Every finding on record at Lakepoint Augusta, LLC

Based on observation, record review, and interview, the facility failed to ensure a medication error rate below five percent. Twenty-six medications administrations were observed with 15 errors identified, resulting in a medication error rate of 57.69 %. Findings included:1. Review of the Electronic Health Record (EHR) for Resident (R) 6 revealed the following orders:Finasteride (medication used to treat male pattern hair loss or enlarged prostate) five milligrams (mg), give one tablet via gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) one time a day.Fludrocortisone acetate (a synthetic corticosteroid) 0.1 mg, give one tablet via G-tube one time a day.Furosemide (a loop diuretic) 40 mg, give two tablets via G-tube in the morning.Gabapentin (medication used to treat nerve pain and to control certain types of seizures) 600 mg, give one tablet via G-tube three times a day.Metoprolol (medication used to treat high blood pressure) 25 mg, give via one tablet via G-tube in the morning.Midodrine (medication used to treat low blood pressure when standing) 10 mg, give one tablet via G-tube three times a day.24-hour (hr) Mirabegron (used to treat the symptoms of overactive bladder) 8 mg/milliliter (ml) extended-release suspension, give 3 ml via G-tube in the morning.Oxybutynin (medication used to treat urinary urgency, frequency, and incontinence) 5 mg, give one tablet via G-tube three times a day.Potassium Chloride (a medication to treat low blood potassium) 15ml/20 milliequivalent (MEQ), give 15 ml via G-tube two times a day.Simvastatin (a medication used to lower cholesterol) oral suspension 40 mg/5ml, give 5 ml via G-tube in the morning.ProSource oral liquid (nutritional supplement), give 30 ml via G-tube three times a day.Probiotic, give one tablet via G-tube one time a day.Clopidogrel (medication used to prevent blood clots) 75 mg, give one tablet via G-tube one time a day.Ferrous sulfate (oral iron supplement) 325 mg, give 1 tablet via G-tube one time a day.R6's EHR lacked orders for medications to be crushed and/or mixed and lacked an order for an oral tablet for simvastatin.Observed on 06/23/2026 at 11:00 AM, Licensed Nurse (LN) H crushed R6's oral tablet medications, which included an oral tablet for simvastatin and mixed them all in a cup with liquid medication. At 11:33 AM provided R6 his crushed and mixed medications via G-tube. LN H performed hand hygiene and wore gloves only. On 06/23/2026 at 11:22 AM, LN H said that all oral medication tablets were crushed and mixed with his ProSource, potassium chloride and mirabegron oral suspensions. She then confirmed there was no current order to crush R6's medications or to combine them and confirmed there should have been an order to crush and combine the medications.2. On 06/22/2026 at 08:05 AM, Certified Medication Aide (CMA) R administered R34's aerosol 160-4.5 micrograms (mcg)/activated clotting time (ACT) (Budesonide-Formoterol Fumarate Dihydrate) one puff inhaled orally two times a day for chronic obstructive pulmonary disease. CMA R did not offer or encourage R34 to rinse her mouth after administration as ordered.On 06/23/2026 at 12:35 PM, Administrative Nurse D said that prior to crushing and/or mixing any medications an order should be obtained from the physician, and the pharmacist should be consulted to ensure medications could safely be mixed.The facility's policy Administering Medications, date April 2019, documented that medications were to be administered in a safe and timely manner, and as prescribed. The policy washer documented that the individual administering the medication was to check the label and verify that it was the right resident, right medication, right dosage, right time, and right method (rout) of administration before giving the medication.

Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 69 remained free from exploitation when facility staff reported that an employee coerced R69 into providing her $80. Findings included:- R69's Electronic Medical Record (EMR) documented diagnoses of major depressive disorder, pain, and insomnia.R69's Quarterly Minimum Data Set (MDS), dated 04/01/2026, documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The assessment documented that R69 had little interest or pleasure in doing things and felt down and depressed.R69's Care Plan, with a revision date of 01/03/2025, documented that she had impaired cognitive function/dementia or impaired thought processes related to dementia. Interventions, dated 01/03/2025, instructed staff to cue, reorient, and supervise R69 as needed. Staff were also instructed to discuss concerns about confusion, disease process, and nursing home placement with R69, her family and caregivers.R69's Care Plan, with a revision of 04/16/2026, documented that she had depression. An intervention, with a date of 04/16/2026, instructed staff to monitor, document, and report as needed any signs or symptoms of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing any negative statements, repetitive or health-related complaints, or tearfulness.Certified Medication Aide (CMA) S's Notarized Witness Statement, dated 05/15/2026, documented she was giving R69's roommate medication and heard a housekeeper ask R69 if she could borrow $65.00 from her and R69 eventually said yes. She said that she heard R69 tell the housekeeper where her wallet was and after she removed that money from the wallet the housekeeper thanked R69 and promised to pay her back. The housekeeper then went around the privacy curtain and was startled to see CMA S in the room. CMA S documented that she immediately went and reported the incident to her supervisor.R69's Notarized Witness Statement, dated 05/15/2026, documented that on the morning of 05/15/2026 Housekeeping U went to R69s room and asked her for $10.00 for a pair of earrings R69 had bought from her. R69 told her she only had $20 bills and asked Housekeeping U if she had change, and she said no. Housekeeping U then asked R69 for an additional $65.00 for food and groceries. R69 documented that she and R69 then asked Housekeeping U to get R69's wallet and R69 pulled out $80.00 and gave it to Housekeeping U.The Facility Investigation, dated 05/15/2026, documented that on 05/15/2026 staff reported concerns regarding possible financial exploitation of R69 by Housekeeping U. It was reported that Housekeeping U had previously sold R69 handmade jewelry for approximately $10 and had approached R69 asking for the money and R69 had told Housekeeping U that she only had a $20 bill and requested change. Another staff member overheard the conversation and heard Housekeeping U request additional money from R69, and R69 then provided Housekeeping U with approximately $80. Based on the investigative findings, the facility terminated Housekeeping U on 05/15/2026, a police report was filed on 05/15/2026, and the facility reimbursed R69 the $80.00 on 05/15/2026.Observed on 06/023/2026 at 10:15 AM, R69 ambulated in the hall with her walker. She greeted other residents and staff pleasantly and with a smile.On 06/22/2026 at 09:02 AM, R69 reported that the previous month a housekeeper told her that she needed to buy groceries and kept telling R69 she had no money. R69 said she felt bad for the housekeeper, so she ended up giving her a total of $80.00. She then said that the facility immediately reimbursed her the $80.00.On 06/23/2026 at 08:28 AM, R45 said staff had never asked her for money or anything, she thought that administration might have talked to her about abuse, neglect, exploitation (ANE).On 06/23/2026 at 08:35 AM, R56 and R66 both said that no staff had ever asked either of them for money or anything and that every so often administration would talk to them about ANE what to do if anything related to ANE occurred. Both said that the most recent education occurred May 2026.On 06/23/2026 at 08:45 AM, Certified Nurse Aide (CNA) M said that she had just hired last month, and the facility provided online education for ANE through an e-learning platform and there had also been a policy handout that was reviewed. On 06/23/2026 at 09:05 AM, Administrative Staff A said that ANE training occurred annually and anytime there was an instance or concern that arose. He said the last ANE education occurred a month ago and it was facility wide. Administrative Staff A said that last month a housekeeper exploited R69 for $80.00 and the facility immediately suspended the housekeeper and performed an investigation and reimbursed R69 the money on 05/15/2026. He said there were 34 residents interviewed by the social services designee (SSD) after the exploitation occurred, all residents had a BIMS of 12 or higher and the sample was throughout the building. He said that ANE education was facility wide and completed on 05/18/2026 and interviews were completed on 05/15/2026. Administrative Staff A also said that the employee was terminated, and a police report was filed. Review of the bank transaction from the facility to R69's account revealed that the facility reimbursed R69 the $80 on 05/15/2026, re-education was completed 05/18/2026, therefore PNC.The facility policy Lakepoint [NAME] Introduction to ANE documented that exploitation was illegal or improper use of an individual's resources for another person's profit or advantage. The policy documented that employees must understand their legal obligation to report any suspected abuse, neglect, or exploitation.

Based on interviews, observation, and record review, the facility failed to ensure Resident (R) 22's was treated with respect and dignity while waiting to be assisted with meals.Findings included:- R22's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), need for assistance with personal care, senile degeneration of brain, and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin).The Annual Minimum Data Set (MDS), dated 05/15/2026, documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R22 was dependent on staff assistance with all activities of daily living.R22's Cognitive Loss/Dementia Care Area Assessment (CAA), dated 05/28/2026, documented she was at risk for a self-care deficit related to her dementia (a progressive mental disorder characterized by failing memory and confusion).R22's Care Plan documented the following interventions: 02/20/2026 - She needed assistance with all decision making. She enjoyed talking with roommate and staff. She had little activity involvement related to her immobility.On 06/22/2026 at 08:18 AM, R22 sat reclined in her Broda chair (specialized wheelchair with the ability to tilt and recline) at the end of the dining room table. She faced away from her table mate. A cup of fluid sat on the table out of reach.On 06/23/2026 at 07:41 AM, R22 sat reclined in her Broda chair at the end of the dining room table. A glass of fluid sat on the table out of reach. She sat with her back to her table mate. At 08:17 AM, her table mate exited the dining room and R22 sat alone at the dining room table. At 08:23 AM, Certified Nurse Aide (CNA) P sat with R22 and assisted her with breakfast.On 06/23/2026 at 11:15 AM, R22 sat at the dining room table in her Broda chair with her back to her table mate. At 11:42 AM, an unidentified staff member placed a cup of fluid on the table out of R22's reach and the staff member sat down alone at another dining room table. At 12:04 PM, CNA P sat down with R22 and assisted her with lunch. On 06/24/2026 at 09:26 AM, CNA Q stated a resident should not have to sit in the dining room waiting for assistance with meals more than five to 10 minutes.On 06/24/2026 at 09:47 AM, Licensed Nurse (LN) G stated a resident should never sit in the dining room more than 20 to 30 minutes before staff assisted them with their meals.On 06/24/2026 at 12:35 PM, Administrative Nurse D stated R22 enjoyed sitting in the dining room. She stated R22 could ask to be moved if she wanted to sit in a different position.The facility's Dignity policy, last revised 02/2021, documented each resident would be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Based on observation, record review, and interviews, the facility failed to ensure safe and appropriate self-administration of medication for Resident (R) 23, R37, and R45, which placed these residents at risk for unnecessary medication side effects and self-administration errors.Findings included:1. R23's Electronic Medical Record (EMR) from the admission Minimum Data Set (MDS), dated 05/28/2026, documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition.Review of R23's EMR physician orders under the Orders tab lacked an order for self-administration of medications.Review of R23's EMR under the Assessment tab lacked an assessment for safe self-medication administration.On 06/22/2026 at 08:11 AM, R23 laid on her bed with the bedside table next to the bed, a paper medication cup with pills sat on the bedside table. 2. R37's EMR from the Quarterly MDS, dated 04/17/2026, documented a BIMS score of 12, which indicated moderately impaired cognition. Review of R37's EMR physician orders under the Orders tab lacked an order for self-administration of medications.Review of R37's EMR under the Assessment tab lacked an assessment for safe self-medication administration.On 06/22/2026 at 08:54 AM, R37 laid on his bed with the bedside table next to his bed, a paper medication cup with a pill sat on the bedside table.3. R45's EMR from the Significant Change MDS, dated 05/28/2026, documented a BIMS score of 15.Review of R45's EMR physician orders under the Orders tab lacked an order for self-administration of medications.Review of R45's EMR under the Assessment tab lacked an assessment for safe self-medication administration.On 06/22/2026 at 08:54 AM, R45 laid on his bed with the head of his elevated bedside table next to his bed. A paper medication cup with pills sat on the bedside table.On 06/24/2026 at 09:47 AM, Licensed Nurse (LN) G stated the residents can administer their own medications. LN G stated they are evaluated and determined to be safe by their BIMS score and then the physician would give an order for the residents to keep their medications in their room.On 06/24/2026 at 12:35 PM, Administrative Nurse D stated the residents are assessed for self-administration of their medications to determine if they are safe. She stated that assessment was documented in the resident's EMR under the Assessment tab. Administrative Nurse D stated then the resident's physician would give an order to self-administer their medication if they decide that was safe to do so. The facility's Self-Administration of Medications policy, last revised, 02/2021 documented residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.

Based on observation, interview, and record review, the facility failed to verify Resident (R) 7's advanced directive (a legal document in which a person specified what actions should be taken for their health, which may or may not include a do not resuscitate [DNR-decision whether, or not, to withhold medical intervention in the event the resident's heart stops] order) was properly documented on his charts and care plan. Findings included: - Review of the Electronic Health Record (EHR) for R7 included diagnoses of transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic pain due to trauma, quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), major depressive disorder, and anxiety disorder.R7's Annual Minimum Data Set (MDS), dated 05/21/2026, documented a Brief Interview of Mental Status (BIMS) of 15, which indicated intact cognition.R7's Care Plan, dated 05/23/2025, documented that R7 was a full code.R7's EHR home screen documented his code status (full code or DNR) as DNR.R7's EHR documented a Physician Order for DNR, dated 05/22/2026.R7's EHR, under the admission section, had a signed DNR, dated 05/14/2026, with an uploaded date of 06/23/2026 by Administrative Nurse D.Review of R7's hard chart, kept behind the nurse's station, contained a blue sheet which read full code.Observation on 06/23/2026 at 10:00 AM of R7's hard chart revealed a blue dot on the spine of the chart.On 06/23/2026 at 02:22 PM, Licensed Nurse (LN) I said the blue dot on the resident's hard chart notified staff that they were a full code and there was a DNR or blue sheet in the front of the chart, the code status was also in the EHR, and the resident care pan listed the code status. She verified R7's EHR listed him as DNR with an order and confirmed there was no DNR paperwork in the EHR. LN I said medical records performed the chart audits to make sure they were accurate and confirmed R7's Care Plan documented him as full code.On 06/23/2026 at 02:37 PM, R7 said that he wished to be a DNR. He reported that he had signed a DNR. On 06/24/2026 at 12:35 PM, Administrative Nurse D said that a resident's code status should be accurately uploaded in the EHR and the paper chart was to reflect the EHR. She also said it was a team effort to ensure the charts and EHR were accurate and should be corrected and updated regularly.The facility policy Advance Directives, dated September 2022, documented that if the resident or resident's representative had executed one or more advance directives, or executed one upon admission, copies of those documents were to be obtained and maintained in the same section of the resident's medical record and be readily retrievable by any facility staff. The policy also documented that the plan of care for each resident was consistent with his or her documented treatment preferences and/or advance directive.

