Every finding on record at Mountain Ridge Rehabilitation and Healthcare Cente

Based on observation, record review, staff interviews, Wound Care Consultant Physician Assistant interview, and Physician interview, the facility failed to position Resident #62 in an upright position to safely drink a hot beverage for 1 of 3 residents reviewed for accidents (Resident #62). This failure caused the resident to spill hot liquid onto her chest and upper back and resulted in actual harm in the form of partial thickness burns. Findings included: Resident #62 was admitted to the facility on [DATE] with diagnoses which included non-Alzheimer's dementia. Resident #62's care plan revised 9/26/25 had an activity needs focus which included coffee cart. Resident #62's quarterly Minimum Data Set, dated [DATE] coded resident as severe cognitive impairment and set up or clean-up assistance with eating. She was coded for moderate assistance to roll left and right in bed, maximum assistance for sitting to lying on the bed and lying to sitting on the side of the bed. Activity Assistant #1's signed, typewritten undated statement read that on 02/28/2026, she went to give coffee to Resident and asked her if she wanted coffee, she was just waking up. She said she did want coffee. Activity Assistant #1 fixed her coffee and sat it on her table. Activity Assistant went to take resident's roommate coffee when she heard Resident #62 say 'oh it's hot, it's hot. Activity Assistant #1 immediately turned the call light on; tried to help her sit up so she could get her clothes off. The Nursing Assistant (NA) came in right away and helped her. An interview with Activity Assistant on 07/08/26 at 8:17 AM revealed she placed the coffee on the bedside table, did not verify resident positioning, and had no guidance indicating the resident needed upright positioning. She stated Resident #62 was lying flat in her bed with the bedside table on the right-hand side of her bed. A telephone interview with Nursing Assistant (NA) #1 on 7/8/26 at 10:42 AM revealed she was working on 2/28/26 and assigned to care for Resident #62. She stated she observed the resident was laying flat in bed when she entered the room. There was spilled coffee on her right side and the resident's skin was red. NA #1 notified the nurse and assisted with changing the resident's clothes. Nurse #1's progress note dated 2/28/26 at 7:49 PM read that at 8:30 AM she heard the resident scream in room. NAs went to check on resident who was lying flat in bed and activity assistant stated resident had reached for her coffee which had been set on her bedside table by activity assistant. Resident complained of burning pain to chest and upper back. Gown immediately removed, cold towels put on chest and upper back then gown applied after resident was gotten out of bed and bedding changed. No open areas noted. Skin is very red in above mentioned places. Notified family and physician. Order received for antibiotic burn cream to be applied daily. A Physician's order dated 2/28/26 at 1:49 PM for Silvadene external cream 1% to apply to chest and upper back topically every day shift for burn. An in-person interview with Nurse #1 on 7/09/26 at 10:07 AM revealed that she was working on 2/28/26 and assigned to care for Resident #62. She stated she heard a scream and went into resident's room. She helped change the resident, assessed her, notified the family and physician, and ordered the burn cream. She also stated she did not observe the coffee cup. The red areas were measured, and the right chest was 11 centimeters (cm) by 3 cm and upper back area was 20 cm x 20 cm.The Nurse Practitioner progress note dated 3/03/26 read that the resident had sustained a second-degree burn to the upper chest wall shoulder and back area from spilled coffee and noted her right upper chest and back area were improving with resolving blisters. She was receiving antibiotic burn cream daily. This note included a diagnosis of partial thickness burn of chest wall. The Wound Care Nurse's progress note dated 3/06/26 at 2:27 PM read that Resident #62 had a burn to the right upper chest and upper posterior back. The chest area measured 25.0 centimeter (cm) length, 8 cm width, and 0.3 cm deep. Pain present during treatment and was able to assist resident with breathing techniques to assist with pain control. Telephone consent obtained for in-house wound care with wound care consultant weekly. Posterior back measurements are 3.0 cm length, 3.0 cm width, 0.2 cm deep. New treatment order per wound care consultant is to apply daily petroleum-based dressing, cover with pad and secure with tape. No signs or symptoms of infections are present. Moderate drainage present. Continue to monitor and treat. A telephone interview with the Wound Care Nurse on 7/8/26 at 11:32 AM revealed she was not at the facility when the burn occurred. She stated she provided Resident #62 wound care at times for her burns until they healed. She noted no signs or symptoms of infection for the burns. A telephone interview with the Physician on 7/08/26 at 1:42 PM revealed he had been notified of Resident #62's burns. He stated they were not very deep, 2nd degree burns which healed quickly and she had no long-term effects. A telephone interview with the Wound Care Consultant Physician's Assistant (PA) on 7/08/26 at 2:57 PM revealed he assessed and treated Resident #62's right chest and back burns on 3/06/26. He stated the resident had partial thickness burns which measured 25 cm by 8 cm by 0.3 cm with no signs or symptoms of infection and her wound resolved on 3/20/26. Her back burn measured 3 cm by 3 cm by 0.2 cm with no signs or symptoms of infections and her wound resolved on 3/20/26. An in-person interview with the Director of Nursing on 7/09/26 at 12:29 PM revealed she had been notified of the accident when it happened. She also stated nursing and activities staff had been educated on the hot beverage policy and the resident now used a cup with a lid at all times. An in-person interview with the Administrator on 7/09/26 at 12:45 PM revealed it was her understanding that the Activity Assistant #1 was passing coffee and placed it on the table before the resident had been pulled up and positioned in bed. She stated staff immediately addressed the accident, interventions were put into place, a plan of correction was initiated, and audits implemented. The facility provided the following corrective action plan with a completion date of 3/07/26. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 2/28/2026 at approximately 9:00am, Resident # 62 was provided coffee by Activities Assistant #1. Resident #62 picked up the cup of coffee while lying flat, spilling the coffee. Resident #62 was immediately assessed by Licensed Nurse #1. Red areas were noted to the chest and back of Resident #62. Licensed Nurse #1 immediately applied cool towels to Resident #62's chest and back. Red areas were measured by the Licensed Nurse #1: right chest area was noted to be 11cm x 3cm, left chest area was noted to be 13cm x 3cm, and upper back area was noted to be 20cm x 20cm. On 2/28/2026, Licensed Nurse #1 called the on-call provider. New treatment orders were initiated. On 2/28/2026 Licensed Nurse #1 notified Resident # 62's Responsible Party. On 2/28/2026 Activities Director #1 immediately re-educated Activities Assistant #1 on Safety of Hot Liquids and ensuring residents are positioned upright and awake prior to offering hot liquids. On 3/2/2026 the Director of Nursing reviewed the individual care plan for Resident #62 to ensure the care plan was accurate for the required assistance and interventions. Changes to Resident #62's care plan included: resident should receive hot beverages when sitting upright with a clothing protector and a cup with a lid. The Director of Nursing notified all staff who deliver hot beverages to Resident #62 and the Responsible Party for Resident #62 of the care plan revisions. On 3/2/2026 the Director of Nursing completed a Hot Beverage Risk Review for Resident #62, which included assessment of cognition, mood, behavior, tremors, contractures, strength, mobility and interventions with hot beverages. Interventions were implemented for Resident #62, which included receiving hot beverages when sitting upright with a clothing protector and a cup with a lid. The Director of Nursing notified all staff who deliver hot beverages to Resident #62 and the Responsible Party for Resident #62 of these interventions. On 3/2/2026 Resident #62 was screened by Occupational Therapy to ensure interventions were appropriate for hot beverages. No additional recommendations were identified. On 3/3/2026 Resident #62 was assessed by the Nurse Practitioner with no new orders, and to continue current treatment. On 3/6/2026 Resident #62 was assessed by the facility's contracted Wound Care Provider's Physician's Assistant. The Physician Assistant noted the chest/shoulder area measured 25cm in length x 8 cm wide x depth of 0.3cm. Posterior back measured 3cm in length x 3cm wide x 0.2 cm depth. No signs or symptoms of infection. New treatment orders were obtained. The Wound Care Provider resolved/healed the wound on 3/20/2026. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents with cognitive impairment and residents who require assistance with positioning, bed mobility, and/or have medical conditions that can affect a resident's ability to handle hot beverages safely have the potential to be affected. On 3/2/2026 the Regional Clinical Director and the Director of Nursing reviewed the facility policy and procedures for Safety of Hot Liquids and Incident/Accident Management. No revisions were required. On 2/28/2026 the Director of Nursing/Designee completed skin assessments for all residents with a Brief Interview for Mental Status (BIMs) of 12 or less to ensure no signs/symptoms of burns. No concerns were identified. These were completed on 3/3/2026. On 2/28/2026 the Regional Clinical Director reviewed all incident reports for the last 30 days to ensure there were no other issues with hot beverages. No concerns were identified. On 3/2/2026 the Director of Nursing/Designee completed Hot Beverage Risk Reviews for all residents, which included assessment of cognition, mood, behavior, tremors, contractures, strength, mobility and any interventions for hot beverages. Any concerns were immediately addressed with interventions, which included: providing cups with lids, sitting upright with a table in front of resident, a lap/clothing protector, staff to assist residents with drinking hot beverages, and residents to use dominate hand/splint for hand stability, prior to delivering hot beverages. Care plan revisions were completed as indicated. Hot Beverage Risk Reviews are completed when an identified risk, such as a change in the ability of the resident to safely handle hot beverages. The Director of Nursing/Designee notified all staff that deliver hot beverages to residents of the Kardex/Care Plan revisions. Residents and/or Responsible Parties were notified by the Director of Nursing/Designee of intervention changes and Kardex/Care Plan revisions. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 3/2/2026 the Director of Nursing/Designee began education with all staff, including all Licensed Nurses, Nursing Aides (NA), Activities, Dietary, Therapy, and Department Managers using the facility policy and procedures for Safety of Hot Liquids and Incident/Accident Management. This education included:Ensuring residents are seated in an upright position with a table in front of them, prior to providing beveragesEnsuring residents are awake and aware of beverages being providedUtilizing the correct cup, including providing a lid as indicated per each individual resident's Kardex/Care Plan.Kardex/Care Plan review for interventions/needs, which are in the individual resident's electronic medical records. Staff were educated to review at the beginning of each shift, and that Kardex/Care Plan is updated, by the interdisciplinary team, with any changes. The Kardex/Care Plan may include interventions such as: providing cups with lids, sitting upright with table in front of resident prior to delivering hot beverage, lap/clothing protector, and staff to assist residents with drinking of hot beverages as indicated.Providing a lap cover or clothing protector to protect skin from accidental spills. Lap covers/clothing protectors are offered to all residents with each delivery of hot beverages. Lap covers/clothing protectors are located in the Dining Room and in the Clean Linen Closets on each unit for staff to access.Immediate notification to the Director of Nursing/NHA/Licensed Nurse of a change in the resident's ability to safely handle hot beverages. With any change in ability to safely handle hot beverages, the hot beverage should be removed immediately for resident safety, if residents are cognitively intact and agreeable, residents should be educated, if applicable, on safety reasons for not having hot beverages until evaluated by a Licensed Nurse and/or therapy. If residents are not cognitively intact, hot beverages should not be served or delivered by any staff member until evaluated by a Licensed Nurse and/or therapy, utilizing the Hot Beverage Risk Assessment. Immediate notification of the Director of Nursing/NHA for incidents/accidents with injuries. All education was completed on 3/3/2026. Any employee who is not educated will receive this education prior to working their next shift. The Director of Nursing/Designee will be responsible for this education. This education will be added to the facility orientation program for all newly hired staff and will be the responsibility of the Director of Nursing/Designee. An ADHOC Quality Assurance Performance Improvement Committee Meeting was held on 3/3/2026 to discuss, review, and approve the plan that had been initiated and implemented by the Regional Clinical Director and the Director of Nursing on 3/2/2026. The Quality Assurance Performance Improvement Committee also reviewed the policy and procedure for Safety of Hot Liquids and Incident/Accident Management. The decision to monitor the plan was also decided upon during the Quality Assurance Performance Improvement Committee meeting on 3/3/2026. Root Cause Analysis was completed and determined that Activity Assistant #1 failed to follow the facility policy and procedure for delivering hot beverages. The facility lacked a standardized process for interdisciplinary/ancillary services process and education regarding the safe delivery of hot beverages to residents, including education to ensure residents are appropriately positioned before hot beverages are left within reach. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Include dates when corrective action will be completed. Beginning on 3/5/2026 the Director of Nursing/Designee will observe staff delivering hot beverages to 5 residents during random mealtimes, which includes breakfast, lunch, and/or dinner and/or during activities when activities staff are providing hot beverages, across all shifts, weekly for 12 weeks to ensure proper positioning/set up, lids and clothing protectors, when required. The DON/Designee will be responsible for reporting results of these audits to the facility's monthly QAPI committee meeting for 3 months. The QAPI committee will make recommendations and changes as indicated based upon the findings of these audits. Compliance Date: 3/7/2026 The plan of correction was reviewed and validated on 7/09/26 by interviews with the Activity's Director, Activity's Assistant, Dietary Manager, Nurses, Nursing Aides (NA), and Therapy. Included in the validation was a review of the plan of correction, educational inservices and audits. The inservices included the hot beverage policy and incident/accident management policy and procedure. A review of the monitoring and audits was completed. An in-person interview with the Activity Director on 7/08/26 at 8:11 AM revealed she had educated the activity staff about hot liquids safety and resident positioning prior to offering hot liquids. An in-person interview with Activity's Assistant #1 on 7/08/26 at 8:17 AM revealed she had received education about hot liquids safety, resident positioning, and alertness of resident prior to offering hot liquids. She stated Resident #62 care plan was revised to include a lid on her coffee cup and to wear a clothing protector when drinking hot beverages. A hot beverage risk assessment was initiated on 3/02/26 for Resident #62 and signed on 3/03/26. A telephone interview with Nursing Assistant (NA) #2 on 7/08/26 at 10:28 AM revealed she was familiar with the resident and provided care for her regularly. She stated she received education about hot liquids safety, resident position, and the alertness of resident prior to offering hot liquids. She also stated that Resident #62 was care planned to have a lid on her coffee cup and a clothing protector when drinking hot beverages. An in-person interview with the Dietary Manager on 7/08/26 at 10:54 AM revealed the dietary staff provided lids for the coffee cups. She stated she educated all dietary staff about the hot liquids safety, resident positioning, and alertness of resident prior to offering hot liquids. An in-person interview with the Rehabilitation Director on 7/09/26 at 8:31 AM revealed Resident #62 was screened by Occupational Therapy (OT) on 3/03/26. He stated she received OT through the end of April on strengthening exercises due to her cognitive and physical decline. An in-person interview with the Occupational Therapy Assistant (OTA) on 7/09/26 at 10:55 AM revealed she had received education about hot liquids safety, resident positioning, and alertness of resident prior to offering hot liquids. A review of the documented audits revealed all skin assessments were completed on 3/03/26 for all residents with a Brief Interview for Mental Status (BIMS) of 12 or less. A review of documented audits revealed a hot beverage risk assessment was completed on 3/02/26 for all residents. The corrective action plan's completion date of 3/07/26 was validated.

Based on observations and interviews with staff, the facility failed to remove thickened liquids stored for use past the use by date in the facility's walk-in refrigerator. This was for 1 of 3 refrigerators (walk-in) observed in the kitchen. The deficient practice had the potential to affect thickened liquids served to residents. Findings Included: On 7/6/26 at 9:59 AM an observation was conducted with the District Dietary Manager in the walk-in refrigerator. The observation found 6 unopened cartons of thickened liquid with use by date of 6/22/26 located on a shelf. On 7/2/26 at 10:02 AM, the District Dietary Manager stated the dates of items stored in the walk-in refrigerator were checked weekly on food delivery days. She stated the food order had been delivered earlier in the morning and she had not yet put up stock or checked the dates. The District Dietary Manager stated the previous week, a fill-in Dietary Manager had worked at the facility and had overlooked the expired cartons or thicken liquid. On 7/9/26 at 3:48 PM the Administrator was interviewed. The Administrator stated the kitchen overlooked the expired items in the walk-in refrigerator.

Based on observation, record review, and staff interviews, the facility failed to follow their infection control policy for Enhanced Barrier Precautions (EPB) when two nurse aides (NAs) transferred Resident #92 who had a dialysis port without sanitizing their hands before putting on gloves and not donning a gown for 2 of 6 staff members observed for infection control practices (NA #1, NA #2). Findings included: The facility's policy titled Categories of Transmission Based Precautions revised October 2018 was reviewed. The policy included appropriate notification of enhanced barrier precautions (EBP) is placed so personnel and visitors are aware of the need for EBP. The signage informs the staff of instructions for personal protective equipment (PPE) use while providing high contact resident care activities. EBP requires the use of gowns and gloves for high-contact resident care that includes transferring a resident. The policy included to sanitize hands when entering a resident room and before putting on gloves. Hands needed to be sanitized when gloves are removed and when changing gloves. The policy also specified that a hemodialysis catheter was an indwelling medical device and resident with a hemodialysis catheter should be placed on EBP. On 7/9/26 at 2:21 PM NA #3 and NA #4 entered Resident #92's room and put on gloves without sanitizing their hands and did not don gowns. There was no Enhanced barrier Precautions (EBP) signage and personal protective equipment (PPE) were not observed outside or inside the resident's room. A hand sanitizer dispenser was observed attached to the wall in the hall opposite the resident's room. Resident #92 was sitting in his wheelchair and wanted to be transferred to his recliner chair and required the use of a lift. The resident's sling was hooked onto the lift; the resident was raised and transferred to the recliner. After placing the resident into the recliner, NA #3 and NA #4 rolled Resident #92 to his left hip and then to his right hip to remove the transfer sling he was sitting on. NA #3 and NA #4 removed their gloves, sanitized their hands in the resident's room and left Resident #92's room.On 7/9/26 at 2:36 PM NA #3 was interviewed and stated she was unaware if Resident #92 had been placed on enhanced barrier precautions and there was not any signage or PPE in the resident's room that would tell her the resident needed EBP. On 7/9/26 at 3:00 PM a follow up interview with NA #3 was conducted. NA #3 stated she had received prior education on EBP and any resident with a catheter, wounds, and ports needed EBP when staff were performing resident care. NA #3 said transferring Resident #92 was performing resident care and PPE was needed. NA #3 said a nurse or charge nurse would communicate with the NA if a resident were placed on EBP, and she had not been informed Resident #92 required EBP. NA #3 clarified there was no signage or PPE in the resident's room and at the time they transferred the resident, it did not occur to her he required EBP.On 7/9/26 at 2:38 PM NA #4 stated it was her first day working with Resident #92 and she did not know he required EBP. She specified had there been signage and PPE in the resident's room, she would have worn the required PPE and followed the precautions.On 7/9/26 at 2:41 PM Resident #92's assigned nurse (Nurse #3) stated it was her first day working with the resident. Nurse #3 agreed Resident #92 should have been on EBP because he had a dialysis port, and she had not realized the resident did not have signage or the necessary PPE. On 7/9/26 at 3:18 PM the Director of Nursing (DON) stated the facility followed the Centers for Disease Control (CDC) guidelines for EBP. The DON indicated she was the acting Infection Preventionist (IP) for the facility, and they followed the CDC guidelines which did not list dialysis shunt as an indwelling device and Resident #92 was not placed on EBP. The DON reviewed Resident #92's physician's orders and said Resident #92's dialysis port appeared to be an indwelling medical device, and an indwelling device required signage and PPE for EBP when performing high contact resident care. The DON confirmed transferring a resident was considered high-contact resident care. The DON added that the facility's IP was out on leave and would normally review admission notes and physician orders to find out if a resident needed EBP.On 7/9/26 at 3:41 PM the Administrator was interviewed and stated that a resident with indwelling devices, wounds, or dialysis ports should be placed on EBP and PPE should be worn when high contact care was provided which included transfers. The Administrator indicated the facility misunderstood that a dialysis device required EBP for Resident #92.

