Every finding on record at Knute Nelson Care Center

Based on interview and record review the facility failed to ensure the resident bill of rights ([NAME]) were provided verbally and in writing for all the facility residents, this had the potential to affect all 63 residents in the facility. Findings Include:On 5/12/26 at 10:33 a.m., Resident Council Minutes Forms were reviewed for 2/24/26, 3/26/26, and 4/16/26. The minutes lacked documentation that the [NAME] were reviewed. On 5/12/26, at 11:15 a.m., seven residents (R61, R62, R35, R24, R21, R17, R18) were present at a resident council meeting held by surveyor. When questioned if the resident ([NAME]) had been reviewed, the residents present stated the rights had not been reviewed. R61 stated she thought [NAME] was given at time of admission, and they were posted in the facility. R62 indicated had been admitted years ago and was not coherent at that time. The residents indicated they would like them to be reviewed. At 11:45 a.m. the [NAME] poster near the nurses' station was reviewed and was dated 9/19, not the current [NAME] from 12/25. During interview on 5/12/26 at 11:51 a.m., administrator stated that life enrichment supervisor (LES)-A was responsible for the resident council meetings. Administrator verified that the [NAME] were not reviewed during resident council meetings and was aware the [NAME] poster was not current. Administrator indicated it was important for residents to understand their [NAME], to provide them with a great experience and due diligence regarding what they could ask for and what they were to be provided. The facility policy titled Resident And Family Council modified 5/12/26, identified the facility would designate a staff liaison to assist when requested, provide meeting space and ensure residents were informed of meeting opportunities and encourage participation. The facility would provide written responses to council concerns and leadership would review and respond to council concerns within a reasonable timeframe. The policy lacked inclusion of [NAME] review in its agenda.

Based on observation, record review, and interviews, the facility failed to ensure all required information was included daily on the facility staff posting. This had the potential to affect all 63 residents in the facility and their visitors who may wish to view the information.Findings include:The staff schedule and facility staff posting documentation dated 4/13/26-5/13/26, was reviewed and failed to include all of the following requirements for the daily staff posting: 1) Facility Name 2) Current Date 3) Facility Census (clearly identifiable) 4) Total number of actual hours worked by licensed staff. 5) Total number licensed staff, and their designation or title.From 4/13/26-5/12/26, the facility staff posting contained: the date, the total number of licensed staff and their designation. However it lacked the total number of actual hours worked by licensed staff, the name of the facility, and the census number (clearly identified as such). On 5/13/26 at 9:00 a.m., the senior manager of scheduling operations stated they were responsible for updating and posting the daily facility staffing information Monday through Thursdays in the evening and then would post the whole weekend on Friday night. The nurses working the weekend would be responsible for updating any changes over the weekend. The senior scheduling manager stated they were unsure of the exact requirements to be included in the posting.On 5/13/26 at 11:24 a.m., the registered nurse (RN)-A on duty confirmed they worked weekends, and if they had a change in staffing, they would email the DON, scheduling team and update their internal daily sheets on the units but was unaware of their responsibility to update the daily facility posting information. On 5/13/26 at 11:24 a.m., the director of nursing (DON )stated they were unsure if the information was being updated on the weekends because they are not sure if it is always being done. The DON confirmed it was the charge nurse's responsibility on the weekends to complete any changes.On 5/13/26 at 11:34 a.m., The administrator confirmed the scheduling team was responsible for updating and posting the daily staffing information. The administrator stated the posting needed to include the census and how many nurses and nursing assistants were in the building every day. The administrator stated they expected it to include all required information and be posted daily. Furthermore, the administration stated the importance of posting all information accurately so the residents and visitors to the facility could understand the staff structure, how many nurses there are in the building, and to ensure they knew the staffing levels were adequate.The facility sufficient staffing policy last modified 4/15/26, indicated the direct daily care staffing information will be posted in accordance with CMS requirements and maintained for the required retention period.

Based on observation, interview, and document review, the facility failed to ensure food and beverages stored in the refrigerators, were labeled, dated and discarded properly. Further, the facility failed to maintain proper holding food temperatures during the noon meal on the Pines unit. This deficient practice had the potential to affect 59 residents who received food and beverages from the refrigerators. Findings include: On 3/3/25 at 11:05 p.m., during the kitchen tour with the dietary manager(DM), the following concerns were identified: Kitchen refrigerator: -half of a large container of orange sauce with a black crusty substance around the lid with an open date of 1/6/25. -half of a large container of barbeque sauce with a crusty black substance around the lid without a notation of an open date and an expiration date of 1/6/25. - one chicken salad sandwich without notation of a date. - three bowls of pureed bread without notation of a date. -bottle of staff pop without notation of a date. Freezer: -six pork sausages in a bag without notation of an opening date. Food temps: During an observation on 3/3/25 at 11:25 a.m., DM removed one of approximately 30 bowls of potato salad from the refrigerator and temped the one bowl of potato salad in the main dining room prior to meal service. Temperature of the potato salad was 39 degrees F (Fahrenheit). The remaining bowls of potato salad were placed on a cart without any ice and delivered to the Pines unit to be served at the noon meal. During an observation on 3/3/25 at 12:25 p.m., there were approximately 20 small bowls of potato salad present on the counter without any ice in the Pines dining room During an observation on 3/3/25 at 12:30 p.m., after meal service had began and approximately eight residents had been served the potato salad in the Pines dining room, dietary aide (DA)-A temped one of the remaining small bowls of potato salad. The temperature of the potato salad was 51 degrees F. DA-A continued serving the potato salad. During an interview on 3/3/25 at 12:45 p.m., DA-A stated all cold food should have been served at 41 degrees F. or lower. DA-A stated she should have put the potato salad on ice while serving to ensure the temperature remained in a safe zone to prevent food borne illness. During an interview on 3/3/25 at 1:00 p.m., DM verified the above findings during the kitchen tour. DM stated his expectation was that all opened food should have been dated and thrown away after the shelf life or the expiration date. DM further stated his expectation was all cold food should have been held at 41 degrees F or lower to prevent food borne illness. Review of a facility policy titled Food Labeling revised 1/25, identified all foods should have been labeled with contents, preparation date and any specific instructions. Review of a facility policy titled Food Temperature Policy revised 1/25, identified all cold food items must be served to the resident at a temperature of at least 40 degrees Fahrenheit or below at the time the resident receives the food.

Based on interview and document review, the facility failed to notify the Long Term Care (LTC) ombudsman of a facility initiated transfer for 1 of 1 residents (R64) who was transferred to an acute care facility on an emergency basis reviewed for hospitalization. Findings include: R64's admission Minimum Data Set (MDS) dated [DATE], indicated R64 had severe cognitive impairment and had diagnoses which included right femur (long bone in the leg) fracture, cancer, and hypertension (elevated blood pressure). Identified R64 required staff assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Review of R64's progress notes dated 12/3/24, revealed the following: -on 12/3/24 at 5:35 p.m., R64 was seated in the dining room in his wheelchair eating supper. R64 stood up from the wheelchair and as R64 went to sit back down the wheelchair rolled away and R64 landed on the floor and a loud crack was heard. R64 was unable to move his right leg and had shortening of the right leg The medical doctor (MD) and R64's family were immediately notified and R64 was sent to the emergency room for a possible right hip fracture. -on 12/3/25 at 9:19 p.m., R 64 was admitted to the hospital for a closed right hip fracture. R64's medical record lacked documentation the notice of the hospital transfer was sent to the long-term care ( LTC) Ombudsman. During an interview on 3/5/25 at 9:50 a.m., administrator verified the LTC ombudsman had not been notified of R64's emergency hospital transfer. Administrator further stated he was unaware the LTC Ombudsman was to be notified when a resident transferred to the hospital. Review of a facility policy titled Transfer or Discharge Facility-Initiated dated 2001, identified when residents were sent to an acute care setting it was considered a facility- initiated transfer. Further identified a notice of transfer would have been provided to resident and resident representative and to the LTC ombudsman. -

Based on observation, interview and document review, the facility failed to ensure timely assistance with repositioning occurred for 1 of 5 residents (R2) with a current pressure ulcer and at risk for further development of pressure ulcers. Findings include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment and diagnoses which included diabetes mellitus (DM), hypertension (elevated blood pressure) and dementia. Identified R2 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified R2 had two pressure ulcers and was on a repositioning program. R2's annual Care Area Assessment (CAA) dated 10/22/24, identified R2 was a at risk for skin breakdown and had a pressure ulcer to her left heel. Identified R2 required extensive assistance to reposition in bed and in the wheelchair. R2's care plan dated 4/25/24, identified R2 had a pressure ulcer on her left heel. Care plan directed staff to reposition or assist to stand R2 every two hours while awake. R2's weekly wound assessment dated [DATE], identified R2 had a pressure ulcer to her left heel which measured 8 centimeters (cm) in length 5.7 cm in width and had a depth of 0.2 c.m. Identified pressure ulcer was a stage 4 ( a pressure ulcer where the wound extends through all layers of skin, damaging underlying muscle, tendon, and potentially bone, often with visible exposed tissue) and R2 required frequent repositioning. R 2's current physician orders signed 2/22/25, identified left heel: stage 4 pressure ulcer - cleanse area, apply crushed Flagyl 250 mg tablet and place on wound bed to help with odor control with each dressing change, apply skin prep, Hydrofera Blue, ABD, and kerlix 3 x/week and prn. one time a day every Tues, Thur, Sun for wound care and as needed. R2's nursing assistant task sheet undated, directed staff to reposition or assist R2 to stand every two hours while awake. During a continuous observation on 3/4/25 from 9:20 a.m. to 12:30 p.m., the following was revealed: -9:20 a.m., R2 was seated in her wheelchair at the nurses station. -9:28 a.m., activity aide (AA)-A wheeled R2 to the activity room. -10:19 a.m., R2 remained seated in her wheelchair in the activity room. -10:44 a.m., R2 remained seated in her wheelchair in the activity room. -11:06 a.m. AA-A wheeled R2 to her room. -11:24 a.m., R2 wheeled self into the hallway and AA-A wheeled R2 to the front desk. -11:32 a.m., AA-A wheeled R2 into the dining room. -11:36 a.m. R2 remained seated in her wheelchair in the dining room waiting for lunch to be served. -12:04 a.m., R2 remained seated in her wheelchair in the dining room eating lunch. -12:25 p.m., R2 remained seated in her wheelchair in the dining room finishing eating her lunch. -at 12:30 p.m., R2 had remained seated in her wheelchair in the dining room and surveyor requested nursing assistant (NA)-A to reposition R2 after R2 remained seated in her wheelchair and not repositioned for over three hours. During an observation on 3/4/25 at 1238 p.m., NA-A wheeled R2 back to her room. NA-A and RN clinical manager (CM)-A sanitized hands, put a gown and gloves on and hooked R2 up to the mechanical lift and placed R2 onto the bed, changed R2's incontinent product and repositioned R2. During an interview on 3/4/25 at 12:47 p.m.,NA-A stated R2 required staff assistance to reposition and the last time R2 had been repositioned was some time around 9:30 a.m. when NA-A assisted R2 to transfer into her wheelchair after her bath. NA-A stated R2 had a pressure ulcer on her left heel and was at risk for further pressure ulcer development and should have been repositioned every two hrs while in her chair. During an interview on 3/4/25 at 12:52 p.m., CM-A verified R2 had a pressure ulcer on her left heel and recently had one on her buttocks that had healed. CM stated R2 required staff assistance to reposition. CM-A stated R2 was at continued risk of developing further skin breakdown and should have been repositioned every two hours during the day. CM-A stated her expectation was that R2's care plan would have been followed to help prevent any further skin breakdown. During an interview on 3/4/25 at 2:49 p.m., director of nursing (DON) verified R2 required staff assistance to reposition. DON stated R2 had a pressure ulcer on her left heel and was at risk for further skin breakdown. DON stated her expectation was that R2's care plan for repositioning would have been followed. Review of a facility policy titled Repositioning revised 1/25 identified, staff were to check the care plan or the assignment sheet to determine resident specific positioning needs and number of staff required to complete the procedure.

Based on observation, interview and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 4 of 4 residents (R 21, R29, R48 and R52) who resided on the Pines unit reviewed for food. This deficient practice had the potential to affect all 42 residents residing on this unit. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition ad was able to feed herself after staff set up her tray. R29's quarterly MDS dated [DATE], indicated R29 had intact cognition and could feed himself after staff set up his tray. R48's admission MDS dated [DATE], indicated R48 had impaired cognition and required staff supervision to eat. R52's significant change MDS dated [DATE], indicated R52 had intact cognition ad could feed herself after staff set up her tray. During an interview on 5/20/24 at 1:05 p.m., R52 stated the food was often cold. During an interview on 5/20/24 at 1:25 p.m., R29 stated the food did not taste very good and the hot items were usually served cold. During an observation on 5/20/24 at 4:45 p.m., a cart containing plates of food were wheeled to the kitchen. The cart had a cord however, was not plugged in. The plates were removed from the cart and staff brought them to the tables to be served to the residents in the dining room. At 5:25 p.m., as the last plates were being passed from the cart, a test tray was requested from DA-A. The meal consisted of individual cheese pizzas, mashed potatoes, pureed pizza and pureed carrots. The tray was tested for temperatures and results were as follows: -cheese pizza was 88 degrees Fahrenheit (F). -mashed potatoes were 125 degrees Fahrenheit (F). -pureed pizza was 116 degrees Fahrenheit (F). -pureed carrots were 114 degrees Fahrenheit (F). Surveyor tasted the food from the tray: the pizza was cold, the mashed potatoes, pureed pizza and carrots were luke warm. Dietary aide (DA-A) confirmed the pizza was cold and the remaining items were barely warm. During an interview on 5/20/24 at 5:30 p.m., R52 stated the pizza was cold tonight however, he was hungry so he ate it. During an observation and interview on 5/20/24 at 5:32 p.m., R48 was sitting with her plate in front of her and she had only eaten 1/4 of her pizza and stated her food was cold. On 5/20/24 at 5:34 p.m., as R21 left the dining room she stated to the surveyor that the pizza was cold tonight. During an interview on 5/20/24 at 5:33 p.m., DA-A stated the usual process was to plate the food in the main dining room and serve the food from the warming cart. DA-A confirmed the warming cart had not been plugged in during the meal service as it was easier to move around when it was not plugged in. DA-A stated she was unsure of what the holding temps of food should have been at. During an interview on 5/21/24 at 10:37 a.m., dietary manager (DM) stated the normal process for serving the supper meal was to plate the food in the main dining room, place the food in the warming cart and serve to the long term care unit from the warming cart. DM stated his expectation was that the warming cart would have been plugged in and the holding temperature of the food would have remained at or above 140 degrees Fahrenheit (F). Review of a facility policy titled Food Temperature Policy revised 3/5/20, indicated all hot food items must be served to the resident at a temperature if at least 140 degrees Fahrenheit at the time the resident received the food.

