Every finding on record at Legend Oaks Healthcare and Rehabilitation - New Br

Based on observation, interviews, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 3 of 7 (Resident #11, #32, and #92) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #11's oxygen was administered at the correct setting of 5 liters per minute on 05/20/2026 as ordered by the physician. 2. The facility failed to ensure Resident #32's oxygen concentrator had a clean filter on 5/17/2026. 3. The facility failed to ensure Resident #92's oxygen concentrator had a clean filter on 5/17/2026. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. The findings included: 1. Record review of Resident #11's face sheet, dated 05/20/2026, revealed the resident was a 63-years-old male, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own), chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), and bronchitis (an inflammation on the lining of the bronchial tubes in the lung). Record review of Resident #11's quarterly MDS assessment, dated 05/11/2026 revealed the resident's BIMS score was 13 out of 15 which indicated the resident's cognitive was intact, and he had oxygen therapy in the facility in the Section O (Special Treatment, Procedures, and Program). Record review of Resident #11's comprehensive care plan, dated 11/13/2025, revealed the resident had the care plans of [Resident #11] has COPD (Chronic Obstructive Pulmonary Disease), respiratory failure with hypoxia (low oxygen level in the body) and oxygen therapy. For the intervention - Oxygen per physician orders. Record review of Resident #11's physician order, dated 03/27/2026, revealed the resident had the order of OXYGEN at 5 liter per minute VIA nasal cannula CONTINUOUS for chronic obstructive pulmonary disease, every shift. Observation on 05/20/2026 at 9:00 a.m. revealed Resident #11 was on the bed in his room and wearing a nasal cannula connected to the oxygen concentrator located at the bedside, and it was set up to 4.5 liters per minute. Interview on 05/20/2026 at 9:11 a.m., LVN-A said Resident #11's oxygen concentrator was set up to 4.5 liters per minute, but the resident's physician order indicated oxygen at 5 liters per minute. The LVN-A stated she did not know what reason Resident #11 was receiving oxygen 4.5 liters per minute, instead of 5 liters per minute, but the resident should have received 5 liters per minute as ordered, and the nurse should have checked the oxygen every shift to make sure the resident was receiving oxygen correctly as ordered. The LVN-A said she did not check the oxygen rate on 05/20/2026 because she was very busy, but she checked the resident's oxygen saturation, and it was 97%, and he did not have any sign or symptoms regarding hypoxia. The LVN-A said if the resident did not receive correct oxygen rate as ordered, he might have hypoxia. Interview on 05.20/2026 at 11:43 a.m., the DON said Resident #11 should have received oxygen5 liters per minute via nasal cannula as ordered, instead of 4.5 liters per minute, and the facility nurse should have checked it every shift. The DON stated if the resident did not receive correct oxygen rate as ordered, he might have hypoxia. 2. Record review of Resident #32's face sheet dated 5/20/2026 revealed a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses that included: COPD (an incurable lung disease that restricts airflow and makes it difficult to breath), pleural effusion (water on the lungs), and tachycardia (elevated heart rate). Record review of Resident #32's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15, cognitively intact. Further review revealed she was independent of all ADLs. Record review of Resident #32's Care Plan dated 5/14/2026 revealed the resident was care planned for oxygen therapy as needed, dementia, and for risk of falls. Record review of Resident #32's physician orders dated 4/30/2026 revealed the resident had an order for oxygen at 3 liters per minute with a nasal canula as needed. Record review of Resident #92's face sheet dated 5/19/2026 revealed an [AGE] year-old female was admitted to the facility on [DATE] with diagnoses that included: COPD, pneumonia, legal blindness, and heart failure. Record review of Resident #92's quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15, cognitively intact. Further review revealed she required minimal assistance with ADLs and mechanical lift for transfers. Record review of Resident #92's Care Plan dated 3/6/2026 revealed the resident was care planned for oxygen therapy, DNR (Do Not Resuscitate) code status, hard of hearing, and falls. Record review of Resident #92's physician orders dated 4/7/2026 revealed the resident had orders for oxygen at 3 1/2 liters per minute, continuously. Observation and interview on 5/17/2026 at 11:34 AM revealed, Resident #32 was sitting in bed with her knees to her chest, oxygen with a nasal canula in place, and she said things were fine. Resident #32 allowed the surveyor to check the concentrator that supplied the oxygen. The setting was on 3 liters and the filter that was in a tray in the back of the concentrator was dirty. The resident saw the filter and stated, Oh wow, that's dirty. She said she could not notice anything different with her oxygen coming through the nasal canula, but she did not want it to become a problem for her one day. During an observation and interview on 5/17/2026 at 11:40AM revealed Resident #92 was asleep in bed with the oxygen per nasal canula in place set at 3 1/2 liters per minute. The filter on the back of the concentrator behind a door of the unit. The door of the unit was opened and revealed the filter remained dirty. During an interview on 5/19/2026 at 11:12AM, Resident #92 was asleep in bed with oxygen in place. The surveyor checked the filter in the back of the concentrator revealed it remained dirty. During an interview and observation on 5/19/2026 at 11:14AM, Resident #32 was sitting on the side of her bed. The resident allowed the surveyor to look at the filter on the concentrator and when the drawer was opened, the filter was still dirty. Resident #32 said she did not believe anyone checked or cleaned the filter. RN E was shown the dirty filters of Resident #32 and Resident #92. RN E said it was the responsibility of the night shift to clean the filters daily and all the nurses that had residents that used oxygen were supposed to check the filters to make sure they were clean. RN E said it was important to ensure that the filters on the concentrators were clean to ensure that the residents did not acquire respiratory illness or not have adequate oxygen delivered through the nasal canula. During an interview on 5/19/2026 at 11:30AM, the DON said it was the night shift's responsibility to check and clean the filters every day. The DON said it was important to clean the filters to prevent inhalation of dirty air that could cause respiratory infections and possibly respiratory distress for the resident. Record review of the facility policy, titled Oxygen Administration, undated, revealed It is the policy of this facility that oxygen therapy is administered by licensed nurses as ordered by the physician or as a nursing measure and an emergency measure until the order can be obtained. 6. Oxygen concentrators will be maintained in room with clean filters and cannula or mask.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed.The facility failed to ensure that 4 bags of gravy mix located in the dry storage room were labeled and dated when they were received. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: During an observation on 5/17/2026 at 9:30AM the dry storage room had 3 bags of chicken gravy mix not labeled with a date and 1 bag of pork gravy mix not labeled with a date when the packaged gravy mixes were received. During an interview on 5/17/2026 at 9:35AM, the CDM stated, Oh my God, those should have been labeled with a date, and she removed the bags to show them from the shelf. The CDM said all packaging should be labeled with the date the packages were received. During an interview on 5/20/2026 at 11:34AM, the CDM said it was important to label and date food to prevent expired foods from being served, which could cause foodborne illness to the residents. Record review of the facility's policy did not reveal information on how dry foods should be stored. Record review of Texas Health and Human Services titled, Kitchen Sanitation and Food Safety dated10/2024 stated under, Food Storage: Key Elements that, Dry food storage is clean, covered/sealed, labeled, and dated.

The facility failed to ensure that the garbage and refuse containers were in good condition (no leaks) and is waste properly contained in dumpsters or compactors with lids or otherwise covered and that the garbage storage area was well maintained in a sanitary condition to prevent the harborage and feeding of pests for 1 of 1 garbage disposal area reviewed. The facility failed to keep the area around the outdoor garbage receptacle clear of debris when a bag of trash and broken-down boxes were observed outside the garbage receptacle and on the ground. The facility failed to keep the lids closed on the outdoor garbage receptacle during observation of the garbage receptacles. These failures could cause unpleasant odors and attract pest and rodents to the facility. During an observation and interview on 5/17/2026 at 9:55AM revealed, the dumpster outside was in an enclosed area. The DM opened the doors and there was a bag of garbage on the ground, boxes were broken down on the ground, and the door on the dumpster was opened. The CDM stated, It was the nursing side that left the bag of garbage and the boxes on the ground, but unfortunately, it was dietary's responsibility to make sure no garbage was on the ground and the door of the dumpster was closed. During an interview on 5/20/2026 at 11:34AM, the CDM said it was important to keep trash off the ground, and the dumpster door closed to prevent infestation of pests and rodents that could cause food contamination and food borne illness of the residents if they entered the building. Record review of the facility's policy titled, Garbage Disposal and Dumpster Sanitation not dated, under policy stated: To ensure proper containment, handling, and disposal of garbage preventing odors, pest infestation, and infection control risks. Under procedure, stated: 4. Be kept closed when not actively in use. 5. Be free from overflow, excess buildup, or exposed waste. 6. Staff must close lids immediately after depositing trash.

Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 2 (Resident #11 and #43) of 28 residents reviewed, in that: 1. Resident #11's personal refrigerator located in his room was observed on 05/17/2026, and there were one piece of cake, sandwich, and one cup of milk inside the refrigerator, but no date on the food. 2. Resident #43's personal refrigerator located in her room was observed on 05/17/2026, and there was melting ice cream inside the refrigerator, instead of freezer area, but no date on it. This deficient practice could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included: 1. Record review of Resident #11's face sheet, dated 05/20/2026, revealed the resident was a 63-years-old male, originally admitted on [DATE], and readmitted to the facility on [DATE] with diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own), chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), and bronchitis (an inflammation on the lining of the bronchial tubes in the lung). Record review of Resident #11's quarterly MDS assessment, dated 05/11/2026 revealed the resident's BIMS score was 13 out of 15 which indicated the resident's cognitive was intact, and he required Setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) to eating. Record review of Resident #11's comprehensive care plan, dated 12/10/2025, revealed the resident had the care plans of [Resident #11] is at risk for malnutrition related to diabetes. For intervention - Diet as ordered by the physician. REGULAR diet, REGULAR texture, THIN LIQUIDS consistency. Observation on 05/17/2026 at 11:02 a.m. revealed Resident #11 was sleeping on the bed, and there was small refrigerator in his room, and one piece of cake, one sandwich, and one cup of milk were inside the refrigerator, but no date on the food. Interview on 05/17/2026 at 11:13 a.m. with Resident #11 refused interviewing by saying he did not want to speak. Interview on 05/17/2026 at 11:14 a.m., LVN-D stated he saw one piece of cake, one sandwich, and one cup of milk inside Resident #11's refrigerator in the resident's room. He said there were no dates on the food, so he did not know how long the foods had been inside the refrigerator. LVN-D said the facility nurse should have checked the food when they checked the resident's refrigerator's temperature and should have written a label and date on the food to prevent possible food illness. 2. Record review of Resident #43's face sheet, dated 05/20/2026, revealed the resident was a 73-years-old female and admitted to the facility on [DATE] with diagnosis of fracture of upper end of left humerus (fracture to left shoulder), conversion disorder (psychiatric condition in which the body's emotional and psychological stressors are converted to physical symptoms that cannot be explained by a neurological or medical condition), and hypertension (high blood pressures). Record review of Resident #43's admission MDS assessment, dated 4/30/2026, revealed the resident's BIMS score was 14 out of 15 which indicated the resident's cognitive was intact, and she required Setup or clean-up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) to eating. Record review of Resident #43's comprehensive care plan, dated 05/03/2026, revealed [Resident #43] has potential for a nutritional problem related to weakness. For intervention - Diet as ordered by the physician. REGULAR diet, REGULAR texture, THIN LIQUIDS consistency and Provide, serve diet as ordered. Monitor intake and record every meal. Observation on 05/17/2026 at 10:24 a.m. revealed there was a small refrigerator inside Resident #43's room, and ice cream was melting inside the refrigerator, instead of freezer area, and no date on the ice cream. Interview on 05/17/2026 at 10:25 a.m., Resident #43 said she did not know when and how the ice cream was on the refrigerator. Interview on 05/17/2026 at 11:28 a.m. with RN-C stated she saw the ice cream melting inside the refrigerator, instead of freezer area inside Resident #43's refrigerator in the resident's room. but no date on the ice cream, so the nurse did not know how long the ice cream was inside the refrigerator. The RN-C said the facility nurse should have checked food when they checked the resident's refrigerator's temperature and should have written labels and date on the food to prevent possible food illness. Interview on 05/20/2026 at 11:43 a.m. with the DON said the facility nurse should have checked foods and written labels and dates on the foods to prevent possible food illness per the facility policy. Record review of the facility policy, titled Resident Personal Food Storage, review date 04/2025, revealed Food or beverage in from outside sources for storage in facility pantries, refrigeration units, or personal/resident room refrigeration units will be monitored by designated facility staff for food safety.5. Resident and individuals bring food in from outside sources will be educated on safe food handling and storage techniques by designated facility staff as needed.

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 (200 /300-hall Nurse Cart) of 6 medication carts and 1 (Resident #123) of 28 residents reviewed for storage and medication carts. 1. The narcotic box inside 200 and 300-hall nursing cart was totally taken out from the cart without affixing permanently to the cart. 2. There were two bottles of Curad Plain Packing Strip for wound care (it used for boils, abscess, or other draining wounds) on the resident's nightstand unattended. This failure could place residents at risk of misappropriation of medications and using packing strip for wound care to different purpose, such as eating it. The findings were:1. Observation on 05/18/2026 at 2:30 p.m. revealed one narcotic box inside 200 /300-hall Nursing Cart, that was not permanently affixed to the cart. The narcotic box was taken out of the cart by the surveyor. Further observation revealed there were 13 narcotic blister packs inside the box. Interview on 05/18/2026 at 2:31 p.m. with LVN-B stated the narcotic box inside the 200/300-hall Nursing Cart should have been affixed to the cart permanently. She said the box was not secured and somebody might be able to take the box from the cart. She said it could cause drug diversion because the box had a total of 13 narcotic blister packs inside it. Interview on 05/18/2026 at 11:43 a.m., the DON said all narcotic boxes should have been affixed to the carts permanently to prevent possible drug diversion. 2. Record review of Resident #123's face sheet, dated 05/20/2026, revealed the resident was a 71-years-old male and admitted to the facility on [DATE] with diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own), malignant neoplasm of colon (cancer to colon or rectum), and ileostomy status (an opening on the abdomen that connects the last part of the small intestine to the outside of the body). Record review of Resident #123's admission MDS assessment revealed that the MDS assessment was in progress on 05/20/2026 because the resident was admitted to the facility on [DATE]. Observation on 05/17/2026 at 10:45 a.m. revealed Resident #123 was sleeping on the bed, and there were two bottles of Curad Plain Packing Strip for wound care (it used for boils, abscess, or other draining wounds) on the resident's nightstand unattended. Interview on 05/17/2026 at 10:47 a.m. Resident #123 refused to interview the surveyor and kept sleeping on the bed. Interview on 05/17/2026 at 11:22 a.m. with RN-C stated she saw two bottles of Curad Plain Packing Strip for wound care on Resident #123's nightstand unattended. The RN-C said she did not know the reason they were on the resident's nightstand unattended, and all medications should have been stored inside medication carts for safety because the resident might use it incorrectly. Interview on 05/20/2026 at 11:43 a.m. with the DON said all medications including Curad Plain Packing Strip for wound care should have been stored inside medication carts for safety because some confused residents might use it incorrectly. Record review of the facility policy, titled Medication Access and Storage, undated, revealed . 2. Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medication (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 7. Scheduled III and IV controlled medications are stored separately from the other medications in a locked drawer or compartment designated for that purpose. Alternatively, Schedule III-V medications may be stored in the trays with the other medications. Schedule II medications are stored in a separated area under double lock. Reconciliation of controlled medication are done at least every shift by the incoming and outgoing licensed nurses at change of shifts.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #123) of 4 residents reviewed for baseline care plans. The facility failed to include Resident #123's ileostomy care, oxygen care, and wound care in his baseline care plan. This failure could result in residents not receiving needed care and treatment. Findings Included:Record review of Resident #123's face sheet, dated 05/20/2026, revealed the resident was a 71-years-old male and admitted to the facility on [DATE] with diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own), malignant neoplasm of colon (cancer to colon or rectum), and ileostomy status (an opening on the abdomen that connects the last part of the small intestine to the outside of the body). Record review of Resident #123's admission MDS assessment revealed that the MDS assessment was in progress on 05/20/2026 because the resident was admitted to the facility on [DATE]. Record review of Resident #123's physician orders, dated 05/15/2026, revealed the resident had the orders of monitor ileostomy and provide ileostomy care every shift, oxygen at 3 liters per minutes via nasal cannular continues for chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), and Right Groin: Cleanse with wound cleanser and pat dry - Place plurogel (unique burn and wound dressing to protect the wound and soften wound debris) to wound bed and cover with calcium alginate and secure with bordered foam dressing twice weekly on Tuesday and Friday. Record review of Resident #123's baseline care plan, dated 05/17/2026, revealed that the baseline care plan did not include the resident's care plans regarding ileostomy, oxygen, and wound. Observation on 05/17/2026 at 10:45 a.m. revealed Resident #123 was sleeping on the bed and had oxygen at 3 liters per minute via a nasal cannular, ileostomy bag on the abdomen area, and dressing dated 05/19/2026 to the right groin area. Interview on 05/20/2026 at 9:31 a.m., the MDS nurse said Resident #123 was admitted to the facility on [DATE] with ileostomy, oxygen and wound, and the facility provided ileostomy care, oxygen care, and wound care as ordered, but there were no baseline care plans regarding the resident's ileostomy, oxygen and wound. The MDS nurse stated making baseline care plans was the Registered Nurse's responsibility, including DON, and she did not know the reason the Registered Nurses did not develop the care plans. Interview on 05/20/2026 at 9:51 a.m., the DON said she should have developed Resident #123's baseline care plans regarding his ileostomy, oxygen and wound because the resident was admitted to the facility with them. She said the resident received care as ordered and did not have any adverse effect. She said the team might not have full knowledge regarding the resident's ileostomy, oxygen and wound status, and it could result in inappropriate care to the resident. Record review of the facility policy, titled Comprehensive Person-Centered Care Planning, undated, revealed 1. The facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 6 medication carts (200/300-hall medication aide cart) reviewed for pharmacy services. The facility failed to ensure one bottle of medication (Simethicone 125 mg for gas relief) that expired on 03/2026 was not on 200 and 300-hall medication aide cart on 05/18/2026. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects. The findings included: Observation on 05/18/2026 at 2:44 p.m. revealed one bottle of Simethicone 125 mg for gas relief was found inside the 200 and 300-hall medication aide cart, and it expired 03/2026. Interview on 05/18/2026 at 2:45 p.m., LVN-B stated one bottle of Simethicone for gas relief was found inside the 200 and 300-hall medication aide cart, and it expired 03/2026. The LVN-B said she did not know the reason expired medication was inside the medication aide cart used for 200 and 300-hall. She said nurses and medication aides should discard all expired medications from the carts as per the facility policy. She said the potential harm was if nurses or medication aide used the expired medication, the expired medication might not have therapeutic effects. Interview on 05/20/2026 at 11:43 a.m. with the DON said facility nurses or medication aides should discard all expired medications from the medication carts. Nurses or medication aides had responsibility to make sure all expired medications should have been removed from carts, and if nurses or medication aide might use the expired medication, residents who took the medication might not have gas relief. Record review of the facility policy, titled Medication Access and Storage, undated, revealed . 11. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exist.

