residents reviewed (Resident #38). The facility reported a census of 38 residents. The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 0 which indicated severely impaired cognition. The MDS revealed the resident had diabetes mellitis and dementia; had a stage 2 pressure ulcer. The Clinical Record revealed the resident's pressure ulcer was first documented on 7/3/23, no depth measurement was located in the resident's clinical record. The Prevention of Pressure Ulcers Policy last reviewed February 2018 lacked information related to pressure ulcer measurement. In a concurrent record review and interview on 9/27/23 at 12:09 PM, with Director of Nursing (DON), Licensed Practical Nurse (LPN) Supervisor, and Staff B, Registered Nurse (RN), the resident's pressure ulcer to her coccyx was verified as a stage II pressure ulcer on 7/3/23. The depth of the wound could not be located in the resident's medical record. The DON reported that she would expect the depth measured with a stage 2 pressure ulcer.

Based on clinical record, facility policy, and staff interview, the facility failed to provide restorative therapy for 1 of 1 resident reviewed (Resident #20). The facility reported a census of 52 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #20 revealed the resident had severely impaired skills for cognitive daily decision making, had inattention, and disorganized thinking. The MDS revealed the resident had diagnoses of Alzheimer's disease, dementia, anxiety, and depression; required the extensive assistance of 2 staff for bed mobility, transfers, and toileting; required the extensive assistance of 1 staff with eating; did walk in her room or corridor; had functional limitation in range of motion for both lower extremities; was frequently incontinent of urine and bowel; did not have restorative therapy in the last 7 calendar days. The Clinical Record revealed the resident had 4 restorative therapy sessions out of a total of 22 possible sessions for AROM (active range of motion) from 8/25/23 to 9/25/23: 9/5/23, 9/13/23, 9/15/23 and 9/21/23. The Care Plan dated 9/27/23 revealed: 1. She is non ambulatory (does not walk). 2. Further declines are anticipated due to progression of end stage Alzheimer's. 3. Encourage participation in Aged for Action. Resident refuses even with supervision and cues due to diagnosis of dementia. The Care Plan Item Detail last revised 9/27/23 revealed the resident had restorative active ROM (range of motion). The Restorative Therapy Program Policy last revised September 2022: 1. Residents will be assessed for restorative needs and placed in facility programs as indicated. Each program purpose is directed toward assisting residents to achieve and maintain optimal levels of self care and independence, thus enhancing self-esteem, promoting active participation in daily living and improving quality of life. The programs will be carried out, recorded, and evaluated on a regular basis. 2. Restorative Nursing is a dynamic process which assist a resident in achieving optimum physical, emotional, psychological, and social potential. This process is exercised in an atmosphere that maintains the resident's dignity and self-respect and promotes a lifestyle that is as independent and self fulfilling as possible. 3. To provide individualized programs to maintain a resident's current functional level, identify and prevent loss in at risk residents, and restore residents to their highest functional level. 4. Identify a resident's strengths and improve their self-image and self-esteem. 5. To develop criteria for resident entry to, movement within, and discharge from the program. 6. Active Range of Motion - Exercises performed by a resident, with cueing or supervision by staff, that are planned, scheduled, and documented in the clinical record. 7. Take your time, and allow the residents to take their time. Watch for signs of fatigue or frustration before assisting. 8. Provide structured, well planned, individualized programming. 9. Measurable goals and interventions must be documented in the care plan and in the clinical record. 10. Evidence of periodic evaluation (quarterly) by a licensed nurse must be present in the clinical record. This documentation will reflect progress towards goals and whether the goal remains appropriate. 11. This program does not include exercise groups with more than four residents per supervising helper or caregiver 12. Must have daily documentation that the treatment was carried out. 13. Must show progress toward goals, or be necessary to prevent a decline in the level of functional independence 14. This program is a means of providing treatment for those residents identified as having: a. A change in function that has stabilized and is no longer in need of skilled therapy A potential for functional decline b. Already exhibited a functional decline c. A potential for functional improvement 15. You may specifically find the resident in need of a program if they are: a. Incontinent b. Being fed c. Non-ambulatory d. Restrained e. Catheterized f. Identified as having a decubitus g. Requiring partial or complete assistance with ADL's (Activities of Daily Living) 16. As with all nursing records it is essential to maintain accurate and timely documentation on the Restorative Program. 17. Daily documentation will be recorded on the EMR, and is completed by the Caregiver who provides the treatment to the resident on the day of program delivery. 18. The specific approaches should be specified on the EMR intervention list. (e.g., RUE - ROM to all extremities, passive, 10 repetitions) 19. Notify the Charge Nurse of all refusals and withheld treatments to assure appropriate action is taken based on the circumstances and that the consequences of refusal was reviewed with the resident. Same day documentation is required if there is a variation from the plan or in a resident's response to the planned approaches. 20. The quarterly summary should include: a. Type of restorative nursing program b. Resident's overall tolerance of the program c. Resident's increased, decreased, or maintained function as related to the care plan goal d. Proposed changes in the program goals or approaches In an interview on 9/27/23 at 1:13 PM, Staff C, Licensed Practical Nurse (LPN) reported that the resident very rarely attends group exercise class. In a concurrent record review and interview on 9/27/23 at 12:41 PM, the Director of Nursing (DON) agreed that the area in which documentation of restorative therapy was correct in the clinical record. AROM (active range of motion) listed in the care plan means the resident will attend a group exercise class that is held Monday through Friday and not have 1 on 1 assistance with range of motion exercises. The resident is not cooperative with exercises in the group exercise class even when staff sit next to her to provide assistance. The DON reported that the frequency of restorative therapy program is the same as when group exercise class is held. When asked what the facility is doing for a restorative program in regards to prevent a further a decrease in the resident's limited range of motion, the DON reported that she misunderstood the earlier portions of the interview and that the resident has had 1:1 assistance with AROM and continued with non cooperative behaviors when this was performed. The DON was unable to locate the Physical Therapy (PT) recommendation for restorative program in the resident's clinical record. In an Electronic Mail (email) on 9/27/23 at 1:25 PM, documentation of resident's behaviors with AROM or group exercise class was requested. As of 9/28/23 at 9:30 AM, this documentation was not provided.

Based on clinical record review, observations, staff interviews, and facility policy review, the the facility failed to ensure residents were safe during mechanical lift transfers for 1 of 1 residents reviewed (Resident #1). The facility reported a total census of 52 residents. Findings include: The The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses depression, hypertension and Peripheral Vascular Disease (PVD)The MDS included a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Interview on 9/25/23 at 1:16 p.m., with Resident #1 revealed she does not feel safe when the staff use the EZ stand with her. Resident #1 further revealed the staff does not use the straps or tighten them up when they use the lift with her. Review of Resident #1 ' s Care Plan with a revision date of 8/15/23 revealed the following: a. Resident will often refuse to utilize the strap around her lower extremities. She has been educated on the safety risks. b. Resident transfer on and off of the toilet with the stand aid with 1 staff assistance. c. Resident use the stand aid for all transfers. Observation on 9/25/23 at 1:36 p.m., of Staff A, Certified Nursing Assistant (CNA) transfer Resident #1 with the sit to stand lift revealed Staff A attached the lift harness around the resident and buckled the safety strap. Staff A attached the lift harness to the sit to stand machine. Staff A lifted Resident #1 with the sit to stand and the safety strap loosened up. Staff did not tighten up the strap. Resident was pushed into the bathroom and lowered onto the toilet. After Resident #1 was finished using the restroom Resident #1 was raised with the lift harness still attached to the sit to stand and the safety strap loosened up when lifting. Staff A did not tighten the strap. Resident #1 was then pushed into the room to her wheelchair and was lowered down. Resident #1 was assisted into her chair and staff finished assisting her. Review of the EZ Way Smart Stand operators manual with a revision date of 6/14/23 revealed as the patient is being raised, simultaneously tighten the safety strap buckled around their torso. Interview on 9/27/23 at 9:19 a.m., with the Director of Nursing (DON) revealed staff should have tightened the safety strap when lifting Resident #1.

Based on observations, facility policy review and staff interviews, the facility failed to perform proper hand hygiene during routine cares for 1 of 3 residents reviewed (Resident #1). The facility reported a total census of 52 residents. Findings include: The The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses depression, hypertension and Peripheral Vascular Disease (PVD)The MDS included a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Observation on 9/25/23 at 1:36 p.m., of Staff A, Certified Nursing Assistant (CNA) transfer Resident #1 with the sit to stand lift to the restroom. Staff A entered Resident #1 and did not perform hand hygiene applied gloves with no hand hygiene, Staff A removed a soiled brief and placed it in the trash. Staff A removed soiled gloves, placed them in the trash, did not perform hand hygiene. Staff A opened a package of wet wipes and took out wipes and placed them on the top of the package. Staff A without performing hand hygiene then applied a clean pair of gloves, opened the cabinet door and took out a clean brief. With gloves on, applied the brief on Resident #1. Staff A with soiled gloves moved her hair off of her shoulder, with the soiled gloves still on and placed left hand onto the bar of the lift and the right hand on the bathroom counter. When Resident #1 was finished Staff A with soiled gloves still on raised the lift so Resident #1 was standing above the toilet. Staff A with soiled gloves still on performed peri care, when completed Staff A pulled Resident #1 ' s clean brief up, pulled her underwear up, moved the loose strap around the abdomen out of the way and pulled Resident #1 ' s jeans up. Staff A removed soiled gloves and did not perform hand hygiene. Staff A assisted Resident #1 back to her wheelchair and removed the resident ' s lift harness and placed it on her bed. Staff A assisted the resident in getting comfortable in her chair and assisted her with pulling her shirt down. Staff A then took sanitizing wipes and wiped down the sit to stand lift and when completed pushed the lift out of the room. Left the lift in the storage area. Staff A then completed hand hygiene. Review of facility provided policy titled Hand Hygiene with a revision date of 4/2020 revealed hand hygiene is the single most important procedure of the control of infection. If hands are not visibly soiled, use the system approved alcohol-based hand rub for routinely decontaminating hands in most clinical situations including before each patient contact, after routine care where this is no contact with body fluids, after glove removal, before touching clean supplies Interview on 9/27/23 at 9:19 a.m., with the Director of Nursing (DON) revealed staff should have performed hand hygiene prior to putting gloves on and after taking off. She should have changed her gloves when they were soiled.

