Every finding on record at Naples Health and Rehabilitation Center

Based on record review, staff interviews, resident interview and observation, the facility failed to protect the resident's right to be free from neglect by failing to provide antibiotics in a timely manner to 1 (Resident #1) of 4 residents reviewed. The failure to provide the necessary care, antibiotics for a positive wound culture, to avoid physical harm placed the resident at risk for sepsis, a life-threatening response to an infection. The findings included: Review of facility policy titled Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin, revised 8/2024 which stated, Neglect 1. Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.Review of Resident #1's clinical records documented she is a [AGE] year-old female admitted to the facility on 4/9/ 2026. The primary admitting diagnosis was surgical aftercare following surgery of the digestive system. Secondary diagnosis include diverticulitis of intestine, sepsis, and unspecified open wound of abdominal wall.Resident #1's care plan initiated on 4/9/26 and revised on 4/17/26 documented the resident is at risk for skin breakdown related to new ileostomy, indwelling catheter, impaired mobility. Interventions included to observe for signs and symptoms of infection or delayed healing and report to physician PRN (as needed): Redness / erythema drainage, fever, increased discomfort to wound, bowel odor from wound.Resident #1 Minimum Data Set (MDS) completed on 4/21/26 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident is cognitively intact.Resident #1 abdominal wound culture report documented the specimen was collected on 6/22/26, received in the lab on 6/23/26 and resulted on 6/25/26 at 12:14 p.m. The abdominal wound culture was positive for Escherichia coli bacteria.Resident #1 physician orders documented an order for Midline placement for intravenous (IV) antibiotic via IV access dated 6/28/26. An order for Ertapenem Sodium Injection Solution 1 gram (GM) was placed 6/28/26 with the antibiotic start date of 6/29/26.Nursing progress note dated 6/22/26 at 10:51 a.m. documented by the facility wound care nurse stated, This nurse while performing wound care to patient observed ileostomy site to be soiled, when replacing wafer noted abdominal wound appeared with excessive drainage. Notified MD (Medical Doctor) who then gave orders for wound culture. Culture has been obtained and is in the fridge on north, labeled with requisition PCC order put into pop up on night shift for (lab) to pick up.Nursing progress note dated 6/26/26 at 10:51 p.m. documented, Ileostomy wafer and bag were changed; New dressing was applied. Site looks red and resident complained of pain from the site.Nursing progress note dated 6/27/26 at 10:59 p.m. documented, Resident is alert and oriented called and requested antibiotic. Resident stated antibiotic was prescribed by her surgeon X1 week. She was informed that there was no RX (prescription) for antibiotic noted. Culture results reviewed, waiting to be signed by MD or NP (Nurse Practitioner). She denied any pain at present. Verbal report given to upcoming nurse to message MD in the morning regarding resident concerns. Comfort care maintains.Nursing progress note dated 6/28/26 at 11:45 a.m. documented, Reviewed wound culture results; Escherichia coli detected in abdomen wound; notified NP. She confirmed new orders of starting antibiotic OK ertapenem IG IV daily for 7 days. Called (Intravenous access insertion company) and they will call back facility to confirm ETA (estimated time of arrival).On 7/1/26 at 9:25 a.m., observed resident #1 in bed with dressing to right arm. Resident #1 said the wound nurse thought her wound was infected and sent a wound culture on 6/22/26 when she did her dressing. She had an appointment with her surgeon that day too and he said he thought it was infected and was starting antibiotics. The resident said she thought she was getting her antibiotic in the cup of pills they give her daily. I was under the impression I was getting my antibiotics. I asked the nurses and was told that I didn't have any antibiotics ordered. I was told that the culture came back positive and they just put it in the file. Then they did not follow up with the doctor.On 7/1/26 at 10:50 a.m., interviewed the wound care nurse who said she was changing the dressing on the abdominal wound on 6/22/26, It sparked my interest since she complained of pain which she does not usually do. I reached out to the medical director and the NP and they agreed to send a swab. The wound care nurse confirmed the culture was collected 6/22/26, sent to the lab 6/23/26 and resulted on 6/25/26. Saying, The resident, told me verbally the surgeon prescribed antibiotics. I was off Friday 6/26/26 and noted it on 6/29/26 so I assumed she knew what she was talking about. I should have checked for the orders even though she is with it. The wound care nurse said not starting the antibiotics until 6/29/26 was a delay and put the resident at risk for getting sicker.On 7/1/26 at 11:05 a.m., interviewed Licensed Practical Nurse (LPN) Staff A who said about Resident #1, It was this weekend on Sunday, and she asked if she was on antibiotics, and I said no. She said the GI (Gastrointestinal) doctor put her on them. That is when she said she had the wound culture. I saw the results. I notified the primary doctor, and they stated she needed a PICC (Peripherally inserted central catheter) and to start the antibiotics. No one told me about a culture pending.On 7/1/26 at 11:15 a.m., interviewed the Director of Nursing (DON) who confirmed Resident #1 had a wound culture collected 6/22/26, processed 6/23/26 and resulted 6/25/26, a PICC line started on 6/28/26 and antibiotics started on 6/29/26. The DON said that it was Not acceptable about the delay in reporting the positive culture and starting antibiotics.On 7/1/26 at 12:00 p.m., in an interview, the Assistant Director of Nursing (ADON) confirmed that Resident #1's wound culture resulted as positive on 6/25/26 and there were no nursing notes documenting communicating with the MD or the NP prior to 6/28/26. The ADON said the risk of not having interventions or treatment for a positive wound culture would be sepsis and or getting sicker. We should have seen it earlier and followed up the NP/ MD earlier.On 7/1/26 at 12:40 p.m., the facility Administrator said, If the resident stated she was starting antibiotics the staff should have followed up. The results were positive on 6/25/26, They should have called the next day. That's a delay in service. I will need to find out why. The Administrator said the delay in treatment could put the resident at risk for septicemia and this is a compromised population.On 7/1/26 at 1:40 p.m., interviewed facility NP over the phone who said she was first notified of the culture results on 6/28/26. The NP said she should have been notified right away or at least the morning after the culture resulted. I don't know why there was a delay with Resident #1 results. The NP said there was a risk of sepsis, ending up in the hospital. It's not anything to be taken lightly. This is unfortunate and should not have happened.

Based on record review, facility policy review, and staff interviews the facility failed to ensure staff notified providers of abnormal lab results in a timely manner for 1 (Resident #1) of 4 residents reviewed.The findings included: Review of facility policy titled Condition Change and Physician Notification Policy and Procedure reviewed January 2024 which stated, Doctor (Designee)/ Family Notification of a resident condition change will occur when a resident experiences a change of condition including but not limited to acute change in condition fever, nausea vomiting diarrhea, behavioral changes, lab work, falls, etc. If unable to reach family all attempts will be documented. If a resident attending physician does not return call timely, the DON and Medical Director must be notified.Review of facility policy titled Episodic and Narrative Documentation and Physician Notification, reviewed 1/2026 which stated, Documentation will occur in the Nurses Progress notes to reflect a change in status, event, or notification of the Responsible Party or Physician . A single narrative entry will occur for the following episodes including but not limited to, the following: change in condition . Physician notification . Document the date and time the Physician and Responsible Party were notified. Document whether physician orders were obtained or not.Review of Resident #1's clinical records documented she is a [AGE] year-old female admitted to the facility on 4/9/ 2026. The primary admitting diagnosis was surgical aftercare following surgery of the digestive system. Secondary diagnoses included diverticulitis of intestine, sepsis, and unspecified open wound of abdominal wall.Resident #1's care plan initiated on 4/9/26 and revised on 4/17/26 documented the resident is at risk for skin breakdown related to new ileostomy, indwelling catheter, impaired mobility. Interventions included to observe for signs and symptoms of infection or delayed healing and report to physician PRN (as needed): Redness / erythema drainage, fever, increased discomfort to wound, bowel odor from wound.Resident #1 Minimum Data Set (MDS) completed on 4/21/26 documented a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident is cognitively intact.Resident #1 abdominal wound culture report documented the specimen was collected on 6/22/26, received in the lab on 6/23/26 and resulted on 6/25/26 at 12:14 p.m. The abdominal wound culture was positive for Escherichia coli bacteria.Resident #1 physician orders documented an order for Midline placement for intravenous (IV) antibiotic via IV access dated 6/28/26. An order for Ertapenem Sodium Injection Solution 1 gram (GM) was placed 6/28/26 with the antibiotic start date of 6/29/26.Nursing progress note dated 6/22/26 at 10:51 a.m. documented by the facility wound care nurse stated, This nurse while performing wound care to patient observed ileostomy site to be soiled, when replacing wafer noted abdominal wound appeared with excessive drainage. Notified MD (Medical Doctor) who then gave orders for wound culture. Culture has been obtained and is in the fridge on north, labeled with requisition PCC order put into pop up on night shift for Ecolab to pick up.Nursing progress note dated 6/26/26 at 10:51 p.m. documented, Ileostomy wafer and bag were changed; New dressing was applied. Site looks red and resident complained of pain from the site.Nursing progress note dated 6/27/26 at 10:59 p.m. documented, Resident is alert and oriented called and requested antibiotic. Resident stated antibiotic was prescribed by her surgeon X1 week. She was informed that there was no RX for antibiotic noted. Culture result reviewed, waiting to be signed by MD or NP (Nurse Practitioner). She denied any pain at present. Verbal report given to upcoming nurse to message MD in the morning regarding resident concerns. Comfort care maintains.Nursing progress note dated 6/28/26 at 11:45 a.m. documented, Reviewed wound culture results; Escherichia coli detected in abdomen wound; notified NP. She confirmed new orders of starting antibiotic OK ertapenem IG IV daily for 7 days. Called IV access and they will call back facility to confirm ETA (estimated time of arrival).On 7/1/26 at 9:25 a.m., observed resident #1 in bed with dressing to right arm. Resident #1 said the wound nurse thought her wound was infected and sent a wound culture on 6/22/26 when she did her dressing. She had an appointment with her surgeon that day too and he said he thought it was infected and was starting antibiotics. The resident said she thought she was getting her antibiotic in the cup of pills they give her daily. I was under the impression I was getting my antibiotics. I asked the nurses and was told that I didn't have any antibiotics ordered. I was told that the culture came back positive and they just put it in the file. Then they did not follow up with the doctor.On 7/1/26 at 10:50 a.m., interviewed the wound care nurse who said she was changing the dressing on the abdominal wound on 6/22/26, It sparked my interest since she complained of pain which she does not usually do I reached out to the medical director and the NPC and they agreed to send a swab. The wound care nurse confirmed the culture was collected 6/22/26, sent to the lab 6/23/26 and resulted on 6/25/26. Saying, The resident, told me verbally the surgeon prescribed antibiotics. I was off Friday 6/26/26 and noted it on 6/29/26 so I assumed she knew what she was talking about. I should have checked for the orders even though she is with it. The wound care nurse said not starting the antibiotics until 6/29/26 was a delay and put the resident at risk for getting sicker.On 7/1/26 at 11:05 a.m., interviewed Licensed Practical Nurse (LPN) Staff A who said about Resident #1, It was this weekend on Sunday, and she asked if she was on antibiotics, and I said no. She said the GI (Gastrointestinal) doctor put her on them. That is when she said she had the wound culture. I saw the results. I notified the primary doctor, and they stated she needed a PICC (Peripherally inserted central catheter) and to start the antibiotics. No one told me about a culture pending.On 7/1/26 at 11:15 a.m., interviewed the Director of Nursing (DON) who confirmed Resident #1 had a wound culture collected 6/22/26, processed 6/23/26 and resulted 6/25/26, a PICC line started on 6/28/26 and antibiotics started on 6/29/26. The DON said that it was Not acceptable about the delay in reporting the positive culture and starting antibiotics.On 7/1/26 at 12:00 p.m. the Assistant Director of Nursing (ADON) interviewed who confirmed that Resident #1's wound culture resulted as positive on 6/25/26 and there were no nursing notes documenting communicating with the MD or the NP prior to 6/28/26. The ADON said the risk of not having interventions or treatment for a positive wound culture would be sepsis and or getting sicker. We should have seen it earlier and followed up the NP/ MD earlier.On 7/1/26 at 12:40 p.m., the facility Administrator said, If the resident stated she was starting antibiotics the staff should have followed up. The results were positive on 6/25/26 They should have called the next day. That's a delay in service. I will need to find out why. The Administrator said the delay in treatment could put the resident at risk for septicemia and this is a compromised population.On 7/1/26 at 1:40 p.m. interviewed facility NP over the phone who said she was first notified of the culture results on 6/28/26. The NP said she should have been notified right away or at least the morning after the culture resulted. I don't know why there was a delay with (Resident #1) results. The NP said there was a risk of sepsis ending up in the hospital. It's not anything to be taken lightly. This is unfortunate and should not have happened.On 7/1/26 at 2:45 p.m., interviewed LPN Staff B over the phone who confirmed she cared for Resident #1 over the past weekend. LPN Staff B said she did not know that Resident #1 had a wound culture pending. LPN Staff B said, I probably overlooked it and after the resident asked for her antibiotics I looked then. We usually call the MD with any results like a positive culture. That is the expectation. LPN Staff B said she made sure to tell the nurse starting her shift after her to contact the MD. Asked why she did not notify the MD or NP when she saw the result LPN Staff B replied, I don't know, it was late.

Based on observation, record review, residents and staff interviews, the facility administration failed to provide effective oversight and failed to take appropriate actions to protect residents' safety from foreseeable and avoidable incidents from unsafe smoking practices and unsafe storage of ignition devices. This failure created an environment that placed four (Residents #37, #67, #118 and #119) of 17 resident smokers at a likelihood of serious injury, impairment or death from an accidental fire and resulted in the determination of Immediate Jeopardy. The findings included:Refer to F689, F926Review of the Director of Nursing's job description revealed that the essential duties and responsibilities included: Plan, develop, organize, implement, evaluate, and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, policies/procedures and guidelines that govern the long-term care facilities. Regularly inspect the facility and nursing practices for compliance with federal, state, and local standards and regulations.On 11/3/25, the Director of Nursing (DON) signed that she understood this job description and its requirements.Review of the Administrator's job description revealed that essential duties and responsibilities included: Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed. Consult with department managers concerning the operation of their departments to assist in elimination/correcting problem areas, and/or improvement of services.The Administrator signed the job description on 1/5/26.Review of the facility's Resident Smoking Supervised and Unsupervised - Use of Electronic Smoking/Vaping Devices policy and procedure from the Nursing/Clinical Quality of Care Manual revealed, Standard: The facility shall establish and maintain safe resident smoking practices, and/or use of electronic smoking/vaping devices. Guideline: Safety practices apply to smoking and non-smoking residents in accordance with State and Federal regulations. All smoking/vaping materials shall be kept at the nurse's station or other designated facility location. Smoking/vaping materials will be returned to the nurse's station or other designated facility location following each smoking session . Residents may not maintain cigarettes, e-cigarettes (electronic cigarettes), vaping materials or lighters in their possession .Resident #37Resident #37 was a smoker with an admission date of 1/29/24. Review of the clinical record revealed diagnoses included primary progressive Multiple Sclerosis (progressive degenerative disorder), Generalized muscle weakness, major depressive disorder, anxiety disorder, schizoaffective disorder, bipolar type (chronic mental health condition). Resident #37 smoked cigarettes.The Quarterly MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 11/6/25 revealed Resident #37 scored 12 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition.On 3/2/26 at 11:04 a.m., Resident #37 was observed in his room, in bed. In an interview, Resident #37 said that staff usually takes him outside to smoke around 12:30 p.m. He said that he keeps his cigarettes and lighter in his bedside table. Resident #37 was observed removing cigarettes and a lighter from the front pocket of his gown. He flicked the lighter, producing a visible flame. Resident #67Resident #67 was a smoker with an admission date of 9/3/25. Review of the clinical record revealed diagnoses included opioid dependence, sedative, hypnotic or anxiolytic dependence, anxiety disorder, generalized weakness and repeated falls.Review of the nursing progress notes revealed that on 9/14/25, Resident was caught smoking in his room. When confronting resident, he put it out and said, I know that I am not supposed to do it, but I don't care because I can't sleep.The care plan created on 9/15/25 noted, Smoking in room/educated.On 3/2/26 at 12:01 p.m., Resident #67 was interviewed in his room. The resident said that he goes outside to smoke any time he wants. Resident #67 said that he knew he was not supposed to have a lighter but kept one in his pocket and stored his cigarettes in a box on his bedside table. Cigarettes were observed in a box on the resident's bedside table and the outline of a lighter was observed in the pocket of the resident's sweatshirt.Resident #118Resident #118 was a smoker with an admission date of 3/15/24. Review of the clinical record revealed diagnoses included Anxiety Disorder, history of other mental and behavioral disorders, chronic respiratory failure with hypoxia (lack of adequate oxygen level) and protein-calorie malnutrition.The care plan for smoking initiated on 3/19/24 documented that Resident #118 was a safe smoker with supervision. The most recent smoking evaluation was dated 3/25/25.On 3/2/26 at 11:14 a.m., an observation of Resident #118's room revealed a white lighter left unattended and unsecured on the resident's bedside table. Resident #118 was not in the room at the time of the observation.On 3/2/26 at 2:21p.m., observation of Resident #118's room with the DON revealed the white lighter remained on the resident's bedside table.Resident #119Resident #119 was a smoker with an admission date of 9/12/24. Review of the clinical record revealed diagnoses included syncope and collapse, alcohol dependence, alcohol abuse with withdrawal, nicotine dependence, cigarettes, chronic obstructive pulmonary disease, generalized muscle weakness, repeated falls.Review of the care plan with a revision date of 11/10/25 revealed Resident #119 was at risk for substance abuse related to a history of ETOH (alcohol) abuse. The resident was non-compliant with policies regarding alcohol in his room.The care plan noted the resident frequently went out via his wheelchair and returned ETOH (intoxicated).On 3/3/26 at 9:58 a.m., Resident #119 was interviewed in his room. He verified that he smokes cigarettes. In an interview, Resident #119 said that he keeps his cigarettes and a lighter with him. He said, If you put smoking materials in the lock box, they leave the box open. Cigarettes and a lighter were observed in the pocket of the resident's shirt.On 3/5/26 at 11:04 a.m., in an interview, the DON said the facility's policy noted that the smoking evaluation is done on admission, annually and with completion of the MDS with a significant change. She said that a Certified Nursing Assistant (CNA) is assigned to the courtyard for 16 hours a day. They ask that smoking items be returned to them at the end of the smoking break. The DON said they found out this week during the survey that residents are not as honest and may hide paraphernalia. She said the residents doing it had a high BIMS score. The DON said, They can be a bit manipulative and confabulate. She said they were educated in the past. They have even caught residents door-dashing smoking supplies before. The DON said, From time to time we do room sweeps and try to explain the safety concerns. She said if they had a repeat offender, they definitely educated the resident, but with continued noncompliance, they can issue a 30 day discharge notice as we cannot continue to jeopardize the safety of other residents. The DON said on July 7, 2025, they educated residents on the smoking policy.On 3/5/26 at 11:22 a.m., in an interview the Administrator said they had not identified the smoking concerns revealed this week. The facility had a guardian angel program in which the managers are assigned residents' rooms. They have a check list of things to look for, including a section for any hazards. He said the list does not include smoking materials but he would expect his staff to document any unsafe items and bring them to morning meeting to be addressed. He said he started employment at the facility about a month ago and attended a Resident Council meeting to reiterate that they have to follow the smoking policy for safety. He said that if a resident is found with smoking supplies, they are taken from them and placed in the smoking supplies box. The Administrator said that safety trumps rights. They continue to reinforce the policy but the population is so much younger in that facility. They are constantly ordering packages, which they have a right to do, but they can get just about anything delivered. If they have repeat offenders, they need to just keep reiterating the rules. They can also issue a 30-day discharge notice, if they are putting others at risk, they don't need to be here.On 3/6/26 at 10:57 a.m., in an interview, the Administrator said that per policy, smoking privileges can be revoked, but that has not happened since he started employment at the facility.