Based on observations, interviews, and record review the facility failed to ensure all drugs and biologicals were locked in compartments under proper temperature controls and permitted only authorized personnel to have access to the keys, for 1 of 6 medication carts (the 400-hall medication cart) reviewed for security. LVN B left the 400-hall medication cart unsupervised, unattended, and unlocked for more than 9 minutes on 4/28/2026. This failure could place residents at risk for misappropriation of property and or not receiving the therapeutic effects of their medications.The findings include: During an observation and interview on 4/28/2026 at 9:10 AM, revealed the 400-hall with a medication cart positioned at the beginning of the hall. The medication cart was unattended, unsupervised, and unlocked. Continued observation revealed 2 staff walked by the unlocked medication cart, without recognizing the cart was unlocked. Residents were observed ambulating the facility, including the 400-hall. The State Surveyor intervened and alerted LVN A. LVN A stated the medication cart was the 400-hall medication cart and was assigned to LVN B. LVN A stated the cart housed residents' injectable insulin and oral medications. During an interview on 4/28/2026 at 10:15 AM, the DON stated her expectation and nurse training was for nurses to lock their medication carts when the cart was not in use. The DON stated the potential negative outcome could be uncontrolled medications. A record review of the facility's undated Medication Administration and General Guidelines policy revealed, Medications are administered as prescribed, in accordance with state regulations using good nursing principles and practices and only by persons legally authorized to do so. procedure: . when administering as needed medications at times other than medication pass, the dose may be prepared in the medication cart storage area and taken to the residence bedside, leaving the cart locked and secured.

Based on observation, interview and record review, the facility failed to provide food that was palatable to meet the needs of each resident for 3 of 5 residents (Resident #2, #3 and #4), reviewed for Dining services in that:The facility failed to provide food that was palatable in that residents were given burnt food during meal. This failure could place residents who ate foods from the kitchen at risk of a diminished quality of life. Findings included: 1.Record review of Resident #2's admission Record dated 9/10/2025 revealed she was admitted on [DATE] with diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia (difficulty or discomfort in swallowing), Apraxia following a cerebral infarction (a neurological disorder that affects a person's ability to plan and execute skilled movements, despite having normal muscle strength and coordination), Aphasia following a cerebral infarction (a language disorder caused by damage to the brain areas responsible for language processing), lack of coordination, cognitive communication deficit, and need for assistance with personal care. Record review of Resident #2's consolidated orders for August 2025 was documented she was on a regular diet texture with fortified meal plan at all times. Record review of Resident #2's Quarterly MDS (minimum Data Set) dated 9/4/2025 was documented with a BIMs score of 15/15 (cognitively intact), ADL for eating she was set-up or lean -up assistance, no swallowing issues at time of assessment. Record review of Resident #2's Care Plan dated 7/3/2025 ADL was documented self-care performance deficit related to weakness, hemiparesis and apraxia. This included the intervention for eating was independent with assistance with set-up. Observation on 9/9/2025 at 12:14 PM in the Dining room revealed Resident #2 was sitting down and eating her lunch and had an Italian roll burned at the bottom.Interview on 9/9/2025 at 12:15 PM in the Dining room Resident #2 stated she was not going to eat the Italian bread because it was burned at the bottom. 2. Record review of Resident #3's admission Record dated 9/10/2025 with admission record of 12/30/2023 with diagnoses of Dementia (group of conditions that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment.), Diabetes II (a condition characterized by high blood sugar levels (hyperglycemia) caused by an inability of the body to produce or effectively use insulin, a hormone that regulates blood sugar), Alzheimer's Disease ( progressive neurodegenerative disease that primarily affects memory, thinking, and behavior), and cognitive communication deficit. Record review of Resident #3's consolidated orders for September 2025 was documented Regular diet texture. Record review of Resident #3's Quarterly MDS dated [DATE] was documented her BIMS score was 3/15 (severely cognitively impaired), and she was independent with eating. Record review of Resident #3's Care Plan dated 6/6/2025 was documented ADL eating was the resident was independent. Observation on 9/9/2025 at 12:16 PM in the Dining room revealed Resident #3 was sitting down and [NAME] her lunch and had an Italian roll burned at the bottom. Interview on 9/9/2025 at 12:17 PM in the Dining room with Resident #3 stated she was not going to eat the Italian bread because it was burned at the bottom. 3. Record review of Resident #4's admission Record dated 9/10/2025 was documented he was admitted on 7/12024 with diagnoses of Muscular Dystrophy (a group of genetic disorders that cause progressive muscle weakness and loss. contracture to multiple sites, muscle weakness (difficulty swallowing, involves trouble moving food or liquid from the mouth to the stomach), cognitive communications deficit, and need for assistance with personal care. Record review of Resident #4's consolidated orders for September 2025 was documented he had a regular diet. Record review of Resident #4's Quarterly MDS dated [DATE] was documented BIMS score 15/15 (cognitively intact), and ADL for eating was independent. Record review of Resident #4's Care Plan dated 8/18/2025 was documented for eating he required a tray set up assistance and supervision for meals. Observation on 9/9/2025 at 12:18 PM in the Dining room revealed Resident # 4 was sitting down and [NAME] his lunch and had the alternate hamburger, the bread was not burned. Interview on 9/9/2025 at 12:19 PM in the Dining room Resident #4 stated the residents often have burned food and does not eat it or ask for an alternative. Interview on 9/10/2025 at 2:39 PM DON had no response when discussed the bread was burned at bottom for lunch. Interview on 9/10/2025 at 2:44 PM FSM stated she did help the cook with the lunch meal but did not see any burned bread or get complaints. Policy requested from Administrator on 09/10/2025, Administrator provided surveyor with Texas Food Establishment Rules, dated August 2021

Based on interview and record review the facility failed to implement COVID-19 immunizations policies and procedures to ensure that resident's medical record includes documentation that indicates that the resident or resident representative was offered provided education regarding the benefits and potential risks associated with COVID-19 vaccine for 1 of 5 (#1) residents reviewed for COVID-19 vaccination status in that:The facility failed to provide documentation that Residents #1 had received education regarding the benefits and potential risks associated with COVID-19 vaccine.These failures placed residents at risk for not being informed/educated about immunization and decline in health status. infections, the transmission of infectious disease, and a decline in health status. Findings included: Record review of Resident #1's admission Record was documented she was admitted on [DATE], re-admit date [DATE] with diagnoses of heart failure, acute respiratory failure, dementia, cognitive communication deficit, and need for personal assistance.Record review of Resident #1's consolidated orders for September 2025 documented she had a personal history of COVID-19.Record review of Resident #1's Quarterly MDS dated [DATE] documented BIMS score was 12/15 (moderately cognitive impairment), ADL was documented was independent for eating.Record review of Resident #1's Care Plan dated 8/6/2025 documented no care plan for the COVID-19 vaccination.Record review of Resident #1's consent form dated 10/4/2024 documented, her responsible party signed a consent for the COVID-19 Vaccine. Record review of Resident #1's neurologist visit dated 8/27/2025 documented in 2021, she was in the hospital with COVID-19.Record review of Resident #1's chart documented she received her last COVID-19 vaccination on 12/22/2023. Interview on 9/10/2025 at 11:34 AM the RP for Resident #1 stated she had consented for Resident #1 to have a CVOID-19 vaccination, and the facility had not provided this to her. Interview on 9/10/2025 at 5:45 PM the DON stated the resident should have been offered a COVID-19 vaccine yearly with a consent form. Interview on 9/10/2025 at 6:02 PM with RN A, who was the previous ADON, stated she was not sure they were still administering COVID-19 vaccines for residents. No Covid-19 vaccine was provided to Resident #1. Interview on 9/10/2025 at 7 :30 PM with ADM stated, if the family/residents provided consent the facility will provide a COVID vaccination to the resident.Record review of policy, COVID-19, no date was documented It is the policy of this facility to ensure that: When COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized per the CDC recommendations. Before offering COVID-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. The resident, resident representative, or staff member has the opportunity to accept or refuse a COVID-19 vaccine and change their decision. The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and PURPOSE: To minimize the risk of residents acquiring, transmitting, or experiencing complications from COVID-19 by ensuring that each resident: Is informed about the benefits and risks of immunization. Has the opportunity to receive, unless medically contraindicated or refused or already immunized, the COVID-19 vaccine. Offering vaccinations: The facility will offer residents and staff vaccination against COVID-19 when vaccine supplies are available to the facility through the facility's pharmacy partner. If the resident' resident representative consented to the vaccine, a physician's order will be obtained for the COVID-19 vaccine. For residents who receive vaccination, the following information will be documented in the resident's electronic health record: The date of vaccination Lot number, Expiration date, Site of vaccination, Name of person administering the vaccine.

Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #43), reviewed for pharmacy services. The facility did not have Resident #43's ordered PRN (as needed) hydrocodone (pain medication) available for 9 days from his admission on 2/28/25 to his discharge on 3/8/25. This failure could place the residents at risk of pain and not receiving needed care and services. The findings were: Record review of Resident #43's face sheet dated 3/26/25 revealed the resident was a [AGE] year-old male admitted to the facility on [DATE], discharged to the hospital on 2/18/25 and readmitted on [DATE]. His diagnoses included metabolic encephalopathy (diffuse disease of the brain that alters brain function or structure caused by metabolic changes due to underlying health conditions), acute pulmonary edema (a condition caused by excess fluid in the lungs. This fluid collects in the numerous air sacs in the lungs, making it difficult to breathe), pressure ulcer of sacral region stage III (localized skin and soft tissue injuries that develop due to prolonged pressure exerted over specific areas of the body, typically bony prominences, Stage III=A full-thickness loss of skin extends to the subcutaneous tissue but does not cross the fascia beneath it). The resident was discharged on [DATE]. Record review of Resident #43's annual MDS assessment dated [DATE] revealed the resident had a BIMS of 8 out of 15 indicating the resident was moderately cognitively impaired. The resident did not receive scheduled pain medication but did receive PRN pain medication for occasional pain and had pain intensity at a level of 5 and it interfered with his sleep, and day to day activities rarely or not at all. Record review of Resident #43's 5-day scheduled MDS assessment dated [DATE] revealed the resident had a BIMS of 8 out of 15 indicating the resident was moderately cognitively impaired. The resident did not receive scheduled pain medication and had not received PRN pain medications. The resident had received non medication interventions for pain but had no pain. The rest of the pain questions were blank. Record review of Resident #43's undated care plan did not have a focus or interventions for pain. Record review of Resident #43's physician orders revealed an order with a start date of 2/28/25 and a discontinue date of 3/10/25 for hydrocodone-acetaminophen 10-325 mg (milligram) give 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident #43's physician orders revealed an order with a start date of 2/28/25 and a discontinue date of 3/10/25 for acetaminophen 650mg by mouth every 6 hours as needed for pain. Record review of Resident #43's EMAR for February 2025 revealed on 2/28/25, the resident received a non-pharmacological intervention for pain of a code 2, which indicated rest. Record review of Resident #43's EMAR for March 2025 revealed the resident received a non-pharmacological intervention for pain of a code 2, which indicated rest on 3/1/25, and 3/2/25 for day, evening, and night shifts. Record review of Resident #43's EMAR for March 2025 revealed on 3/7/25 at 3:23 p.m. the resident received acetaminophen 650mg for a pain level of 4 and was effective. The resident also received this same dose on 3/8/25 at 10:24 a.m. for a pain level of 2 and was effective. Record review of Resident #43's EMAR for March 2025 revealed no hydrocodone was administered to the resident for the month of March 2025. Record review of Resident #43's EMAR for February of 2025 during his previous stay at the facility from 2/11/25 to 2/18/25 the resident received the same dose of hydrocodone on 2/12/25 at 11:36 a.m. for a pain level of 5 that was effective and again on 2/15/25 at 8:25 p.m. for a pain level of 8 that was effective. Record review of Resident #43's progress notes revealed a nursing note dated 3/8/25 at 2:27 p.m. by RN A Authorization to pull prn medication denied due to no active script of file at pharmacy. MD to be made aware. Record review of Resident #43's progress notes revealed a nursing note dated 3/8/25 at 5:16 p.m. by RN A the resident's physician had been notified the PRN medication was not delivered and the physician had sent the prescription to the pharmacy. In an anonymous interview it was stated Resident #43 was observed to be in pain on 3/8/25 and was moaning and groaning and hydrocodone was requested from RN A. It was stated RN A medicated the resident and when Resident #43 asked what the medication was RN A answered it was Tylenol (acetaminophen) and the resident took it. When questioned about the hydrocodone because they felt the resident needed something stronger than acetaminophen RN A stated the facility did not have any hydrocodone for Resident #43 and had run out. In an interview on 3/28/25 at 9:31 a.m. RN A stated he remembered Resident #43 and on 3/8/25 a family member was requesting the resident's ordered hydrocodone pain medication for the resident and there was no hydrocodone for the resident. RN A stated he attempted to pull the hydrocodone from the emergency kit and it was denied due to no prescription on file with the pharmacy. RN A stated he called the pharmacy to find out what was going on and the pharmacy told RN A they did not have an active prescription for the resident's hydrocodone. RN A stated he immediately called the physician directly and the physician had informed RN A that he had sent the electronic prescription to the pharmacy many times and would send again. RN A stated there had been issues during the week with the same thing and he had overheard LVN B attempting to get Resident #43's hydrocodone during the weekday the previous week. RN A stated he called the pharmacy again and there was no prescription per the pharmacy. RN A stated he called the physician again and the physician sent RN A proof that he had sent it to the pharmacy. RN A then called the pharmacy again and it was determined that it had not gone to the right place within the pharmacy and the physician was notified and sent it to the correct place. RN A stated he verified with the pharmacy they had received it and were entering it and he would be able to pull it from the emergency kit soon. RN A stated the resident was sleeping and did not appear to be in pain, and he was not noted to be moaning and groaning except when turning the resident and he gave the resident Tylenol while waiting, but the family was getting frustrated. The resident was sent to the hospital for evaluation at the family's request prior to giving the pain medication. RN A stated the resident's previous hydrocodone was not on site at the facility and he was unsure why. In an interview on 3/28/25 at 1:59 p.m. LVN B stated he remembered Resident #43 and had notified the Dr. about the pharmacy stating they did not have the hydrocodone prescription several times but unsure of the dates and times. LVN B stated he checked the facility discontinued medications for Resident #43's previous hydrocodone stock but the previous hydrocodone had been turned in and destroyed during the pharmacist visit while the resident was in the hospital. LVN B stated the resident did not complain of pain during that time but LVN B continued to attempt to get the hydrocodone to the facility as it was ordered. LVN B stated the resident worked with therapy and never complained of pain nor did his assessment indicate pain. LVN B stated different physicians have different protocols and for Resident #43, the nurses were to contact his physician directly and the physician was sending the prescription each time and it ended up being an error. LVN B stated he was unsure if the prescription went to the wrong pharmacy or it was an electronic submission error. LVN B stated the resident would only moan or groan when turned or repositioned but not like he was in pain. In an interview on 3/28/25 at 4:20 p.m. MD P stated he did not feel the resident was harmed due to not having his hydrocodone. MD P stated he had cared for the resident since his long-term acute care hospital stay prior to his admission to the facility and he had examined him at the facility on his last admission and his assessment did not reveal the resident was in any pain. In an interview on 3/28/25 at 4:45 p.m. the DON stated if a medication were not available for a resident the expectation was the nurse would notify the physician as soon as possible whether it was a new order or a reordered medication. The DON stated the nurse should call the pharmacy and try to find out what happened to the medication delivery and notify the physician. The DON stated the possible consequences of a resident not having their PRN pain medication available would be the resident could have pain. Review of the facility policy on pharmaceutical services reviewed 12/2024, under policy was It is the policy of this facility to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of each resident. And under procedures was The pharmacist, in collaboration with the facility and the medical director helps develop and evaluate the implementation of pharmaceutical services procedures that address the needs of the residents, are consistent with state and federal requirements and reflect current standards of practice.