Based on observations, record review and staff and resident interviews, the facility failed to assess a resident's ability to self-administer a medicated anti-itch lotion for 1 of 1 resident observed for self-administration of medication (Resident #36). The findings included:Resident #36 was admitted to the facility on [DATE] with diagnoses that included postherpetic polyneuropathy (long-lasting nerve pain that remains after a shingles rash heals). Review of Resident #36's medical record revealed a physician order dated 11/20/25 for triamcinolone acetonide (a steroid medication that reduces inflammation and itching) 0.1% every 12 hours as needed, and no order for 1% pramoxine hydrochloride (a topical anesthetic that numbs the skin to relieve itching). Resident #36's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact.The medical record also revealed no assessment and/or care plan for self-administration of medications. An observation and interview with Resident #36 on 7/06/26 at 2:00 PM revealed a 6-ounce bottle of anti-itch lotion containing 1% pramoxine hydrochloride on his bedside table. Resident #36 indicated he had used the anti-itch lotion for the past year to manage itching from areas on his skin where he previously had shingles. He reported his family brought the anti-itch lotion to him. An observation of Resident #36's room with Nurse #2 on 7/08/26 at 11:16 AM revealed the 6-ounce bottle of anti-itch lotion was on the bedside table. Nurse #2 removed the anti-itch lotion from Resident #36's room. An interview with Nurse #2 on 7/08/25 at 11:17 AM revealed she had been in Resident #36's room that morning and she did not notice the anti-itch lotion on his bedside table and indicated if she had seen it, she would have removed it. Nurse #2 reported that she did not know whether Resident #36 had been assessed as safe to self-administer medications and indicated that all staff were responsible for checking for medications kept at residents' bedsides.An interview with the Director of Nursing (DON) on 7/09/26 at 10:53 AM revealed that residents who requested to self-administer medications were assessed for self-administration of medication by the nurse and the DON. The DON indicated she would contact the physician after the assessment and obtain an order if the resident was determined to be safe to self-administer medication. The DON revealed she did not recall if Resident #36 had been assessed for self-administration of medication and reported she did not recall seeing the anti-itch lotion on Resident #36's bedside table. An interview with the Administrator on 7/09/26 at 1:47 PM revealed the anti-itch lotion should not have been left in Resident #36's room without a physician order and a completed self-administration of medication assessment demonstrating the resident's ability to self-administer.

Based on record review and staff interviews, the facility failed to maintain accurate advanced directives throughout the medical record for 1 of 1 resident reviewed for advanced directives (Resident #4). Findings included:Resident #4 was admitted on [DATE] with diagnoses that included dementia. A review of Resident #4's medical record found a Medical Orders for Scope of Treatment (MOST) form dated [DATE] with status as full code.Resident #4 had a care plan dated [DATE] that specified full code.Further review found a MOST form dated [DATE] for Do Not Resuscitate (DNR) with limited interventions, antibiotics as needed, intravenous fluids (IV) fluids, and no feeding tube. Resident #4 had a physician's order dated [DATE] for Cardiac Pulmonary Resuscitation (CPR), limited interventions, antibiotics if indicated, IV fluids, and no feeding tube. The Social Worker (SW) was interviewed on [DATE] at 9:36 AM. The SW stated she was not aware Resident #4's MOST form had been changed from a Full Code to a DNR. She stated the MOST form signed by the physician on [DATE], for DNR was uploaded to the resident's chart on [DATE] without her knowing. Resident #4's MOST form and physician's order should have matched. The SW added the normal process was for the physician to sign the MOST form after speaking with the resident or resident representative. A nurse would then notify the SW of the change and place the MOST form in her mailbox and then she would review the MOST form. The SW said she checked that the physician order for the MOST had been entered, scanned and uploaded it to the resident's chart, and then placed the MOST form in the code book. The Administrator stated on [DATE] at 3:52 the MOST form for Resident #4 did not make it to the SW after being signed, to be reviewed and uploaded. The MOST form was uploaded by medical records when it was placed in her mailbox. Resident #4's MOST form and physician order should have matched.

Based on record review, and interviews with staff, Medical Director, Emergency Medical Services (EMS) Supervisor, Physician Assistant and emergency room Physician, the facility failed to leave Resident #1 in place on the floor after a headfirst fall from a mechanical lift while being transferred by Nurse Aide (NA) #1 and NA #2 on [DATE]. The resident was prescribed two medications that increased the risk of bleeding. Resident #1 reported head and neck pain to Nurse #1 when she was assessed immediately after the fall. Resident #1 was lying on her back and was turned onto the mechanical lift pad and returned to her bed using the mechanical lift prior to an evaluation by Emergency Medical Services (EMS). Emergency Medical Services (EMS) was called and when they arrived, they were told Resident #1 fell from the mechanical lift, struck her head and complained of neck pain. EMS placed a cervical collar (neck brace used to stabilize the neck/head during emergencies) before sliding her over to the stretcher and transferred Resident #1 to the emergency room (ER) where she was diagnosed with a C1 ring fracture (first cervical vertebra, where the skull and neck meet). Resident #1 was evaluated by surgery who determined that she was not a suitable surgical candidate, and she was placed in an Aspen collar (brand name for a rigid cervical collar used to immobilize and support the neck after an injury or surgery). She was discharged to an acute hospice facility on [DATE] and expired on [DATE]. When someone sustains a headfirst injury the head and neck should be protected from moving and they should be left on the floor until EMS completes an assessment. Moving a person with a suspected head and neck injury could cause more damage like shifting of bony fractures, severing of the spinal cord, paralysis, and death. Any movement with a C1 fracture is likely to cause additional harm and moving the person can make the C1 fracture worse, and this can cause irreparable damage to the spinal cord, affect respirations, and/or death. Resident #1's Certificate of Death dated [DATE] indicated Resident #1 was pronounced dead on [DATE] at a hospice facility. The immediate cause of death listed was complications of blunt force trauma to neck. This deficient practice affected 1 of 3 residents reviewed for quality of care (Resident #1).Immediate jeopardy began on [DATE] when Resident #1 who had a witnessed headfirst fall to the floor was transferred back to bed by staff using the mechanical lift before she was assessed by EMS. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective.The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), normal pressure hydrocephalus (excessive accumulation of cerebrospinal fluid in the brain), aphasia (language disorder that affects a person's ability to communicate), hemiplegia and hemiparesis (paralysis and weakness) affecting the left and right side, contracture of the right upper arm, osteoarthritis, osteoporosis, wedge compression fracture of thoracic vertebra 11 to thoracic vertebra 12 and lumbar vertebra and history of left foot drop.The Significant Change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was moderately cognitively impaired, had no behavioral symptoms, and had range of motion impairment on both sides of either upper or lower extremities. She was dependent on staff assistance with chair/bed-to-chair transfer. The MDS further indicated that Resident #1 had no falls since prior assessment and received hospice care while a resident at the facility.Resident #1's care plan last reviewed on [DATE] indicated Resident had an activities of daily living self-care performance deficit related to muscle weakness and left and right sided hemiparesis/hemiplegia due to stroke. Interventions included the resident required total assist by two staff to move between surfaces as necessary using a mechanical lift.A review of Resident #1's Medication Administration Record for [DATE] indicated she received Aspirin 81 milligrams one tablet by mouth one time a day (Aspirin's adverse effects include an increased risk of bleeding due to its antiplatelet properties) and Clopidogrel (antiplatelet medication used to prevent clots) one tablet by mouth one time a day. (The most common adverse effects of Clopidogrel are bleeding and bruising more easily).A review of an Incident Report dated [DATE] at 11:05 AM by Nurse #1 indicated a witnessed fall involving Resident #1. The nurse aide yelled out in the hall for the nurse to come to (Resident #1's room) quickly. Upon entering the room, (the nurse) found Resident #1 lying supine (lying on back with face upward) in the floor with head nearest the door and legs facing the bed, partially underneath the bed. Bed was in a raised position. Noted mechanical lift beside Resident #1 with lift pad remaining on equipment. The nurse aide stated Resident #1 slipped out of the side of the lift and fell on the floor, clarifying that she did hit her head. No bumps or bruises noted on head at this time. Resident #1 was awake and alert and oriented, pupils equal and reactive. Resident #1 complained of left shoulder hurting, also head and neck pain. Resident #1 verified slipping out of mechanical lift pad. Immediate Action Taken: Resident #1 was turned and placed on mechanical lift pad and with 4 assist was transferred into bed using the mechanical lift. Staff education on mechanical lift transfers. Lift and lift pad audit. Injuries Observed at Time of Incident: bruise to left forearm, fracture (per report from hospital, Resident #1 with cervical vertebra 1 fracture), skin tear to left finger.A phone interview with NA #1 on [DATE] at 10:36 AM revealed he and NA #2 walked in Resident #1's room to get her ready for the day on [DATE] and transfer her from the bed to her wheelchair using a mechanical lift. NA #1 stated that as soon as Resident #1's left foot came off the bed, the lift bar tilted over to the right side, and then Resident #1 slipped out of the sling on the left side. NA #1 stated that Resident #1's upper body came out of the sling, and she hit the floor headfirst. They were both unable to get to Resident #1 in time, and neither of them had their hands on Resident #1. NA #1 further stated that he saw Resident #1's head hit the floor as he heard a noise from her head hitting the floor. NA #1 further stated that he stayed with Resident #1 while NA #2 went to get Nurse #1. Nurse #1 assessed Resident #1 and Resident #1 was crying and complained to Nurse #1 that her neck hurt. After Nurse #1 said it was safe to move Resident #1, they rolled her to her back and used the same sling and mechanical lift to get her back on the bed. A phone interview with NA #2 on [DATE] at 4:12 PM revealed she and NA #1 went in to get Resident #1 up and dressed for the day on [DATE]. NA #2 stated that Resident #1's left foot caught onto the bed in the middle of the bare mattress while NA #2 was moving the mechanical lift away from the bed. NA #2 stated she continued to pull the lift away from the bed with Resident #1's left foot dragging on the bed, and as soon as Resident #1's foot got off the bed, the lift bar turned, and Resident #1 fell out of the sling. Resident #1 was on her back after she fell on the floor and complained that her left arm was hurting in the shoulder area. NA #1 stayed with Resident #1 while NA #2 alerted the nurses. NA #2 further stated that Nurse #1 and Nurse #2 came into the room and checked Resident #1 over. After assessing Resident #1, Nurse #2 said to get her up off the floor, so they got her back up with the mechanical lift onto her bed. Nurse #2 called EMS while Nurse #1 stayed with Resident #1.A nursing progress note dated [DATE] at 11:42 AM by Nurse #1 indicated at 11:05 AM, Nurse #1 was called down to Resident #1's room when the nurse aide yelled for help in this room. Upon entering the room, Resident #1 was found lying supine on the floor with her head nearest her door and her legs facing and partially underneath the bed. Resident #1 was conscious and answered appropriately. Nurse #1 noted the mechanical lift by resident and the lift pad still remained on the lift about 4 feet up in the air. Resident #1's skin warm and dry and a small amount of bleeding coming from her left middle finger was noted. Resident #1 was turned and placed on mechanical lift with 4 assist into bed. Resident #1 was crying and stated that her head and neck hurt. Large bruised and bulging area to lateral left forearm measuring 9 centimeters (cm) by 4.5 cm. The on-call primary care provider and family were called and an order to transfer resident out to hospital was received. Resident #1 was transferred to the hospital via stretcher with EMS.An interview with Nurse #1 on [DATE] at 11:23 AM revealed when she came into Resident #1's room, her head was facing the door, and her legs were facing the bed which was raised. Nurse #1 stated that Resident #1 was responsive and that she knew where she was. Resident # 1 was paralyzed on her legs and her right arm, and she could move a little bit of her left arm but not very much. Nurse #1 stated that Resident #1 said her head and her neck hurt so Nurse #1 immediately suspected there might be a subdural hematoma or a neck fracture. Nurse Aide (NA) #1, NA #2 and Nurse #2 were also in the room with her. After checking Resident #1's neurological status, they log-rolled her to get her on the mechanical lift pad. While lifting Resident #1 using the mechanical lift and sling, Nurse #1 kept Resident #1's head stabilized by holding her head and keeping it straight. They got her in the bed and kept her flat on the bed. Resident #1 did not seem confused, but she complained of her head and neck increasingly hurting. Nurse #1 stated that she stayed with Resident #1 and told EMS when they came in that she needed a cervical collar. EMS put a cervical collar on Resident #1 before they transferred her to the stretcher.A follow-up interview with Nurse #1 on [DATE] at 2:28 PM revealed in retrospect, it probably would have been a good idea to leave Resident #1 on the floor or use a slide board. Nurse #1 stated she took responsibility for the situation because she was in charge of Resident #1, and she should have stepped up and said that they were going to use a slide board or not move Resident #1 and wait for EMS to get her. Nurse #1 stated she had second thoughts about the situation afterwards, and she just went by what Nurse #2 had decided after she assessed Resident #1.A second follow-up interview with Nurse #1 on [DATE] at 3:22 PM revealed she couldn't recall if Resident #1 complained of neck pain or was saying up, up while she was on the floor. Nurse #1 stated that when Resident #1 was on the floor, Nurse #2 asked her to turn her head and Resident #1 did, but she couldn't remember if Resident #1 complained of pain in her neck then. Nurse #1 further stated that when Resident #1 got back into the bed, she was complaining more of her neck hurting. Nurse #1 also stated that she was aware of inconsistencies in her statements from the incident report and progress note, and that this was due to everything happening so fast. Nurse #1 stated that she knew she documented Resident #1 complaining of neck pain, but she could not remember if it was before or after they had moved her off the floor. She stated that they did not have a cervical collar available at the facility.An interview with Nurse #2 on [DATE] at 11:41 AM revealed she was working on the other hall on [DATE] when NA #2 poked her head out of Resident #1's room and asked for help. Nurse #2 stated that she saw Nurse #1 go into the room. Nurse #2 went into Resident #1's room and as she walked in, she saw Nurse #1 assessing Resident #1. Nurse #2 stated she saw blood on the floor and Resident #1 was on her left side with her left elbow underneath her. Resident #1 was complaining of her head hurting, so they checked her for injury. They rolled Resident #1 to her back, and Resident #1 complained of her head and her left arm hurting. Resident #1 had a big bruise on her left elbow, and she kept on saying the words hurt and up. Resident #1 told her she hit her head, so they checked her pupils which were normal. Nurse #2 indicated she decided to get Resident #1 back into the bed because she was alert and talking, so they got the sling underneath her, immobilized her head by Nurse #1 holding it straight, and lifted her using the mechanical lift back into bed. Nurse #2 called the on-call doctor and Resident #1's family member who agreed to send Resident #1 to the hospital for evaluation. Nurse #2 called EMS and requested an emergent transfer.A follow-up interview with Nurse #2 on [DATE] at 3:16 PM revealed Resident #1 complained of her head and her left arm hurting when she was on the floor, and she never complained of neck pain to her. Nurse #2 stated that she assessed Resident #1 by talking to her and asking her to turn her head. Nurse #2 stated that Resident #1 was shaking and nodding her head, but she did not complain of neck pain to her. Nurse #2 indicated Resident #1 complained of pain all over, that the floor was cold, and she kept on saying up, up which meant she wanted up off the floor.A review of the local county EMS record dated [DATE] for Resident #1 indicated EMS arrived on scene at the facility where Resident #1 presented lying supine in bed, alert, skin pink/warm/dry. Staff advised that at approximately 11:00 AM, Resident #1 was being lifted in a mechanical lift and slid out onto her left side. The resident endorsed a head strike, but no loss of consciousness. They were able to get assistance to get her back into bed. Resident #1 complained of neck pain, but no injuries to head were noted, no bleeding, no hematoma. A cervical collar was placed, and Resident #1 was slid over to stretcher and loaded into ambulance without issue.A phone interview with the EMS Supervisor on [DATE] at 12:12 PM revealed that for a patient who fell headfirst to the floor, it would be up to the discretion of the medic who arrived on scene on what to do, but the usual procedure would be to put a cervical collar and immobilize the spine especially if the patient was on a blood thinner. The EMS Supervisor stated they didn't always put a cervical collar on a patient with a suspected head and neck injury before moving them and each situation was different, but it would be better to leave them on the floor. The EMS Supervisor stated that it would have been better if the facility staff left Resident #1 on the floor and kept her comfortable until EMS came to get her. He further stated that if the patient was uncomfortable on the floor, it was fine to move them, but if they were complaining of neck and back pain, then they would suspect spinal injuries, and they would need to take the necessary precautions like putting a neck brace, and providing spinal immobilization prior to moving them. The EMS Supervisor stated that moving a patient with suspected head and neck injury would cause more pain, and if the neck injury was severe, it could cause paralysis.A review of Resident #1's hospital Discharge summary dated [DATE] indicated Resident #1 presented to the emergency room on [DATE] after falling from a (mechanical) lift while being moved at her nursing facility. She was unsure how this occurred, but she did report falling to her left side, striking her head but not losing consciousness. She was returned to her bed by the facility staff and EMS was contacted. Resident #1 was transported to the hospital where she was found to be neurologically intact to her normal level but with imaging demonstrating a cervical vertebra 1 fracture involving the right anterior and posterior arches. Imaging of the brain was unremarkable. An MRI (magnetic resonance imaging) of the cervical spine without contrast dated [DATE] for Resident #1 indicated right C1 ring (first cervical vertebra of the spine, located at the base of the skull where the skull and neck meet) fractures with moderate displacement (movement of a tissue from its usual or proper location) of the anterior ring (front part of the ring-shaped C1 vertebra) and associated disruption (rupture or tearing of tissue) of the right transverse ligament with small avulsion fragment ( avulsion happens when a small piece of bone attached to a ligament or tendon breaks away from the rest of the bone) to the posterior lateral of the dens (bony projection that extends superiorly from the body of the second cervical vertebra). She was referred to the Hospital Medicine service and admitted for further evaluation. It was noted Resident #1 was on Hospice at her facility and had recently transitioned to this due to a history of multiple strokes. She was evaluated by surgery who determined that she was not a suitable surgical candidate. Given this, it was felt that she would need to transition to General Inpatient Hospice. She was placed in an Aspen collar (brand name for a rigid cervical collar used to immobilize and support the neck after an injury or surgery) at admission and will require a Philadelphia collar (rigid cervical orthosis used to immobilize the neck and spine after an injury or surgery) for bathing. (Philadelphia collar is made of rigid plastic and foam, while the Aspen collar refers to a specific brand of more modern, adjustable collar that uses breathable, moisture-wicking pads.) Resident #1 was considered to be stable for discharge to hospice on [DATE].A review of Resident #1's Certificate of Death dated [DATE] indicated Resident #1 was pronounced dead on [DATE] at a hospice facility. The immediate cause of death listed was complications of blunt force trauma to neck.An interview with the Interim Director of Nursing (DON) on [DATE] at 1:43 PM revealed the nurse should assess the resident and determine from the assessment what actions should be taken next. If the resident had a change of condition after the fall such as excessive bleeding, altered level of consciousness, expression of pain that was not at baseline or unusual or if the resident had a fall with head injury or strike, the nurse should contact the on-call provider with what they found during their assessment of the resident. Whether a resident should be moved off the floor after a headfirst fall would be on a case-by-case basis. The DON stated that for Resident #1's case, there was some blood involved, and the nurse needed to move the resident to determine the source of bleeding. The DON stated that she was told there was blood on the floor and they did not know where it was coming from. She also stated that the nurses should follow the facility policy for potential for head injury after a fall which included performing an assessment and notifying the physician of any signs of injuries. The DON indicated she could not say if they should have moved the resident because she was not there when Resident #1 fell.A phone interview with the Medical Director on [DATE] at 1:20 PM revealed they did not like any fall to happen, but he had reviewed Resident #1's fall incident with facility staff, and it sounded like the staff followed the process. He stated that there were two people doing the transfer and they used the correct sling. The Medical Director also stated that he was aware Resident #1 obtained a cervical vertebra 1 fracture which was most likely from the fall. He added that he couldn't think of anything else that might have caused this fracture.A follow-up interview with the Medical Director on [DATE] at 2:34 PM revealed from what the nurse told him, Resident #1 was moving her head, and she complained more about her neck hurting after they had moved her off the floor. The Medical Director stated after the nurse's assessment, they had stabilized Resident #1's neck, and she was moving her neck before they transferred her from the floor to her bed. He further stated that if Resident #1 had complained of neck pain while she was on the floor, they should have just stabilized her on the floor and let EMS move her. He also shared that the possible harm of moving Resident #1 from the floor to the bed after a headfirst fall was the possibility of a fracture which she had and neurological compromise which he did not see in her hospital records.A phone interview with the emergency room Physician Assistant (PA) on [DATE] at 11:54 AM revealed she examined Resident #1 in the ER on [DATE]. The PA stated that Resident #1 was sent to the ER for a work-up after she slipped or fell out of a mechanical lift at the nursing facility. The PA stated Resident #1 was diagnosed with C1 fracture and a left arm hematoma and was admitted to the hospitalist's care. The PA further stated that they talked to the neurosurgical team to get their input, and they determined that Resident #1 wasn't a surgical candidate, so she was admitted to the inpatient hospice. The PA stated that she couldn't say whether the facility should have left Resident #1 on the floor instead of moving her to the bed without using a cervical collar, and that it was hard to say what possible outcomes Resident #1 would have experienced from this. The PA also stated that she couldn't talk about Resident #1's prognosis after the injuries she obtained from the fall.A phone interview with the emergency room (ER) Physician on [DATE] at 1:28 PM revealed he did not examine Resident #1 while she was in the ER on [DATE]. The ER Physician stated he just signed off on the PA's assessment, and he agreed with everything she did. The ER Physician stated that if an elderly person falls headfirst and it was witnessed just like Resident #1's fall, and if this happened in the ER, they would do cervical spine immobilization first by using a cervical collar or a neck brace before moving the patient off the floor. The ER Physician stated cervical spine immobilization would be important in this case to prevent further spinal cord injury. He also stated that he couldn't say for sure if the displacement on the MRI result was from the fall itself or from being moved off the floor without proper immobilization.The Administrator was notified of immediate jeopardy on [DATE] at 1:00 PM.The facility provided the following credible allegation of immediate jeopardy removal:1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On [DATE], Resident #1 fell head first to the floor during a mechanical lift transfer. As a result of the fall, Resident #1 suffered a head/neck injury. The staff on scene, which included the Staff Development Coordinator, RN floor nurse, Nurse Aide #1 and Nurse Aide #2, moved Resident #1 back to bed using the mechanical lift. Resident #1 should not have been moved. Resident #1 was transferred to the Emergency Department and diagnosed with a C1 neck fracture. Other residents that are likely to suffer a serious adverse outcome as a result of this noncompliance are any residents sustaining a fall or other injury that results in a head and/or neck trauma. Risk Management (incident/accident) reports from [DATE] to [DATE] were reviewed to identify any other incidents involving a mechanical lift transfer or falls with major injury, with a focus on any incidents that involved head or neck injury that were moved and should not have been. There were no falls or accidents found that involved head and neck injury, or serious injury of any type, resulting from a resident falling on their head, that were moved that should not have been. This review was completed on [DATE] by the Interim Director of Nursing. On [DATE] the Interim Director of Nursing reviewed all resident transfers to an acute care hospital from [DATE] to [DATE]. The Interim Director of Nursing reviewed the reason for transfer to identify if the transfer to the hospital involved a serious injury resulting from a fall on their head. None were transferred for head or neck injury. On [DATE] the Administrator reviewed all Facility Reported Incidents from ([DATE] to [DATE]) reported to the North Carolina Department of Health and Human Services to identify any potential reported incidents that involved serious injury resulting from a fall on their head or neck. None were identified. On [DATE] the Administrator confirmed that no additional reports had been sent to the North Carolina Department of Health & Human Services for any reason since [DATE]. On [DATE] the Administrator reviewed the grievance log from [DATE] to [DATE] to identify any complaints of serious injury resulting from a fall on their head or neck. None were identified. On [DATE] the Administrator confirmed that there have been no grievances made that involved physical injury of any kind since [DATE]. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On [DATE] the Administrator collaborated with the Medical Director to develop the content of education to be provided to Licensed Nurses on appropriate post fall response actions, including recognizing the severity of the fall and potential injury. This education was developed from the facility policy Potential Head Injury, and direction from the Medical Director. The Medical Director indicated signs and/or symptoms of unconsciousness, complaints of head or neck pain, tenderness of head or neck on physical examination and obvious deformities should be addressed by maintaining the resident's physical alignment and spine, while not moving the resident when awaiting emergency service personnel arrival. The education included possible additional serious injury (that include paralysis and/or death) that could result from the act of moving a resident after a serious accident (fall on their head) resulting in head or neck injury. On [DATE] all Licensed Nurses that were working were educated by the Interim DON on the training developed by the Medical Director for assessing a resident, when not to move them and the potential additional injury that could result from moving them after a head or neck injury resulting from a fall on their head. The facility does not utilize agency staff. All newly hired staff will receive this education by the Interim DON or designee during orientation. Starting on [DATE] all nurses not previously educated will be called by the Interim DON prior to their next shift, starting with the night shift for [DATE]. The Interim Director of Nurses will review the education developed by the Medical Director for assessing a resident, when not to move them and the potential additional injury that could result from moving them after a fall on their head resulting in a head or neck. The Interim Director of Nursing will also inform the Licensed Nurses that this same information has been provided in writing and at each nurses' station. The Interim Director of Nurses will confirm the nurses understanding of the education and inform them to call with any questions. This will continue until all Licensed Nurses have been educated by phone. The Interim DON or designee is maintaining the list of staff to confirm education. The facility does not utilize agency staff. Starting on [DATE] the Staff Development Coordinator, or Interim Director of Nursing, or the Wound Care Nurse or the Minimum Data Set Nurses will again educate all nurses in person, on assessing a resident, when not to move them and the potential additional injury that could result from moving them resulting from falling on their head and acknowledge that they understand the information provided. This in person education will be completed on or before their next shift. The Interim DON or designee is maintaining the list of staff to confirm education. The facility does not utilize agency staff. On [DATE] all Nurse Aides that were working were educated by the Interim DON that when a resident is found down on the ground or has a fall or accident they are not to move the resident. They are to immediately notify the licensed nurse and wait for instructions on when and if it is safe to move the resident. Starting [DATE] all Nurse Aides not previously educated were called by the Interim DON, Wound Care Nurse, and the MDS Nurse and educated that when a resident is found down on the ground or has a fall or accident, they are not to move the resident. They are to immediately notify the licensed nurse and wait for instructions on when and if it is safe to move the resident. All newly hired Nurse Aides will be educated by the Interim DON or designee during orientation. The facility does not utilize agency staff. The Interim DON or designee is maintaining the list of staff to confirm education. Starting on [DATE] the Licensed Nurses will review with each Nurse Aide on their unit that they cannot move a resident that has fallen or found down until the Licensed Nurse assess the resident. This will be done at the beginning of each shift for the next 2 weeks by the licensed nurse to the nurse aides during shift change. Starting on [DATE] the Administrative staff, Activities staff, Therapy, Housekeeping, Laundry, Maintenance and Dietary Departments will be educated by the Administrator, the Director of Maintenance or the Certified Dietary Manager that no resident can be moved if they are found on the ground or have a fall or accident. They are to immediately notify the licensed nurse. All staff will be educated on or before their next shift by the Administrator or designee. Newly hired staff will be educated by the Interim DON during orientation. Starting on [DATE] the Interim DON, Administrator, Minimum Data Set Nurses will review 5 days a week, the incident/accident reports, 24-hour report, the order listing report for medication changes, the Discharge report, and grievance log to ensure that all falls and injuries, resulting from a fall on their head, have been handled according to this plan. Completion Date: [DATE]On [DATE] the facility's credible allegation of immediate jeopardy removal was validated by the following:Review of facility audits revealed the facility completed audits of all incidents, hospital transfers, grievance logs, and facility reportable incidents from [DATE] to [DATE]. Incident reports were audited by the facility for falls with injury, head/ neck injury, and reviewed for if residents with injury was moved inappropriately. The facility did not identify any issues from the incident report audit. The facility completed an audit of resident hospital transfers to identify any hospital transfers related to a fall with injury or head/ neck injury; there were no issues identified. Facility reportable incidents were reviewed and did not contain any reportable incidents related to falls with injury. Grievance log audits were completed to identify any grievance related to physical injury; there were no issues identified.Grievance logs, facility reportable incident logs, incident logs, and hospital transfer logs were reviewed. There were no issues related to falls with injury, head/ neck injury, or residents being moved in appropriately. All facility audits were reviewed and verified as completed.Review of education revealed specific post fall education was developed by the Medical Director and included assessment steps to take after a resident has a fall, when to not move a resident, and when to call emergency medical services (EMS). The education included additional injury and/or adverse outcomes if a resident was moved after a head or neck injury.Review of in-service education logs revealed the education material developed by the Medical Director was used to educate licensed nurses on assessing a resident after a fall, when not to move a resident after a fall, and additional injury that could incur if a resident was moved. It was verified the Staff Development Nurse and involved floor nurse received the education.In-service logs revealed all staff were educated to notify the nurse and to not move a resident after a fall.Addit[TRUNCATED]