Based on observations, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement and enforce the facility's Resident Smoking Supervised and Unsupervised policy to ensure safe smoking practices for 4 (Residents #37, #67, #118 and #119) of 4 sampled residents reviewed for safe smoking out of 17 total smokers in the facility.The facility failure to enforce the smoking policy that clearly addressed the safe storage of ignition devices by allowing residents to keep lighters/ignition devices unsecured in their rooms created an avoidable fire safety risk, placing four of 17 resident smokers at a likelihood for serious harm, injury or death. These concerns resulted in the determination of immediate jeopardy. The findings included:Cross reference F689, F835Review of the facility's policy and procedure titled Resident Smoking Supervised and Unsupervised - Use of Electronic Smoking/Vaping Devices from the Nursing/Clinical Quality of Care Manual revealed, Prior to, and upon admission, residents shall be informed of the facility smoking policy, including use of electronic smoking/vaping devices, designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. Residents and/or resident's representative will be required to review, sign and therefore agree to the terms of the facility Smoking/Vaping Contract as applicable. The resident will be evaluated on admission to determine if he or she is a smoker and/or uses an electronic smoking/vaping device . If a smoker, the evaluation will include . ability to smoke safely with or without supervision. A resident's ability to smoke safely and/or use an electronic smoking/vaping device will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff and shall be noted on the care plan. Residents who have independent smoking privileges are NOT permitted to keep cigarettes, e-cigarettes (electronic cigarettes), pipes, tobacco, nicotine, and other smoking/vaping articles in their possession including all forms of lighters, matches . Residents without independent smoking privileges may not have or keep any smoking/vaping materials, including cigarettes, e-cigarettes . except when they are under supervision.Review of the Smoking/Vaping Contract Acknowledgement form that residents or resident's representative are required to review and sign revealed, Absolutely no tobacco paraphernalia and/or tobacco products are to be kept in resident rooms. If at any time, a resident is found with. smoking materials (including lighters, matches .) in his/her room or is found smoking . in the room or inside the facility, such articles will be removed, smoking/vaping privileges will be revoked and could result in Resident discharge from the facility. If at any time this policy/contract is violated, smoking/vaping and/or tobacco/nicotine usage privileges will be revoked. Procedure: A licensed nurse will evaluate residents who smoke . upon admission or at the start of such activity and as cognitive or physical status changes warrant. Residents will periodically be reviewed to reassess their ability to smoke . safely .Review of the Exhibit C, Smoking Policy revised 10/20/23, included in the admission Packet revealed, To assure maximized safety, all residents who choose to smoke will be supervised smokers. All smoking materials will be kept in a lock box at the adjacent nurse's station. Residents who smoke will turn in all smoking materials and paraphernalia to the staff person in charge when leaving the smoking area. No resident may have or keep any smoking materials or paraphernalia, including cigarettes . lighters, matches etc. in their possession outside the designated smoking area.Review of the undated facility provided list of 17 current residents who smoke tobacco products revealed Residents #37, #67, #118 and #119 were smokers.Resident #37:On 3/2/26 at 11:04 a.m., Resident #37 was observed in his room, in bed. In an interview, Resident #37 said that he keeps his cigarettes and lighter in his bedside table. Resident #37 was observed removing cigarettes and a lighter from the front pocket of his gown. He flicked the lighter, producing a visible flame. Review of the clinical record for Resident #37 revealed an admission date of 9/27/2024.The smoking evaluation was dated 10/2/25. The evaluator entered No for the question, Has the policy related to smoking and storage of smoking materials been reviewed with the resident? and Yes for the question, Is the resident able to acknowledge understanding of smoking policy?The resident's care plan did not address smoking and the result of the smoking evaluation.On 3/3/26 at 3:26 p.m., in an interview the MDS (Minimum Data Set) nurse said that smoking was removed from Resident #37's care plan in 2025 as he quit smoking. The observation of the lighter and cigarettes in Resident #37's possession in his room and the observation of the resident smoking cigarettes in the designated smoking area were shared with the MDS nurse. She said she did not know Resident #37 had started to smoke again and would have to speak to the Unit Manager about it.On 3/4/26 at 3:11 p.m., the Director of Nursing (DON) provided an acknowledgement of smoking rules that Resident #37 signed on 12/18/18.Resident #67:On 3/2/26 at 12:01 p.m., Resident #67 was interviewed in his room. The resident said that he knew he was not supposed to have a lighter but kept one in his pocket and stored his cigarettes in a box on his bedside table. Cigarettes were observed in a box on the resident's bedside table and the outline of a lighter was observed in the pocket of the resident's sweatshirt.Review of the clinical record for Resident #67 revealed an admission date of 9/3/25.On 3/4/26 at 2:20 p.m., upon request for the smoking contract for Resident #67, the DON provided the admission agreement Resident #67 signed on 9/9/25 and said the admission agreement included the smoking policy.A nursing progress note dated 9/14/25 noted, Resident was caught smoking in his room. When confronting resident, he put it out and said, I know that I am not supposed to do it, but I don't care because I can't sleep. Will continue to monitor resident for compliance.The care plan created on 9/15/25 and revised on 12/22/25 noted, Smoking in room/educated. The goal was Resident #67, will have a minimized risk of disruptive behaviors and/or harm through next review. The target date was 3/22/26. The care plan interventions did not include how Resident #67 would be monitored for compliance.Resident #118:On 3/2/26 at 11:14 a.m., an observation of Resident #118's room revealed a white lighter left unattended and unsecured on the resident's bedside table. Resident #118 was not in the room at the time of the observation.On 3/2/26 at 2:21p.m., observation of Resident #118's room with the DON revealed the white lighter remained on the resident's bedside table. Resident #118 was visibly upset and told the DON to get out of his room. The DON took the resident's lighter and said that residents were not supposed to have smoking material in their possession.Review of the clinical record for Resident #118 revealed an admission date of 3/15/24.The smoking evaluation was dated 3/25/25.The care plan created on 3/19/24 and revised on 3/3/26 noted that Resident #118 was a safe smoker with supervision.The Annual MDS (Minimum Data Set) Assessment with an Assessment Reference Date of 9/2/25 had No entered for current tobacco use.On 3/4/26 at 2:20 p.m., the DON provided an undated Exhibit C. Smoking Policy form with digital initials on the bottom of the form. The DON said the initials were Resident #118's electronic signature, acknowledging that he had read the policies attached to his contract. On 3/5/26 at 11:04 a.m., in an interview, the DON said smoking evaluations are usually done annually and if something has changed or something significant.Resident #119:On 3/3/26 at 9:58 a.m., Resident #119 was interviewed in his room. Resident #119 said that he smokes cigarettes and keeps his cigarettes and a lighter with him. He said, If you put smoking materials in the lock box, they leave the box open. Cigarettes and a lighter were observed in the pocket of the resident's shirt.Review of the clinical record for Resident #119 revealed an admission date of 9/12/24.Review of the care plan with a revision date of 11/10/25 revealed Resident #119 was at risk for substance abuse related to a history of ETOH (alcohol) abuse. The resident was non-compliant with policies regarding alcohol in his room.The care plan noted the resident frequently went out via his wheelchair and returned ETOH (intoxicated).The care plan created on 3/3/26 noted that Resident #119 must smoke with supervision.On 3/4/26 at 3:08 p.m., when asked about a smoking contract for Resident #119, the DON provided a smoking evaluation dated 12/17/25. The evaluation noted that the policy related to smoking times and storage of smoking materials have been reviewed with and understood by the resident. The DON verified that there was no smoking contract signed by Resident #119.On 3/5/26 at 11:22 a.m., in an interview the Administrator said that the residents are all given the policy on admission and sign a smoking contract that they will adhere to the policy. He said the facility has smoking aides 16 hours a day who sit in the courtyard to monitor the smoking area. He said the smoking material is kept in a locked cart.

Based on observation, record review, review of facility's policies and procedures, residents and staff interviews, the facility failed to implement processes to prevent avoidable accidents by failing to ensure the appropriate storage of ignition devices for four (Residents #37, #67, #118 and #119) of 17 smokers observed with lighters in their rooms. The unsafe practice of allowing four of 17 residents who smoke to store unsecure ignition sources such as lighters in their rooms created a significant fire hazard from accidental ignition. A possible accidental ignition and fire risk created a likelihood of serious injury, impairment or death and resulted in the determination of Immediate Jeopardy.The findings included:Cross reference F835, F926Review of the facility's policy and procedure titled, Resident Smoking supervised and Unsupervised - Use of Electronic Smoking/Vaping Devices issued 2/1/26 revealed, Residents who have independent smoking privileges are NOT permitted to keep cigarettes, e-cigarettes (electronic cigarettes), pipes, tobacco, nicotine, and other smoking/vaping articles in their possession including all forms of lighters, matches, and electronic smoking/vaping device paraphernalia . Residents without independent smoking privileges may not have or keep any smoking/vaping materials, including cigarettes, e-cigarettes, tobacco, nicotine, etc., except when they are under supervision .Resident #37On 3/2/26 at 11:04 a.m., Resident #37 was observed in his room, in bed. In an interview, Resident #37 said that staff usually takes him outside to smoke around 12:30 p.m. He said that he smokes cigarettes and keeps his cigarettes and lighter in his bedside table. Resident #37 was observed removing cigarettes and a lighter from the front pocket of his gown. He flicked the lighter, producing a visible flame. Review of the clinical record for Resident #37 revealed an admission date of 1/29/24. Diagnoses included unspecified Parkinsonism, primary progressive Multiple Sclerosis (progressive degenerative disorder), Generalized muscle weakness, major depressive disorder, anxiety disorder, schizoaffective disorder, bipolar type (chronic mental health condition).Review of the Quarterly MDS (Minimum Data Set) Assessment with an assessment reference date of 11/6/25 revealed Resident #37 scored 12 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment.The most recent completed smoking evaluation for Resident #37 was dated 10/2/25. The evaluation did not indicate if the resident had independent smoking privileges. The smoking evaluation noted that the resident was able to acknowledge understanding of the smoking policy. No was entered for question, Has the policy related to smoking times and storage of smoking materials been reviewed with the resident?The resident's care plan did not address smoking. On 3/3/26 at 3:18 p.m., in an interview the Director of Nursing (DON) said that each resident should have smoking in their care plan if they are a smoker.On 3/3/26 at 3:26 p.m., in an interview the MDS nurse said that smoking was removed from Resident #37's care plan since he quit smoking in 2025. When asked about the observation of Resident #37 smoking in the smoking area and the observation of cigarettes and a lighter in the resident's pocket, the MDS nurse said she would have to speak to the Unit Manager about it. She said she was not aware Resident #37 had started to smoke again. On 3/4/26 at 3:11 p.m., the DON provided an acknowledgement of smoking rules that Resident #37 signed on 12/18/18.On 3/5/26 at 11:04 a.m., in an interview, the DON said she was not employed at the facility when Resident #37 signed the acknowledgement of smoking rules. She said the resident has been here so long that they may not have had him sign another acknowledgement of smoking rules since he had already signed one in 2018. Resident #67:On 3/2/26 at 12:01 p.m., Resident #67 was interviewed in his room. The resident said that he goes outside to smoke any time he wants. When asked about storage of smoking materials, Resident #67 said he stored his cigarettes in a box on his bedside table. He said he knew he was not supposed to have a lighter but kept one in his pocket. Cigarettes were observed in a box on the resident's bedside table, and the outline of a lighter was observed in the pocket of the resident's sweatshirt.Review of the clinical record for Resident #67 revealed an admission date of 9/3/25. Diagnoses included opioid dependence, sedative, hypnotic or anxiolytic dependence, anxiety disorder, generalized weakness and repeated falls.The smoking evaluation dated 9/3/25 noted that the resident exhibited signs of confusion.The care plan initiated on 9/3/25 documented that Resident #67 had the potential to display behaviors of entering other residents' rooms without permission and was verbally belligerent. The care plan noted that Resident #67 was not following facility policy, stealing food off other residents' trays.A nursing progress note dated 9/14/25 read, Resident was caught smoking in his room. When confronting resident, he put it out and said, I know that I am not supposed to do it, but I don't care because I can't sleep.The care plan created on 9/15/25 noted, Smoking in room/educated. The interventions included to explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Intervene as necessary to protect the rights and safety of others; Redirect resident as necessary. The care plan did not include supervision to prevent unsafe smoking practices.On 3/3/26 at 12:12 p.m., in an interview, Licensed Practical Nurse (LPN) Staff I said she has been employed at the facility for 4 months. She said that residents who smoke keep cigarettes and lighters with them. Resident #118On 3/2/26 at 11:14 a.m., an observation of Resident #118's room revealed a white lighter left unattended and unsecured on the resident's bedside table, amidst other items, including a television remote, a tube of pain-relieving gel. Resident #118 was not in the room at the time of the observation.On 3/2/26 at 2:21p.m., observation of Resident #118's room with the DON revealed the white lighter remained on the resident's bedside table. The DON walked in the room and leaned over and took the resident's lighter. Resident #118 was in the room at the time of the observation. He appeared angry and yelled at the DON to get out.Upon leaving the resident's room, the DON said that smokers were not allowed to keep lighters at their bedside, the lighters should be locked in the smoking cart.In an interview the DON said smokers were not allowed to keep lighters at their bedside. The lighters should be locked in the smoking cart.Review of the clinical record for Resident #118 revealed an admission date of 3/15/24. Diagnoses included anxiety disorder, history of other mental and behavioral disorders, chronic respiratory failure with hypoxia and protein-calorie malnutrition.The most recent smoking evaluation was dated 3/25/25.Review of the Annual MDS with an Assessment Reference Date of 9/3/25 revealed No was entered for Current tobacco use.The care plan initiated on 3/19/24 noted that Resident #118 was a safe smoker with supervision. No revision was made to the care plan until 3/2/26.Review of the facility provided list of 9 wanderers and residents at elopement risk revealed 2 of the 9 residents resided in close proximity to Resident #118's room where the lighter was observed unsecured and unattended.Resident #119On 3/3/26 at 9:58 a.m., Resident #119 was interviewed in his room. The resident said he smokes cigarettes and keeps his cigarettes and a lighter with him. Resident #119 said, If you put smoking materials in the lock box, they leave the box open. Cigarettes and a lighter were observed in the pocket of the resident's shirt.Review of the clinical record for Resident #119 revealed an admission date of 9/12/24. Diagnoses included syncope and collapse, alcohol dependence, alcohol abuse with withdrawal, nicotine dependence, cigarettes, chronic obstructive pulmonary disease, generalized muscle weakness, repeated falls.Review of the care plan created on 5/11/23 noted that Resident #119 was a safe smoker.The care plan for Resident #119 included accumulates clutter, refuses to organize room, refuses to allow staff to clean/organize his room. Resident #119 is also noncompliant with policies regarding alcohol in his room. He frequently goes out via his wheelchair and returns ETOH (intoxicated).On 3/3/26 at 10:35 a.m., in an interview, the Administrator said he was informed that several Residents had been found with lighters in their possession. He said the facility's policy was to turn the lighters and cigarettes in to the smoking attendant.On 3/5/26 at 11:04 a.m., in an interview, the DON said they tell the residents that any smoking items should be returned to the smoking attendant at the end of the smoking break. The DON said they found out this week that people are not as honest and they may hide paraphernalia. She said they had even caught residents door-dashing smoking supplies before. She said the resident who are doing it have a high BIMS score. They can be a bit manipulative and confabulate. She said they had educated the residents in the past. From time to time, they conduct room sweeps and try to explain the safety concerns to the residents.

Based on observation and interview, the facility failed to ensure medications were secured, locked and inaccessible to unauthorized staff, residents, and visitors, or under direct observation of authorized staff for 4 (Residents # 67, #16, #118, and #132) of 4 residents observed with medications left at bedside.The findings included: Facility policy titled Medication Administration, revision date 10/2023 indicated Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Compliance guideline #15 indicated: Observe resident consumption of medication. On 3/2/2026 at 9:27 a.m., a red tablet was observed on Resident #67's bedside table. Resident #67 walked to the bedside table, picked up the red circular tablet and set it back on the table. He said it was his iron pill and said sometimes he didn't take it. On 3/2/2026 at 9:45 a.m., an inhaler was observed on the bedside table. Resident #16 said the staff just leave the inhaler on her tray table in the morning and then they come back and pick it up later. On 3/2/2026 at 10:58 a.m., two medications cups were observed on Resident #118's bedside table with one white round tablet in each medicine cup. Resident #118 said the staff just give him the cup of medications. He thought the pills might be melatonin and sometimes he didn't take it. On 3/2/2026 at 2:05 p.m., the Director of Nursing (DON) said no resident should have medications at their bedside. She said if a resident was care planned to administer their own medications, they would be able to have medication at their bedside, however the facility currently had no residents care planned to administer their own medications. Photographic evidence obtained. On 3/2/26 at 10:58 a.m., observation of Resident 132's bedside table revealed a medication cup with 2 round medication tablets inside the medication cup. Resident #132 said he thought it was his TUMS medication (antacid) which the nurse had left for him to take later when he was ready. On 3/2/26 at 11:27 a.m., in an interview with Staff I License Practical Nurse (LPN), she said when she had administered Resident #132's medications to him that morning, he told her he wanted to take the TUMS medication later, so she left the medication for him to take later when he was ready, She said she doesn't leave medication for residents to take later but he had told her he would take the medication later when he was ready. On 3/4/26 at 3:19 p.m., in an interview with the Director of Nursing (DON), she said a nurse should not leave medication(s) in a resident's room unattended as per their facility policy and procedure. She said she had started reeducation with the nursing staff to remind them they cannot leave Resident's medication(s) at their bedside unattended and were required to ensure all residents' medication were administered as per physician orders.

Based on observations, interviews and record review, the facility failed to have sufficient staff to provide nursing care and services to maintain safety and the highest level of resident care needed to meet the needs of the residents, # 2, #12, #24 #50, #51, #52, #22, #25,#30, #133, and #140, by failing to ensure enough staff were available to respond to call lights and address resident concerns.The findings included: Review of the Facility Assessment's Staff Assignments plan noted we conduct a comprehensive assessment of each resident's medical, physical, and emotional needs upon admission. The Facility Assessment further states the facility will ensure an equitable distribution of workload among staff to prevent burnout and maintain high-quality care.Resident #50On 3/2/26 at 10:19 a.m., Resident #50 was observed sitting up in bed, removing her blanket, moving to the edge of the bed and pointing at the bathroom. Resident #50's roommate (Resident #22) said she is not able to get up on her own because she will fall.On 3/2/26 at 10:20 a.m., RN (Registered Nurse) Staff A was observed at the Resident #50's room doorway. RN Staff A said they would get help.On 3/2/26 at 10:21 a.m., the call bell was activated.On 3/2/26 at 10:22 a.m. CNA (Certified Nursing Assistant) Staff B was observed entering Resident #50's room. CNA Staff B observed turning off Resident #50's call bell and exiting the room. CNA Staff B did not interact with Resident #50.On 3/2/26 at 10:41 a.m. the call bell was activated and responded to at 10:46 am. By LPN (Licensed Practical Nurse) Staff C.On 3/2/26 at 10:46 a.m. LPN (Licensed Practical Nurse) Staff C was observed entering the room and addressing Resident #50's needs.Record review for Resident #50 showed she was admitted on [DATE] with a diagnosis of a displaced intertrochanteric fracture of left femur, history of falling, muscle weakness, lack of coordination and dementia. Resident #50's brief interview for mental status (a test used to look at cognitive function) on 1/26/26 gave her a score of 3 indicating severe cognitive impairment.Review of Resident #50's care plan (initiated 1/20/26) noted her as a risk for falls with interventions to ensure call light is within reach and encourage use for assistance. Resident #50's care plan also noted Resident #50 has impaired cognitive function/impaired thought processes r/t (related to) decision making problem, dementia, developmentally delayed, head injury, long term memory problem, problem making self-understood, problem understanding others, psychosis (initiated 1/21/26). Resident #50's care plan further noted she needs assist Substantial x1 staff for: showers, bathing, dressing, transfers, toileting, personal hygiene, bed mobility (initiated 1/21/26). Resident #51During an interview on 3/2/26 at 9:32 a.m. Resident #51 said the staff do not come quickly when you press the call light. Resident #51 said on average, he is waiting longer than 30 minutes for staff to answer his call light. He said his colostomy bag needs to be emptied now. Colostomy bag observed full of air. He said he has several CNAs that he asks to do it and never do. Resident #50 said it usually happens on 2nd and 3rd shift. He said his colostomy bag exploded earlier this morning and required him to be cleaned up.Resident #22During an interview on 3/2/26 at 10:16 a.m. Resident #22 said she wishes there were more staff. She said the staff have a lot on their plates, so they forget things and also forget about me. Resident #22 said on average, she is waiting longer than 30 minutes for staff to answer her call light.Resident #25During an interview on 3/2/26 at 11:10 a.m. Resident #25 said nighttime is a problem for staffing. She said they are much slower at night and make excuses for why they don't come.Resident #30During an interview on 3/2/26 at 11:32 a.m. Resident #30 said the staff told her she could not go to the bathroom on her own and to call for assistance. Resident #30 said she will use the call light, and it will take up to 1.5 hours for staff to come and assist her.Resident #133During an interview on 3/3/26 at 8:08 a.m. Resident #133 said it can take a long time for staff to answer the call light. Resident #133 said on average, he is waiting longer than 30 minutes for staff to answer his call light. Resident #140During an interview on 3/3/26 8:12 a.m. Resident #140 said if you got hurt on 3rd shift you would die. Resident #140 said he will call for staff assistance, and it takes up to 2 hours for them to help him.Resident #52During an interview on 3/5/26 at 11:06 a.m. Resident #52 said she has to call the front desk to get help because no one will answer her call light. Resident #52 said they will page overhead and still no one will come to assist her. Resident #52 said she has had to wait for 6 hours in urine.During a resident council meeting conducted on 3/3/26 at 2:55 p.m. the residents at the meeting said they have to wait too long to get care and there is a problem with staffing. They said there are usually not enough CNAs. They said they will have to wait an hour or two to have their needs met. They said if a CNA that is not assigned to them answers the call light, they are told they will have to wait until your CNA comes. Residents also reported long wait times for pain medications and assistance with showers.Review of the Resident Council Minutes from November of 2025 noted call light response too slow, at times, mainly at night. Actions taken noted staff in serviced on call light response times. The outcome was noted as Not Resolved - Action needed.Review of the Resident Council Minutes from December call light response too slow, at times, mainly at night. Actions taken noted staff in serviced on call light response times. The outcome was noted as Not Resolved - Action needed.Review of the Resident Council Minutes from January and February 2026 with no outcome of resolved for call light response concern.Resident #8During an interview on 3/5/26 at 8:20 a.m., Resident #8 said she is the Resident Council President. Resident #8 said there have been concerns with staffing and call light response time mentioned during their Resident Council meetings without improvement. Resident #8 said there is not enough staff. Resident #8 said a lot of residents including herself require 2 to 3 staff to assist them with care. Resident #8 said when they are with her, there are no staff to assist the other resident's needs. Resident #8 said they bring it up each month and nothing is being done. Resident #8 said there has been no improvement with staffing.Resident #12Review of the Resident Grievance Log showed Resident #12 had filed a grievance for call light response time on 11/6/25, 11/8/26, 1/12/26 and 2/10/26. Review of the grievance forms for Resident #12 showed the resident was not satisfied with the grievance resolution.During an interview on 3/5/26 at 10:57 a.m. Resident #12 said CNAs are not coming. Resident #12 said on average it takes an hour for staff to respond to her call light. Resident #12 said she has waited up to 3 hours for assistance. Resident #12 said nothing has been resolved and there has been no improvement. Resident #12 said she needs assistance with perineal care and emptying of her urinary catheter. Resident #12 said she put her grievances in and never saw anyone again.Resident #2Further review of the grievance log showed call light grievances for Resident #2 (filed on 1/12/26) and Resident #24 (filed on 1/17/26) with both marked as resolved.During an interview on 3/5/26 at 11:10 a.m. Resident #2 said on an average day it take an hour to get care. He said he needs a lot of assistance due to his amputation. Resident #2 said he still has to wait over an hour to get care. Resident #2 said nothing has changed since he filed his grievance. Resident #2 said he gave up because nothing is going to change.Resident #24During an interview on 3/6/26 at 9:10 a.m. Resident #24 said she filed a grievance due to slow call light response times from staff. Resident #24 said no one ever came back and discussed anything with her after filing her grievance.During an interview on 3/5/26 at 8:25 a.m., CNA Staff D said there are not enough staff to meet the needs of the residents. CNA Staff D said there are usually only 2 to 3 CNAs on duty in her section. CNA Staff D said a resident in their section requires 4 CNAs to take care of her. CNA Staff D said that there is not enough CNAs to take care of that resident. CNA Staff D said when they are in there with her, they can't take care of the other residents.During an interview on 3/5/26 at 8:35 a.m., CNA Staff E said her typical assignment is 14 to 15 residents with most of the residents in her assignment requiring 2 CNAs to care for them. CNA Staff E said if they have only 3 CNAs, it is hard to take care of all of the residents. CNA Staff E said she does the best she can but there are not enough staff to take care of the residents.During an interview on 3/5/26 at 9:33 a.m., CNA Staff F said there are not enough staff to take care of the residents here. CNA Staff F said the usual assignment is 15 to 16 residents and some days she can have up to 19 residents. CNA Staff F said they are responsible for giving showers, serving meals, feeding the residents and doing other all other care. CNA Staff F said if she has to get another CNA to assist with a mechanical lift, there are no CNAs left on the floor. CNA Staff F said, we are trying our best.During an interview on 3/5/26 at 9:40 a.m., CNA Staff G said there is not enough staff to take care of the residents at the facility. CNA Staff G said she has average assignment of between 14 to 16 residents. CNA Staff G said when a resident requires 2 or more assistance there is no one left on the floor to assist the other residents. CNA Staff G said she has 6 residents today who require 2 or more staff members for assistance with care.During an interview on 3/5/26 at 11:35 a.m., the Director of Nursing (DON) said once she receives a grievance, she does the investigation and education of the staff. She said the Social Services Director will follow up with the resident to make them aware of the corrective action and see if they are satisfied. The DON said her expectation is that call lights are to be answered within 5 to 10 minutes. The DON said when staff answer the call bell, it is her expectation that the staff be polite, respectful and the resident's needs are met. The DON said if a resident is cognitively impaired and is a fall risk, the staff need to get there as soon as possible to assist the resident.During an interview on 3/6/26 at 8:02 a.m., the Social Services Director confirmed the Resident Council has concerns with staffing. The Social Services Director confirmed there is no documentation that the call light concerns from resident council were resolved. The Social Services Director confirmed that no one followed up or resolved Resident #12's grievances for call lights according to documentation. When told that Resident #2 and Resident #12 said no one followed up on their grievances for call lights, she said the people who fill out these forms need to understand that these residents can say whether someone is following up. The Social Services Director said we need to make sure we are following up with all grievances.During an interview on 3/6/26 the Nursing Home Administrator said his expectation with resident council and grievances is they need to get back within 5 days with a resolution or plan. When told about the call light observation with Resident #50, the Nursing Home Administrator said she is a fall risk and could have fallen. The Nursing Home Administrator said someone should have assisted her.