Based on clinical record review, staff interview and policy review, the facility failed to revise and update care plans to include and address opioid medication and anticoagulant medication usage and side effects in 2 out of 16 sampled residents reviewed for comprehensive care plans (Resident #3 and #32). The facility reported a census of 54 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Review of signed physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan with a revised date of 6/15/22 lacked information regarding usage of [MEDICATION(S)] (opioid medication) and side effects. 2. The MDS assessment dated [DATE] for Resident #32 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed a BIMS score of 15, indicating no cognitive impairment. Review of signed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan with a revised date of 5/12/22 lacked information regarding usage of [MEDICATION(S)] and side effects. Interview on 6/22/22 at 11:19 a.m., with the Director of Nursing (DON) revealed she expects opioid and anticoagulant medications should be on the care plan. The DON further revealed the facility does not have a policy on care planning.

Based on record review and staff interview, the facility failed to ensure a resident's complete list of diagnosed mental illnesses were included in the facilities PASARR (Preadmission Screening and Resident Review), ensuring a resident with a serious mental illness received the care and services appropriate to their needs, for 1 of 2 residents reviewed (Resident #54). The facility reported a census of 54 residents. 1. The Minimum Data Set (MDS) for Resident #54 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented the resident interviewed for feeling tired and having little energy for 7-11 days over 2 weeks. The MDS documented psychiatric and mood disorders, as an anxiety and depressive disorders and a [CONDITION(S)]. The PASARR, dated 3/2/2016, identified the resident as having a personality disorder, anxiety and depressive disorder. The submission documented No for the screening of a serious mental illness (SMI), including a [CONDITION(S)]. On 6/21/22 at 1:10 PM, in an interview and joint clinical record review with the DON, determined the resident was identified as having a [CONDITION(S)] continuously from 9/6/2012 to present, on the facility's MDS submissions. On 6/21/22 at 3:15 PM, in a joint interview with Staff A and the DON, Staff A stated she could not explain the omission of including the resident's [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/22/22 1:56 PM, in an interview with the DON, she stated she expected all psychiatric diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, chart review, review of the alarm reports and interviews with staff and administration, the facility failed to properly supervise residents and failed to follow up on interventions to keep them safe from accidents and hazards for 1 resident reviewed, ( Resident #55). Resident #55 had episodes of agitation and confusion and threatened to leave the facility unattended. On February 26, 2021 the resident eloped from the facility undetected and was discovered on the ground in the parking lot by community members. The elopement findings caused an Immediate Jeopardy (IJ) situation to the residents' health and safety. The facility also failed to properly operate the sit to stand mechanical lift in a safe manner and failed to follow up on interventions established to prevent falls for 1 resident reviewed, (Resident #55). The facility reported a census of 57 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #55 had diagnoses that included [CONDITION(S)], [CONDITION(S)] and diabetes. The MDS showed upon admission the resident required extensive assistance with the help of one for transfers and the help of two with walking and toileting needs. The MDS included a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating he had moderate cognitive deficits. The MDS dated [DATE] included diagnosis of dementia. A Care Plan dated 1/3/21 included a problem focus area of mood state and described behaviors such yelling at staff, physically acting out, throwing things, kicking and hitting staff. The Care Plan focus area stated when Resident #55 got agitated sometimes he was looking for his wife. The Care Plan included Social Services was looking for different placement at memory care nursing home due to his continued exit seeking and behavioral needs. The Care Plan included a problem area of falls and indicated the resident had a history of falls and was admitted with femoral fractures and rib fractures post fall. According to the Elopement Risk Assessments dated 1/4/21 and 1/28/21, Resident #55 was determined not to be at risk for elopement. A note entered on 1/4/21 at 3:02 PM in the Elopement Risk Assessment documented the resident had been out of his room and walking in others rooms as well as going out to the courtyard. Staff redirected him and he became agitated. An Elopement Risk Assessment entered on 2/26/21 at 7:55 PM indicated the resident was at risk for elopement. An Incident Report dated 2/27/21 showed Resident #55 was found sitting outside the facility by the curb in front of the wellness center on 2/26/21 at 7:30 PM. Community members who were driving by saw the resident sitting on the ground next to the wheel chair. They called the facility and Licensed Practicing Nurse (LPN) Staff D went outside and found the resident was laying on his back by the curb. There were 2 police officers and 2 community members standing by the resident. Staff D noted the resident did not complain of any pain at that time with assessment. He told the police he was trying to leave the facility and find his wife. According to the report the resident spoke to his wife on the phone earlier in the evening and told her that he wanted to escape and come home. The Incident Report indicated Staff D left the facility at 7:48 PM to bring the resident back inside. The report indicated Resident #55 remained uncooperative after the incident. The report stated he refused to transfer from his wheelchair to a recliner due to complaints of leg pain but would not allow staff to transfer him to the emergency room to be evaluated until his wife came to the facility and wheeled him over to the emergency department where he was evaluated and discharged back to the facility without injuries. On 7/6/21 at 12:07 PM the Police Officer that responded to a call for help by the community members said he first saw two people standing by a man on the ground in front of a wheelchair. He said it was dark and there was no snow or ice on ground. He remembered the resident said that he was trying to get away. He said it was within 5 minutes that staff were there to help him up and get him back inside. He stated the speed limit on the street in front of the building was 25 miles per hour. On 6/29/21 at 9:10 AM the Director of Nursing (DON) explained there were two possible explanations as to how the resident was able to exit the building without being detected. One possibility she said could have been he was able to get the code to disarm the alarm in Cedar Hall as he passed down the hallway. The other explanation she thought was he passed through the beauty shop therefore bypassing the alarm that was attached to the wall in the hallway between the two doors that enter the beauty shop. The DON showed the Cedar Hallway which is entered from the middle of Meadow Lane Community where there is a common area/dining room. Cedar Hall begins at resident room #42, then #41, and then the first doorway into the beauty shop. If one were to go past the door that enters the beauty shop there was a motion-censored alarm attached to the wall at this point. (On 6/29/21 at 11:56, CNA Staff I said when the alarm was set off, it would continue until the code was entered.) The DON went further down the hallway, past the alarm and pointed out that just beyond the alarm a second door to the beauty shop had been taken out and was walled over. She stated they believed Resident #55 had gone in the first door into the beauty shop, through the shop and out the door on the other side of the room (that had been taken out at the time of the survey) that exited out into the hallway, therefore by-passing the alarm that was attached to the wall in the hallway. From that point, they believe he exited through a push-bar fire door (that is not alarmed) and entered the wellness center department of the building. She believed he then wheeled himself past the reception area, several offices and to the doors that exit to the outside parking lot in front of the building. The DON said after the incident, they reprogramed all of the door codes and had walled off the second door to the beauty shop. She said they put in a plan of correction to make sure the beauty shop door was always kept locked when not in use. The door was unlocked when she took this worker down the hallway to explain where the resident had gotten out. The DON said they interviewed all of the staff that were working the night of the elopement and no one heard an alarm from Cedar Hall near the time that it was believed he exited. An Alarm Report generated from the computer in the front office revealed the security alarm in the Cedar Hall was set off on 2/26/21 at 7:28 PM and continued for one minute and sixteen seconds. According to the Police Call Report, the call came in on 2/26/21 at 7:48 PM. In an interview on 6/29/21 at 11:56 AM Certified Nursing Assistant (CNA) Staff I said she was working the night that Resident #55 exited the building unattended. She said she normally worked the day shift but had picked up some extra hours in the evening on 2/26/21. She remembered that she and another CNA were in with a different resident doing some exercises when they heard Resident #55 getting agitated. She said he was heading down the hallway toward an exit door and said that he was going to leave. She stopped him before he got to the alarm and was able to get him back to the dining room area and alerted the nurse to his agitation and exit seeking. She said she then went back to help get residents to bed and it was a very busy night. She said the last time she had seen him before he left the building he had been with the nurse in the dining area. Staff I said she did not hear an alarm go off and nothing came over the Walk-Talkies that the CNA's carry at all times. She thought it could have been about an hour from the last time she had seen him and when they got the phone call that he was outside. Staff I said she had not gone out to help get him back in because the nurse and other CNA went out and she stayed back with the residents. On 6/29/21 at 12:20 PM CNA Staff R said she was working with Staff I the night Resident #55 eloped. She remembered Resident #55 had been very irritated from the time he was admitted and he would often talk about leaving the facility and going home to his wife. She said most of the time, they would be able to calm him by letting him talk to his wife on the phone. Staff R said it was a very busy night on 2/26/21 and she had been trying to train the other CNA that hadn't worked nights before. She remembered he had been kicking the door earlier that night (double door that goes to the hallway) and they brought him back to sit with the nurse. She and Staff I went in to help other residents getting ready for bed and when she came back to the dining room area, she noticed Resident #55 was not in the dining room area and she thought maybe the nurse had sent him to the emergency room due to his agitation because they had done that before. She sat down to do some charting and it was about 5 minutes later when they got a call that he was found outside. She notified the nurses that he had gone out the wellness center. She said he had gone down that hallway before on different days and set off the alarm and she thought he may have been able to see them punch in the code to the alarm. Staff R said when she and nurse got outside to find him, he was on the ground in front of his wheel chair. She said he continued to be very agitated and didn't want anyone to touch him. She thought his wife came later that night to help calm him down. Staff R said there was no snow or ice on the ground, it was cold but not extreme. Staff R said the alarm in the Cedar Hallway where he exited would trigger a message to the Walkie-Talkies and it had not gone off that night when he got out. She said the door to the beauty shop, which is in the Cedar