Every finding on record at Lake Pleasant Post Acute Rehabilitation Center

Based on closed record review, staff interviews, review of facility process and policy the facility failed to ensure that all transfer/discharge notifications were made for one resident (#130). The sample size was four. The deficient practice could lead to notifications and pertinent information regarding the discharge/transfer not being provided.Findings include:Regarding Resident #130 -Resident #130 was admitted to the facility on [DATE] with diagnoses of orthopedic aftercare following surgical amputation, anemia, adjustment disorder, muscle weakness, and dysphagia. An admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. Additionally, the BIMS documented that the resident received physical therapy, occupational therapy, and speech therapy while at the facility. A physician order dated December 5, 2025 indicated that the resident would be discharged to a group home on December 9, 2025. A Discharge Summary - Nursing note dated December 5, 2025 revealed that the resident's planned discharge is on December 9, 2025. The note indicated that the discharge instructions were provided to the resident/resident representative. The note documented that the resident will be discharged to an assisted living group home. The note listed the contact information for the ombudsman. However, the note did not indicate whether a copy of the discharge notification was provided to the ombudsman. The discharge MDS assessment dated [DATE] revealed a planned discharge marked return not anticipated. The resident was noted to discharge to home/community. The Discharge Summary and Post-Discharge Plan of Care dated December 9, 2025 documented the reason for discharge as resident's health had improved sufficiently and that the resident no longer needed the services of the facility. The Notice of Proposed Transfer/Discharge dated December 9, 2025 indicated that the resident was transferred to an assisted living group home. The form indicated that the notice was provided on December 9, 2025. Additionally, the notice revealed that the State Agency (SA) was listed as an appeals authority. However, the SA is not an appeals authority for transfer/discharge issues. Review of the resident's clinical records did not reveal documentation that a copy of the proposed transfer/discharge was provided to the ombudsman. Additionally, review of the facility documentation did not reveal documentation that a copy of the proposed transfer/discharge was provided to the ombudsman. A Case Manager note dated December 9, 2025 documented that a denial letter was received from the insurance company and a copy was provided to the resident with instructions on how to appeal. Another Case Manager note dated December 9, 2025 indicated that resident was unable to provide information to go on private pay and case management spoke with resident to discuss discharge plan. The note revealed that the resident agreed to discharge to a group home the same day. A Case Manager note dated December 9, 2025 documented that the resident discharged to a group home. An interview with the facility's Ombudsman (staff #200) was conducted on February 23, 2026 at 12:00 p.m. The Ombudsman stated that she receives a monthly list of who discharges. However, she had not received any copy of discharge notices provided to the resident/resident representative. The Ombudsman indicated that she has informed the facility that per regulation, she should receive a copy of the notice of discharge but the facility has not complied. Per the Ombudsman, due to this, she does not get informed about the discharge until after the resident has already left the facility. An interview with the Discharge Planner (staff #124) and Case Manager (staff #110) was conducted on February 25, 2026 at 11:43 a.m. Staff #110 said that the notice of proposed discharge/transfer is given to the nurse so that it can be given to the resident on the day of discharge. Staff #110 stated that a copy of the notice of proposed discharge/transfer is not given to any outside agency. However, it is sometimes provided to the resident's insurance company if requested. Staff #110 said that it is important to provide the notice of proposed discharge/transfer so that residents know where they are going and what the plan is. Staff #124 stated that discharge plan can sometimes change so notification is important in order for arrangements to be made. Staff #124 noted that the impact of not providing the notice of proposed discharge/transfer is that the resident would not have information and resources. Per staff #124 it is Social Services (staff #166) that sends out ombudsman notification. An interview with the Social Services Director (SS Dir/staff #166) was conducted on February 25, 2026 at 12:02 p.m. Staff #166 stated that she sends the ombudsman notification via email at the end of the month with a list of the discharge/admission and hospitalization report. Staff #166 also keeps a copy of what she sends in a binder. Staff #166 stated that she does not send the ombudsman a copy of the proposed discharge/transfer because she had never been told that she had to. Staff #166 noted that she had seen the form. Additionally, she is not given a copy of the form as it is directly uploaded into the resident's record. Per staff #166 ombudsman notification is important because the ombudsman is part of patient advocacy. The notification enables the ombudsman to be another resource and advocate for the resident. The impact of not notifying the ombudsman about the discharge/transfer is that the ombudsman will not be in the know and there can be a concern and the ombudsman will be unable to follow-up on that concern. In a follow up interview with staff #124 conducted on February 25, 2026 at 12:20 p.m., she stated that the use of the Notice of Proposed Transfer/Discharge started about a month ago. She was unable to say where the information regarding the appeals authority came from or who provided them the form for sure. During an interview with the Director of Nursing (DON/staff #40) conducted on February 25, 2026 at 12:27 p.m., staff #40 stated that ombudsman notification is sent monthly. The DON said that the notification is sent by the SS Dir and the information consists of name resident, date of transfer, and where resident is discharged . The DON stated that the importance of the notification is for coordination of care and for the purpose of ombudsman follow-up if needed. Per the DON she does not think that there is an impact if ombudsman notification is not accomplished since the ombudsman info is provided to the resident during discharge notification. The DON was not aware that a copy of the discharge/transfer notification had to be given to the ombudsman. Additionally, the DON noted that the form they are using had been there for awhile and was not aware that it contained erroneous information related to the appeals authority. The facility policy titled Discharge or Transfer reviewed May 2025 indicated that it is the policy of the facility to provide the resident with a safe, organized, and structed transfer and or discharge. Further review of the facility's policy for discharge/transfer did not reveal that it addressed transfer/discharge notification to resident/resident representative. Additionally, the policy did not indicate what the required information are that is to be provided to the resident/resident representative, and the ombudsman.

Based on observations, staff interviews, review of facility documentation and policies and procedures, the facility failed to ensure that food was prepared, stored, distributed and served in accordance with professional standards for food service safety. The deficient practice could result in food- borne illness.Findings Include: Regarding Kitchen Cleanliness-An initial kitchen observation was conducted on February 23, 2026 at 8:12 A.M. in conjunction with kitchen staff #86. During the initial observation it was observed that floor had several areas of dark matter that appeared to have accumulation in the corners of the tile floor. It was observed that a square, depressed area under the dish sink had black matter that appeared wet within its perimeter. Various pieces of solid debris were located in this area. Visible debris was observed on the floor under food preparation counters. A gray, brown matter was observed covering the vent covers over the area where the food carts were stored in preparation for tray transportation to the units. An observation of the roll up door on the wall adjacent to the tray line revealed the hinges appeared to be rusted with an orange and brown substance on them. The painted wood under the roll up door had several areas of chipped paint along the length of the wood. An observation of the walls behind and adjacent to the dishwasher revealed many black spots.The follow up observation of the kitchen area on February 24, 2026 at 11:18 revealed the peeling paint and rusty hinges in direct proximity to the tray line, where food was plated to be served to the residents. Black matter and debris were visible in multiple areas of the floor, including no change to the appearance of the depressed area under the dish sink. Additionally, black spots were noted on the wall behind the dishwasher and a sticky brown substance was noted on the side of the range .The vents above the food carts appeared unchanged.Regarding Unit Nourishment Refrigerators-An observation on the 300 hall was made on February 24, 2026 at 12:44p.m. of the nourishment refrigerator accompanied by certified nursing assistant (CNA/ staff #176). A container of whole milk with a first name and no open date or use by date was observed. The bottom area of the refrigerator had several spills, differing in color. Upon this observation, staff #176 stated that the cleaning people should have cleaned the refrigerator and the milk should have been dated with an open and use by date. She was unclear as to how to determine the use by date on resident's food.An observation of nourishment refrigerator on the 200 hall was made on 12:49 p.m. on February 24, 2026 with CNA /staff #56. During this observation, a box of frozen tacos and a quart container of ice cream were found in the freezer area. Both were open with no open date or use by date on the containers. It was noted that the tacos were not individually wrapped and the ice cream was not in individual servings within the container. An observation of the freezer revealed several spills and small pieces of debris along the bottom of the freezer and on the freezer door shelves. An interview was conducted at that time, and CNA /staff #56 stated that the receive date, open date and use by date should be on the containers. She stated that once opened, the food should be served for 3 days and then discarded. Staff #56 further stated that the freezer appeared dirty and should have been cleaned. She stated that the kitchen staff was responsible to check for outdated food and the housekeeping staff were responsible to clean the refrigerator and freezer.A walk through of the kitchen along with a concurrent interview was conducted with the kitchen manager/ staff #138 on February 24, 2026 at 1:16 pm. The condition of the kitchen floor and walls were observed to be unchanged since the initial and follow up kitchen observations. He stated that he has been the kitchen manager for approximately 3 months. He stated that he had not created a kitchen cleaning schedule yet and is not aware of any cleaning schedule in place during the previous kitchen managers tenure. He stated that the floor appeared dirty with accumulation in the corners and under tables and equipment. He stated that the floors should be swept daily and mopped nightly. He further stated that he assumed that kitchen staff were doing those tasks however, he was not sure that the kitchen staff actually completed the cleaning. Staff #138 confirmed that the depressed area under the dish sink has a wet, dark substance within the area and it also contained various debris. The wall behind the dishwasher and under the dish area had dark spots all over the wall area. He stated that the area should also be cleaned but behind the dishwasher was hard to reach, He stated that the vents above the food carts were not clean and he was not sure who was responsible to clean them. He further stated that the sticky substance along the top and side of the stove was the cook's responsibility to clean and it was not done. He further stated that the rust on the roll up door as well as the chipping paint were a concern due to the proximity to the food service. He stated that those items may fall into the food and cause contamination. Staff #138 stated that the state of the kitchen and its cleanliness does not meet his expectations. He stated that a kitchen should be clean and he has been working on improving the cleanliness. He stated the cleanliness of the kitchen was much worse under the last kitchen manager and he has tried to make improvements.Staff #138 stated that upon viewing the nourishment refrigerators, they both needed to be cleaned by kitchen staff. He stated both refrigerators/freezers did not meet his expectations as they were not clean, He further stated that the undated items were put in by the CNAs and they have been told repeatedly that all items must be dated once opened. Items are thrown away by kitchen staff 3 day after opening.A review of the policy Resident/Personal Food Storage( revised 1/2026) revealed that food storage areas should be clean at all times and that designated staff will monitor foods and beverages brought in from outside sources. It further revealed that food will be handled according to safe food handling guidelines.A review of a document titled Daily Kitchen Cleaning Duties (undated, no author) revealed that to stock and clean nourishment fridges and to sweep and mop were included in the daily duties.No policy was available for kitchen cleaning or nourishment refrigerator cleaning.No schedule was available for the nourishment refrigerators or kitchen cleaning.