44020 Based on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 3 of 6 residents (Residents #76, #85 and #252) were reviewed for respiratory care. 1. Nursing staff failed to clean the oxygen concentrator regularly for Resident #76. 2. Nursing staff failed to clean the oxygen concentrator regularly for Resident #85. 3. Facility failed to ensure Resident #252 had physician orders for oxygen that was observed being used on 03/25/2025 and 03/26/2025. This failure could place residents at risk of illness and respiratory complications. Findings included: 1. Review of Resident #76's face sheet, dated 3/28/25, revealed he was admitted to the facility on [DATE] with a primary diagnosis of Encounter for surgical aftercare following surgery on the digestive system. Review of Resident #76's consolidated physician orders for March 2025 revealed an order for O2 AT 2-4 L/MIN CONTINUOUS PER NC every shift Active 02/21/2025. Review of Resident #76's MDS assessment, dated 2/2/25, revealed Resident #76 was receiving oxygen therapy. Review of Resident #76's Care Plan, initiated on 2/10/25, read Resident #76 has Oxygen Therapy r/t COPD, ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPERCAPINA, ACUTE RESPIRATORY FAILURE WITH HYPOXIA, ASTHMA, CHRONIC PULMONARY EDEMA. Interventions included CHANGE O2 TUBING & HUMIDIFIER BOTTLE every night shift every. Thursday for maintenance. Observation on 03/27/25 at 02:50 PM revealed Resident #76 lying in bed; he woke up as soon as knocked on the door. Further observation revealed Resident #76 was receiving oxygen at 2 liters per minute. The oxygen concentrator was full of white dust all over including on the vent port where the filter was placed. Interview on 03/27/25 at 03:20 PM with LVN B revealed night staff would change the tubing/humidifier on the oxygen concentrators. He stated nursing staff should also clean the filter and concentrator casing to keep Resident #76 from inhaling dust particles which could cause an infection. Observation and interview on 03/27/25 at 03:27 PM reveled Resident #76 receiving oxygen at 2 liters per minute via nasal cannula. Interview with LVN I commented, oh yeah it's dirty. She stated the filter was inside behind the vent port and stated dirt could be circulated inside the concentrator and cause Resident #76 an infection or have other respiratory problems. 2. Review of Resident #85's face sheet, dated 3/27/25, reviewed she was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure with Hypercapnia (according to Mayo clinic, Respiratory failure is a condition where you don ' t have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia) and Chronic Pulmonary Edema (according to Mayo clinic, condition caused by too much fluid in the lungs). Review of Resident #85's consolidated physician orders for March 2025 revealed an order, O2 AT 2-4L/MIN CONTINUOUS PER NC every shift Active 1/31/2025. Review of Resident #85's admission MDS, dated [DATE], revealed Resident's BIMS was 15 of 15 indicating no cognitive impairment. Review of Resident #85's Care Plan initiated on 2/4/25, revealed she used Oxygen Therapy r/t Respiratory illness. One of the interventions included CHANGE O2 TUBING & HUMIDIFIER BOTTLE every night shift every. Thursday for maintenance. Observation on 03/25/25 at 10:22 AM revealed a black oxygen concentrator between A bed and the nightstand. It was full of dust. Observation and interview on 03/26/25 at 10:59 AM revealed Resident #85 lying in bed with oxygen infusing at 2 liters per minute via nasal cannula. Resident #85's family member stated he saw staff coming in periodically to check on the concentrator. Observation and interview on 03/26/25 at 11:28 AM revealed 02 concentrator with white speckles all over it including around the outer vent portal containing the filter Observation and interview on 03/27/25 at 03:25 PM with LVN I revealed she was wiping Resident #85's concentrator down. She stated it was very dusty. LVN I stated the filter was inside behind the vent portal and stated dirt could be circulated inside the concentrator and cause Resident #85 an infection or to have other respiratory problems. Interview on 03/28/25 at 12:30 PM with the DON revealed nursing staff was supposed to clean the filter and the concentrator casing to keep dust from building up. She stated she was not sure if they would clean the filter if it was located within the concentrator. She stated the company who they rented the concentrators from might service them, but did not know if they had serviced them. The DON stated it was important to keep the filter and the casing clean so the residents did not inhale dust or other contaminants because the residents could get an infection or it could cause other respiratory complications. The DON stated she was also aware the physician orders and care plans did not include to clean the filter and the oxygen casing but both should include the cleaning of the items. 3. Record review of Resident #252's face sheet, dated 03/25/2025, revealed Resident #252 was admitted on [DATE] with a diagnosis of shortness of breath. Record review of Resident #252's Admission MDS, dated [DATE], was still in progress. Record review of Resident #252's IDT-BIMS dated 03/18/2025, revealed Resident #252's BIMS score was 08 for moderately cognitive impairment. Record review of Resident #252's undated care plan revealed no focus or interventions for oxygen therapy. Record review of Resident #252's physician order summary report, dated 03/25/2025, revealed no orders for oxygen use. Record review of Resident #252's nurse practitioner notes, dated 03/18/2025, read Initial History and Physical, Interval: Nurse reports concerns for drowsiness and low oxygen. Patient initially wakes for short period on exam, answering minimal questions. Oxygen sat 99% on exam, 2L O2 in place. Record review for Resident #252's electronic health record revealed under weights & vitals it was documented Resident #252 was wearing oxygen on 03/24/2025 at 9:27 a.m., 03/24/2025 at 2:17 p.m., 03/25/2025 at 2:00 p.m., and on 03/26/2025 at 2:53 p.m. by unknown nurse. Observation and interview on 03/25/2025 at 11:06 a.m. revealed Resident #252 lying in bed with oxygen on and nasal cannula off to the right side of his nose. He stated it moves around and they always come and fix it fussing over it. Resident #252's oxygen concentrator was set at 2.5 liters with tubing dated 03/21/2025. Observation and interview on 03/26/2025 at 3:19 p.m. revealed Resident #252 lying in bed with the head of his bed elevated, oxygen nasal cannula to the side of left side of his head on the bed, and concentrator set at 2.5 liters. Resident #252 denied any trouble breathing and did not seem to be in distress. Interview and observation on 03/26/2025 at 3:26 p.m. LVN E stated Resident #252's oxygen was PRN. LVN E further stated Resident #252 would let them know when he needed the oxygen and believed it was to be set at 2 liters or 2.5 liters. LVN E then proceeded to turn off the concentrator as she spoke. LVN E was observed using a pulse-ox (a non-invasive medical procedure that measures the oxygen saturation of the blood) and stated Resident #252's hands were really cold and was not getting a reading on the pulse-ox. LVN E asked Resident #252 if he was breathing okay and if he was cold of which he stated he was fine. LVN E reviewed of Resident #252's orders at her medication cart. LVN E revealed resident did not have an order for his oxygen. LVN E stated Resident #252 was usually in the high 90's for her when she would check his oxygen saturations and had not had to use the oxygen during her shift. LVN E further stated usually the orders would read to start oxygen at 2 liters and to administer below 91 or 92 depending on the physician. LVN E stated she would have to contact the physician prior to administering oxygen if his oxygen saturations were low. During an interview on 03/26/2025 at 3:48 p.m. the DON revealed Resident #252 did not have orders for oxygen and he should have had them as it had been used. The DON stated orders gave structure on how to administer, and the liters that should be used. The DON further stated nursing would start oxygen, then call the physician if a resident needed oxygen and would get a clarification order. The DON stated she believed Resident #252 had a change and that he was also tested Flu at the time the oxygen was started, however she was not sure. Observation on 03/27/2025 at 2:22 p.m. revealed Resident #252's oxygen concentrator had been removed from his room. During an interview on 03/27/2025 at 3:45 p.m. the DON stated the oxygen was removed yesterday from resident's room after an assessment was performed revealing Resident #252 did not want the oxygen and he was not hypoxic. During an interview on 03/28/2025 5:09 p.m. the administrator stated the nurses were responsible for getting the orders for oxygen as soon as there was change or it was needed. Record review of facility's policy titled Oxygen Administration, revised 01/2025, read Policy: It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. Review of an oxygen manual which Resident #76 and Resident #85 used read in relevant part Caring for your [name] oxygen concentrator. Filter door with vents. Inspect the vents periodically and wipe with a dry cloth as needed to remove dust. Service and maintenance should only be performed by appropriately trained and authorized [name] personnel and/or service centers.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure dietary staff used proper hand placement and hand hygiene during plate preparation. The facility failed to ensure a divided plate was properly dried prior to serving a grilled cheese sandwich in it. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: Observation on 03/25/2025 at 11:47 a.m. revealed [NAME] F washing hands prior to the meal service, however, [NAME] F, proceeded to review the diet tickets, handling diet tickets as he reviewed and then began to prepare resident plates. While serving [NAME] F would reach for the souffle bowls, grabbing the bowls by placing thumb or fingers on the inner side of the bowl. [NAME] F was further observed to grab divided plates and placed thumb or fingers inside a section of the plate while picking up the plate. [NAME] F was then observed placing the diet tickets on top of the serving bar next to the plates for the dietary aide to place on trays between servings. During an interview on 03/26/2025 at 11:55 a.m. the dietary supervisor stated the meal tickets would not be considered a clean item when handling them prior to serving. The dietary supervisor further stated the cook placing his fingers in the bowls or plates could cause cross contamination. During an interview on 03/26/2025 at 12:02 p.m. [NAME] F stated by placing fingers or thumbs in the bowls or plates was not clean. [NAME] F further stated by doing this could affect residents by putting them at risk of getting sick. Observation on 03/27/2025 at 12:13 p.m. revealed during plate preparation and tray service a divided plate sitting in an insulated base, on top of the plate warmer, with water droplets and pooling of water in the different sections of the divided plate. The dietary supervisor was observed placing a grilled cheese sandwich in the divided plate that had not air dried properly and then the plate was placed on a tray. Observation and interview on 03/27/2025 at 12:17 p.m. trays were observed leaving the kitchen and tray cart followed to the dining room, grilled cheese sandwich served in the dining room. Resident was observed eating the sandwich with no voiced concerns. The dietary resource was present when cover was removed and identified the divided plate had not fully been dried prior to being used. Dietary resource stated the kitchen air dries all dishes. During an interview on 03/27/2025 at 2:25 p.m. the dietary resource stated the divided dish by not having been dried fully and having been served with standing drops of water could cause cross contamination. The dietary resource further stated it could make residents very sick. The dietary resource stated the plate should have been pulled once the liquid was seen and not served. The dietary resource stated she was too focused on checking other divided plates in the kitchen and did not take the plate that was served. During an interview on 03/27/2025 at 2:31 p.m. the dietary supervisor stated he did not notice the water in the divided plate when he served the grilled cheese sandwich but stated it could cause cross contamination. The dietary supervisor further stated the dishes are air dried. During an interview on 03/28/2025 at 4:59 p.m. the DON stated there was the potential of cross contamination of food by dishes not being dried thoroughly. The DON further stated it could have the potential for causing infections. The DON stated she felt it would be multiple people's responsibility to not serve food on improperly dried plates if it was not caught in the kitchen the other staff should catch in passing of trays. During an interview on 03/28/2025 at 5:11 p.m. the administrator stated residents could get sick if there was cross contamination from not properly handling the dishes. The administrator further stated the dietary supervisor was responsible to ensure dishes were air dried and even the cook on duty was responsible. Review of facility's policy Handling Clean Equipment and Utensils, not dated, read Policy: Clean equipment and utensils will be handled properly to prevent contamination. Procedure: 1. When handling cleaned and sanitized equipment, staff will avoid touching the parts that will come in contact with the food. Review of facility's policy Cleaning Dishes/Dish Machine, not dated, read Policy: All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use .Procedures: 9. Dishes should be air dried on the dish racks .10. Inspect for cleanliness and dryness and put dishes away if clean. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-301.14, When to Wash, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTNESILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks;.

Based on observation, interview and record review the facility failed to assess the resident for risk of entrapment from bed rails prior to installation; review the risks and benefits of bed rails with the resident or resident representative for 2 of 8 residents (Resident #85 and Resident 95) whose records were reviewed. Nursing staff failed to assess Resident #85 and Resident #95 for the use of side rails, discuss the risks versus benefits of using side rails with the resident and or representative upon admission. This deficient practice could affect residents who used side rails and could contribute to avoidable injuries. The findings were: 1. Review of Resident #85's face sheet, dated 3/27/25, reviewed she was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure with Hypercapnia (according to Mayo clinic, Respiratory failure is a condition where you don ' t have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia). and Chronic Pulmonary Edema (according to Mayo clinic, condition caused by too much fluid in the lungs). Review of Resident #85's consolidated physician orders for March 2025 revealed an order, MAY USE 1/4 BILATERAL MOBILITY BARS TO AIDE IN EASY TURNING & REPOSITIONING WHILE IN BED. Review of Resident #85's assessments revealed there was not an assessment for the use of side rails or any documentation to support nursing staff discussed the risks versus the benefits of using the side rails. Review of annual MDS, dated [DATE], revealed Resident's BIMS was 15 of 15 indicating no cognitive impairment. Review of Resident's CP, revised on 2/13/25, revealed there was no indication she used a SR for repositioning and mobility. Interview on 03/27/25 at 03:53 PM MDS Coordinator/LVN G revealed there was not an assessment for the use of side rails for Resident #85. Interview on 03/28/25 at 12:30 PM with the DON revealed nursing staff was required to, conduct an assessment, to explain the benefits versus the risks of using the side rails and to obtain a consent for the use of side rails from a resident or family representative upon admission or at the time the side rails would be used for repositioning and or bed mobility. She stated it was important to determine whether a resident could safely use the side rails to avoid any accidents or injuries. 