Hallway, is always kept locked in the evening. On 6/29/21 at 12:52 PM Licensed Practicing Nurse (LPN) Staff E said she was working 6 PM-6 AM shift the night of the elopement. She remembered Resident #55 had been very agitated that night and had gone down the Cedar Hallway 2 or 3 times but hadn't gotten far enough down the hallway to set off the alarm. She said they had redirected him back to the dining room area every time. She said she had gone into another room with the med-aide and that's when they got the phone call that he was out in the parking lot. She didn't recall how much time had gone by from the last she saw him and they got the call but she thought it was about 10 minutes. Staff E said the door to the beauty shop is usually locked in the evening but she could not say for sure if it had been locked the night of the elopement. She said they started a plan of correction that the door is kept locked in the evening when not in use. She said she had no knowledge of the alarm malfunctioning. On 7/7/21 at 11:29 AM Staff E said Resident #55 had been wearing his winter jacket the night he eloped and he had his shoes with him throughout the evening. She said she did not have any knowledge of the alarm going off from Cedar Hall that night or of anyone having turned the alarm off. She recalled the CNA's reported throughout the evening that they had redirected the resident back to the dining room many times and that was the last place she saw him before they got the phone call he was outside. On 6/30/21 at 11:54 AM Staff S CNA was asked to set off the alarm in Cedar Hallway to hear the message that transferred to the Walkie-Talkies. As she set off the alarm, it did not come across the Walkie-Talkie and she acknowledged that the alarm alone could not be heard at the end of other hallways or when staff are in the rooms with residents. On 06/30/21 at 12:02 PM Staff S checked the alarm again and it did not transfer to the Walkie-Talkies. On 06/30/21 at 2:40 PM the Director of Senior Services said after checking the alarm in the Cedar Hallway the maintenance department found the battery up in the ceiling that connected the alarm to the Walkie-Talkies and to the computer at the front desk had not been working. She could not say for sure how long it may have been malfunctioning. On 7/6/21 at 12:26 PM the Manager of the maintenance department said the alarm in Cedar Hallway is managed by an outside company and this was the only hallway in the facility with that type of an alarm. He said they didn't have this alarm with the battery on a regular check but going forward will change the batteries when they do the smoke alarms around the facility. On 7/6/21 at 3:03 PM the DON stated that no alarm on the Alarm Report coincided with the time of the elopement and after the elopement all the staff had been interviewed and they all said they did not hear an alarm. On 7/7/21 at 9:45 AM the Director of Senior Services acknowledged the Alarm Report from 2/26/21 indicated the alarm from Cedar Hall went off at 7:28 PM and was on for one minute and sixteen seconds. She maintained this was not enough time for him to have gotten down the hallway and through the double doors without having been detected by staff. She said they have not been able to determine who turned this alarm off. On 7/7/21 at 9:39 AM the DON stated if an alarm was going off and staff don't see anyone around they were educated to not just shut it off. She stated they had questioned everyone on staff and were unable to find who shut off the alarm at 7:28 PM on 2/26/21. She said if an alarm is going off and no one is visible in the hallways they notify the charge nurse who starts the elopement response plan. She stated they provided education on the 2nd Tuesday in March, not everyone was in attendance. 2.) According to the MDS assessment dated [DATE] Resident #55 required extensive assistance with the help of one for transfers and according to the MDS dated [DATE] he required extensive assistance with the help of two people for transfers. According to the Care Plan dated 4/14/21, Resident #55 required the stand-aid for transfers from the recliner and for toileting. In an observation on 6/29/21 at 9:11 AM Certified Nursing Assistants (CNA) Staff I and Staff G placed the sit-to-stand mechanical lift in front of Resident #55, who was sitting in his recliner, and assisted him to get his feet on the platform. As they put the sling around the resident's back, his eyes were closed and he did not respond to their requests for him to move his feet. They strapped the sling around his mid-section, put his hands on the hand bars and started the mechanical lift, lifting him out of the recliner. As they lifted, the sling held the weight of the resident in his arm pits, his body was in a seated position and his feet dangled just above the platform. Staff G and Staff I encouraged him to use his leg strength but he did not respond. At 9:13 AM, they lowered him onto the toilet and unbuckled the sling. When asked if they ever used the Hoyer Lift to transfer the resident Staff G said they only use Hoyer if he's on the floor and can't use his muscles. At 9:15 AM they buckled the sling around his midsection again and assisted him with placing his feet on the platform. The residents heals were off of the platform and they encouraged him to move them and use his muscles but he did not respond. As they began to lift him off the toilet, his feet slid off of the platform so they lowered him back down on the toilet and decided to get the nurse to look at placement. Staff G indicated she thought there was a problem with the shin pads on the machine, that they were loose and not supporting the resident. She thought maybe maintenance should look at the lift. She then thought maybe the guards were supposed to tilt slightly. At 9:22 AM the resident's eyes were closed and he appeared to be sleeping on toilet as they waited for a nurse. At 9:24 AM Registered Nurse (RN) Staff A entered and took a look at the shin guards and decided that there wasn't a problem with the guards. At 9:26 AM they assisted him to put his feet on the platform of the stand-aid and then strapped his legs onto the mechanical lift. As they lifted him off of the toilet, the resident did not put pressure on his feet and his body weight was supported by the sling that slid up into his arm pits and his body was in the sitting position as they moved him to the wheel chair. They asked him if he was doing okay he said it's not very comfortable. RN Staff A stated they should talk to physical therapy about assessing his transferring. On 6/30/21at 8:58 AM CNA Staff S and CNA Staff I assisted Resident #55 with the sit-to-stand lift and helped him put his feet on platform. LPN Staff D was present to take a look at a pressure area on his bottom. The CNA's strapped the residents legs to the shin guard and began to lift him up out of his recliner. Staff D acknowledged at that point the sling was bearing his weight and that he was not standing. She took a look at his bottom while he hung from the sling and they then transferred him to the toilet. At 9:06 AM they lifted him off of the toilet so Staff D could apply lotion to his bottom and she asked is that hard on your arms? and use those legs the resident did not respond and did not put weight on his feet. At 9:07 AM they lowered him back down onto the toilet and the LPN checked his groin area. At 9:09 AM they raised him off of the toilet again and encouraged him to use his legs. The resident moaned but did not speak. The LPN then applied a patch to his bottom. He was not bearing weight with his legs and his arms were parallel to the floor, body in a sitting position and the sling was sliding further up his back. At 9:10 AM they lowered him down in to the wheel chair. On 7/8/21 at 10:07 AM Physical Therapist (PT) Staff T stated she was not aware of a certain percentage of weight that a resident should be able to bear for using the sit to stand but they need to have some weight on the platform. She said PT did get a referral to assess Resident #55 and result of that assessment was a recommendation the Maxi lift be used for transfers for him. According to the operators instructions for the EZ Way Smart Stand, have feet on foot plate and position their shins into the shin pad. As the patient is being raised simultaneously tighten the safety strap buckled around their torso. Stop lifting when the patient is in a standing position. When the patient is in standing position, transfer the patient to the desired location. According to the Lift Policy last approved on 7/2021, all staff are accountable for utilizing proper body mechanics, lifting techniques and resident safety. Staff will utilize the proper transfer/lift procedure of each resident. This includes the use of the resident transfer devices (Tempo Lift, EZ Way, Maxi Sky, [MEDICATION(S)], Sara Plus, etc). On 7/7/21 at 12:16 PM the DON stated in an email when a resident declines in their ability to transfer, the nursing staff would request a PT evaluation. She said the facility did not have a specific policy for the use of sit-to-stand mechanical lift. 3) According to the Care Plan dated 1/3/21, Resident #55 was admitted to the facility on [DATE] and was a fall risk as he had suffered with a displaced femoral fracture prior to admission. The Care Plan included intervention to check on him every 2 hours and to use a video monitor in his room for safety. The Care Plan included interventions after falls as follows: a) On 1/6/21 wear gripper socks at all times and install grip strips on the floor by his bed. b) On 1/9/21 the resident slid out of the recliner and the intervention was to assure he had a Dycem pad in the recliner to help prevent sliding. c) On 1/16/21 after an unwitnessed fall staff were to take monitor on rounds when passing medication and anytime they were away from the nurses' station. d) On 5/15/21 an unwitnessed fall, resident found scooting on the floor by his room, fall was not witnessed on the camera as camera was malfunctioning. The 5/15/21 fall intervention was to ensure the video monitor is working properly on the off hour of rounds. Keep monitor on the front end of nurse's station. Observations as follows: 1) On 6/29/21 at 9:06 AM Resident #55 wearing white socks, not grippers. No gripper strips on the floor by the chair or by the bed. 2) On 6/29/21 at 9:09 AM gripper sock was on the left foot only and slipper was on the right foot. 3) On 6/30/21 at 7:04 AM the resident was asleep in his recliner with a blanket over his lap. Staff I CNA removed the blanket. The resident's feet were bare. 4) On 7/1/21 at 8:00 AM he was wearing slippers and no socks. No Dycem in recliner and no gripper strips on the floor. 5) In an observation on 6/30/21 at 6:43 AM the monitor for Resident #55 was not at nurses station. At 6:51 AM observed Medication Aide, Staff F had all three monitors on her med cart. The camera for Resident #55 was not working. Staff F said when they got further away from the resident's room, the monitors didn't work. She stated it happens often that the monitor will quit working the farther away they get from the camera. The facility corrected the IJ on 7/7/21 when they implemented the following: Maintenance will change batteries in all of the alarms annually in the month of July. They will document the weekly alarm checks and Director of Senior Services will be responsible for auditing of the documentation. The charge nurses will check the door alarms twice a day at the change of shift and the DON will be responsible for auditing the documentation. Elopement assessments will be conducted upon admission and with each quarterly MDS update. If a resident is determined to be at risk, the interdisciplinary team will discuss and implement interventions. The DON will be responsible for auditing of the documentation and follow up interventions. If a resident is exit-seeking, confused or aggressive nursing staff will contact the physician and family member or representative. Visits will be encouraged if appropriate. The resident will be put on 15 minute behavior checks until resolved. RN Case Manager will be responsible for the auditing of the documentation and follow up interventions. A Healthstream course was assigned to all staff titled; Helping Prevent Elopement. Care Plans updated for residents that are determined to be high risk for elopement. At the time of exit, the scope and severity was lowered to a D after verification of staff's implementation of their policies.