Based on clinical record review, staff interviews, facility policy and the Resident Assessment Instrument (RAI) manual , the facility failed to ensure MDS assessment for 2 of 3 sampled residents (#21 and #100) were accurate. The deficient practice could result in assessment inaccurately reflects the resident's status. Findings include:-Resident #100 was admitted on [DATE] with diagnoses of pathological fracture in neoplastic disease, benign neoplasm of left adrenal gland, cerebral palsy and muscle weakness. The face sheet of the clinical record revealed the preferred name of Resident #100. The clinical census sheet of the clinical record included the preferred name of Resident #100. The resident's insurance card on file revealed the resident's preferred name. The Resident #100's driver's license and Medicare card included that resident's legal name. The admission and 5-day MDS (Minimum Data Set) assessments dated October 8, 2025 revealed that the resident's legal name was entered in the A0500 -Legal name section of the MDS. The facility documentation revealed that this assessment was accepted in the QIES system on October 9, 2025. Review of the clinical record revealed that the resident was discharged to a group home on October 31, 2025. The Discharge MDS assessment dated [DATE] revealed the resident had a planned discharge to a home under care of organized home health service organization with return not anticipated. However, the resident's preferred name was documented under A0500-Legal Name section instead of the resident's legal name. Review of the clinical record revealed that a modification of Discharge MDS assessment was modified only on February 24, 2026 to change the A500 Legal Name section to reflect the resident's legal name. -Resident #21 was admitted on [DATE] with diagnoses of encephalopathy, polyneuropathy and UTI (urinary tract infection). The face sheet of the clinical record revealed the hyphenated last name of Resident #21. The insurance authorization form included part of the resident's hyphenated last name. The form also indicated that the hyphenated last name was also known as the resident's legal name. The State Medicaid eligibility information revealed part of the hyphenated last name of Resident #21. The facility's census list included Resident #21's hyphenated last name. The facility profile form revealed the resident's legal last name. The admission MDS assessment dated [DATE] coded for the resident's legal last name. The quarterly MDS assessment dated [DATE] coded for the legal last name of resident #21. However, the discharge MDS assessment dated [DATE] coded for the resident's hyphenated last name. An interview was conducted on February 25, 2026 at 2:33 p.m. with the MDS Coordinator (staff #150)who stated that she checks the dashboard daily for any admission the day before, will open an entry MDS on the day of admission and will open a comprehensive admission assessment for 7 days. She stated that when completing the MDS assessment, she uses all the information in their electronic record (PCC) including therapy documentation/notes, conducts bedside assessment and interviews the resident. She stated that when she goes to see the resident she would verify the identity of the resident by asking the resident their last name and ask them to tell her what their name is and what they preferred to be called. The MDS coordinator stated that Section A0500 in the MDS is auto populated with whatever name was entered in their electronic record system; and that, this section referred to the resident's legal name. She stated that the MDS has A1300 that allows her to enter the resident's preferred names. Regarding resident #100 and #21, the MDS Coordinator stated that completed the admission MDS assessments for both residents using their legal name; however, somehow the legal name on A0500 was changed to the residents preferred name on succeeding MDS assessments for both residents. Further, she stated that she did not complete the discharge MDS assessments for both resident #100 and #21; and did not know who did. An interview with the Director of Nursing, with the CR and CMR present, was conducted on February 25, 2026, at 4:06 p.m. The Corporate MDS Resource stated that they do not manually enter the resident's name in the MDS; the record system automatically populates it. She explained that MDS allows staff to enter a resident's preferred name and said she did not understand why this issue was triggered during the survey task. The DON stated it was surprising that the system did not recognize the assessment as referring to the same resident, even though the preferred name was used and the same Medicare ID and Social Security number were entered. Regarding Resident #100, the DON stated that the Medicare card listed the resident's legal name; and that, the resident's family reported the resident had changed her name while she was working. According to the DON, Resident #100 changed her name because she was tired of being identified as male due to her name. The DON further stated that this was the reason the insurance card listed the resident's preferred name. Regarding resident #21, the DON stated she does know what happened but that the record showed the resident had a hyphenated last name. The RAI manual coding instructions included to code the legal name of the resident in section A0500. Legal Name was defined as Resident's name as it appears on the Medicare card; and, if the resident is not enrolled in the Medicare program, use the resident's name as it appears on a Medicaid card or other government-issued document.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#148) received care and treatment in accordance with professional standards of practice regarding intravenous antibiotic treatment. The sample size was 16. The deficient practice has the potential to cause the wound not to heal and increase the spread of infection.Findings include:-Resident #148 admitted to the facility on [DATE] with diagnoses of sepsis. A hospital Physician Progress Note dated February 16, 2026 documented that resident #148 will be discharged to a SNF (skilled nursing facility). Per the note, the resident had sepsis secondary to a right lower extremity diabetic wound infection with osteomyelitis. The resident al had MRSA (methicillin resistant staphylococcus aureus) and enterococcus bacteremia. The note indicated that resident is on broad spectrum intravenous antibiotics. The note indicated that the resident will need intravenous antibiotics at discharge. The note also indicated that PT (physical therapy). The Patient Discharge Instructions from the hospital printed February 18, 2026 documented that resident #148 was prescribed Vancomycin 1.25 g (grams)/250 mL (milliliter)-NaCl (sodium chloride) 0.9% intravenous (IV) solution. The instructions indicated 1250 mg (milligrams) IV continuous infusion with HD (Hemodialysis) on HD days through March 20, 2026. The instructions revealed that the resident had diagnoses of diabetic ulcer of the foot, MRSA infection, osteomyelitis, and sepsis.A Nursing note dated February 18, 2026 documented that the resident admitted from the hospital with diagnoses of osteomyelitis. The note indicated that resident was alert and oriented x 4 meaning he is fully conscious and aware of person, place, time, and situation.The Order Summary Report revealed an order dated February 18, 2026 which prescribed Vancomycin HCI (hydrochloride) Intravenous Solution. The order directed to use 1.25 gram intravenously one time a day every Tuesday, Thursday, and Saturday for sepsis until March 20, 2026 at 11:59 p.m. The order indicated to send IV ABX (antibiotic) to dialysis. Additionally, another order directed for Vanco (Vancomycin) IV and all labs related to IV ABX be monitored by the dialysis center. Review of the resident's progress notes did not reveal any documentation of whether he received or did not receive IV ABX on February 19, 2026 (Thursday) during his scheduled HD appointment.A care plan initiated on February 20, 2026 revealed that the resident is on IV antibiotic therapy related to sepsis. The care plan noted that the condition was on admission and the treatment is to be administered at HM. Interventions indicated to administer medication as ordered, monitor every shift for adverse reaction, observe for possible side effects, and report pertinent lab results to physician. An NP (Nurse Practitioner)/PA (Physician Assistant) Progress Note dated February 20, 2026 documented that on February 19, 2026 the resident was seen for consult regarding right foot osteomyelitis/diabetic foot infection complicated by prior MRSA/enterococcus bacteremia. The note indicated that resident was receiving IV vancomycin with hemodialysis (Tuesday/Thursday/Saturday) and is tolerating therapy without reported adverse effects.Additionally, an eMAR-Medication Administration Note dated February 20, 2026 documented that resident vitals are within normal limits and that resident was Receiving Iv Abx per order.An NP/PA Progress Note dated February 21, 2026 documented that NP was notified by nursing staff that resident was at HD and that the HD center was unable to administer vancomycin provided by the facility. Per the note, the NP spoke with nurse at the HD center who stated that the vancomycin order had to be faxed to the HD center. The note indicated that the IV ABX will not be administered that day with the next expected dose to be administered at next HD appointment on Tuesday.An eMAR-Medication Administration Note dated February 21, 2026 documented that a report was received from the dialysis nurse that the scheduled dose of vancomycin was not administered during dialysis session due to medication not being approved by the dialysis physician and pharmacy. The note indicated that the attending physician was notified of missed vancomycin dose. The note also documented that the SNF was awaiting further orders regarding antibiotic administration and clarification with dialysis pharmacy and physician.During a screening interview with resident #148 conducted on February 23, 2026 at 10:00 a.m., resident #148 stated that he transferred from the hospital to the facility to receive dialysis and antibiotic treatment for his foot wound. Resident #148 said that the IV antibiotics were supposed to be administered during dialysis. However, he has had two dialysis treatment and his antibiotics had not been provided. He had missed two sessions of antibiotic treatment. Per the resident he informed everyone - facility staff and State Medicaid Agency. However, there has been no resolution thus far. The resident stated that his dialysis days are Tuesday, Thursday, and Saturday. So far, during his Thursday and Saturday appointment, he was not given his antibiotic treatment.A Nursing note dated February 23, 2026 documented that the DON spoke with the dialysis center to coordinate continued care for resident's antibiotics. Per the dialysis center, the nephrology consult indicated for facility to get PICC line placed and manage the ABX in house at the SNF on dialysis days per original order. The note indicated that the PICC line was ordered and provider notified that Vanco will be given on site tomorrow February 24, 2026. Orders placed to draw a random trough for Vanco monitoring levels. The resident was placed on change of condition monitoring due to missed doses of antibiotic for monitoring purposes.The Order Summary Report revealed the following orders dated February 23, 2026:- Place central line to LUE (left upper extremity) midline/PICC (Peripherally Inserted Central Catheter) line related to Vanco therapy one time only for Vanco therapy for 1 day.- Vancomycin HCl Intravenous Solution. The order directed to use 1.25 gram intravenously in the afternoon every Tuesday, Thursday, and Saturday for sepsis until March 20, 2026 at 11:59 p.m. The order indicated that it is to be given after resident returns from dialysis.- Vanco-Trough one time only related to other specified sepsis until February 23, 2026 at 11:59 p.m. Random trough to be drawn for Vanco dosing.An order dated February 24, 2025 indicated Vanco trough before dialysis one time only for 1 day. Further review of the Order Summary Report did not reveal an updated order for monitoring of IV ABX after the administration of the medication changed from the dialysis center to the facility.Additionally, further review of the care plan did not reveal any revision addressing the change in administration of treatment from HM center to the facility. The care plan still reflected that IV ABX was administered at HM center. A NP/PA Progress Note dated February 24, 2026 documented that resident was seen that day for follow-up for right diabetic foot osteomyelitis and history of MRSA/enterococcus bacteremia. The note indicated that it was identified that the resident had not been receiving scheduled IV Vancomycin after HD sessions.Review of the February 2026 Medication Administration Record (MAR) revealed that the order for Vancomycin HCI Intravenous Solution with order date of February 19, 2026 had the following entry:Marked X on February 19.Coded as 7 meaning Other/See Nurse Notes on February 24.An eMAR-Medication Administration Note dated February 24, 2026 documented that resident complained that he should have gotten his Vanco at HD today but did not receive it.The IV Medication Administration Record documented that Vancomycin HCl Intravenous Solution was administered on February 24, 2026 at 4:32 p.m. on the resident's left arm.A follow-up interview with resident #148 was conducted on February 25, 2026 at 2:48 p.m. Resident #148 stated that he finally received his antibiotic treatment last night. The antibiotic treatment was provided in the facility after dialysis treatment. The resident reiterated that prior to last night's treatment, he missed two sessions of IV ABX treatment. An interview with the Dialysis Center's Administrative Assistant (staff #201) was conducted on February 26, 2026 at 9:06 a.m. According to staff #201 the dialysis center was not aware that resident #148 required IV ABX until he came in for his dialysis appointment on February 19, 2026 with the IV ABX. Staff #201 said that per the center's policy, if the medication/treatment is not part of dialysis treatment then the center have to be provided cultures if drawn, receive an order from the physician, and the IV has to come directly to the dialysis center and not from the resident. In the case of resident #148, the resident's infectious disease doctor put progress note regarding the treatment but he was not a practicing doctor at the center and with the medication brought in by the resident the dialysis center cannot administer it. Staff #201 said that she called the hospital case manager but due to the resident already being discharged it was out of the case manager's control. The SNF did not coordinate or contact the dialysis center prior to the resident showing up on February 19 for his scheduled dialysis appointment to verify that treatment can be provided. Staff #201 stated that she called the SNF on February 19 and February 20 to coordinate treatment, asked for the order, and determine if the SNF's pharmacy could deliver the IV ABX directly to the dialysis center. Staff #201 noted that there was no communication with the SNF to inform the dialysis center that the resident discharged from the hospital and will need IV ABX. Staff #201 noted that SNFs normally verifies chair time and schedule, and informs the dialysis center if there are issues that will affect how the resident dialysis. Per staff #201 the resolution ended up being that the resident was given IV ABX at the SNF which was on February 23 after he was cleared to get a PICC line. Staff #201 said IV ABX is important since the resident had a wound on the foot that required that treatment. The impact of the IV ABX not being provided as ordered is that the resident could get re-admitted to the hospital. During an interview with a Licensed Practical Nurse (LPN/staff #58) conducted on February 26, 2026 at 10:36 a.m., staff #58 stated that orders for admitting residents are entered into the system at least an hour before the resident arrives. Staff #58 said that she enters orders into the system as soon as she receives the documents. Per staff #58 when she received the orders she inputted that resident #148 was to receive Vanco and copied the orders and follow-up lab. Staff #58 indicated that she believed she spoke with the dialysis center last Friday to ensure that the Vanco was administered. Staff #58 noted that the medication was at the facility the day that the resident was supposed to go on his first day of dialysis (since arriving at the facility). However, the resident brought the medication back with him. Staff #58 said that she followed-up because she was concerned that it was not administered. Staff #58 stated that she had only dealt with a situation in which the resident had additional treatment that had to be done at the dialysis center once previously. According to staff #58 she assumed that if the medication was sent unopened with the order that it would be administered by the dialysis center. Staff #58 said that resident #148 was supposed to be administered Vanco because he had a foot ulcer/osteomyelitis. Per staff #58 the impact of the resident not receiving Vanco is that a delay in treatment means delay in healing. According to staff #58, facility staff reached out to the dialysis center to coordinate the care after it was determined that the resident had not received his ABX. Staff #58 said that her main job is to set up residents for their admission. It was then the floor nurse's job to ensure that that dialysis went as planned. Staff #58 noted that there should be a progress note if there was an issue with the dialysis treatment on the day that it happened. Additionally, staff #58 indicated that she is unsure if the MAR should have had an X marked on the day that treatment was supposed to be given. However, it was her, then she would have coded it appropriately with a corresponding progress note. An interview with the Nurse Practitioner (NP/staff #202) was conducted on February 26, 2026 at 3:12 p.m. Staff #202 stated that if a resident has an order to receive treatment in addition to dialysis treatment at the dialysis center then she expects the SNF to coordinate with the dialysis center since each dialysis center have different policy/procedures. The NP noted that she expects the SNF's admission nurse to coordinate and ensure that the additional treatment can be provided at the dialysis center. Furthermore, the NP stated that she expects that the resident gets the treatment as ordered. The NP said that Vancomycin is used for osteomyelitis or infection. It is important for the resident to receive ABX since it is managed by the infectious disease doctor to treat infection. The impact of not receiving ABX as ordered is that it can worsen the infection or prolong the infection. It is inappropriate for the resident to not receive ABX as ordered since it would extend the treatment. In the case of resident #148, she was at the SNF doing rounds while the resident was at dialysis and she was informed by a nurse that the dialysis called and explained that they could not administered the ABX. The NP stated that the resident missing his ABX treatment did not meet her expectation. However, she commented that she was not surprised because it is common that there is a delay when the treatment had to be coordinated with the dialysis center. Regarding resident #148, he ended up getting a PICC line placed and the ABX ended up being administered at the SNF after dialysis. The NP stated that she is unsure if the delay will result in the course of treatment being extended.During an interview with the Director of Nursing (DON/staff #40) conducted on February 26, 2026 at 3:41 p.m., staff #40 stated that her expectation is that the admission nurse transcribe orders from hospital, meet resident when they arrive, conduct assessments, document admission notes, obtain consents, and coordinate with provider and family regarding care/issues. The DON stated that with regards to treatment administered at the dialysis center, it depends on the resident and the center. When the resident is first admitted to the facility, the admission team will find out about dialysis and coordinate with the unit clerk, set up transportation, and nurse put it the orders. However, the hospital normally coordinates the additional treatment that would need to be administered at the dialysis center. The DON said that typically, once the resident goes to the dialysis center, the center contacts the facility if there are any questions or if there is something unusual. The IV ABX order for resident #148 was transcribed as ordered. The DON noted that she was involved after the resident was not provided the IV ABX. Per the DON the SNF is not typically involved in the coordination of care prior to the dialysis since it is case management at the hospital who coordinates the treatment at the dialysis center. The DON said that Vanco is typically used for infection. It is important for residents prescribed Vanco to receive it since it is part of the plan of care and the resident should get it as ordered. The impact of not administering Vanco is case-by-case but infection could increase. In the case of resident #148 it is inappropriate that he did not receive his treatment. The DON explained that the SNF got involved to get the appropriate orders. Resident #48 missed two doses from the two dialysis days in which the Vanco was not administered. However, the resident received his dose once the PICC line was placed. According to the DON, the issue was documented to the provider but she is unsure if it was documented on the resident's chart. During review of the resident's record with the DON, she confirmed that there is no progress note/documentation regarding issue administering the Vanco until February 21. The DON acknowledged that the resident should have received his IV ABX. During review of the resident's February 2026 MAR, the DON acknowledged that February 21 had been coded but that there was no code on February 19 and instead was marked X so it appeared like nothing was brought to dialysis or given.An email correspondence with the Corporate Resource dated February 26, 2026 documented that the facility does not have a Quality of Care policy or a Coordination of Care Policy.The facility policy titled Admission reviewed July 2025 indicated that it is the policy of the facility to have well defined guidelines for processing the resident's entry into the nursing facility. The policy noted that the LPN will initiate any required treatments as ordered.The facility policy titled Physician Orders reviewed July 2025 indicated that it is the policy of the facility to accurately implement orders in accordance with the resident's plan of care.The policy Documentation and Charting reviewed May 2025 noted that it is the policy of the facility to provide a complete account of the resident's care, treatment, response to care, signs, symptoms, and progress of the resident's care.

Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to ensure there was a physician order for oxygen use for one sampled resident (#12). This deficient practice could result in the resident receiving unnecessary oxygen or not receiving the correct oxygen flow rate needed. Findings include:Resident #12 was readmitted at the facility on February 17, 2026 with diagnoses of polyosteoarthritis, chronic pain syndrome and schizoaffective disorder bipolar type. The initial admission record included the resident was alert and oriented x4 and had oxygen at 2 LPM (liters per minute) via NC (nasal cannula). The nursing note dated February 17, 2026 revealed the resident had O2 (oxygen) saturation of 86% on RA (room air); and that, O2 saturation of the resident improved to 94% after resident was placed on 2 liters of oxygen. The documentation also included that the resident was instructed to keep the oxygen on at this time. The initial care plan dated February 17, 2026 included focus areas such as cognition, skin, ADLs (activities of daily living), nutrition, pain, falls and infection. The initial care plan did not include oxygen use as focus area with interventions in place. The physician readmission note dated February 18, 2026 included the resident was on 2 liters of oxygen via NC; and, the resident reported that her breathing was much better. Despite documentation that the resident was on oxygen, the clinical record revealed no evidence of a physician order for its use including orders for replacement of nasal cannula or oxygen tubing, cleaning and filling of the oxygen concentrators. The IDT (interdisciplinary team)-BIMS (Brief Interview for Mental Status) note dated February 20, 2026 included that the resident was able to repeat 3 words with no cuing required after first attempt, was able to report correct year and month. In an observation conducted on February 23, 2026 at 11:41 a.m., Resident #12 was in her room and had her oxygen nasal cannula on her forehead. The oxygen concentrator was on and was at 2LPM. Resident #12 stated that she uses oxygen only on as needed basis. An observation was conducted on February 24, 2026 at 1:08 p.m. Resident #12 was watching television in her room with the one of the oxygen NC prong on her nose and the other NC prong on the side of her nose and the oxygen tubing was connected to the oxygen concentrator which was running at 2 LPM. Resident #12 stated that she had been on oxygen for a while and it used to be on as needed basis only. However, the resident stated that she was told to keep it on today. In an interview with the assistant director of nursing (ADON/staff #184) conducted on February 25, 2026 at 2:01 p.m., the ADON stated that residents with oxygen needed to have a physician order for its use; and that, oxygen rate had to be followed as ordered by the physician. An interview was conducted on February 25, 2026 at 2:14 p.m. with a licensed practical nurse (LPN/staff #46) who stated that residents who are on oxygen had to have an order for its use; and staff had to follow the oxygen rate/dose as ordered by the physician. She stated that if she finds a resident on oxygen and there was no order for its use, she would assess the resident, notify the physician who will then order for oxygen use with prescribed rate for the resident. She said that she would then document this in the clinical record and will ensure that an order is written in the clinical record. An interview was conducted with another LPN (staff #68) on February 25, 2026 at 2:25 p.m. The LPN stated that residents on oxygen have to have a physician order for its use including the parameter such as oxygen rate/dose range depending on the resident's oxygen sat. She stated that the orders usually will tell staff how much to give to ensure the O2 sat of the resident was above 90%. She further stated that if she sees a resident on oxygen and there was no order for its use, she will call and inform the doctor. Another observation was conducted on February 25, 2026 at 2:52 p.m. Resident #12 was laying in her bed watching TV, had her oxygen NC on and had her oxygen concentrator running at 2 LPM. Resident #12 stated that she had been using oxygen for about a couple of months now. In an interview with another LPN (staff #146) conducted on February 25, 2026 at 3:58 p.m., the LPN stated that oxygen use had to have a physician order; and, a resident cannot use oxygen without a physician order except on an emergency. She stated that in the hall/unit where resident #12 was, there were only 2 residents that has or were using oxygen; and this does not include resident #12. During the interview, an observation of resident #12 was conducted with the LPN who stated that resident #12 had nasal cannula on and was using oxygen at 2 LPM. A review of the clinical record was also conducted with the LPN who stated that the clinical record revealed no evidence of a physician order for oxygen use for resident #12. Further, she said that resident #12 was transferred the hall/unit from another hall/unit at the facility; and, resident #12 must have used the oxygen when she was in the other unit/hall. During an interview with the Director of Nursing (DON) conducted on February 25, 2026 at 4:06 p.m., the DON stated that there must be a physician order for oxygen use; and that, iIf the resident comes with oxygen, the order for its use comes from the hospital. She stated that if there was no order for the oxygen, staff were expected to call, inform the physician and get an order for the oxygen use. She said that the order include oxygen care, tubing changed which was usually 1st of every month and as needed, whether staff were able to titrate oxygen and oxygen rate between 1-5 to maintain oxygen saturation. A review of the clinical record was conducted with the DON who stated that the clinical record did not show that the resident had an order for oxygen use. The facility policy on Physician Orders, revised on May 2021, revealed that it is their policy to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care; and, no drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses. All drug and biological orders shall be written, dated, and signed by the person lawfully authorized to give such an order.

Based on observations, resident and staff interviews, the facility failed to provide a dignified dining experience to Resident #62, Resident #149, Resident #47 and Resident #42. The facility census was 99. Findings include: Observation was conducted on May 6, 2024 at 8:20 AM of resident dining during breakfast. Observation revealed residents eating breakfast out of Styrofoam containers with plastic cutlery. Multiple residents reported that food has been served that way for a long time and often was cold by the time they received it. Resident #42 stated in an interview on 5/6/24 at 10:18AM that the food was always cold and came in clamshell containers with plastic silverware. During an interview with Resident #149 conducted on 5/6/24 at 10:33AM, he stated that the food was served in a clam shell container and came cold. In an interview with the ombudsman on 05/07/24 at 12:26 PM, the ombudsman reported that residents have been eating out of Styrofoam for about a year now. She reported that she had discussed with the administrator and the administrator stated that the facility was working on it. Multiple staff and residents report that plasticware has been used for a long time. Interview with the Dietary Supervisor (Staff #36) on 5/8/24 at 1:15PM confirmed that food had been served on plasticware since before he was hired approximately 4 months ago, as previous staff used it. When asked what was keeping the facility from serving on real dishware, he reported that the plate warmer had only just arrived about 3 weeks ago. When asked who made the decision to use plastic ware until the plate warmer arrived, he stated to ask the administration. Interview with Resident #62 on 5/9/24 highlighted dissatisfaction with the dining experience. She complained that her food was served in a box and complained that food was given to her upside-down, causing her food inside to be messy. During an interview with Resident #47 on 5/9/24 at 10:03 AM. Resident #47 explained that the facility had been using Styrofoam clamshells for the last two years. She also stated that dinner the previous night (5/8/24) was served in Styrofoam and was cold. The resident's recounting of what was served aligned with the menu - chicken enchiladas with rice and beans. Resident also stated there was no way to reheat the food because the plastic melts. Interview with the Executive Director (Staff #26) on 5/9/24 at 12:50PM confirmed that food had been served on plasticware since before he was hired on, following the facility plate warmer being stolen. He stated he was unsure when the warmer was stolen, but showed that the process to obtain a new warmer was started in December 2023, and it was finally obtained and operational April 8th, 2024. This administrator claimed the plate warmer had been in use since that date.

Based on observation, staff interviews, and policy review, the facility failed to ensure food was stored in accordance with professional standards for food service safety. The deficient practice could contribute to the spread of foodborne illness. Findings include: Upon initial tour of the kitchenon 5/6/24 at 8:20 AM, it was observed that some of the items, such as dry pasta, stored in original bag that had been tied on itself had no additional labeling or dating. Observation in the refrigerator and freezer revealed lack of labeling and dating of items. Most items were observed stored in cardboard boxes. There were no dates or labels on multiple boxes in the refrigerator and no dates on most boxes in the freezer. Observation was made of sealed bags of shredded lettuce stored in the refrigerator without label or date. Further observation in the refrigerator revealed prepared food items in unlabeled metal tins. Surveyor noted prepared meatballs stored in a metal tin with plastic wrap on top without label or date. A brown gravy in a metal tin was also observed uncovered and unlabeled. Interview with the Dietary Supervisor (Staff #36) on 5/6/24 at 8:35AM revealed that the kitchen staff do not record use-by dates. When asked how the staff knew when an item is no longer safe to use, the Dietary Supervisor stated that his staff used those items very quickly, so there is no need to record a use-by date. He further stated that there was no policy in place on labeling foods with use-by dates. Review of facility policy regarding food storage showed that policy required all TCS foods to be covered, labeled, and dated if not for immediate use. This document further stated that date marking should be visible to indicate the date by which ready-to-eat, potentially hazardous food should be consumed, sold, or discarded.

Based on clinical record review, staff interviews, and policy review, the facility failed to provide evidence that monthly billing statements were issued to one resident (#62). The deficient practice could result in residents not being informed of the monthly payment deducted from their personal accounts. Findings include: Resident #62 was admitted on [DATE] with diagnoses that included cellulitis of buttock, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. Review of the Admission Record face sheet revealed the resident was their own financial responsible party. Review of the MDS revealed a Brief Interview for Mental Status (BIMS) was conducted revealing a BIMS score of 15 which suggests that cognition is intact. An interview was conducted with resident #62 on May 9, 2024 08:37 a.m. Resident #62 stated she is concerned with the amount of money left in her account after her payment to the facility. She stated she does not feel that the financial part has been thoroughly explained to her as why she is only left with forty dollars every month. An interview was conducted with Business Office Manager (BOM/Staff #7) and Business Office Staff (staff # 1) on May 10, 2024 at 10:33 a.m. Staff #7 stated the resident does not have a trust with the facility and her share of cost is determined by Arizona Long Term Care (ALTCS). BOM/Staff #7 stated that the facility is required to provide the resident or their responsible party with a monthly billing statement and the address on the statement is the daughters address and may be going there. She stated the monthly billing statements go out on the 20th of every month. BOM acknowledged the resident is her own financial party. She stated the monthly billing may be mailed to the daughter because she is involved in her care. She further stated the billing statements are hand delivered to the LTC care residents. Staff #1 stated she has hand delivered the statements to resident #62, but does not have a system indicating they were received by the resident. BOM stated they could print the prior months statement and deliver it to the resident. An interview was conducted with resident #62 on May 10, 2024 at 10:55 AM who stated she has not received a billing statement since she was first admitted and they have not been shared with her by her daughter. She stated that is not true at all, they do not hand deliver one to her or she would have it. The resident stated she does not understand why they would go to her daughter when she takes care of her own financial business. Further stating she would like to know where her money is going and deserves to know how it is being spent. Review of the facility policy titled Accounts Receivable Policy and Procedure Resident [NAME] states resident billing is the most important procedure performed in the overall accounts receivable process. 1. Statements will be generated monthly, typically on or about the 20th of the month or upon discharge or request. 6. Print and mail or deliver to the resident or responsible party as appropriate.

Based on clinical record review, staff and resident interviews and policy and procedures, the facility failed to ensure that care and assistance were provided to one resident (#1) with a prosthesis that did not fit properly. The deficient practice could result in a decline in mobility and level of functioning, requiring more assistance and being more dependent. Findings include: Resident #1 was admitted on [DATE], with diagnoses that included fracture of nasal bones, subsequent encounter for fracture with routine healing, type 2 diabetes mellitus with foot ulcer, unspecified open wound, right foot, subsequent encounter, peripheral vascular disease, unspecified, other abnormalities of gait and mobility, acquired absence of left leg below knee, A Medicare 5-day MDS(Minimum Data Set) assessment dated [DATE] revealed the resident scored 13 on the Brief Interview for Mental Status (BIMS), indicating cognition was intact. The MDS assessment revealed no impairment with upper extremity, lower extremity impairment on both sides. The assessment revealed resident required substantial/maximal assistance with toileting, shower baths, lower body dressing and putting on/taking off footwear and partial to moderate assist with upper body dressing. A care plan dated April 11, 2024, revealed the resident required assistance with lower body and upper body dressing. The goal was for the resident to maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene. Review of an Occupational Therapy (OT) Evaluation and Plan of Treatment dated April 12, 2024, revealed the following goals: the resident will safely and effectively perform upper and lower body dressing with supervision or touching assistance in order to be able to return to prior level of living, resident will complete all ADL/self-care tasks with independence using AE as needed/trained. The approaches included for therapeutic exercises and activities, group therapy and self-care management training. The resident's goal was to be able to return home. Per the evaluation, the resident demonstrated good rehab potential as evidenced by active participation in skilled treatment. The OT evaluation also included the resident has had a mechanical ground level fall with head injury, which resulted in a head laceration, nasal bone fracture and has chronic wounds on his right foot with a BKA. He previously required 1 person assist with mobility and has had a prosthesis for his left lower extremity. The evaluation did not include any plan to address the resident's prosthesis, which did not fit properly. Review of an Physical Therapy (PT) Evaluation and Plan of Treatment dated April 12, 2024, revealed the following goals: The resident will enhance functional mobility as evidenced by an increase in score to 10/20 on the Elderly Mobility Scale (Taget:4/25/2024), resident will safely perform functional transfers with partial/moderate assistance to proper positioning before/during transfer and for proper sequencing without medical complications in order to safely return home, resident will safely ambulate 50 feet using two-wheeled walker on level surfaces with partial/moderate with ability to right self to achieve/maintain balance in order to return to prior living and supervision levels. The approaches included for therapeutic exercises and activities, neuromuscular reeducation, gait training therapy, group therapy. The assessment revealed the prosthesis present/assessed was marked yes. Further review of the physical therapy notes revealed a summary note entered 05/10/2024 which stated a consultation was done regarding the fit of the resident's prosthesis. The note stated upon removal of the prosthesis it was found the resident had self-donned prosthesis with sock layers next to skin. The note stated a PTA (Physical Therapy Assistant) educated resident placing neoprene sleeve flush to skin, then appropriate layering of socks for a better fit. Resident #1 was initially screened on 05/06/24 at 10:30 AM. Resident (#1) stated he is no longer able to wear his leg prosthesis, due to the rubber being stretched. He stated he is unable to do anything without his prosthetic leg, stating his leg keeps falling off and the facility has done nothing to help him with it. An interview was conducted on May 10, 2019 at 05/10/24 08:21 a.m., with resident #1. Also present was his nephew, who provided care when at home. He stated the prosthesis for his left lower leg is too big for his stump and that the rubber part of the prosthetic is stretched. He stated that he has complained to staff and staffs are aware and are doing nothing about it. The nephew stated he brought in additional stockings and socks and had placed them on the resident to secure a tighter grip with the prosthesis. He further stated the prosthesis is not fitting due to the resident's weight loss and that his uncle is concerned with it falling off if he tried to walk. An interview was conducted on May 10, 2024 at 8:25 a.m., with a Certified Nursing Assistant (CNA/Staff #105). She stated the resident does have a prosthetic, but stated the resident complained that it did not fit right and looked loose. She said she had not passed on the information that the prosthesis may be too large, because therapy was working with him and thought they already knew about it. On May 10, 2024 at 8:33 a.m., an interview was conducted with a Director of Rehab (Staff #12) She stated resident (#1) was evaluated by both PT and OT on April 12, 2024. She stated PT and OT met with the resident Monday thru Friday five days per week. The resident received 25 minutes of PT and 25 minutes of OT daily. She stated the resident was assessed for strengthening, range of motion, transfers, prevent decline and to progress. She stated she did not know if there were any identified concerns with the resident's prosthesis and would need to consult with his therapist. She stated the initial assessment process would have included an assessment of the resident's prosthesis, and if there are any concerns with fitting the facility has resources that are able to come in and assess the prosthesis. On May 10, 2024 at 9:28 a.m., (Staff #12) stated that PT went in and met with the resident, that this was the first time hearing of the prothesis not fitting correctly. Staff #12 stated they had found the resident had placed too many pairs of socks and stockings and had noted the prosthesis appeared loose when sitting due to contracture of the muscles, but had contacted the Hanger Clinic and Hanger would meet with the resident at 11a.m. that day to evaluate the prothesis. A request was made for facility policy for Prosthesis or Prosthetic Devices on May 10, 2024 at 10:28 a.m. Staff #156 returned the request stating the facility does not have a policy for prosthesis or prosthetic devices.