Based on observation, record review, and interview, the facility failed to keep Resident (R) 23's protected health information (PHI) private on a medication cart parked in the main dining room.Findings included:- On 06/22/2026 at 07:45 AM, during initial tour a medication cart parked outside the dining room in the hallway with a laptop computer sitting on the top, the computer screen was unlocked and open, and R23's PHI was on the screen, visible to all who passed by the medication cart. The information visualized included R23's medications, date of birth , allergy information, and code status.On 06/22/2026 at 07:48 AM, Certified Medication Aide (CMA) R stated the computer screen should have been locked.On 06/24/2026 at 09:47 AM, Licensed Nurse (LN) G stated the medication should be locked, no personal information visible, and no medication left on the cart when staff walked away from the cart.On 06/24/2026 at 12:35 PM, Administrative Nurse D stated the medication cart should be clean, locked, and no personal health information left on the computer for others to see.The Facility's Confidentiality of Information and Personal Privacy policy, last revised 10/2017, documented the facility would protect and safeguard resident confidentiality and personal privacy.

Based on observation, record review, and interview, the facility failed to ensure Resident (R)13's call light was within his reach to enable him to call for staff assistance.Findings included:- R13's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of pain, history of falls, overactive bladder, and need for assistance personal care.The Quarterly Minimum Data Set (MDS), dated 05/15/2025, documented a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented R13 had limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) bilaterally lower extremities. The MDS documented R13 was dependent on staff assistance for toileting, bathing, and transfers.R13's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 12/01/2025, documented she required assistance with activities of daily living.R13's Care Plan documented the following interventions: 09/23/2025 - Staff would ensure her call light was within reach and would encourage her to use it for assistance as needed.On 06/22/2026 at 09:51 AM, R13 sat in her high back wheelchair in her room as she watched TV. R13's call light was pinned to the wall between her TV and dresser, out of her reach.On 06/09/2026 at 09:26 AM, Certified Nurse Aide (CNA)Q stated call lights should be placed on the person or clipped to the bed within reach.On 06/10/2026 at 09:47 AM, Licensed Nurse (LN) G stated call lights should always be within the resident's reach when in the room.On 06/03/2026 at 12:35 PM, Administrative Nurse D stated call lights should be within the resident's reach, if the resident was in their room. The facility's Accommodation of Needs policy, last revised 03/2021, documented the facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being.

Based on record review, interviews and observation, the facility failed to perform a gradual dose reduction (GDR) or provide a physician's rationale for not attempting the GDR for Resident (R) 44's psychotropic medications.Findings included:- R44's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and dementia (a progressive mental disorder characterized by failing memory and confusion).The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 00 which indicated severely impaired cognition. The MDS documented R44 received an antipsychotic and antianxiety medication during the observation period.R44's Care Plan, dated 07/26/2024, documented R44 used psychotropic medications including Quetiapine (antipsychotic) and Haldol (antipsychotic) related to a mild neurocognitive disorder. Staff were to consult with the pharmacy and consider a dosage reduction when clinically appropriate at least quarterly.R44's EMR revealed the following orders:Duloxetine (antidepressant) 60 milligrams (mg) once daily, dated 07/27/2024.Quetiapine fumarate 50 mg twice daily, dated 02/20/2026.R44's EMR recorded a pharmacy consultant noted, dated 02/08/2026, which documented a recommendation was made and directed to see the medication review.The facility provided a Note To Attending Physician/Prescriber stamped as faxed on 02/10/2026 which documented R44 was receiving the following psychotropic medications that were due for review: haloperidol 1mg daily, quetiapine 37.5mg each morning and 25mg at bedtime and duloxetine 60 mg every morning. It listed a rationale that noted the Centers for Medicare and Medicaid (CMS) guidelines required psychotropic medications to be evaluated for dose reduction/discontinuation twice in the first year (at minimum), then at prescriber's discretion thereafter. The note listed several recommendations for GDR and asked for documented rationale. The physician did not mark any of the options listed but documented no change under the physician/provider response section. The response lacked a rationale why no GDR would be attempted.Observation on 06/22/2026 at 10:46 AM revealed that R44 laid in bed and appeared to be sleeping.Observation on 06/23/2026 at 08:39 AM revealed staff changed R44 and used a draw sheet to reposition him with no combative behavior or resistance from R44 observed.Observation on 06/23/2026 at 09:33 AM revealed R44 was in his bed and appeared to be sleeping.Observation on 06/23/2026 at 11:40 AM revealed the hospice nurse in the room assessing the resident who appeared to be sleeping.During an interview on 06/24/2026 at 09:21 AM, Administrative Nurse D stated that they had asked for a rationale for the consultant pharmacist recommendation related to the GDR but only had what was documented on the recommendation.The facility did not provide a policy related to psychotropic medications.

Based on observation, record review and interviews, the facility failed to ensure Resident (R)12, R76 and R37 and their representatives received a written notification of transfer that included a statement of the residents' rights, the transfer location, reason for the transfer and the state ombudsman information, as soon as practicable upon their transfer to the hospital. Additionally, the facility failed to notify the office of the Long-Term Care Ombudsman (LTCO) of the transfers.Findings included:1. R12's Electronic Medical Record (EMR) recorded a Discharge Minimum Data Set (MDS) dated 04/10/2026, which documented an unplanned discharge to an acute hospital with a return anticipated.R12's clinical record lacked evidence that a written notification of transfer was provided to R12 or their representative. Upon request, the facility was unable to provide evidence of the written notification.2. R37's Electronic Medical Record (EMR) recorded a Discharge Minimum Data Set (MDS) dated 04/27/2026, which documented an unplanned discharge to an acute hospital with a return anticipated.R37's clinical record lacked evidence that a written notification of transfer was provided to R37 or their representative. Upon request, the facility was unable to provide evidence of the written notification.3. R76's EMR recorded R76 was transferred to the hospital via Emergency Medical Services (EMS) on 04/30/2026 at 02:15 PM for evaluation of symptoms.R76's EMR lacked evidence that the facility provided written notification of the transfer to R76 and/or her representative.Review of the facility's Monthly Transfer Log to Hospital which was submitted to the LTCO monthly for the timeframe of 02/01/2026 to 05/31/2026 lacked documentation of R12's, R37's and R76's transfer to the hospital.On 06/24/2026 at 08:54 AM, Administrative Staff A stated the facility had not provided R12, R37 and R76 (or their legal representatives) with written notice of their transfer to the hospital. and confirmed the LTCO was not notified. Administrative Staff A stated the social service department was responsible for the notification.The facility did not provide a discharge policy.

Based on observation, interview, and record review, the facility failed to ensure the staff had properly secured storage of resident medications. Findings included:- Observed on 06/22/2026 at 10:38 AM, Licensed Nurse (LN) G unlocked the treatment/nurse cart in the 100/200/300 hall and then left it unattended as she went down the 200 hall and into a resident's room. The cart contained seven boxes that contained nebulized breathing treatments, three containers of Vick's vapor rub, tubes of icy hot muscle rub, several tubes of calmoseptine ointment, and dressing change supplies. Also contained in the treatment cart were two insulin injector pens for Resident (R) 3, one insulin injector pen for R54, two insulin injector pens for R46, two insulin injector pens for R24, two insulin injector pens for R52, two insulin injector pens for R40, two insulin injector pens for R63, two insulin injector pens for R69, and two insulin injector pens for R70.On 06/22/2026 at 10:45 AM, LN G said that a medication or treatment cart should never have been left unlocked and unattended. On 06/24/2026 at 12:35 PM, Administrative Nurse D said that any time a nurse or medication aide walked from the medication cart area or treatment cart the cart should have been cleaned and locked and no resident information readily available for viewing by unauthorized persons.The facility policy Medication Labeling and Storage, dated February 2023, documented that compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals would be locked when not in use, and trays or carts used to transport such items would not be left unattended when open or otherwise potentially available to others.

Based on observation, interview, and record review, the facility failed to ensure staff served meals at safe and appetizing temperatures.Findings include: - On 06/23/2026 at 09:36 AM, Certified Nursing Aide (CNA) L delivered a breakfast meal to a room in the 100 hall. The temperature of the items was as follows:116 degrees Fahrenheit (F) for the hashbrowns.114 degrees F for the cheese omelet.115 degrees F for oatmeal.On 06/22/2026 at 08:15 AM, Resident (R) 70 stated the food arrives to his room cold.On 06/23/2026 at 09:40 AM CNA L said she was not sure how hot the food was supposed to register, but it likely should have been hotter.On 06/23/2026 at 10:55 AM, Dietary BB stated the standing warmer directly inside the door into the kitchen was used to hold the prepared meals for the residents that choose to eat in their rooms. Dietary BB stated the temperature of this warmer, referred to as the hot box, should be 145 degrees F. Dietary BB verified the temperature inside the warmer as 110 degrees F and stated the temperature could not be adjusted higher.The facility policy did not address palatable temperatures.

Based on interviews and observation, the facility staff failed to implement adequate infection control practices related to Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care).Findings included:- During an observation on 06/23/2026 at 11:33 AM, observation revealed there was no signage or readily available personal protective equipment (PPE) to include gowns for Resident (R) 6 who had a gastronomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). Further observation revealed that Licensed Nurse (LN) H donned gloves but no gown and provided R6 his medications via the G-tube. LN H verified that both a gown and gloves should have been worn for EBP.During an interview on 06/23/2026 at 08:45 AM, Certified Nurse Aide (CNA) M reported that EBP and PPE would be used by staff whenever a resident had an infection, CNA M said it was also used if the resident had a urinary catheter.During an interview on 06/24/2026 at 12:35 PM, Administrative Nurse D reported EBP and PPE are used for any indwelling device and any open wound being treated. The facility did not provide a policy for EBP or PPE practices.

The facility reported a census of 67 residents. Based on observation and interview, the facility failed to ensure the posted daily nurse staffing sheets included accurate information to include the daily census. Findings included: During an observation on 06/22/2026 at 10:13 AM, the daily staffing sheet that hung on the wall behind the front desk at the entrance station documented a census of 71.During an observation on 06/23/2026 at 11:05 AM, the same staff sheet dated 06/22/2026 was still posted on the wall. No sheet for 06/23/2026 was observed.On 06/22/2026 during the initial entrance into the facility, Administrative Staff A verified that the census was 67.During an interview on 06/23/2026 at 02:19 PM Administrative Staff A the customer service associate (CSA) updates the daily staffing sheets. He said there were three CSAs employed at the facility to ensure they would have one working every day of the week and if the CSAs were to call in, then the administrator would be responsible for updating the daily staffing sheet. He stated that if the daily staffing sheet had not been filled out correctly the CSA would need to be educated.The facility policy Posted Direct Care Daily Staffing Numbers documented that the facility would post daily for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. The information recorded on the form should include the current date (the date for which the information is posted) and the resident census at the beginning of the shift for which the information is posted.

Based on interview and record review, the facility failed to electronically submit accurate staffing information through the Payroll-Based Journaling (PBJ).Findings included:The PBJ Staffing Data Report provided by the Centers for Medicare and Medicaid Services (CMS) for the Fiscal Year (FY) 2026 Quarter 2 indicated the facility had excessive low weekend staffing.Review of the staffing sheets revealed the same number of direct care staff worked on weekends and weekdays.During an interview on 06/23/2026 at 02:19 PM Administrative Staff A verified the facility did not have low weekend staffing. He said the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Minimum Data Set Nurse (MDS) worked on the weekends as needed.The Reporting Direct Care Staffing Information (Payroll Based Journal) policy, revised August 2022, documented direct care staffing information was reported electronically to CMS through the Payroll-Based Journal system. Complete and accurate direct care staffing information was reported electronically to CMS through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS.