Based on record review, observation, and interviews with staff and the Medical Director, the facility failed to provide a safe transfer of Resident #1 using a mechanical lift. Resident #1 had left foot drop, hemiplegia (paralysis) and hemiparesis (weakness) on both sides and was prescribed an anti-platelet medication. Resident #1 was transferred with a mechanical lift by Nurse Aide (NA) #1 and NA #2 on 10/4/25 and they failed to ensure that Resident #1's feet (with shoes on) cleared the bed while in the mechanical lift. Resident #1's feet got caught on the mattress and as the lift was moved, the force of Resident #1's feet coming loose caused Resident #1 to swing and fall headfirst out of the sling that was approximately 4 feet in the air. Resident #1 landed on the floor and complained of pain in her head/neck area and was transferred to the Emergency Department (ED) for evaluation. Resident #1 was diagnosed with a C1 ring fracture (first cervical vertebra, where the skull and neck meet), and was placed in a cervical collar. She was determined to be not a suitable surgical candidate and transitioned to an acute hospice facility on 10/6/25. Resident #1's Certificate of Death dated 10/15/25 indicated Resident #1 was pronounced dead on 10/15/25 at a hospice facility. The immediate cause of death listed was complications of blunt force trauma to neck. This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #1).Immediate jeopardy began on 10/4/25 when Resident #1 was unsafely transferred using a mechanical lift and fell out of the sling to the floor headfirst. Immediate jeopardy was removed on 10/18/25 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective.The findings included:A review of the manufacturer's instruction manual for the mechanical lift used by the facility read in part: Special care MUST be taken with people with disabilities who cannot cooperate while being lifted. The patient should be elevated high enough to clear the bed and their weight supported by the lift. When the patient is lifted from the bed (with the patient's head supported), he/she will be raised to a sitting position. When patient is clear of the bed surface, swing their feet off the bed by either aiding or guiding the patient. Illustrations were included of a second person supporting the legs of the patient while being aided or guided to swing their feet off the bed. When moving the patient lift away from the bed, turn patient so that he/she faces assistant operating the patient lift. Open control valve lowering patient so that his feet rest on or over the base of the lift, straddling the mast. Close control valve. NOTE: The lower center of gravity provides stability making the patient feel more secure and the lift easier to pull or push. Pull the patient lift away from the bed and push from behind with both hands. Illustrations were included detailing a second person supporting the patient from behind while the lift was being pulled away from the bed.A review of the facility's undated Safe Resident Handling/Transfers policy indicated two facility staff members will participate in the transfer process should a mechanical lift be used and mechanical lift education/training is based on manufacturer's recommendations in conjunction with applicable state/federal regulations and industry standard.Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), normal pressure hydrocephalus (excessive accumulation of cerebrospinal fluid in the brain), aphasia (language disorder that affects a person's ability to communicate), hemiplegia and hemiparesis (paralysis and weakness) affecting the left and right side, contracture of the right upper arm, osteoarthritis, osteoporosis, wedge compression fracture of thoracic vertebra 11 to thoracic vertebra 12 and lumbar vertebra, and history of left foot drop. The Significant Change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was moderately cognitively impaired, had no behavioral symptoms, and had range of motion impairment on both sides of either upper or lower extremities. She was dependent on staff assistance with chair/bed-to-chair transfer. The MDS further indicated that Resident #1 had no falls since prior assessment and received hospice care while a resident at the facility.The Care Area Assessment (CAA) for Falls dated 8/27/25 indicated Resident #1 had a history of stroke and had residual left sided hemiplegia and left foot drop. She was being followed by hospice care starting 8/14/25 due to cerebrovascular accident with left hemiplegia, hydrocephalus, osteoporosis, weakness and hypertension. She had residual left sided facial droop. She was on antiplatelet medications for stroke. She was able to understand and was sometimes able to make herself understood. Speech was clear but slurred at times. She would answer questions with a short delay but most appropriately answered questions. She was able to make needs known. Falls CAA was triggered secondary to antianxiety and antidepressant medication use. Contributing factors included physical performance limitations affecting balance, gait, strength, and muscle endurance. Risk factors included falls and other major and minor injuries related to falls.Resident #1's care plan last reviewed on 8/22/25 indicated Resident #1 had an activities of daily living self-care performance deficit related to muscle weakness and left and right sided hemiparesis/hemiplegia due to stroke. Interventions included the resident required total assist by two staff to move between surfaces as necessary using a mechanical lift. Resident #1 was also at risk for falls related to gait and balance problems. The following interventions were listed: anticipate and meet the resident's needs, be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed, attempt to put call bell on the right side, and educate the resident/family/caregivers about safety reminders and what to do if a fall occurs.A review of Resident #1's Medication Administration Record for October 2025 indicated she received Aspirin 81 milligrams one tablet by mouth one time a day (Aspirin's adverse effects include an increased risk of bleeding due to its antiplatelet properties.) and Clopidogrel (antiplatelet medication used to prevent clots) one tablet by mouth one time a day. (The most common adverse effects of Clopidogrel are bleeding and bruising more easily than usual.)An undated handwritten and signed statement by Nurse Aide (NA) #1 indicated: Me (NA #1) and (NA #2) walked into the room to prepare (Resident #1) for the day by getting her dressed and then prepared to get her out of bed. We grabbed a lift and lift pad. We placed the lift pad under her making sure that it was in the proper position. We then attached the lift pad to the hooks on the lift and began lifting her off the bed. Once she reached a proper height to move her from the bed we began to do so. Her feet rubbed against the bed, so we moved slowly. Just as her feet left the bed, the bar on the lift tilted and she slid out of the lift pad and landed on the floor. We were unable to reach in time to catch her before she landed on the ground. After this happened, I went to check on her as I asked (NA #2) to get the nurse working with us that day. (Nurse #1) and (Nurse #2) came to check on her and her condition. We then got her off the floor once they had determined it was safe to do so. We got her back on the bed. Then (Nurse #2) began to notify people of what happened and (Nurse #1) continued to watch over her as we returned to taking care of the other residents.A phone interview with NA #1 on 10/9/25 at 10:36 AM revealed he and NA #2 walked in Resident #1's room to get her ready for the day on 10/4/25. They changed her brief and put a shirt and pants on her. They put on her socks and shoes and placed the lift pad underneath her. They attached the sling on the lift with NA #1 on the left side and NA #2 on the right side of Resident #1's bed. Then NA #2 proceeded to lift her up off the bed. NA #1 stated that while NA #2 was pulling the lift away from the bed, he didn't notice at first that Resident #1 had not cleared the bed and that her left foot was still touching the bed. NA #1 stated that this was because NA #1 turned away from Resident #1 to get her wheelchair ready and he was not within reach of Resident #1. NA #1 stated that as soon as Resident #1's left foot came off the bed, the lift bar tilted over to the right side, and then Resident #1 slipped out of the sling on the left side. NA #1 stated that Resident #1's upper body came out of the sling, and she hit the floor headfirst. They were both unable to get to Resident #1 in time, and neither of them had their hands on Resident #1. NA #1 further stated that he saw Resident #1's head hit the floor as he heard a noise from her head hitting the floor. NA #1 further stated that he stayed with Resident #1 while NA #2 went to get Nurse #1. Nurse #1 assessed Resident #1. Resident #1 was crying and complained to Nurse #1 that her neck hurt. After Nurse #1 said it was safe to move Resident #1, they rolled her to her back and used the same sling and mechanical lift to get her back on the bed. An undated handwritten and signed statement by Nurse Aide (NA) #2 indicated: (NA #1) and I (NA #2) were getting (Resident #1) out of bed for the day. We got her dressed first. We put on her brief first, then moved to putting her pants on, socks next and shoes last. We moved to getting the sling under her first, rolling her my way, put the sling under her, then moving her (NA #1)'s way getting the rest of the sling under her. I moved the lift towards (Resident #1) and hooked her into the lift. (NA #1) was getting the wheelchair ready as I was moving (Resident #1). Her foot caught onto the bed as I was moving her, which in turn made the lift bar extremely tilt, which caused her to fall out and land on the ground. (NA #1) stayed with (Resident #1) while I ran to get the nurses on the floor. The nurses came and assessed her to see what condition she was in. Once it was deemed safe we moved her from the floor to the bed. (Nurse #2) contacted people to inform them of the situation while (Nurse #1) continued to look after (Resident #1). We returned to taking care of the other residents.A phone interview with NA #2 on 10/9/25 at 4:12 PM revealed she and NA #1 went in to get Resident #1 up and dressed for the day on 10/4/25. They got her dressed and changed. They put the sling under Resident #1 and then NA #2 proceeded to lift her up off the bed while NA #1 got the wheelchair ready. NA #2 stated that she raised the lift just high enough to clear Resident #1's bottom off the bed, but it wasn't raised at the maximum height. NA #2 stated that Resident #1's left foot caught onto the bed in the middle of the bare mattress while NA #2 was moving the mechanical lift away from the bed. NA #2 stated she did not think about stopping or asking NA #1 to support Resident #1's legs once she saw Resident #1's left foot got caught on the bed. NA #2 stated she continued to pull the lift away from the bed with Resident #1's left foot dragging on the bed, and as soon as Resident #1's foot got off the bed, the lift bar turned, and Resident #1 fell out of the sling. Resident #1 was on her back after she fell on the floor and complained that her left arm was hurting in the shoulder area. NA #1 stayed with Resident #1 while NA #2 alerted the nurses. NA #2 further stated that Nurse #1 and Nurse #2 came into the room and checked Resident #1 over. After assessing Resident #1, Nurse #2 said to get her up off the floor, so they got her back up with the mechanical lift onto her bed. Nurse #2 called EMS while Nurse #1 stayed with Resident #1.A review of an Incident Report dated 10/4/25 at 11:05 AM by Nurse #1 indicated a witnessed fall involving Resident #1. The nurse aide yelled out in the hall for the nurse to come to (Resident #1's room) quickly. Upon entering the room, (the nurse) found Resident #1 lying supine (lying on back with face upward) in the floor with head nearest the door and legs facing the bed, partially underneath the bed. Bed was in a raised position. Noted mechanical lift beside Resident #1 with lift pad remaining on equipment. The nurse aide stated Resident #1 slipped out of the side of the lift and fell on the floor, clarifying that she did hit her head. No bumps or bruises noted on head at this time. Resident #1 was awake and alert and oriented, pupils equal and reactive. Resident #1 complained of left shoulder hurting, also head and neck pain. Resident #1 verified slipping out of mechanical lift pad. Immediate Action Taken: Resident #1 was turned and placed on mechanical lift pad and with 4 assist was transferred into bed using the mechanical lift. Staff education on mechanical lift transfers. Lift and lift pad audit. Injuries Observed at Time of Incident: bruise to left forearm, fracture (per report from hospital, Resident #1 with cervical vertebra 1 fracture), skin tear to left finger.A nursing progress note dated 10/4/25 at 11:42 AM by Nurse #1 indicated at 11:05 AM, Nurse #1 was called down to Resident #1's room when the nurse aide yelled for help in this room. Upon entering the room, Resident #1 was found lying supine on the floor with her head nearest her door and her legs facing and partially underneath the bed. Resident #1 was conscious and answered appropriately. Nurse #1 noted the mechanical lift by resident and the lift pad still remained on the lift about 4 feet up in the air. Resident #1's skin warm and dry and a small amount of bleeding coming from her left middle finger was noted. Resident #1 was turned and placed on mechanical lift with 4 assist into bed. Resident #1 was crying and stated that her head and neck hurt. Large bruised and bulging area to lateral left forearm measuring 9 centimeters (cm) by 4.5 cm. The on-call primary care provider and family were called and an order to transfer resident out to hospital was received. Resident #1 was transferred to the hospital via stretcher with EMS.An interview with Nurse #1 on 10/9/25 at 11:23 AM revealed when she came into Resident #1's room, her head was facing the door, and her legs were facing the bed which was raised. Nurse #1 stated that Resident #1 was responsive and that she knew where she was. Resident # 1 was paralyzed in her legs and her right arm, and she could move a little bit of her left arm but not very much. Nurse #1 stated that Resident #1 said her head and her neck hurt so Nurse #1 immediately suspected there might be a subdural hematoma or a neck fracture. Nurse Aide (NA) #1, NA #2 and Nurse #2 were also in the room with her. After checking Resident #1's neurological status, they log-rolled her to get her on the mechanical lift pad. While lifting Resident #1 using the mechanical lift and sling, Nurse #1 kept Resident #1's head stabilized by holding her head and keeping it straight. They got her in the bed and kept her flat on the bed. Resident #1 did not seem confused, but she complained of her head and neck increasingly hurting. Nurse #1 further stated that from what was reported to her by the nurse aides, while they were lifting Resident #1 with the mechanical lift, her weight went to one side and the mechanical lift bar tilted (The lift bar is the swivel bar pad that has hooks on both ends to attach the sling that supports the patient during lift.) and then Resident #1 slipped out of the sling. Nurse #1 stated that Resident #1 fell from about 4 feet off the floor and the sling was still up when she came into the room. Nurse #1 reported that Resident #1 was not able to hold the bar at all with her left hand and that she couldn't see her grasping anything at that point. Nurse #1 stated that she stayed with Resident #1 and told EMS when they came in that she needed a cervical collar. EMS put a cervical collar on Resident #1 before they transferred her to the stretcher. An interview with Nurse #2 on 10/9/25 at 11:41 AM revealed she was working on the other hall on 10/4/25 when NA #2 poked her head out of Resident #1's room and asked for help. Nurse #2 stated that she saw Nurse #1 go into the room. Nurse #2 went into Resident #1's room and as she walked in, she saw Nurse #1 assessing Resident #1. Nurse #2 stated she saw blood on the floor and Resident #1 was on her left side with her left elbow underneath her. Resident #1 was complaining of her head hurting, so they checked her for injury. They rolled Resident #1 to her back, and Resident #1 complained of her head and her left arm hurting. Resident #1 had a big bruise on her left elbow, and she kept on saying the words hurt and up. Resident #1 told her she hit her head, so they checked her pupils which were normal. Nurse #2 decided to get Resident #1 back into the bed because she was alert and talking, so they got the sling underneath her, immobilized her head by Nurse #1 holding it straight, and lifted her using the mechanical lift back into bed. Nurse #2 called the on-call doctor and Resident #1's family member who agreed to send Resident #1 to the hospital for evaluation. Nurse #2 called EMS and requested an emergent transfer. The interview further revealed that Nurse #2 asked both NA #1 and NA #2 what happened afterwards, and they told her that while they were doing a lift transfer on Resident #1, her shoe had caught in the middle of the bed, and then she slipped out the left side of the sling. Nurse #2 stated that with Resident #1's feet coming off the bed, the lift bar swung and caused her upper body to tilt and slide off the sling. Nurse #2 stated that on the lift training, the nurse aides were instructed that the residents had to clear the bed before pulling out the lift, but she didn't know if Resident #1's shoe was still touching the bed when NA #2 started pulling out the lift away from her bed. Nurse #2 added that the nurse aides also needed to have a hand on the resident at all times while lifting them up, but in Resident #1's case, neither of the nurse aides had their hands on Resident #1 while they lifted her up.A review of Resident #1's hospital Discharge summary dated [DATE] indicated: (Resident #1) presented to the emergency room on [DATE] after falling from a (mechanical) lift while being moved at her nursing facility. She was unsure how this occurred, but she did report falling to her left side, striking her head but not losing consciousness. She was returned to her bed by the facility staff and EMS was contacted. She was transported to the hospital where she was found to be neurologically intact to her normal level but with imaging demonstrating a cervical vertebra 1 fracture involving the right anterior and posterior arches. Imaging of the brain was unremarkable. She was referred to the Hospital Medicine service and admitted for further evaluation. Of note, she was on Hospice at her facility, recently transitioned to this due to a history of multiple strokes. She was evaluated by surgery who determined that she was not a suitable surgical candidate. Given this, it was felt that she would need to transition to General Inpatient Hospice. She was placed in an Aspen collar (brand name for a rigid cervical collar used to immobilize and support the neck after an injury or surgery) at admission and will require a Philadelphia collar (rigid cervical orthosis used to immobilize the neck and spine after an injury or surgery) for bathing. (Philadelphia collar is made of rigid plastic and foam, while the Aspen collar refers to a specific brand of more modern, adjustable collar that uses breathable, moisture-wicking pads.) She was considered to be stable for discharge to hospice on 10/6/25.A review of Resident #1's Certificate of Death dated 10/15/25 indicated Resident #1 was pronounced dead on 10/15/25 at a hospice facility. The immediate cause of death listed was complications of blunt force trauma to neck.A phone interview with the Medical Director on 10/9/25 at 1:20 PM revealed they did not like any fall to happen, but he had reviewed Resident #1's fall incident with facility staff, and it sounded like the staff followed the process. He stated that there were two people doing the transfer and they used the correct sling. The Medical Director stated that it seemed like they did not do anything wrong except that Resident #1's foot got caught on the bed. He further stated that if Resident #1's foot didn't get caught on the bed, she might not have fallen. The Medical Director also stated that he was aware Resident #1 obtained a cervical vertebra 1 fracture which was most likely from the fall. He added that he couldn't think of anything else that might have caused this fracture.A phone interview with the Interim Director of Nursing (DON) on 10/14/25 at 12:00 PM revealed she was made aware of Resident #1's fall after she received a text message on 10/4/25 at 11:27 AM. The Interim DON stated that the way Resident #1's fall was explained to her, Resident #1 was in the sling and as they were pulling the sling away from the bed, the sole of her shoe got caught on the mattress and caused the sling to tip and Resident #1 slid out of the side of the sling. The Interim DON shared that they had both nurse aides show them what happened, and at one point, NA #1 turned away to get Resident #1's wheelchair. The Interim DON stated that the only thing she could think of that the nurse aides could have done to prevent Resident #1's fall was that both nurse aides could have kept both of their hands completely on Resident #1 while they lifted her. NA #2 should have stopped moving the lift when she saw Resident #1's shoe get caught on the mattress or have NA #1 guide the Resident #1's leg while she was being lifted.An interview and observation of re-enactment with the Administrator on 10/9/25 at 11:02 AM revealed both nurse aides cleaned Resident #1 up and they had to strip her bed because it got soiled. NA #2 controlled the lift while NA #1 was on the other side of the bed. The Administrator stated that as Resident #1's bottom cleared the bed, NA #2 pulled out the lift with the sling hooked up to the mechanical lift. Resident #1's foot got stuck on the bed and when the foot got unstuck as NA #2 was pulling the lift out, the lift bar tilted to the right side and caused her to swing out of the sling on the left side with her upper body first. The Administrator was notified of immediate jeopardy on 10/14/25 at 12:13 PM.The facility provided the following immediate jeopardy removal plan:1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 10/4/25, at approximately 11:05 am, Resident #1 sustained a fall during a mechanical lift transfer. An immediate assessment of Resident #1's post fall condition, conducted by the Staff Development Coordinator and the assigned, direct care Registered Nurse revealed the need to initiate a transfer to the local emergency department for evaluation and treatment. Resident #1 was complaining of pain in her head/neck area. She had a raised area to her forearm and a skin tear to her finger. The Staff Development Coordinator called the on-call doctor and received the order to transfer. The Staff Development Coordinator called Resident #1's family to inform them of the accident and to let them know that Resident #1 would be transferred to the hospital. Resident #1 exited the facility via emergency services personnel. At exit, Resident #1 was verbally responding to questions that confirmed her continued orientation to person, place and time. The only physical variations from her baseline being a discolored, raised area on her left forearm and a small skin tear on her left middle finger. Resident #1's care plan was updated to reflect the 10/4/25 fall intervention of staff education, the presence of left arm bruising, left middle finger skin tear and the C1 fracture. This was completed by the Minimum Data Set Coordinator on 10/6/25. On 10/4/25 the Staff Development Coordinator called the Interim Director of Nursing (DON) to notify her of Resident #1's incident. On 10/4/25 the Interim Director of Nursing initiated the notification tree which included the Administrator, the Corporate Director of Clinical Services and the Corporate Director of Operations. On 10/4/25 The Staff Development Coordinator, in conjunction with the assigned, direct care Registered Nurse, for Resident #1, completed a visual observation of the scene, resident room [ROOM NUMBER]. This observation did not readily identify the root cause of the incident. In response to the incident, an immediate investigation was initiated by the Staff Development Coordinator, that included the suspension of both Nurse Aides (NA) performing Resident #1's lift transfer. The suspensions were carried out on 10/4/25. On 10/6/25, Nurse Aide#1 and Nurse Aide#2 were required to return to the facility to participate in a reenactment of the 10/4/25 incident as a component of the investigation. The Administrator, interim Director of Nursing and Staff Development Coordinator conducted and observed a demonstration of the lift transfer process, using the exact mechanical lift and lift sling used during the incident. These reenactments were conducted with both Nurse Aide#1 and Nurse Aide#2 independent of one another with the Administrator and Staff Development Coordinator acting as the second staff member. The Nurse Aides were asked to perform the reenactment independently to establish consistency in the description of the events. It was determined that the Nurse Aides failed to ensure Resident #1's feet (with shoes on) would remain free of the bare mattress while in the sling once her lower extremities were relaxed. This occurred when Nurse Aide #1 turned to get the wheelchair Resident #1 was transferring to, at which time, neither Nurse Aide #1 nor Nurse Aide #2 were touching Resident #1. On 10/04/2025 the Staff Development Coordinator removed both the lift and lift sling used during the incident, pending a review by the Maintenance Director, assessing both the function and quality of the equipment. The Maintenance Director completed a thorough examination of all facility lifts for function per the manufacturer guidelines. This was completed on 10/4/25. The Maintenance Director completed a visual observation of all facility lift slings with no evidence of adverse findings per the manufacturer guidelines. This was completed on 10/4/25. A review of current residents in conjunction with interviews of Licensed Nurses and Nurse Aides during incident education was completed to identify residents requiring the use of a lift for transfers. This was completed on 10/4/25 by the Staff Development Coordinator. Sixteen (16) residents out of ninety two (92) were noted to be transferred via lift. The Care Plans were checked by the MDS Coordinator on 10/9/25. Updates were made as needed. However, the intent of this plan is to ensure all residents that have a lift transfer are safe. We understand that other residents with acute issues may require a lift transfer from time to time. Risk Management reports from 7/1/25 to 10/5/25 were reviewed to confirm no other incidents involving a mechanical lift transfer occurred. This was completed by the interim Director of Nursing on 10/5/25. No concerns, unknown to facility management were identified. A component of the ongoing investigation of Resident #1's fall also included the review of the personnel files of both Nurse Aides performing Resident #1's lift transfer to identify any prior disciplinary action regarding lift transfers or resident care. This was completed by the Interim Director of Nursing on 10/5/25 and yielded no concerns. The review of all incidents reported by the facility to the North Carolina Department of Health and Human Services, for the entire employment period of both Nurse Aides, to confirm no historical events of a similar nature occurred was completed by the Administrator on 10/6/25 with no concerns identified. Nurse Aide #1 was hired on 2/6/24 and Nurse Aide #2 was hired on 7/16/24. A review of facility grievance logs for the entire employment period of both Nurse Aides was also completed by the Administrator on 10/6/25 to confirm no historical events of a similar nature occurred. Nurse Aide #1 was hired on 2/6/24 and Nurse Aide #2 was hired on 7/16/24. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Staff Development Coordinator has educated all Nurse Aides on the safe process based on manufacturer instructions and facility guidelines for transferring a resident via lift, to include; always having a partner is required and they must be actively assisting, appropriate lift sling selection (when the resident is placed in the center of the sling, it should extend 3 to 6 inches past their body on each side), correct positioning in sling, secure placement of sling to attachment points, confirmation lift base legs spread, resident is raised above bed, chair or applicable surface and again, confirm sling straps are secure before moving lift. This education was confirmed to be accepted and understood via successful completion of the lift competency. This education and competency was started on 10/4/25 and completed on 10/7/25. Any Nurse Aide not receiving this information and successfully completing an in-person lift competency by this date will complete before their next scheduled shift. This information will be presented in new Nurse Aide orientation by the Staff Development Orientation and will include successful completion of an in-person lift competency prior to first day of floor orientation. The facility does not utilize agency staff. Subsequently, the Staff Development Coordinator educated Licensed Nurses on the proper process (based on manufacturer instructions and facility guidelines) for transferring a resident via mechanical lift and that their observations conducted of Nurse Aides transfers requiring a mechanical lift should include validation of; two qualified staff members' active participation, appropriate lift sling selection, correct positioning in sling, secure placement of sling to attachment points, confirmation lift base legs spread, resident is raised above bed, chair or applicable surface and again, confirm sling straps are secure. This education was initiated on 10/4/25 and completed by 10/7/25. On 10/14/25 The Staff Development Coordinator started a second round of training for the Licensed Nurses. This training will be completed by 10/16/25. Any Licensed Nurse not receiving this education by this date will receive education via phone call by the Staff Development Coordinator prior to their next scheduled shift. This information will be presented in new Licensed Nurse orientation by the Staff Development Coordinator. The facility does not utilize agency staff. All Licensed Nurses will receive lift competency training, which is, the safe process based on manufacturer instructions and facility guidelines for transferring a resident via lift, to include; always having a partner is required and they must be actively assisting, appropriate lift sling selection (when the resident is placed in the center of the sling, it should extend 3 to 6 inches past their body on each side), correct positioning in sling, secure placement of sling to attachment points, confirmation lift base legs spread, resident is raised above bed, chair or applicable surface and again, confirm sling straps are secure before moving lift demonstrating they are qualified to perform lift transfers. This was done by the Staff Development Coordinator. The competency training includes the use of a lift, 2 nurse aides and/or the Staff Development Coordinator as the second person (if needed), sling, and Manikin brand medical model. This was initiated on 10/17/25 and all Licensed Nurses will complete the training on or before their next scheduled shift. All Nurse Aides have been train[TRUNCATED]