Based on personnel record reviews, staff interviews and policies and procedures, the facility failed to ensure that one of 10 sampled employees (#80) had current evidence of freedom from infectious Tuberculosis (TB). The deficient practice could result in the potential of residents and employees being exposed to TB. Findings include: A review of personnel records conducted on May 9, 2024 at 10:57 a.m. with Human Resources Manager (Staff # 43) and HR Clinical Resource (Staff # 157) revealed the following: A review of the personnel record for a Activities Director (ACT/staff #80) revealed a hire date of September 30, 2015. The record further revealed no prior documentation of a negative TB skin, nor was there current documentation that staff #80 was free of TB. Staff #157 stated she would download the document, print and provide a copy. HR Clinical Resource (Staff #157) provided a copy of a completed TB Skin Test Consent Form. Review of the form revealed date given as 5/15/24 at 0700 and date read as 5/17/24 at 0800. An interview was conducted on May 9, 2024 at 03:27 PM with staff (Staff #80) who stated she received her TB test on May 15, 2024, but could not recall who provided her with the TB skin test. Staff #80 confirmed the day date as May 9, 2024. An interview was conducted with Director of Nursing (Staff # 68) who stated she believed TB tests are completed annually or are screened. Staff # 68 reviewed the TB Skin Test Consent Form for Staff # 80 and stated that was not accurate and the dates were wrong. She stated she did not have an explanation how this occurred and the expectations are that documents are documented correctly.

Based on clinical documentation, staff interviews, and facility policy and procedures, the facility failed to monitor and maintain acceptable parameters of nutrition for two residents (#12 and #36). The deficient practice could result in a physical and a mental decline in overall health. Findings include: 1) Resident #12 was admitted to the facility on [DATE] with diagnoses that included quadriplegia, chronic obstructive pulmonary disease, Type II Diabetes, acute kidney failure, and Schizoaffective Disorder. Review of the percentage meal intake task sheets dated December 27, 2023 through January 15, 2024 revealed that the percentage of meal intake was not documented ten times, and was documented as not applicable six times. It also included that the resident refused to eat nine times. Review of the progress notes dated December 27, 2023 through January 15, 2024 did not reveal documentation of the physician being notified by the facility regarding the resident's weight loss or refusal to eat. The mini nutritional evaluation dated December 28, 2023 revealed a score of 10 indicating the resident was at risk for malnutrition. It also included that the resident weighed 218 lbs., had no decrease in food intake and weight loss of 2.2 to 6.6 lbs. in the last three months. Recommendations included to monitor PO intake, monitor weight, super cereal with breakfast, mash potatoes with lunch, pudding with dinner, Magic Cup every day. Encourage PO intake as necessary and assist with meals as tolerated. The order summary revealed: -regular diet, regular texture, thin liquids consistency, diabetic condiments, no added sugar, with diabetic preferences diet ordered December 27, 2023. -weekly weights for four weeks every day shift, every Wednesday ordered December 27, 2023. -resident needs to go to dining room for all meals every day shift ordered January 9, 2024. The nutritional care plan dated December 28, 2023 revealed that the resident had a nutritional problem or potential related to environmental and recent hospitalization . The resident was at risk for involuntary weight loss relate to by mouth (PO) intake not meeting exclusive enteral nutrition (ENN) as evidenced by PO intake 57%. Interventions included: -Diet as ordered by the physician: regular diet, regular texture, thin liquids consistency, super cereal with breakfast, pudding with lunch, mashed potatoes with dinner, diabetic condiments, no added sugar, with diabetic preferences. -Monitor and report to the physician as needed for any serious signs of decreased appetite, nausea and vomiting, unexpected weight loss. -Weekly weights for four weeks and then monthly if stable. Review of the weights revealed the resident was weighed: -December 27, 2023 and weighed 218 lbs. -January 3, 2024 and weighed 210.9 lbs. -January 10, 2024 refused to be weighed. -no weight documented the fourth week. 2) Resident #36 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, hypotension, unspecified dementia, and cognitive communication deficit. Review of the order summary revealed: Weekly weights times 4 weeks every day shift Tuesday ordered December 4, 2023. -Regular diet, puree texture, thin liquids consistency, one-on-one assisted feeding ordered December 5, 2023. -Med Pass four times a day for increased PO intake 2 ounce each by mouth ordered December 6, 2023. Review of the percentage meal intake task sheets dated December 5, 2023 through January 15, 2024 revealed that the percentage of meal intake was not documented twenty-one times, and was documented as not applicable fourteen times. It also included that the resident refused to eat one time and was not available one time. The nutritional care plan dated December 6, 2023 revealed that the resident has a nutritional problem or potential nutritional problem related to impaired mobility and generalized weakness. The mini nutritional evaluation score was 3 indicating the resident was malnourished. The resident was underweight related to previous inadequate energy intake as evidenced by BMI of 14.8. Interventions included to monitor and report to the physician as needed for any serious symptoms (s/s) of: decreased appetite, nausea or vomiting, unexpected weight loss, complaints of stomach pain, etc. The Nutrition Admission Evaluation dated December 6, 2023 revealed that the resident weighed 83.8 lbs. with a desirable weight range of 104 to 127 lbs. The resident had a body mass index (BMI) of 14.8 and was below weight. Recommendations included to encourage and monitor intake. The Nutrition Interdisciplinary Team Review dated December 6, 2023 stated that the purpose of this interdisciplinary team review is to review the nutritional status of the resident and to ensure that the resident is receiving appropriate diet/nutrition for their body size, structure and medical condition, and to evaluate potential risk factors that may have a direct influence in resident outcomes relating to weight loss or weight gains. BMI is less than 19 at 14.8. Added 2 ounces Med Pass four times a day. Refer to physician for weight being a nutritional risk. Continue to monitor for additional changes. Review of weights revealed: -December 5, 2023, 83.8 lbs., -December 13, 2023, 84.1 lbs., -December 20, 2023, 83.4 lbs., -December 27, 2023, 76.2 lbs. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 1 indicating the resident has a severe cognitive impairment. It also included that the resident requires partial/moderate assistance with eating: assistance in lifting, holding, trunk or limbs, but provided less than half the effort. An interview was conducted on January 17, 2024 at 8:15 AM, with a Restorative Nursing Assistant (RNA/staff #82) who stated that she has received training on activities of daily living (ADLs). She stated that of monitoring the percentage of meal intake is to make sure that the resident is consuming enough food. She documents the percentage of meal intake on the task sheet and it should be documented three times a day, one time for each meal. She stated that if the resident refuses to eat, she reports it to the nurse and the risk of not notifying the nurse is that the resident may have a change in weight. If she documents not applicable on the task sheet, it means that it didn't happen or she did not see how much the resident ate. She stated that resident #12 is supposed to have the percentage of meal intake documented. An interview was conducted on January 17, 2024 at 8:41 AM, with the Assistant Director of Nursing (ADON/staff #7), who stated that the Certified Nursing Assistants (CNAs) document the percentage of meal intake in the task sheet and this is done for all the residents. It is her expectation that documentation is completed for breakfast, lunch, and dinner. She stated that the purpose of monitoring the percentage of meal intake for the residents is primarily to monitor nutritional value and their likes and dislikes. She stated that if a resident is refusing to eat, it should be reported to the nurse because the resident may need an evaluation for swallowing, appetite stimulant, and to notify the physician. She stated that there is a risk of weight loss if the documentation is not completed, because we wouldn't know if there was a concern that needed to be addressed. She stated that documenting not applicable means that the resident doesn't take food by mouth (PO) or the resident was not at the facility during mealtime. She thinks the dietician is responsible for monitoring the task sheets to ensure the documentation is being completed. An interview was conducted on January 17, 2024 at 9:01 AM, with the Director of Nursing (DON/staff #1), who stated that the percentage of meal intake is documented for every resident and should be documented when the meal tray is picked up from the resident. She stated that the dietician is responsible for monitoring the percentage for meal intake documentation, which is completed by the CNAs. It is her expectation that the dietician reviews the task sheets to determine if nutritional needs are being met, if supplements are needed, and would discuss any nutritional concerns at the weekly meeting. She stated that not applicable would be documented if the meal tray was not picked up, the resident was NPO, or the resident was not in the facility during meal time. She stated that if the documentation is not being completed or is incorrect, there is no way to determine if the resident is eating and there is a risk of weight loss. An interview was conducted on January 17, 2024 at approximately 11:30 AM, with the registered diet technician (staff #16), who stated that she monitors the weights of the residents by reviewing the percentage of meal intake for the last seven days and if the resident ate less than 50% of the meal intake, she reports it during the weekly meeting. She also reviews the weekly weights and if there is a weight loss, she would then review the task sheets to determine what happened. She stated that she has concerns regarding the lack of documentation, documented refusals, and the documentation of not applicable and has reported it to the team during the weekly meetings. She stated that the DON and the ADON told her they would reeducate the CNAs on documentation. She stated that there is a risk when the documentation is incomplete or incorrect. The facility's policy Nutrition dated states that it is the policy of the facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Each resident is to be weighed upon admission, weekly weights for four (4) weeks a monthly weight thereafter unless otherwise specified by the attending physician. The weight will be entered into the resident's clinical record.

Based on closed clinical record review, staff interviews, facility documentation and policy review and the State Agency database, the facility failed to ensure that an allegation of abuse for one resident (#44) was reported to the State Agency (SA) as required. The deficient practice could result in residents not protected from further abuse and allegation not investigated. Findings include: Resident #44 was admitted on [DATE], with diagnosis of displaced bimalleolar fracture of the left leg. A nursing skilled note dated May 24, 2023 included the resident was alert and oriented to person, place, time and situation, and was verbally appropriate. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A late entry administrative note dated June 02, 2023, at 6:00 p.m. included that the Executive Director informed the Director of Nursing (DON) that the police were on their way after a phone call was made by the resident's family regarding an allegation of abuse. Per the documentation, the resident's family reported that a staff member held a rag with bleach over the resident's face to initiate a seizure. There was no evidence found in the clinical record and facility documentation that the allegation of abuse was reported to the SA as required. Review of the SA database revealed no evidence that the allegation of abuse was reported to the SA on June 2, 2023. During an interview with the Interim Director of Nursing (ADON/staff #55) conducted on December 13, 2023, at 9:20 a.m., he stated that it was his expectation, as well as the facility policy, to report all allegations of abuse within two hours of notification. A review of the clinical record was conducted with the ADON during the interview. The ADON stated that the progress note dated June 2, 2023 noted an allegation of abuse and this was reportable to the SA; however, the ADON stated that the facility did not report this allegation of abuse to the SA as required. The facility policy on Abuse: Prevention of and Prohibition Against revealed that allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside of the facility and to the appropriate State or Federal agencies within the applicable timeframes as per this policy and applicable regulations. The policy also included that the facility will notify the state survey agency and other authorities as required by the Abuse Prevention Policy and as required by law.

Based on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#44) was thoroughly investigated. The deficient practice could result in residents not protected from further abuse and appropriate corrective action not taken. Findings include: Resident #44 was admitted on [DATE], with diagnosis of displaced bimalleolar fracture of the left leg. A nursing skilled note dated May 24, 2023 included the resident was alert and oriented to person, place, time and situation, and was verbally appropriate. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A late entry administrative note dated June 02, 2023, at 6:00 p.m. included that the Executive Director informed the Director of Nursing (DON) that the police were on their way after a phone call was made by the resident's family regarding an allegation of abuse. Per the documentation, the resident's family reported that a staff member held a rag with bleach over the resident's face to initiate a seizure. There was no evidence found in the clinical record and facility documentation that the allegation of abuse was thoroughly investigated. During an interview with the Interim Director of Nursing (ADON/staff #55) conducted on December 13, 2023, at 9:20 a.m., he stated that it was his expectation, as well as the facility policy, to report all allegations of abuse within two hours of notification. A review of the clinical record was conducted with the ADON during the interview. The ADON stated that the progress note dated June 2, 2023 noted an allegation of abuse and this was reportable to the SA; however, the ADON stated that the facility did not report this allegation of abuse to the SA as required. Further, he stated that there was no investigation that had been conducted or any steps taken by the facility to ensure the safety of the resident. The facility policy on Abuse: Prevention of and Prohibition Against revealed that allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside of the facility and to the appropriate State or Federal agencies within the applicable timeframes as per this policy and applicable regulations. The policy also included that the facility will notify the state survey agency and other authorities as required by the Abuse Prevention Policy and as required by law.