The facility reported a census of 70 residents. The sample included three residents reviewed for accident hazards. Based on observation, interview, and record review the facility failed to ensure an environment free from accident hazards when staff failed to provide adequate supervision and respond appropriately to a door alarm, allowing Resident (R) 1 to elope from the facility. On 06/14/25 at 09:20 PM, R1, a cognitively impaired resident at risk for wandering, exited the facility without staff knowledge or supervision. The door alarm sounded, and at 09:26 PM, Certified Nurse Aide (CNA) M cancelled the alarm but did not conduct a search or inspection to identify what triggered the alarm. At 10:00 PM, staff performed rounds and discovered R1 was missing. Staff initiated a search of the areas inside and out and located R1 outside at 10:04 PM. R1 was right outside the door where she exited. Staff found R1 on her knees, wearing only a nightgown. R1 was outside without supervision for 44 minutes. Staff assessed R1 and noted abrasions to her knees and elbow. The facility's failure to provide adequate supervision to prevent unsafe wandering and failure to respond appropriately to the door alarm placed R1 in immediate jeopardy.Findings included:- Review of the Electronic Health Record (EHR) documented R1 had diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion), diabetes mellitus type two (DM2 - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), dependence on supplemental oxygen, and legal blindness. R1's 05/30/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The assessment documented other behavioral symptoms not directed towards others occurred daily, and rejection of care occurred one to three days during the look-back period. R1 utilized a walker and/or wheelchair for locomotion. The 05/30/25 Falls Care Area Assessment (CAA) documented R1 had dementia with impulsive behavior and lacked safety awareness. R1's EHR documented Wander Assessment[s] performed on 02/24/25, 03/26/25, and 06/14/25 with all indicating R1 as at risk of wandering. R1's Care Plan did not contain interventions related to wandering or elopement prior to 06/14/25.On 06/14/25, after the incident, R1's Care Plan was updated to reflect R1's elopement risk related to disorientation, a history of attempts to leave the facility unattended, and impaired safety awareness. The following Care Plan interventions were initiated on 06/15/25:Staff would assess R1 for fall risk.Staff would distract R1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books.Staff would identify patterns of R1's wandering and intervene as appropriate.R1 had a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) placed on her right ankle (revised 06/16/25). R1's Progress Note dated 06/14/25 at 11:38 PM, documented R1 was wandering in and out of rooms and was placed in bed several times. Staff placed R1 at the nurses' station at approximately 09:15 PM. At approximately 10:00 PM, staff realized R1 was not in her room, and staff began a room-to-room search for R1. Staff discovered R1. The note documented R1 appeared to have slipped out of her chair. Staff assessed R1 for injuries and identified abrasions (scraping or rubbing away of skin) on both her knees and her right elbow. Staff placed a WanderGuard. R1's Progress Note dated 06/16/25 at 03:02 PM documented R1 continued to be impulsive and required frequent redirection from staff. Licensed Nurse (LN) H's Witness Statement dated 06/14/25 documented she was at the nurses' station, documenting when a door alarm sounded. LN H documented the alarm did not show up on the screen, and the camera for the hallway was not working. LN H noted she looked up and observed an [unnamed] aide walking down the hall and believed that aide would check the door. LN H noted she was unsure how long the alarm sounded before it was silenced. CNA O's Witness Statement dated 06/14/25 documented the nurse stated they could not find R1, and staff had heard a door alarm. CNA O noted staff went to the area where the door had alarmed, opened the door, and found R1 sitting on the ground outside the door; R1's wheelchair was tipped over. CNA N's Witness Statement dated 06/14/25 documented R1 was last observed at 09:15 PM; staff discovered she was missing during the rounds at shift-change. CNA N noted staff conducted a brief search where they had heard the door alarm and found R1 outside that door. Certified Medication Aide (CMA) S's Witness Statement dated 06/14/25, documented at approximately 10:00 PM on 06/14/25, CMA S was alerted by the nurse R1's location was unknown, and a door alarm was heard. Staff went to where the door alarm sounded, and R1 was banging on the door. CMA S noted the nurse opened the door and staff assisted R1 to her wheelchair; the nurse assessed R1. Administrative Nurse F's Witness Statement dated 06/14/25 documented R1 was wandering in and out of rooms all shift. R1 was placed in bed several times but got up and wandered. At approximately 09:00 PM, staff removed R1 from another resident's room and placed her near the nurses' station. Administrative Nurse F then continued with her previous task. At approximately 10:00 PM, an [unnamed] aide notified Administrative Nurse F that R1 was not in her room and a room-to-room search was initiated. Administrative Nurse F documented staff heard a door alarm earlier, and when she and other staff arrived at the door, R1 was on the ground outside the door; R1 was striking the door.CNA M's Witness Statement dated 06/14/25 documented between 09:00 and 09:15 PM, she heard the back door alarm sounding. CNA M looked for the residents on her assigned hall with wandering behavior, located them, and turned the alarm off. CNA M's Witness Statement did not indicate if the area around or outside the door was searched for residents. Observation on 07/31/25 at 08:00 AM revealed the area around the facility had a residential street approximately 200 feet away with light residential traffic. There was a [NAME] line at the southeast corner of the facility, which led to a parking lot. The facility was located approximately one-half mile from a large lake. During an observation on 07/31/25 at 10:59 AM, R1 rested in bed. Further observation revealed a WanderGuard on R1's right ankle.During an observation of the area where R1 eloped on 07/31/25 at 11:45 AM with Administrative Nurse D, the doorway was in an alcove to the side of a junction between two halls and not fully visible from either hallway. From the doorway outside, approximately 30 feet to the south, was a tree row with fencing that bordered a residential property. Approximately four feet to the side of the door was a window where the entire area outside the door was visible from the inside.On 07/31/25 at 11:25 AM, CMA R revealed if a door alarm sounded, staff should respond to the door and perform a visual check of the area in and outside of the door before silencing the door alarm. CMA R stated one staff member should walk the perimeter of the building. CMA R confirmed she has received additional elopement training since the elopement on 06/14/25.On 07/31/25 at 11:50 AM, Administrative Nurse D reported after CNA M cancelled the alarm, CNA M did rounds on the residents on that side of the building who had wandering behaviors and did not find that any were missing. Admin Nurse D confirmed that CNA M did not completely search the area on the other side of the door to ensure that no residents were present. Administrative Nurse D confirmed the window next to the door allowed an observer to fully view the area outside the door.On 07/31/25 at 12:22 PM, CNA Q stated if a door alarm sounded, all staff in the area who were available should respond and search the area to ensure that no residents were outside. CNA Q reported she had received training related to door alarms and elopement since 06/14/25.On 07/31/24 at 12:25 PM, LN G stated that if a door alarm sounded, all staff who were available would respond to the area and would treat the situation as an elopement. LN G said staff were sent in opposite directions along the perimeter of the building while the staff inside would start a head count of the residents to make sure everyone was accounted for. LN G said after all residents were accounted for, the door alarm would be reset. LN G confirmed she received training related to responding to alarms and elopement since 06/14/25.On 07/31/25 at 01:15 PM, Administrative Nurse F said R1 had been restless, up and down and in and out of bed the whole shift; eventually, staff ended up putting her in her wheelchair at the nursing station in the common area so everyone could keep an eye on her. Administrative Nurse F said she went to administer medications on another hall, and when that task was completed, R1 was not at the nurse's station, and Administrative Nurse F assumed the CNA staff put R1 to bed. Administrative Nurse F said staff then noted R1 was missing during the 10:00 PM shift change, and that is when the door-to-door head count was initiated down the hall that R1 lived on, and then about halfway to the other side of the building. Administrative Nurse F said staff had heard the door alarm, and when CNA staff inspected that door area, they found R1 on the ground outside the door. R1's wheelchair was on its left side. Administrative Nurse F said staff placed a WanderGuard immediately after R1 was assessed for injuries. Administrative Nurse F said the training was initiated and given to second shift personnel who were on shift. On 07/31/25 at 01:28 PM, Administrative Nurse E said she took report from Administrative Nurse F and then initiated education to the staff related to elopement and clearing door alarms and WanderGuard alarms, as well as the appropriateness of clearing the door alarms. On 07/31/25 at 01:30 PM, Administrative Staff A stated all staff had received reeducation that included training on the correct procedures to follow in the event of an elopement or if the door alarms or Wanderguard alarms were triggered. The facility's undated Wandering and Elopements policy documented that the facility would identify residents who were at risk of unsafe wandering. If a resident was identified as at risk for wandering, elopement, or safety issues, the care plan would include strategies and interventions to maintain the resident's safety. On 07/31/25 at 03:00 PM, Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed of the IJ for R1. The facility's corrective measures, fully completed on 07/02/25, included the following, which were verified by the surveyor on-site during the investigation:1. On 06/14/25 at approximately 10:10 PM, Administrative Nurse F placed a WanderGuard on R1's right ankle.2. On 06/14/25 at approximately 10:30 PM, Administrative Nurse F completed reeducation for second shift staff who were in the building.3. On 06/15/25, Administrative Nurse E completed reeducation for third shift staff who were in the building.4. On 06/15/25, Administrative Nurse D, Administrative Staff A, Maintenance U, and Dietary CC initiated reeducation of their respective departments, completed 07/02/25 at the July 2025 staff meeting.5. On 06/15/25, Maintenance U increased the volume of door alarms to be audible on adjoining hallways.6. On 06/17/25, the facility held an ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting.All corrections were completed prior to the onsite survey; therefore, the deficient practice was cited as past noncompliance at a scope and severity of J.

The facility reported a census of 58 residents. Based on observation, interview, and record review the facility failed to ensure staff provided Enhanced Barrier Precautions (EBP use of personal protective equipment to prevent the spread of infections) for Resident (R)3 and R54. The staff failed to provide cleaning of R50's CPAP (Continuous Positive Airway Pressure, a device with a face mask that uses air pressure to keep breathing airways open while a person sleeps) and failed to provide urinary catheter care in a sanitary manner to prevent the spread of infections. The facility failed to ensure R19's dog maintained up-to-date vaccine status. Findings included: - Review of Resident (R)3' medical record revealed diagnoses that included Methicillin Resistive Staphylococcus Aureus (a bacteria that is resistive to multiple antibiotics also known as Multi Drug Resistant Organism, MDRO), sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock), and cutaneous abscess (cavity containing pus and surrounded by inflamed tissue). The Significant Change Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. The Pressure Ulcer Care Area Assessment (CAA), dated 05/01/24, revealed the resident needed help to maintain skin integrity and staff to monitor for skin issues. The Quarterly MDS dated [DATE], assessed the resident with a BIMS of 10 which indicated moderate cognitive impairment and documented R3 had Moisture Associated Skin Damage (MASD skin damage caused by moisture). The Care Plan reviewed 09/27/24 instructed staff the resident had a subcutaneous abscess to her left buttocks and required Hibiclens (an antibacterial solution) showers for infection prevention. The Care Plan lacked the intervention to include Enhanced Barrier Precautions (EBP). A Skin assessment dated [DATE], documented a chronic open area to the left gluteal crease. Skin Assessments dated 10/08/24, 10/15/24 and 10/22/24 documented the open are to the left buttock. Observation on 10/29/24 at 11:06 AM, revealed Licensed Nurse (LN) J provided wound care to the wound on the resident's left buttock cheek. LN J stated the wound was an abscess (cavity containing pus and surrounded by inflamed tissue) that comes and goes, and the resident admitted to the facility with the wound. With gloved hands, LN G, removed the dressing on the resident's left buttock cheek and revealed an open red area approximately 1.5 by 0.5 centimeters (cm) with a small amount of serosanguinous (semi-thick reddish drainage) drainage that dripped onto the resident's brief. With gloved hands, LN J cleansed the wound, applied skin prep (a solution that protects the skin) and applied a bordered foam dressing to the wound. Neither LN J or LN G wore a gown during the procedure and did not know the resident should be in EBP. Interview on 10/30/24 at 10:30 AM, with Administrative Nurse D, confirmed the resident had a history of MRSA in the wound and had been on antibiotics in the past, and had been on contact precautions (safeguards designed to reduce the risk of transmission of microorganisms by direct or indirect contact ) at that time, and should be in EBP since the wound was chronic and open. The facility policy Enhanced Barrier Precautions Reviewed 07/2024, instructed staff EBP are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization and the EBP remain in place for the duration of the resident's stay or until resolution of the wound. The facility failed to ensure staff implemented EBP for this resident with a chronic abscess and history of MRSA to prevent the spread of infection. - Review of Resident (R)54's medical record revealed diagnoses that included renal failure (inability of the kidneys to excrete wastes, concentrate urine and conserve electrolytes). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14, which indicated normal cognitive function. The resident received dialysis. A Physician's Order dated 10/17/24, instructed staff the resident was to receive dialysis services three times a week and monitor the resident's dialysis port to her left chest twice daily and replace the dressing if coming off. Observation, on 10/29/24 at 08:00 AM, revealed Certified Nurse Aide (CNA) P aided the resident with dressing without donning protective barrier precaution equipment. Observation, on 10/29/24 at 08:37 AM, revealed the resident seated in her wheelchair in her room. The resident stated she went to dialysis three times a week and had a port on her upper left chest which was covered with a dry dressing. Interview, on 10/29/24 at 10:00AM, with Licensed Nurse G, revealed the resident had multiple problems with her dialysis access port and had several infections, but did not know what type of infections and did not know that EBP was indicated for this resident. Interview, on 10/30/24 at 10:30 AM, with Administrative Nursing Staff D, confirmed the resident should be on EBP due to presence of her dialysis port and frequent infections of the dialysis catheters which included multi drug resistant organisms (MDRO). The facility policy Enhanced Barrier Precautions Reviewed 07/2024, instructed staff EBP are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization and the EBP remain in place for the duration of the resident's stay or until resolution of the wound. The facility failed to ensure staff implemented EBP for this resident with a dialysis access port, and history of MDRO infections to prevent the spread of infection. - Observation, on 10/28/24 at 10:30 AM, revealed Resident (R)19 in her room with a dog on her bed. R19 stated the dog was her personal pet and stayed in her room with her and her roommate. Interview, on 10/30/24 at **, with Administrative Staff A, confirmed the last rabies vaccine for R19's dog was 05/2023. Administrative Staff A stated the facility did not have a policy for ensuring staff monitored R19 for maintaining annual vaccines for her dog. The facility lacked a policy for annual pet vaccinations. The facility failed to ensure R19 obtained annual vaccines for her dog as required to prevent the spread of infection. 34056 - Review of Resident (R)50's Electronic Medical Record (EMR) revealed a diagnosis of obstructive sleep apnea (a common sleep disorder that occurs when the upper airway becomes blocked during sleep, interrupting breathing). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The resident did not use a Continuous positive airway pressure (CPAP) during the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/13/24, documented the resident had acute mental status changes and required short, simple instructions from staff. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 10, indicating moderate cognitive impairment. The MDS inaccurately documented the resident did not use a CPAP during the assessment period. The care plan, revised 09/08/24, lacked staff instruction regarding the use and care of the resident's CPAP. Review of the resident's EMR revealed the following physician's order: Assist and encourage the resident to utilize his CPAP throughout the night, ordered 09/13/24. On 10/28/24 at 10:01 AM, the resident's CPAP face mask rested, uncovered, on the bed side table of his room. The inside of the face mask contained a flaky, whitish substance. On 10/29/24 at 06:51 AM, the resident's CPAP face mask rested, uncovered, on the bed side table of his room. The inside of the face mask contained a flaky, whitish substance. On 10/30/24 at 06:53 AM, Certified Nurse Aide (CNA) M stated the resident utilized the CPAP at night while he slept. CNA M stated the nurse was responsible for cleaning the face mask each morning after use. On 10/30/24 at 08:28 AM, CNA O stated the resident utilized the CPAP at night when he slept. CNA O stated she was unsure who was responsible for cleaning the face mask. On 10/30/24 at 07:01 AM, Licensed Nurse (LN) I stated the CNAs were responsible for cleaning the resident's face masks. On 10/30/24 at 07:13 AM, Administrative Nurse D stated the CNAs, or the nurse were responsible for cleaning the resident's face mask each morning after use. The facility policy for CPAP/BIPAP Support, revised March 2015, included: Staff shall clean the face mask of the CPAP machine with warm water and allow it to dry in between uses. The facility failed to clean the resident's face mask of the CPAP each morning after use. - Review of Resident (R) 56's Electronic Medical Record (EMR) revealed a diagnosis of neurogenic bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. She had an indwelling urinary catheter (a catheter inserted into the bladder to drain urine) and required substantial to maximum staff assistance with toileting. The Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA), dated 08/09/24, documented the resident had an indwelling urinary catheter due to a diagnosis of neurogenic bladder. Staff were to provide catheter care for the resident every shift. The Care Plan for the indwelling urinary catheter, revised 10/30/24, instructed staff to always position the catheter bag and tubing below the level of the resident's bladder. Review of the resident's EMR revealed a physician's order for staff to provide catheter care every day and night shift, ordered 08/07/24. On 10/29/24 at 08:27 AM, the resident sat in her wheelchair at the dining room table eating breakfast. The catheter bag hung from underneath the seat of her wheelchair and the catheter tubing rested directly on the floor beneath the seat of the wheelchair. On 10/29/24 at 08:57 AM, Certified Nurse Aide (CNA) N transferred the resident from her wheelchair to the recliner in the front commons area. The CNA tossed the catheter bag onto the floor during the transfer and left the bag and tubing on the floor following the cares. On 10/29/24 at 09:03 AM, CNA N stated the resident's catheter bag and tubing should not be on the floor at any time. CNA N stated she forgot to pick the bag and tubing up after transferring the resident. On 10/30/24 at 09:37 AM, Licensed Nurse (LN) G stated catheter bags and tubing should be always kept off the floor. On 10/29/24 at 09:57 AM, Administrative Nurse D stated staff should ensure the resident's catheter bag and tubing be always kept off the floor. The facility policy for Urinary Catheter Care, revised August 2022, included: Staff should ensure the catheter tubing and drainage bag are kept off the floor. The facility failed to always keep the catheter bag and tubing for this dependent resident off the floor.