Based on interview and document review, the facility failed to ensure 4 of 5 residents (R6, R36, R41 and R44) received pneumococcal vaccinations based on shared clinical decision-making in accordance with the Center for Disease Control (CDC) recommendations reviewed for immunizations. Findings include: Review of the current CDC recommendations 3/15/2023, revealed The CDC identified Adults [AGE] years of age or older received the (PPSV23) or (PCV13) at any age and who have not received the Pneumo 20-valent conjugate Vaccine (PCV20) should receive a dose of the PCV20 at least one year after the most recent PPSV23 or PCV13 vaccine. In addition, the CDC identified adults 65 and older who had previously received both PCV13 and PPSV23 at age 65 and older, based on shared clinical decision-making with the patient and the provider one dose of PCV20 at least five years after the last pneumococcal vaccine dose. Review of R6's facesheet identified R6, age 84 was admitted to the facility on [DATE]. Review of R6's Minnesota Immunization Information Connection (MIIC) undated, identified R6 received the PPSV23 on 10/16/1996 and 6/7/2006, and received the PCV13 on 10/16/96 and 5/20/2016. R6's medical record lacked documentation R6 had been offered or received the PCV20 based on shared clinical decision-making. Review of R36's facesheet identified R36, age 76 was admitted to the facility on [DATE]. Review of R36's MIIC record undated, identified R36 received the PPSV23 on 5/23/2014, and the PCV13 on 12/8/2015. R36's medical record lacked documentation R36 had been offered or received the PCV20 based on shared clinical decision-making. Review of R41's facesheet identified R41, age 89 was admitted to the facility on [DATE]. Review of R41's MIIC record undated, identified R41 received the PPSV23 on 11/1/2000, and the PCV13 on 1/25/2015. R41's medical record lacked documentation R41 had been offered or received the PCV20 based on shared clinical decision- making. Review of R44's facesheet identified R44, age 89 was admitted to the facility on [DATE]. Review of R 44's MIIC record undated identified R44 received the PPSV23 on 1/4/2009, and the PCV13 on 1/16/2015. R 44's medical record lacked documentation R44 had been offered or received the PCV20 based on shared clinical decision-making. During an interview on 5/21/24 at 3:15 p.m., director of nursing (DON) verified she was also the infection preventionist (IP). DON confirmed R6, R36, R41, and R44 had not received the pneumococcal vaccinations as recommended by the CDC. DON stated her expectation would have been that all residents had been offered or received all pneumococcal vaccines per CDC recommendations. Review of a facility policy titled Pneumococcal Vaccine dated 2001, identified all residents were to be offered the pneumococcal vaccine to aid in preventing pneumonia/pneumococcal infections. Identified residents were assessed of eligibility to receive the Pneumovax within five working days of the admission to the facility. Further identified administration of the pneumonia vaccine was made in accordance with the Center For Disease Control (CDC) recommendations.

Based on observation, interview and document review, the facility failed to comprehensively assess the use of a restrictive device as a potential restraint for 1 of 1 resident (R6) reviewed for restraints. Findings include: Review of R6's annual Minimum Data Set, dated dated dated [DATE], identified R6 had severe cognitive impairment and had diagnoses which included Parkinson's, Diabetes Mellitus, and anxiety disorder. Indicated R6 required extensive assistance for activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified R6 had one fall with no injury since the last assessment, three months prior and required a wheelchair for mobility. Indicated R6 did not use any restraints. Review of R6's annual Care Area Assessment (CAA) dated 3/6/24, identified R6 had severe cognitive impairment, was a high fall risk and had one fall with no injury since last assessment. CAA identified R6 did not use any restraints. Review of R6's quarterly fall assessment dated [DATE], identified R6 was at risk for falls related to Parkinsons and repeated falls. Fall assessment identified R6 did not require the use of a Velcro release belt. Review of R6's current physician orders signed 4/5/24, did not identify an order for a restraint. R6's medical record lacked any evidence a restraint assessment had been completed. Review of R6's care plan revised 7/13/23, identified R6 had a self care deficit related to cognitive impairment, weakness and falls. Care plan identified R6 was given a new non-restraint belt for her wheelchair, with this belt R6 was allowed to be in her room in her wheelchair. Indicated the belt in the wheelchair should prevent falls and allow for what family requested on behalf of the resident. During an observation on 5/20/24 at 6:45 p.m., R6 was seated in her wheelchair in the day room with a Velcro belt around her waist that contained two straps that were fastened behind R6's wheelchair. R6 had the Velcro belt in her hand and was squeezing the belt with her hand while the belt remained fastened. R6 was attempting to lean forward in her chair however, was having difficulty and was only able to partially lean forward in her chair. During an observation on 5/21/24 at 8:05 a.m., R6 was seated in her wheelchair in the dining room with a Velcro belt around her waist with the straps fastened behind her wheelchair. During an observation on 5/21/24 at 9:50 a.m.,R6 was seated in her wheelchair in the activity room and continued to have the Velcro belt placed around her waist with the straps fastened behind her wheelchair. During an observation on on 5/21/24 at 12:35 p.m., R6 was seated in her wheelchair in the day room. Velcro belt continued to be placed around R6 waist with the straps fastened behind her wheelchair. R6 had the Velcro belt in her hand and was attempting to twist her upper body while attempting to lean forward in her chair however, was having difficulty leaning forward. During an interview on 5/21/24 at 12:46 p.m., nursing assistant (NA)-A stated R6 was cognitively impaired and required staff assistance with her ADL's. NA-A indicated R6 required the Velcro belt across her waist to prevent falls. NA-A stated he had never seen R6 remove the Velcro belt on her own and did not believe she would be able to related to her impaired cognition. During an observation on 5/21/24 at 12:52 p.m., licensed practical nurse (LPN)-A brought R6 to her room and asked R6 to remove the Velcro belt from around her waist. After several minutes of attempting, R6 was unable to remove the belt from around her waist. During an interview on 5/21/24 at 12:58 p.m., LPN-A verified R6 was unable to remove the Velcro belt from around her waist. LPN-A stated she had seen R6 remove the Velcro belt from her waist in the past however, was unsure of the last time R6 was able to remove the Velcro belt from around her waist. During an interview on 5/21/24 at 1:14 p.m., registered nurse (RN)-A stated R6 had severe cognitive impairment and a history of falls. RN-A stated the Velcro belt was placed per family request to keep R6 in her chair because R6 would lean too far forward and fall out of her wheelchair. RN-A stated she did not believe the Velcro belt was a restraint as R6 had previously been able to remove the Velcro belt. RN-A indicated she was unsure if R6 could still remove the Velcro belt. RN-A stated she was unsure if a restraint assessment had been completed. RN-A indicated the only interventions attempted prior to the use of the belt that she was aware of was an alarm in R6's doorway and hourly checks on R6. During an interview on 5/21/24 at 3:39 p.m., director of nursing (DON) confirmed R6's care plan revealed a Velcro belt had been applied to R6's wheelchair. DON stated the Velcro was placed in R6's wheelchair as a reminder for when R6 leaned forward to help her stay positioned and was not meant to be a restraint. DON stated R6 had been able to remove the Velcro belt in the past however, may not have been able to remove upon command. DON verified a restraint assessment had not been completed prior to the placement of the Velcro belt and the use of the Velcro belt had not been reassessed to determine if R6 was able to remove the Velcro belt. DON stated her expectation was that the proper assessments would have been completed. During an interview on 5/21/24 at 4:10 p.m., family member (FM)-A stated R6 had a history of attempting to get out of her wheelchair and falling. FM-A stated the facility came up with the Velcro belt as an intervention about 10 months ago so R6 would not fall. FM-A stated she came to visit often and had never seen R6 remove the Velcro belt. FM-A stated she realized the Velcro belt may have been a restraint since it prevented R6 from sliding to the floor when she leaned too far forward however, she continued to want R6 to utilize the Velcro belt to prevent falls. Review of a facility policy titled identifying involuntary seclusion and unauthorized restraint revised 9/22, identified residents would be free from the use of any physical restraints not required to treat their medical condition. Identified a physical restraint was defined as any manual method, physical, mechanical device, equipment or material that met all of the following criteria: was attached or adjacent to a residents body, could not be easily removed by the resident (in the same manner it was applied by the staff) and restricted the residents freedom of movement or access to his or her body. Inappropriate or unauthorized use of a restraint occurred when it unnecessarily inhibited a residents freedom of movement or activity, was not the least restrictive option or used for the least amount of time, or was not accompanied by ongoing re-evaluation of the need for the restraint. Further identified examples of physical restraints were using devices in conjunction with a chair, such as trays, tables, cushions, bars, or belts, that the resident could not remove and prevented the resident from rising.

Based on observation, interview and document review, the facility failed to ensure physician orders were implemented to prevent potential fluid retention for 1 of 1 resident reviewed for quality of care. Findings include: R33's quarterly Minimum Data Set (MDS) dated [DATE], identified R33 was cognitively intact. Diagnoses included atrial fibrillation and hypertension. Review of Nurse practitioner (NP) signed orders from 4/1/24, revealed an active order for Torsemide (loop diuretic to treat fluid retention and high blood pressure) oral tablet 20 milligrams (mg). Order to give 20 mg one tablet by mouth PRN (as needed) for weight gain > three pounds (lbs) overnight or > five lbs in seven days every day as needed. Order date 3/6/24, start date 3/6/24. Review of the electronic medication administration record (EMAR) dated 3/6/24, the Torsemide order was added to the EMAR. Order read: Torsemide oral tablet 20 mg give one tablet by mouth as needed for weight gain >three lbs overnight or > five lbs in seven days every day as needed. In addition, another order dated 3/7/24, identified an order for daily weights was added to the EMAR. The order stated: daily weights (see prn Torsemide order) update provider with an increase of > three lbs overnight or > five lbs in one week, in the mornings for MD order. Review of the pharmacist's recommendation from Guardian Pharmacy on 4/11/24, the pharmacist gave recommendations to nursing to: Please ensure daily weights were obtained due to parameters for PRN Torsemide. It was recommended weights were obtained right away in the morning before breakfast or liquid intake to help maintain consistency. Review of R33's EMAR from March 2024 through May 2024, revealed the following: -March 2024 EMAR, there were no weights for these dates on the March MAR: March 9, 10, 11, 13, 14, 15, 16, 18, 19, 22, 23, 24, 25, 27, 28, 31. -April 2024 EMAR, there were no weights listed for April 1, 2, 3, 5, 6, 8, 9, 14, 15, 18, 19, 20, 24. -May 2024 EMAR, there were no weights listed for May 3, 4,5,8,9,12,13,14,18,19. Review of R33's weight and vital summary from 3/7/24 to 5/19/24, revealed the following: -March 2024, no weights were entered on the following days: March, 9, 10, 13, 14, 15, 16, 18, 19, 22, 23, 24, 25, 27, 28. -April 2024, no weights were entered for April 5, 6, 8, 9, 14, 15, 18, 19, 24. -May 2024, no weights entered for May 3, 4, 5, 8, 9, 10, 12, 13, 14, 18, 19. Review of R33's progress notes from 3/7/24 through 5/20/24, lacked documentation R33 refused to be weighed. In addition, the progress notes lacked documentation the NP had been updated about the missing weights. During an interview on 5/22/24 at 10:29 a.m., nursing assistant (NA)-B stated R33 was to have a daily weight. R33 had not refused a weight for NA-B. NA-B indicated the facility had a process for daily weights that included a daily weight sheet at the nurse's station for staff to refer to. NA-B stated the weights were recorded on the sheet and then nursing assistants would document the weight in the vital section of EMAR. In addition, NA-B indicated the nurses documented the weight in the EMAR. During an interview on 5/21/24 at 4:00 p.m., NA-C stated her process for ensuring daily weights were completed was to write them down on the daily weight sheet and then enter them into the vital section of the EMAR. During an interview on 5/21/24 at 4:11 p.m., licensed practical nurse (LPN)-A stated obtaining daily weights was everyone's responsibility. LPN-A indicated daily weights should have been obtained before breakfast as most residents on daily weights had parameters for medications. During an interview on 5/21/24 at 5:07 p.m., registered nurse (RN)-A stated R33 was on a diuretic due to excess fluid build-up. RN-A indicated the process for daily weights was the nursing assistants obtained the weights and licensed nurses followed-up. RN-A stated the NA's charted the weights in EMAR. RN-A indicated if R33 had refused a weight, there would have been a note in the EMAR identifying that. RN-A stated nursing staff were responsible for updating the doctor when or if R33 refused to obtain a weight. RN-A indicated daily weights were important to ensure R33 received the proper dose of Torsemide to prevent excess fluid build-up. During an interview on 5/22/2024 at 11:42 a.m., RN-B stated R33 had an order to be weighed daily. RN-B indicated weights were written on the daily weight sheet at the nurse's station desk and then were recorded into the EMAR. RN-B stated the goal was to obtain the weight before the end of the shift. If staff did not obtain the weight on the day shift, the evening shift would attempt to obtain the weight. RN-B indicated it was important for staff to obtain a daily weight on R33 since the administration of the Torsemide depended on the daily weights. During an interview on 5/22/2024 at 11:49 a.m., LPN-B stated R33 received Torsemide to prevent fluid build-up. LPN-B indicated daily weights were charted in the vital section in the EMR. If the day shift did not obtain the daily weight, the evening shift staff were expected to obtain the weight. LPN-B stated staff had missed obtaining R33's weights on a daily basis the past few months. LPN-B indicated daily weights were important as the Torsemide administration was dependent on the daily weights. LPN-B stated if R33 gained more than five lbs staff were expected notify the doctor. During an interview on 5/22/2024 at 11:59 a.m., the nurse practitioner (NP) stated the facility had not informed NP about the daily weights not being completed as ordered. NP indicated the lack of daily weights and not receiving Torsemide as needed could contribute to health issues. NP stated R33's recent health issues were related to pneumonia and infection. NP's expectation would be the facility would obtain the weights as ordered and administer the medications as ordered. During an interview on 5/22/24 at 12:30 p.m., the pharmacist indicated the expectation would be to follow the provider's order. Pharmacist stated providers should have been contacted if weights were not being obtained as ordered and medications not being administered as ordered. During an interview on 5/22/24 at 12:50 p.m., the director of nursing (DON) confirmed R33 had an order for a daily weight and for Torsemide based on the weight. DON stated the daily weight was obtained by a mechanical lift unless R33 refused. DON indicated if there had been refusals, they should have been documented in the EMAR. DON stated it was important to follow the physician's orders and indicated staff were expected to follow the physician's orders. A policy regarding vitals and weights was requested however one was not provided.

Based on observation, interview and document review, the facility failed to ensure timely assistance with repositioning occurred for 1 of 5 residents (R6) with a history of pressure ulcers and at risk for further development of pressure ulcers. Findings include: Review of R6's annual Minimum Data Set (MDS) dated [DATE], identified R6 had severe cognitive impairment and diagnoses which included Parkinson's, Diabetes Mellitus, and anxiety disorder. Indicated R6 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified R6 had a turning and repositioning program, was at risk for pressure ulcers and had a scar over a bony prominence from a previous pressure ulcer. R6's annual Care Area Assessment (CAA) dated 3/6/24, identified R6 was at risk for skin breakdown related to diagnosis of Parkinson's, anxiety, and diabetes mellitus (DM). Identified R6 required extensive assistance with ADL's. R6's care plan dated 8/6/2019, identified R6 was at risk for skin breakdown related to medical diagnosis and history of pressure ulcers. Care plan directed staff to reposition R6 every two hours. R6's nursing assistant task sheet undated, directed staff to reposition R6 every two hours. During a continuous observation on 5/21/24 from 9:50 a.m., to 12:50 p.m., the following was revealed: - at 9:50 a.m., R6 was seated in her wheelchair in the activity room - at 10:30 a.m., R6 continued to be seated in her wheelchair in the activity room. - at 10:49 a.m., activity aide (AA)-A wheeled R6 back to the unit and placed R6 in the day room. -at 11:30 a.m., R6 continued to be seated in her wheelchair in the dayroom. -at 12:00 p.m. registered nurse (RN)-A wheeled R6 to the dining room for lunch. -at 12:25 p.m., R6 remained in the dining room eating lunch. -at 12:35 p.m., licensed practical nurse (LPN)-A wheeled res back to the day room and R6 remained seated in her wheelchair as several staff walked by R6. -at 12:50 p.m., R6 remained seated in her wheelchair in the day room and surveyor requested LPN -A to reposition R6 after R6 had remained seated in her wheelchair and had not been repositioned for at least three hours. During an observation on 5/21/24 at 12:52 p.m. LPN-A wheeled R6 back to her room and R6 stated she needed to poo. LPN hooked R6 up to the pal and placed R6 on the toilet. Once R6 was done using the bathroom, LPN-A applied gloves and assisted R6 to wipe. LPN-then sanitized hands and assisted R6 off the toilet using the pal lift. During an interview on 5/21/24 at 1:00 p.m., nursing assistant (NA)-A stated R6 was at risk for skin breakdown and required extensive assist to reposition. NA-A indicated he was unsure the last time R6 had been repositioned however, according to the care plan, R6 should have been repositioned at least every two hours. During an interview on 5/21/24 at 1:05 p.m., LPN-A confirmed the last time R6 had been repositioned was at 7:30 a.m. LPN-A confirmed R6 required extensive assistance to reposition. LPN-A stated R6 was at risk for skin breakdown and should have been repositioned every two hours. During an interview on 5/21/24 at 1:14 p.m., RN-A confirmed R6 required extensive assistance to reposition. RN-A stated R6 had a history of pressure ulcers on her buttocks which would have placed her at risk for acquiring a pressure ulcer. R6 stated her expectation was R6 would have been repositioned every two hours. During an interview on 5/21/24 at 3:29 p.m., director of nursing (DON) stated R6 was able to slightly offload on her own however required staff assistance to fully reposition. DON stated R6 was at risk for pressure ulcers and her expectation was that R6's care plan for repositioning would have been followed. Review of a facility policy titled Repositioning in Bed and Chair; Applying Lift Sheets Policy revised 2/24, directed staff to check the resident's care plan or Kardex to identify the resident's specific repositioning needs and encourage the resident to change position or shift weight as often as possible.