Based on interviews and record review the facility failed to respond and follow up with grievances and concerns brought forward by the resident council for 2 of 4 Resident Council meetings minutes reviewed (November and December 2025).The findings included: Review of the facility Resident Right- Grievances policy (last revised 2/1/26) states the resident has right to and the facility will make prompt efforts by the facility to resolve grievances the resident may have. The policy further states ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions the regarding resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued.During a resident council meeting conducted on 3/3/26 at 2:55 p.m., the residents at the meeting said they have to wait too long to get care and there is a problem with staffing. They said there are usually not enough Certified Nursing Assistants (CNAs). They said they will have to wait an hour or two to have their needs met. They said if a CNA that is not assigned to them answers the call light, they are told they will have to wait until your CNA comes. Residents also reported long wait times for pain medications and assistance with showers.Review of the Resident Council Minutes from November of 2025 noted call light response too slow, at times, mainly at night. Actions taken noted staff in serviced on call light response times. The outcome was noted as Not Resolved - Action needed.Review of the Resident Council Minutes from December call light response too slow, at times, mainly at night. Actions taken noted staff in serviced on call light response times. The outcome was noted as Not Resolved - Action needed.Review of the Resident Council Minutes from January and February 2026 with no outcome of resolved for call light response concern.During an interview on 3/5/26 at 8:20 a.m., Resident #8 said she is the Resident Council President. Resident #8 said there have been concerns with staffing and call light response time mentioned during their Resident Council meetings without improvement. Resident #8 said there is not enough staff. Resident #8 said a lot of residents including herself require 2 to 3 staff to assist them with care. Resident #8 said when they are with her, there are no staff to assist the other resident's needs. Resident #8 said they bring it up each month and nothing is being done. Resident #8 said there has been no improvement with staffing.During an interview on 3/6/26 at 8:02 a.m., the Social Services Director confirmed the resident council president have brought forward concerns with staffing. The Social Services Director confirmed that Resident Council have concerns with staffing. The Social Services Director confirmed there is no documentation that the call light concerns from resident council were resolved.During an interview on 3/6/26 the Nursing Home Administrator said his expectation with resident council and grievances is they need to get back within 5 days with a resolution or plan.

Based on record review, review of facility policy and procedure, residents and staff interviews, the facility failed to ensure prompt resolution and follow-up for grievances for 3 (Resident #12 Resident #2 and Resident #24) of 3 residents reviewed for grievances.The findings included: Review of the facility Resident Right- Grievances policy (last revised 2/1/26) states the resident has right to and the facility will make prompt efforts by the facility to resolve grievances the resident may have. The policy further states ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of pertinent findings or conclusions the regarding resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued.Review of the Resident Grievance Log showed Resident #12 had filed a grievance for call light response time on 11/6/25, 11/8/26, 1/12/26 and 2/10/26. Review of the grievance forms for Resident #12 showed the resident was not satisfied with the grievance resolution.During an interview on 3/5/26 at 10:57 a.m., Resident #12 said CNAs are not coming. Resident #12 said on average it takes an hour for staff to respond to her call light. Resident #12 said she has waited up to 3 hours for assistance. Resident #12 said nothing has been resolved and there has been no improvement. Resident #12 said she needs assistance with perineal care and emptying of her urinary catheter. Resident #12 said she put her grievances in and never saw anyone again.Review of Resident #12 clinical records documented a Brief Interview of Mental Status (BIMS) completed 1/2/26 score of 15 indicating Resident #12 is cognitively intact.Further review of the grievance log showed call light grievances for Resident #2 (filed on 1/12/26) and Resident #24 (filed on 1/17/26) with both marked as resolved.During an interview on 3/5/26 at 11:10 a.m., Resident #2 said on an average day it take an hour to get care. He said he needs a lot of assistance due to his amputation. Resident #2 said he still has to wait over an hour to get care. Resident #2 said nothing has changed since he filed his grievance. Resident #2 said he gave up because nothing is going to change.Review of Resident #2 clinical records documented a BIMs completed 12/26/25 score of 14 indicating Resident #2 is cognitively intact.During an interview on 3/6/26 at 9:10 a.m., Resident #24 said she filed a grievance due to slow call light response times from staff. Resident #24 said no one ever came back and discussed anything with her after filing her grievance.Review of Resident #24 clinical records documented a BIMs completed 2/6/26 score of 15 indicating Resident #2 is cognitively intact.During an interview on 3/5/26 at 11:35 a.m., the Director of Nursing (DON) said once she receives a grievance, she does the investigation and education of the staff. She said the Social Services Director will follow up with the resident to make them aware of the corrective action and see if they are satisfied.During an interview on 3/6/26 at 8:02 a.m., the Social Services Director confirmed the Resident Council and Resident Council President have concerns with staffing. The Social Services Director confirmed there is no documentation that the call light concerns from resident council were resolved. The Social Services Director confirmed there that no one followed up or resolved Resident #12's grievances for call lights according to documentation. When told that Resident #2 and Resident #12 said no one followed up on their grievances for call lights, she said the people who fill out these forms need to understand that these residents can say whether someone is following up. The Social Services Director said we need to make sure we are following up with all grievances.During an interview on 3/6/26 at 9:25 a.m., the Nursing Home Administrator said his expectation with resident council and grievances is they need to get back within 5 days with a resolution or plan.

Based on interview and record review the facility failed to ensure Level 1 PASRR (Preadmission Screening and Resident Review Process- a federal requirement for nursing facilities to screen individuals for mental illness (MI), intellectual / developmental disabilities (ID/DD) to ensure appropriate placement and access to specialized services preventing unnecessary institutionalization and supporting community living) assessments were completed accurately and Level 2 pre-admission screening and resident review (PASRR) screenings were completed as required for 2 (Residents #8 and #50) of 3 residents reviewed.The findings included: Facility policy Coordination-PreFacility policy Coordination - Pre-admission Screening and Resident Review (PASRR) Program. Policy: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review, in accordance with State and Federal Regulations. Procedure: 1. The facility will coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. 2. Coordination includes: a. Incorporating the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care. b. Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.Review of clinical admission records for Resident #50 documented that she was [AGE] year-old and diagnosed with major depressive disorder and a severe cognitive impairment prior to admission on set date 1/20/26. The PASRR completed 1/20/26 for Resident #50 failed to document the resident had major depressive disorder and had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for her developmental stage. A Level 2 PASRR was not completed.Review of clinical admission records for Resident #8 documented that she was a [AGE] year-old diagnosed with bipolar disorder onset 8/29/22 and was cognitively intact. The PASRR completed on 8/10/25 for resident #8 failed to document the resident had bipolar disorder and had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for her developmental stage. A Level 2 PASRR was not completed.On 3/4/2026 at 9:18 a.m., in an interview the Director of Admissions said the Unit Manager and Director of Nursing (DON) review admission packets for PASRR/Clinical Documentation. She said she has noticed PASRRs seemed to be incorrect. The diagnoses aren't listed correctly. She said nurses call her all the time saying, 'this is not right.' She said according to facility policy the facility should ensure PASRRs are completed in accordance with State and Federal Regulations. The Director of Admissions said not only should they be completed, but they should also be correct.On 3/4/26 at 10:12 a.m., in an interview, Staff H Registered Nurse (RN) Unit Manager said she reviews the PASRR for all new admissions to be sure it's completed correctly and that there is nothing missing. Staff H RN Unit Manager said if there are items missing, staff notify admissions to request information or correction from the hospital.On 3/4/26 at 12:35 p.m., in an interview, the DON said she reviews the PASRR for new admissions. She said their policy is to ensure the PASRR is completed correctly, not just that it is done. The DON reviewed the clinical records for Residents #8 and #50 saying Resident #8 has a diagnosis of major depressive disorder that is not documented on the PASRR, which is an error. She said the resident has a disorder which results in functional limitations in major life activities that would otherwise be appropriate for her developmental age. She said this resident should have had a Level II PASRR. The DON said Resident #50 has a diagnosis of bipolar disorder that is not documented on the PASRR also in error. She said the resident has a disorder which results in functional limitations in major life activities that would otherwise be appropriate for her developmental age. The DON said this resident should have had a Level II PASRR. On 3/4/26 at 1:00 p.m., in an interview the Director of Social Services said she normally reviews PASRR, though she has not done so at this facility yet because she has only worked there for 2 weeks. She reviewed the clinical record for Resident #8. She said the resident has a diagnosis of major depressive disorder that is not documented on the Level I PASRR. She said that it's possible a Level II PASRR should have been completed. She reviewed the clinical record for Resident #50 and said that the resident has bipolar disorder and is on medication for depression. She said the resident should have had a Level 2 PASRR.

Based on observation, record review, staff and resident review, the facility failed to provide the necessary services to maintain personal grooming and hygiene for 1 (Resident #132) of 3 residents requiring assistance with activities of daily living. This had the potential to cause psychological harm to the resident.The findings included: On 3/2/26 at 11:02 a.m., Resident #132 was observed laying in his bed wearing a hospital gown, his fingernails on both hands were observed to be uneven and extending approximately 3/4 of an inch long with dark brown substance noted under each nail. Resident #132's hair and beard were uncombed and long. Resident #132 said his fingernails had not been trimmed in a long time and he had asked the staff to trim his fingernails several times over the past few months.Review of Resident #132's medical record revealed he was admitted to the facility on [DATE]. Review of Resident #132's Minimum Data Set (MDS) quarterly assessment on 2/19/26 noted a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. A BIMS score is a screening tool that aids in detecting cognitive impairment.Review of the Activities of Daily Living (ADL) form to be completed each shift by Resident #132's Certified Nursing Assistant (CNA) stated ADL - personal hygiene resident prefers longer nails, please encourage this resident to have his nails cut. Review of January, February and March 2026, ADL documentation, noted the CNA had not documented Resident #132 had refused getting his fingernails cut as of 3/2/26.On 3/3/26 at 3:00 p.m., in an interview with Staff H Registered Nurse (RN) Unit Manager (UM), she said the nursing staff were required to complete daily ADL care for all residents to include trimming a resident's nails, unless they were diabetic. She said if a resident refused ADL care to include the trimming of their fingernails, the CNAs were required to try again later and if the resident continues to refuse ADL care they should inform the resident's nurse.She said after reviewing Resident #132's medical record, she confirmed Resident #132 was care planned for liking his nails long, but staff were required to encourage Resident #132 to have his nails trimmed. She said she was unable to find documentation Resident #132's CNAs had documented that Resident #132 was refusing to have his fingernails trimmed during ADL care.On 3/3/26 at 3:15 p.m., an observation of Resident #132 with Staff A UM and Resident #132's Power of Attorney (POA) confirmed Resident #132's fingernails on both hands were uneven and extending approximately 3/4 of an inch long with dark brown substance noted underneath each nail. Staff A UM said due to Resident's #132's long fingernails she was unable to determine when the last time they were trimmed.On 3/3/26 at 3:17 p.m. in an interview with Resident #132's POA, she said she had asked the nursing staff to trim Resident #132's fingernails and beard since December 2025 and on January 19, 2026, his birthday, but as of this time the nursing staff had not honored her request. She said staff had not informed her Resident #132 was refusing to have his fingernails cut and/or have his beard trimmed. She said if they had, she would have come to the facility and encourage him to have his fingernails and beard trimmed. She and Resident #132 said it was okay to take a picture of his fingernails on both hands.On 3/4/25 at 3:19 p.m., in an interview with the Director of Nursing (DON) she said the nursing staff were required to complete a resident's ADL care daily. She said if they were unable to complete a resident's daily ADL care to include trimming a resident's fingernails, the nursing staff should document their attempts to complete the ADL care, the resident refusal and any action taken to complete the required ADL care.The DON said she had reviewed Resident #132's medical record and confirmed his ADL plan of care stated Resident #132 likes to have his fingernails long, but staff are required to encourage him to have his nails cut. I showed the DON the picture of Resident #132's fingernails on both hands and she confirmed Resident #132's fingernails were uneven and extending approximately 3/4 of an inch long with dark brown substance noted under each nail. The DON said the nursing staff should attempt to trim Resident #132's fingernails, and if Resident #132 refuses his fingernail care the staff were required to encourage him to have his fingernails trimmed. She said the nursing staff did not document Resident #132's refusal to have his fingernails trimmed except on 2/2/26 as required nor the interventions to encourage Resident #132 to have his fingernails trimmed on a routine basis.

Based on clinical record review, residents and staff interviews, the facility failed to ensure 3 (Residents #7, #8, and #3) of 3 dependent residents reviewed received their scheduled showers. The findings included: 1. On 5/29/25 at 9:30 a.m., in an interview Resident #7 said she asks staff regularly for a shower but has only received one shower since her admission to the facility. She said once she refused a shower as she was already in bed for the night. Review of the clinical record revealed Resident #7 was admitted on [DATE]. The 5-Day Minimum Data Set (MDS) assessment with a target date of 5/21/25 revealed Resident #7 scored 12 on the Brief Interview for mental status (BIMS), indicative of moderate cognitive impairment. Diagnoses included weakness and history of falling. The MDS assessment revealed Resident #7 required partial assistance with bathing and showers and did not reject care. Review of the shower schedule revealed Resident #7 was scheduled for a shower on the evening shift on Monday and Thursday. Review of the Certified Nursing Assistant (CNA) bathing task documentation for Resident #7 revealed: On 5/15/25 at 9:59 p.m., 5/19/25 at 11:41 a.m., and 5/22/25 at 9:59 p.m., Not Applicable was documented for the scheduled shower. On 5/19/25 at 6:27 p.m., and 5/29/25 at 1:20 p.m., a bed bath was documented. On 5/26/25 at 9:59 p.m., Resident refused was checked off. On 5/30/25 at 10:54 a.m. CNA Staff E said Resident #7 refuses showers when she offers them. The progress notes revealed no documentation that Resident #7 refused a shower. 2. Review of the clinical record revealed Resident #8 was admitted on [DATE]. Review of the physician note dated 4/25/25 at 5:23 p.m., revealed Resident #8 had a wound vac in place (a medical device that uses negative pressure wound therapy to help heal difficult or slow-healing wounds.) Review of the 5-day MDS assessment dated ,d+[DATE] 25 revealed diagnoses of digestive system surgery, perforation of the intestine, and need for assistance with personal care. The MDS revealed Resident #8 required maximum assistance with bathing and showers and did not reject care. Review of the shower schedule revealed Resident #8's showers were on Tuesdays and Fridays. Review of the ADL care plan dated 5/8/25 revealed Resident #8 preferred a bed bath twice a week. The CNA Kardex (provides instructions for safe care) documented to give a bed bath twice a week. Review of the CNA Task documentation from 4/30/25 through 5/29/25 revealed Resident #8 received bed baths. On 5/29/25 at 5:32 p.m., in an interview Resident #8 said he took showers his whole life and wondered why no one offered him a shower. He said he did not tell the nurse he preferred bed baths. On 5/29/25 at 5:35 p.m., in an interview the MDS Coordinator RN Staff C said she documented in the ADL care plan that Resident #8 preferred bed baths. She said she obtained the information from the nursing admission assessment. She did not ask Resident #8 if he wanted a shower. On 5/29/25 at 6:10 p.m., in an interview Licensed Practical Nurse (LPN) Staff D said she documented in the admission assessment for Resident #8 to receive bed baths because of the abdominal surgery and the wound vac. She said she did not ask the resident if he wanted a shower. On 5/29/25 at 6:17 p.m., in an interview the Director of Nursing said the wound vac was discontinued on 5/14/25 and the resident's abdominal wound was healed on 5/18/25. The DON said the resident could have started receiving showers after 5/18/25 if the resident wanted one. The DON said he did not know the resident did not receive a shower. On 5/30/25 at 11:38 a.m., in an interview the Regional Director of Nursing said Resident #8 had an open wound and a wound vac that prohibited a shower. He said, There are no odors here and the residents are being taken care of. 3. Review of the clinical record for Resident #3 revealed an admitted [DATE]. The Nursing Admission Evaluation dated 5/23/25 noted: Bath was documented for preference and choices for question, What type of bathing would you prefer? (Example- shower, bed bath, etc.), and Twice a week was documented for question, How often do you want to have your shower/ bath/ etc during your stay. The Admission MDS assessment with a target date of 5/28/25 revealed Resident #3 scored 15 on the Brief Interview for Mental Status, indicating intact cognition. Diagnoses included fusion of cervical spine, opioid dependence, and diabetes. The MDS noted Resident #3 required substantial/maximal assistance with shower/bathing. The resident's interview for daily preferences revealed it was very important for the resident to choose between a tub bath, shower, bed bath or sponge bath. On 5/29/25 at 12:13 p.m., in an interview Resident #3 said he has not received a shower since his admission. He said he usually showers every day. He begged for a shower, his hair has not been washed in 2 weeks. Review of the shower schedule revealed Resident #3's showers were scheduled for Tuesdays and Fridays. Review of the CNA documentation from 5/24/25 through 5/29/25 revealed Resident #3 received a bed bath on 5/24/25, 5/25/25, 5/26/25, 5/27/25 and 5/29/25. There was no documentation the resident received or refused the scheduled showers. On 5/30/25 at 10:54 a.m., in an interview Certified Nursing Assistant (CNA) Staff E said when a resident refuses a shower you document it in the CNA tasks and report to the nurse. On 5/30/25 at 11:11 a.m., in an interview CNA Staff F said if a resident refuses a shower, you report it to the nurse and document it in the CNA tasks. On 5/30/25 at 11:14 a.m., in an interview CNA Staff G said when a resident refuses a shower you report to the nurse and document in the record. On 5/30/25 at 11:18 a.m., in an interview CNA Staff H said you tell the nurse and document in the record whenever a resident refuses a shower.