The facility reported a census of 58 residents. Based on observation, interview, and record review the facility failed to establish a system to keep drug records in order for all controlled drugs to be maintained and reconciled. Findings included: - Review of the Narcotic Count Shift Verification sheet on 10/28/24 at 08:13 AM, the following areas of concern were noted: 1. The east hall Narcotic Count Shift Verification form, from October 1 through October 27, 2024, lacked a total of 63 staff signatures. 2. The west hall Narcotic Count Shift Verification form, from October 1 through October 27, 2024, lacked a total of 30 staff signatures. On 10/28/24 at 08:13 AM, Certified Medication Aide (CMA) T stated staff were to count with the oncoming and off going nurse or CMA at the beginning and end of their shift. Both of the staff were expected to sign the Narcotic Count Shift Verification form to indicate the narcotic count was correct at the time they counted. On 10/30/24 at 08:53 AM, Administrative Nurse D stated both nurses or CMAs were expected to count the narcotics when coming onto their shift and when leaving their shift. By signing the Narcotic Count Shift Verification they were documenting the narcotic count was accurate. The facility policy for Controlled Substances, revised November 2022, included: The nursing staff shall count the controlled medication inventory at the end of each shift in order to reconcile the inventory count. The nurse coming on duty and the nurse going off duty shall make the count together. The facility failed to establish a system to keep drug records in order for all controlled drugs to be maintained and reconciled.

The facility reported a census of 58 residents. Based on observation, interview, and record review the facility failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), when the facility failed to accurately report weekend licensed nurse staffing for the month of August 2024. Findings included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for August 2024, revealed the facility failed to accurately report weekend licensed nurse staffing for the month of August 2024. On 08/03, Saturday (SA), On 08/04, Sunday (SU), On 08/10, SA, On 08/11, SU, On 08/17, SA, On 08/18, SU, On 08/24, SA, On 08/25, SU, On 08/31, SA, On 10/29/24 at 01:15 PM, Administrative Nurse D stated she and Administrative Nurse F would come in and work during the weekends in August. Their hours were not counted on the PBJ for those times as they are both salaried employees. On 10/29/24 at 04:00 PM, Administrative Staff A stated they would look into a way for Administrative Nurse D and Administrative Nurse E to clock in so the PBJ report would be accurate. The facility lacked a policy for the completion of the PBJ reports. The facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report weekend staffing for the month of August, 2024.

The facility reported a census of 58 residents with 18 residents sampled. Based on observation, interview, and record review the facility failed to complete an accurate Minimum Data Set (MDS) for three Residents (R)15, regarding incomplete triggered Behavioral Symptoms and Psychosocial Well-Being Care Area Assessments (CAA), R 56, regarding an incomplete CAA for the triggered area of Behavioral Symptoms and R 7, regarding incomplete CAAs for all triggered areas. Findings included: - Review of Resident (R)15's electronic medical record (EMR) revealed a diagnosis of neurocognitive disorder with behavioral disturbance (a condition where a person has both cognitive deficits and behavioral disturbances). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive disturbance. He had didsorganized thinking behavior which fluctuated and other behaviors which disrupted the living environment of other residents. He had wandering behaivors one to three days of the assessment period and received antipsychotic (medication used to treat psychosis--any major mental disorder characterized by a gross impairment in reality perception)) and antidepressant (medication used to treat depression--a mood disorder that causes a persistent feeling of sadness and loss of interest) during the assessment period. The Behavioral Symptoms Care Area Assessment (CAA) and the Psychosocial Well-Being CAA, dated 06/11/24, both triggered, but lacked an analysis of findings. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. He had inattention and disorganized thinking behavior present during the assessment period and physical behavioral symptoms directed towards others one to three days of the assessment period. He receivced antipsychotic, antianxiety (medications used to treat anxiety--mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and antidepressant medication during the assessment period. The care plan, revised 09/07/24, instructed staff the resident received antianxiety medications, antidepressant medications and psychotropic medications. Staff were to monitor the resident for adverse side effects of the medications and report any behaviors to the nurse. Review of the resident's Medication Administration Record (MAR), for October 2024, included the following physician's orders: Haloperidol (an antipsychotic medication), 1 miligram (mg), by mouth (po), every day (QD), for anxiety, ordered 06/11/24. Seroquel (an antipsychotic medication), 50 mg, po at bed time (HS), for neurocognitive disorder with behavioral disturbances, ordered 06/04/24. Trazodone (an antidepressant medication), 50 mg, po Q HS, as needed (PRN), for insomnia (the inability to sleep), ordered 06/04/24. Review of the resident's October 2024 MAR, revealed the resident received all of these medications, as ordered. On 10/30/24 at 08:53 AM, Administrative Nurse D stated it was the expectation for all triggered CAAs contain an analysis of findings. On 10/30/24 at 10:39 AM, Administrative Nurse E confirmed the Behavioral Symptoms and Psychosocial Well-Being CAAs on the admission MDS, dated , triggered but lacked an analysis of findings. The facility policy for Care Areaa Assessments, revised November 2019, included: The care area assessments are used to help analyze data obtained from the MDS and to develop individualized care plans. The facility failed to complete an accurate MDS for this dependent resident with behaivors by failing to complete the triggered CAAs on his admission MDS. - Review of Resident (R)56's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. She had verbal behaviors directed towards others one to three days of the assessment period with no impact on the resident or others. The Behavioral Symptoms Care Area Assessment (CAA), dated 08/09/24, triggered but lacked an analysis of findings. The care plan for behaviors, revised 10/30/24, instructed staff the resident had the potential to become verbally aggressive. Staff were to monitor the side effects of the resident's medicationns and report any ususual behaviors to the nurse. Review of the resident's EMR revealed the following phsyician's order: Escitalopram (an antidepressant medication used to treat depression--a mood disorder that causes a persistent feeling of sadness and loss of interest), 20 miligrams (mg), by mouth (po), every day (QD) in the morning, for depression, ordered 08/02/24. Review of the resident's October 2024 MAR, revealed the resident the medication, as ordered. On 10/30/24 at 08:53 AM, Administrative Nurse D stated it was the expectation for all triggered CAAs contain an analysis of findings. On 10/30/24 at 10:39 AM, Administrative Nurse E confirmed the Behavioral Symptoms and Psychosocial Well-Being CAAs on the admission MDS, dated , triggered but lacked an analysis of findings. The facility policy for Care Areaa Assessments, revised November 2019, included: The care area assessments are used to help analyze data obtained from the MDS and to develop individualized care plans. The facility failed to complete an accurate MDS for this dependent resident with behaivors by failing to complete the triggered CAA on her admission MDS. 36881 - Review of Resident (R)7's Physician Orders (POS) dated 10/08/24 documented diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes ((DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), pain, insomnia (inability to sleep), and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident cognitively intact, no behavior or indication of depression. He was occasionally incontinent of urine. The resident received opiod (narcotic-controled medication) pain medication as needed (prn) and reported frequent moderate pain which interfered with his day-to-day activities and sleep. He was 71 inches tall and weighed 246 pounds. R 7 received medications which included antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), and antianxiety (class of medications used to treat mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The following Care Area Assessments (CAA)dated 03/25/24 triggered and lacked the required analysis of findings related to the causes , contributing factors, and/or rationale: 1. Urinary Incontinence CAA 2. Falls CAA 3. Nutritional Status CAA 4. Psychotropic Drug CAA 5. Pain CAA On 10/29/24 at 02:42 PM, Administrative Nurse E reviewed the residents MDS as noted above . He confirmed the resident's Admission MDS dated [DATE], lacked the required completion of the triggered CAAs. He stated he was aware the analysis of findings/CAA completion was necessary to meet the criteria of a completed comprehensive assessment . Administrative Nurse E stated the facility used the Resident Assessment Instrument Manual, (RAI) for guidance to complete the MDS. 0/30/24 at 09:13 AM, Administrative Nurse D confirmed the above findings. She confirmed the resident's Admission MDS lacked the required completion of the triggered CAAs. He stated he was aware the analysis of findings/CAA completion was necessary to meet the criteria of a completed comprehensive assessment . Administrative Nurse D stated the facility used the Resident Assessment Instrument Manual, (RAI) for guidance to complete the MDS. She stated the facility used the Resident Assessment Instrument Manual, (RAI) for guidance to complete the MDS. The facility policy for Care Areaa Assessments, revised November 2019, included: The care area assessments are used to help analyze data obtained from the MDS and to develop individualized care plans. The Resident Assessment Instrument, (R.A.I.) Manual, Section 2.7 titled The Care Area Assessment (CAA) Process and Care Plan Completion, dated 2019, documentation included . Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The RAI process, which includes the Federally mandated MDS, is the basis for an accurate assessment of nursing home residents. The MDS information and the CAA process provide the foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each of which includes MDS-based Trigger conditions that signal the need for additional assessment and review of the triggered care area. Detailed information regarding each care area and the CAA process, including definitions and triggers, appear in Chapter 4 of this manual. Chapter 4 also contains detailed information on care planning development utilizing the RAI and CAA process. CAA(s) completion is required for comprehensive assessments. The facility failed to complete the Care Area Assessment (CAA-analysis of findings), as required related to a Comprehensive Minimum Data Set (MDS), comprehensive for the resident, to address the underlying cause, risk factors, and other contributing factors to ensure this resident received care based on their individual needs.

The facility reported a census of 58 residents with 18 sampled for review. Based on observation, interview, and record review, the facility failed to complete an accurate assessment/Minimum Data Set (MDS) for four residents (R)7 related to antipsychotics (class of medications used to treat major mental conditions which cause a break from reality), R 33 related to rejection of care, R R5 related to hospice and R 50 related to continuous airway positive pressure (CPAP). Findings included: - Review of Resident (R)7's Physician Orders (POS) dated 10/08/24 documented diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type 2 diabetes ((DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), pain, insomnia (inability to sleep), and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident cognitively intact, no behavior or indication of depression. He Received medications which included antipsychotic (class of medications used to treat major mental conditions which cause a break from reality). The Quarterly MDS dated [DATE], lacked documentation the resident received antipsychotic medication., Review of the POS dated 10/08/24, revealed the resident with prescribed medications which included Lurasidone Hydrochloric (HCl ) tablet, 80 milligrams (MG), (Lurasidone HCl), (antipsychotic medication) tablet by mouth, at bedtime for bipolar disorder with moderately severe depression, ordered 03/11/2024. The resident received antipsychotic medication during the 08/20/24 Quarterly MDS look back period . The MDS lacked accurate documentation to reflect the use of antipsychotic medication. On 10/29/24 at 10:00 AM, R 7 was lying in the bed facing the window. The room was dark. He participated in the interview appropriately without tearfulness or restlessness noted. On 10/30/24 at 08:25 AM , R 7 was lying in the bed watching television. He reported he slept pretty well the night before and commented on his preference for watching westerns on TV. His conversation was appropriate, and his facial expressions were consistent with his conversation. He did not exhibit any signs of discomfort. On 10/29/24 at 02:42 PM, Administrative Nurse E reviewed the residents MDS coding as noted above . He confirmed the resident's 08/20/24 Quarterly MDS was inaccurate. He stated the MDS lacked accurate documentation to reflect the resident's use of antipsychotic medication . Administrative Nurse E stated the facility used the Resident Assessment Instrument Manual, (RAI) for guidance to complete the MDS. On 10/30/24 at 09:13 AM, Administrative Nurse D confirmed the above findings. She stated the Quarterly MDS dated ,d+[DATE]/ 24 should have been coded to reflect the resident's use of antipsychotic medications. Administrative Nurse D stated the facility used the Resident Assessment Instrument Manual, (RAI) for guidance to complete the MDS. The Center for Medicare and Medicaid (CMS) RAI Manual Version 3.0, dated October 2019 documentation included the intent of the items in section N of the MDS is to record select medications received by the resident. An antipsychotic medication review has been included. Including this information will assist facilities to evaluate the use and management of these medications. Each aspect of antipsychotic medication uses, and management has important associations with the quality of life and quality of care of residents receiving these medications. The facility failed to complete an accurate assessment/ Minimum Data Set (MDS) for the resident related to the use of antipsychotic medication. 28560 - Review of Resident (R)33's medical record revealed diagnoses that included depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and unspecified dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated normal cognitive function. The resident received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) and antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medications. The MDS lacked indication of the behavior of rejection of care. The Behavior Care Area Assessment (CAA), dated 09/23/24, assessed the resident had history of being verbally aggressive with threats noted. The Care Plan reviewed 10/03/24, instructed staff to educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Review of the Medication Administration Record (MAR) for September 2024, revealed the resident refused to the following medications from 09/16/24 through 09/23/24. Levetiracetam (a medication for seizure prevention) 750 milligrams (mg) twice a day (BID) for seven doses. Sinemet (a medication used to treat Parkinson's disease slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness ) 25/100mg three times a day for nine doses. Sertraline (a medication given for depression) 75mg, daily for three doses. Seroquel (class of medications used to treat psychosis and other mental emotional conditions) 150 mg daily for three doses. Observation, on 10/28/24 at 09:00 AM, revealed the resident ambulated with his walker with a steady gait and answered questions appropriately. Interview, on 10/29/24 at 03:00 PM, with Certified Medication Aide (CMA) RR, revealed the resident refused medications frequently, but had no other behaviors. Interview, on 10/30/24 at 09:34 AM, with Licensed Nurse (LN) G, revealed the resident did refuse treatments and medications and the physician was aware of the resident's refusal of medications and behaviors. Interview, on 10/30/24 at 10:29 AM, with Administrative Nurse D, revealed the resident refused cares and medications. Interview, on 10/30/24 at 11:15 AM, with Administrative Nurse E, confirmed the resident refused medications during the Significant Change MDS dated [DATE], look back period and should be coded as the behavior of rejection of care. The facility policy Comprehensive Assessments reviewed 07/2024, instructed staff to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity using the Resident Assessment Instrument. The facility failed to accurately assess this resident's behavior of refusal of medications as rejection of care on the Significant Change MDS as required. 34056 - Review of Resident (R)5's electronic medical record (EMR) revealed a diagnosis of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. She did not have a condition or chronic disease that would result in a life expectancy of less than six months and was not receiving hospice care. The Functional Abilities Care Area Assessment, dated 06/28/24, documented the resident rerquired staff assistanace with all activities of daily living (ADL). The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 11, indicating modereate cognitive impairment. The resident had a condition or chronic disease that may result in a life expectanccy of less than six months and was not receiving hospice care. Review of the care plan, revised 10/17/24, instructedstaff the resident received hospice cares due to her diagnosis of MS. Staff were to ensure the resident was kept comfortable. Review of the resident's EMR, revealed the following physician's order: Admit to hospice care for terminal diagnosis of MS, ordered 11/24/23. On 10/30/24 at 08:29 AM, Administrative Nurse E stated the resident originally admitted to hospice in June of 2022 with a diagnosis of MS. Administrative Nurse E stated the MDSs, dated 09/18/24 and 06/28/24, were inaccurate as the resident was on hospice at the time of both of the assessments. On 10/30/24 at 08:53 AM, Administrative Nurse D stated it was the expectation for staff to complete the MDSs accurately. The facility failed to accurately complete two MDS for this dependent resident on hospice. The facility utilizes the Resident Assessment Instrument (RAI) manual for completion of the MDS. - Review of Resident (R)50's Electronic Medical Record (EMR) revealed a diagnosis of obstructive sleep apnea (a common sleep disorder that occurs when the upper airway becomes blocked during sleep, interrupting breathing). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The resident did not use a Continuous positive airway pressure (CPAP) during the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/13/24, documented the resident had acute mental status changes and required short, simple instructions from staff. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 10, indicating moderate cognitive impairment. The MDS inaccurately documented the resident did not use a CPAP during the assessment period. The care plan, revised 09/08/24, lacked staff instruction regarding the use and care of the resident's CPAP. Review of the resident's EMR revealed the following physician's order: Assist and encourage the resident to utilize his CPAP throughout the night, ordered 09/13/24. On 10/28/24 at 10:01 AM, the resident's CPAP face mask rested, uncovered, on the bed side table of his room. The inside of the face mask contained a flaky, whitish substance. On 10/29/24 at 06:51 AM, the resident's CPAP face mask rested, uncovered, on the bed side table of his room. The inside of the face mask contained a flaky, whitish substance. On 10/30/24 at 06:53 AM, Certified Nurse Aide (CNA) M stated the resident utilized the CPAP at night while he slept. On 10/30/24 at 08:28 AM, CNA O stated the resident utilized the CPAP at night when he slept. On 10/30/24 at 08:29 AM, Administrative Nurse E stated the resident did utilize a CPAP while asleep and the MDSs, dated 07/13/24 and 10/11/24, were inaccurate. On 10/30/24 at 08:53 AM, Administrative Nurse D stated it was the expectation for staff to complete the MDSs accurately. The facility failed to accurately complete two MDS for this dependent resident with a CPAP machine. The facility utilizes the Resident Assessment Instrument (RAI) manual for completion of the MDS.