Based on observation, interview and document review, the facility failed to comprehensively assess smoking safety for 1 of 1 residents (R38) who currently smoked. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], indicated R38 was moderately cognitively impaired and had diagnoses which included tracheostomy (also known as a tracheotomy, was a small surgical opening that was made through the front of the neck into the windpipe, or trachea. A curved plastic tube, known as a tracheostomy tube, was placed through the hole allowing air to flow in and out of the windpipe) anxiety, depression, history of falling, weakness, hypertension (high blood pressure) and history of alcohol dependence. Identified R38 was independent with transfers, toileting, bed mobility, locomotion with use of cane, dressing and personal hygiene. The MDS did not identify R38 as a smoker. R38's care plan prior to 5/21/24, lacked documentation R38 was a cigarette smoker. On 5/21/24, R38's care plan was then updated and identified R38 was a cigarette smoker. He was alert and oriented, able to light and extinguish his cigarettes safely. He was educated and understood he needs to go off-property to smoke. Education provided regarding programs to help with cessation and smoking safety. An initial smoking assessment dated [DATE], identified R38 was not a smoker. R38's electronic health record (EHR) lacked any additional smoking assessments prior to 5/21/24. During an interview on 5/21/24 at 2:39 p.m., R38 stated he was a cigarette smoker prior to admission. R38 indicated he began to smoke cigarettes again shortly after admission when he regained strength. R38 indicated he usually smoked four times a day however, had not gone outside that week due to the weather. R38 stated he exited the building through different doors and stood in the grass. R38 verified there was not a designated smoking area off the facility property and that there was no place to sit or extinguish his cigarette. R38 confirmed he managed his cigarettes and lighter himself, kept them in his room, extinguished his cigarettes with his fingers and then threw the butts in the garbage can in his room. During an interview on 5/21/24 at 3:01 p.m., licensed practical nurse (LPN)-C confirmed R38 was a smoker and he would usually go outside after each meal to smoke. LPN-C stated R38 should have been assessed for smoking safety and supervised while smoking due to a history of falls and weakness. LPN-C verified R38's electronic heath record (EHR) lacked a smoking assessment and the care plan lacked interventions prior to when the care plan was updated on 5/21/24. During an interview on 5/21/24 at 3:06 p.m., clinical manager (CA)-A confirmed R38 was a smoker. CA-A confirmed R38's EHR lacked a smoking assessment or a care plan with interventions for smoking prior to when the care plan was updated o 5/21/24. CA-A stated the facility was a non-smoking facility and R38 would have to go off-property to smoke. CA-A verified the facility lacked a designated smoking area. CA-A was unaware R38 used his cane to prop open the facility door when going outside to smoke or that he brought his extinguished cigarette butts inside and threw them in his garbage can. CA-A verified R38 should not have been disposing his cigarette butts in the garbage can due to a fire risk. During an observation/interview on 5/22/24 at 8:04 a.m., R38 walked out a back door of the facility and utilized his cane to prop the door open and prevent the door from locking behind him. R38 indicated he would walk across the parking lot over the curb without his cane and stand in the grass off the facility property. During an observation on 5/22/24 at 11:29 a.m., cigarette butts were observed in R38's garbage can in his room. MDS Coordinator confirmed the cigarette butts were in R38's garbage can and stated she was unaware R38 was disposing of them there. MDS Coordinator verified throwing the cigarette butts in the garbage can was a fire risk for everyone in the facility. During an interview on 5/22/24 at 9:52 a.m., nursing assistant (NA)-D confirmed R38 was a smoker and was unaware of the location R38 went to smoke as there was no smoking allowed on the facility property. During an interview on 5/22/24 at 11:47 a.m., director of nursing (DON) stated the facility expectation would be R38 would go off site to smoke and she would expect R38 to let staff know when he was exiting the building and where he was going. DON confirmed it was a fire risk for R38 to be throwing his cigarette butts in the garbage can. Review of the facility policy titled Resident Smoking/Tobacco Policy revised 2/24, identified tobacco products were prohibited throughout the facility and on the grounds. Residents who chose to use tobacco products needed to go off facility grounds. All tobacco products were be kept at the nursing station and distributed by the nursing staff. The interdisciplinary team (IDT) were to assess the mental, physical and visual ability of the resident to possess tobacco products. If the tobacco product were kept in the resident room, it must have been kept in a secure location.

Based on observation, interview and document review, the facility failed to maintain personal privacy for 4 of 4 residents (R1, R4, R5, R6) who had video monitoring devices in their bedrooms as an intervention to prevent falls and elopement. Findings include: R1's admission Minimum Data Set, dated dated dated [DATE], identified intact cognition, diagnosis of a stroke with wandering tendencies that placed R1 at significant risk of getting to a potentially dangerous place (e.g. outside facility, stairs). R1 used a walker and a wheelchair for mobility, impairment of lower extremity on one side, and required supervision with transfers, locomotion on and off unit, dressing, personal hygiene, toileting, and always continent of bowel and bladder. R1's care plan dated 9/18/23, identified R1 elopement risk and video monitor used along with wander guard applied. R1 resided in alarmed unit and staff were directed to check wander guard every shift. R4's significant change MDS dated [DATE], identified severely impaired cognition and diagnosis of dementia. R4 required extensive assistance with bed mobility, transfers, personal cares, toileting, locomotion on unit, dressing, and was frequently incontinent of bladder and occasionally incontinent of bowel. R4 used a walker and wheelchair for mobility. R4's care plan dated 7/20/23, identified R4 high risk for falls due to history of falls and instability. Staff were directed to place call light within reach, bed in lowest position with blue mat on floor next to bed, used concave mattress, ensure adequate lighting and clear pathways to room, video monitor in room, and wipe up fluid spills form floor. R4 was also identified as risk for elopement due to dementia. Staff were directed to provide frequent checks on resident and wander guard placement and workability. R4's progress notes dated 9/15/23, identified an unwitnessed fall in bathroom. R4's new intervention implemented: video monitor placed in room. R4's family/wife notified of fall. R5's quarterly MDS dated [DATE], identified intact cognition and daily verbal and physical behavioral symptoms not directed toward others. R5's diagnoses included hemiplegia (weakness on one side), anxiety, depression, post-traumatic stress disorder (PTSD). R5 required extensive assistance with bed mobility, transfers, dressing eating, personal hygiene, toileting, and locomotion per wheelchair on and off the unit. R5 had impairment upper and lower extremities on one side, and frequently incontinent of bowel and bladder. R5's care plan dated 10/26/22, identified R5 received psychotropic medications related to behavior management, depression, anxiety, OCD (obsessive compulsive behaviors, and pseudobulbar effect (nervous system disorder that can make you laugh, cry, or become angry without being able to control it). Video monitor was to be placed in R5's room for close monitoring of R5 due to history of suicidal statements. R5 was aware and wife aware of monitor in room. R5's progress note dated 11/25/22, identified discontinued hourly checks as resident has made no more suicidal comments. R5 continued to have video monitor in his room for staff to keep close supervision while in his room. R6's quarterly MDS dated [DATE], identified severely impaired cognition and no behaviors. R6's diagnoses included Alzheimer's disease, anxiety, and depression. R6 required extensive assistance with bed mobility, transfers, mobility on and off the unit, toilet use, and personal hygiene. R6 was frequently incontinent of bowel and bladder. R6 had daily use of wander/elopement alarm and used a walker and wheelchair for mobility. R6's care plan dated 6/13/23, identified R6 elopement risk. R6 resided in an alarmed unit, wander guard applied to right ankle, and video monitored R5's location when in room. R6's progress notes dated 3/17/23 at 4:50 a.m. fall occurred on 3/16/23 follow up indicated R6 denied pain, monitored for bruising and new pain. New intervention: monitor in place. During intermittent observation in Pines unit on 9/21/23 from 11:00 a.m. to 12:00 p.m., in the center of the unit was a nurse's station against a wall with a counter surrounding the entire square space with an opening to walk in located at the front. The nurse's station was accessible from front by staff and visitors. Located on the right-side counter were five colored monitor receivers turned on (designated for R1, R4, R5, and two other resident residents) and located on the left side counter were three (designated for R6 and two other residents) colored monitor receivers turned on and broadcasting the live activity of reach resident from cameras in their rooms. The monitor screens measured approximately five inches by three inches and could be seen by anyone walking past and stopping at the nurse's station. The nurse's station was in a common area where residents, visitors, and staff frequented throughout the day. Located on all eight monitors was a yellow sticky that identified which room number the resident was located. Nursing assistants (NAs) and registered nurses (RNs) walked by nurse's station and glanced at screens occasionally, at times the Pine nurse's station was left unattended, but live video feed from all eight resident rooms ran continuously and could be seen by anyone who glanced into the nurse's station. Observation during this time showed: -R1 laid in bed on his back fully clothed, uncovered with eyes closed. -R4 laid in bed on his left side covered up with a patchwork blanket, eyes closed. -R5's bed made and unoccupied. -R6's camera view showed top half of bed, unoccupied. During observation on 9/22/23 at 2:00 p.m., video feed from R1, R4, R5, R6 rooms identified: -R1 lying in bed, fully clothed with shoes, pants and shirt on uncovered. R1's wife was also observed on the monitor camera as she sat next to the bed side table in a chair occasionally looking at camera. R1 folded his arms over his abdomen and closed his eyes. -R4 lying on his left side in bed, faced the camera, covered with a patchwork blanket. -R5's bed was unoccupied and made. At 2:11 p.m. a visitor in a pink dress sat on the edge of R5's bed and went through a bag of items. R5 sat in wheelchair talking to visitor. -R6's monitor camera screen showed blue with small print on it. Licensed practical nurse (LPN)-D worked on the monitor while she sat at the nurse's station. During an interview on 9/21/23 at 8:53 a.m., R1 stated he was aware of the camera in his room and felt he was he was being monitored which made him feel confined and spied on. R1 indicated he did not feel he was given a choice as to whether he wanted the monitor camera in his room. R1 also indicated he had no privacy in his bedroom and had to go into the bathroom and close the door to not be on the camera or have people watching. During an interview on 9/21/23 at 12:30 p.m., licensed practical nurse (LPN)-A stated monitor cameras helped staff supervise those residents that crawled out of the bed and helped prevent falls. LPN-A indicated the monitor cameras were left on all the time so that the resident was monitored while they laid in bed, sat in a chair, and ate however, staff were expected to turn the camera away when cares were completed. LPN-A also stated the facility had used those monitor cameras for at least one year or more now. During an interview on 9/21/23 at 4:30 p.m., RN-A stated the monitor camera was used for residents that self-transferred, restless, and high risk for falls. RN-A stated when staff saw movement of a resident in their bed, they would head to that room quickly to assist the resident. RN-A verified no written consent was obtained and only verbal discussion/consent with resident and/or family occurred, and information was placed in care plan, RN-A stated R1 had been educated on the monitor camera, educated that it could be turned off while he had visitors, staff would have noticed it was off at the nurse's station and turned it back on for him later. During an interview on 9/22/23 at 10:03 a.m., R1's family member (FM)-A stated she had not been approached by staff to talk about the placement of the monitor camera, one day it just suddenly appeared and was used to monitor R1 in his room due to wandering. FM-A indicated she had asked about the monitor camera when R1 wanted to change clothes and was concerned about R1's privacy. FM-A stated had thought it was weird others would be able to see him, assumed we could not move the camera or shut it off during my visit but was not quite sure. During an interview on 9/22/23 at 10:10 a.m., FM-B stated yesterday (9/21/23) she had noticed at least six monitors with screens when at the nurse's station and thought it was odd. FM-B stated she could see on the monitor screens residents laying in bed, sitting in a chair and her father lying in bed. FM-B stated she had been concerned about privacy because other people and staff could see her dad in bed and other residents as well. During an interview on 9/22/23 at 10:47 a.m., via telephone R6's FM-C stated she was not made aware a camera monitor was implemented for R6. FM-C state R6 was a very private person and if she could speak for herself, she would not have allowed the monitor camera in her room. FM-C stated R6 would not appreciate someone being able to watch her, especially while she laid down and slept. FM-C added she was unsure why a camera monitor would even be necessary for R6 because she no longer attempted to get out of bed and was not at that great of risk. During an interview on 9/22/23 at 11:13 a.m. LPN-B stated facility started to use the monitor cameras over one year ago. LPN-B indicated monitors were used on those residents with a history of falls, fall risks, and elopement risk. LPN-B stated nursing staff were expected to check the resident monitors throughout the shift and when charting was completed at the nursing station. LPN-B identified written consent had been used and documented in the medical record, and usually family or resident were able to consent. LPN-B stated nursing staff were expected to turn the camera when cares were provided. During an interview on 9/22/23 at 11:30 a.m., RN-B stated once all other options were exhausted then they used a monitor camera because there were so invasive and was the last resort. RN-B stated no written consent was needed and only verbal from resident if cognition was intact or from family. RN-B stated the monitor cameras were used primarily for fall prevention and staff were expected to turn camera when they provided cares. During an interview on 9/22/23 at 11:36 a.m., R5 stated had been aware of the monitor camera and that it was continuously on when in his room. R5 stated he did not like it. R5 indicated he did not have much privacy but felt he did not have a choice in the matter if he continued to live at this facility. During an interview on 9/22/23 at 11:45 a.m., LPN-C stated the monitor cameras were used as an intervention and helped prevent falls and elopements. LPN-C indicated the monitor cameras were used as a type of supervision, helped staff monitor movement of the resident, showed if the resident had attempted to exit bed and/or left the room. LPN-C stated staff were expected to turn camera away during cares but were discouraged to turn the camera off, which defeated the purpose. During an interview on 9/22/23 at 11:53 a.m., NA-A stated the facility had used the monitor cameras at least for one year now. NA-A stated the monitor cameras were used so staff could monitor residents who were at risk of getting out of bed by themselves to prevent falls. NA-A verified the monitor cameras helped supervise the residents but not used very well. NA-A indicted staff were not always able to stop and view the cameras frequently. During an interview on 9/22/23 at 1:41 p.m., NA-B indicated they checked the monitor cameras usually about every 30 minutes. NA-B stated she had observed resident care being completed on the receivers of the cameras. NA-B stated there were staff who had forgot to turn the camera away, were in a hurry, and completed cares with camera on. NA-B indicated she had been instructed by other staff to never turn the cameras off, make sure it was just turned sideways during cares to provide privacy. During an interview on 9/22/23 at 1:45 a.m., NA-C stated there were eight monitor cameras located at the Pines nursing station and visitors would be able to see the monitor screens when they stood at the nurse's stations and possibly what the resident was doing but unable to identify which resident was on each screen due to the screen size. During an interview on 9/22/23 at 1:57 p.m. NA-D stated the monitor cameras located at the Pines nurse's station were on continuously and were checked mostly during the morning when she arrived at work. NA-D indicated she saw on the screens residents laid in bed, sat up in bed, and sleeping. NA-D stated the monitor cameras were used to help prevent falls. NA-D stated she turned the camera away during cares to help provide privacy. During an interview on 9/22/23 at 2:25 p.m. director of nursing (DON) stated the monitor camera was initiated on a resident after all other interventions had been tried usually after a fall or elopement. DON stated a written consent was not needed and a verbal consent was required from either the resident and/or family. DON stated staff were not trained during orientation, they are infant monitors, and staffed were educated by email after a fall and updated as to what was done. DON stated staff were expected to turn camera away in the room during cares and then move camera back to the same position after cares. DON indicated a resident with intact cognition was instructed on how they could turn the camera away during a visit from family and friends. DON verified the monitor cameras located in transitional care unit (TCU) were located behind a wall at the nurse's station out of the public view and the monitor cameras on Pine were located at the nurse's station in a more central area and the monitor screens were small. The facility failed to ensure resident privacy in bedrooms by using video camera monitoring as a replacement for staff supervision and monitoring. Facility policy titled Quality of Life-Dignity dated 5/1/23, identified each resident should be cared for in a manner that promotes and enhances quality of like, dignity, respect, and individuality. Staff were directed to promote, maintain, and protect resident privacy, which included bodily privacy during assistance with person care and during treatment procedures. Demeaning practices and standards of care that compromise dignity was prohibited. Facility policy titled Wander Guard Policy/Video Monitor dated 9/22, identified video monitor was used after verbal consent from resident and/or family for resident's identified at risk for elopement.

