Every finding on record at Michaelsen Health Center

Based on observation, interview and record review, the facility failed to ensure a resident's arms were positioned safely outside the sling during a transfer using a sit-to-stand mechanical lift. This failure resulted in the resident falling through the sling, sustaining a head injury that required five staples. This applies to 1 of 4 residents (R2) reviewed for mechanical lift transfer safety. The findings include:R2's face sheet documents diagnoses of dementia, anemia, major depressive disorder, degenerative disc disease, gastro-esophageal reflux disorder, history of falling, cognitive communication deficit and dysphagia. R2's MDS (Minimum Data Sheet) dated 3/6/26 documents R2 has severe cognitive impairment, requires substantial/maximal assist with transfers, is frequently incontinent with bladder, and is always incontinent of bowel. On 4/9/26 at 9:30 AM, V5 (RN-Registered Nurse) said on 3/22/26 at approximately 10:00 AM, she responded to V4's (CNA- Certified Nurse Assistant) call for help. V5 said she saw R2 was lying on her right side on the floor in her room. V5 said she saw a pool of blood under R2's head and assessment showed R2 had bleeding coming from the right side of her head. V5 said she immediately called paramedics and R2 was sent out to a local hospital where she received five staples on the right side of her head.On 4/9/26 at 10:00 AM, V4 (CNA) said on 3/22/26 at approximately 10:00 AM, she was providing incontinence care to R2 by herself. V4 said R2 was on the sit-to-stand mechanical lift while she was providing care. She said she was on R2's left side and she was bent over fastening the right side of R2's incontinence briefs. V4 said she felt R2's hand hit her head and when she raised her head, she saw R2's arms were inside the sling. She said R2 had her arms raised up and R2 slid in between the belt of the sit-to-stand mechanical lift's sling and fell on the floor. V4 said she did not see R2 take her hands off the sit-to stand's hand grip, did not see R2 put her arms inside the sling and did not see R2 raise her hands, because she was bent over and was providing incontinence care.On 4/9/26 at 9:20 AM, V11 (RN-Registered Nurse) said R2 transfers using a sit-to stand mechanical lift. She said due to R2's cognition, she needs close supervision and constant cueing to keep her hands on the sit-to-stand lift's hand grips.On 4/9/26 at 3:21 PM, V9 (Restorative Nurse) said residents who are cognitively impaired and using the sit-to-stand mechanical lift require close supervision and constant prompting during transfers. V9 said it is not safe to provide incontinence care while on the sit-to-stand mechanical lift. She said sit-to-stand mechanical lifts are used for transfers because residents cannot stand on their own and cannot balance themselves. V9 said providing incontinence care while in the sit-to-stand mechanical lift creates a balance issue and staff will not be able to see if residents are keeping their hands where they are supposed to be for safety.On 4/9/26 at 4:18 PM, V10 (R2's Physician) said staff should watch residents closely during transfers using sit-to-stand mechanical lifts to prevent accidents.R2's hospital record dated 3/22/26 shows she had a laceration repair on 3/22/26.Sit-to-stand mechanical lift's manual documents for standing sling: Ensure that the patient's arms are outside the sling. The facility was unable to provide a policy on toileting.

Based on observation, interview and record review, the facility failed to follow policy on Contact Isolation on a resident with known history of Clostridium Difficile. The facility also failed to follow policy on EBP (Enhanced Barrier Protection). This applies to 16 of 16 residents (R4, R5, R8, R9, R16, R21, R39, R43, R48, R59, R64, R72, R73, R82, R95, R96) reviewed for Infection Control in the sample size of 20.The findings include: 1. On 02/17/26 at 3:00 PM, R4 did not have an EBP (Enhanced Barrier Precaution) or a contact isolation sign on the door or the wall outside of the room. There was no PPE (Personal Protective Equipment) bin outside of the room. On 02/18/26 at 11:37 AM, R4 continued to not have any signage on the door or wall outside of the room before entering for EBP or contact isolation. On 02/17/26 at 11:05 AM, V22 (RN/Registered Nurse) was in the room with R4. V22 was not wearing PPE while in the room. On 02/17/26 at 11:06 AM, V22 stated R4 was not on isolation but was receiving Vancomycin for gastrointestinal issue. On 02/18/26 at 10:54 AM, V3 (Assistant Director of Nursing/Infection Preventionist) stated R4 continues to have loose bowel movements, once per day, and was still receiving Vancomycin. V3 stated on 02/12/26 R4 had gone without loose bowel movements and orders were discontinued for contact isolation. V3 stated R4 started to have loose bowel movements again on 02/17/26 and 02/18/26. She had a loose bowel movement yesterday and one the day before. On 02/18/26 at 2:18 PM, V3 stated the ID NP (Infectious Disease Nurse Practitioner) should have been notified when R4 began to have loose bowel movements again, so that R4 could be placed on contact isolation again. On 02/18/26 at 12:50 PM, V4 (ID NP) stated R4 has a history of c-diff and is currently receiving Vancomycin. V4 stated he was not informed of R4 having loose bowel movements for the last few days. V4 stated if R4 had loose bowel movements, there is a risk for transmission of the bacteria, and possibility of a c-diff outbreak, if not following isolation policies. V4 stated R4 should have been placed back on contact isolation when the loose bowel movements began since she has a history of c-diff. R4 was admitted to the facility on [DATE] with multiple diagnoses which included enterocolitis due to clostridium difficle, cerebral infarction, neuromuscular dysfunction of bladder, urinary tract infection, encounter for attention to gastrostomy, dysphagia, and hypertensive heart disease. R4's Physician Order Sheet for February 2026 showed an active order for Firvanq 50/mg (milligrams)/mL (milliliter), indication: history of c-diff, every six hours, for 14 days, ordered 02/18/26. R4 did not have orders for EBP on or contact isolation on 02/17/26. R4's MAR (Medication Administration Record) for the months of January and February 2026 showed R4 was administered Firvanq each day starting 01/29/26 to 02/20/26. R4's EMR (Electronic Medical) showed R4 had a stage four wound to the right thigh. R4's gastrointestinal care plan showed interventions: assess and monitor bowel elimination patterns and gastrointestinal status, assess and monitor gastrostomy site for complications. R's Progress Notes dated 02/18/26 at 1:00 PM, showed, Patient placed on contact precautions per ID NP. Received order to dc (discontinue) cefdinir and change vanco order x 14 days. Orders carried out. The facility's Clostridium Difficile Policy, revised October 2018, showed, Policy Statement: Measures are taken to prevent the occurrence of Clostridium difficle infections (CDI) among residents. Precautions are taken while caring for residents with C. difficile to prevent transmission to other residents. 2. Residents considered at high risk of developing symptoms associated with C. difficle include those with: c. previous confirmed infection with c. difficle; and d. antibiotic or anti-neoplastic therapy. 9. Residents with diarrhea associated with C. difficle (i.e., residents who are colonized and symptomatic) are placed on contact precautions. 2. According to facility's EBP List, R39 is on EBP for wound. During facility tour done on 2/17/26 at 10:15 AM, 2/18/26 at 9:30 AM and 2/20/26 at 8:30 AM, EBP signage and PPE (Personal Protective Equipment) were inside the room. R39's POS (Physician Order sheet) reviewed and does not have any order for EBP. Facility's wound list given on 2/17/26 documents R39 has wound on left buttock. 3. According to facility's EBP List, R21 is on EBP for indwelling urinary catheter and presence of wound. During facility tour on 2/17/26 at 10:32 AM, 2/18/26 at 9:35 AM and 2/20/26 at 8:31 AM, EBP signage and PPE bin were inside R21's room. R21's POS reviewed and does not have any order for EBP. Facility's wound list given on 2/17/26 documents R21 has wounds on left buttock, right thigh and left abdomen. 4. According to facility's EBP List, R73 is on EBP for wound. On 2/20/26 at 8:32 AM, EBP signage and PPE bin were inside R73's room. R73's POS reviewed and does not have any order for EBP. Facility's wound list given on 2/17/26 documents R73 has wound on left buttock. 5. According to facility's EBP List, R72 is on EBP for wound. On 2/20/26 at 8:33 AM, EBP signage and PPE bin were inside R72's room. R72's POS reviewed and does not have any order for EBP. Facility's wound list given on 2/17/26 documents R72 has wound on right buttock, left foot and right foot. 6. According to facility's EBP List, R82 is on EBP for wound. On 2/20/26 at 8:34 AM, EBP signage and PPE bin were inside R82's room. R82's POS reviewed and does not have any order for EBP. Facility's wound list given on 2/17/26 documents R82 has wound on right scalp, right buttock, scrotum and right thigh. 7. According to facility's EBP List, R48 is on EBP for wound. On 2/20/26 at 8:35 AM, EBP signage and PPE bin were inside R48's room. R48's POS reviewed and does not have any order for EBP. Facility's wound list given on 2/17/26 documents R48 has wound on left leg. 8. According to facility's EBP List, R8 is on EBP for wound. On 2/20/26 at 8:45 AM, EBP signage and PPE bin were inside R8's room. R8's POS reviewed and does not have any order for EBP. Facility's wound list given on 2/17/26 documents R8 has wound on her back. 9. According to facility's EBP List, R9 is on EBP for having a central line. On 2/20/26 at 8:46 AM, EBP signage and PPE bin were inside R9's room. R9's POS reviewed and does not have any order for EBP. 10. According to facility's EBP List, R43 is on EBP for indwelling urinary catheter. On 2/20/26 at 8:47 AM, EBP signage and PPE bin were inside R43's room. R43's POS reviewed and does not have any order for EBP. 11. According to facility's EBP List, R64 is on EBP for presence of PEG (Percutaneous Endoscopic Gastrostomy) tube. During facility tour on 2/17/26 at 10:00 AM, 2/18/26 at 10:30 AM and 2/20/26 at 10:30 AM, EBP signage and PPE (Personal Protective Equipment) were inside the room. R64's POS (Physician Order sheet) reviewed and does not have any order for EBP. 12. According to facility's EBP List, R5 is on EBP for indwelling urinary catheter and presence of wound. During facility tour on 2/17/26 at 10:32 AM, 2/18/26 at 9:35 AM and 2/20/26 at 8:31 AM, EBP signage and PPE bin were inside R5's room. R5's POS reviewed and does not have any order for EBP. Facility's wound list given on 2/17/26 documents R5 has a wound on his right ankle. 13. According to facility's EBP List, R59 is on EBP for wound. On 2/20/26 at 9:32 AM, EBP signage and PPE bin were inside R59's room. R59's POS reviewed and does not have any order for EBP. Facility's wound list given on 2/17/26 documents R59 has wound on right hip. 14. According to facility's EBP List, R95 is on EBP for wound. On 2/20/26 at 9:33 AM, EBP signage and PPE bin were inside R95's room. R95's POS reviewed and does not have any order for EBP. Facility's wound list given on 2/17/26 documents R95 has wound on right ankle. 15. According to the facility's EBP List, R96 is on EBP for wound and IV (intravenous access). On 2/20/26 at 9:34 AM, EBP signage and PPE bin were inside R96's room. R96's POS reviewed and does not have any order for EBP. Facility's wound list given on 2/17/26 documents R96 has wound on left calf. 16. According to facility's EBP List, R16 is on EBP for indwelling urinary catheter. On 2/20/26 at 9:35 AM, EBP signage and PPE bin were inside R16's room. R16's POS reviewed and does not have any order for EBP. On 2/20/26 at 8:36 AM, V5 (RN-Registered Nurse) said EBP signage and PPE bin should be at the door. She said she is an agency nurse and had to look on her list to identify residents on EBP. On 2/20/26 at 8:38 AM, V6 (RN/Nurse Manager) said EBP signage and PPE bin are placed inside the room, so staff knows the difference between contact precautions and EBP. On 2/20/26 at 8:40 AM, V7 (LPN-Licensed Practical Nurse) said EBP signage should be posted by the door and PPE bin should be outside the room. V7 said he does not know why EBP signage and PPE bin are now inside resident's room. On 2/20/26 at 10:08 AM, V3 (ADON-Assistant director of Nursing/IP (Infection Preventionist) said facility does not ask for order for resident to be on EBP because it is just a precaution. V3 said EBP signage and PPE bin are inside the resident's room because staff do not need to be dressed prior to entering the room. She said facility decided it was best to put signage and PPE bin inside resident's room as a reminder to staff. V3 read facility's Policy on Enhanced Barrier Precautions and could not say why they are not following facility policy. Facility's Policy on Enhanced Barrier Precautions dated August 2022 documents the following: Policy Statement: Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug organisms (MDROs) to residents. Policy Interpretation and Implementation 10. signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 11. PPE is available outside of the resident rooms. CDC (Centers for Disease Control and Prevention) Guidelines, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) sates that for Enhanced Barrier Precautions, facilities should Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (Personal Protective Equipment)

Based on observation, interview, and record review, the facility failed to ensure resident medication regimens remain free from unnecessary medications.This applies to 1 resident (R81) reviewed for medication regimen in a sample of 20 residents. Findings include:On 2/18/26 R81's POS (Physician Order Sheet) was noted to show the following active orders:Triamcinolone acetonide 0.1% topical ointment two times daily for fungal dermatitis start date 9/17/25. No stop date.Miconazole nitrate 2% topical cream daily for groin fungus start date start date 5/27/25. No stop date.R81's MAR (Medication Administration Record) was reviewed from May of 2025 through February 2026 and showed R81 had been receiving both topical ointments since their start dates, as ordered. Triamcinolone steroid ointment was given for 5 consecutive months, twice daily. Miconazole antifungal cream was given for 9 consecutive months, daily.On 2/20/26 at 10:46 AM, V7 (LPN/Licensed Practical Nurse) said R81's groin redness has been present on and off and is related to R81's hygiene. V7 said he has administered both ointments- Triamcinolone (a steroid cream) and Miconazole (an antifungal) daily as they are ordered. V7 said sometimes when he was applying the ointments R81's skin was clear and without redness. On 2/20/26 at 10:52 AM, R81's bilateral groin was visualized in the presence of V7 and was clear, no redness noted. R81 said his groin redness had cleared up about a month ago and the staff continued to put both topical medications on him.On 2/18/26 at 1:34 PM, V3 (Infection Preventionist Registered Nurse) said both topical ointments were ordered continuous/ongoing, and not as needed even though R81's skin condition comes and goes. On 2/18/26 at 12:43 PM, V4 (Infectious Disease Nurse Practitioner) said there are side effects of taking triamcinolone steroid ointment long-term including skin breakdown and thinning of the skin. V3 said the topical medications, triamcinolone and miconazole, should not be taken long term, and are usually only temporary treatment orders. V4 said the triamcinolone should be discontinued and the miconazole should be ordered on an as needed basis for a fungal outbreak, not continuous.The facility's policy titled, Administering Medications revised 4/2019 states, Policy Statement: Medications are administered in a safe.manner.Policy Interpretation and Implementation:.8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician or the facility's medical director to discuss the concerns.

Based on interview and record review, the facility failed to provide timely and comprehensive pain and physical assessment after a fall. This delay resulted in R1 experiencing untreated prolonged pain for five hours from a fracture after a fall and a delay in treatment. This applies to 1 of 3 residents (R1) reviewed for fall-related incidents. The findings include: The Electronic Medical Record (EMR) showed that R1, an [AGE] year-old resident, had an extensive medical history, including but not limited to: B-cell lymphoma with lymph node metastasis, lung cancer, intracerebral hemorrhage, atrial fibrillation, heart disease, hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, venous insufficiency, left below-knee amputation, chronic kidney disease, anemia, frontal temporal neurocognitive disorder, urinary reflux, phantom limb pain, anxiety, hyperlipidemia, osteoarthritis, Barrette's esophagus, benign prostatic hypertrophy, carotid artery disease, hypomagnesemia, cholecystitis, acute kidney failure, mood disorder, malignant neoplasm of bone, non-Hodgkin's lymphoma, obesity, hyponatremia, psychophysical visual disturbances, fall history, impaired gait, generalized weakness, and right foot drop. R1 was admitted to the facility on [DATE], at 1:00 P.M., following a hospitalization from [DATE] to April 4, 2025, for acute conditions including urinary tract infection (UTI), urinary retention, toxic metabolic encephalopathy (TME), and altered mental status. Hospital records dated March 29, 2025, documented hallucinations secondary to UTI and TME, which were managed with intravenous antibiotics. R1 was admitted to the facility on continued oral antibiotic treatment. Physician notes by V3 (Attending Physician), dated April 4, 2025, at 11:08 A.M., documented R1 as alert and oriented to person and place but unable to state the reason for his admission. Nurse Practitioner notes by V4 from April 4, 2025, at 5:16 P.M., document R1 as alert and oriented to 1-2, with identified risks of muscle weakness, gait disorder, dependency in ADLs (Activities of Daily Living). The medical plan physical/occupational therapy and fall precautions. Nursing documentation on April 6, 2025, at 2:33 A.M. by V5 (RN/Registered Nurse) showed that R1 was found by V6 (CNA/Certified Nurse Assistant) at approximately 9:45 P.M. on April 5, 2025, sitting on the floor next to his reclining chair. R1 reported striking his head, left side, and left hip during the fall and rated his left hip pain as 6/10 (moderate pain). The facility was unable to provide documentation of a comprehensive assessment, including evaluation for range of motion limitations, extremity alignment, or a detailed pain assessment to identify potential injury severity. During an interview on April 16, 2025, at 11:00 A.M., V5 said she did not assess R1 for signs of musculoskeletal injury such as range of motion restriction or limb deformity. V5 also confirmed that a complete pain assessment was not conducted. On April 6, 2025, at 9:30 A.M., V7 (RN) documented that R1's left hip pain had escalated to 10/10 and was unrelieved by Tylenol pain medication. V7 said that due to the absence of timely x-ray imaging, R1 was subsequently transferred to the hospital at 2:00 P.M. for further evaluation and treatment. This was a duration of approximately 5 hours for R1 experiencing pain. V7 stated on April 16, 2025 at 11:45AM, that after R1's pain intensified, she contacted V3 for an x-ray order. When the x-ray was delayed and R1's pain remained uncontrolled, V7 arranged for hospital transfer. In a separate interview on April 16, 2025, at 1:00 P.M., V3(Attending Physician) stated she had seen R1 on April 5, 2025, prior to the fall, and noted R1's confusion and poor safety awareness. V3 said that following R1's fall, V5 reported the incident to her, initially stating there were no injuries. V3 further explained that few minutes later after the first call, V5 had called again and informed her that based on standard facility policy for residents on anticoagulants, R1 should be send out to the hospital secondary to R1 being on anticoagulant and suffering an unwitnessed fall. V3 said she gave order to V5 for R1 to be sent to the hospital on the night of April 5, 2025. V3 expressed concern upon learning that R1 had remained at the facility overnight and only later was found to have sustained a left hip fracture requiring surgical repair. V3 stated: If I had been informed that R1 was still in the facility and experiencing increasing pain, I would have ordered immediate hospital transfer. This extent of injury could have been identified through a thorough post-fall assessment, including checking for extremity misalignment, rotation, swelling, discoloration, and a complete pain evaluation. Earlier identification would likely have reduced R1's prolonged and unnecessary pain. Hospital records dated April 6,2025 showed that R1 was admitted on [DATE], with an acute left hip fracture, which was surgically repaired on April 7, 2025.