The facility reported a census of 44 residents with three residents sampled for assisted transfers using a Hoyer lift (a total body mechanical lift used to transfer residents). Based on observation, interview, and record review, the facility failed to ensure staff used the proper Hoyer lift transfer sling for Resident (R) 1 to prevent a fall out of the sling, which required medical treatment at a hospital as a result of the fall. R1 was injured when she slipped through the opening of the lift sling after staff instructed her to cross her arms across her chest instead of holding her arms outside of the sling causing her legs to strike the Hoyer lift, and her back, hip and head to strike the floor. Finding included: -The Physician's Orders dated 05/30/23, included diagnoses of dementia with behavioral disturbance (progressive mental disorder characterized by failing memory confusion) and anxiety (a mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. R1 required total assistance of staff with all transfers. The Care Plan dated 08/30/23 documented R1 was at risk for falls related to physical limitations, medical diagnosis, and use of high-risk medication. Staff were to use two staff members for transfers. The care plan lacked specific guidance to staff on the type of transfer sling required to transfer R1. The Fall assessment dated [DATE], indicated R1 had a history of one to two falls, which occurred in the last three months, while standing or changing positions. The Nurse's Progress Note dated 09/07/23 at 02:08 PM, revealed staff attempted to transfer the resident from her wheelchair to her bed and the resident fell to the floor. When LN G entered the resident's room, R1 was on the floor, on her right side. The resident complained of pain in her right hip and back area. Facility staff sent the resident to the hospital for an evaluation. The Nurse's Progress Note dated 09/08/23, revealed R1 returned to the facility with a right knee immobilizer for a sprained right knee. Observation on 09/11/23 at 12:40 PM revealed R1 in her bed with a brace on her right knee. Interview with Certified Nurse Aide (CNA) M on 09/11/23 at 11:54 AM, revealed CNA N and CNA M were in the process of transferring the resident from the wheelchair to the bed, using a hygiene lift sling when the resident fell . CNA M stated the hygiene sling had an open area for residents to use the bathroom, the sling went around the resident's body and connected in the front like a belt. The resident did not have her arms on the outside of the sling, instead her arms were crossed across her chest, which caused her to slip out of the sling to the floor. R1 hit her legs on the lift, and her bottom and head hit the floor. Interview with CNA N on 09/11/23 at 01:25 PM revealed after lunch CNA N and CNA M transferred R1 from the wheelchair to the bed with the use of a hygiene sling. CNA N stated R1 did not like the full sling would swing her arms around as she had anxiety with the use of the lift. CNA N stated they instructed R1 to place her arm across her chest, which caused her to fall out of the sling. Interview with Licensed Nurse (LN) G on 09/11/23 at 02:05 PM, reported the nurse aides used the hygiene sling, and R1 moved her arms from the outside of the sling to the inside of the sling, which caused R1 to fall out of the sling. Interview with Administrative Nurse D on 09/11/23 at 02:10 PM, reported they completed education with the nursing staff regarding use of transfer slings after the resident fell . The facility removed the hygiene slings from being used for any resident. The undated facility policy for Using a Full Body Mechanical Lift Procedure revealed two staff members must always use the full body mechanical lift. If assisting a resident after a fall, a nurse would guide the process. Full body mechanical lifts may be used when transferring a resident from even and uneven surfaces for the residents who are unable to bear their own weight. The resident shall be transferred using full body mechanical lift, before a team member assist a resident for the first time with a full body mechanical lift, the team member shall be tested for competency in the use of the device. The facility failed to ensure staff used the proper Hoyer lift transfer sling for Resident (R) 1 to prevent a fall out of the sling, which required medical treatment at a hospital as a result of the fall. R1 was injured when she slipped through the opening of the lift sling after staff instructed her to cross her arms across her chest instead of holding her arms outside of the sling causing her legs to strike the Hoyer lift, and her back, hip and head to strike the floor.

The facility reported a census of 51 residents. The sample included three residents reviewed for neglect. Based on interview and record review, the facility failed to ensure staff reported allegations of verbal and mental abuse, which included threats of bodily harm when Certified Nurse Aide (CNA) M threatened cognitively impaired Resident (R)1 after he became upset when staff transferred him in the bathroom. R1 stated to get a gun and Shoot me and in response CNA M threatened this upset resident that he would be a second Samurai, bring two [NAME], and if the first one failed, he had the second [NAME]. Licensed Nurse (LN) I, Licensed Nurse J, and Certified Nurse Aide (CNA) P witnessed the mental and verbal abuse, and did not contact Administrative Staff, Corporate Staff, or local law enforcement. This failure to report allowed CNA M to continue his presence in the facility around all of the residents and staff. R1's family members witnessed the unsafe transfer and inappropriate comments by CNA M, which made the resident and family members afraid for their safety and to remain in the facility. This placed the residents in immediate jeopardy for mental and verbal abuse from CNA M. Findings included: - R1's 03/31/23, signed Hospital Discharge Order, documented the facility admitted the resident on 03/31/23. The resident's diagnoses included atrial fibrillation (rapid, irregular heartbeat), ataxia (impaired ability to coordinate movement), muscle weakness, unsteadiness of feet (abnormality of walking), and morbid obesity (excess body fat). The 04/03/23 Admission Minimum Data Set (MDS), documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. He required total dependence of staff for transfer and toileting. The resident was not steady and was only able to stabilize with staff assistance. The resident used a manual wheelchair and walker for mobility. The 04/10/23 Cognitive Loss/Dementia Care Area Assessment (CAA), documented the resident had deficits with orientation, memory, and recall. The 04/10/23 Activities of Daily Functional Status Care Area Assessment (CAA), documented the resident required assistance with ADL's. The resident had impaired balance and transition during transfer and functional impairment. The 03/31/23 Baseline Care Plan, revealed R1 required total dependence with transfer and toileting. The resident used a manual wheelchair, walker and mechanical lift. The 03/31/23 Nursing/Therapy Communication, revealed the resident required maximum assistance of two staff members for transfers. Staff were to use a gait belt, and if the resident had difficulty standing, the staff members were to utilize the Hoyer (a full body mechanical lift). The Clinical Notes, dated 04/02/23 through 04/04/23, documented the resident required the mechanical lift for transfer, and on 04/06/23, the resident was unable to stand with two staff members assistance. The mechanical lift was used to transfer the resident from the toilet to the bed. The Clinical Progress Notes dated 03/31/23 through 04/11/23, located in the electronic health records, lacked documentation related to the verbal threat made by CNA M. On 04/11/23 at 09:00 AM, Administrative Staff A reported the staff members who provided assistance for the cognitive impaired resident and witnessed the verbal abuse, failed to notify her there was an incident on 04/06/23 between R1 and certified medication aide (CMA) M, until 04/10/23 at 11:30 AM. CNA M, LN I, LN J and CNA P were in the resident's room and provided assistance for the resident. CNA M placed a gait belt around the resident and assisted the resident to stand. The resident's legs became weak, the resident and staff member slid down the wall, next to the toilet, and CNA M lowered the resident to the toilet seat. The resident's right thigh broke the toilet paper dispenser. Administrative Staff A reported the resident's baseline care plan, dated 03/31/23, revealed the resident required total dependence with toileting and transfers. The resident's mobility devices were walker, wheelchair, and mechanical lift. Administrative Staff A verified the baseline care plan was incorrectly coded, and the resident should be total dependence with the mechanical lift for transfers and toileting. On 04/17/23 at 08:30 AM, Administrative Nurse D reported on 04/06/23, an unidentified staff member told her the resident had a decline in his physical ability to stand and he now required a mechanical lift. Administrative Nurse D reported on 04/06/23, a staff member who provided assistance with toileting, witnessed an unsafe transfer and the verbal abuse from CNA M. She reported an unidentified family member reported their concerns on 04/10/23 at approximately 11:00 AM to Social Worker X. On 04/10/23 at 11:30 AM, the Social Worker X reported the concerns to the facility administration and an immediate investigation was started. CNA M was interviewed and filled out a witness statement. In his witness statement, he admitted that he used the word Samurai. On 04/10/23 at 11:30 PM, CNA M was suspended and then terminated on 04/13/23 On 04/17/23 at 02:13 PM Social Services X reported an unidentified family member of R1 expressed concerns regarding CNA M. The unidentified family member reported R1 was care planned to be transferred with the Hoyer (a full body mechanical lift). CNA M did place the gait belt around R1 and stood the resident up. R1 reported to CNA M that he was unable to stand, and his legs were too weak to stand. The family member reported CNA M threw R1 against the wall in the bathroom, R1 slid down the wall, his right thigh broke the toilet paper roll, caused a bruise on his right thigh. The CNA M stated to the resident, if you will just try you would do it The resident then told CNA M why don't you just shoot me now? The unidentified family member reported she overheard CNA M who told R1 he would be his Samuari, he would bring two [NAME], and if he failed with the first one, he would have a second one. On 04/18/23 at 12:54 PM, Licensed Nurse I reported she asked for additional staff members to assist R1 to transfer the resident from the toilet to his wheelchair. LN J and CNA P also provided assistance. CNA M placed a gait belt around the resident, his arms around the resident and stood the resident up. The resident expressed to the staff members that his legs were too weak to stand, and the resident voiced he needed to sit down. CNA M advised the resident to try to stand up so that the other staff members could provide pericare and place the clean brief on him. The resident legs buckled, the resident and CNA M leaned on the wall and the resident slid onto the toilet seat. The resident's legs were too weak for the sit to stand lift and the staff members obtained and used the full body mechanical lift. LN I reported she did hear the resident state, just get a gun and shoot me. CNA M stated ok, I will just get the samurai [NAME]. The resident was care planned for maximum two-person assist, total dependence. His mobility devices are walker, wheelchair, and mechanical lift. On 04/18/23 at 01:08 PM, Certified Nurse Aide (CNA) M reported he was asked by LN I to assist with a transfer for R1. CNA M had proved cares for the resident once. CNA M reported that he and did not know the resident was care planned for toileting and transfer. CNA M reported the resident became very upset because the staff members attempted to assist him stand. The resident stated, just get a gun and shoot me. CNA M stated, I told him that was illegal, but I do understand that you do not want to suffer anymore but I would be your second Samurai (noble [NAME]). Staff member stated, I stupidly quoted a culture that no one believes in and I should not have said that to the resident. The facilities policy Preventing Resident Abuse, Revised 12/2013, documented the facility would not condone any form of resident abuse. The policy included training all staff how to resolve conflicts appropriately, helping staff to deal appropriately with stress and emotions, training staff to understand and manage a resident's verbal or physical aggression, monitor staff on all shifts to identify inappropriate behaviors towards residents. The facilities policy Abuse Prevention Program, revised 08/2006, documented the residents have the right to be free from abuse and neglect. The policy and procedures direct staff to report allegations of abuse and or neglect in a timely manner to Administration. The facilities policy for, Safe Lifting and Movement of Residents, dated 12/2013, documented staff would promote the safety and well-being of staff and residents, promote quality of care, use appropriate techniques and devices to lift and move residents. The facility failed to ensure the residents remained free from verbal and mental abuse, which included threat of bodily harm, when staff failed to report to the administrative management ,CNA M threatened this confused resident with bodily harm. This deficient practice was cited as past non-compliance after the facility completed acceptable corrections on 04/10/23 at 01:30 PM, prior to the surveyor entrance on 04/11/23. The corrections reviewed and completed onsite on 04/11/23 included the following: 1. On 04/10/23 at 11:30 AM, the Facility Administration, became aware of the incident and began the investigation of the allegations. This included interviewing and suspending the alleged perpetrator at 01:30 PM. 2. On 04/10/23 at 11:30 AM, the facility-initiated Abuse and Neglect and Reporting of Incidents to the facility by the Administrator or Designee immediately. 3. On 04/10/23 at 01:00 PM, the facility administration met with the Medical Director. 4. On 04/10/23 at 5:07 PM, the investigation of allegation was reported the State Agency. 5. On 04/13/23 at 01:30 PM, The alleged perpetrator was terminated. 6. On 04/16/23 at 11:30 AM, Abuse and Neglect Education was provided for all staff members available. Staff members who have not had Abuse and Neglect Education will be educated prior to working their next shift. 7. On 04/18/23 at 04:40 PM, State Surveyor verified a sign was posted at the facility time clock, that staff members are not allowed to work until education for Abuse and Neglect Police and Procedure had been completed. 8. New hires will be educated upon hire for Abuse and Neglect Police and Procedure, Safe Transfers/Body Mechanics/Lift Use/Communication, Reporting of Incidents, Following Care Plan, and Communication with Dementia Behavior. 9. All incidents of Abuse and Neglect & Failure to Report will be monitored through QAPI. 10. Furthermore, on 04/19/23 through 04/21/23, the facility continued further advanced training and provided a Skills Fair 2023 for Skills Checklist from 02:00 PM through 04:30 PM for all staff members. The facility provided education on Safe Transfers/Body Mechanics/Lift Use/Communication, Resident Rights/Care plan meetings/Communication with Dementia/Non-Pharmalogical Interventions, and Abuse, Neglect & Exploitation Review/Customer Services/QAPI. This deficient practice was cited as past non-compliance after the facility completed approved corrections on 04/10/23 at 01:30 PM, prior to the surveyor entrance to the facility on [DATE].