Based on record review and interview, the facility failed to demonstrate prompt efforts to address grievances, including steps taken to investigate the grievance and failed to maintain evidence of the result of the grievance voiced by the family member of 1 (Resident #1) of 3 residents reviewed for grievances. The findings included: Review of the facility policy titled Resident Right - Grievances, issued 11/7/2024 revealed, It is the policy of the facility to allow the resident and or legal representative to voice a grievance in such a manner to acknowledge and respect resident rights . The resident has the right to and the facility will make prompt efforts by the facility to resolve grievances the resident may have . All residents, staff, and visitors will have access to the professional designated to manage the Grievance Program, Grievance Officer. The grievance policy must include . Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. On 5/29/25 at 10:07 a.m., in a telephone interview Resident #1's niece in-law said Resident #1 passed away at the facility on 3/11/25. She said she lives out of state. She spoke with several people at the facility and asked them to box and store Resident #1's belongings until she could pick them up in a few weeks. When she arrived on 3/27/25 to pick up the resident's ashes and belongings, the Social Worker (SW) handed her a small plastic bin. Many of Resident #1's belongings were missing. The SW took her to various closets, including Resident #1's former room to search for the missing items but nothing was found. She said the next day she called and spoke with the former interim Administrator who said he would look for the missing items and call her back. Resident #1's niece said the Administrator never called her back even after she left several phone messages. The niece said she did not have an inventory of Resident #1's belongings but really wanted his address book to contact his friends and a book he wrote his memories in. Review of Resident #1's clinical record failed to reveal an inventory list. There was no documentation in the clinical record of communication with Resident #1's family about the disposition of the resident's possessions. On 5/29/25 at 11:24 a.m., in an interview the Administrator said an inventory list is completed on admission. When new items come, the inventory list should be updated. She said sometimes family members bring in different items and they do not inform the facility. If a resident passes away, the belongings are kept for 30 days. The family is contacted to pick up the resident's possessions or let them know what to do with them. She said typically the Social worker is the Grievance Officer but the facility currently did not have a Social Worker (SW). On 5/29/25 at 2:15 p.m., in an interview the Corporate Traveling Director of Nursing (DON) said Resident #1's was admitted in 2019. They did not have an inventory list as they didn't own the company at that time. On 5/29/25 at 2:30 p.m., in an interview Licensed Practical Nurse (LPN) Staff A said she frequently worked with Resident #1. He had a lot of paperwork like journals. He had some bagged items, but she didn't know what they were. She said usually the Social Worker would gather the resident's belongings but she wasn't there when Resident #1 passed away. On 5/29/25 at 2:43 p.m., in an interview LPN Staff B said she frequently worked with Resident #1. He had a lot of papers in his room, and a tumbler cup he liked. There were some boxes in the closet, but she didn't know what was in them. She said she was not taking care of Resident #1 when he passed away but believed the SW packed up his belongings and called the family. On 5/29/25 at 2:55 p.m., in a telephone interview the former Social Worker (SW) said when he came back from vacation, he had a message from Resident #1's niece asking about his belongings. The SW said the nurses had packed the resident's belongings in a clear plastic tote and placed the tote in a closet used to store residents' belonging. He said he gave the clear plastic tote to Resident #1's niece when she came to collect the resident's belongings. The niece said some of Resident #1's possessions were missing. He notified the Interim Administrator. The niece also called and spoke with the Interim Administrator but he didn't know what happened from there. He said Resident #1 had a lot of stuff in his room, like a hoarder but he only had one clear tote to give to the niece. On 5/29/5 at 3:01 p.m., in a telephone interview the former interim Administrator said he believed Resident #1 passed before he started working at the facility. He said residents' belongings get bagged and stored in a designated area at the facility. He verified Resident #1's niece called and said some of his possessions were missing. He was not sure if anyone wrote a grievance but he told her to follow up with the Social Worker. He said he did not know what was given to the niece but staff told him all of Resident #1's belongings had been packed in bags. On 5/29/25, review of the facility's grievance log failed to reveal documentation of the grievance voiced by Resident #1's niece or steps taken to resolve it.

Based on observation, interviews, and records review, the facility failed to identify, investigate and prevent misappropriation of physician prescribed medication for 1 (Resident #4) of 3 residents reviewed. The findings included: Review of the facility policy titled, Abuse, Neglect, and Exploitation with a date reviewed/revised of 11/16/23 revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit . exploitation and misappropriation of resident property. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Review of the facility policy titled, Pharmacy Services with a date reviewed/revised of 4/17/23 revealed, The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs . to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice . Review of the clinical record revealed Resident #4 had an admitted [DATE]. Review of the physician's orders revealed an order dated 2/28/25 for Fioricet capsule 50-300-40 mg (Butalbital-Acetaminophen-Caffeine), 1 capsule by mouth every 8 hours as needed for headache/Migraine. On 5/29/25 at 2:51 p.m., in an interview Resident #4 said on 5/24/25 during the night, the nurse gave him a Fioricet and said there was no Fioricet left, he'd have to reorder from the pharmacy. Resident #4 said when he asked for a Fioricet on 5/25/25, the nurse told him the Fioricet had not been delivered yet. Resident #4 said he did not receive the Fioricet until 5/26/25 in the evening. Resident #4 said he was in so much pain he felt as though his head would explode. He said it was unacceptable, the facility knows he requires the medication for migraine headaches, and he did not like that someone was messing with his medication. Review of the grievance log revealed on 5/27/25 Resident #4 filed a Medication concern. The log noted, Medication ordered on 5/24 and received on 5/25 and medication is PRN (as needed). Review of the grievance report dated 5/27/25 revealed Resident #4 complained about not having his migraine medication for one day. The documentation of investigation and facility follow up noted the PRN migraine medication was ordered on 5/25 and received the same day. Review of the pharmacy Packing Slips revealed the pharmacy delivered 30 capsules of Fioricet on 5/14/25 for Resident #4. On 5/29/25 at 2:26 p.m., during a telephone interview, the pharmacy representative verified 30 capsules of Fioricet were delivered for Resident #4 on 5/14/25. Review of the Medication Administration Record (MAR) for May 2025 showed Resident #4 was administered a total of 11 capsules of Fioricet from 5/14/25 through 5/24/25, leaving 19 capsules of Fioricet unaccounted for. Resident #4 received one Fioricet on 5/24/25 at 2:26 a.m. The next dose was administered two days later, on 5/26/25 at 7:42 p.m. The pharmacy packing slips revealed on 5/26/25 at 5:50 p.m., the pharmacy delivered an additional 30 capsules of Fioricet. The MAR for May 2025 revealed Resident #4 received a total of 7 doses of Fioricet from 5/26/25 at 5:50 p.m., through 5/29/25 at 1:57 p.m. On 5/29/25 at 3:00 p.m., observation of the pharmacy package of Fioricet revealed 8 capsules of Fioricet had been removed from the package, leaving one capsule of Fioricet unaccounted for. On 5/29/25 at 3:07 p.m., in an interview Licensed Practical Nurse (LPN) Staff I said they were trying to get the Fioricet to be placed in the double locked drawer. On 5/29/25 at 3:37 p.m., an observation of the medication cart was done with the Director of Nursing (DON) and LPN Staff I. The DON verified no additional package of Fioricet was found in the medication cart for Resident #4. On 5/30/25 at 9:52 a.m., during a telephone interview the pharmacy consultant said Fioricet was not a controlled substance therefore not required to be double locked. She said she audits medications by pulling cards and checking expiration dates. She said she does not recall spot checking Resident #4's Fioricet medication. She said she did not know there was a problem until 5/29/25. She said one ingredient in Fioricet is Butalbital which is a barbiturate. On 5/30/25 at 1:26 p.m., in an interview the Corporate Traveling DON said she did not think anyone could truly determine what occurred with Resident #4's medication. She said it looked like a documentation error, and the nurses did not sign out the medication approximately 20 times.

Based on record review and staff interviews the facility failed to protect residents' right to be free from physical restraint for 1 (Resident #1) of 1 resident reviewed for restraints. The findings included: Review of the clinical record revealed Resident #1 was readmitted to the facility on [DATE]. Diagnoses included Traumatic Subdural Hemorrhage (bleeding in the brain), Aphasia (language disorder affecting ability to speak) following Cerebral Infarction, and muscle weakness. The Admission Minimum Data Set (MDS) assessment with a target date of 11/12/24 noted the resident's cognition was severely impaired with a Brief Interview for Mental Status score of 05. Review of the facility's incident investigations revealed on 11/25/24 at 7:45 a.m., the Director of Rehab reported to the Administrator when the Certified Occupational Therapist Assistant (COTA) went to get Resident #1 for therapy, she found the resident in his room, in his wheelchair with a sitter. The resident had a gait belt around his abdomen and secured to the back of the wheelchair. The resident was assessed and there were no injuries. The investigation noted Resident #1's sitter said in an interview that she was assigned to provide one to one supervision to Resident #1 during the alleged incident. She said she had been assigned to the resident for a double shift starting at 10:00 p.m. She said Resident #1 for up at around 5:00 a.m. Resident #1 kept getting up. The therapist came by and said she would be right back to bring the resident to therapy. The sitter said she put the gait belt on because Resident #1 kept getting up. She said she was holding onto the gait belt with the resident in the wheelchair waiting for the therapist to return. It was only a few seconds and she did not attach the gait belt to the wheelchair. The investigation noted the COTA said when she went to get the resident for therapy, she saw the gait belt around the resident's abdomen and attached to the wheelchair. It wasn't tight to cause injury but secured to keep the resident in the chair. The facility's conclusion noted Resident #1 kept getting up and the sitter used the gait belt to keep the resident from getting up until therapy returned. On 4/10/2025 at 10:50 a.m., in an interview the Social Services Director said he has been at employed at the facility for about three years. He could not remember exactly what the resident said but he assisted in conducting interviews with other residents. He said all staff were educated on abuse and neglect training. He said he has never seen a staff member restrain a resident and would report to a supervisor if he did. On 4/10/2025 at 11:15 a.m., in an interview Occupational Therapy Assistant Staff A said on 11/25/24 when she went into Resident #1's room for therapy she noticed the gait belt was wrapped around Resident #1 and the wheelchair. His caregiver was in the room next to him. She reported it to her Supervisor immediately. She said the resident was fine with no injuries. She said she removed the gait belt. She said the belt was around the residents waist to the back of wheelchair. She said she has never seen any other resident restrained and if she did she knew what to do. On 4/10/2025 at 11:20 a.m., in an interview Sitter Staff B said she has worked for the facility since 2001. She said she remembers Resident #1 and was working as a sitter for him on the day in question. She said Resident #1 was trying to jump out of bed and she put him in wheelchair and put gait belt around him but did not fasten it. She said she was just holding it to keep him from falling out of the wheelchair. She said the therapy lady said she was coming to get the patient and she forgot to remove the belt. She said she had never seen the gait belt in the room before that day. She said she was sent home while there was an investigation. She said she has since had training for abuse and neglect and not to use gait belt anymore. She now works only in dietary. She said she has never seen any resident restrained but if she did she would report it.

Based on observation, review of facility policy and procedure, review of the clinical record and resident and staff interview, the facility failed to provide the necessary care and services to maintain personal hygiene for 3 (Resident # 899, #800 and #7) of 3 residents reviewed for ADL's (activities of daily living). The findings included: The facility policy Activities of Daily Living (ADL's) implemented 11/2020 (revised 11/22/21) documented Residents who are unable to carry out activities of daily living independently will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. 1. Review of the clinical record revealed Resident #899 had a readmitted [DATE] with diagnoses including cerebral palsy, contracture of hands and left leg, and muscle wasting. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated of 5/10/24 documented the resident was dependent on staff assistance for personal hygiene, dressing and bathing. The MDS noted Resident #899's cognitive skills for daily decision making were intact. The care plan initiated on 4/18/24 noted Resident #899 had an ADL self-care deficit due to cerebral palsy, weakness and contractures. The goal for Resident #899 was to have bathing, grooming, toileting, and ADL needs met with assistance from staff through next review. On 8/7/24 at 10:15 a.m., during observation and interview Resident #899 was observed in his room in bed. He was unshaven with approximately four days of facial hair growth. He said no one had shaved him in days and he was not receiving his scheduled showers. Resident #899 said he did not like facial hair, would like to be shaved and showered. He said had not received oral care in a week or so and when they do brush his teeth, they do it very quickly and harsh. Resident #899 said he was incontinent. He said he gets up and spends five hours sitting in his wheelchair every day. He said no one changes his incontinent briefs when he's up in the wheelchair for five hours. On 8/7/24 at 10:00 a.m., in an interview Certified Nursing Assistant (CNA) Staff A said Resident #899 required the use of a mechanical lift for transfers and the assistance of two for turning and incontinent care. Staff A said Resident #899 refuses showers. When asked about incontinent care, Staff A declined to say how often she provided incontinent care to the resident. On 8/7/24 at 10:45 a.m., in an interview Licensed Practical Nurse (LPN) Staff B said staff are supposed to toilet residents every two hours and when they request it. Staff B said, I know sometimes he refuses showers; we document it. On 8/7/24 at 12:20 p.m., in an interview Registered Nurse (RN) Unit Manager Staff D said, Resident #899 refuses showers all the time. He said he does not want any water on his ears so she offered him a shower cap. They told him they could wash his hair in the sink and shower him and he refused. Staff D said they have had multiple care plan meetings with Resident #899 and his representatives and he refuses to be shaved. Staff D said Resident #899's showers are scheduled on Tuesdays and Fridays during the 7:00 a.m., to 3:00 p.m. shift. She said Resident #899 has had issues with staff and refused care from at least six Certified Nursing Assistants (CNAs). He will call them names and curse at them. She said she has told the CNAs repeatedly to document when a resident refuses care and find out the reason for the refusal. Review of the CNA documentation for June 2024 and July 2024 showed Resident #899 received a bed bath on 6/4/24, 6/7/24, 6/11/24, 6/14/24, 6/18/24, 7/2/24, 7/5/24, 7/19/24 and 7/26/24 in place of the scheduled shower. On 7/12/24 N/A (Not applicable) was entered for the shower. On 6/21/24, 7/16/24, 7/23/24 and 7/30/24, no documentation was entered for showers. There was no documentation in the CNA charting or nursing notes indicating the resident had refused the scheduled showers. The clinical record lacked documentation personal hygiene was provided on 6/16/24, 6/19/24, 6/21/24, 6/22/24, 6/24/24, 7/1/24, 7/16/24, 7/20/24. 7/23/24, 7/24/24, 7/25/24, 7/28/24 and 7/30/24 during the day shift (7:00 a.m., to 3:00 p.m.), or on 6/8/24, 6/16/24, 6/18/24 and 6/30/34 during the evening shift (3:00 p.m., to 11:00 p.m.). 2. Review of the clinical record revealed Resident #800 had an admitted [DATE] with diagnoses including chronic kidney disease stage 3, type 2 diabetes and muscle weakness. The care plan initiated on 5/26/23 and revised on 12/13/23 documented the resident was at risk for decreased ability to perform ADLS in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to impaired mobility. The interventions noted Resident #800 prefers a shower and, Assist of 1 staff with bathing. On 8/8/24 at 9:45 a.m., in an interview Resident #800 said, Sometimes I don't get my showers, I don't know why but I never complained about it. I don't complain about anything ask anybody they will tell you. On 8/8/24 at 11:00 a.m., CNA Staff C was observed dressing Resident #800 to get her out of bed. In an interview during the observation, Staff C said sometimes Resident #800 doesn't want the shower. She likes to stay outside and smoke all day. She never refuses care and never complains about anything. CNA Staff C said, Sometimes it is just easier to give her a bed bath so she can get outside and smoke. Review of the CNA documentation revealed Resident #800's preferred showers. The showers were scheduled on Wednesdays and Saturdays during the 7:00 a.m., to 3:00 p.m., shift. The CNA documentation for June 2024, and July 2024 revealed on 6/1/24, 6/5/24, 6/8/24, 6/12/24, 6/15/24, 6/19/24, 6/22/24, 6/26/24, 6/29/24, 7/3/24, 7/6/24, 7/10/24, 7/13/24, 7/17/24, 7/20/24, 7/24/24 and 7/31/24 Resident #800 received a bed bath in lieu of the scheduled shower. On 7/27/24 no documentation was entered for the scheduled shower. The clinical record lacked documentation Resident #800 refused showers or requested a bed bath on 6/1/24, 6/5/24, 6/8/24, 6/12/24, 6/15/24, 6/19/24, 6/22/24, 6/26/24, 6/29/24, 7/3/24, 7/6/24, 7/10/24, 7/13/24, 7/17/24, 7/20/24, 7/24/24 and 7/31/24. 3. Review of the clinical record revealed Resident #7 had an admitted [DATE]. Diagnoses included chronic back pain, anxiety and multiple sclerosis. The care plan initiated on 4/26/23 and revised on 5/25/23 documented Resident #7 was at risk for decreased ability to perform ADLS in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion and toileting related to multiple sclerosis and pain. The care plan interventions noted Resident #7 preferred showers and, Assist of 1 with bathing. On 8/8/24 at 10:20 a.m., in an interview Resident #7 said, I have no complaints here except for showers not being given. I'm lucky I have my motorized chair and once they get me in it, I can go to the bathroom sink and wash up. Resident #7 said, Would I like to be showered, hell yes. Bathing at the sink can only do so much, I need a good washing. Review of the CNA shower schedule showed Resident #7 was scheduled for showers on Mondays and Thursdays during the 7:00 a.m., to 3:00 p.m., shift. Review of the CNA documentation for June 2024, and July 2024 showed Resident #7 received a bed bath on 6/3/24, 6/6/24, 6/10/24, 6/20/24, 6/24/24, 6/27/24, 7/1/24, 7/4/24, 7/8/24, 7/11/24, 7/15/24, 7/18/24, 7/25/24 and 7/28/24 in place of her scheduled showers. On 6/13/24 and 7/1/24, no documentation was entered for the scheduled showers. On 8/8/24 at 11:15 a.m., in an interview Licensed Practical Nurse (LPN) Staff E said the CNAs are to go back and try different times to encourage the residents to shower. If the resident continues to refuse, then they'll document it. There was no documentation in Resident #7's clinical record indicating the resident had refused the scheduled showers or requested bed baths instead of the showers.

Based on observation, record review, staff and family interview, the facility failed to establish a communication process between the nursing facility, the hospice provider, and the responsible party to ensure the resident needs are met for 1 resident (#1) of 3 residents reviewed who are currently receiving hospice services. Hospice is a specialized form of medical care that provides comfort and quality of life while facing a life limiting or terminal condition. Coordination of care between facility services and Hospice services is vital to ensure the highest level of comfort and care during the end of life. The Findings Included: Coordination of Hospice Services Policy implemented 11/4/2020, Reviewed 11/29/2022, said, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the residents highest practicable physical, mental, and psychosocial well-being. Policy Explanation and Compliance Guidelines included: 1. The facility maintains written agreements with hospice providers that specify the care and services to be provided and the process for hospice and nursing home communication of necessary information regarding the resident's care. 2. The facility and hospice provider will coordinate a plan of care and will implement interventions in accordance with the residents needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative . 3. The facility will communicate with the hospice and identify, communicate, follow, and document all interventions put into place by hospice and the facility. 4. The facility will immediately contact and communicate with the hospice staff, attending physician/practitioner and the family resident representative regarding any significant changes in the resident's status, clinical complications, or emergent situation. On 3/27/24, a review of Resident #1's medical record revealed Resident #1 was admitted to hospice services on10/23/23 for the diagnosis of End Stage Cerebral Atherosclerosis. Resident #1 was admitted to the facility on [DATE]. On 2/20/24, Resident #1 fell out of bed. An X-ray was completed showing a femur (upper leg) fracture. Resident #1 was sent to the emergency room and returned the same day with a leg immobilizer after consulting with the emergency room physician and decided for comfort measures and conservative treatment. On 3/27/24 at 12:34 p.m., during an interview the Unit Manager said the nurse will enter a progress note in the electronic health record when hospice provides any updates. Ultimately the facility nurse is responsible for that patient. I was told during a routine skin assessment she had developed a small wound and the bone was sticking out on 3/6/24. My first call to hospice related to the exposed bone was on 3/13/24. I did not call the primary physician or the Nurse Practitioner and tell them the bone was sticking out. I did not call the family at any point about the resident having pain or a bone sticking out of her leg. That call would have been done by the primary nurse taking care of her. On 3/27/24 at 2:33 p.m., Resident #1's Responsible Party/Power of Attorney (POA) said, When she fell and fractured her leg, the facility did not call me. They told my wife the next day when she came to visit the facility. The Responsible Party said Resident #1 developed a wound which became infected. She was being moved to inpatient hospice because of the pain. The inpatient hospice called and told us they were sending her to the hospital. That was the first I heard about the bone sticking out. The doctor called and said the only appropriate action is to amputate because the bone was dead. She was discharged to inpatient hospice and passed away on March 23rd, 2024. On 3/27/24 at 2:50 p.m., Staff A, Registered Nurse (RN) said, I called hospice and asked them about her pain and activity. I did the dressing on her leg, there was not so much drainage, and she was started on antibiotics. Staff B, Licensed Practical Nurse (LPN) found the bone and he should have contacted everyone. They were supposed to discuss it with the hospice doctor. I didn't call the family. On 3/27/24 at 3:05 p.m., the facility wound care nurse said she became aware of the exposed bone and wound during the weekly skin check on 3/6/24 with the Nurse Practitioner. The facility wound care nurse said, I didn't speak with the family or responsible party. On 3/27/24 at 3:17 p.m., the Administrator verified Resident #1 had a piece of bone come through the skin on 3/6/24. The administrator said the normal procedure would be for the assigned nurse to call the responsible party when the wound developed, and the bone was exposed. The Administrator said, I am the risk manager, but I personally don't make notifications to the family. The Administrator said the Director of Nursing said on 3/13/24 Resident #1 was not someone we could provide care for and suggested transfer to either the hospital or inpatient hospice for continued care. The unit manager contacted the hospice on 3/13/24 and Resident #1 was transferred to inpatient hospice. The hospice manager contacted the family and they agreed to have Resident #1 transferred to inpatient hospice. On 3/27/24 at 4:00 p.m., Resident #1's friend/ spouse of POA said, They never called and told us anything about the bone sticking out. The spouse of POA confirmed the transport company took Resident #1 to inpatient hospice but discovered the exposed bone and notified the hospice provider. Hospice did not accept Resident #1 for inpatient services and they called 911 for her to be sent to the hospital. The hospital surgeon called us and explained the bone was dead, there was infection and the leg needed to be amputated or she would die. The facility never called about the infected wound, or exposed bone and the hospice nurse never called. POA spouse said, I had one meeting with a social worker and nurse when she was admitted to the nursing home and hospice did not come to the meeting. We would have wanted to know what was happening. On 3/27/24 at 4:10 p.m., Staff B, LPN said in a telephone interview he was aware the bone was sticking out and gave report to the oncoming shift that hospice was called and would be out to assess the increased pain. LPN Staff B said when a resident is under hospice care we call them with any changes, and they notify the family or responsible party. On 3/27/24 at 4:20 p.m., during an interview the Director of Nursing said she returned from leave on 3/13/24 and was informed the bone was protruding for Resident #1. We called hospice and explained the concerns about the bone and wound. They said they contacted the hospice doctor who recommended consulting the family. My understanding was they talked about it and decided no aggressive treatment and she was transferred to hospice. On 3/28/24 at 8:10 a.m., the Hospice manager said the unit manager called and reported increased pain and requested the resident be sent to inpatient hospice. The hospice manger confirmed the facility did not talk to the family about having the resident moved saying, They should have. They are the primary caretaker of the patient; they need to let the family and hospice know but they said no they called us first. They did not explain why she had so much pain. When she arrived at the inpatient unit, we found the bone sticking out, I took pictures. If they had let us know we would have told them to call 911 because that is a medical emergency. Even if she was on hospice, that was an emergency and she needed to be seen in the hospital. We did not know about the bone. Hospice manager said they had talked to the unit manager who said the transfer was for pain management and never said anything about the bone. On 3/28/24 at 8:55 a.m., the facility social worker confirmed he had not had any conversations with the responsible parties for Resident #1 after the initial care plan meeting. On 3/28/24 at 9:06 a.m., during a telephone interview the medical director verified Resident #1 was her patient. The Medical Director said the Nurse Practitioner (N)P informed me and hospice about the bone being exposed. Hospice saw the patient first and opted to do conservative management. I believed my NP, or the nursing staff talked with the family about a plan and options. I assumed hospice had talked with the family, but I should have reached out to confirm with them myself. The NP initially wanted to send the Resident #1 to the hospital, but the nursing staff told her hospice decided on conservative treatment. On 3/28/24 at 1:00 p.m., the NP said, I knew she was on hospice. When she fell , I sent her to the hospital. The nursing staff told me about the wound and bone the next day when I arrived on 3/7/24. My recommendation to Staff nurse B was to contact the family and the hospice for re-evaluation. I knew their preference was for conservative treatment but I did not call them after the bone came through the skin.