Based on clinical record review, staff interviews, and family interview the facility failed to obtain the resident's advanced directives wishes and/or obtain physicians orders for 4 of 15 residents reviewed for rights to formulate advance directives, (Resident #47, #39, #17, and #2). The facility documented in the Electronic Health Record (EHR) and on the facility's report sheet the residents were a No Code (do not provide Cardiopulmonary Resuscitation (CPR) despite the fact the resident and/or resident representative did not agree to those wishes and/or did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #47 with a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS also documented diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on [DATE] at 4:18 PM revealed an untitled, undated facility form that listed Resident #47 as a no code (no cardiopulmonary resuscitation, CPR). In an interview on [DATE] at 4:20,Staff P reported the untitled, undated document which listed Resident #47 as a no code was a form used during shift report and to ensure nurses knew each resident's code status. In an interview on [DATE] at 4:18 PM, Staff P showed the EHR revealed a Durable Power of Attorney (DPOA) document with the resident's Do Not Resuscitate (DNR) designation listed within the document, signed by notary. During the interview, Staff P showed facility document Advance Directives with the resident's wife signature on [DATE] DNR status was not signed by a physician. During the interview, Staff P showed that DNR was listed in the resident's Care Plan dated [DATE]. Observation during the interview revealed DNR status was in a red color on the EHR header. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on [DATE] at 2:30 PM, the Director of Nursing (DON) admitted the facility document Advanced Directives with the resident's legal representative signature on [DATE] marking DNR was not signed by a physician. 2. The MDS assessment for Resident #39 dated [DATE] documented severe cognitive impairment. The MDS revealed the resident required extensive assistance in ADLs (activities of daily living) and was determined to have total dependence on staff. The MDS recorded diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on [DATE] at 4:15 PM revealed an untitled facility document that listed the resident as a no code (no CPR to be performed). In an interview on [DATE] at 4:05 PM, the DON was unable to produce any signed, supporting documentation that the no code was authorized by the resident or her representative or approved by her physician. 3. The MDS dated [DATE] documented Resident #17 with a BIMS score of 9, indicating moderate cognitive impairment. The MDS also documented the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months to live documented by a physician. Record review on [DATE] of a facility untitled undated resident roster listed Resident #17 as a no code (do not provide CPR). Record review of Resident #17's Advance Directive form signed by the resident on [DATE] and signed by the physician on [DATE] lacked documentation of the residents' wishes for CPR or no CPR, however; it did document their decision that they did not want other life support measures to be taken. 4. The MDS dated [DATE] documented Resident #2 with a BIMS score of 00, indicating severe cognitive impairment. The MDS also documented the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months to live documented by a physician. Record review on [DATE]of a facility untitled undated resident roster listed Resident #17 as a no code (do not provide CPR). Record review of Resident #2's Advance Directive form signed by the resident on [DATE] and signed by the physician on [DATE] lacked documentation of the residents' wishes for CPR or no CPR however; it did document their decision that they did not want other life support measures to be taken. Interview on [DATE] at 10:33 AM with the DON revealed the Advance Directive forms for Resident #2 and #17 did not indicate their wishes to have CPR or Not have CPR.

Based on clinical record review, observation, staff, resident, and family interviews, the facility failed to follow, review and revise the Plan of Care for 4 of 16 residents reviewed (Residents #47, #35, #55 and #20). The facility reported a census of 57 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #47 with a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS also documented diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident needed the extensive assistance of one staff member with transfers and the limited assistance of one staff member to walk in either his room or the corridor. In an interview on 6/30/21 at 9:23 AM, the Director of Nursing (DON) reported a gait belt is kept on the resident at all times when he is out of his bed so that staff can be ready to assist the resident at any time as the resident is known to get up out of his wheelchair very suddenly and at times will start running. The DON revealed the resident's family requested the resident to wear a gait belt at all times while in his wheelchair. Observation on 6/30/21 at 10:24 AM revealed Resident #47 sitting in his wheelchair in a common area with no staff nearby and did not have a gait belt on. Observation on 6/30/21 at 3:29 PM revealed Resident #47 sat in his wheelchair in a common area with no staff nearby, he was not wearing a gait belt. Clinical record review on 6/30/21 of Plan of Care dated 5/29/18 revealed Resident # 47 was to wear a gait belt at all times while in his wheelchair. In an interview on 6/30/21 at 4:24 PM, the resident's spouse reported she requested that her husband wear a gait belt at all times. #2 The MDS dated [DATE] documented Resident #35 as independent in decision making with no memory impairment. The MDS identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident required extensive assistance of two or more people in bed mobility, transfers and personal hygiene. A Care Plan initiated on 8/18/20 and reviewed on 2/16/21 identified the resident as quadriplegic and dependent on staff for ADLs (activities of daily living). It established a goal to maintain his participation in a restorative nursing program. Interventions included utilizing the Easy Stand (a mechanical device that raises a person to a vertical standing position) one time daily as tolerated. The Journal of Long Term Effects of Medical Implants Vol 16, 2006 issue 3, included an abstract titled ' The Sit and Stand Chair, A Revolutionary Advance in Adaptive Seating Systems ' It outlines the benefits of vertical positioning (Easy Lift), including a reduction in seating pressure, decreased bone demineralization, enhanced circulatory regulation and reduction in muscle loss and spasms. In an interview on 6/28/21 at 3:52 PM, Resident #35 stated it had been approximately 2 months since he last used the Easy Stand with staff. He denied any events or issues that would have caused the discontinued use of it. The resident stated he did not know why staff stopped using it with him and he had never refused to use it. In an interview on 6/28/21 at 3:52 PM, Resident #35's spouse revealed the Easy Stand had not been used for months and sat in the corner. In an interview on 6/30/21 at 8:25 AM, Staff K, Physical Therapist, stated his Physical Therapy notes indicated he last saw the resident in February 2021 at the request for a consult on neck pain. He stated he consulted with the Occupational Therapist and they placed the resident in the Easy Lift at that time to ensure the resident could tolerate it and that it functioned appropriately. He stated the resident tolerated the therapy without any adverse effects and he did not know why the equipment was not utilized with the resident. In an interview on 6/30/21 8:30 AM, Staff L, Occupational Therapist, confirmed the February 2021 consultation with PT occurred. She stated the resident tolerated the transfer to the Easy Stand without adverse effects, such as blood pressure changes. Staff L stated she suspected the therapy equipment nonuse was related to staff turnover and a lack of training and competency in the use of the Easy Stand. In an interview on 6/30/21 at 8:50 AM, the DON confirmed Resident #35's restorative needs had been a challenge for the facility. She stated maintaining training and competency for staff with the Easy Stand had been a challenge and that had resulted in the therapy not being provided as care planned. 3) According to the MDS dated [DATE] Resident #55 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed that upon admission the resident required extensive assistance with the help of one for transfers and the help of two with walking and toileting needs. Resident #55 had a BIMS score of 7 out of 15, indicating he had moderate cognitive deficits. The MDS dated [DATE] included diaganosis of dementia. The Care Plan for Resident #55 included the following: a) On 5/25/21 keep Allevyn dressing to coccyx area, change on bath days and as needed for drainage saturation. b) On 1/6/21 to prevent falls wear gripper socks on at all times. c) On 1/6/21 grip strips to be applied on the floor by the bed. d) On 1/9/21 Place Dicem material in recliner to prevent him from sliding out of the chair. e.) On 5/25/21 Assure there is a T-gel pressure relieving device used during all sitting. In an observation on 6/30/21 at 8:55 AM Resident #55 was sitting in his recliner with a cloth protective liner on the seat. There was no pressure reducing device and he was wearing regular socks which did not have grippers. On 6/29/21 at 9:10 AM Resident #55 was sitting in his recliner with cloth chuck under him, not pressure reducing. Observed that there were no gipper strips on the floor by his bed or by his recliner. On 6/30/21 at 7:04 AM Resident #55 was in recliner sleeping. Staff I, CNA came in with me and took covers off the resident. The resident was bare footed and did not have pressure reducing device in place, just a cloth chuck under him. 4) According to the MDS dated [DATE] Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was totally dependent with the assistance of two staff for bed mobility, transfers, toileting and locomotion. A Care Plan dated 6/30/16 indicated the resident had been injured in a construction accident and was unable to make voluntary body movements. The Care Plan stated the resident suffered with severe contracture to upper and lower extremities and the plan included passive Range of Motion (ROM) exercises with the use of leg splints to both ankles and lower legs to help prevent the development of further contracture. The Care Plan included detailed instructions to place elbow brace on left elbow, place splints on lower legs and to leave them on for 30 minutes at a time up to three times a day. The Care Plan included a plan to place leg splints on resident with plantar position and bring them up to 90 degrees, and place legs straight while wearing splints. During observations made on 6/28/21 at 1:50 PM and 3:05PM, on 6/29/21 at 7:16 AM and 1:39 PM and on 6/30/21 at 11:17 AM, noted that the splints were on the shelf behind the door in the resident's room. The resident was observed to have a significant contracture to his hands and arms On 6/28/21 at 3:05 PM Staff G, Med Aide said the CNA's do the restorative exercises with Resident #20 and document the activity in the daily charting. On 6/30/21 at 11:17 AM Staff I, CNA said she completes upper and lower body Range of Motion (ROM) with Resident #20. When asked about the splints that were on the shelf in his room she said she did not use them and did not know how they were being used. On 6/30/21 at 11:20 AM Staff D, LPN said the nurses apply the splints and the CNA's do the ROM and take them off. A review of the medical chart revealed a daily intervention to apply the restorative splint brace that triggers on the electronic charting. In this daily charting, in the month of June it was documented the splints had been applied on just one day for 30 minutes on 6/27/21. On 7/8/21 at 1:57 PM the Director of Nursing (DON) stated the splints are used as a restorative prevention for contractures due to his medical diagnosis. These are to be applied 30 minutes a day up to 3 times a day. She said this matter was addressed in a nurses meeting on 7/6/21 as the documentation was not done appropriately. She said that this is a nursing responsibility. 5. A MDS for Resident #2 dated 3/26/21 documented the resident had Alzheimer's disease and a [CONDITION(S)] or [CONDITION(S)]. The MDS also documented the resident was unable to walk and was dependent on staff to get to and from desired locations. Review of a Note to Attending Physician/Prescriber for Resident #2 signed by the physician on 6/2/21 documented the resident continues to have ongoing anxiety. The Physician ordered to continue his as needed Lorazepam order for another nine months. Review of Resident #2's current orders as of 7/11/21 documented the resident receives Lorazepam 1 milligram by mouth as needed every 6 hours. Last taken 7/11/21 at 7:46 PM. Review of Resident #2's Plan of Care with a print date of 6/29/21 lacked interventions for staff to try prior to giving as needed anti-anxiety medication. The Plan of Care also lacked side effects and adverse reactions of anti-anxiety medications for all staff to monitor for.