The facility reported a census of 51 residents. The sample included eleven residents care planned for mechanical lift. The sample of three residents included three residents reviewed for neglect. Based on record review and interview, on 04/06/23, the facility failed to ensure dependent Resident (R)1 remained free from neglect, when Certified Nurse Aide (CNA) M attempted an unsafe transfer of R1 from the toilet to his wheelchair, without the use of the baseline care planned and nursing/therapy communication mechanical lift. R1's legs buckled during the transfer, R1 slumped into the wall next to the toilet, and the CNA M transferred R1 on to the toilet. As R1 slid down the wall next to the toilet, the resident's right thigh broke the toilet paper dispenser. Licensed Nurse (LN) I, Licensed Nurse J, and Certified Nurse Aide (CNA) P assisted CNA M to transfer R1 with the Sit to Stand, R1's legs were too weak. LN I, LN J, CNA P and CNA M then transferred R1 with mechanical lift from the toilet to the resident's bed. LN I, LN J, CNA P and CNA M did not report the unsafe transfer and the Administrator began and investigation on 04/10/23 when unidentified family member expressed concerns to Social Worker X. The staff failure of an unsafe transfer of R1 without the care planned mechanical lift and failure to report placed the resident at harm. Findings included: - R1's 03/31/23, signed Hospital Discharge Order, documented the facility admitted the resident on 03/31/23. The resident's diagnoses included atrial fibrillation (rapid, irregular heartbeat), ataxia (impaired ability to coordinate movement), muscle weakness, unsteadiness of feet (abnormality of walking), and morbid obesity (excess body fat). The 04/03/23 Admission Minimum Data Set (MDS), documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. He required total dependence of staff for transfer and toileting. The resident was not steady and was only able to stabilize with staff assistance. The resident used a manual wheelchair and walker for mobility. The 04/10/23 Cognitive Loss/Dementia Care Area Assessment (CAA), documented the resident had deficits with orientation, memory, and recall. The 04/10/23 Activities of Daily Functional Status Care Area Assessment (CAA), documented the resident required assistance with ADL's. The resident had impaired balance and transition during transfer and functional impairment. The 03/31/23 Baseline Care Plan, revealed R1 required total dependence with transfer and toileting. The resident used a manual wheelchair, walker and mechanical lift. The 03/31/23 Nursing/Therapy Communication, revealed the resident required maximum assistance of two staff members for transfers. Staff were to use a gait belt, and if the resident had difficulty standing, the staff members were to utilize the Hoyer (a full body mechanical lift). The Clinical Notes, dated 04/02/23 through 04/04/23, documented the resident required the mechanical lift for transfer, and on 04/06/23, the resident was unable to stand with two staff members assistance. The mechanical lift was used to transfer the resident from the toilet to the bed. The Clinical Progress Notes dated 03/31/23 through 04/11/23, located in the electronic health records, lacked documentation related to the unsafe transfer and notification to Administration or designee. On 04/11/23 at 09:00 AM, Administrative Staff A reported on 04/06/23 at 12:00 PM, CNA P CNA M, LN I, and LN J provided toileting cares for R1. The CNA M, CNA P, LN I, and LN J attempted an unsafe transfer for the cognitive impaired and dependent resident. The staff members failed to notify her that there was an unsafe transfer on 04/06/23 at 12:00 PM. Administrative Staff A reported that she was notified on 04/10/23 at 11:30 AM by Social Worker X that CNA M placed a gait belt around the resident and assisted the resident to stand. The resident's legs became weak, the resident and staff member slid down the wall, next to the toilet, and CNA M lowered the resident to the toilet seat. The resident's right thigh broke the toilet paper dispenser. CNA P CNA M, LN I, and LN J attempted to transfer R1 with the Sit to Stand. The resident's legs were too weak for the Sit to Stand. The staff members utilized the mechanical lift to transfer the resident from the toilet to resident's bed. Administrative Staff reported the resident's baseline care plan, dated 03/31/23, revealed the resident required total dependence with toileting and transfers. The resident's mobility devices were walker, wheelchair, and mechanical lift. Administrative Staff A verified the baseline care plan was incorrectly coded, and the resident should be total dependence with the mechanical lift for transfers and toileting. On 04/17/23 at 08:30 AM, Administrative Nurse D reported on 04/06/23, an unidentified staff member reported that the resident had a decline in his physical ability to stand and R1 now required a mechanical lift. Administrative Nurse D reported on 04/06/23, a staff member who assisted with toileting, witnessed an unsafe transfer by CNA M. She reported an unidentified family member reported their concerns on 04/10/23 at approximately 11:00 AM to Social Worker X. On 04/10/23 at 11:30 AM, the Social Worker X reported the concerns to the facility administration and an immediate investigation was started. CNA M was interviewed and filled out a witness statement. In his witness statement, he admitted that he used the word Samurai. On 04/10/23 at 11:30 PM, CNA M was suspended and then terminated on 04/13/23 On 04/17/23 at 02:13 PM Social Services X reported an unidentified family member of R1 expressed concerns regarding CNA M. The unidentified family member reported R1 was care planned to be transferred with the Hoyer (a full body mechanical lift). CNA M did place the gait belt around R1 and stood the resident up. R1 reported to CNA M that he was unable to stand, and his legs were too weak to stand. The family member reported CNA M threw R1 against the wall in the bathroom, R1 slid down the wall, his right thigh broke the toilet paper roll, caused a bruise on his right thigh. The CNA M stated to the resident, if you will just try you would do it The resident then told CNA M why don't you just shoot me now? The unidentified family member reported she overheard CNA M who told R1 he would be his Samuari, he would bring two [NAME], and if he failed with the first one, he would have a second one. The unidentified family member reported that CAN P, LN I, and LN J assisted with the unsafe transfer. On 04/18/23 at 12:54 PM, Licensed Nurse I reported she asked for additional staff members to assist R1 to transfer the resident from the toilet to his wheelchair. LN J and CNA P also provided assistance. CNA M placed a gait belt around the resident, his arms around the resident and stood the resident up. The resident expressed to the staff members that his legs were too weak to stand, and the resident voiced he needed to sit down. CNA M advised the resident to try to stand up so that the other staff members could provide pericare and place the clean brief on him. The resident legs buckled, the resident and CNA M leaned on the wall and the resident slid onto the toilet seat. The resident's legs were too weak for the sit to stand lift and the staff members obtained and used the full body mechanical lift. The resident was care planned for maximum two-person assist, total dependence. His mobility devices are walker, wheelchair, and mechanical lift. LN I did not feel that the transfer was reportable since the resident was not hurt or fall on the floor. On 04/18/23 at 01:08 PM, Certified Nurse Aide (CNA) M reported he was asked by LN I to assist with a transfer for R1. CNA M had proved cares for the resident once. CNA M verified he did not know the resident was care planned for mechanical lift for transfers. The facilities policy Abuse Prevention Program, revised 08/2006, documented the residents have the right to be free from abuse and neglect. The policy and procedures direct staff to report allegations of abuse and or neglect in a timely manner to Administration. The facilities policy for, Safe Lifting and Movement of Residents, dated 12/2013, documented staff would promote the safety and well-being of staff and residents, promote quality of care, use appropriate techniques and devices to lift and move residents. The facility failed to ensure dependent Resident (R) 1 remained free from neglect, when Certified Nurse Aide (CNA) M attempted an unsafe transfer of R1 from the bath chair to her wheelchair, without use of the care planned mechanical lift. R1's legs buckled during the transfer and CNA M called for assistance; however, when CNA N entered the room, the two staff continued to transfer R1 to his wheelchair, without use of the care planned mechanical lift. The staff failure of an unsafe transfer of R1 without the care planned mechanical lift and failure to report the fall, placed R1 at harm.