Based on records review, review of facility's policy and procedure, residents, and staff interviews, the facility failed to honor the bathing preferences for 4 (Residents #11, #15, #45 and #85) of 4 residents reviewed for bathing preferences. The findings included: Review of facility policy titled Resident Showers implemented 11/2020 showed, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice . Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Partial baths may be given between regular shower schedule as per facility policy . Review of facility policy titled Activities of Daily Living (ADLs) reviewed / revised 11/29/22 stated, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's ability in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene . Review of facility policy titled, Resident Rights reviewed/revised 3/8/2023 stated, . Respect and dignity. The resident has the right to be treated with respect and dignity including: . The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences . 1. Review of the clinical records for Resident #11 revealed a most recent readmission of 1/23/23. The resident's Kardex (Provides instructions for care) documented Resident #11 was totally dependent on two or more persons physical assistance for bathing. The Quarterly Minimum Data Set (MDS) assessment with a target date of 9/20/23 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #11 was cognitively intact. The care plan initiated on 1/25/23 with a revision date of 6/28/23 showed the resident was at risk for decreased ability to perform ADLs (Activities of daily living) in bathing, and grooming. The interventions included extensive to total assistance with bathing, transfer with a mechanical lift, a sling and two person assistance. Review of facility's shower schedule showed Resident #11 was scheduled for showers on Wednesdays and Saturdays during the 3:00 p.m. to 11:00 p.m. shift. Review of Certified Nursing Assistant (CNA) Point of Care (POC) documentation from 11/1/23 to 11/29/23 failed to show documentation Resident #11 received the scheduled showers on Wednesdays and Saturdays. The POC documentation documented the resident was only provided bed baths during the month of November 2023. There was no documentation that the resident refused the scheduled showers. On 11/27/23 at 11:20 a.m., in an interview, Resident #11 said, I can't do showers because I need the sling to get out of bed. The water would just pool in the sling. When asked if the staff offers to use a mesh shower sling, the resident said he did not know that mesh shower slings even existed. When asked if he would prefer a shower the resident replied, Over a sponge bath? Hell yes. Resident #11 confirmed his shower days were on Wednesdays and Saturdays but twice a week he gets a sponge bath and his hair shampooed. On 11/28/23 at 8:53 a.m., in an interview, Resident #11 confirmed his shower/bath days were Wednesdays and Saturdays. He confirmed no one ever offers him a shower, they just give him a bed bath. Resident #11 said, I would love a shower. I did not know they have lift slings that are good for the shower. On 11/30/23 at 8:03 a.m., in an interview Resident #11 confirmed he did not receive a shower the day before, Wednesday. Resident #11 said, I would love to have a shower instead of a bed bath. No one ever offers me a shower. 2. Review of the clinical records for Resident #15 revealed an admitted to the facility of 10/18/21 with a most recent readmitted [DATE]. Review of the Kardex documented resident #15 was totally dependent on two or more person physical assistance staff for bathing. Resident #15 used a mechanical lift with a large sling for transfers. The 5-day MDS assessment with a target date of 11/17/23 documented a Brief Interview for Mental Status (BIMS) score of 03 indicating Resident #11 was not cognitively intact but able to communicate his needs. Review of care plan showed the resident was at risk for decreased ability to perform ADLs in bathing and grooming. Review of facility shower schedule showed Resident #15 had scheduled showers on Mondays and Thursdays during the 7:00 a.m., to 3:00 p.m., shift. Review of the CNA Point of Care (POC) documentation from 11/1/23 to 11/29/23 showed the resident was only provided bed baths, no showers. There was no documentation that the resident refused the scheduled showers on Mondays and Thursdays. On 11/27/23 at 9:33 a.m., in an interview, Resident #15 he said he could not remember the last time he had been given a shower. On 11/27/23 (Monday) at 3:34 p.m., in an interview, Resident #15 said that he was not given or offered a shower on day shift that day. On 11/28/23 at 9:18 a.m., in a follow up interview, Resident #15 said he did not know the last time he was offered a shower. 3. Review of the clinical record for Resident #45, revealed an admitted [DATE]. Review of the Kardex showed Resident #45 required physical help limited to transfer and one-person physical assistance for bathing. The Quarterly MDS assessment with a target date of 9/5/23 documented a Brief Interview for Mental Status (BIMS) score of 07, indicating Resident #45's cognition was moderately impaired but was able to communicate his needs. Review of care plan initiated on 4/26/23 showed the resident was at risk for decreased ability to perform ADLs in bathing and grooming. Review of the facility's shower schedule noted Resident #45's scheduled showers were on Mondays and Thursdays during the 3:00 p.m., to 11:00 p.m., shift. Review of CNA Point of Care documentation from 11/1/23 to 11/29/23 showed Resident #45 received bed baths, and one shower on 11/16/23. There was no documentation that the resident refused the scheduled showers. On 11/27/23 at 10:40 a.m., in an interview Resident #45 said he did not remember the last time he had a shower. He said, It would be nice. I would like a shower. On 11/28/23 at 9:45 a.m., in an interview, Resident #45 said he had not been offered or given a shower. He said he would like to have a shower. 4. Review of the clinical record revealed Resident #85 was admitted to the facility on [DATE] , and a most recent readmitted [DATE]. Review of the Kardex showed Resident #85 required the physical assistance of one person for bathing. The Quarterly MDS assessment with a target date of 9/20/23 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #85 was cognitively intact. The care plan showed the resident was at risk for decreased ability to perform ADLs in bathing, grooming. Interventions included assistance of one with bathing. Review of facility shower schedule showed Resident #85's showers were scheduled on Wednesdays and Saturdays during the 7:00 a.m., to 3:00 p.m., shift. Review of the CNA Point of Care documentation from 11/1/23 to 11/29/23 showed Resident #85 was only provided bed baths. There was no documentation that the resident received his showers on Wednesdays and Saturdays or that the resident refused the showers. On 11/27/23 at 9:43 a.m., in an interview, Resident #85 said he couldn't remember the last time he had a shower. On 11/28/23 at 9:00 a.m., Resident #85 said he would prefer to shower but he has not been offered a shower. On 11/29/23 at 1:00 p.m., in an interview, Resident #85 said, They only give me bed baths and never even mention showers. On 11/29/23 at 9:00 a.m., in an interview, Registered Nurse (RN) Staff D said the CNAs have a schedule that they follow, then they chart in POC documentation. If the resident refuses a shower, the CNA is supposed to tell the nurse and we try to figure out why they have refused. On 11/30/23 at 8:20 a.m., in an interview, CNA Staff F said all residents have two shower days a week. A beds are done on day shift, and B beds are done on evening shifts. She said, You always offer a shower but sometimes they want a bed bath. If a resident refuses, then we need to document that they refused and tell the nurse. We then mark refused on the skin / shower sheet for the day. On 11/30/23 at 11:08 a.m., during an interview, the Regional Nurse Consultant reviewed the POC documentation, Kardex, and care plans for Residents #11, #15, #45, and #85. The Regional Nurse Consultant confirmed the lack of documentation Residents #11, #15, #45, and #85 received their scheduled showers. She verified the residents required staff assistance to shower and the lack of documentation the residents refused the showers. The Regional Nurse consultant said that the residents should have been given showers or had the reason they did not documented in the clinical records.

Based on record review, review of facility's policies and procedures, staff and resident interviews, the facility failed to file and maintain an accurate record of grievances for 3 (Residents #74, #83, and #3) of 3 residents reviewed. The findings Included: The facility Resident and Family Grievances policy Implemented 11/2020 and revised 3/8/2022 stated, It is the policy of this facility to support each resident's and family member's right to voice grievances . The policy noted the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form; Forward the grievance form to; the Grievance Official as soon as practicable; The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. On 11/27/23 at 11:30 a.m., in an interview, Resident #74 said he had been a resident at the facility for three months. He said the laundry had lost all his clothes. He said he spoke with the laundry again five days ago and has not gotten his clothes back yet. On 11/27/23 at 12:20 p.m., in an interview, Resident #83 said he has not received any clothes back from the laundry in one month. He said that he was missing 96 out of 100 pieces of laundry and had told the Administrator about it. The resident said, I have to keep wearing the same dirty clothes. He said the facility had bought him clothes before to replace the lost ones but now they were lost too. On 11/29/2023 at 5:10 p.m., Resident #83 said the Administrator spoke with him again and he was confident that the laundry problem would be resolved to his satisfaction. On 11/27/2023 at 12:50 p.m., in an interview, Resident #3 said she had been at the facility for six months. She said she had reported lost laundry items to the Administrator a long time ago and nothing had been replaced. On 11/29/2023 at 4:40 p.m., in an interview, Resident #3 stated she had lost 12 bras that had been sent to the laundry. She said when she was admitted to the facility she had 16 bras with her. She said she has spoken to the Administrator, but nothing has been done regarding her missing items. She said she had them upon admission and remembered itemizing them on her property. Resident #3 hard chart was reviewed at the nurse's station. No inventory list of personal belongings were in the chart. On 11/30/23, review of the facility's Grievance Log provided by the facility failed to show documentation of Residents #74, #83, and #3's grievances for the missing laundry items. On 11/30/23 at 11:20 a.m., the Administrator said she knew Resident #74 had complained about missing clothing, but she was unsure what had happened to them. She verified the lack of a written grievance for Resident #74's missing clothes and steps taken to resolve the grievance. She said she was aware Resident #83 complained two different times about missing clothes. She said the facility replaced and paid for the lost clothes and now those were missing. The Administrator said she was not able to locate any grievance addressing Resident #83's missing clothes. The Administrator said the facility started a performance improvement plan in March 2023 for laundry and grievances. She said the facility had, Room for improvement for grievances. The Administrator said Resident #3 never spoke to her about any missing bras. She said inventories are not completed 100% upon admission as they are required to be. She said the facility has a PIP (Performance Improvement Project) that was initiated 3/6/2023 for laundry. It specifically states to use inventory sheet and label clothing items. They have a PIP for grievances that also started in March 2023. The Administrator said the facility Has room for improvement where the grievance PIP is concerned.

Based on record review, review of the facility's policies and procedures and staff interviews, the facility failed to ensure the appropriate Pre-Admission Screening and Resident Review (PASARR) for 2 (Residents #87, and #77) of 2 residents admitted to the facility with a diagnosis of Serious Mental Illness or Intellectual Disability. The findings included: Review of the facility policy for Resident Assessment - Coordination with PASARR Program revised 9/19/22 indicated the facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder (MD), ID (intellectual disability), or a related condition receives care and services in the most integrated setting appropriate to their needs. PASARR Level II- a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. Review of the clinical record for Resident #87 revealed an admitted to the facility of 7/15/23. Resident #87 was transferred to the local hospital with return anticipated on 10/17/23 (returned on 10/20/23), and 11/10/23 (returned on 11/14/23). Review of the Level I PASARR form dated 7/12/23 completed at a local hospital noted the resident had a current diagnosis of an ID (Intellectual disability), mild, moderate, severe, or profound (Section I B). The form noted a Level II PASARR evaluation must be completed prior to admission is any box in section I.A. or I.B. is checked and there is a yes checked in Section II.1, II.2, or II.3, unless the individual meets the definition of a provisional admission or a hospital discharge exemption. Section II (II.1, II.2, and II.3) addressing other indications for PASARR Screen Decision-Making were all checked yes. The form noted Resident #87 was being admitted under the 30-day hospital discharge exemption. The instructions on the Level I PASARR form (Section III) specified, If a provisional admission or hospital discharge exemption is indicated, the individual may enter a NF (Nursing Facility) without a Level II PASRR evaluation/determination if the Level I screen indicates a suspicion of Serious Mental Illness, Intellectual disability or both, and the box in Section II.4 is checked no. Further review of the Level I PASARR form showed the box in Section II.4, Has the individual exhibited actions or behaviors that may make them a danger to themselves or others? was checked yes. Review of the Admission Minimum Data Set (MDS) assessment (standardized assessment to facilitate care management in nursing homes) with a target date of 7/21/23 noted Yes was checked for the question, Has the resident been evaluated by Level II PASARR and determined to have a serious mental illness and/or mental retardation or a related condition? The clinical record lacked documentation a Level II PASARR was completed prior to admission to the facility. On 11/29/23 at 9:33 a.m., the Regional Nurse said she could not locate a Level II PASARR screen in Resident #87's record. On 11/29/23 at 4:07 p.m., in a telephone interview, a representative of the state designated authority confirmed Resident #87 required a Level II screen, but the facility had not applied for it. 44824 Review of the clinical record for Resident #77 revealed an admitted [DATE]. The documented medical history at the time of admission included diagnoses of bipolar disorder and Depression. Bipolar disorder is defined as a disorder associated with episodes of mood swings ranging from depressive lows to manic highs. On 11/27/23 at 12:40 p.m., in an interview Resident #77 said she was diagnosed with Bipolar Disease, years ago. On 11/30/23 at 11:20 a.m., the Administrator provided two level I PASARR forms dated 7/7/23, and 8/25/23 for Resident #77. The forms were inaccurate and did not list the diagnosis of Bipolar Disorder. There was no documentation that the facility completed an accurate Level I PASARR, or referred the resident for a level II review to ensure the resident received services appropriate to her needs. On 11/30/2023 at 1:55 p.m., in an interview, the Administrator said the PASARR I screen should have been corrected and Resident #77 should have been referred for a PASARR II screen since she had a diagnosis of bipolar disorder and depression.