Based on record review, observations, resident and staff interviews, the facility failed to post cautionary and safety signage outside residents' rooms that indicated the use of oxygen for 5 of 5 residents reviewed for respiratory care (Resident #14, Resident #74, Resident #28, Resident #7 and Resident #51). The findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, and acute respiratory failure with hypoxia (a condition in which there is an inadequate supply of oxygen to the body's tissues). A review of Resident #14's physician orders indicated an order dated 4/25/25 for oxygen to be administered continuously via nasal cannula at 3 liters per minute every shift. The quarterly Minimum Data Set assessment dated [DATE] Resident #14 was cognitively intact and received oxygen therapy while a resident at the facility. An observation on 5/27/25 at 10:17 AM revealed Resident #14 sitting in her wheelchair by her bed with oxygen being administered by an oxygen concentrator. There was no signage posted outside Resident #14's room indicating supplemental oxygen was in use. An observation of Resident #14 on 5/28/25 at 12:13 PM revealed her sitting up in her recliner while eating her lunch meal. Resident #14 received oxygen via nasal cannula which was connected to an oxygen concentrator. There was no cautionary or safety signage posted outside her room indicating supplemental oxygen was in use. An interview with Nurse #2 on 5/29/25 at 10:52 AM revealed Resident #14 had always used oxygen, but she was not aware of any oxygen use signage that the facility used for residents receiving supplemental oxygen. An interview with the Director of Nursing (DON) on 5/29/25 at 11:18 AM revealed the facility didn't put oxygen signage by the door of each resident receiving oxygen, and they hadn't done this in years. The DON stated that she would have to look for the reason why they had not been using them, and that she would need to pull the facility's policy on oxygen use. A follow-up interview with the DON on 5/29/25 at 12:00 PM revealed she reviewed the facility's policy which stated that because the facility was located on a smoke-free campus, they only needed to place signage at major entry points of the facility, and that this was what they had been doing. An interview with the Administrator on 5/29/25 at 1:21 PM revealed that they had received conflicting information regarding putting up oxygen signage and whether it was required only at entry points or on each resident room door. The Administrator stated that they would change the facility's policy and put the oxygen signs up in each resident room after he reviewed the current federal guidelines. 2. Resident #74 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease. She was readmitted to the facility on [DATE] for acute respiratory failure with hypoxia (a condition in which there is an inadequate supply of oxygen to the body's tissues), and pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot). The admission Minimum Data Set assessment dated [DATE] indicated Resident #74 was cognitively intact, but she did not receive oxygen therapy while a resident at the facility. A review of Resident #74's physician orders indicated an order dated 5/28/25 for oxygen to be administered at 2 liters per minute as needed via nasal cannula to maintain oxygen saturation above 90%. An observation and interview with Resident #74 on 5/27/25 at 11:02 AM revealed she only started receiving oxygen when she was at the hospital where she had a blood clot in her lungs. Resident #74 was observed receiving oxygen via nasal cannula which was connected to an oxygen concentrator and was running at 2 liters per minute. There was no oxygen in use signage visible outside her room by the door. An observation of Resident #74 on 5/28/25 at 12:11 PM revealed her sitting up in her wheelchair while being assisted by a staff member with her lunch tray set-up. Resident #74 received oxygen via nasal cannula which was connected to an oxygen tank at the back of her wheelchair. There was no cautionary or safety signage posted outside her room indicating supplemental oxygen was in use. An interview with Nurse #2 on 5/29/25 at 10:52 AM revealed Resident #74 only started using oxygen after she got back from the hospital wherein she had blood clots in her lungs. Nurse #2 stated that she was not aware of any oxygen use signage that the facility used for residents receiving supplemental oxygen. An interview with the Director of Nursing (DON) on 5/29/25 at 11:18 AM revealed the facility didn't put oxygen signage by the door of each resident receiving oxygen, and they hadn't done this in years. The DON stated that she would have to look for the reason why they had not been using them, and that she would need to pull the facility's policy on oxygen use. A follow-up interview with the DON on 5/29/25 at 12:00 PM revealed she reviewed the facility's policy which stated that because the facility was located on a smoke-free campus, they only needed to place signage at major entry points of the facility, and that this was what they had been doing. An interview with the Administrator on 5/29/25 at 1:21 PM revealed that they had received conflicting information regarding putting up oxygen signage and whether it was required only at entry points or on each resident room door. The Administrator stated that they would change the facility's policy and put the oxygen signs up in each resident room after he reviewed the current federal guidelines. 51464 3. Resident #28 was admitted to the facility on [DATE] with diagnoses that included pneumonia, heart failure and acute kidney failure. A review of Resident #28's physician orders revealed an order dated 5/15/25 for oxygen to be administered continuously every day and night shift via nasal cannula at 2-3 liters per minute to keep oxygen saturation greater than 90%. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 was severely cognitively impaired and was coded for oxygen use. An observation on 5/27/25 at 10:19 AM revealed Resident #28 sitting in her wheelchair by her bed with oxygen being administered via nasal cannula by an oxygen concentrator. There was no cautionary or safety signage posted outside her room indicating supplemental oxygen was in use. An observation on 5/28/25 at 8:34 AM revealed Resident #28 sitting in her wheelchair by her bed with oxygen being administered via nasal cannula by an oxygen concentrator. There was no cautionary or safety signage posted outside her room indicating supplemental oxygen was in use. During an interview with Nurse #3 on 5/29/25 at 2:12 PM it was revealed nursing staff were responsible for placing oxygen signage on the resident's door upon admission or if oxygen was a new order. She did not know why Resident #28 did not have signage on her door. An interview on 5/29/25 at 11:18 AM with the Director of Nursing (DON) revealed the facility did not put signage on the individual doors of residents receiving oxygen. She indicated she would look up the facility policy on oxygen signage use. During a follow-up interview with the DON on 5/29/25 at 12:00 PM she revealed the facility's policy stated that because the facility was a smoke-free campus oxygen signage only needed to be placed at the major entry points of the facility. An interview with the Administrator on 5/29/25 at 1:21 PM revealed he had received conflicting information regarding oxygen signage and whether it was required only at entry points or on the door of each resident receiving oxygen. The Administrator indicated they would amend their policy and place oxygen signage on the door of each resident receiving oxygen and educate staff on the amended policy. 37014 4. Resident #7 was readmitted to the facility on [DATE] with diagnoses that included respiratory failure and chronic obstructive pulmonary disease (COPD, difficulty breathing). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had intact cognition and received oxygen therapy while a resident at the facility. A physician's order dated 05/12/25 for Resident #7 revealed she was to receive continuous oxygen administered via nasal canula at 2 liters per minute (LPM) every shift. An observation on 05/27/25 at 2:08 PM revealed Resident #7 lying in bed receiving supplemental oxygen via nasal cannula with the flow rate on the oxygen concentrator set at 2 LPM. There was no cautionary signage posted on the door, doorframe or in Resident #7's room to indicate oxygen was in use. A subsequent observation conducted on 05/28/25 at 3:43 PM revealed Resident #7 lying in bed receiving supplemental oxygen via nasal cannula with the oxygen concentrator set at 2 LPM. There was no cautionary signage posted on the door or doorframe of Resident #7's room to indicate oxygen was in use. During an interview on 05/29/25 at 10:11 AM, Nurse #4 confirmed Resident #7 received continuous oxygen. Nurse #4 stated the facility did not use oxygen cautionary signage for residents receiving supplemental oxygen. During an interview on 05/29/25 at 11:18 AM, the Director of Nursing (DON) revealed the facility didn't put oxygen cautionary signage on or by the room doors of residents receiving supplemental oxygen and hadn't done so in years. The DON stated she wasn't sure why the facility did not use oxygen cautionary signage and would check the facility's policy for oxygen use. During a follow-up interview on 05/29/25 at 12:00 PM, the DON stated the facility's policy for oxygen use stated that because the facility was a smoke-free campus, they only needed to place cautionary signage at the major entry points of the facility which was what they had been doing. During an interview on 05/29/25 at 1:21 PM, the Administrator stated they had received conflicting information regarding oxygen cautionary signage and whether it was required only at entry points to the facility or on the room doors of the residents receiving supplemental oxygen. The Administrator state they would change the facility's policy to reflect placing oxygen signage on the room doors of residents receiving supplemental oxygen and would educate staff on the policy change. 5. Resident #51 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, emphysema (lung condition that causes shortness of breath) and chronic obstructive pulmonary disease (COPD, difficulty breathing). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had intact cognition and received oxygen therapy while a resident at the facility. A physician's order dated 03/12/25 for Resident #51 revealed he was to receive continuous oxygen administered via nasal canula at 2 liters per minute (LPM) every shift. During an observation and interview on 05/27/25 at 10:26 AM, Resident #51 was sitting up in bed receiving supplemental oxygen via nasal cannula connected to an oxygen concentrator set at 2 LPM. Resident #51 revealed he had received supplemental oxygen at 2 LPM for quite some time, which helped him with his breathing. There was no cautionary signage posted on the door or doorframe of Resident #51's room to indicate oxygen was in use. An observation conducted on 05/28/25 at 3:52 revealed Resident #51 sitting in his wheelchair receiving supplemental oxygen via nasal cannula that was connected to a portable, oxygen cylinder fastened to the back of his wheelchair. There was no cautionary signage posted on the door or doorframe of Resident #51's room to indicate oxygen was in use. An observation conducted on 05/29/25 at 10:58 AM revealed Resident #51 lying in bed with the head of the bed slightly elevated and sleeping soundly. He was receiving supplemental oxygen via nasal cannula connected to an oxygen concentrator set at 2 LPM. There was no cautionary signage posted on the door or doorframe of Resident #51's room to indicate oxygen was in use. During an interview on 05/29/25 at 11:18 AM, the Director of Nursing (DON) revealed the facility didn't put oxygen cautionary signage on or by the room doors of residents receiving supplemental oxygen and hadn't done so in years. The DON stated she wasn't sure why the facility did not use oxygen cautionary signage and would check the facility's policy for oxygen use. During a follow-up interview on 05/29/25 at 12:00 PM, the DON stated the facility's policy for oxygen use stated that because the facility was a smoke-free campus, they only needed to place cautionary signage at the major entry points of the facility which was what they had been doing. During an interview on 05/29/25 at 1:21 PM, the Administrator stated they had received conflicting information regarding oxygen cautionary signage and whether it was required only at entry points to the facility or on the room doors of the residents receiving supplemental oxygen. The Administrator state they would change the facility's policy to reflect placing oxygen signage on the room doors of residents receiving supplemental oxygen and would educate staff on the policy change.