2. Review of Resident #95's face sheet, dated 3/28/25, revealed he was admitted to the facility on [DATE] with diagnoses including Encephalopathy (according to Mayo Clinic, is a general term describing a disease that affects the function or structure of your brain), Respiratory Failure and Sepsis (according to Mayo clinic, is a serious condition in which the body responds improperly to an infection). Review of Resident #95's admission MDS assessment, dated 2/19/25, revealed his BIMS score was 8 reflective of moderate cognitive impairment. Review of Resident #95's Care Plan, revised on 2/28/25, read Resident #95 has an ADL Self Care Performance Deficit r/t weakness. One of the interventions included Utilizes mobility bars as an enabler in Bed Mobility. Review of physician orders for March 2025 revealed an order for MAY USE 1/4 MOBILITY BARS TO AIDE IN EASY TURNING &REPOSITIONING WHILE IN BED every shift Phone Active 02/15/2025. Observation and interview on 03/25/25 at 10:00 AM revealed Resident #95 was lying in bed with quarter side rails up on both sides of the bed. Observation and interview on 03/27/25 at 03:00 PM revealed Resident #95 sitting in a wheelchair with 1/4 side rails up on both sides of the bed. Resident #95 stated used side rails to lean his back on them so could lie at an angle. Resident #95 stated he did not remember anyone talking to him about the side rails. Interview on 03/28/25 at 12:30 PM with the DON revealed nursing staff was required to, conduct an assessment, to explain the benefits versus the risks of using the side rails and to obtain a consent for the use of side rails from a resident or family representative upon admission or at the time the side rails would be used for repositioning and or bed mobility. She stated it was important to determine whether a resident could safely use the side rails to avoid any accidents or injuries. Review of facility policy, Nursing Administration, revised 10/2024, read It is the policy of this facility that the resident has the right to be free from any physical or chemical restraint for purposes of discipline or convenience, and not required to treat resident's medical symptoms. Purpose: To attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstance in which the resident has a medical symptom that warrant the use of restraints. Procedures: 1. A physician's order is necessary for the use of a physical restraint. 2. The use of a restraining device must first be explained to the resident, family member, or legal representative. 3. The facility must explain, in the context of the individual resident's condition and circumstances, the potential risks and benefits of all options under consideration including using a restraint, not using a restraint, and alternatives to restraint use. 5. Use of side rails as restraints is prohibited unless necessary to treat a resident's medical symptoms. 6. Medical symptoms that warrant the use of restraints must be documented in the resident's medical record, ongoing assessments, and care plans. 7. A device that does not prevent the resident from getting out of bed, or from movement, and or the resident can remove with minimal effort is not considered a restraint.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframe's to meet a resident's medical and nursing needs for 2 of 8 Residents (Resident #85 and #92) whose records were reviewed. 1. Nursing staff failed to include Resident #85 used side rails for repositioning and mobility on the comprehensive Care Plan, dated 2/4/25 2. Nursing staff failed to include Resident #92 used side rails for repositioning and mobility on the comprehensive Care Plan, dated 2/24/25. This deficient practice could affect any resident and result in resident's not receiving care and services as needed. The findings were: 1. Review of Resident #85's face sheet, dated 3/27/25, reviewed she was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure with Hypercapnia (according to Mayo clinic, Respiratory failure is a condition where you don ' t have enough oxygen in the tissues in your body (hypoxia) or when you have too much carbon dioxide in your blood (hypercapnia). and Chronic Pulmonary Edema (according to Mayo clinic, condition caused by too much fluid in the lungs). Review of Resident #85's consolidated physician orders for March 2025 revealed an order, MAY USE 1/4 BILATERAL MOBILITY BARS TO AIDE IN EASY TURNING & REPOSITIONING WHILE IN BED. Review of Resident #85's admission MDS, dated [DATE], revealed Resident's BIMS score was 15 of 15 indicating no cognitive impairment. Review of Resident #85's Care Plan initiated on 2/4/25, revealed there was no indication she used side rails for repositioning and mobility. Observation on 03/26/25 at 10:59 AM revealed Resident #85 lying in bed with 1/4 side rails up on each side of the bed. Interview on 03/27/25 at 03:53 PM with MDS Coordinator/LVN G revealed the use of side rails should be reflected in Resident #85's Care Plan so staff would be aware that she used them. It would also ensure nursing staff monitored for any risks involved. She stated Resident #85's Care Plan did not reflect the use of side rails and it could result in staff not monitoring the risks involved and it could further result in an accident or injury. 2. Review of Resident #92's face sheet, dated 3/28/25, revealed he was admitted to the facility on [DATE], with diagnoses including Encounter for Orthopedic aftercare following surgical amputation and acquired of left leg above the knee. Review of Resident #92's consolidated physician orders for March 2025 revealed and order for the use of 2 1/4 side rails for repositioning and mobility. Review of Resident #92's admission MDS assessment, dated 2/23/25 revealed his BIMS score was 15 of 15 reflective of no cognitive impairment. Review of Resident #92's Care Plan, initiated 2/24/25, revealed no indication Resident #92 used side rails for mobility and repositioning. Observation on 03/25/25 at 11:08 AM Resident #92 lying in bed to the left side with 1/4 side rails up on both sides of the bed. Observation and interview on 03/25/25 at 12:25 PM revealed Resident #92 sitting in a wheelchair eating his lunch meal. He stated he was doing ok but felt cooped up. He stated life changed since his amputation and reported using the side rails for bed mobility. Interview on 03/28/25 at 04:45 PM with MDS Coordinator/LVN G revealed the MDS would reflect the use of side rails if they met the criteria of a restraint. She further stated the use of side rails should be reflected in his Care Plan so staff would be aware that he used them. It would also ensure nursing staff monitored for any risks involved. She stated Resident #92's Care Plan did not reflect the use of side rails and it could result in staff not monitoring the risks involved and it could further result in an accident or injury. Review of facility policy, Comprehensive Person-Centered Care Planning, reviewed 2/2025, read It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview and record review revealed based on a resident's comprehensive assessment, the facility must ensure that a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 8 Residents (Resident #95) whose records were reviewed for weight loss. Nursing staff failed to follow physician orders to weigh Resident #95 weekly for four weeks and then failed to implement dietary interventions once his weight started trending down. This deficient practice could affect residents at risk for losing weight and result in unplanned weight loss and a decline in the resident's overall health. The findings were: Review of Resident #95's face sheet, dated 3/28/25, revealed he was admitted to the facility on [DATE] with diagnoses including Encephalopathy (according to Mayo Clinic, is a general term describing a disease that affects the function or structure of your brain), Respiratory Failure and Sepsis (according to Mayo clinic, is a serious condition in which the body responds improperly to an infection). Review of Resident #95's Nutrition/Hydration Risk Evaluation, dated 2/1825, revealed his score was 19 placing him at risk. Further review revealed the evaluation read XII. Directive: If the Total Score is 10 or Greater, a prevention protocol should be initiated immediately and documented in the Care Plan. It was signed by LVN B. Review of Resident #95's admission MDS assessment, dated 2/19/25, revealed his BIMS score was 8 reflective of moderate cognitive impairment and he required touching assistance or supervision during eating. Review of Resident #95's Care Plan, revised on 2/20/25, read :Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss and provide, serve diet as ordered. Monitor intake and record q meal; date Initiated: 02/17/2025. Review of Resident #95's progress notes from admission, 2/26/25 through 3/27/25, the nutrition section read: Taking nutrition and hydration orally. No complaints of thirst. No signs / symptoms of a swallowing disorder. Mucous membranes moist. Res was admitted with diagnosis of sepsis was alert but confused for first 2 to 3 days. Review of Resident #95's exact meal intake from 2/27/25 to 3/27/25 revealed his intake varied from 60 to 100%. Review of Resident #95's weights revealed Resident #95 weighed 129.58 on 2/15/25 and 124.9 on 3/1/25. He lost 3.61 lbs. Review of physician orders for March 2025 revealed an order for Mirtazapine (Remeron) Oral Tablet 15 MG (Mirtazapine) Give 1 tablet by mouth at bedtime for poor PO intake Phone Active 02/19/2025 and an order REGULAR diet, MECHANICAL SOFT texture, THIN LIQUIDS consistency Active 3/3/2025. Observation and interview on 03/25/25 at 10:00 AM revealed Resident #95 was lying in bed. He stated he been in the facility for about 45 days, was anxious to return home but want to make sure was ready because he did not want to come back. He stated while at home he collapsed a couple of time and had lost a lot of weight. He stated when he arrived he was delirious and very weak. Observation and interview on 03/27/25 at 03:00 PM revealed Resident #95 sitting in a wheelchair. He stated he was weighed once and he remembered weighing about 120 pounds which was very low for him. He stated he usually weighed between 145 and 150 lbs. Interview on 03/28/25 at 11:00 AM with CNA H revealed Resident #95 required minimal assistance with most ADL's including eating. She stated Resident #95 did not always have a good appetite. She stated this morning he ate about 50% of his breakfast and yesterday he ate 100 % of his lunch. She stated protocol required her to let the nurse know when a resident ate 50% or less of their meal. CNA H stated she had not said anything to the nurse yet. She stated breakfast was usually over by 8:30 AM but had not had the opportunity to tell the nurse. Interview on 03/28/25 at 11:05 AM with LVN B revealed protocol required staff to weigh all new admissions every 7 days for the first 4 weeks. He stated upon reviewing Resident #95's weights, it looked like he was last weighed on 3/1/25 and his weight was trending down. He stated upon reviewing Resident #95's EMAR, it appeared the order for weekly weights did not transfer from the February 2025 to the March 2025 EMAR. LVN B stated this was probably why Resident #95 was not weighed after 3/1/25. LVN B stated he did not know Resident #95 was a high risk for losing weight. He stated he did not know Resident #95 lost weight prior to his admission and did not realize until reviewing his weights today (03/28/25) that Resident #95 was losing weight. He stated had he known the history and current weight loss, he would have reported the change of condition to the DON. She would then reach out to the Dietician who would implement dietary interventions such as supplemental medication and maybe add double portions for his meals. LVN B stated he recalled calling the PA because Resident #95 had poor appetite upon his admission. The PA added Remeron, an appetite stimulant, but additional interventions would have helped to prevent further weight loss. LVN B stated apparently the Remeron was not sufficient to help Resident #95 from losing weight. LVN B stated the CNA's would report when a resident ate 50% or less of their meal. He stated CNA H had not said anything about Resident #95's intake for breakfast on this date. Interview on 03/28/25 at 11:42 AM with the facility Dietician revealed she met with nursing staff every 2nd week of the month and they discussed residents who were at high risk for weight loss. She stated if a resident was assessed as being a high risk for losing weight from onset then staff would reach out to her to implement a plan including interventions to avoid weight loss. The Dietician stated nursing staff had not reached out to her to report any weight loss for Resident #95. She stated she noted a couple of days ago, during her in-house visit, the resident's weight was trending down. She stated he had not lost any significant weight loss but his weight was trending down. The Dietician stated she added double portions to his meals on 03/27/25. She stated she could also recommend med pass three times a day to prevent further weight loss. The Dietician stated Remeron, an appetite stimulant, was ordered on 2/19/25, but it had not prevented him from losing weight. The Dietician stated there was usually an order to take weekly weights for 4 weeks for new admissions, but she stated she only noted 2 weights entered for Resident #95. She commented they needed to get him back on weekly weights to monitor any additional weight variances so additional interventions were implemented to avoid significant weight loss. Interview on 03/28/25 at 12:30 PM with the DON revealed there were a lot of systems that were broken. She stated she assumed her position about 1 week ago. She stated usually the DON and ADON's would audit resident records and would discuss any major events that were trending such as falls, weight loss and infections. She stated from what she understood it had not been taking place for a while. She stated she was trying to also improve their internal electronic applications to flag high risks trending events. The DON stated the Dietician called her and alerted her that Resident #95's weight was trending down. She stated the IDT had not discussed Resident's weight loss and usually they did not wait until a resident experienced significant weight loss before they started implementing interventions such as medication supplements and dietary supplements. The DON stated she understood the PA added a new order for Remeron, an appetite stimulant, shortly after Resident #95 was admitted . She stated she understood Resident #95 lost almost 5% after only 2 weeks but also noted upon reviewing his records that he had not been weighed since 3/1/25 so she would not know if had continued to lose weight. The DON stated protocol required nursing staff to weigh new admissions weekly for 4 weeks. The DON stated they did not follow their protocol and did not identify Resident #95 was losing weight and although Remeron was ordered it was not enough to keep him from losing weight. Review of facility policy, Nutrition, reviewed 7/2024, read It is the policy of this facility to ensure that all residents maintain acceptable parameters of nutritional status, such as body weights and protein levels, unless the resident's clinical condition demonstrates that this is not possible. This facility utilizes an outside Dietary Consultant Group and incorporates its program in the services provided. PROCEDURES: Assessment 1. Each resident's nutritional status is assessed on admission and at least quarterly thereafter. 2. Each resident is to be weighed upon admission. weekly, weights for four (4l) weeks and monthly weight thereafter unless otherwise specified by the attending physician. The weight will be entered into the resident's clinical record. 3. Monthly weights are to be completed and reviewed by the Registered Dietician. Dietary Technician and/or designee. Dietary Evaluation 1. Evaluations may include determining ideal body weight range, usual body weight, current met order, % of food eaten, possible dental problems, and current illnesses, resident likes and dislikes, psychosocial needs. and an other changes in medical condition that may impact weight gain or loss. Once the resident has been evaluated for nutrition status. the Registered Dietitian, Dietary Technician and/or designee will determine if there is a significant change in the resident's condition. If so, additional nutritional intervention will be offered to those residents. Clinical Evaluation 1. Nutritional as easement may include: o Weighing and weight change o Oral intake of food and fluid o IV therapy o Nutrition prescription/macronutrients o Functional status (assistive devices. cueing, hand-over-hand. extensive assistance o Medications (affecting taste, causing anorexia, increasing appetite, causing nausea/vomiting, lethargy. contusion. constipation o Oral health (oral cavity lesions, mouth pain, decayed teeth. poorly filling dentures) o Chewing and swallowing problems o Affective and behavioral disorders o Relevant conditions and diagnosis o Hypermetabolic states (continuous wandering, skin breakdown) o Abnormal labs o Overall prognosis/condition o Resident choice (advance directives) 2. Any resident weight that varies from the previous reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team to determine the cause of weight loss/gain, intervention required and need for further recommendations and/or referral. Family member/responsible party and attending physician will be notified. 3. Diets will be provided according to physician's orders, including regular and therapeutic diets. Dietician technicians and registered dieticians will make recommendations for therapeutic diets. 4. Care plan will be updated or revised as needed.