Based on observations, record review, review of facility's policies and procedures, and staff interviews, review the facility failed to have processes in place to ensure nursing staff were trained and competent to safely use mechanical lifts for resident transfers. On 8/12/23 Resident #1 sustained a fall during transfer with a mechanical lift resulting in a transfer to the hospital. Resident #1 suffered spinal and pelvic fractures. The Certified Nursing Assistants (CNAs) transferring the resident had no documentation of training and competency in the use of the mechanical lift. The failure to ensure the nursing staff have the necessary training, skills set and competency to safely transfer residents using a mechanical lift created an unsafe environment of avoidable accidents and falls which could result in serious injury, impairment, or death of residents, and resulted in the determination of Immediate Jeopardy. On 8/24/23 at 12:55 p.m., the facility's Administrator was informed of the Immediate Jeopardy (IJ) and provided the IJ Templates. The facility census was 101 with 20 residents who were transferred with mechanical lifts. The facility used five different brands of mechanical lifts for resident transfers. The Immediate Jeopardy began on 8/12/23. On 8/25/23, after the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 8/24/23, and the scope and severity were reduced to no actual harm, with no more than minimal harm. The findings included: Cross Reference to F600, F689, and F835 The facility's policy and procedure titled, Safe Resident Handling/Transfers with a date reviewed/revised of 1/2022 noted, Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur . Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device . The job description for the position for the nurse educator noted, Responsible for the development, coordination and implementation of facility wide training, education, and development program . Essential Duties & Responsibilities: . Works cooperatively with the Administrator, Director of Nursing, and other facility leadership in assessing educational needs and plan programs to meet these needs. Develops, coordinates, and maintains in-service education records and files related to attendance and content of all programs scheduled and presented to facility employees . Conduct new hire and annual orientation programs. Conduct competency skills review on hire and annually for all applicable personnel . The facility did not have a nurse educator at the time of the survey. The Certified Nursing Assistant (CNA) job description dated April 2020 noted, Summary: Perform direct resident care duties under the supervision of licensed nursing personnel. Assist with promoting a compassionate physical and psychosocial environment for the residents . Essential Duties and Responsibilities: . Ambulate and transfer residents, utilizing appropriate assistive devices and body mechanics . 1. Review of the clinical record for Resident #1 revealed an admitted [DATE]. Diagnoses included Arthritis, seizure disorder, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment with a reference date of 7/10/23 noted Resident #1's cognition was intact with a Brief Interview for Mental Status of 15. Resident #1 was totally dependent on the physical assistance of two persons for bed mobility and required extensive physical assistance of two persons for transfer (How the resident moves between surfaces including to or from bed, chair, wheelchair). Resident #1 had functional limitation in range of motion of both lower extremities. On 8/21/23, review of the facility's accidents and incidents investigations revealed on 8/12/23 at approximately 10:49 a.m., CNA Staff I and CNA Staff L were transferring Resident #1 using a total body lift from bed to the chair. There was a loud noise from the lift. The bar of the mechanical lift was shaking. One loop from the sling came loose and the resident fell to the floor. Resident #1 complained of back and hip pain and was transferred to an acute care hospital. Review of the hospital records showed on 8/12/23 Resident #1 presented to the Emergency Department via Emergency Medical Services from the facility, following a mechanical fall . She states she fell from a (brand name) lift. She struck her head and right side of her body . She currently reports posterior head pain, neck pain, right arm, and right leg pain . Movement exacerbates her pain . The hospital record documented Resident #1 suffered spinal and pelvic fractures. 2. Review of the facility's incident investigation into Resident #1's fall from the mechanical lift showed: On 8/15/23 CNA Staff L provided a statement that read, We cleaned her up, changed her clothes and put the sling under the resident. We brought the (brand name) lift to the bed and each of us hooked the two sling straps on our side of the bed. The patient was lifted up off of the bed with no problem. She pulled the (brand name) lift back and the resident was ok. I went to get the wheelchair turned around and placed behind the patient. The bar was shaking. This lift is too light and not stable, but this resident was light (did not have too many pounds). Only one hook came loose but it was the loop at the resident's head on her left side. The other CNA opened the legs of the (brand name) lift and the resident then dropped to the floor. The resident's hand [sic] were across her stomach, she was not holding on to anything. The statement noted two CNAs were using the lift and used a shower mesh sling for the transfer. On 8/15/23 CNA Staff I provided a statement that read, I finished cleaning the resident. The nurse practitioner was standing at the nurses station speaking with the nurse, so I asked another CNA to assist me. I put on the resident's dress and sling under her. I placed the machine and we each hooked two loops on our side of the bed. We lifted the resident above the bed without a problem. I then pulled the machine back towards the door and opened the legs. The other CNA was placing the wheelchair for the resident to be placed. Something was loose on the machine. One loop came loose, and the resident fell to the floor. Each of us hooked two straps. The sling came off all by itself. The statement documented CNA staff I said, I've worked here for [AGE] years, and this is the first time something has happened. Review of the personnel file for CNA Staff I revealed a date of hire of 4/1/2020. The employee file lacked documentation of education, and competency in use of mechanical lifts. On 8/21/23 at 2:30 p.m., CNA Staff I said she has worked at the facility since 2001 and had not received any training on using mechanical lifts. She said they lifted Resident #1 using the mechanical lift, the top hook by the resident's left shoulder came loose and the resident fell out and landed on the floor. She said she did a mechanical lift device training on the computer after the fall. CNA staff I said no one observed her using the mechanical lift after she completed the computer training. Review of the SNF Clinic (computer based) list of training for CNA Staff I revealed on 8/15/23 (Three days after Resident #1 fell from the mechanical lift), CNA Staff I completed a 15 minute computer training on Using a Hydraulic Lift. There was no documentation of a competency evaluation following the computer training. On 8/23/23 at 9:45 a.m., CNA Staff L said she has been employed at the facility since the year 2000 and had not received any training on using mechanical lifts. She said she just used the sling that was in the resident's room. Review of the personnel file for CNA Staff L revealed a date of hire of 8/29/2000. The employee file lacked documentation of education, and competency in use of mechanical lifts. Review of the SNF Clinic list of training for CNA Staff L revealed on 8/17/23 (Three days after Resident #1 fell from the mechanical lift), CNA Staff L completed a 15 minute computer training on Using a Hydraulic Lift. There was no documentation of a competency following the computer training. 3. On 8/21/23 at 10:53 a.m., the lift used to transfer Resident #1 was observed for manufacturer, make and model. On 8/23/23 at 10:08 a.m., the Administrator provided the survey team with a picture of the sling which was used with the mechanical lift to transfer Resident #1 on 8/12/23. The sling was from a manufacturer different from the mechanical lift. Review of the manufacturer's user guide for the mechanical lift used to transfer Resident #1 noted, WARNING. (company's name) RECOMMENDS THE USE OF GENUINE (brand name) PARTS. (Brand name) slings and lifters are not designed to be interchangeable with other manufacturer's products. Using other manufacturer's products on (brand name) products is potentially unsafe and could result in serious injury to patient and/or caregiver. The facility provided sign-in sheets dated 8/12/23 and 8/14/23 for an in-service for (brand name) lift use, as part of their corrective actions. The outline of the in-service was, Staff member provided instructions packet with diagram and demonstration of proper use provided. The in-service was not specific to the different brands and models of mechanical lifts used at the facility with each manufacturer's specification. The in-service did not include the appropriate sling, including manufacturer, and size to use for each resident for comfort and safe transfer. The in-service did not include a return demonstration to verify staff were able to safely use the different mechanical lifts. A total of 24 of 48 CNAs employed by the facility attended the training. The instructions provided noted, To raise the consumer the base of the (brand name) Lifter must be spread to its widest possible position to maximize stability . Positioning the lift for use: With the legs of the base open and locked, use the steering handle to push the consumer lift into position . 4. On 8/21/23 at 11:30 a.m., CNA Staff E and CNA Staff F were observed using a mechanical lift to transfer Resident #18 from bed to chair. The CNAs positioned the base of the mechanical lift under the bed without spreading the legs of the base open. They placed the resident in the lift and guided the lift toward the chair without spreading the legs of the base open. Review of the education sign-in sheet revealed CNA Staff E and CNA Staff F attended the in-service on 8/14/23. There was no competency evaluation documented after the in-service for CNA Staff E and CNA Staff F. On 8/21/23 at 3:50 p.m., CNA Staff J and CNA Staff K were observed using a mechanical lift to transfer Resident #18 from chair to bed. The CNAs opened the legs of the base of the lift and placed the resident on the sling. They did not lock the wheels of the lift as per the in-service provided on 8/12/23 and 8/14/23. The CNAs moved the lift back, closed the legs of the base and wheeled the lift to the bed. They transferred the resident to the bed without spreading the base or locking the lift. On 8/21/23 at 4:00 p.m., CNA Staff J verified they did not lock the lift or spread the legs of the base to safely transfer Resident #18 to bed. She said since she's been employed at the facility in 2019, she has not received training on mechanical lifts. She said last week they told her what to do but no one showed her or worked with her to make sure she uses the lifts correctly. On 8/21/23 at 4:05 p.m., CNA Staff K said, They tell us what to do, they don't show us what to do. They just tell us in words and have us sign a paper. Review of the sign in sheet showed CNA Staff K attended the use of the lift in-service on 8/14/23. There was no documentation of a competency evaluation after the in-service for CNA Staff K. There was no documentation CNA Staff J attended the in-service. On 8/21/23 at 10:10 a.m., CNA Staff X said her current assignment included two residents who require a mechanical lift for transfers. Review of the in-service on use of the lifts revealed CNA Staff X attended the in-service on 8/14/23. There was no documentation of competency evaluation following the in-service. On 8/21/23 at 10:43 a.m., CNA Staff G said she did not recall receiving mechanical lift training at the facility. She said, The machines we have here are old. I don't recall any training here. Most places have specific slings and the loops on the sling represent different weights like blue is for patient that weighs 300 to 400 pounds. All the slings are mixed up and the person using the sling might not use the one with the correct fit. If that happens you can see the sling does not fit the patient. If the patient does not have enough space in the middle of the sling, then the patient will be uncomfortable. A new person will just use the sling, they don't know how to use good judgement to use the sling. If they don't have the correct size, they just take whatever is available. If we don't have one that's the correct size, we try to tie them to make it the smaller size. I know we are not to use it that way, but we explain that we can't leave the patient out of bed. On 8/21/23 at 5:30 p.m., CNA Staff Z said she has been working at the facility since 2001. She said she was trained on using a (brand name) mechanical lift, a long time ago. She said she did not have any recent training; she just knows what to do. The CNA said she just knew which colored loops to use when positioning a resident in a sling for mechanical lift transfer. When asked how she knew which loops to use CNA Staff Z said, I don't know, I just know. She was unable to explain the process to ensure the correct size of sling, or which colored loop to use to secure the sling to the lift during transfers. She said she received a recent in-service on 8/12/23 related on use of the mechanical lifts but no competency evaluation. She said she had not had a skills evaluation, for many years. Review of in-service on mechanical lifts conducted by the Director of Nursing showed CNA Staff Z attended the in-service on 8/12/23. There was no documentation of a competency evaluation following the in-service for Staff Z. On 8/21/23 at 5:45 p.m., CNA Staff T said she has worked at the facility for [AGE] years. She said she has not received any recent training on the use of mechanical lifts but, I know what I am doing. Review of the in-service on mechanical lifts dated 8/12/23 conducted by the Director of Nursing showed Staff T attended the in-service. There was no documentation of a competency evaluation following the in-service for Staff T. On 8/22/23 at 8:56 a.m., CNA Staff X, and Licensed Practical Nurse (LPN) Staff Y were observed transferring Resident #5 from the bed to the chair using a total body mechanical lift. They did not open the legs of the base of the lift when they wheeled the lift from the bed to the chair. On 8/22/23 at 9:05 a.m., CNA Staff X said she has not had any training on using the mechanical lifts in over a year. She said, We just know how to do it, depending on how big the people are. Review of the sign-in sheet for the in-service on use of the mechanical lift showed CNA Staff X attended the in-service on 8/12/23. There was no documentation of a competency evaluation following the in-service for Staff X. There was no documentation LPN Staff Y attended the in-service. On 8/21/23 at 6:43 p.m., LPN Staff C said the management did not do any training about mechanical lifts for nurses. On 8/21/23 at 6:52 p.m., agency LPN Staff D said she has been working at facility since July 2023. She said there had been no training for using mechanical lifts, and no competency evaluation done since coming to this facility. On 8/21/23 at 6:55 p.m., the Director of Nursing (DON) said he did not structure the education on 8/12/23 and 8/14/23 like a competency but since he had them return demonstration of the use of the mechanical lift, he felt it perhaps could count as a competency. The DON added, I would not consider it an annual competency. I wanted to be sure they knew how to use the machine since we did not really know what happened when the resident (Resident #1) fell . The DON confirmed he did not educate the nurses and did not document any competency for the CNAs who participated. 5. On 8/22/23 at 9:20 a.m., the Regional Nurse Consultant verified 20 current residents require the use of a mechanical lift. She said all residents using a mechanical lift should have it listed on their Kardex (provides instructions for care) and their care plan. She confirmed it was not the case for the 20 current residents requiring mechanical lifts for transfer. She said the colored loops on the slings were for positioning of the resident during transfer and the CNAs were responsible for owning which loops to use. When asked how CNAs were educated on which loops to use when transferring, the Regional Nurse Consultant said they were not addressing the loops, just the size of the sling at this time. On 8/22/23 at 9:45 a.m., CNA Staff L confirmed she was shown how to use the mechanical lift when she was hired in 2000 but has not received any education since then, until the incident with Resident #1. The CNA said the facility has not done annual competencies for years saying, They used to do them but not anymore. On 8/22/23 at 9:50 a.m., the DON said when he did the staff training on 8/12/23 and 8/14/23, he did not address how to use the various colored loops to secure the sling to the mechanical lift. The DON said, I don't remember the exact words, but the staff need to use the loops that keep the resident in the sitting position. The CNAs determine that. On 8/22/23 at 12:30 p.m., CNA, Staff I who was transferring Resident #1 at time of incident said she only opens the legs of the base when the base does not fit under the chair or bed. When asked if she uses the brakes on the chairs or lifts when transferring residents, she said, sometimes but not always. Only if I need to. 6. On 8/23/23 at 10:27 a.m., LPN Staff O said he has been a Unit Manager for about three months. He said he did not receive a full orientation to the manager's role and had to hit the ground running. The Unit Manager said he ensures safe care is being provided by monitoring his staff all of the time but does not maintain a log or audit for the monitoring. He said the majority of his staff speak English as a second language. He said, It is a challenge to communicate with the staff overall. He said the facility does not have a staff development coordinator, so they have not scheduled any skills fairs or competency fairs as far as he knew. The Unit Manager said, I know we need to do them. This is my first job as a manager, so I am doing my best. He said he has not participated or heard anything related to staff evaluations since he started employment at the facility. When asked if he had been trained on the use of mechanical lifts at the facility, he replied, I have been everywhere and anywhere. I don't do direct patient care, so I wasn't and don't need to be trained here. These are the same lifts I have used at many different places I have worked. He confirmed he had no formal training for the mechanical lifts used at this facility. On 8/23/23 at 11:15 a.m., LPN Staff P said she became a Unit Manager at the facility four months ago after working as a staff nurse through an agency for over a year. She said she did not get a full orientation to her new role. She was not aware of a skill checklist or competency for staff. She said most of the staff speak Creole primarily. She has been used as a translator, but hand outs are in English. She said it was a challenge for the leadership to communicate with the staff and she reminds them they need to try to understand when education is being done. She said she received education on monitoring staff, but nothing related to the use of mechanical lifts. She said, I wasn't trained here. I was trained in 15 facilities in the last three years, and I feel comfortable using the different types of lifts. LPN Staff P said she had no audits of staff using the mechanical lifts. 7. On 8/23/23 at 11:40 a.m., the Facility Administrator provided an annual education calendar for 2023 which listed Mechanical lift skills for February 2023 but said she could not confirm the Mechanical lift skills check was done. The Administrator said, The Staff Development Coordinator (SDC) is the position that is tasked with that responsibility. Currently, we do not have an SDC, so it falls to the DON and then me after him. Ultimately, I am responsible for ensuring the DON is ensuring staff are properly trained. The Administrator confirmed annual performance evaluations should be completed for the staff and annual competencies were needed as well. 8. Review of employee files with the Administrator for seven randomly selected direct care staff who use mechanical lifts, including, CNA Staff I, CNA Staff L, CNA Staff S, CNA Staff T, CNA Staff U, Registered Nurse (RN) Staff V and LPN Staff W revealed the most recent evaluations and competencies were completed in February 2021, and did not include the use of mechanical lifts. The administrator confirmed there were risks for not completing staff evaluations and competencies. She said, We would be unaware of the staff skills and level of competence since we do not have the return demonstrations. It would be unsafe for the residents. The administrator had no explanation for the lack of evaluations for direct care staff. She said she has been employed at the facility since February 2023 but has not looked for evaluations until now. On 8/23/23 at 1:00 p.m., in a telephone interview, the DON said he was unaware of an education calendar at the facility. He was also unaware direct care staff had not had evaluations or competencies documented. The DON confirmed he was responsible for ensuring staff had appropriate competencies documented including safely using mechanical lifts. He said, It is about the safety of the patients if we don't do evals and competencies then how would we know if we are giving safe care. He said prior to Resident #1's fall during transfer with a lift, he assumed staff had been trained on the mechanical lifts, so there had been no education or monitoring of the lift use. The DON said, Ultimately it is my responsibility to ensure they have their competencies done and are providing safe care. On 8/24/23 at 11:05 a.m. in a telephone interview the DON said on 8/12/23 and 8/14/23, he educated the staff step by step as the handout he used. The observation of CNA Staff J, CNA Staff K, CNA Staff E, and CNA Staff F, using the mechanical lift to transfer Resident #18 without opening the legs of the base, and the observation of CNA Staff X, and Licensed Practical Nurse (LPN) Staff Y, using the mechanical lift to transfer Resident #5 without opening the legs of the base as per the manufacturer's instructions was shared with the DON. The DON said, I'm not surprised. We have such a bad language barrier but if I need to educate six times I will, to be sure that the CNAs understand and provide safe care. On 8/25/23, the immediate actions to remove the Immediate Jeopardy implemented by the facility and verified by the surveyor included: Facility Administrator and Director of Nursing were re-educated on 8/21/23 by Regional Nurse Consultant on developing a process to validate education, training and competencies with initial focus on mechanical lift safety. The surveyor verified through record review. An electronic training system for providing, tracking and documenting training and education was added as an additional resource on 8/15/23. The surveyor verified through review of education records. Immediate education was provided on-site on 8/12/23 to all working Nursing staff on mechanical lift safety by the Director of Nursing. Eleven (11) were educated, which is 17.5% of total nursing staff. This mechanical lift education was continued through 8/14/23 with an additional 13 (thirteen) nursing staff which equals 38.09% of the total nursing staff. Total nursing staff are 63 (sixty-three). There are 19 nurses and 44 CNAs on staff. The above mechanical lift education represents 43% CNAs, and 26% nurses. The surveyor verified through record review. This was done after DON was educated by Regional Nurse Consultant for basic functionality and safe use. The surveyor verified through record review. Education with return demonstration competencies started on 8/21/23 and continued for use of mechanical lifts through today, 8/24/23 with all working staff in compliance. 76% of nursing staff have been trained as of this date, 63.15% are nurses, and 81.81% are CNAs. This training includes the sizes indicated for each resident and where to find this information on the Kardex. The surveyor verified through record review. A documented checklist for personnel education files was initiated that includes all recommended competencies and education for CNAs and Nurses. The surveyor verified through record review. Audit of personnel files that started on 8/22/23 did not show documented proof of training and competency for staff that utilize mechanical lifts and education was initiated immediately. The surveyor verified through record review. Documentation for the education provided along with competencies is now organized by staff names and includes title and all applicable annual education. A process was initiated to continue this to ensure compliance. The surveyor verified through record review. Facility lifts were all inspected to verify functionality on the date of event 8/12/23 by the Director of Nursing and found to be safe and functional. This was done after DON was educated by Regional Nurse Consultant for basic functionality and safe use. The surveyor verified through record review. Facility maintenance assistant inspected all facility lifts on 8/15/23 and all lifts were found to be safe and functional. These were inspected according to their manufacturer's guidelines. The surveyor verified through record review. Regional director of plant operations inspected all facility lifts on 8/16/23 and verified that they were found to be safe and functional. These were inspected according to their manufacturer's guidelines. The surveyor verified through review of the inspection forms. Slings in the facility that are in use were all inspected starting on 8/12/23 and continued through 8/22/23 and continued daily. Slings that were found in disrepair or torn were discarded on 8/12/23, 8/21/23 and 8/22/23. The surveyor verified through record review. A mechanical sit to stand lift was removed from service on 8/22/23 as it needed battery backup. A mechanical lift was removed from service on 8/22/23 as it needs a U-spreader clip which was ordered. The surveyor verified through documentation provided. Additional mechanical lifts with additional slings have been ordered by the Administrator on 8/24/23 that are appropriate to resident size needs. These lifts and slings ordered are all the same, uniform brand. The sizes were determined by the nursing and therapy team leaders according to residents' weight and height. (Brand name) slings that state they are recommended only to be used on (brand name) lifts were taken out of service on 8/24/23 to prevent incompatible use. The surveyor verified through review of purchase orders. After the new mechanical lifts are received, the previous lifts will all be taken out of service and disposed of, as well as the slings that are in service. The surveyor verified through record review. Residents who require mechanical lifts have all been re-evaluated by the therapy department and nursing department as of 8/22/23. The surveyor verified through review of clinical documentation for residents who use mechanical lifts. As of 8/22/23 the residents who require mechanical lifts have been assigned a corresponding sling size recommendation as evaluated by nursing and therapy, and this information has been communicated to the staff in the electronic record in the care plans and the Kardex. The surveyor verified through review of clinical documentation in the electronic clinical records, and observation of CNAs transferring Resident #18 with a mechanical lift. Residents who require extensive assistance will be transferred using two-person pivot transfer if needed if their sling size is temporarily unavailable. This education to staff is provided daily at the beginning of their shift and the information is also available in the Kardex for all shifts to view. Of the residents who require small slings (initially there were seven) after evaluation three did not need mechanical lifts at all, leaving four. These four will utilize this method of transfer until the ordered slings are delivered. The surveyor verified through review of staff education sign-in sheets identifying residents appropriately.