Based on observations; resident, resident representative, and staff interviews; facility documentation; and review of facility policies, the facility failed to ensure profession standards of care were maintained related to: a physician's order was not obtained before administering oxygen to one resident (#385) and the facility failed to ensure ordered care was provided related to a infection for one resident (#135). The deficient practices could result in resident's getting unsuitable treatment and for negative resident outcomes. Findings include: -Resident #385 was admitted to the facility on [DATE] with diagnoses that included anemia, hypoxemia, heart failure, hypertension, and depression. There was a physicians order dated 01/16/23 for an Albuterol inhaler that ordered the inhalation of 2 puffs every 4 hours as needed for shortness of breath or wheezing. Review of an incomplete Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 14 which indicated the resident had no cognitive impairment. Resident #385's Care Plan initiated on 1/17/2023 included the goal to monitor for shortness of breath due to altered cardiovascular status related to arrhythmia. A review of the providers progress notes dated 1/24/2023 at 07:03 AM, show that Resident #385 had an oxygen saturation of 98% on 2 Liters of oxygen and no wheezing was noted. The progress note dated 1/17/23 state the patient was on 2 to 3 liters of oxygen with an oxygen saturation of 94 to 96%. She does complain of shortness of breath especially with activity. She does have wheezing to her left lobe today. chest x-ray today with Mild interstitial infiltrate is seen throughout the right lung. During a random observation by surveyor on 01/23/23 at 08:55 AM, Resident #385 was observed to be on 2 liters of oxygen, but there was no order in her chart. During an interview with licensed practical nurse Staff #54 on 1/23/23 at 11:10 AM, she confirmed the patient was on 2 Liters of oxygen currently, but an order was not present in her chart. When asked how they knew how much oxygen to put her on without an order, she stated they will have the order from the hospital carry over, and that is what they kept her on. Staff #54 stated they will work on getting an order now. Resident #385 was admitted to the facility directly from the hospital and a review of hospital discharge documents showed a hospital order for 1.5 liters of oxygen. Observation on 1/26/23 at 10:30 AM, showed the chart had not been updated with oxygen orders yet. 38892 -Resident #135 was admitted to the facility on [DATE] with diagnoses that included Methicillin Resistant Staphylococcus Aureus (MRSA) infection, infection and inflammation reaction due to internal left hip prosthesis, and encounter for removal of internal fixation device. Review of the physician's orders revealed: -An order, dated July 23, 2022, for vancomycin hydrochloride (HCL) Solution (antibiotic) 750 milligrams (mg) intravenously (IV) every 12 hours for left hip infection until August 21, 2022. -An order dated July 24, 2022 for vancomycin HCl Solution 750 mg intravenously two times a day for left hip infection until August 21, 2022. Review of the resident's care plan revealed focuses dated July 25, 2022: -The resident was on antibiotic therapy related to prosthetic joint infection suppressive therapy and at risk for possible adverse reaction related to antibiotic therapy. The interventions included to administer the medication as ordered and to report pertinent lab results to the MD; -The resident was on IV therapy required for infection, Peripherally Inserted Central Catheter (PICC) Right Upper Extremity (RUE) with a goal that the IV would be maintained and be free of complications for successful completion of IV therapy August 21, 2022. The interventions included: Check labs as ordered and notify MD with results: and Infuse the fluids or medications as ordered. Review of a physician's order dated July 26, 2022 revealed an order for a STAT trough for hip infection and to fax the results to pharmacy, pharmacy to adjust dosage of medication if needed. Review of the July 2022 IV Medication Administration Record (MAR) revealed: -Additional information- Hold date-from July 26, 2022 10:12 p.m. to July 27, 2022 3:04 p.m. Per the administration documentation the intravenous (IV) vancomycin was held on July 26 at 10:00 PM, and July 27 at 10:00 AM. However, Review of the physician's orders did not reveal orders to hold the medication. Review of the progress notes revealed: -July 26, 2022 provider note that included the resident had a chronic left hip infection with prior removal of left hip hardware after previously undergoing left total hip arthroplasty who was hospitalized and had a MRI to the left hip with reported abscess, fistulous tract, and suspected early osteomyelitis left greater trochanter. She was seen by infectious disease who recommended IV vancomycin for 6 weeks followed by suppressive therapy with doxycycline, IV vancomycin until August 21. -July 26, 2022 nurse's progress note that included MD order for STAT trough. Will communicate results with pharmacy to adjust dosage as needed. Review labs for vancomycin trough revealed: a level collected July 26, 2022/received and reported July 27, 2022 at 10:26 a.m. of 17.7. The report included a notes: Drug dosage and/or time of administration not provided with request; Clinical correlation with patient medical records is advised. The report included a handwritten note; Reported to (providers name) July 27, 2022. Review of the nurse's progress notes dated July 27, 2022 revealed: vancomycin 17.7 reported to Dr; and Lab results sent to Dr for review, no further orders at this time. Review of a physician's order dated July 28, 2022 revealed: vancomycin trough 30 minutes prior to each 4th dose. Fax results to pharmacy. Goal trough 15-20. If trough greater than 20 hold vancomycin, fax to pharmacy, and hold until you receive further instruction from pharmacy. Review labs for vancomycin trough revealed: a level dated July 29, 2022 of 10.8. The report included a note: Drug dosage and/or time of administration not provided with request; Clinical correlation with patient medical records is advised. Review of an Admission Minimum Data Set (MDS) assessment dated [DATE] included the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident's cognition was intact. The diagnoses included infection with a multidrug resistant organism and infection/inflammation reaction due to internal left hip prosthesis. the assessment included a surgical wound, surgical wound care, and daily antibiotic use. Review of the August 2022 IV MAR revealed: -No documentation that the August 3, 2022 10:00 PM, dose of vancomycin was administered (square for administration documentation was left blank). Review labs for vancomycin trough revealed: a level dated August 4, 2022 of 7.5. The report included a note: Drug dosage and/or time of administration not provided with request; Clinical correlation with patient medical records is advised. Handwritten notes: Pharmacy to dose dated August 4, 2022 at 4:00 PM; and a note that the lab was re-drawn last night and waiting for results dated August 6, 2022. Review labs for vancomycin trough revealed: a level collected August 5, 2022/ received and reported August 7, 2022 of 12.8. The report included a notes: Drug dosage and/or time of administration not provided with request; Clinical correlation with patient medical records is advised. Review of a nurse's progress note dated August 7, 2022 included: Writer spoke with lab yesterday to confirm that they received a vancomycin trough from August 8th night shift. Lab stated they received it but needed clarification on the test. Writer clarified and lab said they would run it STAT. Writer called lab at start of shift today as there were no results. Lab said they were unsure of why they did not run it yet and would call and see what happened. Writer called back 2 hours later and test still wasn't processed. Writer pulled another vancomycin trough before handing the a.m. dose of vancomycin. -Results faxed to pharmacy to dose. Review of a physician's order dated August 7, 2022 revealed an order for vancomycin HCL use 1 gram (GM) intravenously two times a day for left hip infection until August 7, 2022. Review a lab dated August 7, 2022 for vancomycin trough revealed: The last dosage of vancomycin was not given, a level dated of 13.4. The report included a notes: Drug dosage and/or time of administration not provided with request; Clinical correlation with patient medical records is advised. Review of a nurse's note dated August 8, 2022 included: vancomycin trough 30 minutes prior to p.m. dose on August 8, 2022 at bedtime pull via PICC and call in STAT, to be drawn August 8. Review of an Infectious Disease provider's progress note dated August 8, 2022 continued to include the plan for IV vancomycin with an end date of August 21. Review a lab dated August 8, 2022 for vancomycin trough revealed: The report had a flag. The last dosage of vancomycin was not given, a level dated of 9.7. The report included a notes: Drug dosage and/or time of administration not provided with request; Clinical correlation with patient medical records is advised. Review of IV tracking form from pharmacy revealed a new order for vancomycin was obtained and due on August 7, 2022. The document did not reveal further information until August 12, 2022. Review of a provider's progress note dated August 8, 2022 revealed the resident was placed on a six-week course of IV vancomycin with plans for suppressive doxycycline. The resident was transferred to the facility on [DATE] for continued care and rehabilitation services. Infectious disease was consulted to assist with management of care. Review of a physician's orders dated August 11, 2022 revealed: -vancomycin HCL solution 1 gm intravenously two times a day for left hip infection until August 25, 2022, pharmacy to dose. -Discontinue PICC; -Place PICC for antibiotic therapy. Review of the August 2022 IV MAR revealed: -No documentation that IV vancomycin was administered after the 10:00 PM, dose on August 7 through August 11, 2022 10:00 AM, dose. The next dose provided was on August 11, 2022 at 10:00 PM. -Discontinue PICC August 11, 2022 6:36 AM, initialed as completed. -Place PICC for antibiotic therapy August 11, 2022 5:50 PM, initialed as completed. Review of a provider progress note dated August 11, 2022 included provider spoke to infectious disease and vancomycin end date was August 21. Assessment and Plan included: IV vancomycin until August 21, per discussion last dosage was on August 7th, resume IV vancomycin and end date will be adjusted for missed doses to August 25th. Review of facility documentation revealed a Medication Error Report dated August 11, 2022 with an error date of August 7, 2022. The report included the Medication as ordered; vancomycin 1 gram (GM) every 12 hours until August 21, 2022. Description of error; Medication was updated for a new dose and the end date was incorrect. Outcome to resident: PICC line was discontinued in error due to belief that the antibiotic was completed. Corrective action taken; PICC line re-inserted, vancomycin re-started on August 11, 2022 and will continue until August 25, 2022. Measures taken to prevent the recurrence of similar error(s); Education provided to nurse. Assistant Director of Nursing to check stop dates for correct dates in daily orders. Assessment and Summary of Error: Type of Error, Wrong stop date/duration; Reason for error; Transcription error. Person making error, Licensed Practical Nurse (LPN/staff #120). Review of facility documentation/In-service with LPN (staff #120) dated August 12, 2022 included: Subject; Updating vancomycin orders. Information reviewed: vancomycin requires updates at times related to dose changes. When updating order, the duration needs to remain the previous duration ordered, unless order changed by provider. Review of a Infectious Disease provider's progress note dated August 18, 2022 included: vancomycin now extended to August 25 due to missed doses. An interview was conducted on January 24, 2023 at 10:05 AM, with a resident representative. He stated the facility called him and told him they pulled out the resident's PICC line and did not administer her antibiotic/IV vancomycin to treat her MRSA leg infection for four days, then re-inserted the PICC line and gave the antibiotics. A interview was conducted on January 25, 2023 at 2:13 PM with the Infection Control Provider (staff #119). She stated, on review of her notes, the antibiotic therapy was extended to August 25 for missed doses. She stated she would not know whether the doses were missed on purpose or accidentally. She stated the nurse would draw the trough and send it to pharmacy and that would decide dosing. She stated the missed doses would not effect the final treatment of the infection, and that the resident did not have an active infection at the time of the final IV antibiotic therapy completion. She stated it was protocol to do suppressive antibiotics for 6-12 months for this resident's diagnosis and that continued antibiotic therapy was for prophylaxis, not for treating an active infection. An interview was conducted on January 26, 2023 at 9:15 AM, with clinical resource staff (#118). She stated there was no documented reason or order for the vancomycin being held on July 26, 2022 at 10:00 p.m. or July 27, 2022 at 10:00 a.m. She also stated there was no documentation that the IV vancomycin was administered as ordered on August 3, 2022 at 10:00 PM. An interview was conducted on January 26, 2023 at 12:09 PM, with a Licensed Practical Nurse(LPN/staff #58). She stated if an antibiotic was stopped prior to planned duration, there should be documentation that directed to hold the medication and why it was being held. On review of the clinical record she stated considering the original order for the Vancomycin through August 21, 2022 the antibiotic therapy would not have been stopped unless the physician gave an specific order to stop the medication or switch to a different form. She stated there should have been another order or documentation explaining why the medication was not being administered. She stated she did not know how it happened and that there should have been a progress note that included the doctor was called and gave orders. She stated the physician's note from August 8th indicated the resident was still supposed to be receiving the IV vancomycin through August 21st. On review of laboratory documentation she stated the trough was low on August 8, which would not indicate that the medication should be held. She stated staff could not give the vancomycin unless pharmacy tells them the dose. She stated she though that the order for the new dose was not obtained from pharmacy and the resident should have been receiving the medications and labs unless directed to hold r/t lab /trough level. She stated that should have been documented, if that was the case. She stated she though something happened with the pharmacy which resulted in not obtaining the dosing order starting August 8, 2022. She stated if IV antibiotic therapy was interrupted/stopped, there was a risk of worsening infection. An interview was conducted on January 26, 2023 at 1:32 PM, with a second Clinical Resource staff member (staff #114). She stated after review of the record and medication error report, the IV vancomycin was not supposed to be stopped from August 8 to 11, 2022. She stated the facility should have continued labs and pharmacy dosing of the medication as planned. She stated there should be notes in the clinical record for any intentional medication holds or dose changes. She stated there was a risk that the medication would not be therapeutic to treat the diagnosis. Review of a facility policy, revised November 2007, for Professional Standards revealed: It is the policy of this facility that services provided by the facility just meet professional standards of quality and be provided by qualified persons in accordance with each resident's care plan. Professional standards of quality means services that are provided according to accepted standards of clinical practice. Standards regarding quality care practices may be published by a professional organization, licensing board, accreditation body or other regulatory agency. Direct care-givers will have information regarding the services and care they provide to the resident. Care will be given by qualified persons in accordance with the resident's care plan. Review of a facility policy, revised August 2022, for Physician's orders revealed: It is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. It is the policy of this facility to accurately implement orders in additions to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illnesses. Drug and biological orders must be recorded in the resident's medical record under orders. Review of a facility policy, revised August 2016, for Administration of Drugs and Fluids, Intravenous revealed: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Medications must be administered in accordance with the written orders of the attending physician. If a medication is withheld, refused, or given other than at the scheduled time, the documentation will be reflected in the clinical record.

Based on resident, resident representative, and staff interviews and facility documentation, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents. This deficient practice resulted in residents' needs not being met. Findings include: During the initial phase of the survey, 14 out of 35 residents and the state appointed ombudsman for the facility identified concerns of not having enough staff. Residents reported they waited up to 2 hours for call lights to be answered. The residents interviewed stated the following: 3 stated They were unable to get care in the facility at night. 2 stated they were unable to find staff when they left their room on one night 2 stated staff had slow response to call lights 4 stated their medications were significantly delayed Review of Resident Council meeting minutes detail the following reoccurring subjects of concern: At the Resident council meeting held on May 8, 2022, residents brought up concerns of medications being given late, and that wait times for assistance at night are long. During the meeting on July 27, 2022 residents discussed showers not being completed. During the Resident council meeting held on August 10, 2022 slow call light response time concerns were discussed. During the meeting on September 21, 2022, residents discussed concerns regarding slow 200 hall call light response times. During the meeting on October 12 2022, they discussed call light responses and concerns that CNAs were answering lights without addressing issues at the time light is answered. During the meeting held on November 15, 2022, they discussed resident's having issues getting medications on time, and that call light response times were a concern due to registry staff. Review of the Facility Assessment updated March, 2022, stated the average daily census ranges for the past year was 89 residents, fluctuating as low as 73, and as high as 100. The facility hires and staffs for an average census of 91. The assessment stated the approximate number of admissions on a monthly basis is 64 and discharges is 61. The Facility Assessment revealed the facility's general approach to ensure sufficient staffing to meet the needs of residents included scheduling 7-10 certified nursing assistant staff members per day shift (6a-6p), and 7-9 CNA's per night shift (6p-6a). This is equal to 84-120 hours during the day shift and 84-108 hours during the night shift. There was a discrepancy on the facility assessment that showed CNA's were staffed on 3 shifts (6 AM-2 PM, 2PM-10PM, and 10PM-6AM). This was brought to the Clinical Resource Staff #114's, attention on 1/25/23 at 1:03 PM. She stated the facility assessment is reviewed annually by Resources which should have been caught by her. When asked if switching CNAs from 8 hour shifts to 12 hour shifts was a reason to update a Facility Assessment, she stated yes. They updated it and provided a copy reflecting the 12 hour shifts. On January 26, 2023 at 11:30 AM, Staff #114 stated the facility assessment was not being used for staffing requirements. The facility assessment was not due to be updated yet, as it was done annually, and the staffing requirements had not been changed. (Staff #114 did provide a Facility assessment with different staffing information reflecting the change from 3 shifts to 2). She stated that contrary to the interview with the Director of Nursing (DON, Staff #113) and staffing coordinator, there was a salaried CNA who worked 'a lot' on overnights and weekends. She was not able to provide any proof that she had worked on the understaffed evenings in question. Staff #114 stated that leadership/IDT team is also available on all overnights and weekends at all times to assist with direct care tasks. Review of the nursing staff postings, staff schedules, punch details, and registry pay schedule revealed the following: On 12/23/22, the facility census was 96. The nurse staff posting information and schedule for that day indicated the actual hours worked was 49.23 hours for nurse aides. On 1/1/23, the facility census was 84. The nurse staff posting information and schedule for that day indicated the actual hours worked was 47.31 hours for nurse aides. Review of the payroll records revealed only 31.12 hours worked by 4 nurse aides on 1/1/23. On 1/13/23, the facility census was 96. The nurse staff posting information and schedule for that day indicated the actual hours worked was 54.49 hours for nurse aides. Review of the payroll records revealed only 29.86 hours worked by 3 nurse aides on 1/13/23. On 1/15/23, the facility census was 102. The nurse staff posting information and schedule for that day indicated the actual hours worked was 58.7 hours for nurse aides. On 1/18/23, the facility census was 106. The nurse staff posting information and schedule for that day indicated the actual hours worked was 51.05 hours for nurse aides. During interview on 1/25/23 at 11:36am with the staffing coordinator, Staff #21, she stated staffing needs are determined based on census, or acuity. She stated she staffed 5 nurses and 9 CNAs during the day shift and 5 nurses and 7 CNAs for the night shift. Weekends are not staffed differently. A list of CNA staffing data that included the below days was reviewed with the staffing coordinator and DON. Per the staffing requirements of 9 CNAs day and 7 CNAs night given during the interview with the SC, the following days were not staffed adequately by CNAs: 12/23/22- 60 scheduled, 49.23 actual worked 12/27/22- 72 scheduled, 56.76 actual worked 1/1/23- 60 scheduled, 47.31 actual worked 1/2/23- 72 scheduled, 68.91 actual worked 1/3/23- 84 scheduled, 58.12 actual worked 1/9/23- 72 scheduled, 59.23 actual worked 1/13/23-60 scheduled, 54.49 actual worked 1/18/23- 72 scheduled, 51.05 actual worked Clinical Resource Staff #118, Staffing Coordinator #21, Director of Nursing #113 were interviewed on 1/26/23 at 9:45 AM. DON and SC were asked why there was such a discrepancy between the scheduled hours/CNAs and the actual hours worked. They stated that the numbers did not reflect registry staff. SC was asked where the actual hours worked total came from on the staff postings, and she stated she calculated them herself. When asked if the staff posting and punch details included registry staff and hours, she stated they did. When asked if the above list of days were adequately staffed, they stated that if those numbers were accurate, they were not, but they would verify the numbers themselves. They were advised the numbers were pulled directly from their staff postings. They did not provide alternate staffing numbers. During an interview with a CNA, Staff #97, on 1/25/23 at 11:19 AM, He stated he is typically responsible for 13-15 residents during his shift. He said that 2 shifts a week, he will not have enough time to complete his assignments and will put off completing charting when that occurs. He stated he is asked to either stay late, come in early, or work overtime two to three times a week. When asked about registry staff and if there are any concern, the CNA stated he is fine with registry staff, except there are times when they do not do any work. During an interview on 1/26/23 at 1:20 PM with Staff #114 and Executive Director, Staff #112, they stated in June 2022, the CNA schedule was changed to 2 twelve hours shifts in order to better serve residents. They reiterated leadership and members of the interdisciplinary team are available to assist on the floor if needed. Staff #112 stated if a resident does not get the help they need, or see staff when they go looking, then that speaks to the work ethic of the staff, not that they are not staffed enough. Clinical Resource Staff #114 and Executive Director stated they had been in the process of switching to a new system during the 3rd Quarter in April-June 2022, and it did not record registry staff in PBJ report. She provided proof it had been corrected and they went up a star rating. Executive Director provided invoices showing registry staff had been present during that 3rd quarter. Review of the facility documentation in the facility assessment The facility considers both census numbers and acuity levels that impact staffing needs, and staffs accordingly. Because the majority of admissions occur in the afternoon/evenings, a fullA time admissions RN is staffed for those hours, in addition to a 12 hour weekend shift supervisor. The RN ADON also flexes her schedule to assist with increase in admissions on any given day. A full-time Social Worker and a full-time nurse case manager is employed to provide coordination of care and discharge planning and education. Nursing Services Staffing Plan, RNs/LPN's post-acute 6am-6pm: 2; RNs/LPNs post-acute 6pm-6am: 2; RN's/LPNs long term care 6am-6pm: 2; RNs/LPNs long term care 6pm-6am: 2; C.N.A.s 6am-2pm: 7-10; C.N.A.s 2pm-10pm: 7-9; C.N.A.s 10pm-6am: 4-5.