Based on interview and record review, the facility failed to notify a resident's emergency contact representative regarding a fall incident. The failure to notify placed the resident at risk for compromised advocacy and potentially delayed medical decision making. This applies to 1 of 3 (R1) residents reviewed for notification of significant medical change. The findings include: The EMR (Electronic Medical Record) showed that R1, an [AGE] year-old with extensive diagnoses that included B cell lymphoma with metastasis to lymph nodes, lung cancer, intracerebral hemorrhage, atrial fibrillation, heart disease, hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, venous insufficiency, left below knee amputee, chronic kidney disease, anemia, frontal temporal neuro cognitive disorder, urinary reflux, phantom limb syndrome with pain, anxiety, hyperlipidemia, osteoarthritis, Barrette's esophagus, benign prostate hypertrophy, carotid artery disease, hypomagnesemia, cholecystitis, acute kidney failure, mood disorder, malignant neoplasm of bone, non-Hodgkin's lymphoma, obesity, hyponatremia, psychophysical visual disturbances, falls, impaired gait, generalized weakness, and foot drop (right). R1 was admitted to the facility on [DATE] at 1:00 P.M. The EMR also revealed that R1 was hospitalized from March 29,2025 to April 4,2025 due to acute medical conditions that included UTI, urinary retention, toxic metabolic encephalopathy, and altered mental status. The hospital record dated March 29,2025 showed that R1 was hallucinating, secondary to UTI and TME (toxic metabolic encephalopathy, which was a condition with cerebral dysfunction manifested by altered consciousness, behavior changes and or seizures). R1 was treated with intravenous antibiotics and was admitted to the facility with continued oral antibiotics for UTI. The Physician notes entered by V3 (Physician) dated April 4,2025 at 11:08 A.M., showed that R1 was seen and examined by V3. The notes showed that R1 was alert and oriented x2. The notes also document that R1 could not answer what brought him to the facility. The Nurse Practitioner Notes (V4) dated April 4,2025 at 5:16 P.M., showed that R1 was alert and oriented x1-2. The notes showed that Assessment and Plan were muscle weakness, gait disorder, assist with ADL's (Activities of daily Living), PT/OT (Physical and Occupational therapy), and fall precautions. The nurse's notes dated April 6,2025 at 2:33 A.M. showed that V5 (Registered Nurse) had documented that R1 was found sitting on the floor next to the reclining chair in his room on April 5,2025 at 9:45 P.M. The notes also showed that R1 had hit his head, left side of the upper body and left hip. The notes further showed that R1 had complained of pain to the left hip area. R1 had voiced pain rating of 6/10. The facility's pain rating showed that 6 /10 was moderate pain with 0 as no pain and 10 as worst possible pain. The notes also showed that V5 notified V3. The notes had no documentation that R1's emergency contacts were notified of R1's fall incident. The facility's incident report dated April 5,2025 showed that R1 fell on [DATE] at 9:45 P.M. The facility's incident report validated no family notification was made regarding the fall. On April 16, 2025 at 11:00 A.M., V5 said she did not notify R1's emergency contact when R1 had a fall incident on April 5,2025. The nurse's notes dated April 6,2025 showed that V7 (Registered Nurse) had documented that R1's left hip pain had worsened to 10/10 in the morning at 9:30 A.M. The notes showed that R1's pain was not relieved with Tylenol medication and x-ray imaging was not available in a timely manner, and therefore a decision was made for R1 to be send out to the hospital. The nurse's notes also showed V8 (R1's wife) arrived at the facility around noon time, found out about R1's fall and was in pain. V8 then requested to V7 that V9 (R1's daughter) be notified. The notes showed also that V9 is R1's POA (Power of Attorney). The face sheet showed that R1's Emergency Contact #1 was V8 (R1's spouse) and V9 was Emergency Contact #2. On April 16,2025 at 11:45 A.M., V7 said she left a message on V8's phone number on April 6,2025. V7 also said that she did not call V9 when she was not able to reach V8. V7 also said that V8 found out R1's change of medical condition related to the fall when V8 came to the facility on [DATE] around noon time. On April 14,2025 at 3:10 P.M., V8 said she was not informed of R1's fall incident. V8 said she found out of R1's change in medical condition when she arrived at the facility on April 6,2025 around 12:30 P.M. V9 was listening to the interview with V8. V9 said that she was not notified of R1's fall incident and R1 was in pain. V9 said that she is R1's POA. V9 expressed concern during the interview that had she been notified sooner; she could have facilitated timely medical intervention. V9 said that R1 left facility to the hospital on April 6,2025 at around 2:00 P.M. The hospital record dated April 6,2025 showed that R1 was admitted with an acute fracture of the left hip. Surgical repair of the fracture was performed on April 7, 2025. On April 16,2025 at 1:15 P.M., V1 (Administrator) and V2 (Director of Nursing) both stated that R1's family were not notified of R1's fall incident on April 5,2025. The facility policy regarding Resident Rights dated October 2010 showed it is the resident's right that services and medical conditions be made aware to the resident and or legal representative.

Based on interview and record review, the facility failed to ensure a resident was rolled in a safe manner by two staff persons during incontinence care for 1 of 3 residents (R1) in the sample of 3 reviewed for safety and supervision. This failure resulted in R1 falling out of bed and sustaining fractures of her right and left femurs. The findings include: R1's Face Sheet dated 4/2/25 shows R1 was admitted to the facility on [DATE] with a diagnosis of osteitis deformans of other bones (chronic condition affecting bone structure). R1's MDS dated [DATE] shows R1 requires substantial/maximal assistance to roll left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed) and with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). This same MDS also shows R1 is always incontinent of bowel and bladder. R1's Clinical Notes dated 3/13/25 at 6:58 AM show the following excerpt, While providing incontinence care, CNA stated she turned resident on her side when her legs then dangled off the bed and caused her to slide off the bed. CNA then did her best to lower resident to the floor. On 4/2/25 at 9:10 AM, R1 was lying in bed on an air mattress. R1 said she broke both of her legs a couple weeks ago after she fell out of her bed. R1 said all she knows is that a lady was on one side, and she was on the other side and, I got dropped. R1 said only one person was with her. On 4/2/25 at 2:45 PM, V7, Certified Nursing Assistant (CNA) said she had been changing R1 by herself (on 3/13/25) and as she was rolling R1 in bed, she moved a little too hard, and R1's feet started to slide off the bed. V7 said R1's legs are dead weight and the weight of her body was pulling her off the bed. V7 said R1's legs are so heavy, the (air) mattress is slippery and R1 has no control over her legs, so R1 started to slide out of the bed. V7 said she was unable to get R1's legs back into the bed so she guided her head and shoulders as R1 fell out of her bed. V7 said it all happened so fast she is not sure if R1's knees hit the floor when she fell out of her bed. On 4/2/25 at 9:29 AM, V10, CNA, said before R1 fell , she required two people to change her, one on each side of the bed. On 4/2/25 at 9:39 AM, V9, CNA, said R1 required two people to change her. V9 said for bed baths, one person could wash R1's front side, but then they would need to get a second person to come help turn R1 and wash her back side. On 4/2/25 at 1:20 PM, V5, MDS (Minimum Data Set) Nurse, said she gathers information from the CNAs and the nurses, does observations of residents, and looks at therapy and doctor's notes to determine a resident's mobility and care needs for their MDS. V5 said a resident who needs substantial/maximal assist needs two staff persons to help complete the given activity. On 4/2/25 at 12:41 PM, V2, Director of Nursing (DON), said a person requiring maximal assist would require two persons to assist with the given activity. On 4/2/25 at 2:22 PM, V6, Registered Nurse (RN), said she was R1's nurse on 3/13/25. V6 said V7 told her she was turning R1 and R1's legs started dangling off the bed and the weight of her legs caused R1 to fall forward, and she slid off the bed. V6 said R1 is heavier and difficult to turn. On 4/2/25 at 2:08 PM, V8, Orthopedic Surgeon, said R1 sustained bilateral femur fractures. V8 said a low energy impact could have caused R1's fractures. V8 said R1 has not been ambulatory for six years and she had poor, weak bone quality. R1's hospital Discharge Summary dated 3/21/25 shows R1 was admitted to the hospital on 3/13/25. in part due to bilateral distal femoral fractures due to a fall. R1's H&P dated 3/13/25 shows R1 presented to the hospital after a fall out of bed, she is bedbound at baseline, but apparently rolled out and fell on to both knees. R1's left femur x-ray resulted 3/13/25 shows a transverse fracture of the distal femoral diametaphyseal junction with impaction of three centimeters (cm) and posterior angulation. R1's right femur x-ray resulted 3/13/25 shows a mildly comminuted fracture of the distal diaphysis of the femur with posterior displacement 18 millimeters.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygeine and handled and transported soiled linen in a sanitary manner, and ensure visitors were educated on isolation practices. This applies to 6 of 6 residents (R50, R21, R56, R52, R58, R188) reviewed for infection control in a sample of 23. Findings include: 1. On 12/17/24 at 12:33 PM, during a dining observation, V4 CNA (Certified Nurse's Assistant) was observed feeding R21, touching her peanut butter and jelly sandwich and giving R21 a spoonful of strawberry ice-cream. Then V4 went to R56's table and began feeding R56. V4 did not clean her hands after feeding R21 her food. Then V4 went back to R21's table and was feeding R21 and feeding R50. V4 was using her same hand she used to feed R56, and she never cleaned her hands after she finished feeding R56. V4 continued feeding R21, R56, and R50 their entire lunches and never stopped to clean her hands in between assisting each resident. On 12/19/24 at 01:30 PM, V2 DON (Director of Nursing) said that V4 should be cleaning her hands between each resident. The facility's Handwashing/Hand Hygiene policy dated August 2019 showed that all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy shows that hand hygiene should be done before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with the residents' intact skin, after contact with blood or bodily fluids, after contact with objects an immediate vicinity of the resident, before and after eating or handling food, before and after assisting a resident with meals. 2. On 12/17/24 at 01:23 PM, V8 (CNA) provided incontinence care for R52 when had urinated and had a bowel movement. V8 cleaned R52's perineal area and rectal area with gloved hands, and then removed the soiled brief and disposable linen protector from under R52. Without changing her gloves or performing hand hygeine, V8 placed a clean brief, readjusted R52 linen and blanket, handled the bed control, and closed R52's drawer. On 12/17/24 at 01:53 PM, V8 said that she did not change her gloves or cleaned her hands after going from a dirty area to a clean area. On 12/19/24 at 02:09 PM, V2 (DON) said that V8 should have cleaned her hands after she went from a dirty area before she went to a clean area for infection control. 3. On 12/17/24 at 01:16 PM, V7 (CNA) carried soiled linen in her arms with the linen touching her clothes. V7 carried the soiled linen from R58's room to the soiled linen container, which was 15 rooms away. V7 said that is how her and the staff do it because there is only one soiled linen container for the hall. On 12/19/24 at 01:39 PM, V2 (DON) said that all soiled linen should be bagged, and it should not touch the staff's clothing while it is being carried for infection control. The facility policy Laundry and bedding, Soiled, dated October 2018 states soiled laundry / bedding shall be handled, transported and processed according to best practices for infection prevention and control. All laundry is handled as potentially contaminated until it is properly bagged and labeled for appropriate processing. Soiled laundry and bedding contaminated with blood or other potentially infectious materials is handled as little as possible and with minimum agitation. Contaminated laundry is placed in a bag or container at the location where it is used. 46003 4. On 12/17/24 at 01:03 PM, R58's bed was stripped and soiled lines were balled up on the floor next to her bed. On 12/19/24 at 03:24 PM, V2 (DON) stated soiled lines should not be left on the floor because of infection control issues. 40054 5. R188 is an [AGE] year-old male with multiple comorbid diagnoses, including viral infection, urinary tract infection, acute respiratory failure, and unproductive cough and wheezing. On 12/18/2024 at 10:05 AM, V10 (Registered Nurse) said R188 had isolation precautions in place for rhinovirus. V22 (R188's family) and V23 (Care Giver) were in the room. V10 was asked whether V22 or V23 were using PPE (Personal Protective Equipment), and V10 said she told them to wear it. Observed R188 in the room and V22 and V23 were siting closely and not wearing any PPE. V22 and V23 said no one told them to wear the PPE. On 10/17/24 at 11:30 PM, V9 (ADON/Asssitant Director of Nursing and Infection Control Nurse) said Nurses should educate, encourage, and emphasize PPE to visitors, and if there is a refusal from the visitors, that needs to be documented. The facility's isolation-transmission-based precautions initiation policy dated 09/2022 showed that the facility should educate visitors about why PPE, ensure staff and visitors enter the room wearing PPE, and dispose before leaving the room.

Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for residents who require assistance from staff for ADLs. This applies to 4 of 4 residents (R11, R46, R52, R60) reviewed for ADLs in a sample of 23. The findings include: 1. On 12/17/24 at 12:02 PM, R52 was observed in her bed and a mat was on the floor next to her bed and her lunch plate and dessert cup was on her over the bedside table out of her reach. On the plate was mashed potatoes and a scoop of a brown substance. There was also a cup of a pureed brown substance in a dessert cup. None of the food had been touched. At 12:23 PM, R52 was observed in her bed, her food was still on her over the bedside table out of reach untouched, and R52 said she was hungry. At 01:03 PM, R52 was still in her bed, her lunch was still out of reach on her over the bedside table and R52 again said that she was hungry. The plate of food was still full and untouched. The surveyor then left R52's room and stood next to R52's door and at 01:04 PM V5 (Kitchen staff) went into R52's room and came back out of her room with R52's full plate and full dessert cup and disposed of the items on her cart. V5 said that she informs the nursing staff when the residents have not eaten their food. R52's 11/13/24 care plan shows that R52 is at risk of weight loss and requires extensive assistance for eating with interventions including requires adequate time to eat, provide cures and encouragement. R52's 11/13/24 MDS (Minimum Data Set) showed that her cognition is severely impaired and she needs substantial/maximal assistance for eating. On 12/19/24 at 02:04 PM, V2 (DON) said that R52 care has just changed from Palliative to Hospice and she has had a significant weight loss. V2 said that because of R52's current care needs, her expectations are for the staff to attempt to feed R52, give her time when she eats, re-approach and try to attempt to feed her again. 2. On 12/18/24 at 11:26 AM, R11 was observed with long jagged fingernails. R11 said that he had not received nail care in a couple of weeks. R11's 10/6/24 care plan showed that R11 requires supervision for personal hygiene with interventions including setting up items, assistance as needed, and supervision and cueing. R11's 10/6/24 MDS showed that R11's cognition is severely impaired. 12/19/24 01:57 PM, V2 DON (Director of Nursing) said that staff should provide nail care as needed. 3. On 12/17/24 at 12:14 PM, R46 was observed in his bed with long toenails, about 1 inch over the top of the toes. R46 said that he could not recall the last time he had toenail care. R46's 10/3/24 MDS showed that his cognition is moderately impaired and that he needs partial/moderate assistance from staff with personal hygiene. On 12/19/24 at 02:01 PM, V2 said that R46 is not a diabetic so the nurse or the CNAs (Certified Nurse's Assistants) should have cut R46's toenail for his comfort, dignity, and safety. 4. On 12/17/24 at 12:56 PM, R60 was observed with long jagged fingernails with nail polish on the upper half of some of the nails. R60 said that she wanted staff to provide nail care for her. R60's 11/20/24 MDS showed that she needs partial/moderate assistance from staff for personal hygiene. On 12/19/24 at 01:52 PM, V2 DON said that nails should be short and neat and not jagged, and staff should be providing nail care as needed for infection control, dignity, and safety.

Based on observation, interview, and record review, the facility failed to ensure medications were safely and securely stored. This applies to 4 of 4 residents (R61, R68, R137, R139) reviewed for medications in a sample size of 23. The findings include: 1. On 12/17/24 at 12:05 PM, R61 was not in her room. On two of her end tables in her room, the following medications were noted: Baush and [NAME] soothe lubricant eye drops, Equate Ultra Strength pain relieving cream which contained (camphor, menthol, methyl salicylate), Refresh plus lubricant eye drops, Gas-x simethicone 125 MG (Milligrams) anti-gas soft gels, extra strength gas relief simethicone 125 MG chewable tablets, and Lidotral 3.88% cream (Lidocaine HCL). On 12/19/24 at 1:50 PM, surveyor went back to her room. The medications were still in her room. R61 stated the medications are always kept in her room. V3 (R61's sister) stated that she brought all those medications for R61 from home and the pharmacy. She stated that R61 has pain and spasms in her legs that wake her up at night. She said that was the reason for the pain creams. R61's face sheet shows diagnoses of other abnormalities of gait and mobility, unsteadiness on feet, restless legs syndrome, GERD (Gastro-esophageal reflux disease) without esophagitis, and multi-system degeneration of the autonomic nervous system. R61's MDS (Minimum Data Set) dated 10/20/24 showed she is cognitively intact. Review of R61's POS (Physician Order Sheet) shows no order for these medications and no order for it to be unlocked and at the bedside. 2. On 12/17/24 at 12:21 PM, R137 had a pill organizer which contained unknown pills in each compartment. R137 stated she brought the medications from home, and she didn't know the names of the medications. R137 stated she was under the impression that the nurses were taking the medications from the pill organizer and giving them to her. On 12/18/24 at 1:48 PM, surveyor went with V2 (DON-Director of Nursing) to R137's room. R137 was not in her room. The same pill organizer with medications was still on her table. R137's assigned nurse was V17 (RN-Registered Nurse). V17 stated, I didn't see this was here. I don't get any medications from here (pill organizer). I get all of (R137)'s medications from the medication cart. V2 stated the medications should be locked up and she was not aware of R137's pill organizer. R137's face sheet shows an admitted [DATE]. R137's face sheet shows diagnoses of unspecified systolic (congestive) heart failure, other pulmonary embolism without acute cor pulmonale, and hypertensive heart disease with heart failure. 3. On 12/17/24 at 12:28 PM, R139 had Fleet glycerin laxative suppository and Cortisone cream on her end table. R139 stated she brought them from home and the medications are always kept in her room. R139's face sheet shows diagnoses of anxiety disorder, unspecified, unsteadiness on feet, other abnormalities of gait and mobility, aftercare following explanation of shoulder joint prosthesis. R139's MDS showed she is cognitively intact. R139's POS does show orders for these medications. On 12/18/24 at 11:35 AM, V2 (DON) stated the facility collects residents' home medications at the time of admission. V2 stated if we were to use them, we must get an order from physician. V2 stated we lock unused meds from home in the medication cart until the family can pick them up. Facility's policy titled Medication Labeling and Storage (February 2023) shows: Policy statement: The facility stores all medication and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Medication storage: 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. 41384 4. On 12/17/24 at 11:46 AM, R68 was in his room and there was 1 bottle of Systane (lubricant eye drop) 10ml 1/3 oz. (milliliters/ounces) at the table next to the bed and 1 bottle of Systane on the over the bedside table. R68 said that the nurse puts the medication in his eyes for him. On 12/19/24 at 11:31 AM, a record review of R68's electronic health record did not show an order for Systane. On 12/19/24 at 01:59 PM, V2 (Director of Nursing) said that the 2 bottles of Systane should not have been in R68's room because they need to be secured safely.

Based on observation, interview, and record review, the facility failed to provide care with dignity to 3 of 3 residents (R21, R56, and R50) reviewed for resident rights in a sample of 23. The findings include: On 12/17/24 at 12:33 PM, during a dining observation, V4 CNA (Certified Nurse's Assistant) was observed standing over R21 while feeding R21 her lunch. Then V4 moved to a nearby table and stood over R56 and began feeding R56. Then after giving R56 a few spoons of food, V4 returned to the first table and stood between R21 and R50, feeding both. This was done for the entire lunch for R21, R56, and R50. On 12/19/24 at 01:30 PM, V2 DON (Director of Nursing) said that the staff should be sitting next to the residents while feeding them for dignity and home life environment. R50's 11/10/24 MDS (Minimum Data Set) showed his mental cognition is severely impaired and he needs partial/moderate assistance from staff for eating. R56's 10/25/24 MDS showed that her cognition is severely impaired and she needs partial/moderate assistance from staff for eating. R21's 9/30/24 MDS showed that her cognition is severely impaired and she needs partial/moderate assistance from staff for eating. The facility's Assistance with Meals policy dated March 2022 shows that residents shall receive assistance with meals in a manner that meets the individual's needs of each resident. Who cannot feed themselves will be fed with attention to safety comfort and dignity for example not standing over residents while assisting them with meals. The facility's Dignity policy dated February 2021 showed that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. When assisting with care, residents are supported in exercising their rights for example, residents are provided with a dignified dining experience.