Based on observation, interview and document review the facility failed to ensure appropriate use of personal protective equipment (PPE) while providing direct care for 1 of 1 resident (R3) with Methicillin-resistant Staphylococcus Aureus (MRSA) urinary tract infection (UTI). In addition, the facility failed to ensure proper disinfection of a multi-use full body mechanical lift was implemented to prevent the spread of infection for 1 of 1 residents (R2) observed to utilize the lift and failed to ensure proper hand hygiene was maintained during personal cares for 2 or 2 residents (R2, R3) observed during the provision of personal cares. Findings include: PPE and HAND HYGIENE R3's significant change Minimum Data Set (MDS) dated [DATE], identified R3 had severe cognitive impairment and diagnosis of dementia. R3 required expensive assistance with transfers, personal hygiene, dressing, and toileting. R3 was frequently incontinent of bladder and always incontinent of bowel. R3's physician orders dated 7/6/23, start facility precautions for MRSA in urine. R3's care plan dated 7/6/23, identified MRSA colonization in urine and directed staff to bag and transport used linen according to facility protocol, preventing skin exposure or contamination. R3 placed in contact isolation and staff were directed to wear gown and masks when changing contaminated linens. During an observation on 7/11/23 at 10:05 a.m. R3 had three contact precaution signs outside the door reading: -Contact Precautions (example: Clostridium difficile [highly contagious bacteria causes diarrhea], Wounds, uncolonized MRSA), gloves on during providing care for a client, change gloves after contact with infectious material. Gown on upon entry of room and should have been worn when body contact with environment surfaces and items in room that maybe contaminated is anticipated. Masks, eye protection should be worn during client care activities likely to generate splashes or sprays of blood. Hand wash. -Sequence for putting on PPE identified how to apply a gown, mask or respirator, goggles, or face shield, and gloves. Use safe work practices to protect yourself and limit the spread of contamination. -How to Safely Remove PPE identified how to remove all PPE, perform hand hygiene between steps if hands became contaminated, and immediately after removing all PPE. During an observation on 7/11/23 at 4:07 p.m., nurse aid (NA)-D pushed R3 in wheelchair into her room with contact precaution signs posted outside the door. NA-D did not apply PPE or sanitize hands and stated was taking R3 to the bathroom. NA-D placed the stand lift in front of the resident while she sat in her wheelchair. NA-D placed R3's feet on footrest, secured lower legs with a belt strap, lift belt around her abdomen, and instructed resident to grab onto the handles. NA-D lifted R3 out of the wheelchair with the sit to stand lift. NA-D placed gloves on her hands, removed saturated brief and then R3 stated that smelled really bad. NA-D removed her gloves, did not sanitize hands, lowered R3 down onto the toilet, and stated R2's pants were saturated with urine and needed to be changed. NA-D knelt on the bathroom floor in front of the toilet while R3 sat on toilet, removed R3' shoes and pants with bare hands. R3 insisted she had to check the pockets of her pants and NA-D stated to be careful because the pants were wet with urine. R3 fumbled with the wet pants and placed her hand into each pocket. NA-D placed clean pants and brief on R3 and pulled to upper thigh area. NA-D placed R3's shoes back on. NA-D placed R3's feet on footrest, applied gloves, and raised R3 off the toilet with the sit to stand lift. NA wiped R3's peri area and rectal area from front to back with two separate wipes, pulled up R3's brief and pants, removed gloves and did not sanitize hands. NA-D pushed resident out of the bathroom on the sit to stand lift, lowered her down into her wheelchair, and removed lift belt loops from machine. NA-D placed R3's feet on wheelchair peddles, combed R3's hair, squirted lotion into R3's hands, and sprayed perfume onto R3's wrists. NA-D pushed R3 towards the doorway in wheelchair, paused to squirt hand sanitizer into her hand, rubbed hands together, then continued to push R3 in wheelchair out of the room, and down the hallway. NA-D did not sanitize R3's hands. At 4:15 p.m. NA-D re-entered R3's room, did not apply any PPE, bagged up the wet pants into a plastic bag without gloves, and sanitized hands as she exited the room carrying the plastic bag. During an interview on 7/11/23 at 4:20 p.m. NA-D confirmed R3 had MRSA infection in her urine and thought that would be the reason to be on contact precautions. NA-D also stated she unsure if a gown was needed to enter R3's room and toilet her but felt she should have placed more PPE on prior to taking R3 to the bathroom. NA-D indicated staff received emails with contact precautions information but she had not read them. NA-D stated she wore gloves but should have protected herself from infection and worn additional PPE. During an interview on 7/12/23 at 2:27 p.m. RN-B stated specific signage was placed by the resident's door indicating which type of precautions they were placed on. RN-B indicted staff were required to read the communications on point click care prior to the start of every shift so they would known how to care for each resident. RN-B stated staff were expected to wipe down and disinfect the multi-use lift machines with the purple top santi cloth wipe after every use and important for infection control. During an interview on 7/12/23 at 4:15 p.m. RN-A stated prior to assisting R3 with toileting staff were expected to wear at the least minimum a gown and gloves but encouraged to also wear goggles and a mask to prevent the spread of MRSA infection to other residents and staff. RN-A staff were expected to disinfect all multi-use lift machines prior to and after resident use with a purple cover bleach wipe to help prevent the spread of nosocomial (facility acquired) infections around the facility. HOYER LIFT and HAND HYGIENE R2's quarterly MDS dated [DATE] indicated severely impaired and diagnoses of Parkinson's, dementia, and depression. R2 required total dependence of staff for transfers, morbidly, personal hygiene, dressing, and toilet use. R2 was always incontinent of bowel and bladder. R2's care plan dated 9/23/22, identified R2 had alteration in elimination due to Parkinson's and history of urinary tract infections (UTI's). Staff were directed to check and change R2 due to frequent incontinence of bowel and bladder, monitor for UTI symptoms, foul-smelling urine, darkening of urine color, and provide peri care after each incontinent episode. During an observation on 7/11/23 at 4:30 p.m., R2 laid in low bed positioned on her back. NA-B and NA-C sanitized hands and entered the room. R2's room had a very strong urine odor. NA-B pushed the total lift machine into R2's room while NA-C raised R2's bed up and removed blanket from R2. NA-B and NA-C applied gloves and removed R2's urine saturated brief from underneath her. NA-C cleaned R2's front peri area from front to back with a wipe. NA-B turned R2 onto her right side while NA-C wiped her rectal area from front to back. Together NA-B and NA-C placed a clean brief on R2, pulled up pants, and placed lift sheet underneath her. Both NA-B and NA-C removed gloves but failed to sanitized hands. NA-B and NA-C attached the lift sheet loops to lift machine. NA-C raised R2 out of bed, lowered her into the wheelchair, and removed the loops from lift machine. NA-B covered R2 with a blanket, placed R2's glasses on her face, picked up the water mug, and offered R2 a drink of water. NA-C made R2's bed, combed her hair, then faced R2, leaned forward, placed her hands on R2's shoulders, asked if she was ok and needed anything else, then positioned R2's soft touch call light on her lap. NA-C sanitized her hands prior to exiting R2's room. NA-B pushed total lift machine out of R2's room without sanitizing her hands. During an interview on 7/11/23 at 4:32 p.m. NA-C stated once the soiled gloves were removed after peri cares were completed hands should have been sanitized and that was not done. NA-C also stated bacteria could have been on the gloves and hands after peri cares were completed, hand sanitization would have helped prevent the spread of bacteria to others. During an interview on 7/11/23 at 4:42 p.m. NA-B stated R2's peri cares were completed by NA-C, she assisted with removal of the soiled brief with gloves on, removed gloves, completed additional cares with R2, then sanitized hands while exiting the room. NA-B verified the multi-use lift was pushed down to the end of hallway and placed in a storage area with out being disinfected. NA-C stated the lift was not disinfected every time a resident used it and only cleaned at the end of every shift. NA-C indicated the total lift machine was not touched by residents and they each had their own lift sheet. During an interview on 7/12/23 at 10:30 a.m. NA-A stated staff were expected to take the multi-use lift out of the resident room after use and disinfect them with a bleach wipe with the purple cover. NA-A indicated all multi-use lifts were expected to be sanitized prior to and after every resident use so that they were cleaned from bacteria and germs and helped avoid transfer of bacteria from resident to resident. During an interview on 7/12/23 at 2:27 p.m. RN-B stated staff were expected to sanitize their hands before entering and prior to leaving a resident room. RN-B also stated staff were expected to remove gloves after cares, sanitize their hands prior to completing other personal cares such as combing hair, placement of call light to help prevent the spread of infection and good hygiene. During an interview on 7/12/23 at 4:15 p.m. RN-A stated staff were expected to foam in and out of every resident room, apply gloves, complete peri cares, remove gloves, and sanitize hands prior to completing additional cares such as combing hair, place the call light, and cover up resident with a blanket to keep all residents safe and prevent the spread of infection. During an interview on 7/13/23 at 11:04 a.m. director of nursing interim (DON) stated staff are expected to foam in and out of all resident rooms. DON also stated staff are expected to wear gloves during peri care, remove the gloves, then sanitize their hands to prevent the spread of germs. DON indicated hand hygiene was the best way to keep everyone healthy. DON verified all multi use lifts were expected to be disinfected with a purple top bleach wipe between each resident use. DON expected staff to wipe down all parts of the lift to also include areas touched by residents to prevent infectious germs to be transferred from one resident room to another. DON indicated staff are expected to wear a gown, gloves, mask, and any eye protection needed to complete toileting cares in an MRSA contact precaution room to help prevent the spread of MRSA to themselves and residents. Facility policy titled Hand Hygiene dated 7/2018, identified hand hygiene continues to be the primary means of preventing the transmission of infection. Perform hand hygiene before and after direct contact with residents, after contact with blood, body fluids or excretions, mucus membranes, non-invasive skin, or wound dressings. Before and after providing personal cares for a resident such as peri-care, bathing, and oral cares. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores is likely to have occurred. Facility policy titled Nurse Manager Responsibilities for Patient with the need for Certain Precautions, dated 8/2015, identified the nurse manager was responsible to assure staff were updated and educated on reason for precautions, resident room number, and type of precautions used for each resident via email and during report. Facility policy titled Cleaning and Disinfecting Mechanical Lifts dated 6/2018, mechanical lifts may transmit pathogens if devices contaminated with blood or body fluids are shared between residents without cleaning and disinfecting between residents. Facility staff were instructed to disinfect all lifts used by a resident and prior to reuse on another resident with a hospital grade disinfectant provided by the facility.

Based on interview and document review, the facility failed to complete a performance review of every nurse aide at least once every 12 months for three of five nurse aides (NA-C, NA-D, and NA-E) reviewed for performance reviews. Findings include: On 4/19/23 at 11:57 AM, performance reviews for five nurse aides were reviewed with the administrator. Review of the performance reviews revealed the following: 1. NA-C was hired on 10/05/20, and did not have a performance review in the past 12 months. 2. NA-D was hired on 11/30/20, and did not have a performance review in the past 12 months. 3. NA-E was hired on 12/18/19, and did not have a performance review in the past 12 months. During an interview on 4/19/23 at 12:32 p.m., the administrator verified each of the above employees were currently employed by the facility and confirmed performance reviews had not been completed on NA-C, NA-D and NA-E within the past 12 months. A policy was requested and one was not provided.

Based on interview and document review, the facility failed to ensure nurse aides had no less than 12 hours of in-service training in the past year for 3 of 5 nurse aides (NA-C, NA-D, and NA-E) reviewed for in-service training. Findings include: On 4/19/23 at 11:57 a.m., in-service training records for five nurse aides were reviewed with the administrator. Review of the in-service training records revealed the following: 1. NA-C was hired on 10/05/20, and did not have any in-service training hours in the past 12 months. 2. NA-D was hired on 11/30/20, and did not have any in-service training hours in the past 12 months. 3. NA-E was hired on 12/18/19, and did not have any in-service training hours in the past 12 months. During an interview on 4/19/23 at 12:32 p.m., the administrator verified each of the above employees were currently employed by the facility. Additionally, the administrator confirmed the three nurse aides were not provided any in-service training for the past year. A policy was requested and one was not provided.

Based on observation, interview and document review, the facility failed to maintain dignity for 1 of 1 resident (R34) who utilized an incontinent pad in his wheelchair. Findings include: R34's admission Minimum Data Set (MDS) dated [DATE], identified R34 had moderated cognitive impairment and diagnosis which included: depression, congestive heat failure (CHF), and kidney disease. Indicated R34 was occasionally incontinent of bowel and bladder and required extensive assistance with dressing, toilet use, and transfers. R34's care plan dated 3/23/23, identified R34 required assistance with bathing, transfers, and elimination. R34's care plan identified R34 was able to alert staff to needs and was incontinent of bowel and bladder. R34's admission Care Area Assessment CAA dated 3/29/23, indicated R34 had occasional incontinence and was admitted with incontinent product use. On 4/17/23, at 12:21 R34 was seated in his wheelchair in his room. R 34's wheelchair had a blue incontinence pad hanging from the back of his wheelchair which hung down four to five inches and was visible from the hallway. On 4/17/23, at 2:45 p.m. R34 was seated in his wheelchair in the day room. R34's wheelchair continued to have a blue incontinence pad hanging down from the back of his wheelchair visible to other residents, staff and visitors. On 4/18/23, at 10:10 a.m. R34 was seated in his wheelchair in the day room. R34's wheelchair continued to have a blue incontinence pad hanging down from the back of his wheelchair visible to other residents, staff and visitors. During an interview on 4/18/23, at 10:25 a.m. nursing assistant (NA)-F confirmed an incontinence pad was present in R34's wheelchair when they transferred R34 into the wheelchair that morning. NA-F stated she was unsure why the incontinence pad was in R34's wheelchair. NA-F indicated it was not dignified for R34 to have the incontinence pad placed in his wheelchair where it was visible to others. During an interview on 4/18/23, at 10:30 a.m. registered nurse (RN)-A confirmed R34's wheelchair had a blue incontinence pad which was visible to others. RN-B stated it was not dignified and should not have been placed in R34's wheelchair. During an interview on 4/18/23, at 2:00 p.m. family member (FM)-A stated she was not aware R34 had an incontinence pad in his wheelchair. FM-A stated it was not dignified to have an incontinence pad used in R34's wheelchair which was visible to others. During an interview on 4/19/23, at 9:55 a.m. director of nursing (DON) stated she was not aware R34 had an incontinence pad placed in his wheelchair. DON stated the incontinent pads should not have been placed in resident wheelchairs where it was visible to other residents, visitors and family members. Review of facility policy titled Quality of Life - Dignity Policy revised 10/22, identified each resident would be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Indicated demeaning practices and standards of care which compromise dignity was prohibited, The policy lacked direction for the use of incontinent products, including incontinence pads.