Based on clinical record review, staff interviews, review of facility documentation and policies, the facility failed to ensure accuracy of provider order for a psychotropic medication that was administered to one resident (#136). The deficient practice could result in adverse medication effects. Findings include: Resident #136 was admitted to the facility on [DATE] with diagnoses that included dementia, major depression disorder, and anxiety disorder. Review of The MED Form dated May 10, 2022/signed May 11, 2022 by a doctor, included the resident was on paroxetine hydrochloride (HCL) (Paxil) 40 mg tab, take one-half tab by mouth every evening and was appropriate for admission to skilled nursing facility for respite care. Review of a Psychoactive Mediation Evaluation dated May 12, 2022/signed May 13, 2022, included the resident was receiving a psychoactive medication of paroxetine 40 mg tab, take one-half tab by mouth every evening. Review of the facility physician's orders revealed: -An order dated May 12, 2022 for paroxetine HCL 40 mg tablet by mouth in the evening for antidepressant. -An order, dated May 13, 2022, for paroxetine HCL 40 mg tablet by mouth in the evening for depression As Evidenced By (AEB) self isolation. Review of the May 2022 Medication Administration Record (MAR) revealed documentation that the resident received the 40 mg dose of paroxetine HCL on May 12, 2022 and May 14-21, 2022. Review of the residents care plan revealed a focus, dated May 13, 2022, that the resident was on antidepressant medication with a goals that included the resident would be free from adverse reactions related to antidepressant therapy. The interventions included to monitor for side effects of anti-depressants: common side effects sedation, drowsiness, headache, decreased appetite. Review of a note from the consultant pharmacist dated May 15, 2022 included a recommendation to review the use of Paxil because Paxil was designated as a high risk medication in geriatric patients due to it's strong anticholinergic properties and potential for heavy sedation and orthostatic hypotension. The Physician response, dated May 17, 2022, included the resident was on a respite stay and would continue home med. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] included the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderately impaired cognition. The assessment included the resident received daily antidepressant medication. Review of facility documentation revealed a Medication Error Report dated May 23, 2022 with an error date of May 12, 2022. The report included the medication ordered was Paxil 40 mg, give 1/2 tab daily. Description of error included: When medication transcribed to electronic clinical record, the nurse missed the 1/2 tab and input order as paroxetine 40 mg, one tab each evening. Assessment and summary of error included type of error as wrong dose and reason for error was transcription error. An interview was conducted on January 24, 2023 at 10:36 a.m. with a family member. She stated the resident received 40 mg of Paxil while at the facility, when he was supposed to be receiving 20 mg. An interview was conducted on January 25, 2023 at 1:49 p.m. with the resident's physician (staff #117). He stated would have kept the home Paxil dose if the resident was there for a respite stay. He stated if the dose put in the system was not the same as the residents home dose, it was probably a transcription thing. An interview was conducted on January 26, 2023 at 8:35 a.m. with the pharmacy resource (staff #116). She stated that all orders had to be confirmed by the provider. She stated she would take the orders coming in from outside, review what was put into the resident's medical record and would question the dose change inputted in the system. She stated she would want to double check what she received from the consultant. She stated the higher dose of Paxil would put the resident at an increased risk for potential side effects. An interview was conducted on January 26, 2023 at 9:01 a. m. with a Registered Nurse/Assistant Director of Nursing (RN/ADON staff #81). She stated that all residents came in with a set of orders. She stated staff reviewed the orders, put the orders into the computer, and confirmed the orders with the doctor. She stated if the doctor changed orders on admission, the staff would input the order as per the doctor directions. She stated there was no way to know why a medication dose was changed. She stated the doctor would review the order the next day and makes sure those are the orders he wanted. She stated she did not know about documentation needs if a psychotropic medication dose was changed. She stated that respite would be hospice and the orders would be from the hospice provider. She stated if medication changes were made there should be documented reasons in the providers notes. On review of the resident's clinical record she stated the outside admitting doctor ordered 20 mg of paroxetine. She stated the 40 mg order looked like a transcription error. She stated the dosage change could cause potential adverse side effects from the medication, i.e. somnolence. An interview was conducted on January 26, 2023 at 9:16 a.m. withe the Director of Nursing (DON/staff #113) with two resource nurses present (staff # 114 and 118) He stated he expected staff to give medications as ordered by the provider. He stated the facility would contact the provider if there was any discrepancy with the medication. He stated there should be a progress note to document if order changes were made. He stated the provider should make a progress note to document the rationale for increasing a psychotropic medication dose. On review of the original order and the facility orders he stated the outside provider ordered paroxetine 40 mg 1/2 tab which would be 20mg. He stated the order was input into the clinical record as 40mg tablet and the 1/2 tab portion from the original order was not included. He stated the order did not match the orders sent by the outside admitting source and that it appeared that there was a transcription error. He stated the resident was at risk of not receiving a therapeutic dose and had a potential for adverse effects. Review of the facility policy for Medication Administration revised August 2016 included: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. The seven rights of medication administration included right dose, Medications are administered according to the dose prescribed. Review of the facility policy for Medication Errors and Adverse Reactions, revised May 2021, included: It is the policy of this facility that medication errors and adverse drug reactions be reported to the resident's attending physician. Review of the facility policy for Physician's Orders, reviewed August 2022, included: It is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. It is the policy of this facility to accurately implement orders in addition to medication orders only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. Admission orders are reviewed with the physician upon admission based on the discharge instructions fro the discharging facility and are transcribed accordingly.

Based on review of the clinical records, staff interviews, and facility policies and procedures, the facility failed to notify the legal guardian for one resident (#52) with impaired cognitive status for consents for treatment, the facility failed to notify the legal guardian for one resident (#52) with impaired cognitive status for a change in condition. The deficient practice could result in other guardians not being notified. Findings include: Resident # 52 was admitted on [DATE] with diagnoses that included hemiplegia, cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery, other symptoms and signs involving cognitive functions and awareness, cognitive communication deficit, other symptoms and signs involving cognitive functions following cerebral infarction, bipolar disorder, dysphasia and schizoaffective disorder, bipolar type. An Admission Minimum Data Set (MDS) dated [DATE] included that resident #52 had a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive deficit. The assessment included no documention of behaviors or moods. The assessment included that the resident required extensive assistance for bed mobility, dressing, and personal hygiene. The assessment included diagnoses of cerebrovascular accident, transient ischemia attack or stroke, manic depression, and schizophrenia. The assessment included that the resident received antidepressant medication 6 of the last 7 days. The assessment did not include that the resident received any Antipsychotic medications. The assessment included that the resident and family participated in the assessment but not the guardian or legally authorized representative did not participate. A physician progress note dated November 12, 20221 at 1:08 PM, included that resident #52 had schizoaffective disorder and per the records was legally incompetent. The note included that the resident was alert to place and time and answered questions with some forgetfulness. A Psychiatric note dated December 3, 2021 at 10:14 AM, included that the resident is legally incompetent and that since last visit, the patient's legal guardian relayed concerns that the patient is no longer taking Invega. The note included that the guardian requested that the staff speak with the resident's cardiologist and that the staff had attempted calling cardiology with no success. The note included that the guardian also relayed that she would contact the cardiologist for approval and call us back but there was no approval received at the time of the note. The note included that the resident only had a mild elevation of his QTc (a measurement of heart ventricular repolarization) and appears to be doing well regarding psychotic symptoms. The note included that the resident denied any hallucinations, delusions, or paranoia. Another Psychiatric note dated December 28, 2021 at 9:11 AM, included that the cardiologist approved the resident to resume Invega Trinza. The note included that the provider spoke with the guardian and they requested the resident restart the Invega Trinza and that an order would be put in to start the medication. An eMAR-Medication Administration Note January 2, 2022 at 2:58 PM, included that the Ivnega Trinza 546 mg (milligram)/1.75 mL (milliters) for schizoaffective disorder was coming from the pharmacy. Another eMAR note dated January 2, 2022 at 7:43 PM, included that the order for Invega Trinza needed to be clarified on Monday. A Psychiatric note dated January 4, 2022 at 9:54 AM, included that after an extensive conversation with the guardian, the provider ordered the Invega Trinza. The note included that the insurance company had not yet approved the medication and it was currently on hold. Review of the clinical record revealed no documention of communication of the Invega Trinza being held to the legal guardian. Review of the the clinical record revealed no documentation of consent provided by the guardian with risks and benefits. Another Psychiatric note dated January 25, 2022 at 10:00 AM, included that the resident had recent hallucinations but those hallucinations were not bothersome at this time. A Psychiatric note dated February 8, 2022 at 11:10 AM, included that the resident reported some hallucinations. Review of the Medication Administration Record (MAR) for February 2022 revealed that resident #52 was administered Invega Trinza on February 8 at 3:08 PM. A consent for psychotropic medications without a date included that verbal consent was given by resident #52 and was cosigned by two staff members. Review of the clinical record revealed no consent from the legal guardian for Invega Trinza. A Change of Condition note dated February 14, 2022 at 4:06 PM included that the resident returned from a dermatology appointment with a new prescription for antibiotic therapy and several antibiotic topical treatment and Antifungal shampoo. The note included that the resident's family member was made aware of the changes. Review of the clinical record revealed no documention of the legal guardian notified of the change of condition. A Psychiatric note dated February 15, 2022 at 9:30 AM, included that the resident report some mild anxiety without any hallucinations. The note included the resident started Invega Trinza last week and the potential side effects and benefits had been discussed with the resident. The note included that the resident verbalized understanding and agreement with the plan. Review of the clinical record revealed no documention of a discussion with the legal guardian about the potential side effects and benefits or the plan of care. A Quarterly MDS dated [DATE] included that resident #52 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive deficit. The assessment included no documention of behaviors or moods. An eMAR note dated June 10, 2022 at 4:20 PM, included that Invega Trinza was administered. Review of the MAR for March 2022 revealed that the resident was administered Invega Trinza on March 8 at 11:00 AM. An Influenza Immunization informed consent form dated November 14, 2022 included that resident #52 signed his own consent. Review of the clinical record revealed no documention of the legal guardian being notified of the flu consent. A nursing note dated January 11, 2023 at 1:05 AM, included that the resident was not in his room and the legal guardian was notified. The note included that the guardian informed the facility that the resident was transported to a hospital by the guardian. Review of the clinical record revealed POA documention that included that the resident was an incapacitated ward and/or protected person with the family listed as the guardian and conservator. This document included that it was notarized on October 15, 2018. Review of consents for medications revealed that staff obtained verbal consents from the resident and had the resident sign his own consent for a flu vaccine. Review of the clinical record revealed no documention of the POA being notified or consenting at the time for the medications. It also revealed that the resident did not received his medication related to a delay in authorization from December of 2021 through February of 2022. During an interview conducted on January 25, 2023 at 11:42 AM, with a Registered Nurse (RN/staff #115) and a Clinical Resource Nurse (staff #114), staff #115 stated that the resident was pleasant and cooperative. Staff #115 stated he was able to make his needs known, was alert and orientated, and was able to have a conversation without any concerns. Staff #115 stated she did not know the family was the guardian and staff #115 stated she would have never guessed that resident #52 was incapacitated or incompetent. An interview was conducted on January 25, 2023 at 11:55 AM, with the Director of Nursing (DON/staff #113). The DON stated that the expectation of the staff is to get consent for treatment from the MPOA when a resident is impaired or incapacitated. The DON stated that the guardian for resident #52 was contacted in December of 2021 for the psychotropic medication but the consent was documented as a verbal consent from the resident. The DON stated he believed this to be a documentation error as the guardian knew about the medication. The DON stated that the resident should not have signed his own consents because he had a guardian documented in the medical record. The DON stated the expectation is that if there is a change of condition for anyone that is incapacitated that the guardian would be notified. A facility policy titled Care and Treatment, Psychotropic Drug Use (revised October 2022) included that it is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medications is necessary to treat a specific condition as diagnosed and documented in the clinical record. All effort will be made by the Licensed Nurses to obtain as much history regarding these medications, including prior informed consents, from the previous facility or through resident or resident representative interview. Any information obtained will be documented in the resident's clinical record. A facility policy titled Care and Treatment, Change of Condition Reporting (revised July 2022) included that it is the policy of this facility that all changes in resident condition will be communicated to the physician. Acute medical changes and routine medical changes include notification to responsible parties and documention of notifications.