Based on observations, record review, review of policies and procedures, and staff interviews, the facility failed to protect the residents' right to be free from neglect, in that the facility failed to ensure staff who use mechanical lifts to transfer residents were trained, and competent to safely use the lifts. Resident #1 was dependent on staff for transfer and required the use of a mechanical lift. On 8/12/23 Resident #1 fell from the full body mechanical lift during transfer. Resident #1 was hospitalized and suffered spinal and pelvic fractures. There was no documentation the staff who transferred Resident #1 were trained and competent to safely use the mechanical lift. The facility's failure to provide the necessary structure and processes to prevent neglect placed other residents who require the use of mechanical lifts at a likelihood of avoidable accidents and falls which could result in serious injury, impairment, or death, and resulted in the determination of Immediate Jeopardy. On 8/24/23 at 12:55 p.m., the Administrator was notified of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The facility census was 101 with 20 residents who were transferred with mechanical lifts. The facility used five different brands of mechanical lifts for transfers. The Immediate Jeopardy began on 8/12/23. On 8/25/23, after the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 8/24/23 and the scope and severity were reduced to no actual harm, with no more than minimal harm. The findings included: Cross reference to F689, F726, and F835. The facility's policy and procedure titled, Abuse, Neglect and Exploitation, with a date reviewed/revised of 10/1/2022 noted, The facility will develop and implement written policies and procedures that: Prohibit and prevent . neglect . The facility will make individual determinations in consideration of current staffing patterns, staff qualifications, competency and knowledge, clinical resources, physical environment, and equipment . Identifying, correcting, and intervening in situations in which . neglect is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual resident's care needs . Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors . The facility's policy and procedure titled, Safe Resident Handling/Transfers, with a date reviewed/revised of 1/2022 noted, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines . The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly . Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur . Staff will perform mechanical lifts/transfers according to the manufacturer's instructions for use of the device . Review of the clinical record for Resident #1 revealed an admitted [DATE]. Diagnoses included Arthritis, seizure disorder, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment with a reference date of 7/10/23 noted Resident #1 was totally dependent on the physical assistance of two persons for bed mobility and required extensive physical assistance of two persons for transfer. Resident #1 had functional limitation in range of motion of both lower extremities. The Physical Therapy Plan of Treatment for the period of 3/28/23 to 4/26/23 noted Resident #1 used a mechanical lift. Precautions included fall risk and (brand name) lift. Review of the progress notes revealed on 8/12/23 at 2:07 p.m., the Director of Nursing (DON) documented at 10:49 a.m., two Certified Nursing Assistants (CNAs) were transferring Resident #1 from bed to chair. There was a loud noise from the lift and then the resident was lowered to the floor. The CNAs tried to stop it but were unsuccessful. The Advanced Practice Registered Nurse (APRN) came to the room as the CNAs and the resident were screaming. The resident complained of back and hip pain. The APRN documented on 8/12/23 at 10:52 a.m., she examined Resident #1. The resident was alert and cooperative, had a fall after transfer using a mechanical lift. She went in the room, noted the resident on the floor on her back, yelling out, crying, c/o (complaining of) headache, right hip pain, back pain . The APRN recommended sending the resident to the emergency room for further evaluation. Resident #1 was transferred to the local hospital via EMS (Emergency Medical Services). Review of the hospital records revealed on 8/12/23 Resident #1 was admitted and suffered spinal and pelvic fractures. Review of the Nursing Home Federal Report to the Florida Agency for Health Care Administration (Florida state survey agency) revealed on 8/13/23 a representative of the Florida Department of Children and Families (Florida abuse investigation agency) visited the facility and reported an allegation of neglect related to the care provided to Resident #1, including fractures sustained during the transfer with the mechanical lift. The facility documented they completed a thorough investigation into the allegation of neglect and determined the allegation was not substantiated. The facility's investigative findings noted on 8/12/23, two CNAs used a mechanical lift to transfer Resident #1. Once the resident was lifted off the bed, and the lift moved to place Resident #1 in the chair, one loop of the sling came loose, and the resident fell to the floor. On 8/21/23 the facility provided witness statements from CNA Staff I and CNA Staff L who used the mechanical lift to transfer Resident #1. CNA Staff L provided a statement on 8/15/23 noting the bar of the lift was shaking. This lift is too light and not stable, but this resident was light (did not have too many pounds). Only one hook came loose but it was the loop at the resident's head on her left side. The other CNA opened the legs of the (brand name) lift and the resident then dropped to the floor. CNA Staff I provided a statement on 8/15/23 which included, Something was loose on the machine. One loop came loose, and the resident fell to the floor . The sling came off all by itself. The facility also provided a video re-enactment of the incident, using the same mechanical lift that was used to transfer Resident #1. The video showed the mechanical lift making a clicking noise as the boom, and cradle bars were lowered. The loops from the sling did not come loose, and did not detach from the lift during the re-enactment. The facility's incident investigation did not document a root cause for the loop detaching from the lift and removed the mechanical lift from service. Review of the user manufacturer's instruction manual for the lift used to transfer Resident #1 noted, Important safety information for hazards that might cause serious injury. The instructions included, before using the lift examine slings for fraying or other damage. Do not use if damaged or if the sling shows signs of wear. The investigation did not include documentation CNA Staff I or CNA Staff L inspected the lift or the sling before transferring Resident #1 per facility policy, or manufacturer's safety information. On 8/23/23 at 10:08 a.m., the Administrator provided the survey team with a picture of the sling used with the mechanical lift to transfer Resident #1 on 8/12/23. The sling was from a manufacturer different from the manufacturer of the mechanical lift it was used for. Review of the manufacturer's user guide for the mechanical lift used to transfer Resident #1 noted, WARNING. (company's name) RECOMMENDS THE USE OF GENUINE (brand name) PARTS. (Brand name) slings and lifters are not designed to be interchangeable with other manufacturer's products. Using other manufacturer's products on (brand name) products is potentially unsafe and could result in serious injury to patient and/or caregiver. The facility's investigation did not address the failure of staff to follow the manufacturer's user guide for slings. The facility provided staff education sign in sheets dated 8/12/23 and 8/14/23 for (brand name) lift use. The outline was, Staff member provided (brand name lift) instructions packet with diagram and demonstration of proper use provided. A total of 24 of 48 CNAs employed by the facility attended the training. The instructions provided included, To raise the consumer the base of the (brand name) Lifter must be spread to its widest possible position to maximize stability . Positioning the lift for use: With the legs of the base open and locked, use the steering handle to push the consumer lift into position . The education did not include a return demonstration to verify staff understood the education and were able to safely use the mechanical lifts. The education did not include a visual inspection of the lift and the slings before use as per the manufacturer's specifications. On 8/21/23 at 11:03 a.m., a sit-to-stand lift was observed in the central shower room of the North Unit. The adjustable knee pad was missing a large piece. An orange sticker with a handwritten date of 8/15/23 was observed on the lift. Photographic evidence obtained. A damp transfer sling was observed resting on the lift. The label was torn out. The strap appeared frayed. The buckle of the strap belt that goes around the resident's waist was secured to the belt with a knot. Photographic evidence obtained. Review of the manufacturer's instructions for the sling noted, Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately. DO NOT alter slings. On 8/21/23 at 11:05 a.m., the Maintenance Assistant verified the sit-to-stand lift with the missing piece of the adjustable knee pad was inspected on 8/15/23 as per the orange sticker. The Maintenance Assistant said the sit-to-stand lift was one of the five lifts currently being used to transfer residents. On 8/21/23 at 11:30 a.m., CNA Staff E, and CNA Staff F said the buckle strap must be used to safely use the sling, and verified the buckle was secured to the strap belt with a knot. They said the buckle must have come loose and someone tied a knot to the strap to secure the buckle in place. They both said it would not be safe to transfer a resident with the defective sling. On 8/21/23 at 11:30 a.m., CNA Staff E and CNA Staff F who attended the in-service on 8/14/23 were observed using a full body mechanical lift to transfer Resident #18 from bed to chair. The CNAs positioned the base of the mechanical lift under the bed without spreading the legs of the base open. They placed the resident in the lift and guided the lift toward the chair without spreading the legs of the base open per the in-service of 8/14/23. On 8/21/23 at 1:34 p.m., a full body mechanical lift was observed in the hallway of the South Unit. One of the six hooks of the hanger bar was missing the locking clip. There was no sign on the lift to alert staff of the missing locking clip. Photographic evidence obtained. On 8/21/23 at 3:12 p.m., a sling was observed stored on a full body mechanical lift on the South Unit. A zip tie was observed around one of the loops (green loop) used to attach the sling to the mechanical lift. Photographic evidence obtained. On 8/21/23 at 3:25 p.m., the Maintenance Assistant verified the green loop of the strap had a zip tie around it. He said it shouldn't be on there and offered to cut it off. On 8/21/23 at 3:25 p.m., Occupational Therapist Staff M said she came from a facility where therapy would provide in-services to the staff on the correct use of the lifts. She said, They don't do that here. I tried to get a CNA to help me with a mechanical lift today, but she seemed uncomfortable, so I didn't push. She said they should not put zip ties on the loop strap. On 8/21/23 at 3:50 p.m., CNA Staff J and CNA Staff K (who attended the in-service on 8/14/23) were observed using a mechanical lift to transfer Resident #18 from chair to bed. They did not lock the wheels of the lift. The CNAs moved the lift back, closed the legs of the base and wheeled the lift to the bed. They transferred the resident to the bed without spreading the legs of the base or locking the lift as per the in-service provided on 8/14/23. On 8/21/23 at 4:05 p.m., CNA Staff K said, They tell us what to do, they don't show us what to do. They just tell us in words and have us sign a paper. There was no documentation CNA Staff J attended the in-service on 8/12/23 or 8/14/23. On 8/21/23 at 6:36 p.m., the Regional Maintenance Director verified the full body lift observed in the hallway of the South Unit was one of the five mechanical lifts currently in use. He verified one of the locking clips was missing, and said, They should not use it without the clip. I'm taking it out of service right now. The Regional Maintenance Director verified no one had notified him of the missing clip. On 8/21/23 at 6:30 p.m., the DON said after Resident #1 fell from the mechanical lift, he started educating the CNAs on the use of mechanical lifts. He said he only educated the CNAs on duty on 8/12/23 and 8/14/23. He educated approximately 24 CNAs who use mechanical lifts. The DON said he did not structure the education given to the CNAs like a competency. He said, I wanted to be sure they knew how to use the machine since we did not really know what happened when the resident fell . He said he only provided education to the CNAs even though the nurses also use the mechanical lifts and supervise the CNAs. The facility provided certificates showing on 8/15/23, and 8/17/23 after Resident #1 fell from the lift, CNA Staff I, and CNA Staff L who performed the transfer satisfactorily respectively completed a computer training on CNA- Safely Moving Residents- Lifting and Transferring for 30 minutes and Using a Hydraulic Lift for 15 minutes. The training did not include a competency evaluation. Review of the CNAs daily assignment for 8/21/23 for the 7:00 a.m., to 3:00 p.m., shift revealed two of the nine CNAs on duty assigned to residents who require the use of a mechanical lift for transfers did not attend the in-service on 8/12/23 or 8/14/23. Seven CNAs attended the in-service on 8/12/23 or 8/14/23 for use of the lift but had no competencies or return demonstration on the use of the lift. On 8/21/23 at 2:30 p.m., CNA Staff I said she has been employed at the facility since 2001 and had not received any training on using mechanical lifts. She said after Resident #1 fell from the lift the facility had her complete a mechanical lift device training on the computer, but no one observed her using the mechanical lift after the training. On 8/21/23 at 7:00 p.m., the Administrator said the facility currently did not have an education coordinator, the position has been opened since 1/20/23. A person was hired for a short time on 5/29/23 and stayed through June 2023. The Regional Nurse Consultant who was present during the interview said there was no documented staff competencies for the use of mechanical lifts but will be working on them. On 8/23/23 at 1:00 p.m., in a telephone interview, the DON confirmed he was responsible to ensure staff had appropriate competencies for the use of mechanical lifts. He said, We educate them, we audit them, we mentor them. We try to put measures in place like check lists. Making sure that they know how to safely do their jobs. It is about the safety of the patients. If we don't do evaluations and competencies, then how would we know if we are giving safe care? The DON verified he had not ensured all staff who used mechanical lifts were educated and competent to safely use the lifts after Resident #1 fell from the lift and sustained serious injuries. 44307 The immediate actions to remove the Immediate Jeopardy implemented by the facility and verified by the surveyor on 8/25/23 included: The lift that was in use on 8/12/23 was removed from service and disposed of on 8/15/23. The surveyor verified on 8/21/23 by observation of the discarded lift and interview with the Regional Nurse Consultant and Administrator. Immediate education was provided on-site on 8/12/23 to all working Nursing staff on mechanical lift safety by the Director of Nursing. Eleven (11) were educated which is 17.5% of total nursing staff. This mechanical lift education was continued through 8/14/23 with an additional 13 (thirteen) nursing staff which equals 38.09% of the total nursing staff. Total nursing staff are 63 (sixty-three). There are 19 nurses and 44 CNAs on staff. The above mechanical lift education represents 43% CNAs, and 26% nurses. The surveyor verified by review of education provided. Education for Abuse, Neglect was started on 8/14/23 and continued for all staff in the facility through today and facility is at 72.16% of all total staff (97) for compliance with this education. The surveyor verified by record review of completion of the education. The agency staff are educated on the shift they arrive prior to taking an assignment, and a roster is kept with their signatures. This is done according to the daily schedule provided by the staffing coordinator. The surveyor verified through record review and interview of two licensed nurses. The new staff and the staff returning from leave (FMLA (Family Medical Leave of Absence), vacation, etc.) are tracked on the master education roster and will not work until they have completed all applicable educations. The scheduler provides the daily roster. Administrator and a nurse or designee educate at the start of the shift prior to accepting their assignment. The surveyor verified through review of the education, Administrator and scheduler interview. Education competencies were initiated on 8/15/23 on the electronic training system and on 8/21/23 with return demonstration for use of mechanical lifts through today, 8/24/23 with 76.19% of total nursing staff completed. The surveyor verified by review of the training and competencies completed. The training for the slings and mechanical lift compatibility was initiated on 8/23/23; however, (brand name) slings that state they are recommended only to be used on (brand name) lifts were taken out of service on 8/24/23 to prevent this from occurring. The surveyor verified by review of attestation of sling removal signed by the housekeeping director. Documentation for the education for ANE (Abuse, Neglect, Exploitation) according to policy, and proper use of mechanical lifts with competencies and signatures is confirmed. The percentage for completion is 72% for ANE and 76% for mechanical lifts; 63.15% are nurses, and 81.81% of CNAs. The surveyor verified by review of the in-service and random staff interviews. Facility lifts were all inspected to verify functionality on the date of event 8/12/23 by the Director of Nursing and found to be safe and functional. This was done after DON was educated by Regional Nurse Consultant for basic functionality and safe use. The surveyor verified by review of the lifts inspection and review of attestation of completion completed by the Regional Nurse Consultant and the Director of Nursing (DON). Facility maintenance assistant inspected all facility lifts on 8/15/23 and all lifts were found to be safe and functional. These were inspected according to their manufacturer's guidelines. The surveyor verified through record review. Regional director of plant operations inspected all facility lifts on 8/16/23 and verified that they were found to be safe and functional. These were inspected according to manufacturer's guidelines. The surveyor verified through record review. Slings in the facility that are in use were all inspected starting on 8/12/23 and continued through 8/22/23 and continued daily. Slings that were found in disrepair or torn were discarded on 8/12/23, 8/21/23 and 8/22/23. The surveyor verified by record review and observation of slings. A mechanical sit-to-stand lift was removed from service on 8/22/23 as it needed battery backup. A mechanical lift was removed from service on 8/22/23 as it needed a U-spreader clip which was ordered. The surveyor verified by record review of attestation from the Administrator. Additional mechanical lifts with additional slings have been ordered on 8/24/23 that are appropriate to resident size needs. Sizing was completed utilizing weight and height to calculate need by therapy and nursing department. These lifts and slings ordered are all the same, uniform brand. The surveyor verified by record review of purchase orders, and review of sizing of slings documented in the electronic clinical records. Residents who require mechanical lifts have all been re-evaluated by the therapy department and nursing department and of 20 there were 4 that were found not to require lift assistance and due to admissions an additional two will require mechanical lifts for a total of 18 as of 8/22/23. The surveyor verified by record review documentation of evaluation in Point Click Care, electronic record. The 18 residents who require mechanical lifts have been assigned a corresponding size recommendation by nursing and therapy according to weights and this information has been communicated to the staff in the electronic record in the care plans and the Kardex (provides instructions for care) for nursing staff. The surveyor verified by record review. Seven residents required small slings initially there were seven; after evaluation three did not need mechanical lifts at all, leaving four residents who were found to be able to be transferred using two persons pivot transfer and will utilize this method of transfer until the ordered slings are delivered. This education to staff is provided daily at the beginning of their shift and the information is also available in the Kardex for all shifts to view. The surveyor verified through record review.

Based on observation, record review, review of facility's policies and procedures, family and staff interviews, the facility failed to implement ongoing training, competencies, and supervision of staff to ensure the safe use of mechanical lifts and prevent avoidable accidents. On 8/12/23 Resident #1 fell from a mechanical lift during transfer, was hospitalized and suffered spinal and pelvic fractures. The Certified Nursing Assistants (CNAs) transferring the resident had no documentation of training, or competency for the proper use of the lift. The failure to ensure staff use safe transfer techniques during mechanical lift transfers created an unsafe environment of avoidable accidents or falls which could result in serious injury, impairment, or death of residents from improper use of the lift and resulted in the determination of Immediate Jeopardy. On 8/24/23 at 12:55 p.m., the Administrator was informed of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The facility census was 101 with 20 residents who were transferred with mechanical lifts. The facility used five different brands of mechanical lifts for resident transfers. The Immediate Jeopardy started on 8/12/23. On 8/25/23, after the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 8/24/23 and the scope and severity were reduced to D no actual harm, with no more than minimal harm. The findings included: Cross reference F600, F726 and F835. The facility's policy titled, Safe Resident Handling/Transfers with date reviewed/revised of 1/2022 noted, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines . The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly. Damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy . Ensure that the sling designated for the lift is utilized with that specific lift . Resident lifting and transferring will be performed according to the resident's individual plan of care . Review of the clinical record for Resident #1 revealed an admitted [DATE]. Diagnoses included Arthritis, seizure disorder, and muscle weakness. The Quarterly Minimum Data Set (MDS) assessment with a reference date of 7/10/23 noted Resident #1's cognition was intact with a Brief Interview for Mental Status score of 15. Resident #1 was totally dependent on the physical assistance of two persons for bed mobility and required extensive physical assistance of two persons for transfer (how the resident moves between surfaces including to or from bed, chair, wheelchair). Resident #1 had functional limitation in range of motion of both lower extremities. The Physical Therapy Plan of Treatment for the period of 3/28/23 to 4/26/23, noted Resident #1's prior level of function included the use of a mechanical lift, and precautions included fall risk and (brand name) lift. On 8/21/23, review of the facility's accidents and incidents investigations revealed on 8/12/23 at approximately 10:49 a.m., CNA Staff I and CNA Staff L were transferring Resident #1 using a total body mechanical lift from bed to the chair. There was a loud noise from the lift. The bar of the mechanical lift was shaking. One loop from the sling came loose and the resident fell to the floor. Resident #1 complained of back and hip pain and was transferred to an acute care hospital. On 8/15/23 CNA Staff L provided a statement that read, We cleaned her up, changed her clothes and put the sling under the resident. We brought the (brand name) lift to the bed and each of us hooked the two sling straps on our side of the bed. The patient was lifted up off of the bed with no problem. She pulled the (brand name) lift back and the resident was ok. I went to get the wheelchair turned around and placed behind the patient. The bar was shaking. This lift is too light and not stable, but this resident was light (did not have too many pounds). Only one hook came loose but it was the loop at the resident's head on her left side. The other CNA opened the legs of the (brand name) lift and the resident then dropped to the floor. The resident's hand [sic] were across her stomach, she was not holding on to anything. The statement noted two CNAs were using the lift and used a shower mesh sling for the transfer. On 8/15/23 CNA Staff I provided a statement that read, I finished cleaning the resident. The nurse practitioner was standing at the nurses station speaking with the nurse, so I asked another CNA to assist me. I put on the resident's dress and sling under her. I placed the machine and we each hooked two loops on our side of the bed. We lifted the resident above the bed without a problem. I then pulled the machine back towards the door and opened the legs. The other CNA was placing the wheelchair for the resident to be placed. Something was loose on the machine. One loop came loose, and the resident fell to the floor. Each of us hooked two straps. The sling came off all by itself. The statement documented CNA staff I said, I've worked here for [AGE] years and this is the first time something has happened. There was no documentation in the investigation, CNA Staff I or CNA Staff L inspected the lift prior to use to ensure functionality. The Director of Nursing (DON) noted the mechanical lift was removed from service and labeled. On 8/21/23 at 10:53 a.m., the lift used to transfer Resident #1 was observed for manufacturer, make and model. On 8/23/23 at 10:08 a.m., the Administrator provided the survey team with a picture of the sling which was used with the mechanical lift to transfer Resident #1 on 8/12/23. The sling was from a manufacturer different from the mechanical lift manufacturer it was used for. Review of the manufacturer's user guide for the mechanical lift noted, WARNING. (company's name) RECOMMENDS THE USE OF GENUINE (brand name) PARTS. (Brand name) slings and lifters are not designed to be interchangeable with other manufacturer's products. Using other manufacturer's products on (brand name) products is potentially unsafe and could result in serious injury to patient and/or caregiver. On 8/22/23, review of the hospital records showed Resident #1 presented to the Emergency Department via Emergency Medical Services from the facility, following a mechanical fall . She states she fell from a (brand name) lift. She struck her head and right side of her body . She currently reports posterior head pain, neck pain, right arm, and right leg pain . Movement exacerbates her pain . Review of the Computerized Tomography (CT) scan results from the hospital dated August 12, 2023, at 4:47 p.m., showed Resident #1 suffered: Acute non-displaced fracture of right transverse process of the L5 (5th lumbar) vertebra (lower back bones in spinal column). Acute non-displaced fracture of the body of the sacrum on the right and right sacral ala (bone that is located at the base of the lumbar vertebrae and is connected to the pelvis). Acute non-displaced fracture of right superior pubic ramus (group of bones that make up part of the pelvis). On 8/21/23 the facility provided a staff education sign in sheets dated 8/12/23 and 8/14/23 for (brand name) lift use as part of their corrective actions. The outline was, Staff member provided instructions packet with diagram and demonstration of proper use provided. The education did not include a return demonstration to verify staff understood the instructions and were able to safely use the mechanical lifts. The in-service did not include instructions on slings, including manufacturer, type, or size of sling to use for each resident. A total of 24 of 48 CNAs employed by the facility attended the training. The instructions provided noted, To raise the consumer the base of the (brand name) Lifter must be spread to its widest possible position to maximize stability . Positioning the lift for use: With the legs of the base open and locked, use the steering handle to push the consumer lift into position . On 8/21/23 at 11:30 a.m., CNA Staff E and CNA Staff F were observed using a mechanical lift to transfer Resident #18 from bed to chair. The CNAs positioned the base of the mechanical lift under the bed without spreading the legs of the base open. They placed the resident in the lift and guided the lift toward the chair without spreading the legs of the base open. Review of the education sign-in sheet revealed CNA Staff E and CNA Staff F attended the in-service on 8/14/23. On 8/21/23 at 3:50 p.m., CNA Staff J and CNA Staff K were observed using a mechanical lift to transfer Resident #18 from chair to bed. The CNAs opened the base of the lift and placed the resident on the sling. They did not lock the wheels of the lift as per the in-service provided on 8/12/23 and 8/14/23. The CNAs moved the lift back, closed the legs of the base and wheeled the lift to the bed. They transferred the resident to the bed without spreading the legs of the base or locking the lift. Review of the manufacturer's operating instructions for the lift used by Staff J and K noted, Warning: Never perform a lift/transfer with the legs in the closed/transport position (front casters touching). The closed/transport position is for storage and transport only. On 8/21/23 at 4:00 p.m., CNA Staff J verified they did not lock the lift or spread the legs of the base to safely transfer Resident #18 to bed. She said since she's been employed at the facility (2019) she has not received training on mechanical lifts. She said last week they told her what to do but no one showed her or worked with her to make sure she uses the lifts correctly. On 8/21/23 at 4:05 p.m., CNA Staff K said, They tell us what to do, they don't show us what to do. They just tell us in words and have us sign a paper. Review of the in-service sign in sheet showed CNA Staff K attended the in-service on 8/14/23. There was no documentation CNA Staff J attended the in-service. On 8/21/23 at 2:30 p.m., CNA Staff I said she has worked at the facility since 2001 and had not received any training on using mechanical lifts. She said they lifted Resident #1 using the mechanical lift, the top hook by the resident's left shoulder came loose and the resident fell out and landed on the floor. She said she did a mechanical lift device training on the computer after the fall. CNA staff I said no one observed her using the mechanical lift after she completed the computer training. On 8/22/23 at 8:56 a.m., CNA Staff X, and Licensed Practical Nurse (LPN) Staff Y were observed transferring Resident #5 from the bed to the chair using a total body mechanical lift. They did not open the base of the lift when they wheeled the lift from the bed to the chair. On 8/22/23 at 9:05 a.m., CNA Staff X who signed she attended the in-service on 8/12/23 said she has not had any training on using the mechanical lifts in over a year. She said, We just know how to do it, depending on how big the people are. There was no documentation LPN Staff Y attended the in-service. On 8/23/23 at 1:00 p.m., in a telephone interview, the DON said he has been employed at the facility since May 29, 2023. He said his role includes, We educate them, we audit them, we mentor them. We try to put measures in place like check lists. Making sure that they know how to safely do their jobs. The DON confirmed he was responsible to ensure staff had appropriate competencies for the use of mechanical lifts. He said the training he started after Resident #1's fall from the lift was for the overall use of mechanical lifts, not specific to any lift or sling. He said, I was only reacting to the incident. I should have done both all along. He said he had not received any training on the different lifts the facility utilizes, and he had not personally monitored the staff using the mechanical lift. The DON added, It is about the safety of the patients. If we don't do evaluations and competencies, then how would we know if we are giving safe care? On 8/23/23 at 9:45 a.m., CNA Staff L said she has been employed at the facility since the year 2000 and had not received any training on using mechanical lifts since then. She said she just used the sling that was in the resident's room. Review of the manuals for slings used at the facility revealed: Manufacturer A instructions for use of sling noted, Check the patient's weight and the sling's maximum weight capacity. Ensure the patient's weight does not exceed the sling's maximum weight capacity. Manufacturer B instructions for use of sling noted, (Brand name) slings are made specifically for use with (brand name) lifts. For the safety of the patient, DO NOT intermix slings and lifts of different manufacturers . Selecting the most appropriate sling is crucial since it ensures a safe, dignified and comfortable patient transfer whilst reducing the risks associated with manual handling . Manufacturer B sling instruction manual included a Size & [and] Weight Range Guide (approx.) chart guide which noted, It is very important to use the correct sized sling and ensure it is properly fitted before attempting to lift. This will ensure the person being lifted feels safe, dignified and comfortable. It will also provide the carer with confidence that they can achieve the transfer required and that the procedure will be executed in an effective and safe manner. The sling size chart included: Extra Small: 16-45 kg (kilograms), 35 to 99.2 pounds (lbs.). Small: 34-68 kg, 74.9 to 128 lbs. Medium: 57-91 kg, 125.6 to 200.6 lbs. Large: 80-136 kg, 176.3 to 299.8 lbs. Extra Large: 125-284 kg, 265.5 to 626. 1 lbs. Manufacturer C instructions for slings noted (Brand name) slings and patient lift accessories are specifically designed to be used in conjunction with (Brand name) patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of (brand name) patient lift system . Use only genuine (brand name) slings and lift accessories to maintain patient safety and product utility. On 8/23/23 at 1:52 p.m., Resident #13 and Resident #14 were observed in a wheelchair with a sling from manufacturer A. CNA Staff CC said the lift (lift 3) she used to transfer the residents was not from manufacturer A. Review of the manufacturer's instruction manual for lift 3 noted, Warning! Using accessories, detachable parts, or materials not described in the instruction manual MAY RESULT IN SERIOUS INJURY OR DEATH . The list of slings compatible with mechanical lift 3 did not include slings from manufacturer A. 44307 On 8/25/23, the immediate actions to remove the Immediate Jeopardy implemented by the facility and verified by the surveyor included: Immediate education was provided on-site on 8/12/23 to all working Nursing staff on mechanical lift safety by the Director of Nursing. Eleven (11) were educated which is 17.5% of total nursing staff. This mechanical lift education was continued through 8/14/23 with an additional 13 (thirteen) nursing staff which equals 38.09% of the total nursing staff. Total nursing staff are 63 (sixty-three). There are 19 nurses and 44 CNAs on staff. The above mechanical lift education represents 43% CNAs, and 26% nurses. The surveyor verified through review of the education. Job Descriptions for the Administrator and Director of Nursing were reviewed on 8/23/23 with focus on supervision of staff, prevention of accidents, and the facility education program to ensure understanding of role responsibility. The surveyor verified through record review of newly signed job description for the Administrator and Director of Nursing, and interview with the Administrator. Education for Abuse, Neglect was started on 8/14/23 and continued for all staff in the facility through today and facility is at 72.16% of all total staff (97) for compliance with this education. Included in this education is neglect correlation to preventable accidents. The surveyor verified through record review. Mechanical lift trainings were initiated on 8/15/23 on the electronic training system and on 8/21/23 with return demonstration for use of mechanical lifts through today, 8/24/23 with 76.19% of total nursing staff completed; 63.15% are nurses, and 81.81% are CNAs. This included applicable sling sizes and use of Kardex (provides instructions for care) to determine transfer status. The surveyor verified through record review, and observation of staff members transferring Resident #18 with a mechanical lift. Facility lift that was in use during event of 8/12/23 was removed from service and disposed of on 8/15/23. Surveyor verified through observation of discarded lift. Facility lifts were all inspected to verify functionality on the date of event 8/12/23 by the Director of Nursing and found to be safe and functional as to prevent avoidable accidents or falls. This was done after DON was educated by Regional Nurse Consultant for basic functionality and safe use. The surveyor verified through record review. Facility maintenance assistant inspected all facility lifts on 8/15/23 and all lifts were found to be safe and functional as to avoid accidents or falls. These were inspected according to their manufacturer's guidelines. The surveyor verified through record review. Regional director of plant operations inspected all facility lifts on 8/16/23 and verified that they were found to be safe and functional as to avoid accidents or falls. These were inspected according to their manufacturer's guidelines. The surveyor verified through record review. Slings in the facility that are in use were all inspected starting on 8/12/23 and continued through 8/22/23 and continue daily. Slings that were found in disrepair or torn were discarded on 8/12/23, 8/21/23 and 8/22/23. The surveyor verified through review of attestation documentation provided. The training for the slings and mechanical lift compatibility was initiated on 8/23/23; however, (brand name) slings that state they are recommended only to be used on (brand name) lifts were taken out of service on 8/24/23 to prevent this from occurring. The surveyor verified through record review, observation of transfer of Resident #18 using a mechanical lift, and review of attestation signed by the Regional Nurse Consultant. Two CNAs were interviewed and able to describe the process for safe use of mechanical lifts, including the correct size of slings. Observation of two CNAs transferring Resident #18 with a mechanical lift showed the sling was compatible with the lift used. Residents who require mechanical lifts have all been re-evaluated by the therapy department and nursing department and a total of 18 residents use mechanical lifts as of 8/22/23. The surveyor verified through residents record review and documentation on electronic clinical record. The 18 residents who require mechanical lifts have been assigned a corresponding size recommendation and this information has been communicated to the staff in the electronic record in the care plans and the Kardex for nursing staff. The sling size has been determined by the therapy and nursing leadership team utilizing weight and height. The surveyor verified through record review.