Based on observation and staff interviews the facility failed to discard food with signs of spoilage in 1 of 1 walk-in cooler and date open food items and food ready for use in 1 of 1 walk-in cooler. This practice had the potential to affect food served to residents. The findings included: An observation of the walk-in cooler with the Dietary Manager on 5/27/25 at 9:12 AM revealed the following: a. An opened 32-ounce container of sour cream with no open date. b. An undated egg flat containing 17 eggs. Two of the eggs were cracked on top with shiny clear material noted around the cracks. An interview on 5/29/25 at 1:48 PM with the Dietary Manager revealed the facility's policy stated to put a date on any food item when it was opened, and that any spoiled food should be discarded immediately. She indicated she and the cook were responsible for checking dates on items in the coolers and freezer daily. The Dietary Manager revealed the sour cream container and egg flat should have had an open date, and the broken eggs should have been thrown out. An interview on 5/30/25 at 12:05 PM with the Administrator revealed the Dietary Manager and cook were responsible for labeling and dating items in the kitchen. He expected all food items to be labeled, dated and for the dietary staff to check the coolers and discard any food items that were undated or had visible signs of spoilage.

Based on record reviews and staff interviews, the facility failed to ensure an as needed (PRN) psychotropic medication, Lorazepam (medication used to relieve anxiety), had a stop date of 14 days for 1 or 5 residents (Resident #7) reviewed for unnecessary medications. The findings included: Resident #7 was readmitted to the facility on [DATE] with diagnoses that included anxiety and depression. A physician's order entered by Nurse #1 on 05/04/25 at 4:11 PM for Resident #7 read, Lorazepam 0.5 milligrams (mg) every 12 hours as needed (PRN) for anxiety. There was no stop date. Resident #7's quarterly Minimum Data Set, dated dated dated [DATE] revealed she was cognitively intact, displayed no behaviors or rejection of care and did not receive antianxiety medication. Review of Resident #7's May 2025 medication administration record (MAR) revealed the Lorazepam 0.5 mg every 12 hours PRN for anxiety remained an active order. There were no doses administered. During an interview on 05/29/25 at 2:34 PM, the Director of Nursing (DON) revealed recently, most of their providers had started entering their own orders and weren't always good about putting stop dates for medications when indicated but they did have standing orders that a medication could be discontinued after 60 days if not used. The DON explained Resident #7's order for PRN Lorazepam was verified with the on-call provider upon her return from the hospital on 05/04/25 and the order should have indicated a stop date of 14-days. The DON stated she was confident that the Consulting Pharmacist would have caught that Resident #7's physician order for PRN Lorazepam did not have a stop date when he conducted his monthly medication review for May 2025. A phone attempt for an interview with Nurse #1 on 05/30/25 at 9:10 AM was unsuccessful. During an interview on 5/30/25 at 12:03 PM, the Administrator stated Resident #7's physician order for PRN Lorazepam should have had a stop date of 14 days. He stated it would have been an opportunity for the admitting nurse to have questioned the provider when orders were being verified.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of hospice care, and PASRR for 3 of 4 residents (Resident #25, Resident #31, and Resident #36) whose MDS were reviewed. The findings included: 1. Resident #25 was admitted to the facility on [DATE] with diabetes mellitus. A Hospice Initial Certification dated 2/3/25 indicated Resident #25 was certified as eligible for hospice care based on her diagnosis and current condition, and that she was expected to have a limited life expectancy of 6 months of less if the terminal illness ran its course. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 did not receive hospice care while a resident at the facility. An interview with the MDS Coordinator on 5/29/25 at 8:38 AM revealed Resident #25 was on hospice care, and that she completed Resident #25's quarterly MDS dated [DATE]. The MDS Coordinator stated she was not sure how she missed hospice care on Resident #25's MDS. She stated that it was an oversight and that Resident #25's quarterly MDS should have reflected that she received hospice care. An interview with the Administrator on 5/30/25 at 12:03 PM revealed the MDS should have been coded correctly. 37014 2. Resident #31 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder-depressive type, bipolar disorder and Post-Traumatic Stress Disorder (PTSD). A PASRR Level II determination notification letter dated 01/02/25 revealed Resident #31 had a Level II PASRR with no expiration date. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. During an interview on 05/29/25 at 8:38 AM, the MDS Coordinator confirmed Resident #31 had a Level II PASRR and the MDS assessment dated [DATE] was completed by another MDS Coordinator who was no longer employed. The MDS coordinator stated was not sure how it was missed and the MDS assessment should have reflected Resident #31 had a Level II PASRR. An interview with the Administrator on 05/30/25 at 12:03 PM revealed he expected MDS assessments to be coded correctly. 3. Resident #36 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, delusional disorder, anxiety disorder, and major depressive disorder. A PASRR Level II determination notification letter dated 07/25/24 revealed Resident #36 had a Level II PASRR with no expiration date. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. During an interview on 05/29/25 at 8:38 AM, the MDS Coordinator confirmed Resident #36 had a Level II PASRR and the MDS assessment dated [DATE] was completed by another MDS Coordinator who was no longer employed. The MDS coordinator stated was not sure how it was missed and the MDS assessment should have reflected Resident #36 had a Level II PASRR. An interview with the Administrator on 05/30/25 at 12:03 PM revealed he expected MDS assessments to be coded correctly.

Based on observations and staff interviews the facility failed to remove expired produce from the walk-in refrigerator. The facility also failed to store boxes of food in the walk-in freezer off the floor. This practice had the potential to affect food served to residents. Findings included: a. On [DATE] at 8:43 AM an observation with the Dietary Manager (DM) in the walk-in refrigerator found 2 plastic bags of bell peppers that contained individual peppers with splotchy brown/black spots and were fuzzy in appearance. Other expired produce included a bag of whole lettuce that was brown in appearance and contained off colored liquid in the bottom of the bag. The lettuce had a use by date of [DATE] labeled on the bag. Additionally, the walk-in refrigerator contained 2 boxes of grapes located on the second shelf that were brown in appearance and mushy when touched. The DM immediately removed the expired produce. The DM stated during the observation that the expired produced should have been removed prior. She said the dietary staff who put up stock and the cooks checked the refrigerator for expired food, and the produce was overlooked. b. On [DATE] at 8:49 AM an observation of the walk-in freezer with the DM found 2 boxes of frozen food stored on the floor of walk-in freezer. The DM immediately placed the boxes on a shelf. The DM stated during the observation that the food boxes of food were overlooked when the stock was being stored on the last delivery day (Friday). The Administrator was interviewed on [DATE] at 1:27 PM. He stated the produce in the walk-in refrigerator should have been identified as not good quality for production and disposed of. The Administrator said the boxes of food stored on the floor of the walk-in freezer should have not been left on the floor and stored on a shelf.