Based on observation, interview, and document review, the facility failed to ensure interventions were implemented to prevent falls and/or injury for 1 of 4 residents (R4) reviewed for accidents. Findings include: R4's admission Minimum Data Set (MDS) dated [DATE], indicated R4 was severely cognitively impaired and had diagnoses which included dementia, anxiety disorder and heart failure. The MDS indicated R4 required extensive assistance of one staff for bed mobility, transfers, and ambulation. The MDS identified R4 was not steady with moving from a seated to standing position, walking, turning around facing opposite direction while walking, moving on and off the toilet, surface to surface transfers and required staff assistance to stabilize. The MDS indicated R4 utilized a walker and wheelchair, and had no falls from prior assessment. R4's Falls Risk assessment dated [DATE], indicated R4 was at high risk for falls. R4's care plan revised 1/4/22, revealed R4 was at risk for falls related to history of falls,/injury, multiple risk factors related to urinary tract infection, acute [MEDICATION(S)] (inflammation of the urinary bladder) without hematuria (blood present in urine) and generalized weakness. The care plan indicated R4 required staff assistance with ambulation and transfers. The care plan listed various interventions which included a bathroom door alarm, a low bed with blue mat and call don't fall sign to be hung in room. R4's Care Sheet dated 1/11/22, indicated R4 needed staff assistance of one staff with all activities of daily living (ADL's) including transfers and ambulation. The care sheet identified staff were to check the bathroom door for alarm. The care sheet lacked any other safety measures to prevent falls. R4's Progress Notes under (Falls) dated 1/8/22, indicated R4 had an unwitnessed fall where staff found R4 next to the bed sitting on the floor, legs extended out and her arms were at her sides. R4 was assessed, asked what she was doing and R4 indicated she wanted to get into bed. R4 was assisted back into bed with no injuries sustained and was given education on using call light with understanding expressed by R4. R4's bed was placed in low position, the blue mat was on the floor and staff implemented a new intervention which included hanging a call don't fall sign in R4's room. On 1/11/22, at 10:17 a.m. R4 was observed to be asleep in bed on her back covered with blankets, call light with in reach, bed in low position with blue mat on floor next to her bed and her walker was noted to be across the room. R4's room lacked a sign which stated call don't fall as indicated on her care plan and fall intervention notes. - at 10:35 a.m. R4 remained laying in bed while nursing assistant (NA)-B entered her room. NA-B asked R4 if she wanted to get up for the day. R4 refused several times and then agreed to get up. NA-B assisted R4 with drinks of water, answered a phone call, picked out her clothes for the day and assisted her to sit on the edge of the bed. NA-B removed R4's gripper socks from her feet, applied her tennis shoes and called for assistance from other staff. -at 11:11 a.m. R4 remained seated on the edge of the bed, when NA-A knocked and entered her room. NA-A asked R4 if he could assist her to the bathroom. R4 agreed and NA-B exited the room. NA-A assisted R4 to stand while using her walker and gait belt and assisted her to walk to the bathroom. NA-A asked R4 to sit on the toilet while he assisted R4 with morning cares, which included dressing for the day and providing incontinent cares. NA-A assisted R4 to pivot transfer into her wheel chair utilizing a gait belt and using the bathroom hand rails. NA-A straightened R4's clothes, handed R4 her glasses to place on her face, sanitized his hands, and collected the garbage and linen. NA-A proceeded to open R4's door and informed family R4 was ready and exited the room. A sign which stated call don't fall was not observed or posted in R4's room as indicated on her care plan and fall intervention notes. - at 2:28 p.m. R4 was observed seated in her wheel chair with her feet on foot peddles, bed side table next to her and call light within reach. R4's walker was noted to be across the room., alarm on bathroom door and a sign which stated call don't fall was not observed or posted in R4's room as indicated on her care plan and fall intervention notes. On 1/11/22, at 2:35 p.m. NA-A indicated R4 was at risk for falls and required staff assistance with ambulation and transfers. NA-A stated staff reviewed the Kardex in the resident bathrooms for instruction on how to care for the residents. NA-A checked R4's Kardex in her bathroom and indicated a sign which stated call don't fall was supposed to be posted in R4's room. NA-A verified a sign had not been posted in R4's which instructed R4 to call don't fall. On 1/11/22, at 2:52 p.m. registered nurse (RN)-A confirmed R4 was at risk for falls and required staff assistance with ambulation and transfers. RN-A indicated R4 self transferred at times and had a few falls recently. RN-A stated a sign was expected to be posted in R4's room which instructed R4 to call don't fall after her last fall. RN-A verified R4's careplan and confirmed the sign was not posted in R4's room to remind her to call don't fall. RN-A indicated she expected staff to ensure the fall interventions were in place and being followed. On 1/11/22, at 3:36 p.m. the director of nursing (DON) confirmed R4 was at risk for falls and required staff assistance with ADLs which included transfers, and ambulation. The DON indicated R4 self transferred at times. The DON confirmed R4's care plan and indicated R4 should have had a call don't fall sign posted in her room after the last time she had a fall. The DON indicated she expected staff to ensure the interventions were in place and to follow the care plan. Review of the facility policy, titled Risk/Fall management Policy amended 1/2021, indicated staff were to identify all residents who were at high risk for falls and to develop/implement individual care plans that would maximally protect the resident against falls.

Based on observation, interview and document review, the facility failed to ensure source control personal protective equipment (PPE) was worn properly, this had the potential to affect all 8 residents who dined in the main dining room. FACEMASK USE On 9/13/21, from 5:03 p.m. to 5:25 p.m. during the evening meal service in the short term care dining room the following was observed: - at 5:03 p.m. a dietary aide (DA)-A stood by the service counter and wore a face mask which was positioned below the nose. DA-A walked around the dining room and spoke with several residents and staff members in the dining room. No staff were observed to provide DA-A education or correction to properly position DA-A's face mask over the nose. - at 5:10 p.m. DA-A continued to move throughout the dining room, with mask positioned below the nose. DA-A approached an unmasked resident, stood within 24 inches of the unmasked resident, spoke to her and walked back towards the service counter. -at 5:12 p.m. DA-A was observed at the service counter, with the mask in the same position, waiting for food trays, the regional dietary manager and cook were at the service counter and faced DA-A . Neither were observed to provide education to DA-A to re-position the face mask to cover the nose. -at 5:14 p.m. DA-A remained at the service counter with the mask in the same position, when licensed practical nurse (LPN)-C walked up and stood next to DA. LPN-C wore a properly positioned face mask which covered the nose and was not observed to provide education to DA-A to cover the nose with the mask. - at 5:19 p.m. DA-A was observed to walk over to a resident seated at a table, and DA-A's face mask remained the same. DA-A stood approximately 18 inches from the unmasked resident, took his meal order and walked away. -at 5:22 p.m. DA-A was observed to walk back over to the resident, with the face mask unchanged and set down the residents food in front of him. DA-A bent down and spoke to the resident within 12 inches of the unmasked residents face. -at 5:23 p.m. DA-A stood next to a resident seated at a long rectangular table with several other residents, DA-A's face mask continued to be positioned below the nose. At that time, Registered Nurse Manager (RNM)-B entered the dining room and stood at the end of the long table and spoke to several residents. DA-A leaned down and spoke to an unmasked resident and was within a few feet of two other unmasked residents. DA-A's face mask remained unchanged during the interaction with the residents. -at 5:25 p.m. RNM-B was observed to approach DA-A and provided education to cover the nose with the facemask. DA-A re-positioned the face mask to cover the nose and walked away. During interview on 9/15/21, at 12:55 p.m. Dietary Manager indicated that dietary staff were expected to wear eyewear, gloves when handling food, and a properly positioned facemask which covered the nose while in the resident areas. During interview on 9/16/21, at 8:17 a.m. RNM- B confirmed she had spoken to DA-A on 9/13/21, and had corrected the DA-A's positioning of the face mask. RNM-B stated she expected all staff who had interactions with residents to wear well fitting face masks which were positioned correctly over the mouth and nose. A facility policy was requested, one was not provided.

Based on observation, interview and document review, the facility failed to ensure dignity was maintained for 1 of 1 residents (R258) who utilized an indwelling catheter. Findings include: R258's significant change Minimum data set (MDS) dated [DATE], identified R258 had severely impaired cognition and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R258 required extensive assistance needed with personal hygiene, total dependence with toileting and had an indwelling catheter. R258's care plan updated 9/15/21, identified R258 had an indwelling catheter and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: Position catheter bag and tubing below the level of the bladder and away from entrance room door. The care plan further indicated R258 was totally dependent on staff for toilet use. R258's kardex updated on 9/16/21, identified catheter: position catheter bag and tubing below the level of the bladder and away from the entrance of room door. During an observation on 9/16/21, at 8:14 a.m. R258 laid in bed covered with a blanket with room door wide open. R258's urinary indwelling catheter bag was uncovered, hung under the bed and faced the doorway of the room. The indwelling catheter tubing contained slightly cloudy yellow urine; the collection bag was empty and visible to anyone who walked by the room. During an observation on 9/16/21, between 8:15 a.m. 8:27 a.m. three residents and six staff walked by R258's room with the door wide open. R258's urinary indwelling catheter drainage bag and tubing remained in view from the doorway and contained R258's urinary indwelling catheter bag, tubing hung under the bed and faced the doorway of the room. The urinary indwelling catheter hung on the lower part of the bed uncovered with a small amount of urine in the collection bag visible. During an observation on 9/16/21, at 8:33 a.m. R258's catheter drainage bag with urine present remained in view from R258's doorway with no change in position and an unidentified staff member pushed another resident past R258's open door. During an observation on 9/16/21, at 8:40 a.m. R258's catheter drainage bag with urine present remained in view from F258's doorway with no change in position as a registered nurse (RN)-B looked into R258's room while she walked down the hallway past R258's doorway. During an interview on 9/16/21, at 8:45 a.m. nursing assistant (NA)-G stood by R258's bedside and verified the the catheter drainage bag had been left uncovered and visible from the doorway. NA-G stated R258's catheter drainage bag should have been covered at all times to provide privacy and dignity. During an interview on 9/16/21, at 9:17 a.m. R258's family member (FM) verified R258 had been slightly confused however it would have bothered her if she knew the catheter drainage bag had not been covered up. FM stated she felt the catheter drainage bag should have been covered up. During an combined interview on 9/16/21, at 3:49 p.m. NA-E and NA-F verified staff were expected to cover the urinary catheter bag with a bag holder to assure privacy was provided to each resident. Review of facility policy revised last 8/21, titled Quality of Life-Dignity Policy identified each resident were to be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Residents were to be treated with dignity and respect at all times. Treated with dignity meant the resident were to be assisted in maintaining and enhancing his or her self-esteem and self-worth. Demeaning practices and standards of care that compromised dignity were prohibited. The policy further indicated staff were to promote dignity and assist residents as needed by helping the residents to keep urinary catheter bags covered.

Based on interview and document review the facility failed to notify the physician of a newly diagnosed fracture for 1 of 2 residents (R50) reviewed for change of condition. Additionally, the facility failed to notify the physician of a change in condition (decreased urine output and oral intake) for 1 of 1 resident (R258) reviewed for notification of change. Findings include: R50 R50's Significant Change of Status Assessment (SCSA) Minimum Data Set (MDS) dated [DATE], identified R50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified R50 had severe cognitive impairment and required extensive assistance with activities of daily living (ADLs) of transfers, bed mobility, toileting and locomotion. R50's SCSA Care Area Assessment (CAA) dated 8/26/21, identified R50 had sustained a femur fracture and was dependent on staff for all mobility. R50's Fall note dated 7/8/21, identified R50 had been found on the floor of her room on her right side with extremities extended, however range of motion was within normal limits. The note revealed R50 had denied pain, was assessed for injury and indicated R50 had sustained no injury from the fall. The fall note identified the facility's director of nursing (DON), administrator and R50's primary physician had been notified of the fall. A clinic visit form dated 7/9/21, identified R50 had complained of pain approximately five hours after a fall to her right side. The form revealed R50 had normal ROM, the area was not tender to the touch and R50 had no complaints of pain at rest. The form identified R50's practitioner ordered an X-Ray to be completed at the facility for post-fall pain. R50's x-ray results dated 7/9/21, identified R50's x-ray had been completed at 4:32 p.m. and the results of a distal femur fracture was identified and signed by the radiologist at 5:47 p.m. The x-ray result form had an ineligible handwritten signature at the bottom of the page with a date of 7/12/21. R50's progress note dated 7/9/21, at 11:21 p.m. identified the facility had received R50's x-ray results, which identified a fracture of R50's femur, and had notified the facility DON by phone. The note identified the author of the progress note had placed the x-ray results in the physician binder for the medical doctor to review. R50's progress notes reviewed from 7/9/21, to 7/10/21, lacked any documentation R50's physician was notified of her fractured femur. R50's progress note dated 7/10/21, at 9:05 p.m. R50 was transferred to the hospital by ambulance for an acute change of condition. R50's progress note dated 7/11/21, at 1:30 a.m. identified R50 had been hospitalized with [CONDITION(S)] and femur fracture. On 9/16/21, at 12:34 p.m. during a telephone interview, R50's nurse practioner (NP)-A confirmed he had ordered an x-ray for R50 on 7/9/21, following reports of pain post-fall. He confirmed he had not been notified of R50's fractured femur until 7/12/21, when he had returned to the facility the following Monday. NP-A stated he would have expected himself or the on-call MD to have been notified immediately of R50's x-ray results, indicated he would have consulted with an orthopedic specialist and likely would have admitted R50 to the hospital emergency room sooner than she was sent. On 9/16/21, at 2:33 p.m. the DON confirmed R50's medical record lacked any indication R50's physician had been notified of R50's femur fracture. She indicated she had thought she instructed the nurse who had called her to call the on call MD. The DON stated she would have expected R50's physician or the on-call physician to be notified of a newly identified fracture. On 9/16/21, at 4:18 p.m. during a telephone interview, licensed practical nurse (LPN) -B stated she had received R50's x-ray report on 7/10/21, which had been a Friday, had called the DON and had been directed to place the results in the MD folder for their review. LPN-B confirmed at that time, she had not called the on-call MD or R50's primary physician to notify them of R50's fractured femur. A facility policy titled, Change in a Resident's Condition or Status Policy amended 7/18, identified the facility would promptly notify the residents attending physician of changes in the residents medical/mental condition and/or status.