Based on observations, resident, resident representative, and staff interviews, and facility documentation, the facility failed to ensure necessary services were provided to maintain personal hygiene for one resident (#41). Findings include: Resident #41 originally admitted to the facility on [DATE], and had a reentry date of 02/04/20. Her diagnoses included fusion of spine, muscle weakness, spinal stenosis, glaucoma, heart disease, and neuropathy. Physician orders included prescription for Percocet and Gabapentin. Her Annual Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) of 13 which indicated little to no cognitive impairment. In order to perform Activities of Daily living, such as bed mobility or using the toilet, she required extensive assistance from one staff person. Not on toileting program. Resident is always incontinent of bladder, and frequently incontinent of bowel. She is not on a toileting program. Resident #41 uses a wheelchair at all times for locomotion. Resident #41 alleged that she was not changed for 18 hours on September 29, 2022. The facility investigation stated that Resident #41 was combative, refused treatment, and her care plan was updated to reflect that two staff would care for her at all times (Cares in Pairs). The Care plan initiated on 9/5/19 did not reflect any changes regarding incontinence or care after October 2022. The care plan included the goal to remain from from skin breakdown due to bowel and bladder incontinence. Interventions included checking as required for incontinence and then to wash, rinse and dry perineum, and change clothing as needed. Review of skin evaluations from 9/21/22 to 10/12/22 did not show any skin breakdown. During an interview on 01/25/23 at 11:19 AM, CNA Staff #97 stated that CNAs do hourly checks to see if a resident briefs need to be changed. When asked how brief changes are documented, he stated that if the CNA selects incontinent when charting in CNA tasks, that means the resident was changed. He stated that he knew resident #41, and she did not refuse care, and she on a Cares in Pairs protocol. Certified Nursing Assistant (CNA) Task review for September and October did not show any documentation on 2nd shift of any continence care. For the month of September 2022, across all shifts there were 10 shifts that did no documentation of incontinence care. For October 2022, there were 16 total shifts that did have any documentation of incontinence care. Based on observations, resident, resident representative, and staff interviews, and facility documentation, the facility failed to ensure necessary services were provided to maintain personal hygiene for one resident (#41). Findings include: Resident #41 originally admitted to the facility on [DATE], and had a reentry date of 02/04/20. Her diagnoses included fusion of spine, muscle weakness, spinal stenosis, glaucoma, heart disease, and neuropathy. Physician orders included prescription for Percocet and Gabapentin. Her Annual Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) of 13 which indicated little to no cognitive impairment. In order to perform Activities of Daily living, such as bed mobility or using the toilet, she required extensive assistance from one staff person. Not on toileting program. Resident is always incontinent of bladder, and frequently incontinent of bowel. She is not on a toileting program. Resident #41 uses a wheelchair at all times for locomotion. Resident #41 alleged that she was not changed for 18 hours on September 29, 2022. The facility investigation stated that Resident #41 was combative, refused treatment, and her care plan was updated to reflect that two staff would care for her at all times (Cares in Pairs). The Care plan initiated on 9/5/19 did not reflect any changes regarding incontinence or care after October 2022. The care plan included the goal to remain from from skin breakdown due to bowel and bladder incontinence. Interventions included checking as required for incontinence and then to wash, rinse and dry perineum, and change clothing as needed. Review of skin evaluations from 9/21/22 to 10/12/22 did not show any skin breakdown. During an interview on 01/25/23 at 11:19 AM, CNA Staff #97 stated that CNAs do hourly checks to see if a resident briefs need to be changed. When asked how brief changes are documented, he stated that if the CNA selects incontinent when charting in CNA tasks, that means the resident was changed. He stated that he knew resident #41, and she did not refuse care, and she on a Cares in Pairs protocol. Certified Nursing Assistant (CNA) Task review for September and October did not show any documentation on 2nd shift of any continence care. For the month of September 2022, across all shifts there were 10 shifts that did no documentation of incontinence care. For October 2022, there were 16 total shifts that did have any documentation of incontinence care. Review of the facility policy Incontinent Care revealed It is the policy of this facility to: 1. Remove urine or feces from skin. 2. Check for incontinent episodes and offer throughout the shifts based on resident needs. 3. Cleanse and lubricate skin. 4. Provide dry, odor free perennial care system. Additionally the facility policy ADL, Services to carry out states It is the policy of this facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with a written plan of care.

Based on resident and staff interviews, clinical record review, and policy review, the facility failed to ensure that one sampled resident (#15) was assisted with making a vision appointment. The deficient practice could result in decreased vision abilities. Findings include: Resident #15 was admitted on [DATE] with diagnoses that included anxiety disorder, unspecified fall, subsequent encounter, muscle weakness, generalized; other abnormalities of gait and mobility. A physician order dated December 25, 2022 revealed a vision evaluation and treatment as needed No directions specified for order. Revision date December 25, 2022. Review of the care plan dated July 26, 2021 revealed the resident had impaired visual function. The interventions included ensuring appropriate visual aids (glasses) are available to support participation in activities. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident is cognitively intact. The assessment also included that the resident had adequate vision and is in need of corrective lenses in completing her B1000 Vision An interview was conducted on January 23, 2023 at 11:49 AM with resident #15. Resident #15 stated that her vision is poor and she has been without her eyeglasses for six months. The resident stated she has asked the facility numerous times for a new pair of glasses and reported her inability to see correctly. The resident stated she has asked to see the eye doctor for months and the facility has not made an appointment with an eye doctor and had been told they are looking into it. The resident stated that she had glasses, but the frame was broken by a Certified Nursing Assistant while making her bed. The resident reported she really needs her glasses and is tired of waiting. The resident stated not having her glasses had affected her ability to read and see or participate in some of the activities offered. A review of the residents Inventory of Personal Effects dated January 28, 2022 revealed resident #15 had eyeglasses upon admission. On January 25, 2023 at 01:54 PM an interview was conducted with staff #49 (Social Service Director). Staff #49 stated the policy for resident personal items broken by staff and if listed on the inventory sheet, the item is paid for with petty cash. Staff #49 stated resident #49 reported her eyeglass frames had been broken in December 2022. Staff #49 stated she visited the resident to identify any dental or vision concerns and does not understand how she overlooked her. Staff #49 stated that she had contacted the provider, Eyes on Sight for a frame replacement on December 19, 2022 via telephone call. Staff #49 stated she did not have any documentation of the phone call for the frame replacement. She stated the process should not have taken longer than 30 days from the date of the request. Staff #49 stated the provider; Eyes on Sight comes to the facility to provide services to any resident with vision needs. Staff #49 reported the facility had sought eyeglass services through the resident's insurance and was waiting for approval. Staff #49 was observed as frustrated with the questions and stated I provide transportation for all the residents and I know it falls on me. I guess I didn't follow through like I should have. She stated I admit I have not had time to follow through with her glasses. Staff #49 was informed resident had reported she had been without her glasses for a while and it had affected her daily life, as she relies on them for her vision needs. On January 26, 2023 an interview was conducted at 09:53 AM with Director of Nursing (DON/Staff #113) and Clinical Resource (Staff #114). The DON explained when concerns are brought to their attention and they will speak to the resident, using the grievance process and come up with a resolution. Staff #114 reported the process is completed and falls under Resident Rights. The DON stated the concern for the resident eyeglasses had not been brought to his attention or it would have been resolved immediately. The DON and Staff #114 were informed there was no documentation of the facility's effort in resolving the resident's issue in having her eyeglasses repaired or replaced in a timely manner and the facility failed to ensure the resident was provided with replacement lenses, which had limited the residents vision abilities and activities on a daily basis. Review of the facility policy Resident Rights and Grievances revised November 2016, revealed that the Grievance Official evaluates and investigates the concern and takes immediate action to resolve the concern and prevent further potential violations of any residents' rights while the alleged violations are being investigated.

Based on review of clinical records, staff interviews, and facility policies and procedures, the facility provided a psychotropic medication for Bipolar disorder for one resident (#71) without a diagnosis of Bipolar disorder: Findings include: Resident # 71 was admitted on [DATE] with diagnoses that included fracture of lower end of left humerous, chronic respiratory failure, type 2 diabetes mellitus, Methicillin susceptible staphylococcus Aureus infection, anemia, hypo-osmolality and hyponatremia, hepatomegaly, depression, visual hallucinations, and acute embolism and thrombosis of deep veins of right upper extremity. Review of the clinical record revealed the following provider orders: -ARIPiprazole Oral Tablet 5 MG (Aripiprazole) Give 1 tablet by mouth at bedtime for Bipolar AEB (as evidenced by) Labile mood. Review of the Medication Administration Record (MAR) for January 20 through January 25, 2023 revealed the resident received ARIPiprazole one time a day for six days. Review of the clinical record revealed no documention of a diagnosis of Bipolar disorder. Review of a face sheet presented to the surveyor on January 26, 2023 included a diagnosis of Bipolar disorder. During an interview conducted on January 26, 2023 at 12:43 pm with an Assistant Director of Nursing/Licensed Practical Nurse (ADON/LPN, staff #36), staff #36 stated that on admission orders are verified and entered into the system. Staff #36 stated that when a resident has psychotropic medications there needs to be an order with a diagnosis and symptoms to administer the medication for. Staff #36 stated that a consent needs to be signed for the medication either by the resident or if the resident was incapacitated the MPOA (medical power of attorney). Staff #36 stated that the staff, provider, and pharmacy checks to ensure that medications are ordered and administered correctly. During an interview conducted on January 26, 2023 at 2:20 pm with Medical Records Staff (staff #17), staff #17 stated that she added the diagnosis of Bipolar today, January 26, 2023. Staff #17 stated she did not know where she found the diagnosis in the records or medical history to add it and denied being instructed to add it from any other staff member. During an interview conducted on January 26, 2023, at 2:28 pm with a Clinical Resource (staff #114), staff #114 stated when she presented this surveyor the face sheet with the diagnosis of Bipolar for resident #71, she did not know that it had been added today. Staff #114 stated that the diagnosis was located in some medical records from the hospital but was added to the facility diagnoses on January 26, 2023. A facility policy titled Physician Orders (revised August 2022) included it is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. It is the the policy of this facility to accurately implement orders in addition to medications orders only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. Orders for medications must include a reason or problem for which it is given. A facility policy titled Care and Treatment, Psychotropic Drug Use (revised October 2022) included that it is the policy of this facility to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medications is necessary to treat a specific condition as diagnosed and documented in the clinical record. All effort will be made by the Licensed Nurses to obtain as much history regarding these medications, including prior informed consents, from the previous facility or through resident or resident representative interview. Any information obtained will be documented in the resident's clinical record.

Based on observations, clinical record review, staff interviews, facility documentation, review of the Center for Disease Control (CDC) guidelines and policies and procedures, the facility failed to maintain an effective infection control program, by failing to ensure that contact precautions were followed for one resident (#376) with active [MEDICAL CONDITIONS]. As a result, the Condition of Immediate Jeopardy (IJ) was identified. Findings include: On (MONTH) 3, (YEAR) at 11:11 a.m., the Condition of Immediate Jeopardy (IJ) was identified. The Administrator was informed of the facility's failure to implement infection control procedures for one resident (#376), who was on contact precautions for [MEDICAL CONDITION]. A visitor was observed in the resident's room sitting in a chair and was not wearing a gown or gloves. The visitor was also observed leaving the resident's room carrying a briefcase into the hallway. The Administrator presented a plan of correction on (MONTH) 3, (YEAR) at 12:50 p.m. At 1:27 p.m. the Administrator was informed that the plan of correction needed to address additional areas. A revised plan of correction was presented on (MONTH) 3, (YEAR) at 1:52 p.m. The Administrator was informed that the plan of correction needed to address how visitors would be monitored for compliance with isolation precautions between the hours of 6:00 p.m. to 6:00 a.m. A revised plan of correction was presented on (MONTH) 3, (YEAR) at 2:24 p.m. and was accepted. The plan of correction included the following: all staff were to be provided in-service education regarding visitor compliance with isolation policies and procedures; visitors will be educated regarding wearing protective equipment in the isolation room and hand washing, and as an interim measure staff will monitor visitors to ensure they comply with wearing a gown, gloves and handwashing procedures. Multiple observations were conducted on (MONTH) 3 and 4, (YEAR) of the facility implementing their plan of correction. Staff in-services were being completed and staff interviewed were knowledgeable of infection control procedures, including contact precautions for visitors and staff. In addition, there were no observations of staff or visitors entering the resident's room, without donning a gown and gloves. As the facility was implementing their plan of correction and there were no new concerns identified, the Condition of Immediate Jeopardy was abated on (MONTH) 4, (YEAR) at 11:48 a.m. Resident #376 was admitted on (MONTH) 18, (YEAR), with [DIAGNOSES REDACTED]. A physician's progress note dated (MONTH) 19, (YEAR), included the resident was admitted from the hospital with an infected pressure ulcer of the sacrum, and had been transferred to the facility for continued wound care and IV antibiotics. A bowel movement (BM) report dated (MONTH) 20, (YEAR), included that the resident had an episode of loose/diarrhea stool. A change of condition note dated (MONTH) 20, (YEAR) at 3:50 p.m. included the resident had diarrhea which started on (MONTH) 19, and the physician was notified, and stool softeners were held. A change of condition note dated (MONTH) 21, (YEAR) at 9:45 a.m., revealed the diarrhea had stopped since holding the laxatives. Review of the BM reports revealed the resident had episodes of loose/diarrhea stools on (MONTH) 22, 24, 25, 27, 28 and 29, (YEAR). Review of a dietary note dated (MONTH) 29, (YEAR), revealed the resident had a history of [REDACTED]. A BM report dated (MONTH) 30, (YEAR) included the resident had two episodes of loose/diarrhea stools. A physician's orders [REDACTED]. Per the clinical record, a stool specimen was obtained on (MONTH) 30, (YEAR) and the laboratory test results dated (MONTH) 30, confirmed that the resident was positive for [MEDICAL CONDITION] toxin. A physician's orders [REDACTED]. A care plan initiated on (MONTH) 31, (YEAR) included the resident had [MEDICAL CONDITION] related to IV antibiotic therapy. A goal was for the resident to not have symptoms of dehydration related to [MEDICAL CONDITION]. Interventions included for contact isolation, educate the resident, family and staff regarding preventive measures to contain the infection, and to monitor the resident's family who visits to assure compliance with isolation precautions. The care plan also included that the resident's family member had been educated, but was forgetful. A physician's progress note dated (MONTH) 31, (YEAR) revealed documentation that the resident had reported having diarrhea one week prior to admission to the facility. Also, that a (stool) culture was positive for [MEDICAL CONDITION] and the resident was prescribed [MEDICATION NAME]. A BM report dated (MONTH) 31, (YEAR) included the resident had two episodes of loose/diarrhea stools. A BM report dated (MONTH) 1, (YEAR) included the resident had three episodes of loose/diarrhea stools. A daily skilled note dated (MONTH) 1, (YEAR) at 11:44 p.m. included the resident was on isolation for an infectious disease. The note stated that the resident had [MEDICAL CONDITION] and was on contact precautions. A BM report dated (MONTH) 2, (YEAR) included the resident had three episodes of loose/diarrhea stools. An observation was conducted on (MONTH) 3, (YEAR) at 9:25 a.m., outside of the resident's room. An orange sign was posted on the door frame which read, Stop check with nurse before entering. A small cart was located under the sign next to the door, which contained Personal Protective Equipment (PPE-disposable gowns, gloves, and shoe covers). At this time, the door to the room was open and a visitor was observed in the room and the visitor was not wearing a gown or gloves. The visitor then closed the door and remained in the room. An observation was conducted on (MONTH) 3, (YEAR) at 9:35 a.m., of a Licensed Nursing Assistant (staff #17), who donned a gown, gloves and shoe covers and entered the resident's room. When staff #17 exited the room at 9:38 a.m., the visitor was observed in the resident's room, sitting in a chair next to the resident's bed. The visitor was not wearing a gown or gloves. An interview was conducted on (MONTH) 3, (YEAR) at 9:40 a.m., with the Assistant Director of Nursing (ADON/staff #7). At this time, the ADON was in the hallway near the resident's room and was passing medications. Staff #7 stated that the resident's visitor was a family member, who had been educated on isolation precautions and wearing protective equipment due to the resident having [MEDICAL CONDITION]. Staff #7 stated that although the visitor had been educated regarding wearing a gown and gloves, the visitor refused to wear the protective items. Staff #7 further stated that the resident had multiple loose stools the day before and was considered to have an active [MEDICAL CONDITION] infection. An observation was conducted on (MONTH) 3, (YEAR) at 10:20 a.m., of the visitor exiting the room of resident #376. The visitor was carrying a briefcase out of the room and then stopped and spoke with the Administrator (#110) and two other administrative staff members. An interview was conducted on (MONTH) 3, (YEAR), at 11:11 a.m. with the Administrator (#110). The Administrator stated that the family member who visits the resident puts protective equipment on prior to entering the room, but removes it after entering the resident's room. Continued review of the clinical record revealed that the care plan for [MEDICAL CONDITION] had been revised on (MONTH) 3, (YEAR), to include an intervention that the (family member) of the resident must be banned from visiting immediately, if non-compliant. An interview was conducted on (MONTH) 4, (YEAR) at 8:31 a.m., with a Licensed Practical Nurse (LPN/staff #8). Staff #8 stated that before a visitor enters an isolation room, she would educate them on the protocol for PPE. She stated that visitors are required to wear PPE each time they enter an isolation room. Staff #8 stated that if a visitor refuses to wear PPE, she would contact the Director of Nursing to speak with the visitor, and if the visitor continued to refuse to wear PPE, the visitor would probably be refused entry into the isolation room. Staff #8 further stated that if a visitor brings personal property into the facility, they must leave it outside the isolation room. An interview was conducted on (MONTH) 4, (YEAR) at 8:45 a.m., with a Certified Nursing Assistant (CNA/staff #37). Staff #37 stated that if a visitor approached an isolation room and was not wearing PPE, she would stop the visitor and instruct them regarding the requirement for PPE. She said if the visitor was resistant to wearing PPE, she would tell the visitor that they cannot enter the room without wearing it, and notify the supervisor. She said if a visitor was found inside an isolation room without wearing PPE, she would instruct the visitor to exit the room and she would notify the supervisor. Review of a sample admission packet revealed it contained a policy titled, Visitation Policy Isolation and Prevention, which included that Visitors must observe the facilities policies for isolation practices and barrier precautions. If visitors are not observing isolation practices and barrier precautions, the facility reserves the right to restrict visitation. Review of a policy and procedure titled, Isolation and Prevention revealed that it is the policy of this facility to prevent transmission of infection to residents and visitors. The policy included that Visitors will observe the facility's policies for isolation practices and barrier precautions. In the event that a visitor fails to comply with the facility's isolation protocols, the right to visit will be denied. An infection control policy titled, Contact Precautions for [MEDICAL CONDITION] Infection included that all visitors must comply with isolation precautions, i.e. donning and doffing gowns and gloves, and with handwashing requirements. Visitors will be called and notified when the resident is placed on isolation precautions, and a time will be set up to be in-serviced on isolation precautions. The policy included that visitors will be informed that non-compliance with facility's isolation and handwashing procedures will result in visitation being denied. Review of the CDC guidelines revealed that [MEDICAL CONDITION] is a spore forming bacterium that causes inflammation of the colon known as [MEDICAL CONDITION]. [MEDICAL CONDITION] spores are shed in feces and transferred to patients mainly via the hands of people who have touched a contaminated surface or item. For prevention of transmission of [MEDICAL CONDITION] in healthcare settings, use contact precautions for patients with known or suspected [MEDICAL CONDITION]. The guidelines included to use gloves and gowns when entering patient rooms and during care and for all interactions that may involve contact with patient or potentially contaminated areas in the patients environment. The policy also stated that before exiting the patient room, discard gowns and gloves, and wash hands to contain the [MEDICAL CONDITION] pathogens.