Based on record review, observations and interviews with resident representative, staff, Nurse Practitioner, and Urology Physician Assistant (PA), the facility failed to prevent urinary catheter bags from touching the floor to reduce the risk of infection for 2 of 3 residents (Resident #69 and Resident #51) reviewed for urinary catheters. In addition, the facility failed to obtain physician orders to flush a suprapubic catheter as recommended by the Urology PA for Resident #51. The findings included: 1. Resident #69 was readmitted to the facility on [DATE] with diagnoses that included urinary retention, obstructive uropathy (disorder of the urinary tract that occurs due to obstructed urinary flow), and benign prostatic hyperplasia (BPH - age-associated prostate gland enlargement that can cause urination difficulty). The admission Minimum Data Set assessment dated [DATE] indicated Resident #69 was moderately cognitively impaired, had no rejection of care behaviors, and had an indwelling catheter. Resident #69's care plan last revised on 4/11/24 indicated Resident #69 had an indwelling urinary catheter related to urinary retention, obstructive uropathy, and BPH. Interventions included to position the catheter bag and tubing below the level of the bladder. An observation was made of Resident #69 on 4/29/24 at 8:36 AM while he was lying in bed in his room. Resident #69 had an indwelling catheter connected to a catheter bag with the bottom of the catheter bag touching the floor while it was hooked to his bed. Another observation of Resident #69 on 4/30/24 at 2:55 PM revealed him coming out of his room while propelling his wheelchair into the hallway. Resident #69's catheter bag was touching the floor. During the observation, the Assistant Director of Nursing (ADON) was alerted on 2:57 PM about Resident #69's catheter bag touching the floor. The ADON stopped Resident #69 and requested to take him back into his room to check on how to reposition his catheter bag. The ADON repositioned the catheter bag in the front bar of Resident #69's wheelchair but she was unable to keep his tubing off the floor. The ADON stated that Resident #69's wheelchair was too low, and it was hard to find a spot to clip his catheter bag to and prevent it from touching the floor. By this time, Resident #69 requested to go back to bed, so he was assisted by staff to bed. An interview with Nurse Aide (NA) #1 on 4/30/24 at 3:12 PM revealed she had trouble with positioning Resident #69's catheter bag in his wheelchair and she usually clipped it on the crossbar under his seat, but the clip won't stay on or sometimes won't clip on. An interview with Nurse #2 on 4/30/24 at 3:17 PM revealed she had assisted NA #2 in getting Resident #69 up from bed and into his wheelchair, but she did not notice his catheter bag touching the floor. Nurse #2 stated that Resident #69's catheter bag should have been positioned to where it was not touching the floor. An interview with NA #2 on 4/30/24 at 3:19 PM revealed she clipped Resident #69's catheter bag onto the crossbar under the seat but she did not notice that his catheter bag was touching the floor. A follow-up interview with the ADON on 5/1/24 at 3:05 PM revealed she had figured out that Resident #69's catheter bag should be positioned at the bar on the back of his wheelchair and not the crossbar because it was low. She stated this position would keep the catheter bag and the catheter tubing off the floor. An interview with the Director of Nursing (DON) on 5/2/24 at 12:28 PM revealed that catheter bags should not be touching the floor. The DON stated she had only seen Resident #69's clamp at the bottom of the catheter bag touching the floor but the staff should try to find a place to put his bag to where it would not touch the floor. 2. Resident #51 was admitted to the facility on [DATE] with diagnoses that included neuromuscular dysfunction of bladder and benign prostatic hyperplasia (BPH). Resident #51's care plan revised on 4/16/24 indicated Resident #51 had a suprapubic catheter related to neurogenic bladder and BPH. Interventions included to position the catheter bag and tubing below the level of the bladder. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #51 was severely cognitively impaired, did not exhibit rejection of care behaviors and had an indwelling catheter. a. An observation was made on 4/29/24 at 10:00 AM of Resident #51 while he was sitting in his wheelchair in his room. Resident #51 had a urinary catheter with the urinary catheter bag lying flat on the floor beside his wheelchair foot rests. Another observation of Resident #51 on 4/30/24 at 8:35 AM revealed his urinary catheter bag touching the floor while he was sitting in his wheelchair in the dining room during breakfast. The bottom part of the catheter bag was touching the floor. At 8:39 AM, Resident #51 was observed being pushed out of the dining room, out in the hallway and towards his room by Nurse #1. Resident #51's catheter bag was noted to be touching the floor during this observation. An interview with Nurse #1 on 4/30/24 at 8:43 AM revealed that she noticed Resident #51's catheter bag touching the floor, but she couldn't do anything about it while he was in the dining room. Nurse #1 stated she wanted to place Resident #51 back into his room and check how she could reposition Resident #51's catheter bag. While in Resident #51's room, Nurse #1 was observed positioning Resident #51's catheter bag on the upper bar of his wheelchair in the front. Nurse #1 explained that it was previously positioned on the lower bar which was too low to keep it from touching the floor. Nurse #1 stated she did not know who had taken Resident #51 into the dining room that morning. An interview with Nurse Aide (NA) #1 on 4/30/24 at 9:02 AM revealed that she had gotten up Resident #51 into his wheelchair and had placed him in the dining room for breakfast. NA #1 stated that she did not notice that Resident #51's catheter bag was touching the floor when she pushed him into the dining room. NA #1 also shared that she had been having issues with Resident #51's catheter because he had a really long tubing, and it was hard to find a good position to clip his catheter bag to in his wheelchair. NA #1 stated that the top bar was wider, so she didn't place it on the top bar, and she clipped the catheter bag onto the bottom bar on Resident #51's wheelchair. An interview with the Assistant Director of Nursing (ADON) on 5/1/24 at 3:05 PM revealed that she had checked Resident #51's wheelchair and she figured out that the best position to place it to keep the catheter bag off the floor was the bar behind the wheelchair and not the bars in the front. An interview with the Director of Nursing (DON) on 5/2/24 at 12:28 PM revealed that catheter bags should not be touching the floor. The DON stated that Resident #51 moved around a lot in his wheelchair, but staff should figure out how to properly position his catheter bag during the day to keep it from touching the floor. b. A phone interview with Resident #51's Responsible Party (RP) on 4/29/24 at 11:04 AM revealed she was concerned about Resident #51's urinary catheter having to be changed more often than once a month because it was leaking. The RP stated that the Urologist had told the staff that Resident #51's catheter needed to be flushed daily to prevent it from clogging up. A review of Resident #51's physician orders for April 2024 indicated no orders to flush Resident #51's suprapubic catheter. Further review of Resident #51's medical record indicated an e-mail note from the Urology Physician Assistant (PA) addressed to Resident #51's RP and dated 4/1/24. The note included the following information: For leakage around the suprapubic tube or through the urethra, I would suggest irrigating and aspirating his suprapubic tube with 60 cubic centimeters (cc) of sterile fluid and a catheter tip syringe to see if there was any sediment or blockages that could be cleared which might be the reason why he was leaking around the catheter. The note further indicated: I attempted to reach the facility on 3/27/24 to relay this message. I left a message on the 100 hall nurses' voicemail with no return call back. I just wanted to forward this message to you. The note was initialed by the Nurse Practitioner (NP) on 4/29/24. An emergency room (ER) Report dated 4/20/24 indicated Resident #51 was sent to the ER due to difficulty removing his suprapubic catheter. The note indicated: Multiple attempts were made by staff to remove suprapubic catheter; port was already cut but still unable to remove it. Discussed with Urology and felt slightly uncomfortable pulling any harder than they were already pulling. Recommended CT (computed tomography) to make sure there was no stone or mechanical obstruction. Urology assistance with replacement appreciated. Due to resident's urinalysis (UA) and urology recommendations, will give dose of antibiotics, culture, and send home with antibiotics due to sediment and UA results. The UA results indicated the urine was cloudy, urine pH of 9 (normal value between 4.5 and 8), urine protein greater than 500 (normal value less than 150), urine nitrite negative, urine leukocyte esterase moderate, urine white blood cells 44/hpf (high power field) (normal value 10/hpf or less), bacteria rare, triple phosphate crystal moderate, and budding yeast rare. The CT of pelvis without contrast result indicated: Suprapubic catheter in place. There was granulation tissue along the tract in the soft tissues which was likely within normal limits. The catheter was otherwise normal in appearance. Bladder wall thickening with perivesicular (outermost layer consisting of fat, fibrous tissue and blood vessels) no soft tissue stranding. Findings would be suspicious for underlying cystitis (inflammation of the bladder). Recommend clinical correlation with recent urinalysis. A progress note by the NP dated 4/22/24 indicated Resident #51 was transferred to the emergency department (ED) for an acute visit status post suprapubic catheter obstruction. Here at the facility, the nurses were unable to take out the suprapubic catheter for replacement. The note further indicated that the NP spoke with Resident #51's RP on 4/22/24. The RP was present throughout Resident #51's admission in the ED. He was evaluated by Urology according to the RP and was diagnosed with a urinary tract infection and was started on (antibiotics). Recommendations were to flush the catheter at least once a day to avoid any obstructions or complications. A phone interview with the NP on 5/2/24 at 9:00 AM revealed that it had been an ongoing process with Resident #51's suprapubic catheter leaking, and the staff had been having to replace it often. The NP stated that she knew Resident #51 was being seen by Urology and that he was also seen by a Urologist in the ER. The NP stated that she wanted for the staff to flush Resident #51's catheter because this was the recommendation from the Urology PA from the e-mail note dated 4/1/24. The NP confirmed that she saw this note on 4/29/24 when she initialed it but Resident #51 was also seen in theER on [DATE] by a Urologist. The NP stated that the best source of information regarding Resident #51 was his RP because she was on top of everything that happened with him. The NP stated that Resident #51's RP told her that the Urologist in the ER recommended for them to continue to flush his catheter, but the NP stated she was not sure if she gave an order for this. The NP stated she had concerns about flushing the catheter all the time, but his catheter had a lot of sediments that could cause obstruction so unfortunately, Resident #51's catheter had to be flushed to prevent it from being obstructed. The NP further stated that flushing would increase the risk of infection, but he was colonized so his UA would always show infection. The NP added that she knew that they placed Resident #51 on antibiotics at the ER because they had done a lot of manipulation with his catheter. The NP also shared that flushing Resident #51's catheter would help avoid having obstruction and they should follow the recommendations from the Urologist. She said that she didn't remember if she gave an order to flush the catheter, and she was not sure if she talked to any of the nurses about it. A phone interview with the Urology PA on 5/2/24 at 10:59 AM revealed he received a message on 3/27/24 via patient portal (healthcare-related online application that allows patients to interact and communicate with their healthcare providers) from Resident #51's RP requesting for assistance because Resident #51 had been having difficulty with his catheter leaking all the time. The Urology PA stated he relayed his recommendations which included to try irrigating Resident #51's catheter through his medical assistant who tried to call the facility on 3/27/24. When his medical assistant could not get anyone from the facility to respond, she e-mailed the recommendation to Resident #51's RP via patient portal on 4/1/24. He also stated that he saw the ER notes from Resident #51's visit on 4/20/24 due to leaking/clogged suprapubic catheter but there was no indication that he had significant pain that would suggest true obstruction, and they were able to change the catheter in the ER with no problems. The Urology PA explained that if there was obstruction, Resident #51 would have presented with severe lower abdominal pain and the notes did not indicate that a bladder scan was done to see how much urine was retained in the bladder. The Urology PA further stated that it was difficult to say whether the ER visit could have been avoided if the staff had been flushing his catheter because the catheter could still get blocked because of the sediments even though it was being flushed. A follow-up interview with Resident #51's RP on 5/2/24 at 10:43 AM revealed she had called Urology a few times for issues regarding Resident #51's catheter and they had been responsive to her, but she didn't realize that they had responded through the patient portal. The RP stated that as soon as she saw it, she gave the e-mail note to Nurse #3, but she couldn't remember the date she gave it to her. When the Urologist saw Resident #51 in the ER, they did a CT scan but did not find an obstruction and the Urologist recommended that it should be flushed everyday with sterile water. The RP shared that the Urologist said flushing the catheter would keep the sediment down which could prevent the urine from flowing properly. A phone interview with Nurse #3 on 5/2/24 at 12:17 PM revealed she received an e-mail note from Resident #51's RP but she couldn't remember the date she received it. Nurse #3 stated the note indicated the need to flush Resident #51's catheter and she placed the note in the Medical Records box to be scanned into Resident #51's electronic medical record. Nurse #3 stated she didn't notify the NP about the note and did not know if she let the Director of Nursing, or the Supervisor know about it. She stated that because it did not look like an order, she thought that they were already aware of it and that it was just proof of the RP talking to the Urologist about his recommendations. An interview with the Director of Nursing (DON) on 5/2/24 at 12:28 PM revealed she had not seen the e-mail note from the Urology PA before, but she said that she would think that the NP would reach out to Urology to discuss their recommendations and follow up with them before she initiated any orders. The DON stated that if this was something that Resident #51's RP wanted, the NP probably had already talked to her about the risks and complications of flushing Resident #51's catheter, and that there would be no problem with getting an order for flushing his catheter.

Based on record review and staff interviews, the facility failed to include in the resident's medical record documentation of education provided regarding the benefits and potential side effects of receiving the influenza vaccine or consent forms indicating the acceptance or refusal of the influenza vaccine for 5 of 5 sampled residents (Residents #3, #15, #23 #27, and #68). Findings included: The facility's policy titled Influenza Vaccination, with no effective or revised date, read in part, It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from influenza by offering our residents, staff members and volunteer workers annual immunization against influenza .2) Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized, or refuses the vaccine .7) Individuals receiving the influenza vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. The completed, signed and dated record will be filed in the individual's medical record .9) The resident's medical record will include documentation that the resident and/or their representative was provided education regarding the benefits and potential side effects of the immunization and that the resident received or did not receive the immunization due to contraindication or refusal. 1. Resident #3 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #3 with intact cognition. Review of Resident #3's immunization status revealed he refused the influenza vaccination with no date of the refusal documented. Review of Resident #3's medical record revealed no documentation of consent to indicate he received education on the influenza vaccine and/or was offered, received or declined the influenza vaccine during the influenza season of October 2022 to March 2023. During a joint interview with the Director of Nursing (DON) on 01/12/23 at 10:35 AM, the Wound Nurse confirmed she provided residents and/or their representatives with education on the influenza vaccine and obtained consents prior to administering the influenza vaccination unless they had previously signed a consent indicating they wanted the influenza vaccine every year during their stay at the facility. The Wound Nurse confirmed Resident #3's medical record did not contain documentation of consents to indicate he was educated on the influenza vaccine and either received or declined the influenza vaccine during the influenza season October 2022 to March 2023. The Wound Nurse explained she kept all resident consent forms filed in a binder located in her office and did not realize the documentation needed to be maintained in the resident's medical record as well. She reviewed Resident #3's influenza consent form and stated consent was refused by Resident #3's representative on 12/22/22. During joint interviews with the Administrator and Regional Director of Operations (RDO) on 12/12/23 at 11:54 AM and 2:06 PM, the RDO stated she was aware the facility could not have one signed consent from a resident or their representative for the influenza vaccine that covered every year throughout their stay. She explained education and consent should be obtained each time the influenza vaccination was offered and the documentation maintained in the resident's medical record. The RDO stated she was not sure when or how the process had changed and contributed it to the change in administration staff over the years, such as the Administrator and/or Director of Nursing. 2. Resident #15 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #15 with intact cognition. Review of Resident #15's immunization status revealed she received the influenza vaccine on 10/06/22. Review of Resident #15's medical record revealed no documentation of consents to indicate she was educated on the influenza vaccine and/or was offered, received or declined the influenza vaccine since 10/16/17. During a joint interview with the Director of Nursing (DON) on 01/12/23 at 10:35 AM, the Wound Nurse confirmed she provided residents and/or their representatives with education on the influenza vaccine and obtained consents prior to administering the influenza vaccination unless they had previously signed a consent indicating they wanted the influenza vaccine every year during their stay at the facility. The Wound Nurse confirmed Resident #15's medical record did not contain documentation of consents to indicate she was educated on the influenza vaccine and either received or declined the influenza vaccine during the influenza season October 2022 to March 2023. The Wound Nurse explained she kept all resident consent forms filed in a binder located in her office and did not realize the documentation needed to be maintained in the resident's medical record as well. She reviewed Resident #15's influenza consent form and explained consent was obtained for her to receive the influenza vaccine on 10/16/17 and every year thereafter. The Wound Nurse stated she was unaware education and consents should be obtained each time the influenza vaccination was offered and had just followed the process she was instructed. During joint interviews with the Administrator and Regional Director of Operations (RDO) on 12/12/23 at 11:54 AM and 2:06 PM, the RDO stated she was aware the facility could not have one signed consent from a resident or their representative for the influenza vaccine that covered every year throughout their stay. She explained education and consent should be obtained each time the influenza vaccination was offered and the documentation maintained in the resident's medical record. The RDO stated she was not sure when or how the process had changed and contributed it to the change in administration staff over the years, such as the Administrator and/or Director of Nursing. 3. Resident #23 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #23 with moderate impairment in cognition. Review of Resident #23's immunization status revealed she refused the influenza vaccination with no date of the refusal documented. Review of Resident #23's medical record revealed no documentation of consent to indicate she or her representative received education on the influenza vaccine and/or was offered, received or declined the influenza vaccine during the influenza season of October 2022 to March 2023. During a joint interview with the Director of Nursing (DON) on 01/12/23 at 10:35 AM, the Wound Nurse confirmed she provided residents and/or their representatives with education on the influenza vaccine and obtained consents prior to administering the influenza vaccination unless they had previously signed a consent indicating they wanted the influenza vaccine every year during their stay at the facility. The Wound Nurse confirmed Resident #23's medical record did not contain documentation of consents to indicate she or her representative were educated on the influenza vaccine and either received or declined the influenza vaccine during the influenza season October 2022 to March 2023. The Wound Nurse explained she kept all resident consent forms filed in a binder located in her office and did not realize the documentation needed to be maintained in the resident's medical record as well. She reviewed Resident #23's influenza consent form and stated consent was refused by Resident #23's representative on 08/29/22. During joint interviews with the Administrator and Regional Director of Operations (RDO) on 12/12/23 at 11:54 AM and 2:06 PM, the RDO stated she was aware the facility could not have one signed consent from a resident or their representative for the influenza vaccine that covered every year throughout their stay. She explained education and consent should be obtained each time the influenza vaccination was offered and the documentation maintained in the resident's medical record. The RDO stated she was not sure when or how the process had changed and contributed it to the change in administration staff over the years, such as the Administrator and/or Director of Nursing. 4. Resident #27 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #27 with severe impairment in cognition. Review of Resident #27's immunization status revealed she received the influenza vaccine on 10/06/22. Review of Resident #27's medical record revealed no documentation of consents to indicate she was educated on the influenza vaccine and/or was offered, received or declined the influenza vaccine since 10/08/19. During a joint interview with the Director of Nursing (DON) on 01/12/23 at 10:35 AM, the Wound Nurse confirmed she provided residents and/or their representatives with education on the influenza vaccine and obtained consents prior to administering the influenza vaccination unless they had previously signed a consent indicating they wanted the influenza vaccine every year during their stay at the facility. The Wound Nurse confirmed Resident #27's medical record did not contain documentation of consents to indicate she was educated on the influenza vaccine and either received or declined the influenza vaccine during the influenza season October 2022 to March 2023. The Wound Nurse explained she kept all resident consent forms filed in a binder located in her office and did not realize the documentation needed to be maintained in the resident's medical record as well. She reviewed Resident #27's influenza consent form and explained consent was obtained from her representative to receive the influenza vaccine on 10/08/19 and every year thereafter. The Wound Nurse stated she was unaware education and consents should be obtained each time the influenza vaccination was offered and had just followed the process she was instructed. During joint interviews with the Administrator and Regional Director of Operations (RDO) on 12/12/23 at 11:54 AM and 2:06 PM, the RDO stated she was aware the facility could not have one signed consent from a resident or their representative for the influenza vaccine that covered every year throughout their stay. She explained education and consent should be obtained each time the influenza vaccination was offered and the documentation maintained in the resident's medical record. The RDO stated she was not sure when or how the process had changed and contributed it to the change in administration staff over the years, such as the Administrator and/or Director of Nursing. 5. Resident #68 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #68 with moderate impairment in cognition. Review of Resident #68's immunization status revealed she received the influenza vaccine on 10/05/22. Review of Resident #68's medical record revealed no documentation of consents to indicate she was educated on the influenza vaccine and/or was offered, received or declined the influenza vaccine since 09/03/21. During a joint interview with the Director of Nursing (DON) on 01/12/23 at 10:35 AM, the Wound Nurse confirmed she provided residents and/or their representatives with education on the influenza vaccine and obtained consents prior to administering the influenza vaccination unless they had previously signed a consent indicating they wanted the influenza vaccine every year during their stay at the facility. The Wound Nurse confirmed Resident #68's medical record did not contain documentation of consents to indicate she was educated on the influenza vaccine and either received or declined the influenza vaccine during the influenza season October 2022 to March 2023. The Wound Nurse explained she kept all resident consent forms filed in a binder located in her office and did not realize the documentation needed to be maintained in the resident's medical record as well. She reviewed Resident #68's influenza consent form and explained consent was obtained from her representative to receive the influenza vaccine on 09/03/21 and every year thereafter. The Wound Nurse stated she was unaware education and consents should be obtained each time the influenza vaccination was offered and had just followed the process she was instructed. During joint interviews with the Administrator and Regional Director of Operations (RDO) on 12/12/23 at 11:54 AM and 2:06 PM, the RDO stated she was aware the facility could not have one signed consent from a resident or their representative for the influenza vaccine that covered every year throughout their stay. She explained education and consent should be obtained each time the influenza vaccination was offered and the documentation maintained in the resident's medical record. The RDO stated she was not sure when or how the process had changed and contributed it to the change in administration staff over the years, such as the Administrator and/or Director of Nursing.