Based on interview and document review, the facility failed to provide safe transport for residents who require the use of a wheelchair on the facility bus. This resulted in 1 of 3 residents (R1) who were not strapped in securely and slid out of wheelchair during transport, causing multiple fractures. Findings include: R1's quarterly Minimal Data Set (MDS) dated [DATE], indicated R1's diagnoses included dementia, [CONDITION(S)] and showed moderate cognitive impairments. R1 required extensive assist by two staff members for bed mobility, dressing, toileting and extensive assist of one staff member for locomotion on and off the unit. R1's care plan printed 9/8/21, indicated R1 was at risk for falls related to impaired balance, [CONDITION(S)], [CONDITION(S)], arthritis and anxiety with interventions that included call don't fall signs in room, assist with positioning in wheelchair to assure balance, low bed, floor mat while in bed, and one way glide in wheelchair. Further review of R1's care plan, indicated when on outing- be sure resident is sitting properly in wheelchair, activity staff were educated to call nursing facility on outing if any need for repositioning. Review of facility incident report indicated on 8/27/21, at 11:16 a.m. R1 was attending an outing in the facility van, which was driven by facility staff. R1 was in wheelchair (w/c) and when driver applied brakes at stop light, R1 slid out of w/c to the floor of the van. The driver immediately pulled over and Emergency Medical Services (EMS) were called as resident complained of lower extremity pain. R1's emergency room provider note dated 8/27/21, indicated R1 was in her wheelchair on a bus when the bus driver slammed on her brakes. The wheelchair was locked in place and patient catapulted out of her wheelchair. She landed with her left leg underneath her. She complains of pain about her left ankle and left lower leg. EMS [emergency medical services] noted deformity and when they lifted her it seemed to be rotated. Patient does have a previous history of stroke and left-sided deficits. She does not bear weight but typically uses a wheelchair. Further review of provider notes indicated, Patient has IV [intravenous] access with [MEDICATION(S)] titrated for pain x-ray of the left tib-fib, left ankle and left foot are personally reviewed shows evidence of an acute bimalleolar facture of the left ankle .fracture of the rest of the tib-fib. There is a proximal phalanx fracture of the left great toe. With those fracture I personally placed patient into a posterior splint with stirrup component. Regarding the great toe fracture buddy tape was placed by nurse. R1's progress note dated 8/27/21, indicated resident has a broken Left great toe and Left ankle. R1's fall risk assessment dated [DATE], indicated resident had a fall out of wheelchair while on an activity outing. Seeked [SIK] care at the ER [emergency room ] where she was found to have multiple fractures. New intervention: when on an outing, be sure resident is sitting properly in wheelchair. Activity staff educated to call nursing facility on outing if any need for repositioning. Administrator to be providing further education to life enhancement staff on bus safety. Will monitor for any changes. The fall assessment lacked evidence the failure to have R1 wearing a seatbelt while the bus was in transport was addressed as part of the facility's correction. On 9/8/21, at 10:31 a.m. activities assistant (AA)-A indicated R1 was noted to be unpredictable while in her wheelchair. AA-A indicated she was driving the bus and AA-B was also assisting on the trip and was in the back of the bus with the residents at the time of the incident. AA-A indicated, [AA-B] kept saying [R1] sit back and [R1] kept trying to sit up and get out. We were driving and stopped when [R1] slipped out of her chair. Further, AA-A indicated staff had locked R1's wheelchair to the bottom of the bus and locked the wheelchair brakes, however R1 did not have a seat belt on. AA-A confirmed that each spot on the facility bus has a seatbelt but stated, I usually don't use the seatbelts. In addition, AA-A indicated that there are currently no more planned bus trips (all out of building activities were on hold), but there had also not been any additional training provided regarding safe transportation or seat belt use on the facility bus. On 9/8/21, at 10:41 a.m. AA-B indicated R1 was paralyzed on her left side and utilizes a wheelchair for transportation. AA-B stated while on the outing to the apple orchard, R1 started to jiggle and I directed her to sit still. On the way back, the bus driver put the brake on and R1 came out of her chair. We [staff] pulled over to the right and called 911 and then called [facility]. Further, AA-B indicated R1 was scooted down quite a bit in her wheelchair and she was unable to reposition her due to R1 requiring a mechanical hoyer lift for transfers. In addition, AA-B stated, [R1] was in the back of the bus, her wheelchair was strapped to the floor and locked but there was no strap across her and we were not trained to use the seatbelts. No one is buckled in the bus we [staff] just strap in the chair. The residents in the seats are strapped but the residents in wheelchairs are not wearing a seatbelt. I was never shown to use the strap but just trained to strap down the chair and put the brakes on. AA-B indicated since the incident, there have been no additional training provided to staff related to safe transportation and seat belt use. Lastly AA-B stated, Since the incident nothing has changed, no one has talked to be about the seatbelts or trained me how to use them appropriately. AA-B added that she inquired about more training but has not received any further education. AA-B did confirm all off campus activities requiring vehicle transport were canceled until further notice. On 9/8/21, at 1:10 p.m. administrator was interviewed regarding the incident and stated ultimately it's a lack of foresight. They [AA-A and AA-B] weren't checking and securing; they were both at fault for not ensuring the seat belt was on [R1]. The seatbelt was there, the equipment was there, and they have been trained properly. Further, administrator indicated, we have halted all outings for activities for the time period. I am just seeing how this goes over as of right now I talked to them [AA-A and AA-B] about what was wrong. Administrator indicated staff were expected to use the seat belt for all residents during transport on the bus. On 9/8/21, at 1:33 p.m. R3 indicated she was on the outing and the bus driver applied the brakes, not real hard, and everyone to my knowledge was locked in except the lady in the wheelchair. She should have had on her seatbelt but that is just my opinion. On 9/8/21, at 1:38 p.m. R2 stated staff had strapped her wheelchair to the floor on the outing, however, R2 then stated, I don't think they ever put a seat belt on me. R2 indicated she was in front of R1 at the time of the incident on the bus when the brakes were applied and R1 got thrown forward and hit the back of my chair and I put my arms out to brace myself in front of the next one. [R1] broke her ankle and toe. On 9/8/21, at 2:19 p.m. activities director (AD) indicated R1 had slid out of her seat while on the way back to the facility from the outing. AD indicated she went to meet the bus in a parking lot to help and R1 was on the floor of the bus and 911 was called. AD indicated she expected staff to ensure resident safety while on an outing and assist with applying the seatbelts for both residents in the seats and in personal wheelchairs. AD indicated AA-A and AA-B are the only two staff members for activity outings at this time. Further, AD stated [ AA-A] and [AA-B] have not been re-trained since the incident. I canceled all bus trips for a month. I felt they both needed a break from it and take a breather. We will retrain before we go out again. When asked about education provided to activities staff prior to going on an outing, AD stated I don't have proof of education on the policies. We only have healthcare academy. I should put that in their records that they got that information and were trained. Review of facility policy titled Off Premise Outings dated 11/14/18, indicated the procedure included arrange for appropriate care staff to assist activity staff with lifting and transferring needs when loading resident on/off bus. Once seated, all passengers will wear their seat belts or be securely fastened in wheelchair. Further review of policy, indicated all passengers will wear seatbelts and remain seated while vehicle is in motion. Review of facility policy titled Loading, Riding and Unloading Bus dated 3/6/19, indicated the procedure included when everyone is seated, staff will verify that all passengers are securely belted. Further review of policy, indicated passengers will remain seating and belted while the bus is in motion.

Based on observation, document review, and interview, the facility failed to comprehensively assess and provide adequate supervision to reduce the risk of injury from falls for 1 of 15 (R1) residents reviewed for falls. Actual harm occurred when R1 fell from bed and came into direct contact with the electric baseboard heater that caused first, second, and third degree burns to R1's right foot and left hip. Findings include: Observation of the room used by R1 with the director of nursing (DON) on [DATE], at 12:00 p.m. established R1's bed had been located parallel to the outside window and an electric baseboard heater. The electric baseboard heater was located directly under the outside window and measured 6.25 inches in height by 74 inches in length with an approximate 1 inch open area running along the top of the heater. According to the DON a nightstand measuring 19.5 inches long and 18.75 inches wide was located between the bed and the heater. Additionally, R1 had a wooden bedside table in front of the bedside table that was no longer in the room. R1's medical record was reviewed and established R1 was admitted to the facility on [DATE], from the hospital with [DIAGNOSES REDACTED]. Due to declining health status, on [DATE], R1 was admitted to hospice care. Review of the significant change minimum data set ((MDS) dated [DATE], revealed R1's scored a 10 on the brief interview of mental status (BIMS) assessment indicating R1 was moderately cognitively impaired. The MDS established R1 required extensive assistance from one staff for repositioning in bed, transferring from the bed to the chair, and the use of the toilet. R1 required extensive assistance from two staff and a walker to ambulate in the room and used a wheelchair with staff assistance for longer distances. R1's was unsteady changing positions from sitting to standing and with walking. On [DATE], R1 died at the facility under hospice care. R1's care plan dated [DATE], indicated fall interventions for R1 included keeping the call light within reach, reminding R1 of safety precautions, encourage R1 to use the call light, provide for proper footwear, staff to keep commonly used items within R1's reach, and to remain with R1 when in the bathroom. A progress note dated [DATE], indicated at 7:00 p.m. R1 was found sitting in the doorway between R1's bathroom and bedroom with the wheelchair behind R1. R1 fell during a self transfer attempt from the toilet to the wheelchair. No injuries were observed. The intervention was to have staff remain with R1 when in the bathroom. A progress note dated [DATE], revealed at 8:15 a.m. staff heard R1 call out for assistance. The door to R1's room was shut. R1 was sitting on the floor against a wall with the wheelchair between R1 and the bed. The call light was on and R1 was barefoot. R1 attempted to self transfer to the bathroom without waiting for staff assistance. R1 had bruising on the right upper leg, right elbow, and fingers. The immediate interventions following the fall was for staff to leave R1's room door partially open at night. R1's fall assessment dated [DATE], established R1 had a history of [REDACTED]. R1 stated she self transfers and falls all the time. The assessment stated R1's family refused a bed/chair alarm indicating the noise would upset R1. The intervention was to place a silent alarm clipped to R1's clothing that alarmed through the facility call system. Although the fall assessment addressed environmental risk factors, the assessment failed to address the risk of burns related to the electric baseboard heater. A progress note on [DATE], at 1:48 p.m. established staff met with R1 and R1's family. R1 stated she was upset with the chair and bed alarms. Both R1 and family agreed to discontinue the silent clip alarms if R1 agreed to wait for staff assistance with transferring. Staff explained the risks verses benefits of discontinuing the alarms to R1 and the family however, staff failed to assess and initiate an alternative intervention to prevent falls. A progress note dated [DATE], revealed at 6:30 p.m. staff found R1 laying on her back on the floor in a lounge area of her room with the top of R1' head under the window and feet facing the door. R1 complained of a painful left shoulder with a 5 centimeter (cm) by 2 cm abrasion on the left wrist that required steri-strips. In addition, staff observed a bruise to R1's left eye suggesting R1 hit her head. The note stated family would discuss risks of ongoing falls with R1. The immediate intervention included informing staff to ensure R1's needs were met prior to leaving R1 in her room. The care plan dated [DATE], established R1 required the assistance from two staff for transfers from bed and chair, assistance to use the bathroom and bedside commode, ambulation, and bed mobility. R1 was continent of both bowel and bladder and assisted with toileting according to R1's request. The care plan directed staff to reposition R1 every three hours in bed and every 2-,[DATE] hours in the chair or as requested. Additional fall precautions included leaving R1 room door partially open and a silent clip alarm that alerted staff through the facility's pager system and was clipped to R1's clothing as R1 tolerated.A progress note dated [DATE], at 1:09 p.m. stated R1 was asleep in bed with the silent clip alarm on R1. No other documentation indicated when staff had started using the silent clip alarm. A progress note on [DATE], at 11:31 a.m. stated family indicated that R1 no longer had a memory of her falls and hoped R1 would not try to self transfer. Staff confirmed to family the silent clip alarm was on however family stated when R1 was aware the alarm was there, she would remove it. No further assessment occurred to develop alternative interventions to prevent further falls. Despite R1's history of falls and removing the clip silent tab alarm, staff continued the same intervention to alert staff of R1's attempts at self transferring.A progress note on [DATE], at 5:45 p.m. revealed R1 complained of feeling anxious with tightness in the chest. Staff gave R1 Lorazepam an antianxiety medication and nebulizer treatment. At 8:13 p.m. R1 was sleeping. At 11:13 p.m. R1 was hollering out, hyperventilating, attempting to crawl out of bed. Despite non-pharmacological interventions attempted, staff were not able to calm R1. Lorazepam was given to R1. On [DATE], at 1:41 a.m. staff documented R1 was resting comfortably. A progress note on [DATE], revealed at 7:50 a.m. staff found R1 on on her back on the floor between the bed and window. R1's right leg was above and over her left leg with the right foot and toe in a one inch opening at the top of the electric baseboard heater. R1's left hip was against the lower portion of the heater. At 10:48 a.m. a progress note revealed R1 had a mild left hip burn presenting as redness, most likely a first degree burn without blistering and/or hardness. The red area measured 17 cm by 4 to 5 cm with irregular edges. The right foot assessment described a reddened area that measured 9 cm from the tip of the great toe to the ball of the foot and was 9 cm's wide. The proximal right great toe joint and bottom of the ball of the right foot had blistered, with a scant amount of yellow drainage probably second degree burns. Also, just left of the right great toenail there was an area that measured .25 cm by 3 cm, white in color and hard to the touch probably a third degree burn. Immediate interventions included moving R1's bed away from the electric baseboard heater, replacing the clip alarm with a sensor pad silent alarm in the bed and chair, placing a blue mat on the floor next to the bed, and initiated hourly safety and pain assessments. Review of the incident report dated [DATE], at 11:09 a.m. revealed following the fall with burns, R1 was lethargic and rated her pain at a 5 on a 1 to 10 scale with 10 being the worst pain. R1 was oriented to person, place, time, and situation and no predisposing environmental factors were assessed including the electric baseboard heater. The incident report stated R1 had a history of [REDACTED]. An interview with LPN-A on [DATE], at 10:53 a.m. revealed R1 had a history of [REDACTED]. Staff frequently checked on R1 at least every hour. On [DATE], LPN-A responded to R1's room immediately when notified by nursing assistant (NA)-B that R1 was on the floor. R1 right toe was located in the opening at the top of the electric baseboard heater and R1's hip was against the lower side of the heater. R1 had removed the silent clip alarm which was on the floor next to R1 and not sounding. R1's bed was in the low position. R1 had no complaints of pain. LPN-A and two additional staff transferred the resident with a sling mechanical lift to R1's recliner. LPN-A assessed the burns, moved R1's bed away from the heater, and developed additional interventions. An interview with NA-B on [DATE], at 12:15 p.m. indicated she was aware that R1 had a history of [REDACTED]. NA-B was alerted to R1's room when the silent clip alarm activated on her pager. R1 was lying on the floor between the bed and the window with R1's right toes inside the open space of the electric baseboard heater with her left hip touching the lower portion of the heater. R1's silent clip alarm had been removed and NA-B believed was activated by R1's movements on the floor. NA-B immediately removed R1's toes from the heater and placed her leg between R1's hip and the heater. NA-B said the heater was hot and difficult to keep her leg against the heater. NA-B said R1 often removed the silent clip alarm from her clothing even though staff attempted to place the alarm in various locations. An interview with LPN-C on [DATE], at 4:02 p.m. revealed she worked the night shift prior to R1's fall on [DATE]. LPN-C said R1 would have been checked on by staff during last rounds between 4:00 and 5:00 a.m. LPN-C could not remember whether R1 was awake at 7:00 a.m. for the incentive spirometer and deep breathing treatment to be completed every two hours when R1 was awake. An interview with the employee-D maintenance established an audit of the surface temperatures of the electric baseboard heater was started on [DATE]. The temperatures were taken with a laser infrared device at the base or bottom of the heater. The temperatures varied from 60 degrees Fahrenheit to 119 degrees Fahrenheit. On [DATE], surface temperature were obtained from the top of the electric baseboard heater. The surface temperature for the electric baseboard heater in R1's room was 130 degrees Fahrenheit. After [DATE], staff only monitored the surface temperatures of the lower cooler portion of the heater. Each resident's room had a thermostat that was individually adjusted to a desired temperature. An interview with the Director of Environmental Services (ESD) on [DATE], at 10:36 a.m. established a standard had not been developed for measuring surface temperatures of the electric baseboard heaters. The measurements should always be taken from the same distance. The ESD had not trained staff to have a standard in measuring the temperatures. The ESD said the department continued to complete random audits of the surface temperatures from the base of the heater and not the surface temperature from the top of the heater. The audit information had not been communicated to the nursing staff however, the resident beds had been moved away from the heaters. Review of the facility's policy and procedure titled Risk Management revised [DATE], stated a fall assessment would be completed as needed with a fall incident. If the fall assessment determined a resident to be a high risk for falls the RN will review, select, and care plan appropriate fall precautions. Following a fall, an investigative protocol was to be completed that included identification of hazards and risks, an evaluation and analysis of the incident, implementation of interventions, and monitoring and modifying the plan as needed.