Based on observation, chart review and interview the facility failed to provide restorative services to 1 of 16 residents reviewed, ( Resident #20). Resident #20 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan included restorative goals to prevent contractures and he had splints in his room for his legs and arms to be applied daily. According to the nursing documentation the splints were applied just one time in the month of June. The facility reported a census of 57 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE] Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was totally dependent with the assistance of two staff for bed mobility, transfers, toileting and locomotion. A Care Plan dated 6/30/16 indicated the resident had been injured in a construction accident and was unable to make voluntary body movements. The Care Plan documented the resident had severe contractures to the upper and lower extremities and the plan was to provide passive range of motion exercises and for him to wear left elbow and leg splints to both ankles and lower legs to prevent the development of further contractures. The Care Plan included detailed instructions to place elbow brace on left elbow, place splints on lower legs and to leave them on for 30 minutes at a time up to three times a day. The Care Plan included a plan to place leg splints on resident with plantar position and bring them up to 90 degrees, and place legs straight while wearing splints. During observations on 6/28/21 at 1:50 PM and 3:05 PM, on 6/29/ at 7:16 AM and 1:39 PM and on 6/30/21 at 11:17 AM, noted the splints were on the shelf behind the door in the resident's room. The resident was observed to have a significant contracture to his hands and arms On 6/28/21 at 3:05 PM Staff G, Med Aide said the CNA's do the restorative exercises with Resident #20 and document the activity in the daily charting. On 6/30/21 at 11:17 AM Staff I, CNA said she completes upper and lower body Range of Motion (ROM) with Resident #20. When asked about the splits that were on the shelf in his room Staff I said she did not use them and did not know how they were being used. On 6/30/21 at 11:20 AM Staff D, LPN said the nurses apply the splints and the CNA's do the ROM and take them off. A review of the medical chart revealed a daily intervention to apply the restorative splint brace that triggers on the electronic charting. In this daily charting, in the month of June 2021 it was documented the splints had been applied on just one day for 30 minutes on 6/27/21. On 7/8/21 at 1:57 PM the Director of Nursing (DON) stated the splints are used as a restorative prevention for contractures due to his medical diagnosis. These are to be applied 30 minutes a day up to 3 times a day. She said that this matter was addressed in a nurses meeting on July 6, 2021 as the documentation was not done appropriately. She said that this is a nursing responsibility.

Based on observation, record review, and pharmacy consultant interview the facility failed to provide standards of practice with medication administration by having an error rate of over 5%. During observations of 28 medications administered, 2 errors occurred, resulting in an error rate of 7.14%. The facility failed to follow instructions on both the medication card and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility also failed to give the correct type of Aspirin to a resident. The facility reported a census of 57 residents. Findings include: 1. A Minimum Data Set (MDS) for Resident #2 dated 3/26/2021 documented the resident had Alzheimer's disease and a [CONDITION(S)] or [CONDITION(S)]. The MDS also documented the resident was unable to walk and was dependent on staff to get to and from desired locations. Record Review of Resident #2's active medication list printed 7/12/21 documented: [MEDICATION(S)] XL (extended release) 50 mg (milligrams) by mouth daily ****PLEASE DO NOT CRUSH*****. Review of the residents medication card filled by the pharmacy on 6/15/2021 had a yellow sticker that said do not crush. During an observation on 7/1/21 at 8:49 AM, Staff V, Certified Medication Aide (CMA), took Resident #2's [MEDICATION(S)] 50 mg tablet and crushed in a pill crusher device and administered to Resident #2 in applesauce. Review of a Situation-Background-Assessment-Recommendation (SBAR) fax dated 7/12/20 documented it is ok to crush medications per pharmacy. Interview with the facilities Pharmacy Consultant on 7/12/21 at 4:26 PM regarding Resident #2 and crushing his [MEDICATION(S)]. The Pharmacy Consultant revealed the pharmacy places the yellow do not crush stickers on the card as a indicator to a normal patient. The preferred practice would be not to crush the medication. However, Resident #2 is not a normal patient. There is no harm to it and the med still does its job effectively. 2. A MDS for Resident #23 dated 4/23/21 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's pill bottle on 6/30/2021 at 7:59 AM revealed: Aspirin 81 mg entericoated (EC) by mouth daily. Review of Resident #23's Active Med List dated 7/12/21 documented: Aspirin Chewable 81 mg tablet by mouth daily. Observation on 6/30/21 at 7:59 AM revealed Staff W, CMA administered Resident #23 one tablet of Aspirin 81 mg EC. Interview on 7/12/21 at 2:00 PM with the facilities Pharmacy Consultant revealed the entericoated, chewable and normal pill form of Aspirin are all slightly different.

Based on observation, record review and staff interviews, the facility failed to assure a resident at risk for skin breakdown received routine assessments with measurements to be able to monitor and evaluate effectiveness of the treatment and if changes are needed for 1 of 2 residents reviewed with pressure ulcers (Resident #36). The facility failed to implement planned intervention and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 57 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE] for Resident #36 documented the resident with a Brief Interview of Mental Status (BIMS) of 6, indicating severe cognitive impairment. The MDS indicated the resident required total assistance from staff with bed mobility, transfers and toilet use. The MDS also identified the resident was at risk for pressure ulcer development. Staff recorded the resident as having no pressure ulcers at the time of the MDS assessment. Record review of the facilities Electronic Health Records (EHR) Skin Basic Assessment revealed the facility identified Resident #36 had a coccyx pressure ulcer on 6/3/21. Record review of Resident #36's Care Plan with a print date of 6/28/21 documented an intervention dated 6/7/21 coccyx was red and blanchable (a way to determine if there is underlying tissue injury to the skin by pressing on the site and seeing if it remains red or turns white). The Care Plan directed staff to use an Allevyn patch (pressure reducing patch) for protection. Record review of the facilities EHR Skin Basic Assessment revealed Resident #36's coccyx pressure ulcer site lacked routine measurements to assess for worsening and healing of site from 6/8/21 to 6/18/21 and again from 6/19/21 to 6/29/21. Observation on 6/30/21 at 2:53 PM revealed the resident with a red closed area to his buttocks with a pressure-relieving patch covering the site. Interview on 7/8/21 at 9:30 AM with the Director of Nursing (DON) in regards to Resident #36's coccyx pressure ulcer site she revealed she would expect the nurses at the facility to get measurements twice a week. 2. According to the MDS dated [DATE] Resident #55 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS showed upon admission the resident required extensive assistance with the help of one for transfers and the help of two with walking and toileting needs. The document included a BIMS score of 7 out of 15, indicating he had moderate cognitive deficits. The MDS dated [DATE] included diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Care Plan dated 1/3/21 included a problem area of skin integrity and noted the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan indicated he had two toes amputated prior to admission to the facility. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order continued with a directive to use a T-gel pressure relief device during all sitting. The current Care Plan for Resident #55 included the following interventions: 1) On 5/25/21 keep Allevyn dressing to coccyx area, change on bath days and as needed for drainage saturation. 2) On 5/25/21 Assure there is a T-gel pressure relieving device used during all sitting. In an observation on 6/28/21 at 2:58 PM Resident #55 was sitting in a recliner in his room. He was wearing slippers on his feet that had a fuzzy material inside and no stockings. When asked if he had any sores he took off the slipper on his left foot. There was a bandage on the left second toe dated 6/27/21. On 6/29/21 at 7:32 AM Staff D, Licensed Practicing Nurse (LPN) was asked about the treatment to the toe. Staff D stated the Physical Therapy (PT) department was changing the dressings. The Director of Nursing (DON) was standing nearby and interjected that the area to his toe was healed and PT was no longer monitoring the sore. Staff D said that it had opened back up again and they would talk to PT to have them come over and look at it. In an observation on 6/29/21 at 1:19 PM, Resident #55 was sitting in his recliner. Staff T and Staff U from the Physical Therapy department prepared to provide a treatment to his toe using a low level laser light. Staff T said they had been treating the toe for several months and it had healed in May. She said PT had just gotten a referral from nursing to take a look at it again because it opened up. Staff T took a look at the slippers that the resident had been using and stated the hard top of the slippers was a problem because it could cause friction and rub on the sensitive skin. She said he should be wearing socks and bare feet in the slippers was problematic. According to a Discharge Report from Physical Therapy dated 5/18/21 the wound on the second toe of the left foot was fully epithelialized and the resident was at high risk for reoccurrence. The recommendations from PT dated 5/18/21 at 12:00 stated the wound on 2nd toe is now closed and remodeling. Keep current dressing in place x2 weeks. At that time he may shower/bathe the toe. Redress after and continue for 8 weeks dress with allevyn gentle secured with elastic tape. According to Skin Assessment Nursing documentation dated 6/4/21, 6/8/21, 6/14/21 and 6/27/21 the wound on the second toe of the left foot had been open with sero-sanguineous drainage. The skin documentation indicated the area was intact on 6/17/21 and 6/21/21. In an interview on 6/29/21 at 1:37 PM Staff T, Physical Therapist stated the resident should always have footwear, should keep stockings on and not wear the slippers because the top was rough and hard and could cause friction. On 6/30/21 at 7:04 AM Resident #55 was in the recliner sleeping with a blanket over his lap and legs. Staff I, CNA came in with the surveyor and took the covers off Resident #55's feet. The resident was bare footed. He did not have a pressure reducing device under him. On 7/1/21 at 8:00 AM the resident was in his recliner, no pressure reducing device under him and he was wearing his slippers without stockings. On 6/30/21 at 9:02 AM as the resident was raised from his recliner with the use of the sit-to-stand mechanical lift, Staff D, LPN took a look at the residents coccyx area and noted a small red pressure spot. The area did not have an Allveyn dressing as ordered.