Based on observation, record review, resident and Wound Nurse interviews the facility failed to provide privacy by not closing the door during wound care for 1 of 1 resident (Resident #20) reviewed for wound care. The findings include: Resident #20 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was cognitively intact. On 01/10/23 9:48 AM an observation was made of the Wound Nurse performing a dressing change to Resident #20's venous ulcer which was located on the Resident's left inner shin. The Resident was sitting up in her wheelchair and the venous ulcer was visible from the open door. The Wound Nurse entered the Resident's room announcing her intentions of performing the dressing change to the venous ulcer on Resident #20 and did not provide privacy by closing the door nor did she ask the Resident if she wanted the door closed during the treatment. During the wound care procedure, the Activities Director (AD) approached the open door and proceeded to ask Resident #20 if she wanted fresh ice in her water. Also, during the wound care procedure, at least three different individuals were noted to pass by the Resident's open door and look in the Resident's room. During an interview with Resident #20 on 01/10/23 10:06 AM immediately after the wound care was performed by the Wound Nurse, the Resident stated that she would have preferred for the door to be closed during the wound care because it made her nervous for people to look at her while the procedure was being done. An interview was conducted with the Wound Nurse on 01/10/23 10:08 AM who indicated that she should have provided privacy for Resident #20 by closing the door while she conducted the wound dressing change but forgot because she was nervous. On 01/10/23 10:46 AM during an interview with the Director of Nursing she explained that the Wound Nurse should have provided privacy for Resident #20 by either closing the door to her room or the Nurse could have positioned the Resident's wheelchair so that the ulcer was not visible from the door. An interview was conducted on 01/11/23 2:34 PM with the Regional Director of Operations and the Administrator. They indicated it was their expectation that the Wound Nurse provide privacy for any resident when she performed wound care treatments on the residents.

Based on observation, record review, staff, Wound Nurse, and Nurse Practitioner interviews the facility failed to perform hand hygiene between glove changes during venous ulcer wound care for 1 of 3 residents (Resident #20) reviewed for wound care. The finding included: Review of the facility's undated Clean Dressing Change policy revealed It is the policy of this facility to provide would care in a manner to decrease potential for infection and/or cross-contamination. 7. Wash hands and put on clean gloves. 9. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 10. Remove gloves, pulling inside out over dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. A continuous observation of a venous ulcer wound care was performed on Resident #20's left inner shin by the Wound Nurse on 01/10/23 9:48 AM. The WN sanitized her hands, donned clean gloves, and brought the wound care supplies into the Resident's room and laid the supplies out on a protective barrier. The Wound Nurse proceeded to remove the old wound dressing from the Resident's left shin venous ulcer wound after having to soak the dressing with normal saline before it could be removed from the ulcer. The old dressing contained heavy brownish drainage and bright red blood. She then removed her soiled gloves and donned a new pair of gloves without sanitizing or washing her hands. The WN cleansed the venous ulcer with saline and removed her gloves and sanitized her hands before she donned a new pair of gloves to complete the treatment. During an interview with the Wound Nurse (who also served as the Infection Control Nurse) on 01/10/23 10:08 AM she acknowledged she did not sanitize or wash her hands after she removed the soiled dressing from the venous ulcer and before she donned a clean pair of gloves. The Wound Nurse explained that she did not touch anything after she removed her gloves so therefore her hands were not dirty. When asked what the facility's policy was regarding changing gloves during a wound treatment and if she performed the wound treatment according to the facility's policy, she stated she did not know what the policy was because she had only been doing the treatments for about a year. On 01/10/23 10:46 AM an interview was conducted with the Director of Nursing (DON) who explained the facility's policy was to always sanitizer your hands after you remove your gloves because your hands were always considered dirty after you remove gloves no matter what you were doing.

Based on record reviews, resident and staff interviews, the facility failed to provide residents with their preferred number of showers per week for 2 of 7 residents reviewed for choices and activities of daily living (Resident #1 and #12). Findings included: 1. Resident #1 was admitted to the facility on [DATE]. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #1 was moderately impaired for daily decision making and displayed no rejection of care. The MDS noted Resident #1 required the physical assistance of 1 staff member for bathing. During an interview on 05/03/21 at 2:57 PM Resident #1 stated he had not had a shower in 6 days. Resident #1 reported he was unaware what days he was scheduled to receive showers but stated he would like at least 2 showers each week. Review of the bathing schedule for Resident #1 revealed he was scheduled to receive showers on Tuesday, Thursday and Saturday during the hours of 6:00 AM to 6:00 PM. The bathing documentation report for April 2021 and May 2021 revealed Resident #1 received bathing assistance 5 out of 15 scheduled days on 04/01/21, 04/10/21, 04/15/21, 04/27/21, and 05/04/21. Further review revealed bathing activity did not occur for the scheduled dates of 04/03/21, 04/06/21, 04/08/21, 04/13/21, 04/17/21, 04/20/21, 04/22/21, 04/24/21, 04/29/21, and 05/01/21. During an interview on 05/06/21 at 8:50 AM, Nurse Aide (NA) #2 confirmed she was assigned to provide care to Resident #1 on 04/29/21 which included bathing assistance. NA #2 explained when there was only one NA assigned to the hall, it was difficult to get showers completed for the residents assigned and stated when she documented in the computer system bathing activity did not occur then he did not receive his scheduled shower. During an interview on 05/06/21 at 8:55 AM, NA #3 confirmed she was assigned to provide care, which included bathing assistance, to Resident #1 on 04/13/21 . NA #3 explained when she had to float between two resident halls, she wasn't able to provide bathing assistance for the residents assigned. NA #3 added when she documented in the computer system that bathing activity did not occur then Resident #1 did not receive his scheduled shower. During a telephone interview on 05/06/21 at 1:00 PM, NA #4 confirmed she was assigned to provide care, which included bathing assistance, to Resident #1 on 04/03/21, 04/17/21, and 04/24/21. NA #4 explained she tried her best to get the scheduled showers completed for residents but when there was only one NA on the hall, resident care had to be prioritized as they could not leave the hall unattended to give showers. NA #3 could not recall the specific events on 04/03/21, 04/17/21 or 04/24/21 but stated when she documented in the computer system bathing activity did not occur then Resident #1 was not provided bathing assistance. During an interview on 05/06/21 at 2:24 PM, NA #5 confirmed she was assigned to provide care to Resident #1 on 04/08/21 and 05/01/21 but could not recall why he was not provided his scheduled showers. NA #5 explained when unable to provide a resident with their scheduled shower, she reported to the oncoming shift for them to provide if able. NA #5 verified when she documented in the computer system that bathing activity did not occur then she did not provide Resident #1 with bathing assistance. Telephone attempts on 05/06/21 at 9:32 AM and 3:31 PM to speak with NA #6, who provided care to Resident #1, were unsuccessful. During a joint interview 05/06/21 at 3:57 PM, the Director of Nursing (DON) and Administrator reported they were aware of the issue with residents not receiving bathing assistance as scheduled, audits were conducted and staff education was provided related to documenting when showers were given on non-scheduled days. The DON and Administrator both added they would expect for residents to receive bathing assistance as scheduled or the NA to communicate when they were unable to provide residents with showers so that a make-up day could be arranged. 2. Resident #12 was admitted to the facility 03/22/19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #12 was cognitively intact and required assistance of 2 staff members for bathing. The care plan for activities of daily living (ADL) last updated 02/08/21 revealed Resident #12 required extensive staff assistance with showering 2 to 3 times weekly and as necessary. An interview with Resident #12 on 05/03/21 at 04:03 PM revealed he was supposed to receive a shower three times a week and had not had a shower in a week. Resident #12 stated he wanted three showers a week. An observation of Resident #12 on 05/03/21 at 04:03 PM revealed he had debris in his beard and his hair appeared greasy. Review of the bathing schedule for Resident #12 revealed he was scheduled for showers Tuesday, Thursday, and Saturday on the 06:00 AM to 06:00 PM shift. The bathing documentation for April 2021 and May 2021 revealed Resident #12 received bathing assistance 04/06/21, 04/13/21, 04/15/21, 04/17/21, and 05/04/21. Further review revealed bathing activity did not occur for the scheduled dates of 04/01/21, 04/03/21, 04/08/21, 04/10/21, 04/20/21, 04/22/21, 04/24/21, 04/27/21, and 04/29/21. An interview with Nurse Aide (NA) #3 on 05/06/21 at 11:07 AM revealed she was assigned to provide care for Resident #12, including providing bathing assistance, on 04/01/21 and 04/20/21. She explained on 04/01/21 she was by herself after 02:00 PM and did not have enough time to provide showers. NA #3 stated on 04/20/21 she was the only NA on the floor and did not have time to provide Resident #12's shower. An interview with NA #7 on 05/06/21 at 11:29 AM revealed she was assigned to provide care for Resident #12, including bathing assistance, on 04/01/21, 04/08/21, 04/22/21, and 04/29/21. NA #7 stated she did not recall specific events on 04/01/21, 04/06/21, 04/08/21, 04/13/21, 04/15/21, 04/22/21, and 04/29/21 but if stated if she did not document a shower being given then she did not provide assistance with a shower. NA #7 stated she worked the 06:00 AM to 02:00 PM shift and often did not have time to complete showers on her shift. She explained she notified her partner if she was unable to provide showers on her shift so her partner could possibly provide the shower later in their shift. An interview with NA #9 on 05/06/21 at 01:16 PM revealed she was assigned to provide care for Resident #12, including bathing assistance, on 04/27/21 and 04/29/21. NA #9 explained Resident #12 did not receive his shower on 04/27/21 because there was not enough staff. She stated on 04/29/21 she asked Resident #12 if he was ready for his shower but he did not want his shower at that time and asked her to come back at a later time. NA #9 stated she did not have time to go back later in the shift to provide Resident #12's shower. An interview with NA #10 on 05/06/21 at 02:07 PM revealed she was assigned to provide care for Resident #12, including bathing assistance, on 04/03/21 and 04/10/21. She stated while she did not specifically remember 04/03/21 and 04/10/21 but if she did not document Resident #12 received his shower then he did not receive his shower. NA #10 stated Resident #12 did not receives his showers on those days because there was not enough staff to provide all the showers. An interview with NA #8 on 05/06/21 at 02:11 PM revealed she was assigned to provide care for Resident #12, including bathing assistance, on 04/03/21 and 04/24/21. NA #8 stated she did not specifically recall providing a shower to Resident #12 on 04/03/21 and 04/24/21 but she usually gave Resident #12 his showers on his scheduled shower days. She stated she may have forgotten to document providing the showers in the computer. A joint interview with the Director of Nursing (DON) and Administrator on 05/06/21 at 03:57 PM revealed they were aware of issues with residents not receiving bathing assistance as scheduled. They stated bathing audits were being conducted and staff received education related to documenting showers if they provided showers on non-shower days. Both the DON and Administrator stated they would expect residents to receive bathing assistance as scheduled or the NA to communicate when they were unable to provide residents with a shower so a make-up day could be scheduled.

Based on record review and staff interviews, the facility failed to accurately code Minimum Data Sets (MDS) in the areas of Preadmission Screening and Resident Review (PASRR) and prognosis for 2 of 20 residents reviewed for MDS accuracy (Residents #1 and #19). Findings included: 1. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The North [NAME] Medicaid Uniform Screening Tool (NC MUST) inquiry dated 12/04/20 revealed Resident #1 had a Level II PASRR effective 11/30/20 with an expiration date of 12/30/20. A care plan initiated on 12/04/20 noted Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: consult with behavioral health services as needed, review the PASRR evaluation and implement recommendations as applicable. The admission MDS assessment dated [DATE] noted under Section A1500 for PASRR that Resident #1 had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or intellectual disability. During an interview on 05/06/21 at 1:00 PM, the MDS Nurse reported she had only been in the position since March 2021. The MDS Nurse confirmed Resident #1 had a Level II PASRR that was effective at the time of his MDS assessment dated [DATE] and Section A of the MDS was coded incorrectly. She stated a modification would be submitted to accurately reflect Resident #1's Level II PASRR status. During a joint interview with the Administrator and Director of Nursing (DON) on 05/06/21 at 3:54 PM, the Administrator explained the facility had a transition in the MDS Nurse position in December 2020 and again 2 months ago. The Administrator stated it was her expectation MDS assessments would be accurately coded. 2. Resident #19 was admitted to the facility 02/26/21 with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Hospice financial agreement, with an effective date of 02/16/21, indicated Resident #19 elected to receive Hospice services for end of life care. The admission MDS assessment dated [DATE] indicated under Section O for Special Treatments and Programs that Resident #19 received hospice care; however, under Section J1400 for Prognosis, Resident #19 was not coded as having a condition or chronic disease that might result in a life expectancy of less than 6 months. During an interview on 05/06/21 at 1:00 PM, the MDS Nurse reported she had only been in the position since March 2021. The MDS Nurse confirmed Resident #19 was admitted under hospice care on 02/16/21 and stated it was likely the previous MDS Nurse had been confused with the interpretation of the Resident Assessment Instrument (RAI) manual on how to code prognosis under Section J for MDS assessments. She confirmed the MDS assessment dated [DATE] should have been coded to reflect Resident #19 had a life expectancy of less than 6 months and verified a modification would be submitted to accurately reflect Resident #19's prognosis. During a joint interview with the Administrator and Director of Nursing (DON) on 05/06/21 at 3:54 PM, the Administrator explained the facility had a transition in the MDS Nurse position in December 2020 and again 2 months ago. The Administrator stated it was her expectation MDS assessments would be accurately coded.