The facility reported a census of 74 residents. The sample included 2 residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide adequate supervision to ensure 1 resident (#77,) a cognitively impaired resident, remained free of wandering away from the facility without staff knowledge. The facility staff failed to conduct an adequate search of the outside premises of the facility following the door alarm sounding and the resident exited the facility late at night, at approximately 11:40 PM, walked across a vacant field, with rough terrain, approximately 1 and a half blocks to a place of business, where he/she was found by staff approximately 15 to 20 minutes after the alarm sounded. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #77's signed physician orders, dated 5/17/17, documented the facility admitted the resident on 4/21/17, with [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 4/28/17, revealed the resident had a BIMS (brief interview for mental status) score of 8, which indicated moderately impaired cognition. The resident exhibited wandering, behavior of this type 1-3 days of the assessment period. The resident required extensive staff assistance for transfers, and locomotion. The resident's was balance not steady; and the resident had functional limitation in range of motion to his/her lower extremity on one side. The resident required a wheelchair for mobility. The resident had shortness of breath or trouble breathing with exertion. The resident received an antidepressant (a medication to decrease feelings of sadness, worthlessness and emptiness), antianxiety (a medication to decrease apprehension, uncertainty and irrational fear), and an antibiotic medication. The cognitive loss/dementia CAA (care area assessment), dated 5/4/17, identified the resident with a [DIAGNOSES REDACTED]. The staff encouraged the resident to use the call light for assistance. The CAA for behavioral symptoms identified the resident became anxious at times when his/her spouse left for the day, and when the staff redirected the resident when he/she was non-compliant with non-weight bearing status. The 14 day MDS, dated [DATE], revealed the following changes from the prior MDS dated [DATE]: The resident was without behaviors, and wandering; and the resident required a walker for mobility. The admission elopement assessment, dated 4/21/17, documented the resident with a score of 1, which indicated the resident was a potential elopement risk. The resident's initial and/or temporary care plan, dated 4/22/17, advised the resident had confusion, and required staff assistance for weight bearing. The plan lacked interventions to address the resident's wandering behavior. The elopement assessment, dated 5/8/17, documented the resident had a score of 7. A score of 3 or more indicated the resident was at risk for elopement. The assessment recorded a staff placed a wander guard bracelet (electronic device which will set off an alarm) on the resident, at that time. The care plan updated on 5/8/17, identified the resident was at risk for elopement. The resident was exit seeking, and voiced wanting to leave the facility. Interventions directed staff to place a wander guard bracelet on the resident's wrist, offer activities to redirect, offer to call the resident's spouse, and sit with the resident to verbalize feelings. The care plan updated on 5/10/17, for behaviors, advised the resident may become anxious after his/her spouse left for the day. The resident also became verbal towards the staff when assisting with ADL's, and when redirecting the resident when not following the non-weight bearing status. The care plan included the following interventions: --Approach the resident at a later time with a different care giver. --Do not approach the resident from behind. --Provide one on one as needed --Approach the resident in a calm manner. --Attempt to determine the cause of the resident's behaviors and/or moods. --The resident does best with eye to eye level communication. The nurses progress note, dated 5/26/17 at 3:13 PM, documented the facility readmitted the resident from the hospital after having 2 blood clots removed from his/her right foot. A nurses progress note, dated 5/26/17 at 4:22 PM, documented staff took the resident to his/her room after coming back from the hospital at 1:00 PM. At 1:05 PM, a housekeeper notified the nurse the resident was on the floor. When the nurse went to the resident's room, the resident was observed walking in his/her room. The resident was taken to the nurse's station and neuro checks were initiated. The resident was without complaints of pain. The resident with a red mark on the right side of his/her forehead. Staff removed the leg rest from the resident's wheelchair. The facility elopement risk assessments, dated 5/26/17, documented the resident had a BIMS score of 00, and was a wander and/or elopement risk. The interventions utilized included: A personal safety alarm device. The exit door and stairwell with alarms. The facility utilization of a check in and out log from the facility. The resident's photograph on the wander list. The staff aware of the resident being a wander risk. A nurse's progress note, dated 5/27/17 at 3:31 AM, identified at approximately 11:40 PM, on 5/26/17, staff discovered the resident exited the facility. All staff searched for the resident. Staff located the resident and returned him/her, unharmed to the facility. The nurse's progress notes lacked any further documentation of the elopement. On 6/14/17 at 7:54 AM, observation revealed the distance to the veterinary clinic was approximately 1.5 blocks from the facility. The path the resident took, started with the cemented facility parking lot, then over a small grassy field of uneven terrain, and up a small incline, to another place of business. According to wunderground.com, the temperature on 6/26/17 at 11:54 PM, was 70 degrees Fahrenheit, wind speed of 3.5 miles per hour, and the sky was clear. On 6/14/17 at 6:16 AM, direct care staff M stated staff found the resident leaning on the outside wall of the place of business. The resident was tired when he/she was found outside. Staff M stated he/she observed the resident wander to his/her old room. The resident did not try to exit seek that night. If someone pushed on the 200 hall door for 15-20 seconds, the door would open and alarm, notifying staff someone was exiting the building. On 6/14/17 at 6:26 AM, direct care staff N stated earlier in the shift he/she redirected the resident from the 200 hall, since he/she moved to the 100 hall while at the hospital. The last time staff N observed the resident, around 11:30 PM, when the resident was in his/her room watching television while sitting in his/her wheelchair. Staff N was answered another resident's call light and provided resident care, when he/she heard a door alarm sounding. When he/she finished providing resident care and came out of a room, the nurse was coming up the hall and asked staff N to check and make sure all the residents were accounted for. Staff N started by going to the resident's room and found his/her wheelchair in the room; however the resident was not in his/her room. Staff M and staff N looked in other resident rooms and and then looked outside. He/she drove his/her car, and staff M walked, looking for the missing resident. On 6/14/17 at 7:01 AM, licensed nursing staff L stated on 5/26/17, the staff had to redirect the resident to his/her room, as the resident kept going to his/her old room. When the 200 hall door alarm sounded, he/she went to the door and opened the door and looked outside and did not see anyone. Staff L did not go outside to look around. Staff L then asked staff N to check and make sure the resident was in his/her room, and when staff N did, the resident was not in his/her room. Direct care staff M and N started to check the resident rooms on the other halls, and then staff M went outside. The facility staff completed a check of the building, and the resident was not found in the building. Staff N was driving his/her car around searching for the resident while staff M went on foot behind the facility. Staff N drove into the church parking lot and his/her car lights shined on another place of business where staff N saw the resident learning up against the building and then notified staff M of the resident's position. Staff M and N brought the resident back to the facility and staff assessed the resident. The resident was without injuries. The resident lacked the wander guard bracelet on his/her wrist and staff could not find the bracelet in the facility. Staff L stated he/she had until the end of the shift to check for wander guard placement and document on the TAR (treatment medication record) and he/she had not checked the placement of the resident's the wander guard bracelet, that evening. The resident was outside for about approximately 15-20 minutes. On 6/14/17 at 1:15 PM, licensed nursing staff P stated the resident did have a wander guard in place when he/she returned from the hospital on [DATE], however staff P did not document the wander guard was on a resident's wrist upon return from the hospital. On 6/20/17 at 8:25 AM, administrative nursing staff B stated the resident did not have any further exit seeking behavior during his/her stay. The resident had a staff member 1 on 1 with him/her from 5/27/17 at approximately 12:15 AM, until the time the resident discharged to home, on 5/30/17. The undated facility policy for elopement, documented staff would assess all residents upon admission, annually and with each significant change for the potential for elopement. If a resident was found to be at risk for elopement, an elopement band (wander guard) would be applied. The placement of the elopement band would be checked each day by the charge nurse. The staff to respond immediately to door alarms and check the door monitors. A systematic search would then be conducted of the building. If a search of the building and/or the outside perimeter does not provide knowledge of the missing resident whereabouts, 911 should be notified. A book of residents found to be at risk for elopement would be maintained at each nurse's station. This book would contain a current photo and description of the resident in the event that a resident eloped from the facility. The facility failed to ensure adequate supervision and assistive devices to ensure this cognitively impaired resident assessed as an elopement risk, did not exit the facility without staff's knowledge. The facility staff failed to conduct an adequate search of the outside premises of the facility following the door alarm sounding and the resident exited the facility late at night, at approximately 11:40 PM, walked across a vacant field, with rough terrain, approximately 1 and a half blocks to the veterinary clinic, where he/she was found by staff approximately 15 to 20 minutes after the alarm sounded. This practice placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 6/15/17 at 9:06 PM, when staff completed the following: 1). Reviewed and revised the facility policy and procedure to include staff response to search the outside perimeter of the facility when and where the door alarm sounded. The safety plan, included in the revised elopement policy and procedure documented upon hearing a door alarm the staff member was to immediately respond to the door alarm. At this point the staff should conduct a search on the outside grounds. While the staff search outside, the staff inside conduct a head count and check the sign out log. Upon associate returning and reporting to the charge nurse, a determination should be made of any missing residents. Staff call 911 was about the elopement if the head count identified a resident eloped and the staff searched outside and did not find the resident. Re-education was done immediately to all nursing staff. Associates would not work until re-education has been completed. 2). Inserviced all staff regarding the revised policy and procedure. The deficient practice remained at the scope and severity of a D.