Based on observation, record review, and staff interview, the facility failed to wear adequate personal protective equipment (PPE) with new admissions for 2 of 2 residents reviewed (Resident #1, and #2), failed to assure appropriate eye protection during care, failed to actively screen staff for symptoms of Covid-19, and failed to wear adequate PPE after an outbreak in the facility. The facility reported a census of 58 residents. Findings include: 1) An Admission Record showed Resident #1 admitted [DATE]. A List Resident Note dated 9/23/20, documented the resident arrived with family, and walked from the car to her wheelchair with assist of 1, a gait belt, and front wheeled walker. The resident transported to a room. The nurse and case manager assessed the resident on admission and she denied experiencing Covid symptoms. An interim Care Plan with 9/25/20 date, documented the resident had a Brief Interview for Mental Status (BIMS) of 10, indicating cognitive impairment. During an observation on 9/29/20 at 7:57 a.m. Staff B, Certified Nursing Assistant (CNA) assisted the resident on the toilet. Staff B wore a facemask and a shield. The shield in the front was up in her hairline causing it to jut forward, leaving the sides of her face exposed. Staff B assisted the resident with dressing, at times Staff B's clothing in contact with the resident's clothing, and their faces within 2 feet of each other. The resident did not wear a mask. When finished with care, Staff B exited the room and did not sanitize her shield. During an interview on 9/28/20 at 4:05 p.m. the Director of Nursing stated Resident #1 in quarantine, meaning she would stay in her room. Staff wore a mask and a shield, but not a gown, because she did not have symptoms. The resident did not test for Covid-19 prior to admission. 2) According to the Minimum Data Set (MDS) assessment, dated 9/24/20, Resident #2 admitted to the facility on [DATE] and scored 3 on the BIMS, indicating severe cognitive impairment. The resident depended on staff for bed mobility, transfer, eating and toilet use and required extensive assistance with dressing and personal hygiene. The resident's [DIAGNOSES REDACTED]. During an interview on 9/26/20 at 12:16 p.m. the Case Manager stated Resident #2 quarantined due to his new admission to the facility. During an interview on 9/28/20 the Director of Nursing stated they did not use a gown because the resident had no symptoms (of Covid-19). The resident did not get tested prior to admission. During an observation on 9/29/20 at 9:20 a.m., Staff C Certified Medication Aide (CMA) and Staff D Certified Nursing Assistant (CNA) entered the resident's room to check, change and reposition him. Staff wore an N95 mask and face shield. The resident laid in bed. Staff performed hand hygiene and gloved. Supplies at the bedside were placed on a paper towel on the bed. Staff C cleansed the resident's posterior, changed gloves and performed hand hygiene. Staff C requested Staff E Registered Nurse (RN) get more wipes for use with the resident. Staff E entered the room with the wipes, wearing a mask and a face shield. Staff C performed incontinent care in front. Staff placed a turn sheet and boosted the resident up in bed. Staff C, on the resident's right side leaned into the bed and one of the residents pillows, Staff E leaned up against the resident's bedrail on the resident's left side. Staff D stood at the foot of the bed with her uniform touching the residents linens piled at the foot of the bed (all 3 staff potentially contaminating their uniforms). When staff repositioned the resident, he coughed several times with no covering of his mouth and nose. Staff E wore her face shield high on her head and it jutted forward providing little protection to the front of her face as she looked down at the resident, and no side coverage of the face. Staff C also wore her shield higher up on her head, and while it gave her frontal face coverage, it did not cover the sides of her face. Staff did not sanitize their shields when they exited the room. During an interview on 9/29/20 at 10:45 a.m. the Infection Preventionist stated if shields were visibly soiled they would sanitize, otherwise done at the end of their shift. She said the shields they used were what they had available to them. She said if they touched their shields they should do hand hygiene right away. She said they would put droplet precautions in place if a newly admitted or readmitted resident had symptoms or developed symptoms. The CDC document Preparing for COVID-19 in Nursing Homes Infection, Control for Nursing Homes Updated June 25, 2020 included: a. Prioritizing gowns for activities where splashes and sprays were anticipated (including aerosol-generating procedures) and high-contact resident care activities that provided opportunities for transfer of pathogens to hands and clothing of health care personnel (HCP). b. Creating a Plan for Managing New Admissions and Readmissions whose COVID-19 status was unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. The Iowa Department of Public Health (IDPH) Interim Guidance for New Admissions or Return of Residents to Long-term Care Facilities dated 8/24/20 included guidelines for Admissions. IDPH recommends that all new admissions or returning residents, no matter the source, test result, or COVID-19 status, be quarantined for a minimum of the first 14 days of their stay. Nursing facilities accepting new or returning residents (including those clinically ready for hospital discharge) should be capable of designating an isolated area and should designate dedicated staff who are distinct from staff caring for other residents. These new or returning residents include those with: a. A Pending COVID-19 test; b. Undiagnosed , active respiratory symptoms; or c. Any other discharged individuals with an unknown status. When cohorting residents, and if facility space allows, it is recommended to cohort known COVID-19 positive residents, cohort new admissions with an unknown status, and cohort current, healthy asymptomatic residents, separately from each other with designated staffing for each group. 3) According to the MDS assessment, dated 7/17/20, Resident #3 scored 15 on the BIMS, indicating no cognitive impairment. The resident needed limited assist with bed mobility and dressing. The resident's [DIAGNOSES REDACTED]. Patient Care System documentation regarding Covid-19 symptoms dated 9/26/20 at 10:45 a.m. documented the resident complained of sore throat and started Covid precautions. A View of Covid-19 Symptoms document indicated the resident had a sore throat and new fatigue. The resident quarantined with proper PPE placed outside her door. They would notify the family and offer testing. During an interview on 9/26/20 at 12:16 p.m., the Case Manager stated Resident #3 developed symptoms, family refused testing, and they put her on droplet precautions. During an interview on 9/28/20 at 10:25 a.m., the Director of Nursing stated Resident #3 remained on the unit, on droplet precautions. During an observation on 9/28/20 at 10:35 a.m., Staff A Certified Medication Aide (CMA) answered the resident's call light. She wore an N95 mask and flipped her shield down over her face, did hand hygiene and put on a gown and gloves. Staff A wrapped the residents legs and turned on a machine to promote circulation. The resident did not wear a mask. Staff A removed the gown and gloves before she exited the room, and did hand hygiene. She did not sanitize the shield, but flipped it up (so it was not covering her face). The facility LTC Covid-19 Phased Guidance revised 9/20 documented universal source control included if in an outbreak, residents would be asked to wear a mask when staff entered the room. The CDC document Preparing for COVID-19 in Nursing Homes, Infection Control for Nursing Homes Updated June 25, 2020 included: a. Implement a process for decontamination and reuse of PPE such as face shields and goggles. 4) During an observation on 9/28/20 at 5:01 p.m. a staff member filled out the screening log, took her own temperature, and recorded it. During an interview on 9/28/20 at 5:03 p.m. the DON stated the staff member was a CMA and they allowed staff to screen themselves. During an interview on 9/29/20 at 7:35 a.m. Staff F housekeeping stated she screened in to the household and she screened herself. During an interview on 9/29/20 at 8:15 a.m. Staff B stated she screened herself when she came to work. During an interview on 9/29/20 at 9:40 a.m. Staff C stated she screened herself in at the household. No one screened her. During an interview on 9/29/20 at 9:42 a.m. Staff D stated she screened herself in at the household. No one screened her. During an interview on 9/29/20 at 11 a.m. the DON pointed out the facility policy called for staff to self screen at the beginning and end of each shift. An untitled report documented staff who tested positive for Covid-19. The list included Staff D's onset date of symptoms 9/5/20 and included cough, shortness of breath, loss of taste/smell, sore throat and headache. Staff D's last contact in the facility 9/5/20. Staff D tested positive on 9/8/20. A Monitoring Log showed Staff D signed in on 9/5/20 at 6 a.m. She documented a temperature of 96.7 degrees, and circled no to all symptoms. The log showed no end of shift screen for Staff D. During an interview on 9/29/20 at 1:15 p.m. Staff D stated she worked Saturday 9/5/20 6 a.m. to 10 a.m. She said she had a minimal cough that Friday night before and it did not progress. She marked the screen form no for a cough because it had not progressed. She said she should have circled yes. The other symptoms developed Sunday and later. She said initially they treated for [REDACTED]. She said she probably forgot to screen out on 9/5/20. During an interview on 9/29/20 at 2:20 p.m. the Infection Preventionist stated Staff D did not report symptoms until 9/7/20, and had multiple symptoms at that time. She said Staff D had picked up a 6-10 shift 9/5/20 and documented she did not have symptoms by circling no on the screen form. She said if she had indicated a cough she would not be allowed to work. The CDC document Preparing for COVID-19 in Nursing Homes, Infection Control for Nursing Homes Updated June 25, 2020 included: a. Screening all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. 5) During an interview on 9/26/20 at 11:30 a.m. the Chief Executive Officer (CEO) stated they had residents test positive for Covid-19. They did staff testing and 6 staff members tested positive with no symptoms. He said they were already in a staffing shortage and they followed the CDC guidelines for crisis staffing. They used positive staff to care for negative residents as a last resort. They had positive staff work only on 1 unit. An untitled report documented staff who tested positive for Covid-19 included Staff G CNA, testing 9/17/20 with results 9/22/20. During an observation on 9/26/20 at 12:16 p.m. Staff G Certified Nursing Assistant (CNA) worked in a non Covid unit. Staff in the unit wore N95 masks and shields. Staff G assisted a resident from her chair to bed. Staff G wore an N95 mask and a shield. Staff G did not wear a gown or gloves. The facility Pandemic Emergency Preparedness/Infection Control Plan effective 4/13/20 documented infection control practices for healthcare personnel included PPE for standard, droplet, and contact precautions. PPE was used to prevent direct contact with the [MEDICAL CONDITION]. PPE that may be used to provide care included surgical mask, as recommended for droplet precautions, and gown and gloves as recommended for standard precautions. The CDC document Preparing for COVID-19 in Nursing Homes, Infection Control for Nursing Homes Updated June 25, 2020 included: Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility; this could also be considered when there is sustained transmission in the community.