Based on observation and interview the facility failed to ensure a resident's mattress fit the bedframe to prevent injury. This applies to 1 of 6 residents (R334) reviewed for accidents in a sample of 23. Findings include: R334 has diagnoses that include streptococcal sepsis, urinary tract infection, atrial fibrillation, pulmonary embolism, heart failure, spinal stenosis, history of transient ischemic attack, history of cerebral infarction, abnormalities of gait and mobility and unsteadiness on feet. R334's current care plan includes at risk for falls related to history of falls, impaired mobility, impaired balance / gait, psychotropic and cardiac meds, sensory impairment and cognitive impairment. R334's care plan also includes problem related to skin integrity. On 12/17/24 at 11:56 AM, R334 was observed lying in bed. Approximately eight inches of the metal bed frame was exposed on the right side of the bed. On 12/17/24 at 01:23 PM, V13 CNA (Certified Nursing Assistant) stated informed the nurse on 12/16/24 of R334's exposed bed frame. On 12/17/24 at 01:30 PM, V14 RN (Registered Nurse) stated she observed R334 in bed in the morning with the larger bed frame. V14 stated the frame appeared as though it should have a larger mattress and she would notify maintenance. On 12/18/24 at 11:13 AM, R334 was observed lying in bed with metal bed frame still exposed and not covered by the mattress. On 12/19/24 at 11:56 AM, R344 was not in the room. The bed was stripped of linens and the same exposed metal bed frame with the smaller mattress remained in place. On 12/19/24 at 01:00 PM, V15 (Facilities Management Director) and V16 (Associate Director) came to observe the bed. V15 stated nursing decides what kind of bed / mattress residents require. Nursing sends maintenance a request and they bring the bed frame requested. V15 stated the mattress did not fit the frame. V16 stated the frame is extra wide for a bariatric mattress and the mattress that was in place is a regular sized mattress. V16 stated a larger mattress should be placed on the frame. On 12/19/24 at 03:24 PM, V2 DON (Director of Nursing) stated for the resident's safety the mattress should fit the bed frame. It is everyone's responsibility to make sure the resident has the appropriate equipment. The nurses should have sent a work order. The facility policy Hazardous Areas, Devices and Equipment dated July 2017 states all hazardous areas, devices and equipment in the facility will be identified and addresses appropriately to ensure resident safety and mitigate accident hazard to the extent possible. A hazard is defined as anything in the environment that has the potential to cause injury or illness and includes but not limited to devices and equipment that are improperly used or poorly maintained. The facility policy Bed Safety dated December 2007 states the facility will strive to provide a safe sleeping environment. To prevent deaths / injuries from beds and related equipment (including the frame and mattress) the facility shall promote the following approaches: Inspections by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment.

Based on interview and record review, the facility failed to ensure monthly pharmacy recommendations were addressed. This applies to 2 of 5 residents (R21 and R51) reviewed for medication review in a sample of 23. The findings include: On 12/19/24 at 10:44 AM, surveyor requested V2 (DON--Director of Nursing) to provide all the pharmacy monthly medication reviews for R21 and R51 as well as physician responses to pharmacy recommendations from March 2024 to the current date. On 12/19/24 at 03:24 PM, V2 stated he did not have any monthly pharmacy regimen reviews to provide. V2 stated it is his responsibility to submit the pharmacy reviews to the physician for review but he has been behind. V2 stated the process is for pharmacy to email him the recommendations. He is supposed to place the recommendations in a binder for the physician to sign off on, and the physician leaves the addressed recommendations in the binder for him to follow up on. V2 stated documentation for R21 and R51 was not available. The facility policy Medication Utilization and Prescribing- Clinical Protocol dated April 2018 states the consultant pharmacist should use the monthly and interim drug regimen review to help identify potentially problematic medications, including medication regimens that are not supported based on clinical signs or symptoms. Based on input from the staff and resident, the physician will adjust mediations based on their efficacy, indications and the continued presences of clinically significant risks. The physician will provide and / or document a rationale when the indication dose, duration or frequency of a prescribed medication is greater than the commonly accepted practice or the manufacturer's recommendations or the medication is considered high risk compared to other available, relevant alternatives. The physician will document a clinically pertinent rationale for not modifying a medication in a situation where an adverse drug reaction is likely.

Based on interview and record review, the facility failed to transcribe physician medication orders upon admission, which caused a resident to miss her significant medications for four days. This applies to 1 of 3 residents (R135) reviewed for significant medication errors in a sample of 23. Findings Include: On 12/17/2024 at 5:53 PM, V20 (R135's family member) said Eliquis (a blood thinner) and Atorvastatin medications were on R135's admission/transfer form and didn't know why it was not prescribed. V20 said R135 missed a total of eight doses, and the doctor should have been notified. V20 said R135 is [AGE] years old and has atrial fibrillation, mitral valve prolapse, and heart conditions with a pacemaker, and the missing Eliquis could have caused severe conditions. On 12/19/24 11:40 AM, R135 said the faicility failed to give her the Eliquis and cholesterol medication. R135 said something happened when they were transferring the information. She said because she didn't receive the Eliquis, she felt very tired. R135 was a [AGE] year-old female admitted to the facility on [DATE] during the evening shift with diagnoses including atrial fibrillation, hypertensive heart diseases with heart failure, presence of the cardiac heart monitor, mitral valve presence, deep vein thrombosis, diabetes mellites type 2, and hyperlipidemia. Based on multidisciplinary admission progress notes from 12/12/2024- 12/15/ 2024, R135 was cognitively moderately intact and required one person to assist with activities of daily living (ADL), transfers, and bed mobility. A review of the hospital discharge instructions dated 12/11/2024 showed R135 had multiple medications, including Eliquis 2.5 milligrams at 9:00 AM and 5:00 PM daily, and Atorvastatin 10 milligrams every Monday, Wednesday, and Friday at 9:00 PM. The V12's (Registered Nurse-RN) nursing admission progress notes showed that V12 reviewed the medication list with the physician and was okay with continuing all medications. A review of the admission physician orders entered by V18 showed Eliquis and Atorvastatin had been omitted during transcription. R135's December 2024 Medication Administration Record showed R135 received her first dose of Eliquis 2.5 milligrams on 12/15/2024 at 9:00 PM, and Atorvastatin 10 milligrams on 12/18/2024. R135 missed eight doses of Eliquis and three doses of Atorvastatin. On 12/20/2024 at 9:06 AM, V12 (RN) said she called R135's physician and received an order to continue all medications. V12 said since she was busy with nighttime medication administration, V18 (RN-unit Manager) entered the medication orders. On 12/12 /2024 at 10:15 AM, V18 said she helped to enter R135's medication order, and both V12 and V18 said they forgot to review the entered medication orders. On 12/20/2024 at 11:35 AM, V19 (R135's Physician) said that an oversight had occurred, which could have caused a stroke, and fortunately nothing happened. On 12/18/2024 at 3:37 PM, V2 (Director of Nursing) said on the evening of 12/15/2024, R135's family requested the nurse to go over R135's medications list with them and the facility found out R135 had missed her Eliquis and Atorvastatin. R135 received her first doses on 12/15/2024 at 9:00 PM (four days after admission). V2 said it was an oversight from the nursing staff to transcribe the prescribed order, and the staff should have reviewed the orders.

Based on observation, interview and record review, the facility failed to obtain a resident's blood glucose level for sliding scale insulin administration prior to that resident eating a meal. This applies to 1 of 2 residents (R20) reviewed for glucose monitoring. The findings include: R20's Electronic Medical Record (EMR) shows that R20 was admitted to the facility on [DATE] with diagnoses of sepsis due to methicillin susceptible staphylococcus aureus (MRSA), paroxysmal atrial fibrillation, type 2 diabetes mellitus without complication, non-pressure chronic ulcer right foot, and chronic kidney failure. R20's Physician Order Sheet (POS) shows an order to monitor blood sugar, insulin aspart subcutaneous per sliding scale at 8am and 5 pm. On 3/29/24 at 9:11 AM, V7 (RN/Registered Nurse) went in to R20's room to administer his morning medications. R20 had empty plates on his bedside table as he had finished his breakfast. V7 asked how his breakfast was, and R20 said he enjoyed his breakfast. After administering his medication at 9:20 AM, V7 proceeded to check R20's blood glucose levels. R20's blood glucose level was 222. V7 then administered 2 units of insulin aspart per sliding scale. On 4/2/28 at 3:28 PM V2 (DON/Director of Nursing) said resident blood glucose levels should be checked prior to eating and not after eating because it can give a false high glucose level. V2 said the facility does not have a policy regarding checking blood glucose levels.

Based on interview and record review, the facility failed to administer intravenous (IV) antibiotics according to physician orders. This applies to 1 of 8 residents (R2) reviewed for medication administration. The findings include: R2's Electronic Medical Record (EMR) shows that R2 was admitted to the facility on [DATE] and was discharged on [DATE]. R2's census sheet shows that he was at the facility from 2/28/24, was sent to the hospital on 3/1/24, returned to the facility on [DATE], and discharged to the hospital again on 3/18/24. R2 had the following diagnoses of hypertensive heart disease, rhabdomyolysis, localized swelling mass and lump in head, acute kidney failure and benign neoplasm of skin, scalp and neck. R2's Physician Order Sheet (POS) showed an order for IV Zosyn (antibiotic) 4.5 gram/100ml (milliliters) in dextrose piggyback solution every 8 hours for 17 days starting 3/14/24. On 4/2/24 at 1:47 PM, V2 (Director of Nursing/DON) said R2 was sent to the hospital on 3/1/24 because he was not eating, was only alert and oriented to self, was sweaty and clammy. V2 said the nurse assigned to R2 consulted with the NP (Nurse Practitioner) who also assessed R2, and he was sent to the hospital for further evaluation and was admitted to the hospital for pneumonia. V2 said that R2 returned to the facility on [DATE] and was sent back out to the hospital on 3/18/24. V2 said when R2 returned from the hospital on 3/14/24, he had an order for IV Zosyn antibiotic which was what he had been receiving, but on 3/15/24, he received one dose Ampicillin antibiotics instead of Zosyn. V2 said the doctor was informed, orders were given to continue with Zosyn. V2 said the nurse pulled the IV ampicillin from facility's convenience box because his medications had not arrived from the pharmacy. On 4/2/24 at 2:45 PM, V3 (Registered Nurse/RN) said she administered IV Ampicillin instead of Zosyn to R2 and the physician was made aware of the incident. On 4/2/24 at 3:52 PM, V12 (R2's Physician/Medical Director) said R2 did receive one dose of Ampicillin instead of Zosyn and they continued the IV Zosyn after. The facility's Administering Medications policy (revised April 2019) states that medications are administered in accordance with prescriber orders. The individual administering the medication checks the label three times to verify right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on interview and record review, the facility failed to perform monthly Medication Regimen Reviews (MRR) for residents residing in the facility. This applies to 4 of 7 (R2, R21, R34, and R42) reviewed for medication regimen review. The findings include: 1. Face sheet, dated 9/27/23, shows R2 was admitted to the facility on [DATE]. POS (Physician Order Sheet), dated 9/27/23, shows R2 had physician-ordered medications since 4/18/23. Review of Consultant Pharmacist's Medication Regimen Review reports, dated 5/1/23 to 9/13/23, show R2 was not reviewed by the pharmacist during the months of 5/2023, 7/2023, 8/2023 and 9/2023. 2. Face sheet, dated 9/27/23, shows R42 was admitted to the facility on [DATE]. POS, dated 9/27/23, shows R42 had physician-ordered medications since 8/17/22. Review of Consultant Pharmacist's Medication Regimen Review reports, dated 3/1/23 to 9/13/23, show R42 was not reviewed by the pharmacist during the months of 3/2023, 4/2023, 6/2023, 7/2023, 8/2023 and 9/2023. 3. Face sheet, dated 9/27/23, shows R21 was admitted to the facility on [DATE]. POS, dated 9/27/23, shows R21 had physician-ordered medications since 6/17/21. Review of Consultant Pharmacist's Medication Regimen Review reports, dated 3/1/23 to 9/13/23, show R42 was not reviewed by the pharmacist during the months of 6/2023 and 8/2023. 4. POS, dated 9/28/23, shows R34 was admitted to the facility on [DATE]. POS, dated 9/28/23, shows R34 had physician-ordered medications since 10/14/22. Review of Consultant Pharmacist's Medication Regimen Review reports, dated 3/1/23 to 9/13/23, show R34 was not reviewed by the pharmacist during the month 9/2023. On 9/27/23 at 3:00 PM, V2 (Director of Nursing) stated the consulting pharmacist is expected to review each resident's medications monthly. Facility policy/procedure Medication Regimen Review and Reporting, dated 1/23, shows, The consultant pharmacist reviews the medication regimen and medical chart of the resident at least monthly to appropriately monitor the medication regimen and ensure that the medications each resident receives are clinically indicated.

Based on observation and interview the facility failed to ensure a wound remained covered by a dressing as ordered by the physician. This applies to 1 of 3 (R1) residents reviewed for pressure ulcers in a sample of 22. The findings include: R1's EMR (Electronic Medical Record) showed R1 was readmitted to the facility on [DATE] with multiple diagnoses including acute on chronic congestive heart failure, pneumonia, acute respiratory failure with hypoxia, atrial fibrillation and chronic kidney disease stage 3B. R1's MDS (Minimum Data Set) dated 8/22/2023, showed R1 is cognitively intact and required extensive assistance for bed mobility, bathing, toileting, and dressing, is dependent on staff for transfer and required set up assistance for eating. R1's wound care notes dated 9/19/2023 showed R1 was admitted with an unstageable pressure ulcer to the right buttock being treated with medical honey, calcium alginate covered by border foam dressing. R1's TAR (Treatment Administration Record) showed an order for wound treatment to right buttock initiated 9/20/23 to cleanse wound with saline and apply medical honey and calcium alginate and cover with border foam dressing every evening shift and as needed. On 9/27/23 at 10:15 AM, R1 was lying in bed and was being given incontinence care by V5 (CNA- Certified Nursing Assistant). When V5 rolled R1 to her left side, there was no dressing covering the right buttock wound, the unstageable wound was exposed. There was no dressing lying in the brief or in the bed linens. V5 stated she gave R1 incontinence care at 06:00 AM that morning and noticed the dressing was not there at that time. V6 (RN- Registered Nurse) was informed of the missing dressing at 10:15 AM as she entered the room during the observation. On 9/27/23 at 1:45 PM, V6 (RN) stated she would expect to be told that a wound was not covered immediately. V6 provided documentation to show she replaced R1's wound dressing at 11:04 AM on 9/27/23. On 9/27/23 at 2:20 PM, V2 (DON- Director of Nursing) stated the expectation for staff, who notice a wound dressing missing, is to report it to the nurse immediately. The facility's policy for Wound Care, dated October 2010, showed .2. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview, and record review, the facility failed to follow their policy to monitor and document urine output for residents with an indwelling urinary catheter. This applies to 2 of 3 residents (R11 and R15) reviewed for indwelling urinary catheters in the sample of 22. The findings include: 1. The EMR (Electronic Medical Record) showed R15 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, diabetes, and obstructive and reflux uropathy. R15's MDS (Minimum Data Set) dated August 14, 2023, showed R15 was cognitively intact and had an indwelling urinary catheter. R15's undated indwelling urinary catheter care plan showed, Indwelling catheter secondary to urinary retention/BPH (Benign Prostatic Hyperplasia). The care plan continued to show multiple interventions dated August 8, 2023, including, Record output per shift. R15's September 2023 Physician Order Sheet dated September 27, 2023, showed an order dated September 10, 2023, for, Catheter: Record Output in milliliters. Frequency: By shift. On September 25, 2023, at 10:58 AM, R15 was lying in bed with an indwelling urinary catheter draining yellow urine with sediment. R15 said he just came back from the emergency room because his indwelling urinary catheter became plugged up. R15 continued to say his indwelling urinary catheter was not draining for about a day before he went to the emergency room . On September 25, 2023, at 10:42 AM, V7 (RN/Registered Nurse) said R15 just returned from the emergency room because he had indwelling urinary catheter issues and his catheter needed to be replaced. R15's September 2023 Treatments Record dated September 26, 2023, did not show urine output documentation for September 23, September 24, and day shift September 25, 2023. R15's hospital documentation showed a progress note by V8 (NP/Nurse Practitioner) dated September 25, 2023, at 9:59 AM. V8's progress note showed, .Patient was sent from [facility] for evaluation of [indwelling urinary catheter]. Staff noted that his [indwelling urinary catheter] was not draining any urine and patient stated he had pressure in his bladder . [Indwelling urinary catheter] removed and a new [indwelling urinary catheter] inserted in which patient had at least 1000 mL (milliliters) of urine. Urine is positive for leukocytes and bacteria as well as white blood cells. Patient feels much better after new catheter inserted . On September 27, 2023, at 2:03 PM, V2 (DON/Director of Nursing) said R15 was residing in the facility on September 23 and September 24, 2023, with an indwelling urinary catheter. V2 continued to say it is the expectation of facility staff to document a resident's urinary output from the indwelling urinary catheter every shift on the Treatment Record every shift. 2. The EMR showed R11 was admitted to the facility on [DATE], with multiple diagnoses including heart failure, chronic kidney disease, spinal stenosis, and flaccid neuropathic bladder. R11's MDS dated [DATE], showed R11 was cognitively intact and had an indwelling urinary catheter. R11's undated indwelling urinary catheter care plan showed, 18 French indwelling catheter secondary to neurogenic bladder. The care plan continued to show multiple interventions dated May 11, 2023, including, Record output per shift. On September 26, 2023, at 2:09 PM, R11 was lying in bed and had an indwelling urinary catheter draining yellow urine. On September 27, 2023, at 1:54 PM, V2 said R11's indwelling urinary catheter was discontinued on September 21, 2023, but was reinserted. A progress note dated September 21, 2023, at 6:28 PM, by V7 (RN) showed R11 had an indwelling urinary catheter in place. R11's September 2023 Treatment Record dated September 28, 2023, did not show urine output documentation for September 21 to September 27, 2023. On September 27, 2023, at 12:18 PM, V2 said the facility's procedure for measuring and documenting input and out is facility staff should document intake and output every shift. The facility's policy titled, Catheter Care, Urinary dated August 2022, showed, Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections . Intake/Output: 1. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same or increases rapidly, report it to the physician or supervisor. 2. Follow the facility procedure for measuring and documenting input and output .