The facility reported a census of 88 residents, with 4 residents sampled for accidents. Based on observation, interview and record review, the facility failed to provide adequate supervision and safety devices during transfers using the sit to stand mechanical lift to prevent accidents for 4 of the 4 sampled residents. Staff failed to apply the safety straps on the lift for resident #1, who fell from the lift during a transfer and fractured both hips. Staff failed to apply the safety straps on the sit to stand lift, to prevent falls, during transfers for residents #2, #3, and #4, all at risk for falls. Findings included: - The physician's orders [REDACTED].#1 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set, dated dated [DATE], documented the resident's brief interview for mental status score of 15, indicating cognitively intact, and required extensive assist of 2 staff for transfers. The resident had a history of [REDACTED]. The care area assessment for falls, dated 9/22/15, documented the resident at risk for falls related to a history of falls prior to admission, impaired mobility, incontinence and potential effects of medication with a fall in July at home with fractured left fibula. The resident was able to voice needs to staff. The care plan, dated 9/15/15, documented a history of falls and directed staff to remind the resident to rise slowly and sit in an upright position before attempting to transfer. The resident required extensive assist of 2 staff with the sit to stand mechanical lift for transfers. The update, on 11/21/15, documented to transfer the resident with the hoyer lift and 2 person total assist. The update, on 11/30/15, documented the resident on bed rest with emergency hoyer lift only using 2 staff assist. The nurse's note, on 11/21/15 at 11:53 AM, documented staff reported the resident briefly passed out during a transfer at approximately 10:45 AM, and awoke screaming out in pain, rated 10/10, to bilateral hips and did not remember what happened. The resident was sent to the hospital. Addendum to note, at 11:55 AM, documented the resident was sitting on the floor in front of the sit to stand lift with legs straight out in front when the nurse arrived in the room. Assessment revealed external rotation to bilateral lower extremities. Direct care staff transferred the resident from the recliner to the electric wheelchair with the sit to stand lift when the resident passed out and fell from the lift. The strap of the sling was not clamped at the time of this nurse's arrival to the room. The validation of competency for the sit to stand lift documented training was completed on 7/9/15, for direct care staff G and on 8/14/15, for direct care staff F. On 12/1015 at 9:00 AM, the resident observed lying in the bed with the head of bed elevated 45 degrees, abduction wedge (pillow designed to keep legs spread in open position) between legs. At 10:08 AM, 2 staff entered the resident's room and repositioned the resident, weight shifted from the left side to the right side with side positioning pillows and the wedge remained in place. At 2:28 PM, resident remained in the bed with the head of the bed angle decreased to approximately 30 degrees, the resident resting with eyes closed. On 12/10/15 at 9:00 AM, the resident stated he/she was on hospice now, and the doctors do not want him/her to get up and he/she had no desire to get up. The resident remembered having a fall where he/she broke both hips. The resident stated staff used the sit to stand lift to get him/her to the bathroom, when he/she blacked out and fell out of the lift machine, but does not remember beyond that. The resident stated staff always used the lift to help him/her transfer, but never used the safety straps, they just placed the strap under the arms and attached it to the lift arms of the machine. He/She does not ever remember staff strapping across his/her chest and buckling it, or using a strap behind the legs. The resident stated he/she did not remember ever being asked by staff if he/she wanted these straps on or not. If he/she had been asked and explained it was a safety measure, he/she would have wanted the straps on, but the staff never used the straps, never asked, or told him/her about the straps. On 12/10/15 at 11:09 AM, licensed nursing staff C reported he/she expected the direct care staff to have the strap on the chest of the sling buckled and the leg strap applied for all transfers using the sit to stand lift. There are no exceptions to this, for safety reasons. Staff C expects the staff to immediately notify the nurse if a resident refuses either of the safety straps, so the proper education can be done by the nurse, if the resident has a cognition that allows for education to be retained. If so, proper documentation of the refusal and the education would be provided (a risk versus benefit statement). At that time, the nurse and the therapy department would have to come up with an alternate form of safe transfers, because staff cannot transfer a resident with the sit to stand lift without using the proper safety mechanisms, the straps. Staff stated there are no residents in the facility currently that refuse the straps. No direct care staff had reported any resident refusal. Staff C was the nurse on duty when the resident fell from the lift. When he/she entered the room, the resident was on the floor, the lift was in front of the resident and the sling was hanging from the lift, and not buckled. The resident was in severe pain with bilateral broken hips. Staff C asked the two CNAs (certified nursing assistants) how the resident fell and they said he/she passed out without warning, and they did not have the sling buckled around the resident's chest or the leg straps on, so when he/she blacked out, he/she immediately fell directly down to the floor. Due to the resident's size of 300+ pounds, the staff were not able to break the fall when they realized he/she was going down. The CNAs, after the fall, told staff C the resident had refused the strap, but they had never reported this to staff C. On 12/10/15 at 11:20 AM, administrative nursing staff B stated when using the sit to stand lift, staff are to use the chest strap all the time, with every transfer and the leg strap was a case by case determination. There are currently no residents who should not be using the leg strap during a transfer. Staff B confirmed the CNAs did not apply the safety straps during the transfer and the resident fell , breaking both hips. On 12/10/15 at 12:54 PM, consultant staff E stated he/she was responsible for training facility staff how to provide safe transfers with the mechanical lifts. During the training, staff are taught how to put the sling on correctly, which includes buckling the strap in front of the resident. All residents should have the chest strap buckled. All staff had the proper training for safe transfers during orientation. Staff E assume direct care staff are buckling all residents with the chest strap. On 12/10/15 at 2:00 PM, direct care staff F stated the orientation training included how to safely use the sit to stand lift, which was to use both straps every time a resident was transferred. Now, if the residents say they do not want to use the straps, then staff F does not use them. Staff F stated he/she should report any refusal of using the strap to the nurse and should not do a transfer that was not safe. Staff F stated the sling strap was not buckled when the resident fell , because he/she said do not worry about it. Staff F told the nurse the resident refused the strap, but it was after the fall. The resident wanted changed before he/she went into the power chair to go to lunch. Staff F put the sling on the resident, but did not buckle the sling or put on the leg strap. Staff F and Staff G changed the resident and were moving across the room to the chair with the resident up in the lift, when they realized the resident had gone limp, got extremely red and went down. Staff G was behind the resident, screaming he was going down and the resident collapsed to the floor. On 12/10/15 at 2:28 PM, direct care staff G stated the resident required 2 staff with the sit to stand lift for transfers at the time of the fall. But now, the resident does not get out of bed because of the hip fractures. That day, staff G and staff F did not have the safety belt strapped on the resident because the resident did not want it on. Staff G did not let the nurse know the resident refused the strap. Staff G was trained to use the lift on orientation, and that training was to use both straps with every transfer. Since then, staff G quit using the sling strap and the leg strap because some residents just do not want the straps, so staff G does not use them. The Med Care Stand/Lift Operation Manual, dated 8/5/13, documented use of the stands or lifts without proper training could result in serious injury to the person being lifter/transferred. Care stand operations state to position the belt around the resident's lower back, just above the belt line and fasten the buckle to secure the belt. Assist the resident in placing their feet on the foot plate, with their shins against the support pad. If needed, fasten Velcro strap around lower legs. Observation of the instruction video, available at www.medcarelifts.com, revealed the belt buckled around the resident's torso, and the Velcro leg strap attached behind the lower legs of the resident being transferred. The facility failed to provide safety measures by applying the safety straps to the resident's torso and legs, while transferring this dependent resident with the sit to stand lift, who fell out of the sit to stand lift during a transfer and sustained fractures to both hips. - The admission minimum data set for resident #2, dated 11/11/15, documented the resident's brief interview for mental status score of 14, indicating cognitively intact, and required extensive assist of 2 staff for transfers. The resident had a fall history with a fracture prior to admission, and none since admission. The care area assessment for falls, dated 11/11/15, documented the resident at risk for falls related to impaired mobility and weakness, was walking at home when he/she felt like both legs gave out, tried to catch self with left arm and sustained a fracture of the left humerus. The care plan, dated 11/11/15, directed staff to use the sit to stand lift with 2 staff to assist with transfers. Observation of the resident, on 12/10/15 at 9:50 AM, direct care staff G and D entered the resident's room with the sit to stand lift to transfer the resident from the wheelchair to the recliner. Staff placed the sling around the resident's back, under the arms and attached it to the lift on both sides with the loops on the sling. Staff G and D failed to buckle the safety strap around the resident's chest. Staff assisted the resident to place both feet onto the foot platform and began to lift the resident. Staff G and D failed to place the resident's legs into the foam trough for the legs and failed to apply the Velcro safety strap behind the resident's lower legs. Staff G and D completed the transfer to the recliner and failed to ask or talk to the resident about either of the safety straps during the transfer. After the transfer, staff G and D both stated this was a typical resident transfer as they always complete them. Staff G and D advised this was how they transfer any resident while using the sit to stand lift. On 12/10/15 at 9:42 AM, the resident stated he/she was dependent on staff to assist with transfers using the mechanical sit to stand lift. The resident knew nothing about a safety strap for the legs on the lift, had not ever had staff use this during transfers. The resident stated some of the staff buckled the arm sling around his/her chest and some do not. The resident assumed it was optional, because it was not consistently used during his/her transfers with the sit to stand lift. On 12/10/15 at 10:29 AM, direct care staff D reported it was required to use the sling strap across the chest at all times with transfers and use the leg strap too, unless the resident says they do not want it and are cognitive enough to say what they want. Most of our residents refuse the straps. The nurse should be told about any resident that refuses the straps. Staff D had not reported any resident refusal to the nurses. Staff D stated he/she had worked with the residents long enough, he/she just knew if the resident wanted the straps on or not. On 12/10/15 at 11:09 AM, licensed nursing staff C reported he/she expected the direct care staff to have the safety strap on the chest of the sling buckled and the leg safety strap applied for all transfers using the sit to stand lift. There are no exceptions to this, for safety reasons. Staff C expects the staff to immediately notify the nurse if a resident refuses either of the safety straps, so the proper education can be done by the nurse, if the resident has a cognition that allows for education to be retained. If so, proper documentation of the refusal and the education would be provided (a risk versus benefit statement). At that time, the nurse and the therapy department would have to implement an alternate form of safe transfers, because staff cannot transfer a resident with the sit to stand lift without using the proper safety mechanisms, the straps. Staff stated there are no residents in the facility currently that refuse the straps. No direct care staff had reported any resident refusal. On 12/10/15 at 11:20 AM, administrative nursing staff B stated when using the sit to stand lift, staff are to use the chest strap all the time, with every transfer and the leg strap was a case by case determination. There are currently no residents who should not be using the leg strap during a transfer. On 12/10/15 at 12:54 PM, consultant staff E stated he/she was responsible for training facility staff how to provide safe transfers with the mechanical lifts. During the training, staff are taught how to put the sling on correctly, which includes buckling the safety strap in front of the resident. All residents should have the chest strap buckled. All staff had the proper training for safe transfers during orientation. Staff E assumed direct care staff are buckling all residents with the chest strap. On 12/10/15 at 2:00 PM, direct care staff F stated the orientation training included how to safely use the sit to stand lift, which was to use both straps every time a resident was transferred. Now, if the residents say they do not want to use the straps, then staff F does not use them. Staff F stated he/she should report any refusal of using the strap to the nurse and should not do a transfer that was not safe. On 12/10/15 at 2:28 PM, direct care staff G they were trained to use the lift on orientation, and that training was to use both straps with every transfer. Since then, staff G quit using the sling strap and the leg strap because some residents just do not want the straps, so staff G does not use them. The Med Care Stand/Lift Operation Manual, dated 8/5/13, documented use of the stands or lifts without proper training could result in serious injury to the person being lifter/transferred. While we believe that one person can safely operate our equipment each facility has its own policies and procedure regarding the safe lifting and transfer of residents. In the event that your facility policies require more than one staff member to safely perform a transfer with a mechanical lifting device, that policy should be followed. Care stand operations state to position the belt around the resident's lower back, just above the belt line. Fasten buckle to secure belt. Assist the resident in placing their feet on the foot plate, with their shins against the support pad. If needed, fasten Velcro strap around patients lower legs. Observation of the instruction video, available at www.medcarelifts.com, revealed the belt buckled around the resident's torso, and the Velcro leg strap attached behind the lower legs of the resident being transferred. The facility failed to provide the safety straps to prevent falls during a transfer using the sit to stand lift for this dependent resident who was at risk for falls. - The physician's orders [REDACTED].#3 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual minimum data set (MDS), dated [DATE], documented the resident's brief interview for mental status score (BIMS) of 9, indicating moderately impaired cognition, and required extensive assist of 2 staff for transfers, with no falls noted. The quarterly MDS, dated [DATE], documented the resident's BIMS score of 10, with no other changes noted since the previous assessment. The care area assessment for falls, dated 4/7/15, documented the resident at risk for falls related to impaired mobility, incontinence and potential effects of medication. No falls at this time, and staff provided assist with transfers. The care plan, dated 9/30/15, directed staff to transfer the resident with the sit to stand lift. The resident was at risk for falls, and staff directed to remind the resident to rise slowly and sit in an upright position before attempting to transfer. Observation of the resident, on 12/10/15 at 11:02 AM, revealed direct care staff G and F entered the resident's room with the sit to stand lift to transfer the resident from the wheelchair to the toilet. Staff G placed the sling around the resident's back, under the arms and attached it to the lift on both sides with the loops on the sling. Staff G failed to buckle the safety strap around the resident's chest. Staff F assisted the resident to place both feet onto the foot platform and asked the resident if he/she wanted the leg strap applied to which the resident replied, Is there a benefit to using it? Staff G stated to the resident that it was safer when the strap was used, and the resident replied, Then of course I want you to use it, just do it. Staff F applied the leg safety strap, but did not buckle the chest strap and completed the transfer to the toilet. After the staff completed the transfer, staff G stated he/she does not ever use the safety straps when a resident does not want to use it, and this resident never wanted the straps used. Staff G confirmed that this resident had not refused the strap prior to the transfer and when the resident was told it was safer to use the strap the resident wanted to use it. Staff G stated this was the first time he/she had told the resident about the safety strap and had just not used it in the past because other staff had said the resident did not want it. Staff F stated once a resident tells a staff member they do not want to use the safety strap, it was never used again on them. Staff F does not ask about the safety strap each time, they just do not use it. Staff F had never had this resident tell him/her not to use the straps, he/she just knew the resident did not like the straps, so staff F never used the straps on the resident. Observation of the resident, on 12/10/15 at 1:55 PM, revealed direct care staff F and D entered the resident ' s room with the sit to stand lift to transfer the resident from the wheelchair to the toilet. The resident was leaning forward and to the right side, bent over the side of the wheelchair, and had just woken up in this position when the staff entered the room. Staff F placed the sling around the resident's back, under the arms and attached it to the lift on both sides with the loops on the sling without straitening the resident's posture in the wheelchair. Staff F then buckled the sling around the resident's upper torso, above the breasts across the chest. The safety strap was visibly loose on the resident. Staff D place the resident's feet on the foot rest of the stand and failed to apply the safety strap to the legs. Staff F and D completed the transfer. When the resident was raised to a standing position, the sling slid up approximately 4 inches on the resident's torso with a large visible gap of approximately 8 inches between the strap and the resident's chest remained. On 12/10/15 at 2:55 PM, the resident stated he/she was not even aware of the lift having a safety strap for the legs until the staff asked if he/she wanted to use it today. The staff does not use the leg safety strap. The resident stated he/she does not like using the lift at all because it was very scary. When the staff buckle the top strap, it was always very loose and it felt like you could just fall right out of it. The staff do not always buckle the top when they use the machine, it depends on how big of a hurry they are in. The resident stated sometimes, the staff rush through the transfer with the lift and that is when the staff do not buckle the upper strap. Staff have not ever talked to the resident about safety measures while using the lift until today, which was the first the resident had heard of it. On 12/10/15 at 10:29 AM, direct care staff D reported it was required to use the sling strap across the chest at all times with transfers and use the leg strap too, unless the resident says they do not want it and are cognitive enough to say what they want. Most of our residents refuse the straps. The nurse should be told about any resident that refuses the straps. Staff D had not reported any resident refusal to the nurses. Staff D stated he/she had worked with the residents long enough, he/she just knew if the resident wanted the straps on or not. On 12/10/15 at 11:09 AM, licensed nursing staff C reported he/she expected the direct care staff to have the safety strap on the chest of the sling buckled and the leg safety strap applied for all transfers using the sit to stand lift. There are no exceptions to this, for safety reasons. Staff C expects the staff to immediately notify the nurse if a resident refuses either of the safety straps, so the proper education can be done by the nurse, if the resident has a cognition that allows for education to be retained. If so, proper documentation of the refusal and the education would be provided (a risk versus benefit statement). At that time, the nurse and the therapy department would have to implement an alternate form of safe transfers, because staff cannot transfer a resident with the sit to stand lift without using the proper safety mechanisms, the straps. Staff stated there are no residents in the facility currently that refuse the straps. No direct care staff had reported any resident refusal. On 12/10/15 at 11:20 AM, administrative nursing staff B stated when using the sit to stand lift, staff are to use the chest strap all the time, with every transfer and the leg strap was a case by case determination. There are currently no residents who should not be using the leg strap during a transfer. On 12/10/15 at 12:54 PM, consultant staff E stated he/she was responsible for training facility staff how to provide safe transfers with the mechanical lifts. During the training, staff are taught how to put the sling on correctly, which includes buckling the safety strap in front of the resident. All residents should have the chest strap buckled. All staff had the proper training for safe transfers during orientation. Staff E assumed direct care staff are buckling all residents with the chest strap. On 12/10/15 at 2:00 PM, direct care staff F stated the orientation training included how to safely use the sit to stand lift, which was to use both straps every time a resident was transferred. Now, if the residents say they do not want to use the straps, then staff F does not use them. Staff F stated he/she should report any refusal of using the strap to the nurse and should not do a transfer that was not safe. On 12/10/15 at 2:28 PM, direct care staff G stated they were trained to use the lift on orientation, and that training was to use both straps with every transfer. Since then, staff G quit using the sling strap and the leg strap because some residents just do not want the straps, so staff G does not use them. The Med Care Stand/Lift Operation Manual, dated 8/5/13, documented use of the stands or lifts without proper training could result in serious injury to the person being lifter/transferred. While we believe that one person can safely operate our equipment each facility has its own policies and procedure regarding the safe lifting and transfer of residents. In the event that your facility policies require more than one staff member to safely perform a transfer with a mechanical lifting device, that policy should be followed. Care stand operations state to position the belt around the resident's lower back, just above the belt line. Fasten buckle to secure belt. Assist the resident in placing their feet on the foot plate, with their shins against the support pad. If needed, fasten Velcro strap around patients lower legs. Observation of the instruction video, available at www.medcarelifts.com, revealed the belt buckled around the resident's torso, and the Velcro leg strap attached behind the lower legs of the resident being transferred. The facility failed to provide the safety straps to prevent falls during a transfer using the sit to stand lift for this dependent resident who was at risk for falls. - The physician's orders [REDACTED].#4 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual minimum data set (MDS), dated [DATE], documented the resident's brief interview for mental status score (BIMS) of 15, indicating cognitively intact and required extensive assist of 2 staff for transfers, with no falls noted. The quarterly MDS, dated [DATE], documented no change from the previous assessment. The care area assessment for falls, 6/9/15, documented the resident at risk for falls related to impaired mobility, and potential effects of medications with no falls noted. The care plan, dated 9/30/15, documented the resident at risk for falls and directed staff to provided extensive assist with the sit to stand lift for transfers. On 8/22/13, the resident was advised on proper use of the sit to stand sling. The update, on 11/23/15, documented the resident does not always allow staff to use safety strap for the mechanical lift, staff has provided the resident with education on the risks and benefit and safety of using the strap and staff directed to encourage the resident to use the strap for safety. Observation of the resident, on 12/10/15 at 10:10 AM and 12:45 PM, revealed direct care staff F and D entered the resident ' s room with the sit to stand lift to transfer the resident from the wheelchair to the toilet. Staff placed the sling under the resident's arms and attached it to the lift with the loops. Staff failed to buckle the sling safety strap around the resident. Staff placed the resident's feet on the foot plate of the lift and failed to apply the leg safety strap behind the resident's legs. Staff did not talk to the resident during the transfer about the safety straps. On 12/10/15 at 1:45 PM, the resident stated the staff do not use the leg safety strap, and did not know what this strap was, nor does staff buckle the strap around his/her chest. The resident cannot remember ever being told about the safety of the straps, but stated the staff could have a long time ago and he/she just does not remember. The resident stated he/she does not particularly like the feeling of the chest strap when it was buckled, and knows that he/she had complained about that in the past. But, if staff explained to him/her that it was a safety measure, he/she would happily use it, even if he/she did not like the feeling of it. The resident stated he/she wanted to be as safe as possible when he/she is in the lift because it was an uneasy feeling to have the machine in control of your body, when you are suspended into the air and being pushed around that way. On 12/10/15 at 10:29 AM, direct care staff D reported it was required to use the sling strap across the chest at all times with transfers and use the leg strap too, unless the resident says they do not want it and are cognitive enough to say what they want. Most of our residents refuse the straps. The nurse should be told about any resident that refuses the straps. Staff D had not reported any resident refusal to the nurses. Staff D stated he/she had worked with the residents long enough, he/she just knew if the resident wanted the straps on or not. On 12/10/15 at 11:09 AM, licensed nursing staff C reported he/she expected the direct care staff to have the safety strap on the chest of the sling buckled and the leg safety strap applied for all transfers using the sit to stand lift. There are no exceptions to this, for safety reasons. Staff C expects the staff to immediately notify the nurse if a resident refuses either of the safety straps, so the proper education can be done by the nurse, if the resident has a cognition that allows for education to be retained. If so, proper documentation of the refusal and the education would be provided (a risk versus benefit statement). At that time, the nurse and the therapy department would have to implement an alternate form of safe transfers, because staff cannot transfer a resident with the sit to stand lift without using the proper safety mechanisms, the straps. Staff stated there are no residents in the facility currently that refuse the straps. No direct care staff had reported any resident refusal. On 12/10/15 at 11:20 AM, administrative nursing staff B stated when using the sit to stand lift, staff are to use the chest strap all the time, with every transfer and the leg strap was a case by case determination. There are currently no residents who should not be using the leg strap during a transfer. On 12/10/15 at 12:54 PM, consultant staff E stated he/she was responsible for training facility staff how to provide safe transfers with the mechanical lifts. During the training, staff are taught how to put the sling on correctly, which includes buckling the safety strap in front of the resident. All residents should have the chest strap buckled. All staff had the proper training for safe transfers during orientation. Staff E assumed direct care staff are buckling all residents with the chest strap. On 12/10/15 at 2:00 PM, direct care staff F stated the orientation training included how to safely use the sit to stand lift, which was to use both straps every time a resident was transferred. Now, if the residents say they do not want to use the straps, then staff F does not use them. Staff F stated he/she should report any refusal of using the strap to the nurse and should not do a transfer that was not safe. On 12/10/15 at 2:28 PM, direct care staff G they were trained to use the lift on orientation, and that training was to use both straps with every transfer. Since then, staff G quit using the sling strap and the leg strap because some residents just do not want the straps, so staff G does not use them. The Med Care Stand/Lift Operation Manual, dated 8/5/13, documented use of the stands or lifts without proper training could result in serious injury to the person being lifter/transferred. While we believe that one person can safely operate our equipment each facility has its own policies and procedure regarding the safe lifting and transfer of residents. In the event that your facility policies require more than one staff member to safely perform a transfer with a mechanical lifting device, that policy should be followed. Care stand operations state to position the belt around the resident's lower back, just above the belt line. Fasten buckle to secure belt. Assist the resident in placing their feet on the foot plate, with their shins against the support pad. If needed, fasten Velcro strap around patients lower legs. Observation of the instruction video, a