Based on observation, record review and staff interview, the facility failed to provide adequate supervision to protect 1 of 13 resident ' s reviewed (Resident #2). The facility reported a census of 59 residents. Findings included: According to a Minimum Data Set (MDS) with an assessment reference date of 7/11/14, revealed Resident #2's mental status as severely impaired with a Brief Interview for Mental Status (BIMs) of 0. The MDS revealed Resident # 2 required set up help and supervision from staff with ambulation in his/her room and documented the resident required no assistance with toilet use. The MDS identified that Resident #2 required extensive assistance from staff for locomotion off the unit. Resident #2 ' s MDS revealed the following Diagnoses: [REDACTED]. The MDS identified Resident #2 as admitted to the facility on [DATE]. Review of a History and Physical form dated 11/25/13, a Physician documented Resident #2 as unable to remember anything, unable to see because of his/her macular degeneration and seemed as though his/her poor eyesight progressively worsened. Resident #2 listed as unable to care for himself/herself. A Restorative Care Referral form dated 11/18/13 revealed an Occupational Therapist assessed Resident #2 to require stand by assistance from 1 staff member with ambulation. Review of a physician progress notes [REDACTED].#2: History of significant Dementia, Depression, Macular Degeneration, Anxiety. The physician identified for staff to make sure and accommodate Resident #2 ' s eye sight needs. A Fall Risk Assessment completed 7/8/14, identified Resident #2 as a high risk for falls. A narrative style care plan dated 11/27/13 included a section for mobility and safety and a goal for the resident to maintain steady gait and ambulation ability. The care plan revealed staff documented the resident as able to ambulate and transfer independently within his/her room, and staff provided stand by assistance to and from a dining room and within the household. Resident #2 required the use of a wheelchair for long distances. A care plan update dated 1/8/14 identified Resident #2 as high risk for falls with a low bed. Resident #2 required stand by assist with ambulation outside of the room and used a wheelchair for long distances. Resident #2 identified as able to move independently in the room. Review of a fall notification form dated 1/29/14 at 1:10 P.M., revealed a housekeeper heard a noise and found Resident #2 sitting next to his/her bed on the floor. Staff documented Resident #2 told staff he/she slid off his/her bed and incurred no injury. The form included a corrective action for staff to ensure the resident's upper side rail be in an upright position on his/her bed to aide in repositioning. A care plan dated 7/7/14 included a section for mobility and safety and a goal for Resident #2 to maintain steady gait and ambulation ability. The care plan revealed staff documented Resident #2 as able to ambulate and transfer with stand by assist and/or contact guard assist from staff (which changed from ambulating independently in his/her room as noted in the 11/27/13 care plan). Staff documented Resident #2 ambulated slowly with small steps and gait shuffled at times. The care plan included a hand written note dated 8/9/14, for the use of a motion sensor alarm at bedtime. (Note: Even though staff initiated the use of a motion sensor alarm, record review revealed no documentation or rationale for the implementation of a motion sensor alarm on 8/9/14. Also the notation on the care plan for the sensor was crossed out). Review of the same care plan dated 7/17/14, included a form, identified by Staff C, Registered Nurse Manager, as a care plan update form. The care plan update form, with an updated date of 8/11/14, revealed staff documented Resident #2 with an unsteady gait and/or posture. Staff documented use of a noodle under the sheet to prevent rolling out of bed. Resident #2 required contact guard assist of 2 for transfers using a gait belt on the 8/11/14 updated care plan. The care plan identified Resident #2 as high risk for falls with upper and lower side rails for safety and support. Review of a fall notification form dated 9/7/14 at 12:14 a.m., revealed staff documented Resident #2 found on the floor, next to his/her bed during routine 12:00 a.m. rounds. Staff documented a motion sensor alarm in place at the time of the incident, but the form lacked any documentation in regards to the motion sensor alarm sounding. The report lacked mention of a side rail being in an upright position on Resident#2's bed. Staff documented Resident #2 as confused, complained of left knee pain, left hip pain and sustained a laceration to his/her left eyebrow. Staff documented Resident #2 as transferred to an emergency room for evaluation and treatment. The report included a safety implementation for staff to closely monitor Resident #2 through the day and night and offer the use of a restroom periodically. The fall notification form listed continued use of a motion sensor for Resident #2 ' s bed. Hospital radiology report dated 9/7/14 revealed Resident #2 with a left intertrochanteric fracture to the left hip. No pelvic fractures are identified. Review of an operative report form dated 9/8/14, revealed a Physician documented Resident #2 as admitted to a hospital on [DATE] with a left hip fracture following a fall. The Physician documented the resident underwent [REDACTED]. The Physician documented the procedure required a surgical assistant to be present as the surgery required multiple skilled hands for the surgery to be completed in an effective fashion. Review of a Discharge Summary form dated 9/11/4, revealed a Physician documented Resident #2 discharged from the hospital on [DATE]. The summary included an order for [REDACTED]. Review of a Physician order [REDACTED]. Review of a PRN Tylenol Medication Administration form revealed staff documented the resident received PRN Tylenol on 5/14/14 for complaints of back pain. Further review of the same Tylenol Administration form revealed not until approximately 2 months later did the resident received any further PRN Tylenol (following his/her return from the hospital on [DATE].). Ongoing review of the same form revealed the resident received PRN Tylenol on the following dates: 9/12/14 - no pain location documented 9/17/14 - hip pain 9/18/14 - hand pain 9/19/14 - no pain location documented 9/20/14 - no pain location documented 9/22/14 - hip pain 9/26/14 - hip pain 9/27/14 - no pain location documented 9/28/14 - hip pain 9/30/14 - no pain location documented 10/1/14 - hip pain Review of a PRN Tramadol Medication Administration form revealed staff documented the resident received PRN Tramadol on the following dates following return to the facility after his/her hip fracture: 9/11/14 - no pain location documented 9/12/14 - hip pain 9/13/14 - no pain location documented 9/14/14 - no pain location documented 9/16/14 - hip pain Observation on 11/18/14 at 7:35 a.m., revealed the following: Resident #2 sat in a recliner chair in a television bay area. The resident reclined in the chair with his/her feet up on the foot rest of the recliner chair. Observation revealed no facility staff in the area of the bay area. Under constant observation, the resident sat up in the recliner chair, while the chair remained in a reclined position with the foot rest up. Resident #2 placed his/her right foot on the floor, scooted to the end of the chair and attempted to stand. Observation revealed no facility staff in the bay area and the Surveyor needed to alert staff. Staff J arrived in the bay area from another area of the household and assisted Resident #2. Observation on 11/18/14 at 10:15 a.m. revealed Resident #2 located in a recliner in the facility television bay area. The observation revealed Resident #2 sitting in the recliner with eyes closed and no staff members visible in the immediate vicinity. During interview on 11/18/14 at 12:32 p.m. the facility Director of Nursing (DON) confirmed Resident#2's record lacked documentation in regards to Resident #2's side rails being in an upright position prior to finding Resident #2 on the floor on 9/7/14. The DON stated nurses document in the record, the resident being checked every 30 minutes while in bed, with a 1 time initial for the entire shift, but the record lacked documentation by nursing aides in regards to the actual 30 minute checks. During interview on 11/18/14 at 12:32 p.m., Staff C, Nurse Manager, stated frequent or close monitoring meant every 30 minutes 24 hours a day, (even though the care plan dated 10/2/14, lacked direction for staff to complete 30 minute checks). Staff C, Nurse Manager, stated Resident #2's motion sensor alarm was initiated due to the resident wandering in to other resident rooms. Staff C stated the intent of the motion sensor alarm was to alarm staff of Resident #2 leaving his/her room and stated the motion sensor alarm needed to be placed in front of Resident#2's room doorway (Note: record review lacked documentation in regards to Resident #2 wandering into other resident rooms. Record review lacked any documented intent of the motion sensor alarm and lacked direction for staff to place the alarm in front of Resident #2's doorway). Staff C, Nurse Manager, confirmed staff decided not to implement the use of a motion sensor alarm after the resident returned from the hospital on [DATE]. During interview on 11/19/14 at 5:27 a.m., Staff A, Certified Medication Aid (CMA) reported prior to Resident #2's hip fracture, she always ambulated Resident #2 with the use of a gait belt and described the resident needed help with ambulation. During interview on 11/19/14 at 6:35 a.m.., Staff D, Certified Nurse Aid (CNA) confirmed she worked the night of 9/7/14 at the time of Resident #2's fall. Staff D stated at the time she entered Resident #2's room on 9/7/14, she noted a motion sensor alarm in the middle of the room, with the sensor directed toward the resident's bed. Staff D stated the motion sensor alarm failed to alarm/sound. Staff D stated since Resident #2's returned to the facility following his/her hip fracture she checked on Resident #2 every two hours and described the checks as not documented. During interview on 11/19/14 at 9:25 a.m., Staff L, CMA, stated at the time she began employment in February or March of 2014, Resident #2 ambulated independently without difficulty. Staff L stated prior to Resident #2's fall and hip fracture on 9/7/14, the resident shuffled more with ambulation. Staff L stated the resident took him/herself to the bathroom in his/her room as Resident #2 could not remember to use his/her call light if needed help. During telephone interview on 11/19/14 at 12:15 p.m., Staff F, Registered Nurse (RN), confirmed she worked on 9/7/14 at the time of the resident's fall. Staff F described Resident #2's motion detector alarm as typically placed on the bedroom floor, with the sensor directed toward his/her bed. Staff F reported the motion sensor alarm's purpose was to alert staff at the times Resident #2 attempted to get up out of bed independently. Staff F stated Resident #2 tended to get up independently and routinely failed to use his/her call light. Staff F stated Staff D reported the motion sensor alarm as not sounding at the time of the resident's fall. Staff F described Resident #2 as having no wandering behaviors. Staff F, stated since Resident #2's hip fracture, staff checked on the resident every two hours during rounds and described the checks as not documented. During interview on 11/19/14 at 2:25 p.m., Staff J, Licensed Practical Nurse (LPN) reported Resident #2 exhibited no behaviors of wandering or wandering into other residents rooms. Staff J reported the purpose of Resident #2 ' s motion sensor alarm was to alert staff of the resident getting up on his/her own without assistance from staff. Review of a Care Area Assessment form, with an observation end date of 9/26/14 (following the resident's fall/fracture), staff documented the following: The resident had a fall on 9/7/14. The fall occurred due to the resident's poor balance and muscle weakness. Staff documented the resident's gait as unsteady at times. Review of a fall notification form dated 9/27/14 at 9:00 p.m., revealed staff walked in to the resident's room and found the resident on the floor, 2 feet away from his/her bed. Staff recorded no injury of the resident and included a corrective action for staff to monitor the resident every 30 minutes while in bed. A care plan dated 10/2/14 included a section for mobility and safety. The care plan documented the resident had a decline in mobility, documented his/her gait as unsteady and little weight bearing on his/her left leg. Staff documented the resident required 2 staff assistance with for all transfers and documented staff monitored the resident closely while in bed or in his/her recliner. The care plan lacked clarification for close monitoring in regards to time monitoring re; every 30 minutes while in bed or every 30 minutes around the clock. The care plan lacked an intervention for a motion sensor alarm. A fall notification form dated 10/17/14 at 5:00 p.m., revealed staff found Resident #2 on the floor next to his/her easy chair in his/her room. Staff documented the nursing staff failed to check on the resident every 30 minutes and 1 hour had gone by between checks and the time staff found Resident #2 on the floor. Staff documented Resident #2 sustained a skin tear on his/her left arm. A facility policy for Resident Safety described a Nurse leader as being responsible for following through with and establishing interventions. The policy documented the Nurse leader needed to provide proper communication and documentation of the interventions through various means such as care plans, jot sheets, Physical therapy evaluations etc. The policy documented Physical therapy needed to complete an evaluation on all residents that have increased risk for falls with an emphasis on safety and activity of daily living decline. During interview on 11/20/14 at 7:55 a.m., the DON stated she expected rationale for the use of an alarm to be documented somewhere and stated the practice of the facility included the routine check of alarms. The Surveyor asked for the documentation in regards to staff checking Resident #2's motion sensor alarm on 9/7/14 and the DON failed to produce any documentation.