Based on Observation, Interview, and Record Review the Facility failed to have a Physician's order for oxygen administration in accordance with their policy. This applies to 1 of 1 (R1) resident reviewed for oxygen administration in a sample of 22. The findings include: R1's EMR (Electronic Medical Record) showed R1 was readmitted to the facility on [DATE] with multiple diagnoses including acute on chronic congestive heart failure, pneumonia, acute respiratory failure with hypoxia, atrial fibrillation and chronic kidney disease stage 3B. R1's MDS (Minimum Data Set) dated 8/22/2023, showed R1 is cognitively intact and required extensive assistance for bed mobility, bathing, toileting, and dressing, is dependent on staff for transfer and required set up assistance for eating. On 9/25/23 at 2:24 PM, R1 was sitting up in the wheelchair, receiving oxygen at three liters per nasal cannula, while talking the resident exhibited shortness of breath. The resident also had an implanted chest catheter drainage device to the right lower chest covered with a dry dressing. On 9/26/23 at 12:52 PM, R1 is seated in a wheelchair, eating lunch and receiving oxygen at three liters per nasal cannula. On 9/27/23 at 10:15 AM, R1 is lying in bed with nasal cannula and receiving 3.5 liters of oxygen via oxygen concentrator. V6 (RN, Registered Nurse) stated there was 350 milliliters output of drainage from the implanted chest catheter drain during the previous shift. On 9/27/23 at 1:45 PM, V6 validated there was no Physician's order in the EMR for oxygen administration since R1's readmission on 9/15/23, when R1 return from the hospital with the implanted chest catheter drain. V6 also verified that the last documentation of R1's oxygen saturation was on 9/15/23, and there was no documentation that R1 was receiving oxygen. On 9/27/23 at 2:15 PM, V2 (DON, Director of Nursing) stated the expectation for residents receiving oxygen would be to have a Physician's order for oxygen administration and oxygen saturation monitoring parameters in place. The facility policy for Oxygen Administration dated October 2010, showed 1. Verify there is a physician's order for this procedure.and document .3. The rate of oxygen flow, route, and rationale .6. All assessment data obtained before during and after the procedure.

Based on observation, interview, and record review, the facility failed to identify person-centered, non-pharmacological approaches for residents receiving psychotropic medications. The facility also failed to identify resident specific behaviors to monitor the response/effectiveness/side effects of psychotropic medications. This applies to 1 of 5 residents (R49) reviewed for psychotropic medications in the total sample of 22. The findings include: A Progress note written by the V14 (Psychiatric Nurse Practitioner), dated 9/18/23 at 6:41 PM, shows R49 has resided in the facility since 8/11/23, previously living in Assisted Living, now needing increased level of care with declining mobility and other concerns. The MAR (medication administration record), dated 9/26/23, shows R49 has a diagnosis of Parkinson disease, hallucinations unspecified, neurocognitive disorder with Lewy bodies, and dementia in other diseases classified elsewhere. The POS (Physician's Order Sheet) and the MAR (medication administration record) for R49 show R49 is receiving quetiapine (anti-psychotic) 100 milligrams every 2:00 PM and 200 milligrams every 8:00 PM. On 9/25/23 at 11:23 AM, R49 was in a wheelchair in her room. R49's speech was slow. R49 talked about students she is teaching here in this school. R49 stated she is aware she sometimes has hallucinations. R49 was able to respond appropriately to questions about care in the facility after moments of confused speech. R49 had a flat affect. The facility record includes Progress Notes including notes showing some presence of hallucinations and or delusions at times and at baseline. This is the only record of tracking medication effectiveness provided by the facility. On 9/27/23 at 11:08 AM, V2 (Director of Nursing) stated the facility has no psychotropic medication Nurse and has no Psychiatric Medical Director. V2 stated V14 talks with staff weekly and should document information from the discussions. The facility was not able to provide any record of monitored symptoms in any organized tracking for this resident other than discussion between V14 and the nurse on duty. The facility could provide no record of regular monitoring for side-effects from quetiapine for R49. There is no order in the POS for monitoring of effectiveness or of side-effects from quetiapine for R49. The facility could provide no record of targeted non-pharmacological interventions for R49 after repeated requests. The Care Plan for R49, in the facility record, shows interventions are to be done including, Assess behaviors and signs/symptoms of safety risk; and Assess and monitor confusion and signs/symptoms of safety risk. The same Care Plan shows, in the care plan for Falls, Assess for non-pharmacological interventions. The complete Care Plan provided by the facility contains no care plan regarding effectiveness or side-effects of any psychotropic medications. On 9/27/23 at 12:00 PM, V12 (Social Worker) stated she provides information to the MDS (Minimum Data Set) for R49, for the sections on Cognition, Mood, and Behavior from discussion with R49 and a review of the Progress Notes in the facility record. The MDS for R49 dated 8/17/23 shows R49 had no hallucinations or delusions in the period of the assessment. The facility provided the signed Informed Consent for Psychotropic Medications for R49 which shows general purposes for anti-psychotic medications including hallucinations and delusions and also lists possible side-effects including neurological side-effects. The Consent form contains a line stating, The following information has been explained/provided: and there is no information following. The same Consent shows the Black Box warning regarding the use of anti-psychotic medications in persons with dementia. (Copies of the Consents are attached as provided by the facility).

Based on interview and record review, the facility failed to safely position a resident during a bed bath. This failure resulted in R1 falling out of the bed and sustaining a subarachnoid hemorrhage. This applies to 1 of 4 (R1) residents reviewed for falls and accidents. Findings include: On 2/14/23 at 11:40 AM, R1 said on the day of the fall (1/13/2023), V4 (CNA/Certified Nurse Aide) was giving her a bed bath. R1 said that V4 rolled her onto her left side, away from V4. R1 said her right leg went over her left leg and over the bed and she slipped and fell off the bed. R1 said she hit her head when she fell off the bed and she had a big bump on the back of her head. R1 said the staff called the ambulance and she was taken to the hospital. R1 said a CT (Computerized Tomography) scan was done and they informed her that had a brain bleed. R1's face sheet shows R1 was admitted to the facility on [DATE] and was discharged on [DATE]. R1 has the following diagnoses, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hemiplegia affecting right dominant side, history of falling, nondisplaced posterior arch fracture of first cervical vertebra, subsequent encounter for fracture with delayed healing, abnormalities of gait and mobility and lack of coordination. R1's MDS (Minimum Data Set) dated 12/20/22 shows R1's cognition is intact and R1 needs extensive assistance with one person staff assist with bed mobility. R1's care plan initiated 12/2/22 and updated on 1/13/23 (day of the fall) shows that R1 requires two staff assist while providing care in bed. The facility's incident report dated 1/13/23 documents, On 1/13/23 at 10:30 resident had witnessed fall from bed. Staff were assisting resident with care and bed bath, resident lying on her left side moved her legs and slid from bed to floor. Resident sent to ER (emergency room ) via 911. Resident admitted with small sub-arachnoid bleed. On 2/14/23 at 12:04 PM, V4 CNA said while she was giving R1 a bed bath on a low air loss mattress, she asked R1 to turn on her left side so she could wash R1's back. V4 said she turned R1 away from her and R1 was positioned on her left side. V4 stated R1 was holding on the quarter side rail on the other side of the bed. V4 said when R1 turned, she moved her right leg over and R1 fell off the bed; V4 said she was unable to prevent R1's fall. V4 said she saw that R1 hit her head on the bedside table. V4 said R1 did not have any bleeding, only small bump at the back of her head. V4 said that R1 had a cervical collar on (for her existing neck fracture) during the bed bath. V4 said she called out for help and R1's nurse came in to assess R1. V4 said R1 was sent to the hospital via ambulance. V4 said she did not receive any special training for residents that have a cervical collar, she was only informed that R1's cervical collar has to be in place at all times. On 2/14/23 at 12:18 PM, V5 (Agency Nurse) said V4 CNA informed her that R1 fell off the bed during a bed bath. V5 said R1 was on the floor when she got to R1's room. V5 said she assessed R1, there was no bleeding; V5 said they did not move R1 off the floor, she called 911 and R1 was sent to the hospital. V5 said R1's cervical collar was on at the time of the fall. On 2/14/23 at 1:16 PM, V2 (DON/Director of Nursing) said V4 CNA informed her that R1 fell off the bed during a bed bath. V2 said when V4 was attempting to wash R1's back, V4 turned R1 to her left side, and when R1 moved her right leg, the momentum caused R1 to slip off the bed causing R1 to fall. V2 said R1 was admitted to the facility with a cervical fracture, and R1 had to have on cervical collar at times. V2 said R1 needed extensive assistance with one person assist for bed mobility. On 2/15/23 at 10:13 AM, V2 said staff was aware of R1's right sided weakness, and there were no specialized staff training for R1's cervical collar or right sided weakness. V2 said V4 should have had R1 turn towards her instead of away from her to wash her back, or there should have been another staff on the other side to assist, for safety reasons. On 2/15/23 at 10:36 AM, V13 (NP/Nurse Practitioner for Physiatrist) said the low air loss mattress could be slippery, the CNA should have had R1 roll towards her and not away from her since there was no other staff on the other side of the bed to guard and protect the resident and prevent a fall. According to R1's hospital record dated 1/13/23 shows, small region of left posterior superior temporal lobe subarachnoid hemorrhage likely from contrecoup injury as there is a large scalp swelling and hematoma along the right sided parietal and occipital scalp. Review of the facility's Support Surfaces Guidelines (September 2013), Turning a Resident on His/Her Side Away from You (October 2010), and Bath, Bed (March 2021) policies did not specify how many staff members are needed while giving a resident on low air loss mattress a bed bath or how to safely turn a resident in bed.

A. Based on observation, interview, and record review, the facility failed to follow their policy and CDC's (Centers for Disease Control and Prevention) recommendations regarding the use of PPE (Personal Protective Equipment) when caring for residents identified as PUI (Persons Under Investigation) for COVID-19. This applies to 2 of 8 residents (R45 and R262) reviewed for infection control practices in the sample of 17. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on December 6, 2021 at 12:13 PM, when V4 (Certified Nurse Assistant, CNA) entered R262's room without putting on full PPE for Contact and Droplet Isolation Precautions, exited the room, and then entered R45's room, again without donning full PPE for Contact and Droplet Precautions. The Immediate Jeopardy was identified on December 6, 2021 at 12:13 PM. V1 (Administrator), V2 (Director of Nursing, DON), V3 (Assistant Director of Nursing, ADON), and V17 (Interim Administrator) were informed of the Immediate Jeopardy on December 7, 2021 at 5:23 PM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on December 8, 2021 at 7:00 PM; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The Findings Include: The facility floor plan provided on December 6, 2021 at 12:00 PM showed the locations of the Yellow Zone, which housed three PUI residents (including R262 and R45), and the adjacent Red Zone, which housed Covid-19 positive residents. On December 6, 2021, there were two signs present on the wall outside R262's and R45's PUI rooms that showed R262 and R45 were under transmission-based precautions as PUI for Covid-19. One sign read Use Personal Protective Equipment (PPE) When caring for Patients with Confirmed or Suspected Covid-19. The other sign showed Contact Precautions. There was an isolation cart outside R262's and R45's room filled with gowns, gloves, goggles, and N95 masks which are required for staff to put on when entering these rooms. On December 6, 2021 at 9:44 AM, V5 (Registered Nurse, RN) stated PPE is to be worn on the PUI and Covid-19 units, and includes the removal of the personal eye protection and surgical face masks, then putting on the goggles and N95 masks that are in the isolation carts. V5 stated staff also need to put on isolation gowns and gloves. V5 added that before leaving the isolation room, staff are to remove the PPE, place the goggles in the small receptacle for goggles, and once out of room, put on a surgical mask and eye protection. On December 6, 2021 at 12:13 PM, V4 (CNA) wore a surgical mask and eye-shield glasses (which were open at the top and bottom, unlike goggles which fit snugly to the face), and entered R262's Yellow Zone room without performing hand hygiene or putting on an N95, goggles, a gown, or gloves. V4 delivered and set up R262's lunch tray and exited the room. V4 walked approximately 30 feet down the hallway and retrieved another lunch tray from the dining cart. Then at approximately 12:17 PM, V4 entered R45's room (also in the Yellow Zone) and delivered and set up R45's lunch tray. Again, V4 did not remove her surgical mask and eye-shield glasses, nor did she perform hand hygiene, put on an N95 mask, goggles, gown, or gloves before entering R45's room. Both R262 and R45 were in transmission-based precautions as PUI for Covid-19. On December 6, 2021 at 12:23 PM, V4 stated she was supposed to put on full PPE (a new N95 face mask, new goggles, gown, and gloves) before entering resident rooms when the resident is on transmission-based precautions. When asked why she did not put on the full PPE when delivering lunch trays in the Yellow Zone, V4 shrugged her shoulders. On December 7, 2021 at 1:10 PM, V3 (ADON) with V2 (DON) present, said the facility staff are trained monthly regarding infection control and the use of PPE. V3 stated the procedure for staff members donning PPE when entering a Yellow or Red Zone room included removal of the surgical mask and personal eye protection, donning a gown, gloves, a new face shield or goggles, and an N95 mask. V3 stated these supplies are provided by the facility and they are available in the isolation carts outside of the resident rooms. V2 said the staff needed to don new PPE when entering each resident's room, then remove all the PPE prior to exiting the room. V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) also stated the facility had been in outbreak status since November 17, 2021, and at present had two residents positive for Covid-19 residing in the Red Zone, one of which had been fully vaccinated for Covid-19. On December 7, 2021 at 04:30 PM, V2 provided a spreadsheet of the nursing staff's training in several areas. The trainings also included Infection Control: Basic Concepts, Infection Control: Essential Principals, Personal Protective Equipment, Transmission-Based Precautions, Hand Hygiene, Proper PPE, COVID Policy, or PPE training. The provided spreadsheet was reviewed, and it shows V4 has not had training in any of the areas listed above. R262's EMR (Electronic Medical Record) shows R262 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R262's November 29, 2021 Minimum Data Set (MDS) shows R262 is cognitively intact and requires set-up assistance for meals. R262's November 23, 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R45's EMR shows R45 was readmitted on [DATE] after a three-day hospitalization . R45's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R45's December 6, 2021 MDS shows R45 is cognitively intact and requires set-up assistance for meals. A Nursing Progress Note dated December 2, 2021 at 2:42 PM showed Resident is on isolation precautions. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R262's and R45's EMR shows neither resident had been vaccinated for Covid-19, which was confirmed by V2 on December 6, 2021 at approximately 9:00 AM. The facility's policy titled, Donning Doffing Personal Protective Equipment (PPE)/Covid-19 and dated April 9, 2020 shows when caring for patients with confirmed or suspected Covid-19, staff should perform hand hygiene, don (put on) isolation gown, don N95 respirator, don face shield or goggles, perform hand hygiene once again, and wear gloves covering the cuffs of the gown. The facility's policy titled Suspected or Confirmed (Covid-19) and dated July 14, 2020 included facemasks to be used in the event of supply capacity concerns. On December 7, 2021 at 1:10 PM, V2 (DON) and V3 (ADON) confirmed the facility does not have any concerns with PPE shortage. The CDC document updated November 20, 2020 and titled Preparing for Covid-19 in Nursing Homes under the subheading Create a Plan for Managing New Admissions and Readmissions Whose Covid-19 Status is Unknown, shows . HCP (Healthcare Personnel) should wear an N95 or higher-level respiratory (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for new admissions and readmission . The CDC document titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes Updated September 10, 2021 shows under key points that Older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens such as [CONDITION(S)]-CoV-2. The same document under the subheading Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection shows HCP caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) The State of Illinois document titled Covid-19 updated on December 3, 2021 under the subheading Residents Suspected to have Covid-19 shows Staff wear full PPE (N95 respirator, gown, gloves, eye protection) The same document under the subheading New Admissions or Readmissions shows New admission or readmissions that are unvaccinated need to be quarantine for 14 days The CDC document titled Covid-19 Data Tracker printed on December 7, 2021 for the County in which the facility is located shows high risk of transmission of Covid-19. The Immediate Jeopardy began on December 6, 2021 at 12:13 PM and was removed on December 8, 2021, when the facility took the following actions to remove the immediacy: 1. The staff education and return demonstration related to donning and doffing of PPE for residents in contact/droplet precautions started on December 7, 2021. Most of the staff that were scheduled to work were educated by December 8, 2021. 2. The facility revised their policy and procedure regarding Donning and Doffing PPE when entering a room with a resident on contact/droplet transmission-based precautions. 3. The Director of Nursing and Infection Preventionist will monitor for on-going appropriate use of PPE in contact/droplet transmission-based precaution rooms three times in each 12-hour shift daily for two weeks. On-going monitoring will be further refined in the facility's Plan of Correction in response to IDPH's written survey findings. 4. The facility Interdisciplinary Team including V16 (Physician/Medical Director) reviewed, discussed, and approved the Immediate Jeopardy Removal Plan on December 7, 2021 and December 8, 2021. B. Based on interview and record review, the facility failed to have an ongoing system to identify, collect, analyze surveillance data to identify infection trends. This applies to all 64 residents in the facility. The findings include: Resident Census and Condition of Residents, dated 12/6/21, shows the facility's census was 64 residents. On 12/7/21, the facility provided the infection prevention and control surveillance log in a binder. The binder showed surveillance logs for the months of December 2020, February 2021, March 2021, August 2021 through November 2021. There were no records of infection prevention and control surveillance done for the months of January, April, May, June, and July 2021. The log showed residents room numbers, residents names, admitted , onset date, system area affected (e.g., urine, respiratory, skin, ear/eye, blood, GI, other) fever, signs and symptoms, change in mental status, organism on culture, X-ray, treatment, community acquired or healthcare associated infection, whether they met criteria or not. The available logs failed to show organisms on the culture and the antibiotic treatment doses for most residents identified on the logs. There was no indication that residents' infections were resolved or ongoing. There was no documentation regarding monthly trends and comparison of infections based on laboratory cultures and antibiotic orders. There was no evidence that interventions were put in place to prevent future infections. There were no baseline infection rates to compare the infection trend with. There was no way to find out if there is increase/decrease pattern of organism/infections. On 12/8/21 at 11:40 AM, V2 (DON) stated she started at the facility on September 7th, 2021 and have tried to put the logs together starting from August 2021. V2 further stated she cannot speak for what happened when she was not at the facility. Review of facility's policy titled, Surveillance for Infections with a revised date of September 2017 showed: The infection preventionist will conduct ongoing surveillance for healthcare-associated infections (HAI) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The policy also showed: The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections. The policy also showed: Analyze the data to identify trends. Compare the rates to previous months in the current year and to the same month in previous years, to identify seasonal trends. And consider how increases or decreases might relate to recent process changes, events, or activities in the facility However, trends should be monitored.