Based on clinical record reviews, review of facility documentation, staff interviews, and review of facility policy and procedure, the facility failed to ensure that fall prevention measures were in place for one resident (#162) who sustained a fall with injury, and failed to ensure one resident (#196) was transferred safely using a Sabina lift, resulting in an injury. Findings include: -Resident #162 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed an initial data collection tool dated March 12, 2013, noted that the resident had a fall prior to her admission and that her judgement was poor, which may place her at risk for injury. A Fall Risk Evaluation dated March 12, 2013, noted the resident was at risk for falls. The only intervention was the resident was "alert but unable to understand her" and to keep the call light within reach. Review of the falls interim care plan dated March 12, 2013, revealed the resident had a history of [REDACTED]. Interventions included providing assistance of one to two people for transfers, providing assistance for bed mobility, transfers or ambulation, low bed, quarter side rails for positioning, and to educate the resident on call bell use. However, a nurse's note dated March 15, 2013, documented that the resident was unable to use the call bell. A physician's orders [REDACTED]. Review of the nursing notes revealed that the resident sustained [REDACTED]. The resident was noted to have a "goose egg sized" hematoma (a collection of blood in the skin) on the middle of her forehead and was immediately sent to the emergency room per physician's orders [REDACTED]. A Fall Risk Evaluation dated March 18, included the resident continued to be at risk for falls. The fall care plan was updated on March 18, to now reflect the use of a wheelchair alarm, however, it was not updated to reflect a bed alarm, despite the fall being from the bed. Review of the facility investigation revealed that the bed was in the high position at the time of the incident and the floor mat was leaning against the wall. The report also mentioned that a tab alarm was on the dresser. The report further included that prior to the fall, the resident was working with therapy and either therapy or the CNAs, did not replace the safety devices. Review of the hospital records revealed that the resident was admitted to the hospital on March 18, 2013, with the chief complaint of fall with head trauma. The hospital record noted that the resident was transferred from one hospital to another for evaluation of an intracranial bleed, secondary to fall from bed. The physical examination showed that the resident had a forehead bruise with a hematoma. A computed axial tomography (CAT) scan of the resident's brain showed an intracranial bleed. The overall impression noted was that she had a fall from her bed with an acute intracranial bleed and was admitted to the intensive care unit. Further review of the clinical record revealed the resident returned to the facility on [DATE]. Review of the initial data collection tool dated March 22, 2013, revealed the resident continued to be at risk for falls. Interventions on the Fall Risk Evaluation dated March 22, included for a low bed with mat to either side of the bed, and a tab alarm for poor safety awareness. Review of the fall interim care plan dated March 25, 2013, revealed the resident was at high risk for falls. Interventions included for a low bed with floor mats, bed/chair alarm, call light within reach and assist with transfers/toileting. Review of facility documentation revealed that the resident sustained [REDACTED]. At the time of the fall, it was noted that the resident had rolled off the bed and the family had helped the resident to the floor. The report included the bed was in the low position, however, the fall mats were not on the floor. The documentation did not mention if the tab alarm was in place at the time of the fall. No injury was noted. In an interview on July 23, 2013 with one of the CNA's who provided care to the resident on March 18, stated interventions in place were a tab alarm, low bed, and a bed mat. She stated that the resident was not normally able to follow directions and was confused. She stated that on March 18, she entered the resident's room and saw that the resident was on the floor by her bed. She stated that the resident's tab alarm was not on her and the floor mat was not on the floor. She further stated that the resident had a bump on her forehead. In an interview on July 24, 2013, with the LPN who was on duty at the time of the incident on March 18, stated that she was giving report to the next nurse on shift when she was called by a CNA to the resident's room. She stated that the resident was on the floor and that the resident's tab alarm was on the dresser, the bed was at normal height (not lowered), and the resident's fall mat was not on the floor. The nurse did not recall that the resident sustained [REDACTED]. During an interview with the director of nursing (DON) at 11:00 a.m. on July 25, 2013, she stated that she remembered the fall in question and that the resident did not have her fall mat on the floor and her bed was not in the lowest position, as it should have been. She stated that the resident received a bump on her head and a hematoma and was sent to the hospital. Review of a facility policy and procedure regarding Fall Management noted that an interdisciplinary plan of care will be implemented for each resident based on the resident's current safety needs and fall reduction interventions and that interventions should be care planned. The policy also included that it was the responsibility of the primary nurse and CNA to see that care plan interventions were in place at all times. -Resident #196 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed a Falls Reduction Checklist dated June 20, 2012, which documented adaptive equipment included the use of a Hoyer lift. A Fall Risk Evaluation dated December 27, 2012, included that the resident was at risk for falls. An intervention included for Hoyer lift transfers. Review of the CAA's (Care Area Assessment) of the MDS (Minimum Data Set) dated December 29, 2012, revealed that the resident was not steady when moving from a seated to a standing position and when transferred from surface to surface, was only able to stabilize with human assistance. A Montreal Cognitive Assessment/MoCA-Blind assessment for memory, attention, language, recall and orientation dated January 22, 2013, revealed that the resident was oriented to the day and city and scored a 5 of a total score of 22. A score of at least 18 out of 22 was considered normal. A Patient Centered Evaluation monthly visit dated January 22, 2013, included that the MoCA screening indicated dementia. The resident was also assessed to have pain with bilateral shoulder range of motion, muscle wasting, disuse atrophy, and was non-ambulatory. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Further review of the clinical record revealed there were no progress notes for the month of January 2013. A Monthly Summary dated February 7, 2013, included that the resident had arthropathy of the shoulder, muscle weakness, had limited muscle tone, and was bed or chair bound. Review of a physician's orders [REDACTED]. A nurse's note date February 25, 2013, documented the resident had slept in bed on and off during the shift, was very weak and tired, and continued on Tamiflu with no adverse reactions. Review of the MAR (medication administration record) for February 2013, revealed that Tamiflu had been administered every 12 hours from February 25, through February 27, 2013. Review of the ADL (activities of daily living) care plan included the resident needed assistance with ADL's due to impaired mobility and cognitive impairment. Review of the fall care plan revealed that the resident was identified to be at risk for fall and injuries related to impaired mobility, with a goal that the resident would be free from falls. An approach included to transfer the resident with the assistance of a Sabina lift and one staff member. However, a self care deficit care plan updated January 3, 2013, included that the resident required the assistance of one to two staff members with transfers and positioning with the use of the Sabina lift. Review of the Monthly Flow Report completed by the CNA's for February 26, revealed the resident was totally dependent on staff for transfers and toileting, and required two person physical assistance. A progress note dated February 26, 2013 at 9:30 a.m., revealed that a CNA had transferred the resident from the bathroom to a wheelchair using a Sabina lift and the resident "slid out of the sling" and was assisted to the floor by the CNA. The resident was assessed to have had normal range of motion, but complained of left shoulder pain. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A progress note dated February 26 at 9:00 p.m., documented the resident was weak and confused, coughing at intervals, was afebrile, and had flu symptoms. Review of the Reportable Event Record Report dated February 26, 2013, revealed that the CNA stated the resident had gone limp during the transfer and slipped out of the sling, when being transferred via sit to stand lift from the bathroom back to the wheelchair. The report identified that the CNA had not properly positioned the resident in the sling. Per the report, the CNA stated that the resident was usually able to assist by holding onto the bars on the lift during a sit to stand transfer, and that the resident seemed weak, and then went limp in the lift. The CNA was "re-educated" that all mechanical lifts require two persons present. Review of a Rehabilitation Services Multidisciplinary Screening Tool dated February 28, 2013, revealed that during a Sabina lift transfer, the resident's arms "slipped down" causing the resident to fall. The documentation also noted that the resident had been sick causing increased weakness, and that a second person was recommended to assist the resident with toileting and transfers for safety and to reduce the risk of falls. A physician's orders [REDACTED]. During an interview conducted on July 24, 2013, a CNA stated that the difference between a Sabina lift and a Hoyer lift was the amount of assistance a resident needed for transfers. The CNA stated that a Sabina lift was used when a resident could bear weight, required one assist, and was a sit to stand type lift, with a sling going around the resident's upper body. The CNA further stated that when a resident could not stand well, and needed two person assistance for transfers, a Hoyer lift was used and that a Hoyer lift required two people to assist with transfers. During an interview conducted on July 24, 2013, a physical therapy assistant stated that a Sabina lift should not be used for residents that have shoulder concerns, dementia, or are in a weakened state. Additionally, she stated that during a Sabina lift, the lift strap is placed around the resident's trunk, and the plate for the Sabina lift was placed at the resident's knees for support when using the sit to stand lift. The therapy assistant stated that if a resident cannot hold onto the Sabina sling during the transfer, the sling could "slide up" around the resident's arms and slip off. An interview was conducted on July 25, 2013, with the CNA who assisted the resident at the time of the event. She stated it occurred in the early morning around 6:00 - 6:30 a.m., that she got the resident up with the Sabina lift and took her to the bathroom. She said she was in the process of actively transferring the resident and getting her upright from the toilet, when she noticed and told the resident she didn't look good. The resident then shook her head and "passed out." She said she called for help, as the resident was "hanging" with her arms up over her head and "almost slipped out." She stated she lowered the resident to the floor and reported it to the nurse. During an interview conducted on July 25, 2013, licensed staff stated that the type of lift used for transferring residents depended on how strong and competent the resident was in transfers. She stated that when using a Sabina lift, the resident had to be able to hold on to the lift during the transfer, or it would be considered unsafe. Additionally, she added that a resident with dementia would not use a Sabina lift, as the resident "may not be able to cooperate" in transfers and "may not hold on" during the transfer. During an interview conducted on July 25, 2013, a physician stated that she had not directly treated the resident at the time of the event, however, she was familiar with the resident. The physician stated that the facility had an outbreak of influenza while the resident was in the facility and that only those residents that had symptoms were given the Tamiflu, and that resident #196 was symptomatic and was administered Tamiflu. During an interview conducted on July 25, 2013, the regional nurse consultant stated that the facility did not have a specific policy regarding the use of the Sabina lift and that they follow the manufacturer's directions. An instruction guide provided by the facility titled "Sabina II" included that the Sabina was intended for use with patients who were able to actively participate in the raising motion (i.e. the patient grabs the sling bar) and that caregivers need to assure patients are not at risk of falling forward or to the side during lifting. The instruction guide further included that when a patient did not reach a sufficiently upright position when helping the patient to his feet, that sometimes this was due to the patient's state of health or mobility, weakened musculature, and/or lack of strength. The instruction guide did not address if one or two persons were required for its use. Review of a facility policy titled "Mechanical lift use" included to follow the manufacturer guidelines and recommendations in respect to the use of the device, and included that two persons were required to perform the lift procedure.