Based on clinical record review, the facility education information, facility policy review and staff interviews, the facility failed to plan for and direct nursing care and services to ensure Resident #1 received adequate supervision from hazards. Resident #1 fell from a Sara Lift device and sustained a left femur fracture when the staff had not properly placed a secondary support device when the resident had been transferred. Staff reported they had not used the secondary safety device with transfers. The facility reported a census of 80 residents. Findings include: A Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a Brief Interview for Mental Status (BIMS) score of 3 out of 15 (severely cognitively impaired, dependent on 2 staff members with transfers, toilet use and personal hygiene. A Care Plan updated on 11/3/11 identified a problem with mobility and directed the staff to perform the following: a. If the the resident is uncooperative, utilize 2 staff assistance with mobility. b . Transfer the resident via a Sara Lift mechanical device; use 1 to 2 staff assistance pending the resident's mood. c. Do not leave the resident alone on the Sara lift d. Use a gait belt with the Sara Lift transfers (1/4/10). A Fall Risk Assessment form dated 10/21/10 identified the resident had a score of 8 which placed the resident at a moderate risk for falls. A Resident Incident Report Form dated 12/19/11 at 7:30 p.m., indicated Staff B, Certified Nursing Assistant, had attempted to transfer the resident from a chair to bed via a Sara Lift mechanical lift device and one assist without the use of the secondary belt support device. The staff member had been in the process of attempting to pull the resident's pants down to prepare the resident for bed but felt the lift device had been to low. The staff member raised the resident up higher in the device and witnessed one arm slip off the upper torso support. The staff member went around to the back of the of the Sara lift as a means to break the resident's fall but had been unable to do so completely. The resident had been care planned to always utilize a gait belt as a secondary belt when the resident had been transferred for safety. A Falls Management Program Fax Alert/Fax Back Orders form dated 12/19/11 indicated the resident had fallen out of a Sara Lift device, his/her left knee had been swollen and had a bruise on his/her forehead. The on call physician had been aware of the fall and the staff had been using Tylenol as needed for pain, , had applied ice to the resident's knee and would have made an appointment in the morning with the physician. The resident's blood pressure had been 84/44, pulse 54 and the blood sugar had been 269. A staff communication form dated 12/30/09, indicated a gait belt had been required when utilizing the Sara Lift mechanical device. A staff communication form dated 11/12/09, documented the resident had been a 1 person physical assist with the Sara lift transfers unless he/she had been uncooperative before the transfer then he/she would have been a 2 person physical assist. A History and Physical form from the Hegg Medical Clinic dated 12/20/11, documented the resident had a fractured left middle femur. The resident had been placed in a traction splint on the left leg and sent via ambulance to the hospital. The Physician Assistant documented the resident had not seemed to be in a lot of pain until obviously they had started to move the left leg for an x-ray and that had been when the resident's pain started which had been surprising when they looked at the x-ray. The physician documented that either the resident had not told someone she/he had been in pain and/or had been an extremely tough individual. The radiology report dated 12/20/11, documented the resident had an acute oblique or spiral fracture that involved the distal diaphysis of the femur. Offset of the fracture fragments at the fracture site had been observed with overriding of the fracture fragments evident. No subluxation or dislocation of the hip joint or of the knee joint had been observed. [DIAGNOSES REDACTED] degenerative changes involved the hip joint and knee joint. The soft tissue swelling involved the distal thigh/knee. Vascular calcification had been observed. The surgical clips were noted within the soft tissues along the medial aspect of the lower extremity. Review of the hospital transfer form dated 12/24/11, documented the resident had a left hip nailing surgery on 12/20/11. Review of the Nursing Care Notes dated 12/19/11 at 7:30 p.m., documented the nurse had entered the residents room after the Certified Nursing Assistant had attempted to transfer the resident from the wheelchair to bed when the resident fell out of the Sara lift mechanical device. The Certified Nursing Assistant had told the nurse the resident let go of the lift and started to fall so the Certified Nursing Assistant tried to ease the resident's fall. When the nurse entered the room the resident had been sitting on the floor resting his/her back/head on the Certified Nursing Assistants lap. There had been a bruise noted on the residents forehead, the resident had a small nosebleed, had been able to move his/her arms and had been answering questions appropriately. The resident's blood pressure had been 84/44, pulse 54 respirations 18 and had a oxygen saturations rate of 92%. The resident complained of left leg/knee pain and had a swollen left knee. The resident had tried to move his/her leg but had been unable to do so. The resident had been assisted to bed with three staff assistance and as needed pain medications had been given. Review of the Nursing Care Notes dated 12/19/11 at 8 p.m., documented an attempt to locate the physician. Review of the Nursing Care Notes dated 12/19/11 at 8:30 p.m., indicated the nurse attempted to contact the physician again. Review of the Nursing Care Notes dated 12/19/11 at 9 p.m., documented the physician had returned a call to the facility. The fall had been discussed along with the limited movement of the resident's left leg, swelling to the left knee, bruise/bump on the resident's forehead and the small nose bleed. The physician asked about the resident's pain level although the facility staff had been unable to rate the resident's pain, the resident had complained of pain. The physician ordered a pillow be placed under the leg, to keep the knee bent, ice placed for swelling and to make an appointment in the morning. Review of the Nursing Care Notes dated 12/20/11 at 9:20 a.m., documented the resident had been transferred to the clinic, had an x-ray with a possible femur fracture and had been transferred to the hospital for surgery. Review of the Nursing Care Notes dated 12/24/11 at 4 p.m., documented the resident had returned to the facility with a [DIAGNOSES REDACTED]. A Consultation/Office Visit/Communication form dated 3/11/11, documented the resident had an episode at noon, turned gray and would not respond. The spell had lasted approximately 30 seconds. At the time the residents blood sugar had been 279, blood pressure 106/60, pulse 56 and respirations 16 with an oxygen saturation rate of 99 % with oxygen running at 3 liters. On 1/5/12, Staff A, Registered Nurse, confirmed she remembered having the resident's care plan along with other care plans to show staff where instructions for the lift devices had been documented but could not specifically remember talking to the group about the use of the gait belt with the residents that utilized the Sara Lift transfers. On 1/5/11 at 1:25 p.m., Staff B, Certified Nursing Assistant, was interviewed and confirmed she had not used the gait belt when she had transferred the resident on 12/29/11 and had never been instructed to utilize the device by the facility. The staff member verified she had observed other staff members using the Sara Lift mechanical device without the use of the secondary assistive device (gait belt) On 1/6/12 at 12 p.m., Staff D, Certified Nursing Assistant, was interviewed and confirmed the facility had orientated her on how to use the Sara Lift device but could not recall if she had been directed to use a gait belt with all transfers. The staff member confirmed she had transferred the resident without the use of a gait belt in the past and had witnessed other staff members not use the gait belt as well. On 1/5/12 at 2:50 p.m., Staff E, Certified Nursing Assistant, was interviewed and confirmed he had been orientated to the use of mechanical lift devices but not specific to the Sara Lift device. The staff member confirmed the facility had regular mega in-services where staff members were tested on various skills which included mechanical lift devices but had never used the Sara Lift mechanical device, rather staff had been tested out with the newer mechanical lift devices. The staff member remembered having seen a gait belt on the Sara lift device at one time but that had been many months prior and he would have bet it had been when state had been at the facility for the annual survey. The staff member stated he had thought the gait belt had been deemed unsafe and confirmed he had not utilized the gait belt when he transferred the resident with the Sara Lift device. Review of the facilities Lift Policy, documented that the facility Heights would provide a safe work environment for resident care areas by providing and requiring the use of safety materials, equipment and training designed to prevent personnel and resident injury. The facility did not ensure all staff were properly trained with the use of safety devices when utilizing the Sara Lift mechanical device. Multiple staff reported they had not utilized the secondary belt support device when the resident had been transferred. 2. An MDS assessment with a reference date of 11/25/11, documented Resident #3 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a BIMS score of 4 out of 15 (severely cognitively impaired) and required extensive assistance of 2 staff members with transfers and extensive assistance of one staff member with toilet use and personal hygiene. The Care Plan dated 12/22/11, documented the following entries: a. Transfer the resident via a Sara Lift device. b. Ambulate the resident with a front wheeled walker and 1 staff assistance. An observation on 1/5/12 at 1:15 p.m., revealed Staff C, Certified Nursing Assistant, transfer the resident with an EZ Way Smart Stand mechanical lift device from the wheelchair to the the toilet without utilizing the safety device for the resident's lower extremities.