Based on interview, and record review, the facility failed to: - Initiate CPR (Cardiopulmonary Resuscitation) and summon 911 emergency life services for a resident who was a full code. -follow its policy for advanced directives and maintaining individual resident code status -have a system in place so staff could promptly determine the code status of a resident. -ensure that direct care staff (Nurses and Certified Nurse Assistants) have current CPR certificate -ensure that staff was knowledgeable about assessing a resident who had an unexpected death. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on [DATE] at 7:55 A.M. when facility staff failed to initiate CPR on a resident (R1). V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 10:35 A.M. While the immediacy was removed on [DATE] at 3:00PM, the facility remains out of compliance at a Severity Level 2 due to the need to evaluate the new policies, the plan of action and Quality Assurance monitoring tools. This failure applies to all 74 residents currently residing in the facility. The findings include: The POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS for the month of July, August, September, and October of 2020 showed that R1 did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The POSs mentioned showed: Advance Directive: No relevant Advance Directives Entered. The clinical record showed that R1 did not have a completed POLST (Practitioner Order For Life-Sustaining Treatment) form to identify code status, wishes for life sustaining measures whether R1's wish was to be resuscitated or not, and what were her wishes for medical interventions whether full, selective, or comfort focused. The POLST form is a legal and signed documentation that identify there was a discussion made with either the resident, or POA (Power of Attorney), the signature of the patient/POA, signature of the witness to consent, and the signature of the authorized practitioner to validate and ensure resident's life's advance directives. The current care plan effective [DATE] to present showed that the facility did not address R1's advance directives and life sustaining measures. It also did not address R1's wishes for code status whether she wish to be resuscitated or not. The clinical records entered by IDT (interdisciplinary team that included nurses, social worker and physician) from the date of admission ([DATE]) to the time of R1's unexpected death on [DATE] showed the following synopsis of R1's stay at the facility: -[DATE]: R1 was admitted on [DATE] at 10:45 P.M. via ambulance direct from the airport as R1 came from another state. R1 had a fall on ,d+[DATE] and had undergone left hip arthroplasty. -[DATE]: physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . -[DATE]: R1 was seen by V9 (R1's Attending Physician/ Facility's Medical Director). V9 documented as follows: 'chief complaint: weakness, gait disorder, fall of ,d+[DATE], sustained left femur fracture, undergone arthroplasty. Dysphagia, complained of difficulty swallowing. Transferred to the facility for continuation of care and rehabilitation. (R1) Alert, and oriented times 3 with periods of confusion, no complaints of pain or discomfort. PMH/PSH (Past Medial History/Past Social History); Left femur fracture, dementia, depression, hypertension, CAD (Coronary Artery Disease), history of breast cancer, FTT (failure to thrive) and HOH (Hard of Hearing). V9 further documented R1's Assessment /Plan as follows: -weakness, gait disorder= PT (Physical Therapy and OT (Occupational Therapy), fall and safety precaution, CTM (Continue to Monitor) ; -left hip fracture= CTM; -FTT= [MEDICATION(S)], mechanical soft diet; -Dysphagia=ST (Speech Therapy) treatment; -Hypertension= [MEDICATION(S)] medication and CTM; -HLD ([CONDITION(S)]= Aspirin and CTM; -Dementia= [MEDICATION(S)] and CTM -Depression= [MEDICATION(S)] and CTM -Breast Cancer= [MEDICATION(S)], oncology follow up, CTM V9's notes also showed that that (V9) spent 35 minutes > 50 % face to face discussion with V10 (R1's Power of Attorney), (R1), staff discussed and medications reviewed. -[DATE]: R1 ambulated with distance of 10 ft. x 2 with PT and OT. -[DATE]: Telemedicine due to COVID precaution; (R1) well groomed, well nourished, sitting up in wheelchair. -[DATE]: V8 (Social Worker) spoke with V10 regarding R1's last day of Medicare coverage on [DATE] and is eligible for an appeal. -[DATE]: nurse's documentation entered by V11 (Registered Nurse) showed (R1's) left breast bleeding, stained on her clothes. No Pain. Notified (V9) and her reply was second breast cancer and to monitor. -[DATE]: nurse documentation entered by V3 (Registered Nurse) showed Seen by (V9), antibiotic medication and dry dressing to the breast and hospice consult. Call placed to (V10) and update and discussion of hospice. (V10) stated will consider and will get back to me. There was no documentation by V9 regarding this visit, there was no order given by V9 for DNR and there was no documentation to show that DNR status was discussed with V10 by either V9 nor by V3. -[DATE]: V8 (Social Worker) informed V10 that R1's last day of Medicare coverage would be on [DATE]. -[DATE]: documentation entered by V3 showed at 7:30 A.M., V6 (CNA, Certified Nurse Assistant) informed (V3) that (R1) had a foul smelling bowel movement. Out of bed, to chair. Up for breakfast. Provided juice at 7:45 A.M. At 7:55 A.M., (V6) called (V3) to come to (R1's) room. (R1) was yellow, and waxy color, no heartbeat, no respiration. (R1) placed back to bed. (V9) notified. (V10) notified and stated she will see (R1) and that she will wait for her husband to drive her. (V10) arrived at 10:00 A.M., Coroner pick up (R1) remains. The facility's incident report dated [DATE] showed that V6 assisted R1 to get up R1 from bed to chair at 7:30 A.M. V6 returned to R1's room with breakfast tray at 7:55 A.M. As showed on this investigation, V6 observed R1 slumped over and unresponsive. V6 then informed V3. V3 did not detect pulse or respirations. V9, V10, and facility's administration were notified. The investigation also showed that upon further investigation, R1 did not have a POLST form on file and therefore officially a Full Code, and CPR (Cardio-Pulmonary Resuscitation) should have been administered but was not provided. The facility investigation concluded that CPR was not provided to R1, 911 emergency life sustaining measures was not summoned by V3. The investigation also showed that V4 (Nurse Clinician/Unit Manager) who was on duty had failed to review R1's code status and guide V3 to perform CPR. Both V3 and V4 were terminated from their work employment for not following facility's policy for CPR. The investigation also showed that this incident had prompted V8 to review, and update code status for all residents. The facility's investigation also showed that V4 had mentioned that if a resident was a full code, then CPR should be performed. V4 also stated that if a resident does not have a DNR form completed, then consider the resident as full code and CPR should be performed. V4 stated during the facility's investigation that V4 does not know what POLST Form is. The investigation had also showed that V4 mentioned that if she was the primary nurse of R1, V4 would not have done anything differently as R1 was already gone. The facility's investigation also showed that V3 did not realized that R1 was a full code, did not check R1's chart and did not perform CPR to R1 when found unresponsive few minutes (7:45 A.M. to 7:55 A.M. =10 minutes) after being seen alive. The investigation also showed that V3 had mentioned that if a resident had no POLST, then consider them a full code, CPR to be performed. On [DATE] from 8:30 A.M. to 9:02 A.M., V6 and V7 (Certified Nurse Assistants) were both interviewed. V6 and V7 stated that at 7:30 A.M. on [DATE], both of them assisted R1 to get out of bed. V6 stated that R1 had requested to be out of bed. V6 also stated that she did not notice anything different from R1 aside from the foul smelling bowel movement that R1 had. V6 also stated that during the period she assisted R1 out of bed that morning of [DATE], R1 was verbally responsive and was able to verbalize needs and was using call light buttons for assistance. V6 also stated that R1 even made a joke and was excited to get out of bed by saying okay, I'm ready to get out of bed and at the same time R1 had pulled out all of her top beddings. V6 also stated that she did not notice any change of R1's condition. V6 further stated that R1 was at her baseline, making jokes and pulling the call lights frequently. V6 also added that at 7:45 A.M., she saw R1 fiddling her fingers and the silverware. V6 also added that it was less than 10 minutes when she returned to R1's room to bring breakfast tray which was around 7:55 A.M. This was when both V6 and V7 saw R1 slumped over, and was not responding verbally. V6 stated that she went to get V3 at once. V3 came immediately, checked R1's pulse and respiration, and instructed V6 and V7 to put R1 back to bed. V6 and V7 stated that V3 did not initiate CPR. V6 and V7 also stated that neither of them had initiated CPR to R1 since they were not told to do so and they follow what the nurse had said. Besides, V6 and V7 also said that they do not know R1's code status and also do not know where to check the code status of the resident. V6 and V7 also stated We know that (R1) had just passed away, we just saw her just few minutes ago alive and playing with her fingers. (R1) was also was very warm to touch and her body was very flexible and not stiff at all. V6 also stated that she was not sure if her CPR card was current. V6 and V7 stated that around 8:00 A.M., both V3 and V4 came to R1's room. V6 and V7 also stated that V3 and V4 did not perform CPR to R1. On [DATE] at 1:37 P.M., V3 stated that on [DATE] at 7:55 A.M., V6 called her to immediately check R1. V3 added that she quickly went to R1's room and found R1 sitting in her wheelchair, was slumped over and R1's skin color was waxy yellow. V3 also stated that she checked R1's radial pulse, and respiration. V3 stated that R1 had no radial pulse, and was not breathing. V3 also stated that she told V6 and V7 to put R1 back to bed. V3 also stated that she did not initiate CPR to R1 and did not call 911. V3 added that she did not check if R1 was DNR or a FULL CODE. V3 also stated that she later realized around after an hour or so that that R1 was a FULL CODE and should have been resuscitated. V3 also stated that facility investigated R1's unexpected death and found out that R1 did not have a completed POLST Form. V3 further stated that if there was no completed POLST Form, then R1 was considered a FULL CODE. V3 also added that R1 did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 also added that the POLST Forms for residents on both floors were kept in a binder and usually located on the first floor. V3 also stated that if a resident on the second floor had coded, there was no immediate access for the staff to know the residents' code status. V3 also stated that the residents' medical chart hard copy was not updated regarding Advance Directives/POLST. V3 also stated that it will take time to open the computer to check the POS and figure out the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 also stated on [DATE] at 7:55 A.M., she had texted V4 (Clinical Manager) for guidance related to R1's unexpected death. V3 further added that V4 did not response to her text message. V3 also stated that she went to look for V4 on the first floor. V3 found V4 in one of the offices near the nurse station. V3 and V4 went to R1's room around 8:00 A.M., and found V6 and V7 putting R1 back to bed. V3 further stated that all of them including herself, V4, did not check R1's code status and did not initiate CPR to R1. On [DATE] at 12:26 P.M., V4 (Clinical Nurse Manager) stated that she received a text message from V3 at 7:55 A.M. on [DATE] that R1 had just passed away. V4 added that she did not get the message at once since she did not have her mobile phone with her. V4 added that the test message sent showed are you in a meeting, need you stat, (R1) just expired. V4 also added that V3 came to find her on the first floor. V4 added that they went to R1's room, and saw R1 with yellow waxy skin color, (R1's) mouth was open. V4 added that V6 and V7 was cleaning up R1 and that (R1) was gone. V4 also stated when a resident was on the second floor, it's long term care, it is their home, they know it is the end of life and they are going home. (R1) went peacefully, and she did not die in a traumatic way, it was a blessing. V4 also added that no CPR was performed, no 911 was called and neither V3 nor she had checked R1's medical file for code status. V4 also stated that R1 was on the second floor. V4 also added that the facility has no system in place that works for the direct staff to identify code status. V4 also added that she think the POLST Forms binder was on the first floor and that the POLST Forms binder was a mixture of both first, and second floor residents which added more frustration to identify and easy access. V4 added that if a second floor resident coded, you have to go to the first floor to look for the POLST binder which was not current or updated. V4 also added that the medical chart hard copy was not audited for DNR/Full code orders, and has to log in to computer to check the POS if there are any order for code status and this take time. V4 added that I'm sure there is a policy somewhere for CPR/911; emergency situation, assume death policy or assessment to determine death of a resident, but I don't know where these policies are. The nurses did not have a meeting for over months. V4 also stated that she was not familiar with POLST documentation. V4 also stated that she had texted V5 (Assistant Director of Nursing) of R1's unexpected death at 7:59 A.M. on [DATE] and informed her that (R1) had just passed away unexpectedly. V4 added that V5 went to the second floor station around 8:05 A.M. During this time of V5's arrival, V3 was the nursing station talking to V10, and V6 was standing by the station. V4 added that V5 asked them have you notified the department heads and physician? V4 stated that V5 did not go to R1's room, did not check the medical chart hard copy, the POLST binder, and did not open the computer for DNR order in order to determine R1's code status. V4 also added that V5 did not ask V3 and V4 regarding R1's code status nor if they have check R1's POLST. V4 stated that she was sure of the time of the text messages that were sent because she did not erase the messages on her phone. On [DATE] at 1:01 P.M., V5 stated she had received a text from V4 at 7:59 A.M. on [DATE] that (R1) just passed away at 7:55 A.M. V5 added that when she arrived at the facility around approximately 8:30 A.M since she was late that day, she went to the second floor. V5 stated that she saw V3, at the nurse's station and was talking to V10. Meantime, V4 was standing by the nursing station. V5 stated that she did not asked V3 and V4 if R1 was FULL CODE or a DNR. V5 also added that she did not check R1's code status. On [DATE] at 12:54 P.M., V8 (Social Worker) stated that she had provided V10 a POLST Form but did not follow up for completion. V8 also added that she audits the residents' Advance Directives monthly. However, V8 had no explanation how come R1 had no documentation regarding Advance Directives from the month of July, when R1 was admitted , up to [DATE], when R1 had expired. V8 also cannot explain why R1's POS for the past four months (July through [DATE]) showed Advance Directives: No Relevant Advance Directives Entered. V8 also added that the facility started auditing residents' POLST form after the incident with R1. V8 also stated that there was an audit list for this and during the audits, there were multiple residents without POLST documentation. During a random observation on the first and second floor on [DATE] from 12:05 P.M. through 12:30 P.M., interviews were also held at same time with on duty nurses which includes V12 through V15. They have mentioned that the medical chart hard copy was not updated with regards to residents' code status. They also stated that they were not sure of the POLST Form and where it was located. They also added that even after the incident of (R1) with the unexpected death, and in- services, and auditing is in progress, the medical chart hard copy was still not updated with accurate documentation regarding residents' code status. Some of these nurses had pointed the medical chart at the nurse's station that it should have been color coded with a sticky note to promptly identify if a resident was a Full Code and DNR, however, some medical charts as pointed were not color coded. Review of the POLST audit list provided by V1 (Administrator) and V2 (Director Of Nursing) on [DATE] showed that on [DATE] there were 14 out of 78 residents with no POLST completed form, and on [DATE] there were 12 out of 85 residents without a completed POLST forms. The 14 residents identified without POLST form completed on [DATE] were R5 through R18. The 12 residents identified on [DATE] were R5, R7, R8, R10, R12, R15 through R21. This was verified and was confirmed via the audit list dated ,d+[DATE] and [DATE] with V2 (Director of Nursing) on [DATE] at 3:36 P.M. The facility provided a list of all nursing staff which includes CNAs, and nurses. There were 31 out of 59 CNAs and 5 out of 41 nurses that did not have CPR certification documentation, expired CPR certificate and requires recertification. V6 was one of the staff that needed recertification. On [DATE], 2:00 P.M. V1 stated that investigation regarding R1's unexpected death was conducted by V5. V1 also added that V3 and V4 were terminated from their employment on [DATE] for not providing CPR to R1. V1 also added that R1 was a FULL CODE because the POLST Form was not completed and there was no DNR order. V2 (Director of Nursing) also was present during the interview. V2 stated that it is the standard of professional practice and also the facility's policy that if a resident had an incomplete or no POLST form and an advance directive was unclear, then considered the resident a FULL CODE and CPR should be initiated. On [DATE] at 5:08 P.M., V9 (R1's Attending Physician/ Facility's Medical Director) was interviewed. V9 stated that she had discussed with V10 regarding R1's comfort/hospice care. V9 also stated that I assumed that (V10) was aware that (R1) would not be resuscitated if R1 would be under hospice care. But I am not sure if I have documented this. V9 was informed that review of R1's entire clinical record of the IDT (Interdisciplinary team that included nurses, social worker, dietician and physician including V9) showed that she had only documentation on [DATE] and a telemedicine on [DATE]. Surveyor also informed V9 that a nurse's notes dated [DATE] showed that she saw R1 on [DATE] but no documentation of this visit. The clinical record showed no documentation that there was a discussion of DNR nor V9 had given an order of a DNR status for R1. Surveyor verified with V9 regarding R1's no DNR order and POLST not completed. Surveyor also informed V9 that based on interviews gathered from V3, V4, V6 and V7 showed that on [DATE], R1 was last seen alive at 7:45 A.M and was unresponsive at 7:55 A.M. (more or less 10 minutes) and no irreversible signs of death as they noted. V9 was asked for verification what was her professional expectation from the staff since there was no DNR order and that it was around 10 minutes time frame between the time R1 was seen alive and unresponsive and no signs of irreversible death such as rigor mortis. V9 responded I don't expect them to do CPR since (R1) was already dead. Surveyor verified as to when to perform CPR to a FULL code resident, V9 responded when it is needed, I trust my nurses. V9 was also asked for verification if checking radial pulse by palpitation and respiration by auscultation were sufficient enough to pronounce death to a resident who had unexpectedly died . V9 responded I think it is enough, don't you think so.? Surveyor also verified how if R1 was only exhibiting [NAME] - stoke respiration, (temporary stop of breathing) since V3 and V4 did not check R1's pupils if they were fixed or dilated, nor had they checked any loss of sphincter muscles and failed to check pulses to other sites like the carotid pulse. V9 responded I trust my nurses, besides (R1) died of cancer that had metastasize to other parts of her body. The facility's CPR POLICY and POLST POLICY showed If a resident does not have a completed POLST form on file, the resident is considered a FULL CODE. A signed, witnessed, and MD (Medical Doctor) signed POLST must be in chart to be valid. POLST should be kept in the chart as well as the POLST binder on each floor. CPR must be administered and 911 called if DNR is not on file. A CODE BLUE with room number should be announced over the intercom to allow for quick response to the situation. ALL residents should have a POLST filled out, regardless of FULL CODE versus DNR The facility's policy for Emergency Procedure- Cardiopulmonary Resuscitation (CPR) with revised date of February 2018 showed . Personnel have completed training on the initiation of CPR and Basic Life Support 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: A) It is a known that a Do Not Resuscitate (DNR) that specifically prohibits CPR for that individual B) There are obvious signs of irreversible death (e.g. rigor mortis). 7. If the resident's DNR status is unclear, CPR will be initiated 8. Call 911 . The facility's policy for Advance Directives with revision date of [DATE] showed .6. Prior to or upon admission of a resident , the Social Service Director or Designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives . 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Through interviews and record review on [DATE], the survey team confirmed that the facility took the following action to remove the immediacy of the situation: 1. The staff completed an audit of resident medical records for current status of advanced directives related to code status and POLST (Practitioner Orders for Life Sustaining Treatment). 2. An audit was completed to determine nursing personnel current CPR certification. The facility staff's CPR instructor completed a CPR re-certification class for all employees with outdated CPR certicates. This was completed [DATE]. 3. Staff was in-serviced on POLST forms or Identifiers of code status and the location of forms in the chart. 4. To further identify, residents' code status, the color code medical chart hard copy will be completed on [DATE]. 5. Staff have been in-serviced that CPR certification must be current. In the event of finding a resident who is full code in need of resuscitation, CPR is to be initiated immediately. Anyone certified in Health Care Provider CPR may initiate resuscitation. 6. Staff has been in-serviced explaining Advanced Directives indicate resident wishes regarding code status. POLST forms must be read to determine Code Status. 7. The Social Service Designee was in-serviced on completion of Advanced Directive Forms on admission and timely completion of the POLST Forms. 8. The Administrator, DON, Department managers clarified with all staff during in-service that identification of resident code status is located in each resident medical record in the front of the chart and POLST form identified of code status. 9. The CPR instructor, DON will hold mock stations for resident assessment and resuscitation. Licensed staff will demonstrate competency. 10. The POLST forms binder have been updated and more accessible area of the nursing station. 11. For Quality Assurance Measures: a. Licensed personnel will be current with CPR Certification as of [DATE]. b. All newly hired licensed personnel will be Health Care Provider CPR certified prior to being placed on the schedule. c. The DON/Designee will monitor CPR expirations monthly. d. The Social Service Designee will obtain advanced directives and POLST on admission and will audit monthly.