Based on observation, interview and record review the facility failed to ensure the assessment accurately reflect the resident's status for 2 of 8 Residents (Resident #76 and Resident #85) whose records were reviewed. 1. Nursing staff failed to code that Resident #76 was diagnosed with Depression on his annual assessment, dated 2/2/25. 2. Nursing staff failed to code that Resident #85 received oxygen therapy on her annual assessment, dated 2/4/25. This deficient practice could affect any resident and contribute to residents not receiving care and services as needed. The findings were: 1. Review of Resident #76's face sheet, dated 3/28/25, revealed he was admitted to the facility on [DATE] with a primary diagnosis of Encounter for surgical aftercare following surgery on the digestive system. Review of Resident #76's Psychiatric Initial Assessment, dated 2/6/25 revealed he was diagnosed of adjustment disorder with depressed mood (According to Mayo clinic it refers to symptoms of depression that occur for a short time and after facing a significant stressor that has overwhelmed ability to cope). Review of Resident #76's MDS assessment, dated 2/23/25, revealed there was no indication Resident #76 had a diagnosis of Depression. Interview on 03/26/25 at 11:00 AM with Resident #76's family member revealed Resident #76 was in therapy. She stated Resident #76 had a G-tube placement most recently and reported Resident #76 was adjusting to not having food. She stated Resident #76 was a little depressed. Interview on 03/27/25 at 04:02 PM with MDS Coordinator/LVN G revealed Resident #76's MDS assessment did not capture he had been diagnosed with Depression. She stated it was important to accurately reflect Resident #76's status so staff would provide the necessary care and services needed. 2. Review of Resident #85's face sheet, dated 3/27/25, revealed she was admitted to the facility on [DATE], with diagnosis including Chronic Obstructive Pulmonary with acute exacerbation. Review of Resident 85's physician orders for March 2025 revealed an order: O2 AT 2-4L/MIN CONTINUOUS PER NC every shift active 1/31/2025 22:00. Review of Resident 85's annual MDS assessment, dated 2/4/25, revealed there was no indication she was receiving oxygen. Review of Resident #85's Care Plan, revised on 2/13/25, revealed she was using oxygen related to respiratory illness. Observation and interview on 03/26/25 at 10:59 AM revealed Resident #85 lying in bed with oxygen infusing via nasal cannula. Resident #85's family member stated he saw staff coming in periodically to check on the concentrator. Interview on 03/27/25 at 03:56 PM with MDS Coordinator/LVN G revealed Resident #85's annual MDS did not indicate Resident #85 received oxygen. She stated it was important to accurately reflect Resident #85's status so staff would provide the necessary care and services needed. Review of a facility policy, Resident Assessment, reviewed on 3/2023, read It is the policy of this facility to ensure that the assessment accurately reflect the resident's status.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly within 2 of 4 medication carts (med cart in hall 300 and med cart in hall 400) observed for medication storage. One unidentified small round white pill was observed in the bottom drawer of the medication cart on 400 hall. Two unidentified small round white pills were observed in the top drawer of the medication cart on 300 hall. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications as ordered. The findings were: Observation of the medication cart on 400 hall on 03/27/2025 at 2:30 PM revealed a small round white pill on the bottom of the bottom drawer of the medication cart on 300 hall. The pill was loose and not labeled with no identifying markers to indicate what it was. Medication cart was locked and secured. Observation of the medication cart on 300 hall on 03/27/2025 at 3:10 PM revealed two small round white pills on the bottom of the top drawer of the medication cart on 300 hall. The pills were loose and not labeled with no identifying markers to indicate what they were. Medication cart was locked and secured. Interview with CMA C on 03/27/2025 at 2:55 PM revealed CMA C could not identify loose pills located in medication carts for the 300 halls and 400 halls. CMA C stated if a loose pill is found in the medication carts staff are to follow the facility policy to dispose of them. CMA C stated loose pills in the medication carts could cause the resident's to go without necessary medications. Interview with DON on 03/27/2025 at 3:41 PM revealed medications are to be stored in original packaging. DON stated CMAs check the carts daily to ensure they are clean and there are no loose pills. DON stated loose pills in the medication carts would not affect the residents since staff would now dispense loose pills. Record review facility policy titled [Facility Name] Policy/ Procedure - Nursing Clinical section Care and Treatment subject Medication Access and Storage, E kit access, revised 07/2024, revealed 1. The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 1 (Cook D) of 28 employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured [NAME] D received required trainings upon hire and annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained. Findings include: Record review of the personnel records for [NAME] D revealed a hire date of 12/16/2023. Further review of a training log for [NAME] D from the previous 15 months, provided by the HR Manager revealed no evidence of communication training, resident rights training, QAPI training, infection control training, ethics training, behavior health training, dementia training, HIV training, falls training, restraint training or emergency preparedness training being provided annually prior to March 25, 2025. Training log for [NAME] D revealed annual trainings were last completed: - communication training completed 01/25/2024 - resident rights training completed 02/06/2024 - QAPI training completed 01/26/2024 - infection control training completed 01/26/2024 - ethics training completed 01/25/2024 - behavior health training completed 01/26/2024 - dementia training completed 01/26/2024 - HIV training completed 01/26/2024 - falls training completed 01/26/2024 - restraint training completed 02/23/2024 - emergency preparedness training completed 01/26/2024 Interview with HR Manager on 03/28/2025 at 4:35 PM revealed facility relies on the training program Relias to identify staff that have annual trainings due within 30 days. HR Manager stated he runs a weekly report in Relias to identify employees that need to complete annual trainings. HR Manager stated that [NAME] D did not show up on any reports of the weekly reports. HR manager stated it was his responsibility to run the weekly reports and to provide them to the department heads who are responsible to ensure their staff complete trainings. HR Manager stated by not training staff annually it increased the likelihood that a staff member could do something wrong and put the residents in harms way. Interview with Administrator on 03/28/2025 at 4:48 PM revealed HR and Administrator are to ensure staff receive their annual trainings. The Administrator stated a report is run in Relias to identify staff who have trainings that are due in the next 30 days, and it is the responsibility of department heads to ensure staff complete trainings. The Administrator stated staff are required to complete trainings to ensure they are up to date on policies and procedures to ensure quality care is being provided. The Administrator stated if staff are not trained it puts resident at risk for receiving poor care. Record review of facility policy titled In Service Training Program, dated April 2004, revealed 8. The following in-service training classes are mandatory (i.e., each employee must attend a training class on each of the following topics): A. Problems and needs of the aged chronically ill, acutely ill, and disabled patients B. Prevention and control of infections C. Interpersonal relationship and communication skills D. Fire prevention and safety E. Accident prevention and safety measures F. Confidentiality of patient information G. Preservation of patient dignity, including provision for privacy H. Patient rights and civil rights I. HIPAA J. Signs and symptoms of cardiopulmonary distress K. Choking prevention and intervention L. Sexual Harassment M. Elder Abuse and residents rights N. Blood borne pathogens (HIV, Hepatitis B) O. Hazard communication (Material Safety Data Sheets, [MSDS]) P. Resident assessment (MOS, PASARR, PSYCH, Diags.) Q. Restraints R. ADA (American Disabilities Act) A policy addressing required annual training including QAPI training, ethics training, behavior health training, dementia training, HIV training and fall prevention training was requested from the HR Manager on 03/28/2025 at 4:35 PM but was not provided prior to exit. A policy addressing required annual training including QAPI training, ethics training, behavior health training, dementia training, HIV training and fall prevention training was requested from the Administrator on 03/28/2025 at 4:48 PM but was not provided prior to exit.

Based on interview and record review, the facility failed to provide mandatory effective communications training for 1 (Cook D) of 28 employees reviewed for training. The facility failed to ensure effective communication training was provided to [NAME] D annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of the personnel records for [NAME] D revealed a hire date of 12/16/2023. Further review of a training log for [NAME] D from the previous 15 months, provided by the HR Manager revealed no evidence of communication training being provided annually prior to March 25, 2025. The training log for [NAME] D revealed annual training of effective communication training was last completed 01/25/2024. Interview with HR Manager on 03/28/2025 at 4:35 PM revealed the facility relied on the training program Relias to identify staff who had annual trainings due within 30 days. The HR Manager stated he ran a weekly report in Relias to identify employees who needed to complete annual trainings. The HR Manager stated [NAME] D did not show up on any reports of the weekly reports. The HR manager stated it was his responsibility to run the weekly reports and to provide them to the department heads who were responsible to ensure their staff completed trainings. The HR Manager stated by not training staff annually it increased the likelihood that a staff member could do something wrong and put the residents in harm's way. Interview with the Administrator on 03/28/2025 at 4:48 PM revealed HR and the Administrator were to ensure staff received their annual trainings. The Administrator stated a report was run in Relias to identify staff who had trainings that were due in the next 30 days, and it was the responsibility of the department heads to ensure staff completed trainings. The Administrator stated staff were required to complete trainings to ensure they were up to date on policies and procedures to ensure quality care was being provided. The Administrator stated if staff were not trained it put resident at risk for receiving poor care. Record review of facility policy titled In Service Training Program, dated April 2004, revealed 8. The following in-service training classes are mandatory (i.e., each employee must attend a training class on each of the following topics): A. Problems and needs of the aged chronically ill, acutely ill, and disabled patients B. Prevention and control of infections C. Interpersonal relationship and communication skills D. Fire prevention and safety E. Accident prevention and safety measures F. Confidentiality of patient information G. Preservation of patient dignity, including provision for privacy H. Patient rights and civil rights I. HIPAA J. Signs and symptoms of cardiopulmonary distress K. Choking prevention and intervention L. Sexual Harassment M. Elder Abuse and residents rights N. Blood borne pathogens (HIV, Hepatitis B) O. Hazard communication (Material Safety Data Sheets, [MSDS]) P. Resident assessment (MOS, PASARR, PSYCH, Diags.) Q. Restraints R. ADA (American Disabilities Act)

Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from neglect for 2 of 24 residents (Residents #4 and #46) whose care was reviewed for neglect, in that: 1. The facility failed to have structures in place to ensure adequate and appropriate equipment including procedures for how to maintain equipment for rental mechanical lifts and slings, which resulted in injuries to Residents #46 and #4. 2. The facility failed to implement their process for ongoing monitoring and supervision of staff to assure safe transfers of residents as implemented on their written care plan resulting in injuries to Residents #46 and #4. These failures resulted in identification of Immediate Jeopardy (IJ) on 11/07/2019 at 5:37 pm. The IJ was removed on 11/08/2019, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk of falls. These deficient practices resulted in Resident #46 and #4 sustaining injuries and could place other residents requiring assistance with transfers at-risk for injury and harm and created the potential to negatively impact the psychosocial well being of residents such as mental anguish and fear. The findings were: Record review of the facility's policy titled Abuse: Prevention of and Prohibition Against, dated 11/28/2017 and revised 04/2019, revealed: It is the policy of this Facility that each resident has the right to be free from abuse, neglect. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes the rights of the resident to be free from abuse, neglect. D. Prevention - supervising staff to identify and correct any inappropriate or unprofessional behaviors. Assuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents. 1. Record review of Resident #46's face sheet, dated 11/08/2019, revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #46's Care Plan (start date of 07/03/2018 and a revision date of 07/15/2018) for ADLs related to debility revealed interventions which included two staff member mechanical lift for all transfers. Record review of Resident #46's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, which indicated the resident had moderate cognitive impairment, and the resident required extensive assistance with two plus staff persons for physical assistance with transfers. Record review of Resident # 46's Provider Investigative Report, dated 10/25/2019, revealed the resident had an incident involving neglect on 10/25/2019 at 9:10 a.m. in which CNA A performed an improper mechanical lift transfer that resulted in the resident experiencing an occipital contusion and a left tibia and fibula fracture. Further review revealed the facility investigation had noted CNA A had performed an improper mechanical lift technique of, willful violation. Record review of an Administrative Statement written and signed by the DON and dated 10/25/2019 revealed: at 9:10 a.m. Administrative Staff were made aware of a fall during a mechanical lift transfer involving Resident #46. The resident complained of left lower extremity and occipital lobe pain. An assessment revealed pain and swelling to Resident #46's left lower extremity. Resident #46 was transported to a local hospital for treatment. Further review revealed, CNA A stated he performed the lift by himself when the sling's loop jumped track resulting in the fall. CNA A confirmed he did not have assistance with the transfer. CNA A further confirmed he was aware of a facility policy requiring 2 staff members for the mechanical lift transfer. Record review of a Nursing Home to Hospital Transfer Form, dated 10/25/2019, revealed Resident #46 had a fall during a mechanical lift transfer where the sling came loose from the lift and the resident fell back approximately three feet from the air. Further review revealed the resident complained of pain to the left ankle with swelling and had a hematoma to the back of the head. Record review of a Final X-Ray Report from a local hospital for Resident #46, dated 10/25/2019, revealed a displaced fracture to the left tibia and fibula, Osteopenia, and soft tissue swelling. Record review of Resident #46's Nurses Progress Notes, dated 10/25/2019, documented by LVN B and dated 10/25/2019 at 1:12 p.m. revealed LVN B, was informed by CNA A during a mechanical lift transfer the sling slipped off a hook of the lift and Resident #46 fell on to her right side. Resident #46 stated she fell while being transferred with the mechanical lift and stated she hit her head on the floor and was having increased pain to her left leg and ankle. Resident assessment noted increased swelling to left ankle with complaints of pain at a level 8 and hematoma to back of the head. Record review of CNA A's Skills Checklist for Mechanical Lift Use, dated 09/07/2017, revealed CNA A had been evaluated for mechanical lift use on 07/07/2017, 07/09/2018, and 09/16/2019 where demonstrated competency of skills. Observation of a video on 11/6/19 dated 10/25/2019 revealed Resident #46 was in the process of being transferred from bed to wheelchair by CNA [NAME] Further observation revealed Resident #46 fell when the lift was in the high position and the resident was positioned away from the bed. The fall occurred when one corner of the sling came detached from the overhead harness and the resident fell to the ground. Screen shots from the video were used to identify the mechanical lift used during this incident. A thick green rubber band was observed wrapped around the battery pack and frame three times and was secured in place with a knot, black electrical tape was observed on the remote for the mechanical lift, and the mechanical lift's identification plate was also identified. During an interview with Resident #46 on 11/05/2019 at 1:25 p.m., the resident confirmed she had been in the process of being transferred from the bed to a wheelchair by one staff person when she fell and hit her head. Resident #46 stated the fall had caused her, to hurt all over including her head and broke her leg. During an interview with CNA A on 11/06/2019 at 11:05 a.m., CNA A confirmed he performed the mechanical lift transfer of Resident #46 without the assistance of another staff member. CNA A stated the sling's loop, jumped off the track, during the transfer causing Resident #46 to fall to the ground. CNA A stated he was not trained to have the assistance of another staff person for mechanical lift transfers. CNA A further stated the management of the facility knew he was performing the transfers without assistance. During an interview with LVN B on 11/06/2019 at 11:33 a.m., LVN B confirmed he had been notified Resident #46 had fallen from the mechanical lift when he was the charge nurse on duty 10/25/2019. LVN B confirmed CNA A had admitted he had performed the mechanical lift transfer alone instead of with the required two staff person. LVN B stated he had assessed Resident #46 and noted the resident had a hematoma that was approximately a golf-ball sized and slightly smaller to the back of the head, and the resident complained of pain to the left leg. LVN B stated Resident #46 was sent to the ER at a local hospital because she was on anticoagulants and at-risk for bleeding. LVN B stated, A mechanical lift transfer is always two persons. All the CNA's know and have been in-serviced many times. CNA A did not ask for assistance. Observation of a mechanical lift transfer for Resident #46 on 11/07/2019 at 6:11 p.m. revealed the mechanical lift had a thick green rubber band tied around the battery pack and frame of the lift and was secured with a knot and black electrical tape around the remote. Further observation revealed during the transfer the mechanical lift made an audible beep or alarm noise when in use. During an interview with CNA [NAME] on 11/08/2019 at 8:44 a.m., CNA [NAME] confirmed she was trained to perform mechanical lift transfers with two staff persons. CNA [NAME] stated, staff are only using one person for mechanical lift transfers, I am not going to lie. During an interview with CNA F on 11/08/2019 at 9:12 a.m., CNA F stated she did not know about a Kardex or Kiosk for knowing which residents required two staff members. CNA F stated she just learned on the job which residents could get out of bed with one person and which needed two persons. During an interview with the Maintenance Manager on 11/08/2019 at 11:50 a.m., the Maintenance Manager confirmed the mechanical lift with the thick green band wrapped around the battery pack and frame was not functioning correctly. The Maintenance Manager confirmed that mechanical lift had a, remote issue, and was taken out of service on 11/07/2019 after surveyor intervention. The Maintenance Manager further confirmed there was not a system in place to identify and take out of service broken or damaged equipment until surveyor intervention. b. Record review of a Grievance Resolution Form, dated 10/01/2019, revealed Resident #4 made a complaint that she was a two person transfer but only one CNA helped at times due to short(age) of staff. Further review revealed the facility had confirmed the allegation and provided staff education. The document was signed by two staff members including the Administrator on 10/11/2019. Observation of a two-person transfer from wheelchair to toilet for Resident #4 on 11/06/2019 at 10:40 a.m. revealed two staff members, including CNA D and the charge nurse, assisted Resident #4 to a standing position without the use of a gait belt. Further observation revealed Resident #4 was assisted to standing while the resident used the grab bar in the bathroom for leverage and support. During an interview with LVN L on 11/06/2019 at 11:00 a.m., LVN L confirmed Resident #4 required two staff persons for all transfers and assistance. LVN L stated Resident #4 had a history of [REDACTED]. LVN L confirmed all transfers required the use of a gait belt. During an interview with CNA I on 11/06/2019 at 4:55 p.m., CNA I confirmed she had transferred Resident #4 without the assistance of another staff member on 11/05/2019, on the day of surveyor arrival at the facility. CNA I stated there were no other staff to assist her with the transfer, and then confirmed she had not asked any other staff member for assistance. CNA I confirmed she knew Resident #4 required two staff members for a safe transfer. During an interview with the DON on 11/07/2019 at 8:20 a.m., the DON confirmed CNA I had transferred Resident #4 without the assistance of a second staff member as required. The DON confirmed Resident #4 was originally a mechanical lift transfer but had been assessed and determined to be a safe two-person gait belt transfer. During an interview with CNA D on 11/08/2019 at 1:45 p.m., CNA D confirmed Resident #4 was assisted to transfer without the use of a gait belt. CNA D stated a regular-sized gait belt did not fit Resident #4 and further stated she did not have a bariatric gait belt. CNA D confirmed that if Resident #4 began to fall without a gait belt on the staff would be unable to prevent the resident from falling. During an interview with Unit Manager G on 11/08/2019 at 5:00 p.m. Unit Manager G confirmed Resident #4's grievance allegation had been confirmed by the facility. Unit Manager G confirmed no in-service training had been performed, instead he had just talked to the staff member involved. Unit Manager G stated a staff member had assisted Resident #4 to a standing position to change her pants and that a true transfer had not occurred. During an interview with the Administrator on 11/09/2019 at 9:42 a.m., the Administrator confirmed all two-person transfers require a gait belt, including bariatric residents. Record review of the facility's policy titled, Gait Belt Transfer, dated 05/2007, revealed: It is the policy of this facility to: 1. Provide safety for the unsteady resident. 2. Aid in the transfer of the dependent resident. 3. Prevent injuries to employees and residents. 4. Allow the resident and aide to feel more secure during a transfer. Transfer from bed to chair, commode or wheelchair; two-person transfer. 6. Resident may assist . 7. Stand close to resident with your feet about 18 inches apart. 8. Place gait belt around resident's wait; snug but not tight. 9. Stand on either side of resident facing each other. 10. Grasp the gait belt on either side. During an interview with the Medical Director on 11/09/2019 at 9:52 a.m., the Medical Director stated he addressed issues in the facility as they arose and in QAPI meetings held 1-2 times a month. The Medical Director stated he relied on the Administration of the facility to properly document compliance and communicate to him any problems, issues or concerns. The Medical Director confirmed he had been notified of Resident #4's fall incident because he was the physician on-call when the incident occurred. The Medical Director confirmed he was not notified of the fall incident with Resident #46 until 11/08/2019 (after surveyor intervention). Record review of the facility's policy titled Hoyer lift, dated 05/2007, revealed, It is the policy of this facility that the Hoyer lift (mechanical lift) will be utilized for resident transfers only. Assistance of two personnel will be used with Hoyer lift. Record review of the facility's policy titled Equipment Maintenance, dated 05/2007, revealed: It is the policy of this facility to establish procedures for routine and non-routine care of equipment and to ensure that equipment remains in good working order for resident and staff safety. 1. All staff will be trained in proper use of program equipment, as per each manufacturer's instructions. 2. Electrical and hydraulic equipment will be inspected by the Maintenance Supervisor prior to initial use and on a routine basis to ensure that equipment is working properly. 4. Routine inspections and Maintenance will be recorded in the TELS system (building management system). 2. a. Record review of Resident #4's face sheet, dated 11/08/2019, revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 12, which indicated the resident was cognitively intact, and the resident required extensive assistance with two plus staff persons for assistance Record review of Resident #4's Care Plan for ADL self-care, dated 06/03/2019 and revised on 10/25/2019, revealed the resident required a mechanical lift with two staff personal assistance, last revised on 07/05/2019 which revealed the resident required extensive assistance with two staff members. Record review of Resident #4's Nurse's Progress Notes on 09/12/2019 at 4:20 p.m. written by ADON H revealed Resident #4 had a witnessed fall in the room during a transfer with a mechanical lift. Further review revealed an unidentified CNA voiced during the resident's transfer that the sling had detached from the lift and Resident #4 fell to the floor landing on her right hip. Resident #4 voiced pain to right hip/femur area and noted decreased mobility to RLE. Record review of a Provider Investigation Report, dated 09/12/2019, revealed Resident #4 fell while being transferred from bed to her power wheelchair during a mechanical lift transfer due to a sling failure. Further review revealed the resident had right lower extremity pain and a contusion. Resident #4 also presented with drowsiness post-fall and was transported by EMS to a local hospital. Record review of Nurse's Progress notes, dated 09/12/2019 at 4:20 p.m., revealed Resident #4 had a witnessed fall in her room during a transfer from bed to chair. Further review revealed the mechanical lift sling detached from the mechanical lift and the resident fell to the floor on her right hip. Resident #4 experienced decreased mobility to right lower extremity noted, and an X-ray was ordered. Record review of a typed written statement by ADON H, dated 09/13/2019, revealed ADON H was notified by nursing staff that Resident #4 had a witnessed fall during a mechanical lift transfer in which the sling failed. A change in the resident's condition was noted in which the resident was having difficulty arousing to verbal stimuli and neuro checks presented with abnormal findings. Further review revealed 911 was called and the resident was sent to the ER for an evaluation. Record review of a facility fall report dated 09/20/2019, revealed Resident #4 had a witnessed fall caused by a broken sling on 09/12/2019 while being transferred from bed to powerchair. Further review revealed Resident #4 complained of pain 10 out of 10 to right hip and right lower leg. Further review of the facility fall report revealed post-fall investigation Resident #4 was sent to the ER for an evaluation. A sling audit of all slings in the building was completed and staff were in-serviced. Observation of a video on 11/6/19 dated 09/12/2019 revealed Resident #4 fell from a mechanical lift transfer while raised in the highest position. Further observation of the video revealed one loop of the sling fell near the resident's right foot and the second loop fell near right side of the resident's head. Further observation revealed four staff members were identified as being present during the lift, and the broken loop strap was observed on the resident's bed after the fall. During an interview with Resident #4 on 11/06/2019 at 11:45 a.m. Resident #4 confirmed she had fallen from the mechanical lift during a transfer and was sent to the emergency room . During an interview with CNA D on 11/07/2019 at 1:45 p.m., CNA D confirmed Resident #4 fell from the mechanical lift due to a sling failure. CNA D confirmed she did not inspect the sling or mechanical lift prior to its use for the transfer with Resident #4 on 09/12/2019. b. Record review of the Maintenance Manager's last three Logbook documentation dated 08/02/2019, 09/05/2019, and 10/14/2019 revealed: Resident lifts: inspect mobile lifts as needed. Further review of log revealed page 2 steps: conduct lift safety inspection (inspect all that apply) no notes or comments were logged on this document. Record review of a local company invoice for Safety Check Inventory, dated 08/2019, listed four mechanical lifts that were calibrated and inspected. Further review revealed only two mechanical lifts were identified as still in use by the facility, one of which was identified as the lift with the thick green band. During an interview with the DON on 11/07/2019 at 2:40 p.m., the DON confirmed Resident #4's fall from the mechanical lift was a result of a sling failure. The DON stated he did not know why the incident occurred and stated he, would like to think (the sling) was inspected, before use. The DON confirmed that before the incident occurred, there was not a policy in place to inspect the slings for wear and damage and he did not personally inspect any of the slings or mechanical lift equipment. The DON stated Resident #46's fall from the mechanical lift incident occurred because CNA A did not ask for assistance with the transfer. The DON stated resident transfer information was available to all staff and was located on both the Kardex and Kiosk. The DON stated he had in-serviced and repeatedly instructed staff to check the Kardex/Kiosk for resident requirements before performing patient care. The DON confirmed he was not monitoring staff for compliance with resident transfers and stated the staff had been trained over and over. The DON confirmed a family member had informed him of the one-person mechanical lift transfers. The DON confirmed he terminated another employee since the survey began for performing an improper one-person transfer. During an interview with the Administrator on 11/07/19 at 2:55 p.m., the Administrator confirmed before the mechanical lift fall incident with Resident #4, there was not a facility process in place to monitor or track sling manufacture dates or length of time the slings had been in use and no facility policy on how long a sling could stay in circulation. The Administrator stated that if the sling worked and did not look worn or frayed then it was being used. The Administrator confirmed there was no staff monitoring for equipment inspections. The Administrator further stated staff had been trained on two-person mechanical lift transfers and she performed random audits in which she walked in and out of resident rooms to monitor staff but did not keep any records to document staff compliance. The Administrator confirmed she was not aware that one-person transfers were still occurring after Resident #46 had the fall from the mechanical lift. Observation of a mechanical lift transfer for Resident #46 on 11/07/2019 at 3:11 p.m. revealed the mechanical lift had a thick green rubber band tied around the battery pack and frame of the lift and was secured with a knot and black electrical tape around the remote. Further observation revealed during the transfer the mechanical lift made an audible beep or alarm noise when in use. During an interview with LVN I on 11/07/2019 at 3:45 p.m., LVN I confirmed lift #12LS 014 had an out of date inspection of 11/12/2017 and confirmed no other inspection sticker could be located. Observation on 11/07/2019 at 3:45 p.m. of seven mechanical lifts in use in the facility revealed: - One mechanical lift with a thick green rubber band around the battery pack with last inspection date which read, due 8/2019, was in the CNA training room with a piece of paper taped to the frame which read, Safety check inventory. - One mechanical lift white in color last inspected 11/12/2017, inspection due 02/2018, ID #12LS 014. - One mechanical lift identified as belonging to a Hospice company ID # 365 had no inspection date. - Four mechanical lifts identified as belonging to a rental company were without inspection dates. During an interview with the Maintenance Manager on 11/07/2019 at 3:55 p.m., the Maintenance Manager confirmed that the four rental mechanical lifts and one hospice mechanical lift did not have inspection dates. The Maintenance Manager stated that since the five mechanical lifts belonged to a rental company and a hospice company, he did not inspect them before they were placed into service. The Maintenance Manager confirmed he had no way of tracking when the five mechanical lifts had been inspected. The Maintenance Manager stated, they (the mechanical lifts) were from a rental company, I would assume they were inspected already. The Maintenance Manager further confirmed he did not know why one of the facility-owned mechanical lifts had a last inspection date of (YEAR). The Maintenance Manager stated he made rounds and inspected facility-owned mechanical lifts as needed but did not document which mechanical lifts he had inspected or tested . Observation on 11/07/2019 at 4:15 p.m., with the Maintenance Manager, revealed a mechanical lift had several large cracks in the base plate. Further observation revealed the Maintenance Manager moved the mechanical lift slightly and pushed on the base plate with his foot. The Maintenance Manager then left the mechanical lift with the broken base plate in the hallway. During an interview with the Maintenance Manager on 11/07/2019 at 4:16 p.m., the Maintenance Manager confirmed he was not aware of the mechanical lift with several large cracks in the base plate before surveyor intervention. During an interview with CNA C on 11/08/2019 at 7:45 a.m., CNA C confirmed the mechanical lift had malfunctioned during Resident #46's transfer. CNA C stated the mechanical lift's arm would not lift the resident all the way and was hard to maneuver. CNA C confirmed during Resident #46's transfer, she heard the mechanical lift machine beeping the entire time and stated, I didn't know what was wrong with it. The interview further revealed that she had been trained to always check the battery and the brakes before using a mechanical lift but didn't think anything of the beeping. CNA C confirmed the lift had a thick green rubber band tied around the battery pack and frame but stated she didn't know why the band was in place. CNA C confirmed the facility had been using slings, that were really worn. CNA C stated, even the protective ropes on the slings were worn, but we didn't have enough slings. During an interview with ADON H on 11/08/2019 at 11:40 a.m., ADON H confirmed equipment inspections were not occurring prior to surveyor intervention. The ADON stated broken equipment was to be logged into the maintenance book but there had been no follow through with inspections. The ADON further stated he was not aware that staff had been performing one-person mechanical lift and one person instead of two-person gait belt transfers. The Administrator was notified of an IJ on 11/07/2019 at 5:37 pm and was given a copy of the IJ Template and a Plan of Removal was requested. The Plan of Removal accepted on 11/08/19 included the following: Plan of Removal 11/08/2019 Immediate Action - Medical Director notified of IJ - Mechanical lift identified as faulty was taken out of use. Serial # 4A - 5 Mechanical lifts were currently in service and were inspected by an outside company on 11/7/19 & 11/8/19 prior to being used. Serial #'s P 0, PL650HD 013, PL 7, 4A D, PLEA 16. Maintenance director performed safety inspection on all 5 above listed mechanical lifts on 11/8/19 and logged it into the mechanical lift tracker on 11/8/19. - Mechanical lifts were logged into a tracking log by serial number on 11/8/19. A sticker with a date for next annual inspection and initials of certified biomedical technician was placed on the mechanical lift on 11/7/19 and logged on tracking sheet on 11/8/19. - All slings taken out of service and replaced with new slings. - Residents #4 and #46 assessed post fall at time of occurrence and monitored for pain management. Identification of Others Affected: - There are twenty-one residents who are currently transferred via mechanical lift. Systemic Change to Prevent Re-occurrence: - Laundry personnel in-serviced on care of slings per manufacturer's recommendations by Administrator/DON / Laundry Supervisor on 11/8/19 and ongoing. Slings will be washed according to manufacturer's guidelines. Max temp 120 F and air dry only. No chlorine bleach. - Nurses, Nurse Aides, and Therapy personnel in-serviced on slings and Hoyer lift transfers to ensure sling is placed properly under resident and at least 2 people perform each transfer. - Administrator/Designee to keep log of slings to ensure proper care of slings, discarding slings when necessary, to ensure par level of slings to meet residents' needs. New slings were marked with a triangle symbol and number on 11/7/19 so staff could identify them as a new sling. The number on the sling is tracked on the sling tracking log. The sling inspection has been added to the MARS for a daily check by nursing to ensure they are intact and do not have any tears, frays, bleach stains or damage. There are currently 45 slings in house. - Laundry Manager to verify laundry detergent is appropriate for care of sling with chemical vendor. - Maintenance Director to verify operational condition of Hoyer lift with medical equipment vendor, the cosmetic plastic covering on base of lift to be replaced, however, it does not affect safe function of lift. - Maintenance Director to conduct safety check of mechanical lift monthly, safety checked to be tracked as part of the EMR. - Maintenance Director to have an annual check by biomedical technician on all mechanical lifts. Monitoring: - Daily check of slings for tears, frays, bleach stains and damages by Charge nurse/designee beginning on 11/8/19. - Daily check of mechanical lifts for safety for operation status for one week beginning on 11/8/19. The following will be checked: wheels lock, base legs expand with ease, handle operates as intended, lift does not have any frayed wires, remote operates, push handles are in place and secure, battery pack holds a charge, sling attachment points are not bent or damaged and boom raises/lowers without difficulty. - In-services conducted by DON/ADON/Administrator ongoing starting 11/07/19 to nurses, nurse aides and therapy personnel. After 90% of personnel educated, the remaining personnel will be in-serviced prior to their next shift. - DON/ADON will monitor mechanical lift transfers daily x 2 weeks during walking rounds and on random shifts to ensure competency. - Summary of IJ and corrective action to be reviewed by QAPI within 7 days and monthly for 90 days to ensure ongoing compliance. Verification of the Plan of Removal was as follows: a. Reviewed on 11/09/2019 pain management tracking and MAR's for Residents #4 and #46 to ensure adequate pain control and monitoring revealed no concerns identified. b. Reviewed on 11/09/2019 new maintenance logs and checklist for safe operation and inspection of mechanical lifts. c. Reviewed on 11/09/2019 written laundry processes for caring for the mechanical lift slings. d. Reviewed on 11/09/2019 log and tracking of 45 new slings identified in the facility. e. Reviewed on 11/09/2019: new in-service training for all staff on duty. The staff had been re-trained on proper mechanical lift transfers with return demonstration required before being placed on assignment. f. Observation on 11/09/2019 of all mechanical lifts in the facility revealed the facility had taken out of service all existing lifts including the hospice lift and replaced with five replacement lifts. The observations revealed all lifts had been documented on a log and inspected prior to placing in service. g. Observation on 11/09/2019 of all slings in the facility revealed the facility had placed 45 new slings in the facility of various size and weight requirements. All identified slings had a triangle with a number marked on the sling. The triangle and number matched a sling number recorded in the log book to track the manufacture date and date the sling was placed in service. h. Observation on 11/09/2019 where all identified mechanical lifts were utilized: resident rooms, linen closets, laundry, storage rooms and bathrooms were observed for old slings. None were found. i. Observation on 11/09/2019 of three mechanical lift transfers and one two-person bariatric gait belt transfer revealed the staff used the equipment and the number of staff persons indicated by facility policy. j. Observation on 11/09/2019 of the laundry area revealed there was one sling, #22, hang drying in the laundry room. A sign had been placed proximately on the wall indicating all slings were to be hang dried. k. During an interview with Laundry Aide K on 11/09/2019 at 12:11 p.m., Laundry Aide K stated she was able to identify the appropriate detergent, temperature setting, and washer used to launder the slings. Laundry Aide K further stated she knew that all slings needed to be hang dried and any old slings she was able to identify were to be turned in immediately to the Administrator. l. Interviews on 11/09/2019 with all nursing staff present and noted on the 6:00 a.