Based on observation, interview and document review the facility failed to provide timely interventions of repositioning for 1 of 3 (R16) residents reviewed for pressure ulcers. This deficient practice resulted in actual harm for R16 identified with recurrent or multiple stage 2 pressure ulcers. Findings include: R16's annual Minimum Data Set ((MDS) dated [DATE], indicated R16 had severe cognitive impairment and had [DIAGNOSES REDACTED]. The MDS also indicated R16 needed extensive assistance with activities of daily (ADL's), was frequently incontinent of urine, and was at risk for pressure ulcers. The MDS also indicated R16 was on a repositioning program to prevent pressure ulcers, but did not have a pressure ulcer at the time of the assessment. R16's annual Care Area assessment dated [DATE], also identified R16 had [DIAGNOSES REDACTED]. The CAA identified R16 had severe cognitive impairment, needed extensive physical assistance for ADL's, was frequently incontinent of urine and was at risk for developing pressure ulcers. The CAA indicated R16 was to receive assistance with repositioning as indicated on the care plan. Review of R16's care plan dated 5/7/15, identified R16 was at high risk for pressure ulcers related to urinary incontinence and an open area on the right hip. R16's care plan directed facility staff to assist R16 with repositioning every 2 hours while in bed and chair. R16's care plan did not address lying down R16 after meals. The care plan also indicated R16 was incontinent of urine and no longer aware of the urge to void so wore an incontinent brief. Interventions on the care plan directed facility staff to check and change R16 as needed. On 12/09/15, during continuous observations from 1:10 p.m. to 4:17 p.m., R16 was observed seated in a wheelchair without being offered, or assisted, to reposition or toilet. - At 1:10 p.m. R16 was observed wearing sweat pants and a shirt, seated in a wheelchair in the Pines unit dining room next to the table. Nursing assistant (NA)-F walked up to R16's wheelchair and wheeled R16 to the Pines common area, located across from the nurses' station. The common area was observed to have two openings in which to enter and exit the area. R16 sat briefly in the commons area prior to propelling himself with his feet around in a circle in one opening of the common area and out the other opening. -At 1:35 p.m. a restorative aid (RA)-A approached R16, who had continued to propel himself with his feet around the commons area, and offered to bring him to exercises. RA-A stated R16 received exercises of active range of motion (AROM) to both lower extremities 5-6 times a week. RA-A stated R16 needed a mechanical lift for transfers and was unable to reposition himself without staff assistance. RA-A assisted R16 in a wheelchair to a exercise room in an unused hall of the facility and completed exercises to both of R16's lower extremities, but did not offload or reposition the resident. -At 2:00 p.m. RA-A assisted R16, who remained seated in the wheelchair, to a table by the Pines nurses' station. RA-A placed a cup of coffee and juice next to R16 at the table, and exited the area. -At 2:45 p.m. NA-G briefly approached R16 who remained seated at the table. NA-G stood near R16 and asked R16 if he was alright. When R16 nodded his head, NA-G immediately walked away from the area. NA-G was not observed to offer/attempt to assist R16 with repositioning or toileting needs. -At 3:01 p.m. R16 was observed seated in a wheelchair at the table by the nurses' station. No staff were observed during that time to offer/attempt to assist R16 with repositioning of toileting needs. -At 3:27 p.m. R16 continued to be seated in a wheelchair at the table by the nurses' station. NA-G and NA-D walked past R16 and were not observed to attempt/offer to assist R16 with repositioning to toileting needs. -At 3:49 p.m. R16 was observed to continue to be seated in a wheelchair at the table by the nurses station. NA- was observed to walk over to resident and greeted R16. NA-G proceeded to walk away from R16 without offering or attempting to provide assistance with repositioning or toileting needs. -At 3:51 p.m. R16 was observed to be seated in a wheelchair, NA-D approached R16 and questioned how he was. R16 gave no verbal response and NA-D walked away from R16. NA-D was not observed to offer/attempt to assist R16 with repositioning or toileting needs. -At 4:02 p.m. R16 remained seated in a wheelchair at the table by the nurses station, NA- C approached R16 and asked R16 if she could give him a ride. R16 was observed to shake his head and NA-C walked away. R16 remained seated in the wheelchair. -At 4:06 p.m. NA-G approached R16, who continued to be seated in the wheelchair, and asked R16 how he was. R16 gave no verbal or non-verbal response to NA-G. NA-G stated to R16 she was checking on him and walked away from R16. NA-G did not offer or attempt to assist R16 with repositioning or toileting needs. -At 4:14 p.m. the nurse manager (NM)-A was notified by the surveyor that R16 had not been repositioned or offered assistance with toileting for a total of 3 hours and 4 minutes. NM-A approached R16 and asked R16 if she could bring him to his room. R16 initially shook his head no, NM-A asked R16 again if she could bring him to his room to change his position, R16 then nodded affirmatively and allowed NM-A to assist him to his room via wheelchair. NM-A requested the assistance of NA-C to aid in R16's cares. -At 4:17 p.m. NM-A and NA-C utilized a mechanical lift to transfer R16 out of the wheelchair. During the transfer, R16's bottom area of the pants were noted to be wet. The wet area was approximately 12 centimeters (cm) by 12 cm and circular in shape. NA-C and NM-A donned gloves and assisted R16 to move side to side in order to remove his sweat pants. R16 was wearing a white incontinent brief which upon removal was noted to be saturated with blood tinged, amber colored urine. NM-A confirmed R16's brief was saturated with urine and confirmed R16's incontinence had saturated his brief and onto his sweat pants. R16 was then assisted to move to his right side towards NA-C by NM-A and NA-C. R16 was observed to have a [MEDICATION NAME] ( an adhesive dressing consisting of a breathable non-woven top layer and a low-adherent absorbent pad,) dressing on his right buttocks gluteal fold. NM-A removed R16's [MEDICATION NAME] dressing, which was wet with urine on the outside, and R16 was observed to have an open area on the right side of his coccyx. -At 4:26 p.m. NM-A confirmed R16 had a stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured blister,) on his coccyx. NM-A stated R16 had a current urinary tract infection and indicated R16's skin under the [MEDICATION NAME] dressing was dry. NM-A changed gloves and cleansed R16's pressure ulcer. NM-A confirmed R16's stage 2 pressure ulcer measured 1.8 cm x 1.0 cm and was circular in shape. NM-A also confirmed R16's wound bed was covered with granulation tissue (red tissue with cobblestone or bumpy appearance, bleeds easily with injured) and had very little depth. NM-A then applied cream and dressed R16's wound with a new dressing. After pericares were completed and a clean brief applied, R16 was assisted to turn onto his left side. A scabbed wound was observed on R16's right hip area. NM-A stated the scab on R16's right hip was a stage 2 pressure ulcer and was left open to air. The pressure ulcer on R16's hip measured approximately 0.5 cm x 0.5 cm and had no redness. R16 had not been observed to be assisted or offered to reposition/offload for a total of 3 hours and 7 minutes. On 12/9/15, at 4:32 p.m. NA-C stated R16 needed extensive assistance with all cares which included repositioning and toileting needs. NA-C stated R16 was on an every 2 hour repositioning schedule and was supposed to be checked and changed for urinary incontinence as R16 was frequently incontinent of urine. NA-C stated she was not aware of the last time R16 was repositioned or checked and changed. NA-C stated she had attempted to care for R16 at around 4:00 p.m. by asking him to go for a ride, however R16 refused. NA-C stated the staff was unable to offer toileting or repositioning directly to R16 as he would refuse cares. NA-C stated R16 was often more compliant when they asked him to go for a ride. NA-C stated she was aware R16 had a pressure ulcer on his right hip and a newly developed pressure ulcer on the right side of the buttocks crease. NA-C stated R16 had always been on an every 2 hour repositioning schedule and there had been no change. NA-C stated they often would increase the frequency of repositioning of residents when they had pressure ulcers though R16's repositioning schedule had not changed. NA-C stated R16 was unable to make his needs known and staff needed to anticipate R16's needs such as toileting and repositioning. On 12/9/15, at 5:01 p.m. NM-A confirmed R16's current care plan and stated she was unaware of when R16 was last repositioned and had assistance with incontinence care. NM-A stated she thought R16 had refused assistance at 1:30 p.m. NM-A stated R16 had 2 current pressure ulcers, one on his right hip which was healing and one on his right gluteal fold which was first noted on 12/7/15. NM-A stated the intervention put in place at the time the new stage 2 pressure ulcer developed was to lay R16 in bed after meals on his left side or back. NM-A stated R16 often rolled onto his right side independently in bed. NM-A stated she expected R16 to be assisted with repositioning at least every 2 hours, and indicated R16 was often resistive with cares. NM-A stated staff were also expected at that time to check and change R16 for urinary incontinence. NM-A stated R16 was no longer able to feel the urge to void and was frequently incontinent of urine. NM-A confirmed R16 was at high risk for skin breakdown. On 12/09/15, at 5:08 p.m. NA-D stated he was unaware of when R16 had last been repositioned or assisted with incontinence cares. NA-D stated he had not attempted to assist R16 with repositioning or incontinence cares since he'd arrived on shift, around 2:00 p.m. NA-D stated R16 was dependent on staff for his needs and was on a every 2 hour repositioning plan and had current pressure ulcers. NA-D also stated R16 was on a check and change plan for incontinence which was to correlate with repositioning. NA-D stated R16 was often resistive with cares such as toileting and repositioning. NA-D stated R16 was not able to verbalize his needs and staff needed to anticipate needs. On 12/10/15, at 9:49 a.m. the director of nursing (DON) stated R16 was often resistive with cares so staff were encouraged to use alternative approaches for cooperation such as offering to take R16 for a ride. The DON stated R16 had continued to lose weight and refuse cares which increased his risk for pressure ulcers. She stated she thought R16's pressure ulcers may be unavoidable. In addition, the DON stated although R16 resisted cares at times, she expected staff to assist R16 with repositioning and checking/changing for incontinence every 2 hours. The DON verified she was aware R16 had a newly developed pressure ulcer to the right gluteal fold and had decided at that time to not increase R16's repositioning frequency due to R16's continued resistance with cares. The DON stated they were lucky if they could reposition R16 every 2 hours as R16 was unpredictable. The DON again confirmed R16 was at very high risk for skin breakdown and stated R16's overall condition was declining. The DON confirmed R16 had developed a pressure ulcer on the right hip 10/27/15, which was almost healed and at the present had another pressure ulcer on the right gluteal fold. On 12/10/15, at 10:18 a.m. NA-E stated she had offered cares to R16 on 12/9/15, at 1:30 p.m., this however was not observed by the surveyor. NA-E stated R16 required assistance with all cares which included repositioning and check and changing every 2 hours. NA-E stated R16 was at high risk for skin breakdown and at present had 2 pressure ulcers, one on the right hip and right buttocks (gluteal fold.) NA-E stated the last time R16 was assisted with cares on 12/9/15 day shift was 11:00 a.m., prior to the noon meal. NA-E stated R16 was frequently incontinent of urine and was not able to verbalize the need to void or other need. NA-E stated staff needed to anticipate R16's needs Review of R16's progress notes from 10/06/15 to 12/10/15 revealed the following: -A skin assessment dated [DATE], revealed R16 was at high risk for skin breakdown based on a Braden scale (a tool used to identify risk for developing pressure ulcers based on mobility, activity, nutrition, maceration and friction) identified R16 was at moderate risk for development of pressure ulcers. The assessment identified R16 required assistance of 2 facility staff with repositioning every 2 hours to prevent pressure areas. The assessment identified preventative measures that were in place at the time of the note including; repositioning, pressure reduction cushion in wheelchair and a standard pressure reduction mattress. The summary did not indicate R16 had pressure ulcers at the time of the assessment. -A weekly skin check note dated 10/14/15, revealed R16 had no pressure ulcers. -An initial skin/wound note dated 10/27/15, revealed R16 had a 1.0 cm x 0.5 cm open area to the right hip. The note identified R16's open area was caused by R16 laying on the right side and implemented a an air mattress on R16's bed. A daily dressing change was ordered of thera shield and Allevyn. The note lacked information of the tissue type that the ulcer had at the time of origin. -A skin follow-up note dated 10/28/15, revealed R16's right hip treatment included daily dressing changes, and to keep R16 repositioned off the hip when in bed. R16's right hip dressing was to be kept clean and dry. R16's right hip wound measured 1 cm x 0.5 cm. -A wound measurement note dated 11/2/15, identified R16's right hip wound was a stage 2 pressure ulcer, measured 0.9 cm x 0.7 cm x 0.0 cm. The note revealed R16's stage 2 pressure ulcer had 75% [MEDICATION NAME] tissue and 25% granulation tissue present at the time of the assessment. The note further revealed a change in R16's dressing to a Primafore dressing change every 3 days until healed. -A weekly skin note dated 11/3/15, revealed no new skin issues. -An initial skin/wound note dated 11/9/15, identified R16 had an open area on the upper inner thigh under the scrotum due to R16 scratching the groin area throughout the night. The note revealed monitoring would be initiated until healed and staff was to keep R16's finger nails trimmed. -A wound measurement note dated 11/9/15, identified R16's stage 2 pressure ulcer measured 1 cm x 0.5 cm x 0.0 cm, had 75% [MEDICATION NAME] tissue and 25% granulation tissue. The note revealed no changes in treatment and indicated R16's pressure ulcer was healing. -A skin follow-up note dated 11/9/15, identified R16's open area on the scrotum measured 0.5 cm x 0.5 cm and had no signs of infection. - A skin follow up note dated 11/10/15, revealed R16's open area on the scrotum continued to measure 0.5 cm x 0.5 cm and had no signs of infection. The note further revealed R16 was to receive a thera shield and [MEDICATION NAME] dressing to the area. -A wound measurement note dated 11/16/15, identified R16's stage 2 pressure ulcer measured 1.5 cm x 0.5 cm x 0.0 cm, had 75% [MEDICATION NAME] tissue and 25% granulation tissue. The note revealed the wound was slightly inflamed though had no other signs of infection. The note further revealed no treatment change to R16's stage 2 pressure ulcer. -A weekly skin note dated 11/18/15, revealed R16 had no new skin issues. -A skin/wound initial note dated 11/21/15, identified R16 had an open area to the right knee and had been determined to be caused by injury. -A wound measurement note dated 11/23/15, identified R16's stage 2 pressure ulcer measured 0.9 cm x 0.5 cm x 0.0 cm, had 75% [MEDICATION NAME] tissue and 25% granulation tissue. The note identified R16's right hip had a stage 2 pressure ulcer which was healing. -A weekly skin note dated 11/24/15, revealed R16 had no new skin issues. -A wound measurement note dated 12/1/15, identified R16's stage 2 pressure ulcer measured 0.7 cm x 0.5 cm x 0.0 cm, had 100% [MEDICATION NAME] tissue. The note revealed R16's pressure ulcer was healing and no treatment changes were made. -A weekly skin note dated 12/2/15, revealed R16 had no new skin issues. -A skin/wound initial note dated 12/7/15, identified R16 had a new open area on the right lower buttocks gluteal fold which measured 1.8 cm x 1 cm. The wound was assessed to have 100% slough tissue. The note revealed an analysis which identified R16 had declined and lost weight. The note identified a new intervention for R16 of staff assisting R16 to bed after meals on his left side or back. -A wound measurement note dated 12/7/15, identified R16's stage 2 right hip pressure ulcer, measured 0.5 cm x 1.0 cm and had 100% granulation tissue. The pressure ulcers surrounding skin assessed as red and measured 2.5 cm x 2.0 cm surrounding the open area. No treatment changes were indicated on the note. -A initial wound assessment note dated 12/7/15, revealed R16 had a 1.8 cm x 1 cm open area on the right gluteal fold of inner buttocks. The note identified R16 had an overall decline in condition and had lost weight. The assessment further revealed R16 was to be assisted to lay down after meals on the left side or back for pressure relief. The open area was left open to air. -A skin follow up note dated 12/7/15, revealed R16's open area to the right lower gluteal fold measured 1.8 cm x 1.0 cm, had no signs of infection and had been left open to air. -A skin follow up note dated 12/8/15, at 4:48 a.m. revealed R16's open area to the right lower gluteal fold measured 1.8 cm x 1.0 cm, had yellow slough noted in the center of the wound bed. The note further revealed R16's open area was left open to air and staff attempts to position R16 on the left side was ineffective as R16 would roll over to the right side. - An MD note dated 12/8/15, identified R16's open area to the right lower gluteal fold was a pressure ulcer and had received an order to increase R16's nutritional supplement to four times a day. -A skin follow up note dated 12/8/15, at 1:28 p.m. revealed R16's stage 2 pressure ulcer to the right gluteal fold was tender, had no change in measurements. The note further indicated R16 was to be encouraged to reposition and had tolerated repositioning at the present time. A physician progress notes [REDACTED]. Review of R16's unsigned physician orders printed 12/10/15, revealed an order with a start date of 11/7/15, to cleanse OA (open area) to R) (right) hip, change/apply [MEDICATION NAME] dressing every 3 days until healed. R16's physician orders lacked an order for [REDACTED]. Review of the facility policy titled, Repositioning in Bed and in a Chair/Appling (sp) lift sheets dated 4/2015, revealed the purpose of the policy included prevention of skin breakdown and providing pressure relief for residents. The policy directed facility staff to follow the residents care plan for specific repositioning needs in bed and in a chair. Review of the facility policy titled, Comprehensive Skin Care policy, revised 7/1/15, revealed a policy statement which included, a resident who had a pressure sore was to receive the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. The policy directed facility staff to provide skin care to keep skin clean and dry. The policy also directed facility staff to provide repositioning pressure relief per the residents care plan.