Based on interview, and record review, the facility neglected to follow its policy and procedure for advanced directives regarding initiating CPR (Cardiopulmonary Resuscitation) on a resident who was a full code. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on [DATE] at 7:55 A.M. when facility staff failed to initiate CPR on a resident (R1). V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 10:35 A.M. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 due to the need to evaluate the new policies, the plan of action and Quality Assurance monitoring tools. This applies to 1 of 2 residents (R1) reviewed for improper nursing and death in the facility. The findings include: The facility's CPR POLICY and POLST POLICY showed If a resident does not have a completed POLST form on file, the resident is considered a FULL CODE. A signed, witnessed, and MD (Medical Doctor) signed POLST must be in chart to be valid. POLST should be kept in the chart as well as the POLST binder on each floor. CPR must be administered and 911 called if a DNR is not on file. A CODE BLUE with room number should be announced over the intercom to allow for quick response to the situation. ALL residents should have a POLST filled out, regardless of FULL CODE versus DNR The facility's policy for Emergency Procedure- Cardiopulmonary Resuscitation (CPR) with revised date of February 2018 showed . Personnel have completed training on the initiation of CPR and Basic Life Support 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: A) It is known that a Do Not Resuscitate (DNR) that specifically prohibits CPR for that individual B) There are obvious signs of irreversible death (e.g. rigor mortis). 7. If the resident's DNR status is unclear, CPR will be initiated 8. Call 911 . The facility's policy for Advance Directives with revision date of [DATE] showed .6. Prior to or upon admission of a resident , the Social Service Director or Designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives . 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. The POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The POS for the month of July, August, September, and October of 2020 showed that R1 did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The POSs mentioned showed: Advance Directive: No relevant Advance Directives Entered. The clinical record showed that R1 did not have a completed POLST (Practitioner Order For Life-Sustaining Treatment) form to identify code status, wishes for life sustaining measures whether R1's wish was to be resuscitated or not, and what were her wishes for medical interventions whether full, selective, or comfort focused. The POLST form is a legal and signed documentation that identify there was a discussion made with either the resident, or POA (Power of Attorney), the signature of the patient/POA, signature of the witness to consent, and the signature of the authorized practitioner to validate and ensure resident's life's advance directives. The current care plan effective [DATE] to present showed that the facility did not address R1's advance directives and life sustaining measures. It did not address R1's wishes for code status whether she wish to be resuscitated or not. The facility's incident report dated [DATE] showed that V6 assisted R1 to get up R1 from bed to chair at 7:30 A.M. V6 returned to R1's room with breakfast tray at 7:55 A.M. As showed on this investigation, V6 observed R1 slumped over and unresponsive. V6 then informed V3. V3 did not detect pulse, or respirations. V9, V10 and facility's administration were notified. The investigation also showed that upon further investigation, R1 did not have a POLST form on file and therefore officially a Full Code, and CPR (Cardio-Pulmonary Resuscitation) should have been administered but was not provided. The facility investigation concluded that CPR was not provided to R1, 911 emergency life sustaining measures was not summoned by V3. The investigation also showed that V4 (Nurse Clinician/Unit Manager) who was on duty had failed to review R1's code status and guide V3 to perform CPR. Both V3 and V4 were terminated from their work employment for not following facility's policy for CPR. The investigation also showed that this incident had prompted V8 to review, and update code status for all residents. The facility's investigation also showed that V4 had mentioned that that if a resident was a full code, then CPR should be performed. V4 also stated that if a resident does not have a DNR form completed, then considered the resident as full code, and CPR should be performed. V4 also had stated during the facility's investigation, V4 does not know what POLST Form is. The investigation had also showed that V4 mentioned that if she was the primary nurse of R1, V4 would not have done anything differently as R1 was already gone. The facility's investigation also showed that V3 did not realized that R1 was a full code, did not check R1's chart and did not perform CPR to R1 when found unresponsive few minutes (7:45 A.M. to 7:55 A.M. =10 minutes) after being seen alive. The investigation also showed that V3 had mentioned that if a resident had no POLST, then consider them a full code, CPR to be performed. On [DATE] from 8:30 A.M. to 9:02 A.M., V6 and V7 (Certified Nurse Assistants) were both interviewed. V6 and V7 stated that at 7:30 A.M. on [DATE], both of them assisted R1 to get out of bed. V6 stated that R1 had requested to be out of bed. V6 also stated that she did not noticed anything different from R1 aside from the foul smelling bowel movement that R1 had. V6 also stated that during the period she assisted R1 out of bed that morning of [DATE], R1 was verbally responsive and was able to verbalized needs and was using call light buttons for assistance. V6 also stated that R1 even made a joke and was excited to get out of bed by saying okay, I'm ready to get out of bed and at the same time R1 had pulled out all of her top beddings. V6 also stated that she did not notice any change of R1's condition. V6 further stated that R1 was at her baseline, making jokes and pulling the call lights frequently. V6 also added that at 7:45 A.M., she saw R1 fiddling her fingers, and the silverware. V6 also added that it was less than 10 minutes when she returned to R1's room to bring breakfast tray which was around 7:55 A.M. This was when both V6, and V7 saw R1 slumped over, and was not responding verbally. V6 stated that she went to get V3 at once. V3 came immediately, checked R1's pulse and respiration, and instructed V6 and V7 to put R1 back to bed. V6 and V7 stated that V3 did not initiate CPR. V6 and V7 also stated that neither of them had initiated CPR to R1 since they were not told to do so and they follow what the nurse had said. Besides, V6 and V7 also said that they do not know R1's code status and also don't no where to check the code status of the resident. V6 and V7 also stated We know that (R1) had just passed away, we just saw her just few minutes ago alive and playing with her fingers. (R1) was also was very warm to touch and her body was very flexible and not stiff at all. V6 also stated that she was not sure if her CPR card was current. V6 and V7 stated that around 8:00 A.M., both V3 and V4 came to R1's room. V6 and V7 also stated that V3 and V4 did not perform CPR to R1. On [DATE] at 1:37 P.M., V3 stated that on [DATE] at 7:55 A.M., V6 called her to immediately check R1. V3 added that she quickly went to R1's room and found R1 sitting in her wheelchair, was slumped over and R1's skin color was waxy yellow. V3 also stated that she checked R1's radial pulse, and respiration. V3 stated that R1 had no radial pulse, and was not breathing. V3 also stated that she told V6 and V7 to put R1 back to bed. V3 also stated that she did not initiate CPR to R1 and did not call 911. V3 added that she did not checked if R1 was a DNR or a FULL CODE. V3 also stated that she later realized around after an hour or so that R1 was a FULL CODE and should have been resuscitated. V3 also stated that facility investigated R1's unexpected death and found out that R1 did not have a completed POLST Form. V3 further stated that if there was no completed POLST Form, then R1 was considered a FULL CODE. V3 also added that R1 did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 also added that the POLST Forms for residents on both floors were kept in a binder and usually located on the first floor. V3 also stated that if a resident on the second floor had coded, there was no immediate access for the staff to know the residents' code status. V3 also stated that the residents' medical chart hard copy was not updated regarding Advance Directives/POLST. V3 also stated that it will take time to open the computer to check the POS and figure out the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V3 also stated on [DATE] at 7:55 A.M., she had texted V4 (Clinical Manager) for guidance related to R1's unexpected death. V3 further added that V4 did not respond to her text message. V3 also stated that she went to look for V4 on the first floor. V3 found V4 in one of the offices near the nurse station. V3 and V4 went to R1's room around 8:00 A.M., and found V6 and V7 putting R1 back to bed. V3 further stated that all of them including herself, V4, did not check R1's code status and did not initiate CPR to R1. On [DATE] at 12:26 P.M., V4 (Clinical Nurse Manager) stated that she received a text message from V3 at 7:55 A.M. on [DATE] that R1 had just passed away. V4 added that she did not get the message at once since she did not have her mobile phone with her. V4 added that the text message sent showed are you in a meeting, need you stat, (R1) just expired. V4 also added that V3 came to find her on the first floor. V4 added that they went to R1's room, and saw R1 with yellow waxy skin color, (R1's) mouth was open. V4 added that V6 and V7 was cleaning up R1 and that (R1) was gone. V4 also stated when a resident was on the second floor, it's the long term care, it is their home, they know it is the end of life and they are going home. (R1) went peacefully, and she did not die in a traumatic way, it was a blessing. V4 also added that no CPR was performed, no 911 was called and neither V3 nor she had checked R1's medical file for code status. V4 also stated that R1 was on the second floor. V4 also added that the facility has no system in place that works for the direct staff to identify code status. V4 also added that she think the POLST Forms binder was on the first floor and that the POLST Forms binder was a mixture of both first, and second floor residents which added more frustration to identify and easy access. V4 added that if a second floor resident coded, you have to go to the first floor to look for the POLST binder which was not current or updated. V4 also added that the medical chart hard copy was not audited for DNR/Full code orders, and has to log in to computer to check the POS if there are any order for code status and this take time. V4 added that I'm sure there is a policy somewhere for CPR/911; emergency situation, assume death policy or assessment to determine death of a resident, but I don't know where these policies are. The nurses did not have a meeting for months. V4 also stated that she was not familiar with POLST documentation. V4 also stated that she had texted V5 (Assistant Director of Nursing) of R1's unexpected death at 7:59 A.M. on [DATE] and informed her that (R1) had just passed away unexpectedly. V4 added that V5 went to the second floor station around 8:05 A.M. During this time of V5's arrival, V3 was at the nursing station talking to V10, and V6 was standing by the station. V4 added that V5 asked them have you notified the department heads and physician? V4 also stated that V5 did not go to R1's room, did not check the medical chart hard copy, the POLST binder, and did not open the computer for DNR order in order to determine R1's code status. V4 also added that V5 did not ask V3 and V4 regarding R1's code status nor if they have check R1's POLST. V4 stated that she was sure of the time of the text messages that were sent because she did not erase the messages on her phone. On [DATE] at 1:01 P.M., V5 stated she had received a text from V4 at 7:59 A.M. on [DATE] that (R1) had just passed away at 7:55 A.M. V5 added that when she arrived at the facility around approximately 8:30 A.M since she was late that day, she went to the second floor. V5 stated that she saw V3, at the nurse's station and was talking to V10 (R1's POA, Power of Attorney). Meantime, V4 was standing by the nursing station. V5 stated that she did not asked V3 and V4 if R1 was FULL CODE or a DNR. V5 also added that she did not check R1's code status. On [DATE] at 12:54 P.M., V8 (Social Worker) stated that she had provided V10 a POLST Form but did not follow up for completion. V8 also added that she audits the residents' Advance Directives monthly. However, V8 had no explanation how come R1 had no documentation regarding Advance Directives from the month of July, when R1 was admitted , [DATE], when R1 had expired. V8 also cannot explain why R1's POS for the past four months (July through [DATE]) showed Advance Directives: No Relevant Advance Directives Entered. V8 also added that the facility started auditing residents' POLST form after the incident with R1. V8 also stated that there was an audit list for this and during the audits, there were multiple residents without POLST documentation. During a random observation on the first and second floor on [DATE] from 12:05 P.M. through 12:30 P.M., interviews were also held with on duty nurses which includes V12 through V15. They have mentioned that the medical chart hard copy was not updated with regards to residents' code status. They also stated that they were not sure of the POLST Form and where it was located. They also added that even after the incident of (R1) with the unexpected death, and in services and heard auditing was in progress, the medical chart hard copy was still not updated with accurate documentation regarding residents' code status. Some of these nurses had pointed the medical chart at the nurse's station that it should have been color coded with a sticky note to promptly identify if a resident was a Full Code and DNR, however, some medical charts as pointed were not color coded. Review of the POLST audit list provided by V1 (Administrator) and V2 (Director Of Nursing) on [DATE] showed that on [DATE] there were 14 out of 78 residents with no POLST completed form, and on [DATE] there were 12 out of 85 residents without a completed POLST forms. The 14 residents identified without POLST form completed on [DATE] were R5 through R18. The 12 residents identified on [DATE] were R5, R7, R8, R10, R12, R15 through R21. This was verified and was confirmed via the audit list dated ,d+[DATE] and [DATE] with V2 (Director of Nursing) on [DATE] at 3:36 P.M. The facility provided a list of all nursing staff which includes CNAs, and nurses. There were 31 out of 59 CNAs and 5 out of 41 nurses that did not have CPR certification documentation, expired CPR certificate and requires recertification. V6 was one of the staff that need recertification. On [DATE], 2:00 P.M. V1 stated that investigation regarding R1's unexpected death was conducted by V5. V1 also added that V3 and V4 were terminated from their employment on [DATE] for not providing CPR to R1. V1 also added that R1 was a FULL CODE because the POLST Form was not completed and there was no DNR order. V2 (Director of Nursing) also was present during the interview. V2 stated that it is the standard of professional practice and also the facility's policy that if a resident had incompleted, or no POLST form and an advance directive was unclear, then consider the resident a FULL CODE and CPR should be initiated. Through interviews and record review on [DATE] and [DATE], the survey team confirmed that the facility took the following action to remove the immediacy of the situation: (The facility submitted the plan and the submission of this plan does not constitute and admission by Michealsen that Immediate Jeopardy existed, and Michealsen reserves the right to contests the finding of Immediate Jeopardy.) 1. The staff completed an audit of resident medical records for current status of advanced directives related to code status and POLST (Practitioner Orders for Life Sustaining Treatment). The staff completed subsequent audits of resident medical record for current status of advanced directives related to CODE status and POLST. 2. An audit was completed to determine nursing personnel current CPR certification. The facility's CPR instructor will schedules classes for licensed staff certification on [DATE] to begin in the A.M. and go throughout the day to ensure certification of all licensed staff. 3. Staff was in-serviced on POLST forms or Identifiers of code status and the location of forms in the chart. 4. Staff have been in-serviced that CPR current certification is a must. In the event of finding a resident who is full code and in need of resuscitation, CPR is to be initiated immediately. Anyone certified in Health Care Provider CPR may initiate resuscitation. 5. Staff has been in-serviced explaining Advanced Directives indicate resident wishes regarding code status. POLST forms must be read to determine Code Status. 6. The Social Service Designee was in-serviced on completion of Advanced Directive Forms on admission. 7. The Administrator, DON and Department managers clarified with all staff during in-service that identification of resident code status is located in each resident medical record in the front of the chart on the PLOST form or identified of code status. 8. The DON and CPR instructor will hold mock stations for resident assessment and resuscitation. Licensed staff will demonstrate competency. 9. Quality Assurance Measures: a. Licensed personnel will be current with CPR Certification as of [DATE]. b. All newly hired licensed personnel will be Health Care Provider CPR certified prior to being placed on the schedule. c. The DON/Designee will monitor CPR expirations monthly d. The Social Service Designee will obtain advanced directives on admission and will audit monthly. 10. The Quality Assurance Team will review quarterly for compliance.

Based on observation, interview, and record review, the facility failed to safely transfer a resident from the wheelchair to a shower chair. This failure resulted in the resident falling and sustaining a [MEDICAL CONDITION] requiring hospitalization and surgical intervention. This applies to 1 of 3 residents (R1) reviewed for transfers in the sample of 3. The findings include: According to the Electronic Health Record (EHR) R1 had [DIAGNOSES REDACTED]. R1 was in the facility for four days prior to the fall. A Hospital Physical Therapy assessment dated [DATE] showed R1 needed contact guard assistance with verbal cues during transfers from sitting to standing and needed verbal cues with minimal assist (R1) tends to try to sit when not close enough to) when going from standing to sitting position. The discharge Minimum Data Set ((MDS) dated [DATE] showed R1 needed extensive assistance of one person for bed mobility, transfers, walking, and toilet use; and needed physical help of one person for bathing. The MDS showed R1 was five feet two inches tall and weighed 103 pounds. The MDS showed R1's cognition was intact. An Interim Care Plan showed R1 was a fall risk; needed assistance with bathing of one staff member; and needed assistance with transfers of one staff member. On 01/22/2020 at 10:01 AM, V13 (Coroner) said R1 had a fall in the facility and had surgery on 01/09/2020 for a left [MEDICAL CONDITION] sustained during the fall. On 01/22/2020 at 5:20 PM, V5 (Certified Nursing Assistant, CNA), said R1 was alert, oriented and was a one person assist pivot transfer. R1's wheelchair was placed directly facing the shower chair, not on an angle. V5 undressed R1's top clothing while R1 was still seated in the wheel chair. While R1 still had her pants on, V5 had R1 stand up and then turn around with R1's back toward the shower chair. R1 did not have a gait belt on. While R1 was standing with her back to the shower chair, V5 was standing to R1's right side, V5 pulled R1's pants down to around the shin area then had her sit on the edge of the shower chair. V5 said R1 was at the front edge of the chair, partially leaning on the front edge of the bar of the toilet seat but not fully seated on the chair. V5 said R1 was short and the shower chair was a little higher so R1 could not fully sit on the chair from standing without scooting back and forth. V5 remained on R1's right side to try and assist her to scoot back all the way onto the shower chair. V5 had not pulled R1's pants off all the way until the resident was seated back on the shower chair. R1 started scooting back on the chair, making a slight rocking motion by leaning slightly forward and lifting herself using her arms on the arm rests and then moving her buttocks back and forth onto the shower seat. R1 did this scooting motion about three times before she leaned too far forward, fell forward and to the left side onto the floor. V5 said she was unable to stop R1 from falling forward as she was to the side of R1, not in front of her and R1 didn't have a gait belt or any clothing on to grab hold of. V5 said this was the first time caring for R1. V5 said during a one person assist pivot transfer the resident's seat or chair should be either directly in front of or at an angle to the seat they are going to be transferred into so the resident doesn't have to walk. If the resident didn't seem steady, V5 would use a gait belt or get another person to help. The shower chair used for R1 was part of an integrated three sided tub-like cabinet enclosure. The base of the cabinet tub is elevated off the ground approximately four to six inches. The shower seat slides back and forth into and out of the enclosure. It has a bar across the front and resembles a toilet seat with an opening in the middle and also has a backrest. The top of the seat is approximately 26 inches from the floor. On 01/22/2020 at 5:09 PM, V4 (Registered Nurse, RN), said about one hour before getting ready for bed R1 had fallen in the shower. V4 said she was not present in the shower room when it happened but V5 (CNA) reported she had been standing to R1's right sign between the wheelchair and the shower chair when R1 fell . V4 said R1 did not have a gait belt on. V4 said she was not present during the transfer but the procedure for using a gait belt while doing a pivot transfer included placing the gait belt onto the resident, standing in front of the resident, holding the gait belt, once the resident was standing, pivoting the resident from the wheelchair to the other chair while in remaining in front of the resident. A Nursing Progress Note dated 01/08/2020 at 10:00 PM written by V4 (RN) showed at 7:20 PM R1 was observed lying on the floor in the shower room with legs and arms extended. The CNA reported during transfer from the wheelchair to the slide chair in the shower tub with the resident, the resident was attempting to scoot back due to the slide shower chair being higher in height than her wheelchair. CNA reported that the resident was having difficulty and fell forward onto her left side on the shower room floor. CNA stated she was positioned on the resident's right side prior to occurrence and that the resident fell forward to the left side. (R1) was alert and oriented to person, place and time post fall assessment. R1 sustained three skin tears: Left elbow measuring 3.2 centimeters (cm); right upper lateral inner arm 1 by 0.2 cm; and left anterior knee 1.5 cm by 0.8 cm. (R1) was able to slightly bend the left knee but was unable to raise her left upper leg due to pain, crying out from pain with movement. R1 was unable to stand due to left lower extremity pain. The staff transferred R 1 from the floor to the wheelchair using three staff members and a total body mechanical lift. R1 was sent to the hospital emergency room at 9:18 PM. On 01/22/2020 at 1:28 PM, V8 (CNA) said when transferring a shorter resident from a wheelchair to the shower chair he would recommend using the sit to stand mechanical lift. When a resident is standing on the foot plate of the sit to stand mechanical lift, it would raise the resident about six inches off the ground and they would probably be high enough and able to then be lowered to seated onto the shower chair without having to scoot back. On 01/23/2020 at 10:08 AM, V11 (CNA) and V12 (CNA) both said during a pivot transfer they would place the wheelchair at an angle to the shower chair, place a gait belt on the resident then while standing in front of the resident, have the resident stand and do a pivot turn from the wheelchair to the shower chair. The CNAs would pull the resident's pants down if they are not able to do it themselves. V11 and V12 said they do not fully undress the resident or take off the gait belt until the resident would be seated all the way back on the shower chair. On 01/23/2020 at 10:34 AM, V9 (CNA) said when he has a resident in the shower booth he will position the wheelchair on an angle and assist the resident with a pivot transfer using a gait belt while standing in front of them. V9 would stand in front or slightly to the side and pull their pants down while they are standing just prior to sitting on the shower seat. V9 would not remove the gait belt or the resident's clothes on the top until the resident was seated completely on the shower seat. If transferring a shorter resident who had trouble sitting back on the seat V9 said he would probably have two people do the transfer to more easily have them sit onto the seat. On 01/23/2020 at 12:13 PM, V6 (Physical Therapist, PT), said R1 needed contact guard or sometimes minimal assistance during transfers. R1 also needed verbal cues for hand placement with the walker and transfers. R1 was a really tiny, short resident. V6 said even with contact guard assistance the staff person has to hold onto the gait belt incase the resident loses their balance. With contact guard assistance the staff would not need to provide assistance besides holding the gait belt. When R1 would need minimum assistance the staff would be doing one to twenty five percent assistance such as hands on support on the resident's back side area around the gait belt. V6 said any transfers with R1 she would need a gait belt, whether walking or transferring. During therapy, even a regular chair would have been a little high for R1 and R1 would need to scoot back because her feet would be dangling. The therapist would give her assistance in the trunk area to hold them and the gait belt. R1 would lean forward in order to scoot back. A Physical Therapy assessment dated [DATE] at 8:39 AM written by V6 (PT) showed R1 transfers with minimal assistance. R1 requires cues for safety especially hand placement when pivoting to other surfaces, and to control descent to and from chair, to and from supine. The treatment plan summary showed R1 had poor vision and was hard of hearing, alert and oriented to person and sometimes to place, followed one step directions. R1 had generalized weakness, impaired balance and stability, decreased safety awareness, and requires assistance for safe functional transfers. On 01/23/2020 at 12:33 PM, V7 (Occupational Therapist, OT), was unsure if the facility had a specific policy regarding gait belt use or transfers. V7 said the therapy department uses the rule that any resident in the facility receiving therapy needed some kind of contact guard, minimum, moderate or maximum assistance until they are released from therapy stating they are independent in transfers or toilet use. V7 did not see R1 but said the OT discharge assessment showed R1 needed maximum assistance for lower body bathing and dressing and needed maximum assistance with toilet transfer as well. R1 needed minimum assistance for toilet transfers in which the therapist was helping less than 25 percent of sitting to standing or the pivot portion. V7 said the staff would need at the least a little bit of a hand on someone while they are moving. Therapy uses a gait belt with everyone in therapy. On 01/23/2020 at 3:46 PM, V2 (Director of Nursing, DON) said the facility doesn't have a policy specific to gait belt use or resident transfers. V2 was unsure if the CNAs remove the resident's clothing before being transferred into the shower chair or not. On 01/23/2020 at 4:13 PM, V3 (Medical Doctor, MD), stated R1's fracture was a result of the fall. The facility's Safe Lifting and Movement of Residents policy dated (MONTH) (YEAR) showed staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. The policy does not address the procedure of how to do a resident transfer. The National Institutes of Health Medline Plus Moving a patient from a bed to a wheelchair dated 11/15/2017 showed a pivot turn included place a gait belt on the patient to help get a grip during the transfer. Stand as close as you can to the patient, reach around the chest, and lock your hands behind the patient or grab the gait belt. Pivot towards the wheelchair, moving your feet so your back is aligned with your hips. Once the patient's legs are touching the seat of the wheelchair, bend your knees to lower the patient into the seat.