Based on observations, interviews, and record reviews, the facility failed to develop and implement written policies and procedures that ensure residents were free from neglect for 2 of 24 residents (Residents #4 and #46) whose care was reviewed for neglect, in that: 1. The facility failed to have structures in place to ensure adequate and appropriate equipment including procedures for how to maintain equipment for rental mechanical lifts and slings, which resulted in injuries to Residents #46 and #4. 2. The facility failed to implement their process for ongoing monitoring and supervision of staff to assure safe transfers of residents as implemented on their written care plan which resulted in injuries to Residents #46 and #4. These failures resulted in identification of Immediate Jeopardy (IJ) on 11/07/2019 at 5:37 pm. The IJ was removed on 11/08/2019, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk of falls. These deficient practices resulted in Resident #46 and #4 sustaining injuries and could place other residents requiring assistance with transfers at-risk for injury and harm and created the potential to negatively impact the psychosocial well being of residents such as mental anguish and fear. The findings were: 1. Record review of Resident #46's face sheet, dated 11/08/2019, revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #46's Care Plan (start date of 07/03/2018 and a revision date of 07/15/2018) for ADLs related to debility revealed interventions which included two staff member mechanical lift for all transfers. Record review of Resident #46's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, which indicated the resident had moderate cognitive impairment, and the resident required extensive assistance with two plus staff persons for physical assistance with transfers. Record review of Resident # 46's Provider Investigative Report, dated 10/25/2019, revealed the resident had an incident involving neglect on 10/25/2019 at 9:10 am in which CNA A performed an improper mechanical lift transfer that resulted in the resident experiencing an occipital contusion and a left tibia and fibula fracture. Further review revealed the facility investigation had noted CNA A had performed an improper mechanical lift technique of, willful violation. Record review of an Administrative Statement written and signed by the DON and dated 10/25/2019 revealed: at 9:10 am Administrative Staff were made aware of a fall during a mechanical lift transfer involving Resident #46. The resident complained of left lower extremity and occipital lobe pain. An assessment revealed pain and swelling to Resident #46's left lower extremity. Resident # 46 was transported to a local hospital for treatment. Further review revealed, CNA A stated he performed the lift by himself when the slings loop jumped track resulting in the fall. CNA A confirmed he did not have assistance with the transfer. CNA A further confirmed he was aware of a facility policy requiring 2 staff members for the mechanical lift transfer. Record review of a Nursing Home to Hospital Transfer Form, dated 10/25/2019, revealed Resident #46 had a fall during a mechanical lift transfer where the sling came loose from the lift and the resident fell back approximately three feet from the air. Further review revealed the resident complained of pain to the left ankle with swelling and had a hematoma to the back of the head. Record review of a Final X-Ray Report from a local hospital for Resident #46, dated 10/25/2019, revealed a displaced fracture to the left tibia and fibula, Osteopenia, and soft tissue swelling. Record review of Resident #46's Nurses Progress Notes, dated 10/25/2019, documented by LVN B and dated 10/25/2019 at 1:12 p.m. revealed LVN B, was informed by CNA A during a mechanical lift transfer the sling slipped off a hook of the lift and Resident #46 fell on to her right side. Resident #46 stated she fell while being transferred with the mechanical lift and stated she hit her head on the floor and was having increased pain to her left leg and ankle. Resident assessment noted increased swelling to left ankle with complaints of pain at a level 8 and hematoma to back of the head. Record review of CNA A's Skills Checklist for Mechanical Lift Use, dated 09/07/2017, revealed CNA A had been evaluated for mechanical lift use on 07/07/2017, 07/09/2018, and 09/16/2019 where demonstrated competency of skills. During an interview with Resident #46 on 11/05/2019 at 1:25 p.m., the resident confirmed she had been in the process of being transferred from the bed to a wheelchair by one staff person when she fell and hit her head. Resident #46 stated the fall had caused her, to hurt all over including her head and broke her leg. Observation of a video on 11/6/19 dated 10/25/2019 revealed Resident #46 was in the process of being transferred from bed to wheelchair by CNA [NAME] Further observation revealed Resident #46 fell when the lift was in the high position and the resident was positioned away from the bed. The fall occurred when one corner of the sling came detached from the overhead harness and the resident fell to the ground. Screen shots from the video were used to identify the mechanical lift used during this incident. A thick green rubber band was observed wrapped around the battery pack and frame three times and was secured in place with a knot, black electrical tape was observed on the remote for the mechanical lift, and the mechanical lift's identification plate was also identified. During an interview with CNA A on 11/06/2019 at 11:05 a.m., CNA A confirmed he performed the mechanical lift transfer of Resident #46 without the assistance of another staff member. CNA A stated the sling's loop, jumped off the track, during the transfer causing Resident #46 to fall to the ground. CNA A stated he was not trained to have the assistance of another staff person for mechanical lift transfers. CNA A further stated the management of the facility knew he was performing the transfers without assistance. During an interview with LVN B on 11/06/2019 at 11:33 a.m., LVN B confirmed he had been notified Resident #46 had fallen from the mechanical lift when he was the charge nurse on duty 10/25/2019. LVN B confirmed CNA A had admitted he had performed the mechanical lift transfer alone instead of with the required two staff person. LVN B stated he had assessed Resident #46 and noted the resident had a hematoma that was approximately a golf-ball sized and slightly smaller to the back of the head, and the resident complained of pain to the left leg. LVN B stated Resident #46 was sent to the ER at a local hospital because she was on anticoagulants and at-risk for bleeding. LVN B stated, A mechanical lift transfer is always two persons. All the CNA's know and have been in-serviced many times. CNA A did not ask for assistance. Observation of a mechanical lift transfer for Resident #46 on 11/07/2019 at 3:11 p.m. revealed the mechanical lift had a thick green rubber band tied around the battery pack and frame of the lift and was secured with a knot and black electrical tape around the remote. Further observation revealed during the transfer the mechanical lift made an audible beep or alarm noise when in use. During an interview with CNA [NAME] on 11/08/2019 at 8:44 a.m., CNA [NAME] confirmed she was trained to perform mechanical lift transfers with two staff persons. CNA [NAME] stated, staff are only using one person for mechanical lift transfers, I am not going to lie. During an interview with CNA F on 11/08/2019 at 9:12 a.m., CNA F stated she did not know about a Kardex or Kiosk for knowing which residents required two staff members. CNA F stated she just learned on the job which residents could get out of bed with one person and which needed two persons. During an interview with the Maintenance Manager on 11/08/2019 at 11:50 a.m., the Maintenance Manager confirmed the mechanical lift with the thick green band wrapped around the battery pack and frame was not functioning correctly. The Maintenance Manager confirmed that mechanical lift had a, remote issue, and was taken out of service on 11/07/2019 after surveyor intervention. The Maintenance Manager further confirmed there was not a system in place to identify and take out of service broken or damaged equipment until surveyor intervention. The Maintenance Manager confirmed he did not know about the broken base plate until surveyor intervention b. Record review of a Grievance Resolution Form, dated 10/01/2019, revealed Resident #4 made a complaint that she was a two person transfer but only one CNA helped at times due to short(age) of staff. Further review revealed the facility had confirmed the allegation and provided staff education. The document was signed by two staff members including the Administrator on 10/11/2019. Observation of a two-person transfer from wheelchair to toilet for Resident #4 on 11/06/2019 at 10:40 a.m. revealed two staff members, including CNA D and the charge nurse, assisted Resident # 4 to a standing position without the use of a gait belt. Further observation revealed Resident #4 was assisted to standing while the resident used the grab bar in the bathroom for leverage and support. During an interview with LVN L on 11/06/2019 at 11:00 a.m., LVN L confirmed Resident #4 required two staff persons for all transfers and assistance. LVN L stated Resident #4 had a history of [REDACTED]. LVN L confirmed all transfers required the use of a gait belt. During an interview with CNA I on 11/06/2019 at 4:55 p.m., CNA I confirmed she had transferred Resident #4 without the assistance of another staff member on 11/05/2019, on the day of surveyor arrival at the facility. CNA I stated there were no other staff to assist her with the transfer, and then confirmed she had not asked any other staff member for assistance. CNA I confirmed she knew Resident #4 required two staff members for a safe transfer. During an interview with the DON on 11/07/2019 at 8:20 a.m., the DON confirmed CNA I had transferred Resident #4 without the assistance of a second staff member as required. The DON confirmed Resident #4 was originally a mechanical lift transfer but had been assessed and determined to be a safe two-person gait belt transfer. During an interview with CNA D on 11/08/2019 at 1:45 p.m., CNA D confirmed Resident #4 was assisted to transfer without the use of a gait belt. CNA D stated a regular-sized gait belt did not fit Resident #4 and further stated she did not have a bariatric gait belt. CNA D confirmed that if Resident #4 began to fall without a gait belt on the staff would be unable to prevent the resident from falling. During an interview with Unit Manager G on 11/08/2019 at 5:00 p.m. Unit Manager G confirmed Resident #4's grievance allegation had been confirmed by the facility. Unit Manager G confirmed no in-service training had been performed, instead he had just talked to the staff member involved. UM G stated a staff member had assisted Resident #4 to a standing position to change her pants and that a true transfer had not occurred. During an interview with the Administrator on 11/09/2019 at 9:42 a.m., the Administrator confirmed all two-person transfers require a gait belt including bariatric residents. Record review of the facility's policy titled, Gait Belt Transfer, dated 05/2007, revealed: It is the policy of this facility to: 1. Provide safety for the unsteady resident. 2. Aid in the transfer of the dependent resident. 3. Prevent injuries to employees and residents. 4. Allow the resident and aide to feel more secure during a transfer. Transfer from bed to chair, commode or wheelchair; two-person transfer. 6. Resident may assist . 7. Stand close to resident with your feet about 18 inches apart. 8. Place gait belt around resident's wait; snug but not tight. 9. Stand on either side of resident facing each other. 10. Grasp the gait belt on either side. During an interview with the Medical Director on 11/09/2019 at 9:52 a.m., the Medical Director stated he addressed issues in the facility as they arose and in QAPI meetings held 1-2 times a month. The Medical Director stated he relied on the Administration of the facility to properly document compliance and communicate to him any problems, issues or concerns. The Medical Director confirmed he had been notified of Resident #4's fall incident because he was the physician on-call when the incident occurred. The Medical Director confirmed he was not notified of the fall incident with Resident #46 until 11/08/2019 (after surveyor intervention). Record review of the facility's policy titled Hoyer lift, dated 05/2007, revealed, It is the policy of this facility that the Hoyer lift (mechanical lift) will be utilized for resident transfers only. Assistance of two personnel will be used with mechanical lift. Record review of the facility's policy titled Equipment Maintenance, dated 05/2007, revealed: It is the policy of this facility to establish procedures for routine and non-routine care of equipment and to ensure that equipment remains in good working order for resident and staff safety. 1. All staff will be trained in proper use of program equipment, as per each manufacturer's instructions. 2. Electrical and hydraulic equipment will be inspected by the Maintenance Supervisor prior to initial use and on a routine basis to ensure that equipment is working properly. 4. Routine inspections and Maintenance will be recorded in the TELS system (building management system). 2. a. Record review of Resident #4's face sheet, dated 11/08/2019, revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 12, which indicated the resident was cognitively intact, and the resident required extensive assistance with two plus staff persons for assistance Record review of Resident #4's Care Plan for ADL self-care, dated 06/03/2019 and revised on 10/25/2019, revealed the resident required a mechanical lift with two staff personal assistance, last revised on 07/05/2019 which revealed the resident required extensive assistance with two staff members. Record review of Resident #4's Nurse's Progress Notes on 09/12/2019 at 4:20 p.m. written by ADON H revealed Resident #4 had a witnessed fall in the room during a transfer with a mechanical lift. Further review revealed an unidentified CNA voiced during the resident's transfer that the sling had detached from the lift and Resident #4 fell to the floor landing on her right hip. Resident #4 voiced pain to right hip/femur area and noted decreased mobility to RLE. Record review of a Provider Investigation Report, dated 09/12/2019, revealed Resident #4 fell while being transferred from bed to her power wheelchair during a mechanical lift transfer due to a sling failure. Further review revealed the resident had right lower extremity pain and a contusion. Resident #4 also presented with drowsiness post-fall and was transported by EMS to a local hospital. Record review of Nurse's Progress notes, dated 09/12/2019 at 4:20 p.m., revealed Resident #4 had a witnessed fall in her room during a transfer from bed to chair. Further review revealed the mechanical lift sling detached from the mechanical lift and the resident fell to the floor on her right hip. Resident #4 experienced decreased mobility to right lower extremity noted, and an X-ray was ordered. Record review of a typed written statement by ADON H, dated 09/13/2019, revealed ADON H was notified by nursing staff that Resident #4 had a witnessed fall during a mechanical lift transfer in which the sling failed. A change in the resident's condition was noted in which the resident was having difficulty arousing to verbal stimuli and neuro checks presented with abnormal findings. Further review revealed 911 was called and the resident was sent to the ER for an evaluation. Record review of a facility fall report dated 09/20/2019, revealed Resident #4 had a witnessed fall caused by a broken sling on 09/12/2019 while being transferred from bed to powerchair. Further review revealed Resident #4 complained of pain 10 out of 10 to right hip and right lower leg. Further review of the facility fall report revealed post-fall investigation Resident #4 was sent to the ER for an evaluation. A sling audit of all slings in the building was completed and staff were in-serviced. Observation of a video on 11/6/19 dated 09/12/2019 revealed Resident #4 fell from a mechanical lift transfer while raised in the highest position. Further observation of the video revealed one loop of the sling fell near the resident's right foot and the second loop fell near right side of the resident's head. Further observation revealed four staff members were identified as being present during the lift, and the broken loop strap was observed on the resident's bed after the fall. During an interview with Resident #4 on 11/06/2019 at 11:45 a.m., Resident #4 confirmed she had fallen from the mechanical lift during a transfer and was sent to the emergency room . During an interview with CNA D on 11/07/2019 at 1:45 p.m., CNA D confirmed Resident #4 fell from the mechanical lift due to a sling failure. CNA D confirmed she did not inspect the sling or mechanical lift prior to its use for the transfer with Resident #4 on 09/12/2019. b. Record review of the Maintenance Manager's last three Logbook documentation dated 08/02/2019, 09/05/2019, and 10/14/2019 revealed: Resident lifts: inspect mobile lifts as needed. Further review of log revealed page 2 steps: conduct lift safety inspection (inspect all that apply) no notes or comments were logged on this documentation. Record review of a local company invoice for Safety Check Inventory, dated 08/2019, listed four mechanical lifts that were calibrated and inspected. Further review revealed only two mechanical lifts were identified as still in use by the facility, one of which was identified as the lift with the thick green band. During an interview with the DON on 11/07/2019 at 2:40 p.m. the DON confirmed Resident #4's fall from the mechanical lift was a result of a sling failure. The DON stated he did not know why the incident occurred and stated he, would like to think (the sling) was inspected, before use. The DON confirmed that before the incident occurred there was not a policy in place to inspect the slings for wear and damage and he did not personally inspect any of the slings or mechanical lift equipment. The DON stated Resident #46's fall from the mechanical lift incident occurred because CNA A did not ask for assistance with the transfer. The DON stated resident transfer information was available to all staff and was located on both the Kardex and Kiosk. The DON stated he had in-serviced and repeatedly instructed staff to check the Kardex/Kiosk for resident requirements before performing patient care. The DON confirmed he was not monitoring staff for compliance with resident transfers and stated the staff had been trained over and over. The DON confirmed a family member had informed him of the one-person mechanical lift transfers. The DON confirmed he terminated another employee since the survey began for performing an improper one-person transfer. During an interview with the Administrator on 11/07/19 at 2:55 p.m., the Administrator confirmed before the mechanical lift fall incident with Resident #4, there was not a facility process in place to monitor or track sling manufacture dates or length of time the slings had been in use and no facility policy on how long a sling could stay in circulation. The Administrator stated that if the sling worked and did not look worn or frayed then it was being used. The Administrator confirmed there was no staff monitoring for equipment inspections. The Administrator further stated staff had been trained on two-person mechanical lift transfers and she performed random audits in which she walked in and out of resident rooms to monitor staff but did not keep any records to document staff compliance. The Administrator confirmed she was not aware that one-person transfers were still occurring after Resident #46 had the fall from the mechanical lift. Observation of a mechanical lift transfer for Resident #46 on 11/07/2019 at 3:11 p.m. revealed the mechanical lift had a thick green rubber band tied around the battery pack and frame of the lift and was secured with a knot and black electrical tape around the remote. Further observation revealed during the transfer the mechanical lift made an audible beep or alarm noise when in use. During an interview with LVN I on 11/07/2019 at 3:45 p.m., LVN I confirmed lift #12LS 014 had an out of date inspection of 11/12/2017 and confirmed no other inspection sticker could be located. Observation on 11/07/2019 at 3:45 p.m. of seven mechanical lifts in use in the facility revealed: - One mechanical lift with a thick green rubber band around the battery pack with last inspection date which read, due 8/2019, was in the CNA training room with a piece of paper taped to the frame which read, Safety check inventory. - One mechanical lift white in color last inspected 11/12/2017, inspection due 02/2018, ID #12LS 014. - One mechanical lift identified as belonging to a Hospice company ID # 365 had no inspection date. - Four mechanical lifts identified as belonging to a rental company were without inspection dates. During an interview with the Maintenance Manager on 11/07/2019 at 3:55 p.m., the Maintenance Manager confirmed that the four rental mechanical lifts and one hospice mechanical lift did not have inspection dates. The Maintenance Manager stated that since the five mechanical lifts belonged to a rental company and a hospice company, he did not inspect them before they were placed into service. The Maintenance Manager confirmed he had no way of tracking when the five mechanical lifts had been inspected. The Maintenance Manager stated, they (the mechanical lifts) were from a rental company, I would assume they were inspected already. The Maintenance Manager further confirmed he did not know why one of the facility-owned mechanical lifts had a last inspection date of (YEAR). The Maintenance Manager stated he made rounds and inspected facility-owned mechanical lifts as needed but did not document which mechanical lifts he had inspected or tested . Observation on 11/07/2019 at 4:15 p.m., with the Maintenance Manager, revealed a mechanical lift had several large cracks in the base plate. Further observation revealed the Maintenance Manager moved the mechanical lift slightly and pushed on the base plate with his foot. The Maintenance Manager then left the mechanical lift with the broken base plate in the hallway. During an interview with the Maintenance Manager on 11/07/2019 at 4:16 p.m., the Maintenance Manager confirmed he was not aware of the mechanical lift with several large cracks in the base plate before surveyor intervention. During an interview with CNA C on 11/08/2019 at 7:45 a.m., CNA C confirmed the mechanical lift had malfunctioned during Resident #46's transfer. CNA C stated the mechanical lift's arm would not lift the resident all the way and was hard to maneuver. CNA C confirmed Resident #46's transfer she heard the mechanical lift machine beeping the entire time and stated, I didn't know what was wrong with it. The interview further revealed that she had been trained to always check the battery and the brakes before using a mechanical lift but didn't think anything of the beeping. CNA C confirmed the lift had a thick green rubber band tied around the battery pack and frame but stated she didn't know why the band was in place. CNA C confirmed the facility had been using slings, that were really worn. CNA C stated, even the protective ropes on the slings were worn, but we didn't have enough slings. During an interview with ADON H on 11/08/2019 at 11:40 a.m., ADON H confirmed equipment inspections were not occurring prior to surveyor intervention. The ADON stated broken equipment was to be logged into the maintenance book but there had been no follow through with inspections. The ADON further stated he was not aware that staff had been performing one-person mechanical lift and one person instead of two-person gait belt transfers. Record review of the facility's policy titled Abuse: Prevention of and Prohibition Against, dated 11/28/2017 and revised 04/2019, revealed: It is the policy of this Facility that each resident has the right to be free from abuse, neglect. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes the rights of the resident to be free from abuse, neglect. D. Prevention - supervising staff to identify and correct any inappropriate or unprofessional behaviors. Assuring that residents are free from neglect by having the structures and processes to provide need care and services to all residents. The Administrator was notified of an IJ on 11/07/2019 at 5:37 pm and was given a copy of the IJ Template and a Plan of Removal was requested. The Plan of Removal accepted on 11/08/19 included the following: Plan of Removal 11/08/2019 Immediate Action - Medical Director notified of IJ - Mechanical lift identified as faulty was taken out of use. Serial # 4A - 5 Mechanical lifts were currently in service and were inspected by an outside company on 11/7/19 & 11/8/19 prior to being used. Serial #'s P 0, PL650HD 013, PL 7, 4A D, PLEA 16. Maintenance director performed safety inspection on all 5 above listed mechanical lifts on 11/8/19 and logged it into the mechanical lift tracker on 11/8/19. - Mechanical lifts were logged into a tracking log by serial number on 11/8/19. A sticker with a date for next annual inspection and initials of certified biomedical technician was placed on the mechanical lift on 11/7/19 and logged on tracking sheet on 11/8/19. - All slings taken out of service and replaced with new slings. - Residents #4 and #46 assessed post fall at time of occurrence and monitored for pain management. Identification of Others Affected: - There are twenty-one residents who are currently transferred via mechanical lift. Systemic Change to Prevent Re-occurrence: - Laundry personnel in-serviced on care of slings per manufacturer's recommendations by Administrator/DON / Laundry Supervisor on 11/8/19 and ongoing. Slings will be washed according to manufacturer's guidelines. Max temp 120 F and air dry only. No chlorine bleach. - Nurses, Nurse Aides, and Therapy personnel in-serviced on slings and Hoyer lift transfers to ensure sling is placed properly under resident and at least 2 people perform each transfer. - Administrator/Designee to keep log of slings to ensure proper care of slings, discarding slings when necessary, to ensure par level of slings to meet residents' needs. New slings were marked with a triangle symbol and number on 11/7/19 so staff could identify them as a new sling. The number on the sling is tracked on the sling tracking log. The sling inspection has been added to the MARS for a daily check by nursing to ensure they are intact and do not have any tears, frays, bleach stains or damage. There are currently 45 slings in house. - Laundry Manager to verify laundry detergent is appropriate for care of sling with chemical vendor - Maintenance Director to verify operational condition of Hoyer lift with medical equipment vendor, the cosmetic plastic covering on base of lift to be replaced, however, it does not affect safe function of lift. - Maintenance Director to conduct safety check of mechanical lift monthly, safety checked to be tracked as part of the EMR. - Maintenance Director to have an annual check by biomedical technician on all mechanical lifts. Monitoring: - Daily check of slings for tears, frays, bleach stains and damages by Charge nurse/designee beginning on 11/8/19. - Daily check of mechanical lifts for safety for operation status for one week beginning on 11/8/19. The following will be checked: wheels lock, base legs expand with ease, handle operates as intended, lift does not have any frayed wires, remote operates, push handles are in place and secure, battery pack holds a charge, sling attachment points are not bent or damaged and boom raises/lowers without difficulty. - In-services conducted by DON/ADON/Administrator ongoing starting 11/07/19 to nurses, nurse aides and therapy personnel. After 90% of personnel educated, the remaining personnel will be in-serviced prior to their next shift. - DON/ADON will monitor mechanical lift transfers daily x 2 weeks during walking rounds and on random shifts to ensure competency. - Summary of IJ and corrective action to be reviewed by QAPI within 7 days and monthly for 90 days to ensure ongoing compliance. Verification of the Plan of Removal was as follows: a. Reviewed on 11/09/2019 pain management tracking and MAR's revealed for Residents #4 and #46 to ensure adequate pain control and monitoring with no concerns identified. b. Reviewed on 11/09/2019 new maintenance logs and checklist for safe operation and inspection of mechanical lifts. c. Reviewed on 11/09/2019 written laundry processes for caring for the mechanical lift slings. d. Reviewed on 11/09/2019 log and tracking of 45 new slings identified in the facility. e. Reviewed on 11/09/2019: new in-service training for all staff on duty. The staff had been re-trained on proper mechanical lift transfers with return demonstration required before being placed on assignment. f. Observation on 11/09/2019 of all mechanical lifts in the facility revealed the facility had taken out of service all existing lifts including the hospice lift and replaced with five replacement lifts. The observations revealed all lifts had been documented on a log and inspected prior to placing in service. g. Observation on 11/09/2019 of all slings in the facility revealed the facility had placed 45 new slings in the facility of various size and weight requirements. All identified slings had a triangle with a number marked on the sling. The triangle and number matched a sling number recorded in the log book to track the manufacture date and date the sling was placed in service. h. Observation on 11/09/2019 where all identified mechanical lifts were utilized: resident rooms, linen closets, laundry, storage rooms and bathrooms were observed for old slings. None were found. i. Observation on 11/09/2019 of three mechanical lift transfers and one two-person bariatric gait belt transfer revealed the staff used the equipment and the number of staff persons indicated by facility policy. j. Observation on 11/09/2019 of the laundry area revealed there was one sling, #22, hang drying in the laundry room. A sign had been placed proximately on the wall indicating all slings were to be hang dried. k. During an interview with Laundry Aide K on 11/09/2019 at 12:11 p.m., Laundry Aide K stated she was able to identify the appropriate detergent, temperature setting, and washer used to launder the slings. Laundry Aide K further stated she knew that all slings needed to be hang dried and any old slings she was able