Based on record review, observations, resident, and staff interviews the facility failed to provide nail care to 3 of 7 sampled residents who were dependent on staff for assistance with activities of daily living (Resident #25, #26, #53). The findings included: 1. Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #25's cognition as being moderately impaired. Resident #25 required extensive assistance from staff for the Activities of Daily (ADL) task including personal hygiene and total assistance with bathing. The facility review of the care plan on 3/1/21 identified Resident #25 had a self-care deficit related to [CONDITION(S)], CVA, and weakness with the goal to maintain the current level of functioning in dressing, eating, and bed mobility. Interventions included bathing and/or showering 2 to 3 times a week and as necessary and provide limited to extensive assistance with personal hygiene. A review of the bathing records for Resident #25 revealed a shower had been provided on 5/2/21 and 5/5/21. An observation of Resident #25 on 5/3/21 at 4:26 PM revealed the fingernails on the right hand were long with brown colored debris underneath the nail. A second observation with Nurse Aide (NA) #1 present was made on 5/6/21 at 1:50 PM and revealed the fingernails on the right hand remained long with brown colored debris underneath the nails. During an interview on 5/6/21 at 1:50 PM Resident #25 revealed the nails on the right hand were long and needed to be cut. An interview was conducted on 5/6/21 at 1:50 PM with NA #1. NA #1 revealed Resident #25 was dependent on staff to clean and clip her fingernails. NA #1 explained nail care was typically provided during the shower but could done anytime it was needed. NA #1 revealed she hadn't noticed the fingernails were long with debris underneath and stated she would now clip and clean Resident #25's nails. An interview was conducted on 5/6/21 at 1:57 PM with Nurse #1. Nurse #1 explained Resident #25 was dependent on NA staff for ADL care. Nurse #1 was not aware Resident #25's fingernails were long and dirty underneath and explained nail care was provide by NA staff during showers. An interview was conducted with Director of Nursing (DON) on 5/6/21 at 3:55 PM. The DON explained resident nail care was provided during a shower or a bed bath on scheduled bathing days. The DON revealed Resident #25 was dependent on nursing staff for nail care that should have been provided during the shower or anytime it was needed. The DON expected Resident #25's fingernails were clipped and clean underneath the nail. 2. Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly MDS dated [DATE] assessed Resident #26's cognition as being severely impaired. Resident #26 required extensive assistance from staff for the ADL task of personal hygiene and total assistance with bathing. The facility review of the care plan on 3/2/21 identified Resident #26 had an ADL self-care performance deficit related to deconditioning. The goal was for staff to anticipate and meet the needs of Resident #26 as evidence by appearing clean and appropriately groomed through the next review. Interventions for bathing and personal hygiene included extensive to total assistance be provided 2 to 3 times a week and as needed. A review of the bathing records for Resident #26 revealed a shower was provided on 5/3/21 and bed bath on 5/6/21. An observation was made on 5/5/21 at 11:52 AM. Resident #26 was observed to have long fingernails on both hands with brown and black colored debris underneath the nails. A second observation with NA #1 present was made on 5/6/21 at 1:50 PM and revealed Resident #26's nails remained long with black and brown colored debris underneath the nails. An interview was conducted on 5/6/21 at 1:50 PM with NA #1. NA #1 explained Resident #26 was dependent on nursing staff who anticipated the resident's care needs. NA #1 explained nail care was typically provided during the shower but could be done anytime it was needed. NA #1 explained Resident #26's Responsible Party (RP) liked the fingernails kept long and painted. NA #1 revealed she hadn't noticed the black/brown debris underneath the nails and stated she would now clean Resident #26's fingernails. An interview was conducted on 5/6/21 at 1:57 PM with Nurse #1. Nurse #1 explained the RP preferred Resident #26's fingernails were kept long and painted knowing that was how the resident liked her nails. Nurse #1 explained Resident #26 was dependent on nursing staff for ADL care and fingernails should not be dirty underneath. Nurse #1 was aware Resident #26's fingernails were long but not that they were dirty underneath the nails. An interview was conducted with Director of Nursing (DON) on 5/6/21 at 3:55 PM. The DON explained resident nail care was provided during a shower or a bed bath on scheduled bathing days. The DON revealed Resident #26 was dependent on nursing staff who had to anticipate the resident's care needs. The DON expected Resident #26's nail care be provided during a shower or bed bath or anytime it was needed. 3. Resident #53 was admitted to the facility on [DATE]. Current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] indicated Resident #53 had moderate impairment in cognition and required extensive staff assistance with personal hygiene and total staff assistance with bathing. The MDS noted Resident #53 had an impairment on one side of both the upper and lower extremities. An observation of Resident #53 on 05/03/21 at 3:15 PM revealed his fingernails on the left hand were long and extended approximately one-quarter of an inch beyond his fingertips. Subsequent observations conducted on 05/04/21 at 8:27 AM, 05/05/21 at 11:58 AM and 05/06/21 at 1:01 PM revealed the fingernails on Resident #53's left hand remained untrimmed. During an interview on 05/06/21 at 1:01 PM, Resident #53's voiced his nails were too long and needed to be trimmed. During interview on 05/06/21 at 8:50 AM, Nurse Aide (NA) #2 revealed she provided nail care to residents during their showers and as needed unless the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . NA #2 added she noticed Resident #53's fingernails were long on his left hand and notified Nurse #2 this morning. During an observation and interview on 05/06/21 at 10:30 AM Nurse #2 confirmed nurses were responsible for trimming the fingernails of residents who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #2 observed Resident #53's nails and agreed they needed to be trimmed. Nurse #2 asked Resident #53 if he would like his fingernails trimmed and he replied yes. During a telephone interview, Nurse #3 confirmed she was assigned to provide care to Resident #53 on 05/03/21 to 05/05/21. Nurse #3 stated nurses were responsible for trimming the fingernails of residents who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse #3 added she did not notice the fingernails on Resident #53's left hand were long and needed trimmed and stated he would usually let someone know when he wanted his fingernails trimmed. During an interview on 05/06/21 at 3:57 PM, the Director of Nursing (DON) explained if a resident was a diabetic, nurses were responsible for checking and cutting the resident's fingernails. The DON explained Resident #53 was dependent on nursing staff and was not someone who would directly ask for nail care. The DON stated she would expect nursing staff to provide Resident #53 with nail care as needed.

Based on record review and staff interviews, the facility failed to provide a CMS- SNF ABN (Centers for Medicare and Medicaid Services Skilled Nursing Facility Advanced Beneficiary Notice) prior to discharge from Medicare Part A skilled services to 3 of 3 residents reviewed for beneficiary protection notification review (Residents #12, #31 and #71). Findings included: 1. Resident #12 was admitted to the facility on [DATE]. A review of the medical record revealed a CMS- Notice of Medicare Non-Coverage letter (NOMNC) was discussed with Resident #12's Responsible Party (RP) on 08/26/20 which indicated Medicare Part A coverage for skilled services would end on 08/27/20. Resident #12 remained in the facility. A review of the medical record revealed a CMS- SNF ABN was not provided to Resident #12 or his RP. An interview was conducted with the Social Services Director (SSD) on 05/04/21 at 3:33 PM. The SSD explained either she or the Social Services Assistant issued the NOMNC prior to Medicare Part A services ending and then gave the copy of the NOMNC to the Receptionist/Accounts Payable (RAP) staff member to issue a SNF ABN if needed. An interview was conducted with the RAP staff member on 05/05/21 at 3:17 PM who confirmed she issued the CMS- SNF ABN when Medicare Part A services were ending only for residents who also had Medicaid insurance. She confirmed Resident #12's RP was not issued a CMS- SNF ABN prior to Medicare Part A services ending on 08/26/20. An interview was completed with the Administrator on 05/05/21 at 4:45 PM. The Administrator explained she had misinterpreted the corporate policy for providing SNF ABNs and residents were only issued a SNF ABN if they received Medicare Part B services. The Administrator did not realize a SNF ABN should also be provided when a NOMNC was issued due to Medicare Part A services ending. 2. Resident #31 was admitted to the facility on [DATE]. A review of the medical record revealed a CMS- Notice of Medicare Non-Coverage letter (NOMNC) was signed by Resident #31 on 04/26/21 which indicated Medicare Part A coverage for skilled services would end on 04/30/21. Resident #31 remained in the facility. A review of the medical record revealed a CMS- SNF ABN was not provided to Resident #31. An interview was conducted with the Social Services Director (SSD) on 05/04/21 at 3:33 PM. The SSD explained either she or the Social Services Assistant issued the NOMNC prior to Medicare Part A services ending and then gave the copy of the NOMNC to the Receptionist/Accounts Payable (RAP) staff member to issue a SNF ABN if needed. An interview was conducted with the RAP staff member on 05/05/21 at 3:17 PM who confirmed she issued the CMS- SNF ABN when Medicare Part A services were ending only for residents who also had Medicaid insurance. She confirmed Resident #31 was not issued a CMS- SNF ABN prior to Medicare Part A services ending on 04/30/21. An interview was completed with the Administrator on 05/05/21 at 4:45 PM. The Administrator explained she had misinterpreted the corporate policy for providing SNF ABNs and residents were only issued a SNF ABN if they received Medicare Part B services. The Administrator did not realize a SNF ABN should also be provided when a NOMNC was issued due to Medicare Part A services ending. 3. Resident #71 was admitted to the facility on [DATE]. A review of the medical record revealed a CMS- Notice of Medicare Non-Coverage letter (NOMNC) was discussed with Resident #71's Responsible Party (RP) on 01/22/21 which indicated Medicare Part A coverage for skilled services would end on 01/24/21. Resident #71 remained in the facility. A review of the medical record revealed a CMS- SNF ABN was not provided to Resident #71's RP. An interview was conducted with the Social Services Director (SSD) on 05/04/21 at 3:33 PM. The SSD explained either she or the Social Services Assistant issued the NOMNC prior to Medicare Part A services ending and then gave the copy of the NOMNC to the Receptionist/Accounts Payable (RAP) staff member to issue a SNF ABN if needed. An interview was conducted with the RAP staff member on 05/05/21 at 3:17 PM who confirmed she issued the CMS- SNF ABN when Medicare Part A services were ending only for residents who also had Medicaid insurance. She confirmed Resident #71's RP was not issued a CMS- SNF ABN prior to Medicare Part A services ending on 01/24/21. An interview was completed with the Administrator on 05/05/21 at 4:45 PM. The Administrator explained she had misinterpreted the corporate policy for providing SNF ABNs and residents were only issued a SNF ABN if they received Medicare Part B services. The Administrator did not realize a SNF ABN should also be provided when a NOMNC was issued due to Medicare Part A services ending.

Based on record reviews, resident interviews and staff interviews, the facility failed to maintain 1 of 2 sampled residents right to be free from abuse (Resident #36). The findings included: 1. Resident #165 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Admission nursing notes dated 05/26/16 stated Resident #165 was alert and oriented times 4 spheres. Review of a grievance dated 05/30/16 revealed Resident #165 stated that nurse aide (NA) #2 came to put her to bed Sunday night (05/29/16). She explained to NA #2 that he had to use the lift to transfer her because when he lifted her by hand he had caused skin tears. After asking him twice to use the lift, he slung the lift, which was in the room, into the wall and told Resident #165 Fine, then you can just sit there and think about it. NA # 3 was in the room and told NA #2 to stop and use the lift like he was supposed to and he just got madder. Then NA #3 got Nurse #2 and NA #2 got into Resident #165's face and talking very loudly told her she was telling lies on him. Review of the written statement by NA #3 who was in the room during this incident revealed that on Sunday 05/29/16 at 11:30 PM NA #2 attempted to transfer Resident #165 under the arms. The resident stated he hurt her twice transferring her that way and told him to use the lift. He proceeded to tell her he was certified by the state to lift manually. She again asked him to use the lift which was in the room. He did not and told the resident she could just sit there. She was upset, crying and screaming. Resident #165 then asked for an antianxiety medication and NA #3 went to get Nurse #2. In the presence of Nurse #2, NA #2 got into the resident's face and loudly told Resident #165 he did not like being lied on. He went on and on very belligerently before leaving the room. NA #3 was interviewed via phone on 06/02/16 at 9:35 AM. She stated that around 11:30 PM on 05/29/16, NA #2 asked her to help him transfer Resident #165. She brought the lift into the room but NA #2 tried to transfer the resident without the lift. Even though Resident #165 told NA #2 she wanted him to use the lift as he had caused skin tears to her skin by lifting manually, he told her he was certified to lift her manually. She got very upset and was crying. NA #2 then pushed the lift away and told her to just sit there. NA #2 then left the room. When Nurse #2 came in with the requested antianxiety medication, NA #2 came back in the room and got in the resident's face and stated she was lying on him and he was tired of being lied on and he was just getting a battery for the lift. NA #3 stated she felt he was being abusive when he got into the resident's face and told her to just sit there. The resident had been upset. NA #3 stated she told everyone she could think of including the nurses and nurse aides about what occurred. Review of the statement by Nurse #2 revealed on 05/29/16 NA #2 called her to Resident #165's room because she misunderstood him and she wanted something for her nerves. When the nurse got to the room, Resident #165 was crying loudly and screamed at NA #2 that she did not want him taking care of her anymore and when she told him he ripped her skin and wanted him to use the lift he just pushed it up against the wall and walked out. NA #2 then spoke up that he had to get a battery for the lift. A phone interview with Nurse #2 on 06/02/16 at 9:02 AM revealed she may have misunderstood the situation and was surprised when she was asked to write a statement of the events involving Resident #165 and NA #2. She stated she did not think NA #2 abused the resident as both the resident and NA #2 were upset. She further stated the facility policy was to use the lift and the nurse felt the resident was not accusing him of abuse but just wanted him to use the lift. He did not seem rude to the resident just aggravated. Nurse #2 spoke with the other nurse in the facility and they decided to send NA #2 home. During interview on 05/31/16 at 3:25 PM Resident #165 answered yes to the question if she had ever been abused in the facility and stated that a male nurse aide (NA) was rough with her during a transfer causing her to have skin tears. She stated she reported it to staff and they were investigating the incident. On follow up interview with Resident #165 on 06/01/16 at 2:50 PM, Resident #165 stated NA #2 refused to use the lift to transfer her to bed even though the lift was in the room. She stated she tried to explain that he had caused skin tears previously when he transferred her manually and he accused her of lying. NA #2's refusal to use the lift and accusing her of lying got her so upset she needed some antianxiety medications. She stated she was shaking so badly and told the nurse she did not want him in her room anymore. On 06/02/16 at 1:56 PM an interview was conducted with the Administrator, Social Worker (SW), interim Director of Nursing (DON) and Unit Manager (UM). The SW, UM and DON spoke with Resident #165 who was scared of NA #2 and didn't want him back in her room. The SW, DON and UM all stated that Resident #165 acted and looked fearful of NA #2 when they spoke with her.

Based on observations, record review and staff interviews the facility failed to provide supervision of a resident seated on a shower chair which resulted in a fall and did not utilize a mechanical lift to transfer a resident for 1 of 3 residents reviewed for accidents (Resident #6). The findings included: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 was severely impaired in cognitive skills for daily decision making. The MDS further revealed Resident #6 had a history of [REDACTED]. A review of the care plan dated 05/16/14 revealed Resident #6 had a history of [REDACTED]. The goal indicated Resident #6 would have no avoidable injury related to falls through the next review dated 08/29/14 and the interventions included in part to anticipate and meet resident's needs as much as possible, keep Resident #6 within eyesight and within arm's reach at all times when in the shower and the use of a mechanical lift for all transfers. A review of the nurse's notes dated 06/20/14 revealed Nurse #1 was called to the shower room on the 300 hall at 9:45 PM and Resident #6 was observed lying in the floor on her right side. The notes revealed NA #1 stepped away from Resident #6 to pick up towels and the resident fell out of the shower chair. Resident #6 was observed to have a laceration over her left eyebrow measuring approximately 1.5 centimeters and three skin tears to the left elbow. The notes further indicated Resident #6 showed increased agitation and the on-call physician was notified and ordered the resident to be sent to the emergency room for evaluation and treatment. Review of the facility incident report dated 06/20/14 revealed Nurse #1 was called to the shower room and observed Resident #6 lying on her left side with a laceration above her left eyebrow and three skin tears to her left arm. The report indicated Resident #6 was oriented to person with complaints of pain to her left hip and above her left eyebrow. The report also indicated Resident #6's fall was witnessed by NA #1 when she stepped away from the resident to pick up towels. The report revealed predisposing environmental factors of a wet floor and predisposing physiological factors of confusion, incontinence, gait imbalance and weakness/fainted. A review of the hospital discharge summary dated 06/20/14 indicated Resident #6 was evaluated and treated in the emergency roiagnom on [DATE] for a laceration above her left eye brow that required the laceration to be repaired with surgical glue. An interview was not able to be conducted with Nurse Aide #2 (NA) but a hand written statement dated 06/19/14 revealed she helped NA #1 transfer Resident #6 arm and arm from the wheelchair to the shower chair and helped her shower the resident. The statement indicated NA #2 then showered another resident and took them back to their room with the intention of returning to help NA #1 transfer Resident #6 back to her wheelchair. Observations of Resident #6 on 07/16/14 at 11:53 AM revealed her to have a light blue bruise above her left eyebrow and light purple bruises to her left arm. During an interview on 07/16/14 at 4:33 PM Nurse #1 stated NA #3 came to get him to assess Resident #6 who had fallen in the shower room. Nurse #1 stated Resident #6 was lying on her left side when he went into the shower room with skin tears on her left arm and a laceration along her left orbital bone. Nurse #1 stated NA #1 told him she had left Resident #6 in the shower chair to pick up towels and she observed her falling before she could get back to her. During an interview on 07/16/17 at 4:45 PM with NA #3 stated NA #1 requested his help in the shower due to Resident #6 falling out of her shower chair. NA #3 stated when he went in the shower room he observed Resident #6 lying in the floor on her left side and he immediately went to get the nurse. During an interview on 07/17/14 at 11:19 AM NA #1 stated she had taken Resident #6 to the shower room and was assisted by NA #2 to arm and arm transfer her to the shower chair. NA #1 stated she knew Resident #6 was to be transferred with a lift but the lift agitated the resident so she didn't use it. NA #1 stated she showered Resident #6 and was waiting on NA #2 to return to the shower room to help her transfer the resident back to her wheelchair and she stepped about an arm's length away from the resident to pick up some towels and saw her fall before she could get to her. NA #1 stated she shouldn't have left Resident #6's side while she was sitting in the shower chair. An interview with the Director of Nursing (DON) on 07/17/14 at 7:24 AM revealed she received a phone call on 06/19/14 from Nurse #1 that Resident #6 had fallen out of the shower chair and was being sent to the emergency room for evaluation. The DON stated NA #1 reported she was alone in the shower room with Resident #6 waiting on NA #2 to return and help her transfer the resident back to her wheelchair and she left Resident #6's side to pick up some towels and saw Resident #6 fall and could not reach her in time to prevent her fall. The DON stated it was not acceptable to leave a resident unattended while sitting in a shower chair and Resident #6 was a total lift for all transfers and should not have been manually transferred which could have resulted in another accident.