Based on interview and document review, the facility failed to provide the necessary emergency services of initiating cardiopulmonary resuscitation (CPR) for 1 of 1 residents (R1) who had a directive signed on [DATE], directing staff to initiate CPR when found unresponsive with no pulse or respirations. Findings include: Review of R1's medical record revealed R1 was admitted to the short term rehab unit on [DATE] with [DIAGNOSES REDACTED].) R1's admission nursing assessment, dated [DATE], indicated that R1 was alert and oriented with bouts of confusion with a discharge plan of returning home. R1's "Resuscitation Guideline" form, which the facility uses to identify the resuscitation directives of residents, was signed by R1 on [DATE], and directed staff to initiate CPR, call 911, and perform treatment as appropriate. A progress noted dated [DATE] at 5:30 p.m. revealed at 4:00 p.m., a nursing assistant (unidentified) reported to licensed practical nurse (LPN)-A that R1 had pain. It was not in the designated time for R1 to to receive pain medication, so LPN-A directed the nursing assistant to reposition R1 and provide a warm blanket, as alternative pain interventions. LPN-A entered R1's room at 4:20 p.m. to assess if the interventions were effective in reducing R1's pain. LPN-A found R1 unresponsive. LPN-A notified registered nurse (RN)-B, and RN-B assessed R1. R1 had no pulse or respirations. R1 was "very ashen gray in color, skin was cold to the touch, and (R1's) oral cavity was pale and cold to the touch." The "Patient seemed to have expired several minutes prior to nurses entering room, no CPR was performed." A progress note dated [DATE] at 5:42 p.m. revealed R1's body was released to the funeral home at 6:00 p.m. When interviewed on [DATE] at 1:05 p.m., nursing assistant (NA)-C stated that on [DATE], she responded to R1's call light around 4:00 p.m. and assisted R1 to bed. NA-C stated that she did not recall R1 having pain at that time, and gave R1 a urinal per R1's request. When NA-C returned at 4:15 p.m., R1 complained of pain. NA-C repositioned R1, and immediately reported R1's pain to LPN-A. When interviewed on [DATE] at 2:15 p.m., LPN-A stated that on [DATE], at approximately 4:00 p.m., NA-C reported that R1 had pain. LPN-A stated that R1 received scheduled pain medication, and did not have pain medication scheduled until 7:00 p.m. LPN-A directed NA-C to reposition and give R1 a warm blanket. When LPN-A entered R1's room at approximately 4:20 p.m., R1 was laying in bed, unresponsive. LPN-A stated that R1 was not breathing and did not have a pulse. LPN-A left the room to notify RN-B and review the chart for R1's resuscitation guidelines. While RN-B assessed R1, LPN-A informed RN-B that R1's resuscitation guidelines directed to initiate CPR. RN-B informed LPN-A not to initiate CPR as R1's fingers were stiff and R1's skin was ashen in color and cool to the touch. LPN-A confirmed that CPR was not initiated. LPN-A stated that she believed that CPR should have been initiated, but was a new nurse and looked for RN-B for guidance. When interviewed on [DATE] at 9:00 a.m., RN-B stated that she assessed R1 on [DATE] at approximately 4:15 p.m. R1 had no pulse or respirations. R1 was "purple" and R1's oral cavity was cold. RN-B stated that she attempted to place an oximeter probe on R1's finger and indicated that R1's hand was stiff. RN-B stated that she was unaware of R1's resuscitation status, but CPR should be initiated if a resident's resuscitation status is unknown. RN-B stated that CPR was not initiated related to R1's signs of death, and RN-B's determination that R1 would not benefit from CPR. When interviewed on [DATE] at 3:50 p.m. the director of nursing (DON) confirmed that R1 had signed the facility's resuscitation guidelines indicating CPR was to be initiated if no pulse or respiration. The DON interviewed RN-C regarding R1's death on [DATE], and RN-C stated that she was aware that R1's resuscitation guidelines directed to initiate CPR, but RN-C did not believe that she needed to initiate CPR as R1's last breath was not witnessed. The DON stated that licensed staff are expected to initiated CPR on all residents who's resuscitation guidelines indicate CPR. The DON stated that she would have expected CPR to be initiated on R1. When interviewed on [DATE] at 08:03 a.m., R1's physician (E) stated that R1 had signed the facility's resuscitation guidelines form and desired for CPR to be initiated. Physician E stated that he would have expected for staff to follow the facility's policy and initiated CPR and call an ambulance. The facility's policy with the current revision date of [DATE], titled "RESUSCITATION GUIDELINES AND ORDERS" revealed, at the time of admission, each resident will have a a "Resuscitation Guideline" form completed. The policy directed staff "...to initiate CPR unless otherwise indicated in documentation by the resident/patient, responsible party, legal representative or physician that DNR/DNI (do not resuscitate/do not intubate) is requested." "The decision for resuscitation will be made by the resident/patient when possible."

Based on observation, interview and document review, the facility failed to ensure manufacturer's guidelines and care plan interventions were followed to minimize the risk of injury for 1 of 4 residents (R24) reviewed for accidents. In addition the facility failed to ensure a safety assessment had been completed for 1 of 1 resident (R223) who utilized an ill-fitting mattress. This practice resulted in actual harm for R24. Findings include: According to review of nurses' notes, R24 (closed record) experienced a fall from a full body mechanical lift during staff assisted transfer from a reclining chair to a bed on 9/14/13, at 6:50 p.m. The facility had not followed the manufacturer's instructions for individualized assessment of the lift sheet selection, proper positioning of the lift sheet and care plan interventions during the transfer for R24. R24 sustained a laceration to the head, which required staples, a contusion to the left chest wall, and lower back pain. Review of R24's medical record identified R24 had [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], identified R24 had moderate cognitive impairment, had impairments on both sides of upper and lower body and did not ambulate. The MDS identified R24 required extensive assistance of 2 staff for all activities of daily living (ADL), including transfers, bed mobility and toileting. The Care Area Assessment (CAA), dated 9/3/13, identified R24 was 5 feet 8 inches tall and weighed 220 pounds, had memory problems,required verbal reminders, and utilized oxygen for episodes of shortness of breath. Further, the MDS identified R24 required assistance with ADLs and mobility and was transferred with assist from two staff and a full lift. R24's care plan, revised 9/30/13, identified a problem related to transferring with a goal for continued safe transfers with no falls or injury. The care plan directed two person transfers utilizing a maxilift (full body mechanical lift), and use of an amputee transfer/lift sheet for transfers. The care plan further directed staff to leave the lift sheet in place when in recliner per request, due to his discomfort while trying to place lift sheet in place when time to transfer to bed. Review of progress notes from 9/14/13, to 10/5/13, identified R24's fall in room on 9/14/13, at 6:50 p.m. while being transferred from recliner to bed. The note indicated R24 slipped out of the lift sheet resulting in his head landing on the floor and legs still entwined in the lift sheet. R24 had a laceration on the top of his head, complained of pain in the left lower rib area, and lower back. R24 was grimacing and stated it was painful when he inhaled. The note identified the root cause or source of occurrence of injury as "lift sheet too small." The progress note at 7:40 p.m., identified R24 had been transferred to the emergency room for treatment after the fall. Review of the emergency room physician documentation dated 9/14/13, identified R24 had slipped out of the lift, fallen, hitting the right side of his head on a dresser and hitting the right upper chest on the floor. R24 complained of head pain, and bilateral (both sides) lower rib pain, and new lower back pain. emergency room treatment included x-rays of the head, spine, abdomen, staples placed for the three centimeter (cm) head laceration and a narcotic pain medication was ordered for R24's pain. Review of the follow up documentation of the fall from the lift, completed by involved facility personnel revealed the following: - Nursing assistant (NA)-H identified R24 was seated in his reclining chair, staff placed the lift sheet around R24 and while R24 was in the air being transferred to the bed, with the use of the mechanical lift, he slipped out of the lift sheet and fell to the floor. NA-H documented no recent change in R24's condition, and R24 had not been trying to do anything. - NA-I identified R24 was in his chair when staff placed the lift sheet under him, as R24 was transferred he slipped out of the lift sheet. NA-I documented "he fell because the sheet slipped". NA-I documented no recent change in R24's condition, and R24 had not been trying to do anything. - Licensed practical nurse (LPN)-A identified the resident was being transferred from his recliner to his bed using the full body mechanical lift, when he slipped out of the lift sheet and hit his head on the floor. - A form titled Fall Investigation Form dated 9/14/13, identified prior to R24's fall on 9/14/13, at 6:50 p.m. staff had performed catheter care and changed R24, no unusual actives or behaviors were present 3 hours prior to the fall. The form included an identified concern with transfer technique had been documented as "possible that lift sheet is to small." -The director of nursing (DON) documentation of the fall identified R24's fall from a full body lift on 9/14/13, resulted in an emergency room visit for staples placed for a head laceration and [DIAGNOSES REDACTED]. NA-I and NA-H started to lift R24 with the mechanical lift, his buttock was out some on the left side of the lift, they pulled it down and continued with the transfer. R24 was noted to lean to the right and as he was moved near the bed, R24 moved and slid out of the lift sheet to the floor. The documentation indicated after the fall, NA-I and NA-H were instructed the lift sheet was to remain under R24 at all times when up, and a larger lift sheet with 3 hooks on each side was to be used for resident safety. - Registered Nurse (RN)-A's fall follow up documentation dated 9/19/13, identified LPN-A, NA-I, and NA-H, were re-educated on the importance of correct lift sheet size use, correct way to apply the lift sheet to R24, and the correct application of the lift sheet to the full body lift. However, the facility lacked documentation that all nursing staff were educated on the proper size selection and positioning for lift slings. An e-mail (electronic mail) correspondence, provided by the facility, from the director of nursing (DON) to the administrator, dated 9/15/13, at 4:00 p.m. identified R24 care plan included the need for a lift sheet to remain under him, however it had been removed and staff had placed a lift sheet under him prior to use of the lift. The e-mail further identified the "NA felt that maybe the lift sheet wasn't placed as evenly on both sides as it should have been so when he leaned to the left side he fell out of the sheet." The e-mail indicated the NA stated a larger sheet, one with three hooks on each side should be used as it would be "much safer" for R24. Review of the medical record revealed the care area assessment (CAA) dated 9/3/13, identified R24 utilized a full body mechanical lift for transfers, however the record lacked documentation of an assessment for lift sheet sizing or type for R24. No further assessments of proper sling use or sizing was found in the medical record. During interview on 2/13/14, at 1:30 p.m. the assistant director of nursing (ADON) confirmed R24's care plan and confirmed R24 had fallen while transferred with the full body lift, which resulted in injury for R24. The ADON stated an investigation had been completed and determined the lift sheet was "too small." The ADON further confirmed the staff involved with this incident were reeducated after the fall. During interview on 2/14/14, at 9:21 p.m. registered nurse (RN)-A indicated R24's fall was due to use of a lift sheet that "was too small." RN-A was not aware what lift sheet type or size was used during R24's transfer and was not aware why a lift sheet which was too small had been used. RN-A confirmed that no documented assessments for lift sheet size were performed. She stated she was not aware of a specific person in charge of choosing the correct lift sheet size for residents and stated the individual lift sheets used for transfers were chosen by any staff member including the nursing assistants. Once the lift sheet was placed in a residents' room for use, the lift sheet remained there unless it needed laundering. RN-A indicated at times physical therapy would assess and recommend use of the mechanical lift for resident transfers. However, therapy would not recommend a specific size of lift sheet for the individual residents. RN-A stated she instructed staff involved with R24's fall on the proper size lift sheet for each resident and reviewed how to apply a lift sheet. She indicated all nursing staff completed an annual competency review of mechanical lift use. RN-A indicated she was unaware of how the sizing of the lift sheets were determined and stated, "I think they are color coded." During interview on 2/14/14, at 10:02 a.m. the administrator confirmed R24's care plan at the time of the fall, and confirmed the findings in the investigation of the fall. The administrator was not aware of the reason R24 did not have a lift sheet under him or why a lift sheet which was too small had been used during the transfer. The administrator confirmed the current facility policy and stated the DON was responsible for the follow up of the fall and had done so. During interview on 2/14/14, at 11:03 a.m. LPN-E confirmed the manufacturer's guidelines for lift use and Positioning Instructions & Sling Application Guide, and stated these were in a cloth pouch on each mechanical lift, to be available for staff reference. During interview on 2/14/14, at 12:23 p.m. the ADON confirmed she would expect the manufacturer's guidelines for mechanical lift use were to be followed by all staff. The ADON confirmed staff were expected to follow care plan interventions. Review of the product information provided by the facility revealed the manufacturer's guidelines from T.H.E. Medical, professional patient care products titled Sling Models and Specifications listed various models for use with sizing and average weight guidelines. However, the form identified weight guidelines were approximate only, and identified proper sizing depended more on patient body composition (muscle tone, medical condition, % of body fat etc.). The specifications directed patient assessment to be performed on a case by case basis to ensure safe sling sizing. Review of the literature attached to the facility mechanical lifts revealed the following: - Operating Instruction's Manual, Ultralift 2500X/3500X dated 8/23/07, revealed various instructions which included running the boom and maintenance of the lift. However, the manual did not include instructions for proper sizing, placement and use of the lift sheets using with the mechanical lift device. - Patient Positioning Instructions and Sling Application Guide, undated, by T.H.E. Medical Professional Patient Care Products, included instructions for positioning for proper placement of a sling and directed to ensure the sling is properly centered under the patient. The facility's policy titled Safe Patient Handling /Limited Lift Policy, review date 5/2013, indicated initial screening was required on all residents to assess transfer status. The policy also indicated a registered nurse should perform the assessments with the potential assist of physical therapy, and a charge nurse or nurse manager was responsible for changes to the care plan. Review of the facility form titled, Competency Checklist, Maxi Mechanical Lifts, dated 6/27/12, listed Critical Elements for use of the mechanical lift during transfers. However, the competency checklist did not include elements related to proper sizing of the slings to be used for residents. R223 utilized one side rail and had a mattress that was not compatable with her bed frame, potentially exposing gaps with the risk for entrapment, without assessment of her safe use of these atypically matched devices. R223's hospital admission records dated 1/24/14, revealed she had a history of [REDACTED]. The admission MDS dated [DATE], identified R223 was cognitively intact and required extensive assistance of one with bed mobility and transfers. Review of the care plan dated 1/24/14, indicated R223 required assistance of one staff for dressing, ambulation, and transfers. The care plan did not address bed mobility. During observation on 2/11/14, at 12:29 p.m. R223 was on the bed, lying on her back. R223's eyes were closed and a silver colored one-half side rail was noted on the outer side of the bed, in the upright position. The mattress on R223's bed was observed to be shorter than the length of the bed. There was a four inch gap from the head of the bed to the top of the mattress. On 2/11/14, at 3:25 p.m. NA-A stated R223 required one assist with transfers and utilized a walker with an arm raiser on the walker due to her fractured arm. NA-A added, R223 required one assist to sit up in bed and was independent in bed mobility. On 2/11/14, at 4:07 p.m. the ADON confirmed the mattress on R223's bed was too small for the bed frame. However, the ADON indicated she was not previously aware she had an ill-fitting mattress. The ADON verified no assessment had been completed to evaluate R223's safety with use of the ill-fitting mattress. She added, she expected the correct mattress to be used for each bed. On 2/11/14, at 4:10 p.m. RN-B confirmed R223's mattress was not compatible with the bed frame. However, she was not aware how the mismatch occurred. During observations on 2/12/14, at 7:10 a.m. and 7:27 a.m., R223 was lying in bed with the same ill-fitting mattress. At 7:46 a.m., the ADON confirmed the mattress had not yet been changed. At 8:07 a.m., R223's mattress was replaced with a mattress that was appropriate for the bed frame. On 2/12/14, at 8:07 a.m. the certified occupational therapy assistant (COTA) said they were working with R223 with ADLs, transfers in and out of bed, and toilet transfers. The COTA indicated R223 required a minimal amount of verbal cues from staff and required standby assistance of one. The facility did not have a policy for correct mattress sizing but used the undated, manufacturer guidelines for bed assembly instructions. The guidelines indicated the Maxxum bed had been designed to minimize the risk of entrapment and the side rails worked together with the mattress to minimize the gaps exposed to during normal use. In addition, it directed it was up to the end user to determine whether a different mattress was suitable for minimizing entrapment risks.