Based on observations, record reviews and interviews the facility failed to ensure the resident environment remained as free of accident hazards as possible for 2 of 24 residents (Residents #4 and #46) reviewed for care and 7 of 7 mechanical lifts reviewed in that: 1. The facility did not document, track, inspect, and maintain equipment in a safe operational manner for mechanical lifts and mechanical lifts slings. a. Resident #46 was transferred with a mechanical lift that was not functioning properly. b. During Resident 4's mechanical lift transfer the lift sling detached from the mechanical lift resulting in a witnessed fall. Resident #4 complained of pain to right hip and right lower leg and was sent to the emergency room for evaluation and suffered a contusion to her right hip. c. Facility rental and Hospice mechanical lifts were not being inspected and maintained by facility. 2. The facility did not monitor staff to ensure residents were being transferred in a safe manner with mechanical lifts and two person transfers. a. Resident #46 was transferred by a mechanical lift using one person assist instead of two as required. Resident #46 fell and suffered an occipital contusion and a left tibia and fibula fracture. b. CNA I transferred Resident #4 as a one person assist when the resident required a two person assist for transfers and staff were not using the necessary gait belt for safe transfers. These failures resulted in identification of Immediate Jeopardy (IJ) on 11/07/2019 at 5:37 p.m While the IJ was removed on 11/08/2019, the facility remained out of compliance at a level of actual harm with a scope identified as a pattern until interventions were put in place for all residents at risk of falls. These deficient practices resulted in Resident #46 and #4 sustaining injuries and could place other residents requiring assistance with transfers at-risk for injury and harm and created the potential to negatively impact the psychosocial well being of residents such as mental anguish and fear. The findings were: 1. a. Record review of Resident #46's face sheet, dated 11/08/2019, revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #46's Care Plan (start date of 07/03/2018 and a revision date of 07/15/2018) for ADLs related to debility revealed interventions which included two staff member mechanical lift for all transfers. Record review of Resident #46's Quarterly MDS, dated [DATE], revealed a BIMS score of 9, which indicated the resident had moderate cognitive impairment, and the resident required extensive assistance with two plus staff persons for physical assistance with transfers. Record review of Resident # 46's Provider Investigative Report, dated 10/25/2019, revealed the resident had an incident involving neglect on 10/25/2019 at 9:10 am in which CNA A performed an improper mechanical lift transfer that resulted in the resident experiencing an occipital contusion and a left tibia and fibula fracture. Further review revealed the facility investigation had noted CNA A had performed an improper mechanical lift technique of, willful violation. Record review of an Administrative Statement written and signed by the DON and dated 10/25/2019 revealed: at 9:10 am Administrative Staff were made aware of a fall during a mechanical lift transfer involving Resident #46. The resident complained of left lower extremity and occipital lobe pain. An assessment revealed pain and swelling to Resident #46's left lower extremity. Resident # 46 was transported to a local hospital for treatment. Further review revealed, CNA A stated he performed the lift by himself when the slings loop jumped track resulting in the fall. CNA A confirmed he did not have assistance with the transfer. CNA A further confirmed he was aware of a facility policy requiring 2 staff members for the mechanical lift transfer. Record review of a Nursing Home to Hospital Transfer Form, dated 10/25/2019, revealed Resident #46 had a fall during a mechanical lift transfer where the sling came loose from the lift and the resident fell back approximately three feet from the air. Further review revealed the resident complained of pain to the left ankle with swelling and had a hematoma to the back of the head. Record review of a Final X-Ray Report from a local hospital for Resident #46, dated 10/25/2019, revealed a displaced fracture to the left tibia and fibula, Osteopenia, and soft tissue swelling. Record review of Resident #46's Nurses Progress Notes, dated 10/25/2019, documented by LVN B and dated 10/25/2019 at 1:12 p.m. revealed LVN B, was informed by CNA A during a mechanical lift transfer the sling slipped off a hook of the lift and Resident #46 fell on to her right side. Resident #46 stated she fell while being transferred with the mechanical lift and stated she hit her head on the floor and was having increased pain to her left leg and ankle. Resident assessment noted increased swelling to left ankle with complaints of pain at a level 8 and hematoma to back of the head. Record review of CNA A's Skills Checklist for Mechanical Lift Use, dated 09/07/2017, revealed CNA A had been evaluated for mechanical lift use on 07/07/2017, 07/09/2018, and 09/16/2019 where demonstrated competency of skills. Observation of a video on 11/6/19 dated 10/25/2019 revealed Resident #46 was in the process of being transferred from bed to wheelchair by CNA [NAME] Further observation revealed Resident #46 fell when the lift was in the high position and the resident was positioned away from the bed. The fall occurred when one corner of the sling came detached from the overhead harness and the resident fell to the ground. Screen shots from the video were used to identify the mechanical lift used during this incident. A thick green rubber band was observed wrapped around the battery pack and frame three times and was secured in place with a knot, black electrical tape was observed on the remote for the mechanical lift, and the mechanical lift's identification plate was also identified. During an interview with Resident #46 on 11/05/2019 at 1:25 p.m., the resident confirmed she had been in the process of being transferred from the bed to a wheelchair by one staff person when she fell and hit her head. Resident #46 stated the fall had caused her, to hurt all over including her head and broke her leg. During an interview with CNA A on 11/06/2019 at 11:05 a.m.,CNA A confirmed he performed the mechanical lift transfer of Resident #46 without the assistance of another staff member. CNA A stated the sling's loop, jumped off the track, during the transfer causing Resident #46 to fall to the ground. CNA A stated he was not trained to have the assistance of another staff person for mechanical lift transfers. CNA A further stated the management of the facility knew he was performing the transfers without assistance. During an interview with LVN B on 11/06/2019 at 11:33 a.m., LVN B confirmed he had been notified Resident #46 had fallen from the mechanical lift when he was the charge nurse on duty 10/25/2019. LVN B confirmed CNA A had admitted he had performed the mechanical lift transfer alone instead of with the required two staff person. LVN B stated he had assessed Resident #46 and noted the resident had a hematoma that was approximately a golf-ball sized and slightly smaller to the back of the head, and the resident complained of pain to the left leg. LVN B stated Resident #46 was sent to the ER at a local hospital because she was on anticoagulants and at-risk for bleeding. LVN B stated, A mechanical lift transfer is always two persons. All the CNA's know and have been in-serviced many times. CNA A did not ask for assistance. Observation of a mechanical lift transfer for Resident #46 on 11/07/2019 at 6:11 p.m. revealed the mechanical lift had a thick green rubber band tied around the battery pack and frame of the lift and was secured with a knot and black electrical tape around the remote. Further observation revealed during the transfer the mechanical lift made an audible beep or alarm noise when in use. During an interview with CNA [NAME] on 11/08/2019 at 8:44 a.m., CNA [NAME] confirmed she was trained to perform mechanical lift transfers with two staff persons. CNA [NAME] stated, staff are only using one person for mechanical lift transfers, I am not going to lie. During an interview with CNA F on 11/08/2019 at 9:12 a.m., CNA F stated she did not know about a Kardex or Kiosk for knowing which residents required two staff members. CNA F stated she just learned on the job which residents could get out of bed with one person and which needed two persons. During an interview with the Maintenance Manager on 11/08/2019 at 11:50 a.m., the Maintenance Manager confirmed the mechanical lift with the thick green band wrapped around the battery pack and frame was not functioning correctly. The Maintenance Manager confirmed that mechanical lift had a, remote issue, and was taken out of service on 11/07/2019 after surveyor intervention. The Maintenance Manager further confirmed there was not a system in place to identify and take out of service broken or damaged equipment until surveyor intervention. The Maintenance Manager confirmed he did not know about the broken base plate until surveyor intervention. b. Record review of Resident #4's face sheet, dated 11/08/2019, revealed an admission date of [DATE], with a readmission date of [DATE], with [DIAGNOSES REDACTED]. Record review of Resident #4's Quarterly MDS, dated [DATE], revealed a BIMS score of 12, which indicated the resident was cognitively intact, and the resident required extensive assistance with two plus staff persons for assistance Record review of Resident #4's Care Plan for ADL self-care, dated 06/03/2019 and revised on 10/25/2019, revealed the resident required a mechanical lift with two staff personal assistance, last revised on 07/05/2019 which revealed the resident required extensive assistance with two staff members. Record review of Resident #4's Nurse's Progress Notes on 09/12/2019 at 4:20 p.m. written by ADON H revealed Resident #4 had a witnessed fall in the room during a transfer with a mechanical lift). Further review revealed an unidentified CNA voiced during the resident's transfer that the sling had detached from the lift and Resident #4 fell to the floor to right hip. Resident #4 voiced pain to right hip/femur area and noted decreased mobility to RLE. Record review of a Provider Investigation Report, dated 09/12/2019, revealed Resident #4 fell while being transferred from bed to her power wheelchair during a mechanical lift transfer due to a sling failure. Further review revealed the resident had right lower extremity pain and a contusion. Resident #4 also presented with drowsiness post-fall and was transported by EMS to a local hospital. Record review of Nurse's Progress notes, dated 09/12/2019 at 4:20 p.m., revealed Resident #4 had a witnessed fall in her room during a transfer from bed to chair. Further review revealed the mechanical lift sling detached from the mechanical lift and the resident fell to the floor on her right hip. Resident #4 experienced decreased mobility to right lower extremity noted and an X-ray was ordered. Record review of a typed written statement by ADON H, dated 09/13/2019, revealed ADON H was notified by nursing staff that Resident #4 had a witnessed fall during a mechanical lift transfer in which the sling failed. A change in the resident's condition was noted in which the resident was having difficulty arousing from verbal stimuli and neuro checks presented with abnormal findings. Further review revealed 911 was called and the resident was sent to the ER for an evaluation. Record review of a facility fall, report dated 09/20/2019, revealed Resident #4 had a witnessed fall caused by a broken sling on 09/12/2019 while being transferred from bed to powerchair. Further review revealed Resident #4 complained of pain 10 out of 10 to right hip and right lower leg. Investigation post-fall revealed Resident #4 was sent to the ER for an evaluation. A sling audit of all slings in the building was completed and staff were in-serviced Observation of a video on 11/6/19 dated 09/12/2019 revealed Resident #4 fell from a mechanical lift transfer while raised in the highest position. Further observation of the video revealed first one loop of the sling fell near the resident's right foot from the lift and was followed closely by the second loop falling near the resident's right side of the resident's head. Further observation revealed four staff members were identified as being present during the lift, and the broken loop strap was observed on the resident's bed after the fall. During an interview with Resident #4 on 11/06/2019 at 11:45 a.m., Resident #4 confirmed she had fallen from the mechanical lift during a transfer. During an interview with CNA D on 11/07/2019 at 1:45 p.m., CNA D confirmed Resident #4 fell from the mechanical lift due to a sling failure. CNA D confirmed she did not inspect the sling or mechanical lift prior to its use for the transfer with Resident #4 on 09/12/2019. c . Record review of the Maintenance Manager's last three Logbook documentation dated 08/02/2019, 09/05/2019, and 10/14/2019 revealed: Resident lifts: inspect mobile lifts as needed. Further review of log revealed page 2 steps: conduct lift safety inspection (inspect all that apply) no notes or comments were logged on this document. Record review of a local company invoice for Safety Check Inventory, dated 08/2019, listed four mechanical lifts that were calibrated and inspected. Further review revealed only two of those mechanical lifts were identified as still in use by the facility, one of which was identified as the lift with the thick green band. During an interview with the DON on 11/07/2019 at 2:40 p.m., the DON confirmed Resident #4's fall from the mechanical lift was a result of a sling failure. The DON stated he did not know why the incident occurred and stated he, would like to think (the sling) was inspected, before use. The DON confirmed that before the incident occurred there was not a policy in place to inspect the slings for wear and damage and he did not personally inspect any of the slings or mechanical lift equipment. The DON stated Resident #46's fall from the mechanical lift incident occurred because CNA A did not ask for assistance with the transfer. The DON stated resident transfer information was available to all staff and was located on both the Kardex and Kiosk. The DON stated he had in-serviced and repeatedly instructed staff to check the Kardex/Kiosk for resident requirements before performing patient care. The DON confirmed he was not monitoring staff for compliance with resident transfers and stated the staff had been trained over and over. The DON confirmed a family member had informed him of the one-person mechanical lift transfers. The DON confirmed he terminated another employee since the survey began for performing an improper one-person transfer. During an interview with the Administrator on 11/07/19 at 2:55 p.m., the Administrator confirmed before the mechanical lift fall incident with Resident #4, there was not a facility process in place to monitor or track sling manufacture dates or length of time the slings had been in use and no facility policy on how long a sling could stay in circulation. The Administrator stated that if the sling worked and did not look worn or frayed then it was being used. The Administrator confirmed there was no staff monitoring for equipment inspections. The Administrator further stated staff had been trained on two-person mechanical lift transfers and she performed random audits in which she walked in and out of resident rooms to monitor staff but did not keep any records to document staff compliance. The Administrator confirmed she was not aware that one-person transfers were still occurring after Resident #46 had the fall from the mechanical lift. Observation of a mechanical lift transfer for Resident #46 on 11/07/2019 at 3:11 p.m. revealed the mechanical lift had a thick green rubber band tied around the battery pack and frame of the lift and was secured with a knot and black electrical tape around the remote. Further observation revealed during the transfer the mechanical lift made an audible beep or alarm noise when in use. Observation on 11/07/2019 at 3:45 p.m. revealed the mechanical lift with a thick green rubber band around the battery pack had a last inspection date which read, due 8/2019, was in the CNA training room with a piece of paper taped to the frame which read, Safety check inventory. During an interview with the Maintenance Manager on 11/07/2019 at 3:55 p.m., the Maintenance Manager confirmed that the four rental mechanical lifts and one hospice mechanical lift did not have inspection dates. The Maintenance Manager stated that since the five mechanical lifts belonged to a rental company and a hospice company, he did not inspect them before they were placed into service. The Maintenance Manager confirmed he had no way of tracking when the five mechanical lifts had been inspected. The Maintenance Manager stated, they (the mechanical lifts) were from a rental company, I would assume they were inspected already. The Maintenance Manager further confirmed he did not know why one of the facility-owned mechanical lifts had a last inspection date of (YEAR). The Maintenance Manager stated he made rounds and inspected facility-owned mechanical lifts as needed but did not document which mechanical lifts he had inspected or tested . During an interview with CNA C on 11/08/2019 at 7:45 a.m., CNA C confirmed the mechanical lift had malfunctioned during Resident #46's transfer. CNA C stated the mechanical lift's arm would not lift the resident all the way and was hard to maneuver. CNA C confirmed Resident #46's transfer she heard the mechanical lift machine beeping the entire time and stated, I didn't know what was wrong with it. The interview further revealed that she had been trained to always check the battery and the brakes before using a mechanical lift but didn't think anything of the beeping. CNA C confirmed the lift had a thick green rubber band tied around the battery pack and frame but stated she didn't know why the band was in place. CNA C confirmed the facility had been using slings, that were really worn. CNA C stated, even the protective ropes on the slings were worn, but we didn't have enough slings. During an interview with ADON H on 11/08/2019 at 11:40 a.m., ADON H confirmed equipment inspections were not occurring prior to surveyor intervention. The ADON stated broken equipment was to be logged into the maintenance book but there had been no follow through with inspections. The ADON further stated he was not aware that staff had been performing one-person mechanical lift and one person instead of two-person gait belt transfers. During an interview with the Maintenance Manager on 11/08/2019 at 11:50 a.m., the Maintenance Manager confirmed the mechanical lift with the thick green band wrapped around the battery pack and frame was not functioning correctly. The Maintenance Manager confirmed that mechanical lift had a, remote issue, and was taken out of service on 11/07/2019 after surveyor intervention. The Maintenance Manager further confirmed there was not a system in place to identify and take out of service broken or damaged equipment until surveyor intervention. 2. a. Record review of Resident # 46's Provider Investigative Report, dated 10/25/2019, revealed the resident had an incident involving neglect on 10/25/2019 at 9:10 am in which CNA A performed an improper mechanical lift transfer that resulted in the resident experiencing an occipital contusion and a left tibia and fibula fracture. Further review revealed the facility investigation had noted CNA A had performed an improper mechanical lift technique of, willful violation. During an interview with Resident #46 on 11/05/2019 at 1:25 p.m., the resident confirmed she had been in the process of being transferred from the bed to a wheelchair by one staff person when she fell and hit her head. Resident #46 stated the fall had caused her, to hurt all over including her head and broke her leg. During an interview with CNA A on 11/06/2019 at 11:05 a.m., CNA A confirmed he performed the mechanical lift transfer of Resident #46 without the assistance of another staff member. CNA A stated the sling's loop, jumped off the track, during the transfer causing Resident #46 to fall to the ground. CNA A stated he was not trained to have the assistance of another staff person for mechanical lift transfers. CNA A further stated the management of the facility knew he was performing the transfers without assistance. b. Record review of a Grievance Resolution Form, dated 10/01/2019, revealed Resident #4 made a complaint that she was a two person transfer but only one CNA helped at times due to short(age) of staff. Further review revealed the facility had confirmed the allegation and provided staff education. The document was signed by two staff members including the Administrator on 10/11/2019. c. Observation of a two-person transfer from wheelchair to toilet for Resident #4 on 11/06/2019 at 10:40 a.m. revealed two staff members, including CNA D and the charge nurse, assisted Resident # to a standing position without the use of a gait belt. Further observation revealed Resident #4 was assisted to standing while the resident used the grab bar in the bathroom for leverage and support. During an interview with LVN L on 11/06/2019 at 11:00 a.m., LVN L confirmed Resident #4 required two staff persons for all transfers and assistance. LVN L stated Resident #4 had a history of [REDACTED]. LVN L confirmed all transfers required the use of a gait belt. During an interview with CNA I on 11/06/2019 at 4:55 p.m., CNA I confirmed she had transferred Resident #4 without the assistance of another staff member on 11/05/2019, on the day of surveyor arrival at the facility. CNA I stated there were no other staff to assist her with the transfer, and then confirmed she had not asked any other staff member for assistance. CNA I confirmed she knew Resident #4 required two staff members for a safe transfer. During an interview with CNA D on 11/08/2019 at 1:45 p.m., CNA D confirmed Resident #4 was assisted to transfer without the use of a gait belt. CNA D stated a regular-sized gait belt did not fit Resident #4 and further stated she did not have a bariatric gait belt. CNA D confirmed that if Resident #4 began to fall without a gait belt on the staff would be unable to prevent the resident from falling. During an interview with Unit Manager G on 11/08/2019 at 5:00 p.m. Unit Manager G confirmed Resident #4's grievance allegation had been confirmed by the facility. Unit Manager G confirmed no in-service training had been performed, instead he had just talked to the staff member involved. UM G stated a staff member had assisted Resident #4 to standing in order to change her pants and that a true transfer had not occurred. During an interview with the DON on 11/07/2019 at 8:20 a.m. the DON confirmed CNA I had transferred Resident #4 without the assistance of a second staff member as required. The DON confirmed Resident #4 was originally a mechanical lift transfer but had been assessed and determined to be a safe two-person gait belt transfer. During an interview with the Administrator on 11/09/2019 at 9:42 a.m. the Administrator confirmed all two-person transfers require a gait belt including bariatric residents. Record review of the facility's policy titled, Gait Belt Transfer, dated 05/2007, revealed: It is the policy of this facility to: 1. Provide safety for the unsteady resident. 2. Aid in the transfer of the dependent resident. 3. Prevent injuries to employees and residents. 4. Allow the resident and aide to feel more secure during a transfer. Transfer from bed to chair, commode or wheelchair; two-person transfer. 6. Resident may assist . 7. Stand close to resident with your feet about 18 inches apart. 8. Place gait belt around resident's wait; snug but not tight. 9. Stand on either side of resident facility each other. 10. Grasp the gait belt on either side. During an interview with the Medical Director on 11/09/2019 at 9:52 a.m., the Medical Director stated he addressed issues in the facility as they arose and in QAPI meetings held 1-2 times a month. The Medical Director stated he relied on the Administration of the facility to properly document compliance and communicate to him any problems, issues or concerns. The Medical Director confirmed he had been notified of Resident #4's fall incident because he was the physician on-call when the incident occurred. The Medical Director confirmed he was not notified of the fall incident with Resident #46 until 11/08/2019 (after surveyor intervention). Record review of the facility's policy titled Hoyer lift, dated 05/2007, revealed, It is the policy of this facility that the Hoyer lift (mechanical lift) will be utilized for resident transfers only. Assistance of two personnel will be used with Hoyer Lift. 10. Count links to be sure there are the same number on each side. Record review of the facility's policy titled Equipment Maintenance, dated 05/2007, revealed: It is the policy of this facility to establish procedures for routine and non-routine care of equipment and to ensure that equipment remains in good working order for resident and staff safety. 1. All staff will be trained in proper use of program equipment, as per each manufacturer's instructions. 2. Electrical and hydraulic equipment will be inspected by the Maintenance Supervisor prior to initial use and on a routine basis to ensure that equipment is working properly. 4. Routine inspections and Maintenance will be recorded in the TELS system (building maintenance system). The Administrator was notified of an IJ on 11/07/2019 at 5:37 p.m. and a Plan of Removal was requested. The Plan of Removal included the following: Plan of Removal 11/08/2019 Immediate Action - Medical Director notified of IJ - Hoyer lift identified as faulty was taken out of use. Serial # 4A - 5 Mechanical lifts were currently in service and were inspected by an outside company on 11/7/19 & 11/8/19 prior to being put to use. Serial #'s P 0, PL650HD 013, PL 7, 4A D, PLEA 16. Maintenance director performed safety inspection on all 5 above listed hoyers on 11/8/19 and logged it into the hoyer tracker on 11/8/19. - Mechanical lifts were logged into a tracking log by serial number on 11/8/19. A sticker with a date for next annual inspection and initials of certified biomedical technician was placed on the hoyer on 11/7/19 and logged on tracking sheet on 11/8/19. - All slings taken out of service and replaced with new slings. - Residents #4 and #46 assessed post fall at time of occurrence and monitored for pain management Identification of Others Affected: - There are twenty-one residents who are currently transferred via mechanical lift. Systemic Change to Prevent Re-occurrence: - Laundry personnel in-serviced on care of slings per manufacturer's recommendations by Administrator/DON / Laundry Supervisor on 11/8/19 and ongoing. Slings will be washed according to manufacturer's guidelines. Max temp 120 F and air dry only. No chlorine bleach. - Nurses, Nurse Aides, and Therapy personnel in-serviced on slings and Hoyer lift transfers to ensure sling is placed properly under resident and at least 2 people perform each transfer. - Administrator/Designee to keep log of slings to ensure proper care of slings, discarding slings when necessary, to ensure par level of slings to meet residents' needs. New slings were marked with a triangle symbol and number on 11/7/19 so staff could identify them as a new sling. The number on the sling is tracked on the sling tracking log. The sling inspection has been added to the MARS for a daily check by nursing to ensure they are intact and do not have any tears, frays, bleach stains or damage. There are currently 45 slings in house. - Laundry Manager to verify laundry detergent is appropriate for care of sling with chemical vendor - Maintenance Director to verify operational condition of Hoyer lift with medical equipment vendor, the cosmetic plastic covering on base of lift to be replaced, however, it does not affect safe function of lift. - Maintenance Director to conduct safety check of mechanical lift monthly, safety checked to be tracked in as part of the EMR. - Maintenance Director to have an annual check by biomedical technician on all mechanical lifts. Monitoring: - Daily check of slings for tears, frays, bleach stains and damages by Charge nurse/designee beginning on 11/8/19. - Daily check of mechanical lifts for safety for operation status for one week beginning on 11/8/19. The following will be checked: wheels lock, base legs expand with ease, handle operates as intended, lift does not have any frayed wires, remote operates, push handles are in place and secure, battery pack holds a charge, sling attachment points are not bent or damaged and boom raises/lowers without difficulty. - In-services conducted by DON/ADON/Administrator ongoing starting 11/7 to nurses, nurse aides and therapy personnel. After 90% of personnel educated, the remaining personnel will be in-serviced prior to their next shift. - DON/ADON will monitor hoyer transfers daily x 2 weeks during walking rounds and on random shifts to ensure competency. - Summary of IJ and corrective action to be reviewed by QAPI within 7 days and monthly for 90 days to ensure ongoing compliance. Verification of the Plan of Removal was as follows: a. Reviewed on 11/09/2019 pain management tracking and MAR's were reviewed for Residents #4 and #46 to ensure adequate pain control and monitoring with no concerns identified. b. Reviewed on 11/09/2019 new maintenance logs and checklist for safe operation and inspection of mechanical lifts. c. Reviewed on 11/09/2019 written laundry processes for the laundry room. d. Reviewed on 11/09/2019 log and tracking of 45 new slings identified in the facility. e. Reviewed on 11/09/2019 new in-service training for all staff on duty. The staff had been re-trained on proper mechanical lift transfers with return demonstration required before being placed on assignment. f. Observation on 11/09/2019 of all mechanical lifts in the facility revealed the facility had taken out of service all existing lifts including the hospice lift and replaced with five replacements lifts. The observations revealed all lifts had been documented on a log and inspected prior to placing in service. The lift equipment appeared to be in good operational order. g. Observation on 11/09/2019 of all slings in the facility revealed the facility had placed 45 new slings in the facility of various size and weight requirements. All identified slings had a triangle with a number marked on the sling. The triangle and number matched a sling number recorded in the log book to track the manufacture date and date the sling was placed in service. h. Observation on 11/09/2019 of all identified mechanical lift resident rooms, linen closets, laundry, storage rooms and bathrooms were observed for old slings. None were found. i. Observation on 11/09/2019 of three mecha (TRUNCATED)