Based on observations, interview and record review, the facility failed to provide supervision from a resident with history of wandering. This failure resulted in R1 sustaining a hemotoma with hospitalization that required evacuation of the hematoma. This applies to 1 of 3 residents (R1) reviewed for behaviors affecting others in a total sample of 8. The findings include: R1's EMR (electronic medical record) showed that R1 was admitted to the facility on [DATE] and discharged to hospital on [DATE]. EMR also showed that R1's medications on discharge included Xarelto (one tablet oral) 15 mg (milligrams) one time a day starting 3/2/18. R1's admitting [DIAGNOSES REDACTED]. R1's 1/3/18 quarterly MDS (minimum data set) showed that R1's cognition was moderately intact with BIMS (brief interview of mental status) score of 10. Facility incident report (3/11/18) included the following: Interviews of R1's physician (V13) and medical director (V14) concurred that it is conceivable that R2 sitting down on R1 could result in a hematoma due to R1's use of Xarelto and R1's structure (thin and bony). On (MONTH) 26, (YEAR) at 5:10 PM, V2 (family member) stated that R1 had to be hospitalized for [REDACTED]. V2 stated that the R1 had to have emergency surgery on her legs and they (hospital) are going to send R1 to a wound specialist. V2 stated that R1 had told her that the hematoma developed because R2 had come into her room with a wooden box and slammed it on her legs. V2 stated that R1 had told her originally in the beginning of February, (YEAR) about R2 coming to her room and flopping on R1's legs. V2 stated that when she learned of this, she had told V6 (CNA/certified nursing assistant) and other CNA's to keep R2 out of R1's room. V2 stated that around (MONTH) 12, (YEAR) she spoke to V9 (social worker) about it and V9 told her that that they (facility) are going to put stuffed socks in R1's doorway. V2 stated that R1 became anxious and told her that she is afraid to sleep at night with R2 coming into her room. V2 stated that she also spoke to V10 (R1's nurse) about R2 coming into R1's room and that its affecting R1's sleep. On (MONTH) 27, (YEAR) at 1:10 PM, V10 (R1's nurse) stated that V2 (family member) had told her a couple of months ago about R2 going into R1's room and sits on her bed. V10 stated that it usually occurs during the night shift. V10 stated that reports of the matter were given to V3 (nurse manager). On (MONTH) 27, (YEAR) at 1:00 PM, V9 (social worker) stated she was aware of R2 going into R1's room when V2 called and reported it about 2 months ago. V9 stated she reported it to V3 . V9 stated V1 (administrator) was made aware of it. On (MONTH) 27, (YEAR) at 1:45 PM, V3 (nurse manager) stated V9 had reported that V2 had called about R2 going into R1's room and sitting on her bed. V3 stated on learning this, the staff upped the rounding on R2. V3 stated that when they first started the rounding on R2 it was every 15 minutes but then R2 seemed to settle in so rounding was as needed. V3 stated that R2 tends to wander more in the evening and at night time. On (MONTH) 27, (YEAR) at 10:15 AM, V5 (CNA) stated that on 3/11/18 at around 6:05- 6:10 AM, she heard R1 screaming help me and she and V6 (CNA) went to R1's room and saw R2 standing by R1's bed looking at her. V6 stated that R2 had nothing in her hands and was redirected back to her room. V6 had verified the facts stated the same day at 1:15 PM. Both V5 and V6 stated they were aware of R2's wandering into other residents rooms. On (MONTH) 28, (YEAR) at 9:55 AM, V11(nurse PM) stated on 3/11/18 at around 6:40 AM, while she was standing in the second floor hallway near her medication cart, V7 (CNA) brought R1 in a wheel chair to her. V11 stated V7 told her that R1 said that someone came to her room and sat on her leg. V11 stated that R1 complained of pain (of score 10) to her right leg. V11 stated that she looked at R1's right leg and saw a raised hematoma (5 cms(centimeters) times 5 cms). V11 stated that she gave R1 Tylenol and paged the doctor. On (MONTH) 27, (YEAR) at 10:35 AM, V4 (nurse am) stated when she started her shift on 3/11/18 at around 6:50 AM, she saw R1 crying out in pain at the nurses station saying please help me, I need to go to the hospital. V4 stated that V11 told her that she had given R1 Tylenol and texted the doctor. V4 stated when she looked at R1's right leg, she was afraid of the lack of blood flow to the leg and called 911 and sent R1 to the emergency room . V4 stated R2 is very restless and tends to wander to other residents rooms despite redirection as R2 does not have the capability of understanding. V4 stated that in the period of the last two months, she has overheard reports of R1's family expressing concerns that R2 will sit on R1's bed . V4 stated that they watch R2 during the day shift but she not sure if there is the same staff ratio in the other shifts. On (MONTH) 27, (YEAR) at 3:15 PM, V1(administrator) stated R2 came to the facility around January, (YEAR) and was very confused and disoriented with the move. V1 stated that the facility was working on behavior tracking/ monitoring. V1 stated that she got reports a little over a month ago that R2 was wandering to other residents rooms. V1 stated that the staff were watching and keeping checks on R2. V1 stated R2 tends to wander into the adjacent rooms and R1's room had the same layout as R2's room. While at the facility, R2 was observed to wander the hallways on second floor magnolia wing and go in and out of few residents rooms in the afternoon hours with staff redirection. R5 and R7 whose rooms were adjacent to R1 and R2's were also interviewed. On (MONTH) 28, (YEAR) at 12:30 PM, R5 stated that R2 comes into her room on/off. R5 stated that one little lady came into my room in the middle of the night and sat on her bed near her leg and startled her. R5 stated that she did not know if it was R2 as it was dark. R5 stated that no staff were with that lady when incident happened but she told staff about it later. R5's 14 day (1/2/18) MDS showed that R5 was cognitiively intact with BIMS score of 13. On (MONTH) 28, (YEAR) at 3:05 PM, R7 stated that she keeps her door closed as much as possible as the one next door wanders into her room and sits on her recliner and throws her stuffed animals on the floor. R7's comprehensive (2/17/18) MDS showed that R7's cognition was moderately intact with BIMS score of 8. On (MONTH) 28 at 1:08 PM, V13( R1's physician) stated that having another person sitting on R1 with her taking Xarelto (blood thinner) can cause a hematoma. R1 stated that the bleeding was superficial and had not gone deeper to tissue and muscle without compartmental syndrome. V13 stated that the reason that the orthopedic doctor took her to the O.R (operating room) for evacuation of the hematoma, was that if it was not done R1 would have necrosis of the skin which would take longer to heal. R1's hospital records showed that R1 was admitted on [DATE] and discharged on [DATE]. R1's admitting hospital [DIAGNOSES REDACTED]. Hospital admitting chief complaint included leg (unknown) injury with right leg hematoma with possible deformity. Hospital records also showed that R1 had a wound vac (negative pressure wound therapy) at the time of discharge from hospital. R2's EMR included [DIAGNOSES REDACTED]. R2's care plan included that R2 has been wandering in and out of other residents rooms and staff will provide redirection as needed.

Based on interview and record review, the facility failed to insure a resident was safely transferred by staff in accordance with facility policy. The facility also failed to ensure residents were monitored during toileting and failed to implement safety precautions documented in the resident record to prevent falls. This failure resulted in R1 sustaining bilateral femur fractures, being admitted to hospice and expiring on [DATE]. This applies to 3 of 3 residents (R1, R2, R3) reviewed for falls. The findings include: 1. The facility's Occurrence Report for R1's fall dated [DATE] shows: At 0500 (5:00 AM) staff RN called the supervisor to report that resident sustained [REDACTED]. At 0400 (4:00 AM) resident was agitated and restless. CNA was getting up resident with the (mechanical lift), the resident was fighting with the CNA, she was combative. When she got in the wheelchair, she slid off and fell on the floor on her back. (Z2) stated that he was transferring resident, resident was agitated and struggling for balance. When she got in the wheelchair she slid off the wheelchair and fell on her back. On [DATE] at 11:20 AM, during initial tour of the facility, R1 was not in her room. E3 (CNA-Certified Nursing Assistant) said R1 was in the hospital. On [DATE] at 1:58 PM, R1 was laying in bed. R1 was sleeping but arousable by staff. R1 was not interviewable due to confusion. E10 (RN-Registered Nurse) said R1 had been in the hospital since [DATE] and returned to the facility several minutes earlier under the care of hospice due to injuries sustained during a fall several days earlier. R1' face sheet dated [DATE] shows R1 was admitted to the facility in [DATE] with multiple [DIAGNOSES REDACTED]. R1's MDS (Minimum Date Set) dated [DATE] shows R1 has severe cognitive impairment, requires extensive assistance by two people for transfers and toileting, and is always incontinent of urine and frequently incontinent of bowel. The MDS shows R1 has functional range of motion impairment on both lower extremities, uses a wheelchair for mobility, and is unable to stabilize herself during surface-to-surface transfers (transfer between bed and chair or wheelchair) unless she has the assistance of facility staff. The MDS also showed R1 has a history of falls. On [DATE] at 1:30 PM, E5 (RN-Night Supervisor) said, I was called to (R1's) room by E11 (RN) around 5:00 AM on [DATE]. E11 told me (R1) had fallen. When I arrived in the room, (R1) was sitting in the wheelchair. She had fallen and hit her head. I immediately did a neurological assessment of (R1). I was told Z2 (CNA) transferred (R1) using a mechanical lift but did not have a second person with him for the transfer. E11 said she had helped Z2 multiple times during the night but the one time Z2 did it alone (R1) fell . (R1's) injury could have been avoided, I don't know why Z2 transferred her by himself. On [DATE] at 4:10 PM, Z2 (CNA) said, I was taking care of (R1) on [DATE] around 4:00 AM when she fell . She was agitated since about midnight, hitting the wall multiple times with her call light and fist, and crying out. I wanted to make her comfortable and I thought if I got her up in the chair, maybe she would be happier. The only mistake I made was transferring her by myself. I used the mechanical lift, and as soon as I put her in the chair, I moved the mechanical lift and she slid out of the chair. Her legs were out in front of her, her back was on the floor, and the sling from the mechanical lift was under her. I know she is a two-person assist, that was my biggest mistake. I think they want us to have two people during transfers with the mechanical lift for safety and security purposes. I think I need two people so the person doesn't get hurt. If two people would have been there, one person could caught her or held her while I moved the mechanical lift. On [DATE] at 1:50 PM, E2 (DON-Director of Nursing) said, The facility's policy is that all mechanical lift transfers should be done with two staff members present. On [DATE] at 3:40 PM, E8 (CNA) said, On [DATE] around 4:00 AM or 5:00 AM, I was across the hall from (R1's) room, helping another resident. I was not in the room when (R1) fell . E11 asked me to come help. (R1) was laying on the floor. The sling from the mechanical lift was under her. We raised her up and put her in the wheelchair. Z2 did not ask me to help him with any residents that evening. I asked Z2 if he knew he shouldn't use the mechanical lift by himself. On [DATE] at 3:30 PM, E9 (CNA) said, (R1) just got back to the facility. She is bedridden now. All we are supposed to do is turn her every two hours and let the nurse know if she is in pain. She was not bedridden before she fell . She could sit in her wheelchair and wheel around by herself. She would come out of her room to eat meals. On [DATE] at 2:53 PM, Z1 (Physician) said, The facility called me on [DATE] and told me (R1) had fallen. I would expect the staff would follow the facility's policy for transfers. I was notified of (R1's) fractures the following day and we sent her to the hospital. Her fractures were caused by the fall. Because of her prior weakness, it will be very hard for her to recover from this. Z4's (NP-Nurse Practitioner) documentation for R1 dated [DATE] shows: This is a [AGE] year old patient seen today for right knee swelling and BLE (bilateral lower extremity) pain. Patient slid off and fell on the floor on her back on [DATE]. Upon exam, pt is alert and has a lot of pain on her lower extremities. Her right knee is swollen, no skin breakdown. Pt is in significant amount of pain even with slight touch or repositioning. Both lower legs with chronic swelling. Assessment/Plan: BLE pain, right knee swelling. Will do X-ray of both knees and legs today . R1's X-ray results dated [DATE] showed: Left: subacute or acute fracture which is nondisplaced involving the distal femur. Right: There is a displaced fracture deformity involving the distal femur with angulation at the fracture site. Z6's (physician) documentation for R1 dated [DATE] showed: Bilateral distal femur fracture with history of fall.No surgical intervention as will not change her quality of life. She has been w/c (wheelchair) bound, needing (mechanical lift) for transfers. Addendum - d/w (discussed with) (Z7) (family member) and (Z8) (family member) this afternoon regarding hospice. Wanting to go ahead with same. Possibly return to (facility) tomorrow and start (hospice) care there. On [DATE] at 2:56 PM, E6 (RN) said R1 expired on [DATE] at around 10:45 AM. The facility's policy for full-body mechanical lifts, revised [DATE] shows: Policy: to enable two people to transfer a non-weight bearing resident safely. This device is used to aide in transfer, toileting, brief changes. (Full-body mechanical lift) transfers are always performed with two people assisting. Procedure: 1. Assemble equipment: evaluate that all equipment is in working order and battery is charged. Two staff members are required for use with transfer via (full-body mechanical lift).16. Two staff members for lift with one standing next to resident during lift and through entire transfer.20. To lower resident, stand next to resident and push the down button on the device until resident is fully lowered. Ensure resident is safely positioned. 2. The facility's occurrence report for R2, dated [DATE] at 6:00 PM showed: CNA called this nurse to (R2's) bathroom. Resident was lying on left side on floor. Did hit head per resident. Alert. Neuro checks wnl (within normal limits). ROM (range of motion) wnl. 1 cm. (centimeter) skin tear to right posterior elbow. Observed egg size bump on back of head in center. C/O (complained of) some nausea and slight headache. CNA was in bathroom with resident toileting. When resident finished toileting, resident stood holding onto bars around the toilet. When CNA turned to get wipe for cleaning resident, CNA observed resident on the floor lying on left side. CNA called for help STAT. On [DATE] at 1:57 PM, R2 was sitting in her room. A wound was observed on her right elbow. The wound was open to air, and two sutures were present. R2's face sheet dated [DATE] shows R2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The [DATE] POS (physician order [REDACTED]. R2 was sent to the local hospital and returned to the facility with sutures in her right elbow. On [DATE] at 9:00 AM, E2 (DON) said, R2 fell on [DATE] during toileting. R2 was sitting on the toilet and the CNA turned away to retrieve wipes. R2 attempted to stand and fell . The CNA was inserviced on using a gait belt and having hygiene items close by. R2's MDS dated [DATE] shows R2 has moderate cognitive impairment, requires extensive assistance with ADLs (activities of daily living), including toileting, and is frequently incontinent of bowel and bladder. The MDS shows R2 is only stabilize herself with staff assistance for moving from seated to standing position, moving on and off toilet and surface-to-surface transfers. R2's fall risk evaluation dated [DATE] shows R2 is a fall risk, Initiate fall prevention protocol for identified risk in any category. Initiate fall management Program. Fall Risk Care Plan. The fall risk assessment done on [DATE] was the only fall risk completed by the facility to date. No quarterly fall risk assessments were documented, nor was a fall risk assessment done following her fall on [DATE]. R2's care plan dated [DATE] showed: (R2) is high fall risk and needs continuous monitoring during programs/activities to help prevent future falls. R2's fall care plan did not show any interventions for the prevention of falls. R2's care plan had not been updated after her fall on [DATE]. On [DATE] at 9:00 AM, E2 (DON) said fall risk assessments should be done for every resident on admission, quarterly, and after a fall. E2 said R2 was a high fall risk and her fall risk had not been reassessed since her admission in [DATE]. At 12:00 PM the same day, E2 said R2's care plan should have been updated, as well as the touch screen used by the CNAs to determine transfer status and ADL care needs. 3. The facility's Occurrence Report for R3, dated [DATE] at 21:35 (9:35 PM) shows: (R3) observed on the floor at approximately 21:35 laying on his right side with a laceration 4 cm. in length by 1 cm. width to the back of the head. Resident statement: I was returning from the bathroom and I don't know how it happened. The report shows R3 was sent to the local hospital for treatment. The report also shows no alarms were present at the time of the fall, and that the fall risk reassessment was completed and the plan of care for falls was completed following the fall. R3's face sheet dated [DATE] shows R3 was admitted to the facility [DATE] with multiple [DIAGNOSES REDACTED]. R3's MDS dated [DATE] shows R3 has severe cognitive impairment, no behaviors of rejection of care, requires extensive assistance with ADLs and is frequently incontinent of bowel and bladder. The MDS also shows R3 is not steady during balance transitions and walking, and R3 is only able to stabilize himself with staff assistance. R3's fall risk assessment dated [DATE] shows: Score 12 - Initiate fall prevention protocol for identified risk in any category. Fall Management Program initiated. Fall Risk Care Plan - yes. On [DATE] at 11:29 AM, R3 was sitting in his room in a recliner, sleeping. No chair alarm was present. On [DATE] at 2:03 PM, R3 was sitting in his room in a recliner, sleeping. No chair alarm was present. R3's wheelchair was approximately 10 feet away from R3, and a chair alarm was visible on the seat of R3's wheelchair. R3 was briefly hospitalized in February 2017 and a fall risk assessment was completed but a score was never calculated to show R3's fall risk upon his readmission. The facility did not complete a fall risk reassessment following R3's fall on [DATE]. R3's Resident Summary Template dated [DATE] showed: Fall risk due to: unsteady, bed and w/c (wheelchair) alarm. The Resident Summary Template is the template visualized by the CNAs on the computer to confirm resident needs. E3 (CNA) demonstrated the use of the facility computer screen to visualize the resident's care needs, including transfer status and safety measures. R3 did not have a fall care plan in place at the time of his fall, nor was a care plan initiated following his fall on [DATE]. On [DATE] at 12:00 PM, E2 said, (R3's) fall risk was never calculated when he was readmitted to the facility in February, 2017. He had a care plan for falls prior to his hospitalization , however upon his return in February the care plan did not carry over to his active record. E7 (RN-Nurse Manager) was present during the interview and said, We aren't using the alarms for (R3) because he always removes them and they aren't effective. E2 and E7 acknowledged the Resident Summary Template shows chair alarms and bed alarms should be in place for R3. E2 and E7 also acknowledged R3's medical record does not show documentation of R3's rejection of care regarding the use of alarms or alternative interventions to prevent falls. The facility's Fall Prevention Process Flow Chart dated [DATE] shows: Assessment of fall risk on admission. Ongoing assessment: Assess resident per facility protocol: changes in condition. Resident response to interventions. Communicate interventions to caregivers and family when any are removed, initiated.Ongoing care plan review and new interventions with any change of condition: Care plan developed or revised based on fall risk assessment and risk factors. If no changes in interventions, document reasons. Document revisions in chart and communicate to caregivers any changes. The facility's Post Fall Process Flow Chart dated [DATE] shows: Assessment of fall risk on admission.Care Plan and Interventions: Immediate interventions. Care plan developed or revised based on cause/reason for fall as identified in post fall assessment, investigation and risk factors. If no change in interventions, document reasons. Document revisions in chart and communicate to caregivers. The facility's policy entitled Falls and Fall Prevention in Skilled Nursing dated February 17, 2017 shows: Policy: It is the policy of the (facility) to enable all individuals the ability and right to achieve and maintain the highest level of function in the least restrictive environment. (Facility) is responsible for providing care in a manner promoting quality of life and safety. The resident environment will remain free from accident hazards as possible and each resident will receive adequate supervision and assistance devices to prevent accidents. Implementation and Guidelines: .4. Comprehensive assessment of fall and fall risk potential. 5. Resident centered care plan with interventions to promote highest level of functioning in the least restrictive environment while maintaining safety.12. Post fall evaluation and assessment with updated care plan interventions. Thorough investigation of all falls with recommendations to prevent recurrence.

Based on observation, interview, and record review the facility failed to conduct a pressure injury risk assessment and to analyze the root cause of R 1's development of facility acquired pressure injuries. Failed to develop an individualized plan of care and interventions to address the specific needs of R1 and also failed to analyze R 1's tissue tolerance in order to implement a specific repositioning plan and to provide a specific off-loading device to promote healing of pressure injury. This resulted in R1's acquiring 4 areas of unstageable pressure injuries on the right and the left hip and the right and the left heels. This applies to 1 of 2 residents (R1) reviewed for pressure injuries in the sample of 16. The findings include: On February 22, 2017 at 9:17 AM, R 1 was in the room sitting in his wheelchair. R1 was noted wearing non-skid socks. R1 explained he has several wounds located on both of his feet and on his hips. R1 stated, There's really no fixed time for me to go back to bed. I will tell you though that some people have to sit up longer than others do, it depends on the helper (staff). It is tiring to sit for a long period of time so I look forward to going back to bed today. I am more comfortable when I am in bed. R 19 (R 1's wife) explained that the facility staff usually gets up R1 at around 5:00 AM to 5:30 AM, which is not his choice. At 11:15 AM R 1 was transferred from wheelchair to bed. E9 (Certified Nursing Assistant) stated, For repositioning he (R1) can do it but needs to be reminded at times and he needs a little help. On February 23, 2017 at 10:30 AM, E6 (Nurse) and E7 (Certified Nursing Assistant) were observed changing pressure injury dressing. During this time E6 identified the following locations of pressure injury, measurement and described the wounds as follows: (1) Right heel measured at 3.0 cm X 7.0 cm with 90% eschar (2) Left heel measured at 5.0 cm X 3.5 cm with 100% eschar Both feet described as warm to touch, with pedal pulses and R1 denies any pain when legs are elevated. (3) Right hip measured at 4.5 cm X 5.5 cm with 100% eschar (4) Left hip measured at 4.5 cm X 5.5 cm with 100% eschar E6 identified all of these wounds as Stage 3 and all are pressure injuries. Based on the updated staging system from the National Pressure Ulcer Advisory Panel (NPUAP) if a wound is obscured by an eschar these wounds should be identified as Unstageable Pressure Injury (Obscured full-thickness skin and tissue loss). E6 did not identify with accurate stage of R1's pressure injuries according to (NPUAP). On February 23, 2017 at 12:15 PM, E2 (Director of Nursing) stated that these four areas were all acquired in the facility. When the sores were initially identified, they were at 100% necrotic stage. E2 explained that the right and the left heel were noted on December 27, 2016 and the right and the left hips were noted on February 21, 2017. E2 was unable to provide a comprehensive assessment to identifying the root cause or risk factors for R1's acquiring multiple pressure injuries. R 1's assessment and plan of care recommendation from the wound doctor dated February 21, 2017 showed a recommendation to off-load R 1's wound on the right and left hips This recommendation was not followed. On February 23, 2017 at 1:35 PM R1 was noted sleeping in bed, positioned on his left side, directly on his left hip wound. R1's heels were noted resting on the mattress, not elevated to relieve pressure on both his heels. There were no positioning or heel suspension device noted, no off loading from the mattress. E7 stated that R1 has no special boots when in bed or up in chair. On February 23, 2017, E11 (Minimum Data Set / Care Plan Coordinator) presented R 1's skin care plan. The problem list includes all of skin alterations to the feet, elbow, heels, hips .There was no care plan developed for each wound and no individualized interventions specific to R 1's needs and no specific repositioning plan was identified. The care plans showed turn and reposition accordingly. The initial Minimum Data Set, dated dated dated [DATE] showed R1 was admitted at the facility on December 8, 2016 with [DIAGNOSES REDACTED]. R1 was identified that he needs limited assistance for transfer, but on February 24, 2017 at 10:20 AM, R1 was observed being transferred from wheelchair to bed using a mechanical transfer device (sit to stand). On February 24, 2017 at 10:45 AM interviewed Z1 (Attending Physician) via telephone. Z1 stated, I am aware of R 1's wounds, I was told about it. I just cannot remember when, so I referred him to weekly wound rounds. Of course we need to try to keep him off of those areas (wounds) to promote healing.

Based on observation, record review, and interview the facility failed to ensure nursing staff followed the policy and procedure for safely transferring residents with standing mechanical lifts and failed to ensure a resident's safety while the resident was being escorted in a wheel chair by staff. As a result of this failure R1 fell from the standing mechanical lift sling and sustained a fracture to her left leg. As a result of this failure R3 fell from her wheel chair and sustained a laceration to the right brow and a fracture to the left 5th finger. This is for 5 of 5 residents investigated for falls/safety/standing mechanical lift transfers. (R1, R2, R3, R4, and R5). Findings include: 1. Review of the facility's incident reports showed on 11/10/13 at 8:30 a.m. E5 (CNA - Certified Nurses Aide) was transferring R1 into R1's wheel chair using a mechanical sit to stand lift. The incident report showed E5 was the only CNA transferring R1. The report showed E5 unbuckled the mechanical lift sling before ensuring R1 was placed back far enough in her wheel chair. When E5 unbuckled the mechanical lift sling; R1 fell to the floor complaining of left leg pain when she hit the floor. A facility x-ray dated 11/10/13 was done which showed results of "Acute undisplaced fracture of distal left fibula." Observation of R1 on 11/20/13 at 12:00 noon showed R1 to have a below the knee cast to her left leg. R1 was verbal, alert, and oriented to person, time, and place. R1 stated at this time, "This was an unnecessary fall. I shouldn't have this fracture. The CNA (R5) didn't have me back far enough in my wheel chair before she lowered me from the sit to stand lift. I fell and landed on my left ankle. I either fractured my tibia or fibula. I will be in this cast for 3 months. They always just use one person to transfer me. I don't want this to happen to anyone else." Review of the facility's policy and procedure for the standing lift included, "Two staff members are needed for use with transfer via standing lift." Review of R1's transfer assessment dated [DATE] and the ADL (activities of daily living) plan of care dated 10/27/13 showed R1 should be transferred with the standing lift with 2 person assist. 2. On 11/20/13 at 1:00 p.m. E6 (CNA) and E7 (Restorative CNA) were observed performing a mechanical standing lift transfer on R4 from wheel chair to bed. R4 was wearing rubber sole gym shoes. R4's room was carpeted. Before the transfer E7 was observed swiftly moving R4 around in the room several times in an attempt to position R4 in front of the mechanical lift for transfer. R4's wheel chair did not have leg rests and E7 did not ask R4 to lift his feet. R4 was observed to move his feet sporadically and plant his feet abruptly while E7 was moving him around the room. 3. On 11/20/13 at 1:10 p.m. E8 and E10 (CNA's) were observed performing a mechanical standing lift transfer on R5. When operated the lift to raise R5 to a standing position, R5's right leg was not placed in the shin form, thereby not ensuring R5's safety when standing. E8 and E10 had to be told by the surveyor that R5's legs were not properly positioned in the mechanical lift's shin forms. Review of the facility's operating instructions for the standing mechanical lift included "Have patient place feet on platform and position their shins into the shin forms." 4. On 11/20/13 at 1:20 p.m. E8 and E9 (CNA's) were observed performing a standing mechanical lift transfer on R2. When E9 operated the lift to raise R2 to a standing position, R2's right foot was not on the foot platform of the lift. R2's right heel was hanging over the back of the foot platform thereby not ensuring R2's standing balance and/or safety. E8 and E9 had to be told by the surveyor that R2's right foot was not on the foot platform. Review of the facility's policy and operating instructions for the mechanical standing lift included "Have patient place feet (help patient if needed) on platform...." 5. Review of R3's admission face sheet showed R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's quarterly MDS (minimum data set) dated 9/4/13 showed R3 had short and long term memory problems. Review of facility incidents showed R3 had 3 falls from 10/6/13 to 11/1/13 (10/6, 10/20, and 11/1/13). The incident dated 11/1/13 at 9:30 a.m. showed "Resident was being hand held down the hallway by CNA while propelling her wheel chair with her feet when resident abruptly planted her feet firmly to the ground and slipped out of her wheel chair face first to the ground." The incident report showed R3 sustained a laceration to the right brow and a fracture to the left 5th finger. R3 was sent to a nearby hospital. Hospital x-ray dated 11/1/13 of R3's left hand showed findings of "There is a fracture through the base of the fifth proximal phalanx, with suspected extension into the metacarpophalangeal joint." Upon return from the hospital nursing note documentation dated 11/1/13 10:19 p.m. showed, "Left hand 5th digit splinted. Purple bruising noted to left forearm and hand. Right eye, right side of forehead and face swollen with redness and abrasion on forehead. Complain of left hand 5th digit pain." On 11/20/13 at 11:15 a.m. E1 (Administrator) stated the CNA did an improper mechanical lift transfer with R1 which resulted in R1 falling and fracturing her left leg/ankle. This was also verified during interview with E2 (Director of Nurses) on 11/21/13 at 1:00 p.m. This information was also documented on the conclusion on R1's incident report regarding R1's fall. On 11/20 and 11/21/13 during interviews with E1 and E2 and interview with E3 (RN - Restorative Nurse) on 11/21/13 at 11:30 a.m. all stated the CNA's are to follow the policy and procedure when transferring residents with mechanical lift transfers and ensure the correct placement of the residents' feet, legs, arms, etc...before transferring the resident.

Based on observation, record review and interview the facility failed to conduct a comprehensive assessment and analyze pressure sore risk factors to indicate why residents (R1, R2 & R3) have developed pressure sores in the facility; Develop individualized plan of care with specific interventions to prevent pressure sore and promote heeling of pressure sore for R1, R2 & R3 and monitor progression or regression of pressure sores and implement interventions to promote healing of the pressure sore including positioning to relieve pressure on heels for R3 and use of appropriate shoes for R2. This failure resulted in R3 having red areas to his right heel which progressed to unstageable and measured it measured 4 cm x 5 cm. This is for three of five residents (R1, R2 & R3) in the sample who have pressure sores. Findings include: 1. On 3/2/11 the facility presented a list of pressures sores in which it was identified that R3 acquired a pressure sore to his right heel on 1/21/11. The stage was noted to be unstageable and measurement noted to be 1.5 cm x 1.5 cm. On 3/3/11 at 10:35 am R3 was lying in bed, had a flat pillow under his legs and his both feet were in soft heel protectors, his feet were pressing against the mattress. Surveyor verified the observation with the Nurse (E3) and Certified Nurse Aide (CNA), E4. E4 went to get additional pillows to reposition R3's feet. At 2:15 pm surveyor observed the pressure sore treatment. At this time the pressure sore measured 4 cm x 5 cm and the site was covered with darkened eschar tissue. R3 was loudly moaning constantly during the treatment. R3's medication administration indicated he had not had any pain or relaxation medication since 7:30 am. On 3/3/11 the survey team discussed the concern with the facility Administrator (E1) and the Director of Nurses (E2). On 3/4/11 E2 stated she saw R3's pressure sore on 2/25/11 and the measurement was as noted in the records (1.5 cm x 1.5 cm), but confirmed as of 3/3/11 the measurement was 4 cm x 5 cm and unstageable. E2 also stated that the facility had no formalized assessment tool to indicate assessment besides Braden Scale and Clinical Notes and some times she documents in clinical notes. R3's clinical notes indicated he has persistent red area on back of right heel 1.5 cm x 1.5 cm. The same measurement was noted through 2/25/11 1.5 cm x 1.5 cm and it is dry and light brown in color which is not consistent with actual observation of 3/3/11 at 2:15 pm. R3's weekly skin checks for January and February 2011 noted he has no pressure sores. The facility had Minimum Data Set (MDS) on record: Annual 4/1/10; Quarterly 12/30/10. The Annual MDS had no trigger for pressure sore; the Quarterly indicated R3 at risk for the development of pressure sore. None of these MDS had any Care Assessment Area (CAA) for pressure sore. The facility uses a Braden Scale to identify risk factors for pressure sores. R3 scored '12' which indicates he is at high risk for the development of pressure sores. There is no analysis of the risk factors or there is any documentation to indicate why R3 developed pressure sore or if the pressure sore was preventable or not. There is no plan of care with individualized interventions to promote healing of pressure sores. R3 acquired a 4 cm x 5 cm unstageable preventable pressure sore to his right heel. 2. Review of the facility's Skin Care Form dated 2/25/11 showed R1 developed 2 pressure sores to his heels on 2/15/11. The measurements for these pressure sores on the Skin Care Form showed; left heel 2 cm x 2 cm ad right heel 2 cm x 2 cm. The measurements were the same on the clinical note dated 2/15/11 when the pressure sores were first identified. The Skin Care Form documentation showed these 2 pressure sores were unstageable. Review of the facility's computerized Braden Scale assessment for pressure sore development for R1 showed a score of 16 (noting R1 was only at risk for pressure sore development.) Further review of pressure sore documentation only showed a note dated 2/22/11 with the same measurements as noted above. There was no other documentation or further assessment as to how/why R1 developed these pressure sores on his heels. On 3/3/11 at 10:25 a.m. R1 was observed resting in his bed. R 1's heels were not off loaded on pillows so the heels would not touch the bed. Review of R1's plan of care addressing pressure sores shows an intervention to Keep heels off loaded on pillows. On 3/3/11 at 2:30 p.m. E3 (LPN) was observed performing pressure sore treatment to R1's heels. R1 was observed resting in bed. Both of R1's heels were observed with blackened tissue to the heel sites. E3 measured both pressure sore sites. R1's left heel site measured 3 cm x 1 cm. R1's right heel site measured 1.8 cm x 2.5 cm. E3 applied the prescribed skin prep and left the sites open to air as ordered. E3 admit R1's heels should be off loaded with pillows when R1 is in bed. R1 also admitted that she did not know how R1 developed the pressure sores to his heels. 3. Review of the facility's Skin Care Form dated 2/25/11 showed R1 developed an unstageable pressure sore to her right heel on 11/26/10. The right heel site pressure sore measured 2.9 cm x 2.9 cm x 0.1 cm on 11/26/10. Clinical note documentation (nurses note) dated 11/26/10 and interview with E6 (RN) on 3/3/11 noted both to say R1's pressure sore site developed from ill fitting shoes with the shoe rubbing on R1's left heel. Further interview with Review of wound care assessment documentation dated 3/1/11 showed the pressure sore measurement as 2.0 x 2.5 x 0.1 cm. On 3/3/11 E6 was observed performing pressure sore treatment to R1's left heel. E6 removed the old dressing from R1's left heel site. R1's pressure sore site was noted with a small to moderate amount of purulent drainage on the old dressing. This site was observed with approximately 60% yellowish slough tissue. E6 measured the site which measured 3.2 cm x 2.6 cm x 0.6 cm. R1 stated she did have pain to the site, especially at night. Interview with E2 (Director of Nurses) on 3/4/11 noted E4 to say, "R1 went out on pass for Thanksgiving and came back complaining of pain to the left heel. It was a blister. R1 had been wearing the same shoes she always wore." Further review of documentation for R1 showed no thorough assessment for the development of pressure sores and/or prevention of pressure sores. Review of the information presented on the facility's Skin Care Form showed the information was not accurate. The Skin Care Form showed R1 acquired her pressure sores to her heels on 1/16/11. Interview with E2 noted to say, "I made a mistake. R1 acquired her pressure sore on 2/15/11. Review of information for R1 showed there was no site documented for R1's pressure sore. E2 also informed the surveyor and documented that R1 had a pressure sore on the right heel. Observation of R 1 showed R1 had a pressure sore on the left heel. Review of information for R1 showed no site documented for R1's site.