Based on observation, record review, and interviews, the facility's Administration failed to utilize resources effectively to protect the residents right to be free from neglect in that the Administration failed to ensure staff who use mechanical lifts were trained and competent in the safe use of the lift to transfer residents. On 8/12/23 Resident #1 sustained a fall during a transfer with a mechanical lift resulting in multiple fractures and transfer to the hospital. The CNAs using the lift were not trained and competent to use the mechanical lift. The facility's Administration failure to ensure the nursing staff had the appropriate skills and competency to safely transfer residents with a mechanical lift created a likelihood of avoidable falls and accidents which could result in serious injury, impairment, or death of residents, and resulted in the determination of Immediate Jeopardy. On 8/24/23 at 12:55 p.m., the facility's Administrator was informed of the Immediate Jeopardy (IJ) and provided the IJ Templates. On 8/21/23, the census was 101, with 20 residents who were transferred with mechanical lifts. The facility used five different brands of mechanical lifts for resident transfers. On 8/25/23, after the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 8/24/23 and the scope and severity were reduced to no actual harm, with no more than minimal harm. The findings included: Cross Reference to F600, F689, and F726. The facility policy titled Job Descriptions and Performance Evaluations revised September 2020 noted, The objectives of our job descriptions and performance evaluations are to: a. clarify who is responsible for particular duties; b. assist employees in understanding essential functions, responsibilities, working conditions, qualifications, and specific physical requirements of the positions; c. Prevent misunderstandings about job responsibilities and how each job is evaluated; d. Aid management in analyzing and improving the facility's services and structure of its organization; e. Provide a basis for job evaluation . and to improve quality of work performances . The signed Administrator Job Description dated 3/20/23 noted, Summary: Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Essential Duties and Responsibilities: Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed . Responsible for QA (Quality Assurance) program. Maintain a working knowledge of and confirm compliance with all governmental regulations . Recognize employees for exceptional care and job performance on a regular basis and as part of their performance evaluations . Provide guidance and leadership throughout the survey process to ensure state and federal regulations are met and adhered to . The signed Director of Nursing Job Description dated 5/29/23 noted, Summary: To manage the overall operations of the Nursing Department in accordance with company policies, standards of nursing practices and governmental regulations to maintain excellent care of all residents' needs. Essential Duties and Responsibilities: Plan, develop, organize, implement, evaluate, and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, policies/procedures and guidelines that govern the long-term care facility. Assume administrative authority, responsibility and accountability for all functions, and activities of the nursing department . Ensure the provision of appropriate departmental in-service education programs in compliance with Corporate, State and Federal guidelines . Direct the performance and delivery of nursing services and resident care services in compliance with corporate policies and State and Federal regulations . Regularly inspect the facility and nursing practices for compliance with federal, state, and local standards and regulations . Participate in monthly QA. Participate in the Facility Assessment . Ensure all department employees have annual performance reviews and competencies timely . On 8/21/23, review of the facility's incidents and accidents logs revealed on 8/12/23 Resident #1 fell from a mechanical lift during transfer, was hospitalized and suffered spinal and pelvic fractures. Review of the employee files for Certified Nursing Assistants (CNAs) Staff I (date of hire of 4/1/2020) and L (date of hire of 8/29/2000) who used the total body mechanical lift to transfer Resident #1 failed to show documentation CNAs Staff I and L were trained and competent in the use of mechanical lifts at the time of the incident. Review of the SNF Clinic list of training for Staff I, and Staff L revealed on 8/15/23, and 8/17/23 respectively CNA Staff I, and CNA Staff L completed a 15 minute computer training on Using a Hydraulic Lift. There was no documentation of a competency evaluation following the computer training. On 8/21/23 through 8/23/23, observation revealed the facility utilizes five different brands of mechanical lifts. The facility provided staff education sign-in sheets dated 8/12/23 and 8/14/23 for (brand name) lift use as part of their corrective actions after Resident #1 fell from a lift. The outline of the in-service was, Staff member provided instructions packet with diagram and demonstration of proper use provided. The in-service was not specific to the different brands and models of mechanical lifts used at the facility with each manufacturer's specification. The in-service did not include the appropriate size of sling to use for each resident for comfort and safe transfer. A total of 24 of 48 CNAs employed by the facility attended the training. The in-service did not include a return demonstration to verify staff were able to safely use the different mechanical lifts. On 8/21/23 the facility provided a list of 20 current residents who require the use of a mechanical lift for transfers. Review of the CNAs assignment schedule for 8/21/23 for the 7:00 a.m., to 3:00 p.m. shift revealed nine CNAs, including CNAs Staff E, Staff F, Staff I, Staff K, Staff T, and Staff X were assigned to care for residents who require the use of a mechanical lift. Seven of the nine CNAs attended the in-service on 8/12/23 or 8/14/23 but lacked documentation of a competency evaluation. On 8/21/23 at 11:30 a.m., CNA Staff E and CNA Staff F who attended the in-service on 8/14/23 were observed using a mechanical lift to transfer Resident #18 from bed to chair. The CNAs positioned the base of the mechanical lift under the bed without spreading the base open. They placed the resident in the lift and guided the lift toward the chair without spreading the base open per the in-service of 8/14/23. On 8/21/23 at 3:50 p.m., CNA Staff J and CNA Staff K (who attended the in-service on 8/14/23) were observed using a mechanical lift to transfer Resident #18 from chair to bed. They did not lock the wheels of the lift. The CNAs moved the lift back, closed the base and wheeled the lift to the bed. They transferred the resident to the bed without spreading the base or locking the lift as per the in-service provided on 8/14/23. On 8/21/23 at 4:05 p.m., CNA Staff K said, They tell us what to do, they don't show us what to do. They just tell us in words and have us sign a paper. There was no documentation CNA Staff J attended the in-service on 8/12/23 or 8/14/23. On 8/21/23 at 10:10 a.m., CNA Staff X said she had two residents in her assignment who require the use of a mechanical lift to get up to their chairs. The CNA denied receiving any recent education on the use of mechanical lifts, even though she signed the in-service attendance for the use of mechanical lifts on 8/12/23. On 8/21/23 at 10:43 a.m., CNA Staff G with a date of hire of 2/24/14 said she had not received any training on the use of mechanical lifts at the facility. There was no documentation CNA Staff G attended the in-service on 8/12/23 or 8/14/23. On 8/21/23 at 5:45 p.m., CNA Staff T said she has worked at the facility for [AGE] years. She said she has not received any recent training on the use of mechanical lifts even though on 8/12/23 she signed she attended the in-service on the use of mechanical lifts. She said, I know what I am doing. On 8/21/23 at 6:55 p.m., the Director of Nursing (DON) said he did not structure the education on 8/12/23 and 8/14/23 like a competency but since he had them return demonstration of the use of the mechanical lift, he felt it perhaps could count as a competency. The DON said, I would not consider it an annual competency. I wanted to be sure they knew how to use the machine since we did not really know what happened when the resident (Resident #1) fell . The DON confirmed he did not educate the nurses and did not document any competency for the CNAs who participated. On 8/22/23 at 8:56 a.m., CNA Staff X, and Licensed Practical Nurse (LPN) Staff Y were observed transferring Resident #5 from the bed to the chair using a total body mechanical lift. They did not open the legs of the base of the lift when they wheeled the lift from the bed to the chair. On 8/22/23 at 9:05 a.m., CNA Staff X said she has not had any training on using the mechanical lifts in over a year. She said, We just know how to do it, depending on how big the people are. There was no documentation LPN Staff Y attended the in-service. Review of the employee list revealed Unit Manager, LPN Staff O had a permanent hire date of 5/22/23. Review of the job description for the LPN Unit Manager position showed LPN Staff O signed the job description on 8/23/23 (three months after the hire date). The position summary noted, Twenty-four-hour responsibility for supervision and the delivery of care and services to residents on their assigned unit . Essential duties & [and] Responsibilities: . Supervise nursing staff on assigned unit(s). Make round to monitor resident care and status of residents . Ensure nursing policies and procedures are implemented and followed, educating nursing support staff as necessary and according to facility guidelines . On 8/23/23 at 10:27 a.m., LPN Staff O said he has been a Unit Manager for about three months. He said he did not receive a full orientation to the manager's role and had to hit the ground running. The Unit Manager said he ensures safe care is being provided by monitoring his staff all of the time but does not maintain a log or audit for the monitoring. He said the majority of his staff speak English as a second language. He said, It is a challenge to communicate with the staff overall. He said the facility does not have a staff development coordinator, so they have not scheduled any skills fairs or competency fairs as far as he knew. The Unit Manager said, I know we need to do them. This is my first job as a manager, so I am doing my best. He said he has not participated or heard anything related to staff evaluations since he started employment at the facility. The Unit Manager said he had not received any formal training for the mechanical lifts used at this facility. He said, I have been everywhere and anywhere. I don't do direct patient care, so I wasn't and don't need to be trained here. These are the same lifts I have used at many different places I have worked. On 8/23/23 at 11:15 a.m., LPN Staff P said she became a Unit Manager at the facility four months ago after working as a staff nurse through an agency for over a year. She said she did not get a full orientation to her new role. She was not aware of a skill checklist or competency for staff. She said most of the staff speak Creole primarily. She has been used as a translator, but hand outs are in English. She said it was a challenge for the leadership to communicate with the staff and she reminds them they need to try to understand when education is being done. She said she received education on monitoring staff, but nothing related to the use of mechanical lifts. She said, I wasn't trained here. I was trained in 15 facilities in the last three years, and I feel comfortable using the different types of lifts. On 8/23/23 at 11:40 a.m., the Administrator provided an annual education calendar for 2023 which listed Mechanical lift skills for February 2023 but said she could not confirm the Mechanical lift skills check was done. Review of employee files with the Administrator for seven randomly selected direct care staff who use mechanical lifts, including, CNA Staff I (Date of hire 7/3/2001), CNA Staff L (Date of hire 8/29/2000), CNA Staff S (Date of hire 4/17/2013), CNA Staff T (Date of hire 8/28/2003), CNA Staff U (Date of hire 7/28/1992), Registered Nurse (RN) Staff V (Date of hire 3/7/2023) and LPN Staff W (Date of hire 7/2/2019) revealed the most recent evaluations and competencies were completed in February 2021, and did not include the use of mechanical lifts. The Administrator said, The Staff Development Coordinator (SDC) is the position that is tasked with that responsibility. Currently, we do not have an SDC, so it falls to the DON and then me after him. Ultimately, I am responsible for ensuring the DON is ensuring staff are properly trained. The administrator confirmed there were risks for not completing staff evaluations and competencies. She said, We would be unaware of the staff skills and level of competence since we do not have the return demonstrations. It would be unsafe for the residents. On 8/23/23 at 1:00 p.m., in a telephone interview, the DON said he was unaware of an education calendar at the facility. He was also unaware direct care staff had not had evaluations or competencies documented. The DON confirmed he was responsible for ensuring staff had appropriate competencies documented including safely using mechanical lifts. He said, It is about the safety of the patients. If we don't do evals and competencies then how would we know if we are giving safe care? He said prior to Resident #1's fall during transfer with a lift, he assumed staff had been trained on the mechanical lifts, so there had been no education or monitoring of the lift use. The DON said, Ultimately it is my responsibility to ensure they have their competencies done and are providing safe care. The immediate actions to remove the Immediate Jeopardy implemented by the facility and verified on 8/25/23 by the surveyor included: Facility Administrator was re-educated on Abuse, Neglect and Exploitation on 8/21/23 by Regional Nurse Consultant with specific regard to mechanical lifts, CNAs comprehension of ANE as it pertains to reporting and the event that occurred on 8/12/23. The surveyor verified through reviewed documentation of reeducation for DON and administrator. Facility Administrator and Director of Nursing were re-educated on Failure to Prevent Incidents and Accidents regarding Supervision, preventing avoidable accidents and oversight of the education program, calendar, and competencies on 8/23/23 by Regional Nurse Consultant. The surveyor verified through review of the Administrator and DON signed attestations for education. Facility Administrator and Director of Nursing were re-educated on 8/21/23 by Regional Nurse Consultant on developing a process to validate education, training and competencies with initial focus on mechanical lift safety. The surveyor verified through review of the education. On 8/23/23, Administrator job description was reviewed by Regional Nurse Consultant, including understanding supervision and adherence to the training and education of staff. Administrator was re-educated on role and responsibilities of this position. The surveyor verified through review and signature of newly signed job description. On 8/23/23, Director of Nursing job description was reviewed by Regional Nurse Consultant, including supervision and adherence to the training and education of staff. DON was re-educated on role and responsibilities of this position. The surveyor verified through review of the signed job description. Education calendar has been reviewed. Validation completed for the education program. An electronic system for delivering and tracking education and in-services has been implemented. Training and competencies that were previously planned and not completed have been rescheduled in accordance with administration utilizing effective resources to ensure staff are trained and competent. The surveyor verified through reviewed of scheduled education assignments in SNF clinic for staff meetings. The DON, Regional Nurse Consultant and Administrator trained additional leaders to utilize a Train the [NAME] system to ensure all shifts are educated and able to perform return demonstrations. The surveyor verified through review of the attestation signed by administrator of the train the trainer education. Administrator was educated by Regional Nurse Consultant regarding ensuring staff are educated and competent to safely use mechanical lifts. The surveyor verified through review of the Administrator's signed attestation of education. DON was educated by Regional Nurse Consultant regarding ensuring staff are educated and competent to safely use mechanical lifts. The surveyor verified through record review of the education. Immediate education was provided on-site on 8/12/23 to all working Nursing staff on mechanical lift safety by the Director of Nursing. Eleven (11) were educated which is 17.5% of total nursing staff. This mechanical lift education was continued through 8/14/23 with an additional 13 (thirteen) nursing staff which equals 38.09% of the total nursing staff. Total nursing staff are 63 (sixty-three). 8/25/23 reviewed sign in sheets and electronic education records with checklist completion attestation. The surveyor verified through record review of education. There are 19 nurses and 44 CNAs on staff. The above mechanical lift education represents 43% CNAs, and 26% nurses. The surveyor verified through record review of education. Training and competencies for mechanical lift safety has continued through 8/24/23 with 100% of working staff in compliance. The percentage for completion is 76% total nursing staff for mechanical lifts; 63.15% are nurses, and 81.81% are CNAs. The surveyor verified through review of documented process in place for capturing staff as they work their next shift. The agency staff are educated on the shift they arrive prior to taking an assignment, and a roster is kept with their signatures. This is done according to the daily schedule provided by the staffing coordinator. The surveyor verified through record review of the process in place for capturing staff as they work their next shift. The new staff and the staff returning from leave (FMLA (Family Medical Leave of Absence), vacation, etc.) are tracked on the master education roster and will not work until they have completed all applicable educations. The scheduler provides the daily roster. NHA and a nurse or designee educate at the start of the shift prior to accepting their assignment. The surveyor verified through record review of the process in place for capturing staff as they work their next shift. Additional mechanical lifts with additional slings have been ordered on 8/24/23 that are appropriate to resident size needs. These lifts and slings ordered are all the same, uniform brand. The nurse leaders and therapy staff selected appropriate sizes according to weight and height. The surveyor verified through review of purchasing orders. Once the new mechanical lifts and slings arrive, all of the previous slings and lifts will be disposed of to prevent and incompatibility. The surveyor verified through review of the attestation statement from the Administrator. Regional Nurse Consultant educated Administrator and Director of Nursing on QA&A (Quality Assessment and Assurance) and QAPI (Quality Assurance and Performance Improvement) processes with focus on how to effectively utilize resources to ensure staff are trained and competent. The IDT (Interdisciplinary) team also attended and are in agreement. The surveyor verified through review of the education completed 8/24/23, and interview with the Administrator. An Ad-hoc (impromptu) QAA meeting was held on 8/24/23 to review the IJ templates and gather input for suggestions. There were no additional suggestions at this time. The surveyor verified through review of the content of the meeting held on 8/24/23 addressing the Immediate Jeopardy, and interview with the Administrator. The manufacturer was contacted and message left for reporting this equipment failure concern on 8/23/23. An email will follow. The surveyor verified through review of the attestation signed by the Administrator. FDA (Food and Drug Administration) form Medical Device Reporting (MDR) How to report medical device problems/FDA form: MedWatch form 3500A was submitted on 8/25/23 as the initial form used was incorrect. The surveyor verified through review of the attestation statement by administrator.

Based on observation, clinical record review, review of facility policies and procedure and staff interviews the facility failed to provide the necessary interventions and treatment to prevent the development and worsening of pressure ulcers for 2 (Resident #1 and #2) of 3 sampled residents identified as at risk for developing pressure ulcers. The findings included: The facility policy Pressure Injury Prevention and Management documented, This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. The policy defined a pressure ulcer/injury as localized damage to the skin and or underlying soft tissue usually over a bony prominence. The policy defined avoidable pressure ulcer as the resident developed a pressure ulcer/injury and the facility did not do one or more of the following: evaluate the residents' clinical condition and risk factors, define and implement interventions that are consistent with resident needs, resident goals and professional standards of practice, monitor and evaluate the impact of the interventions or revise the interventions as appropriate. A stage 2 pressure ulcer is described as a partial thickness loss of the dermis (the inner layer of the two main layers of skin), presenting as a shallow open ulcer. Stage 3 pressure ulcer is described as a full thickness tissue loss. 1. Review of the clinical record indicated Resident #1 had a hospital admission on 1/29/22 from home and had previously spent 3 months in a skilled nursing facility. The hospital physician identified a pressure ulcer on the sacrum about 1 centimeter (cm) in size with tunneling (passageway) in the deep tissue. The hospital physician discharge summary note dated 2/22/22 documented, Decubitus ulcer on the sacrum, likely stage 3-4. Seems the patient acquired it over the course of 3 months at a skilled nursing facility, last time ambulatory [DATE]. Wound care -prefer not to debride, dressing to be provided, Medi honey applied, air mattress provided, pressure offloading, turning form side-to-side every 2 hours. Encourage frequent repositioning and out of bed to chair. The clinical record showed Resident #1 was transferred from the hospital to the skilled nursing facility on 2/22/22. On 2/23/22 the Certified Registered Nurse Practitioner documented a wound to the sacrum present on admission measuring 3.35 centimeters (cm) length by 5.75 cm width by 1.0 cm depth. The practitioner's note included to ensure compliance with turning protocol, wedge/ foam cushion for offloading, specialty bed, Dakin's moist to dry, bordered gauze. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was transferred from the facility to a hospice facility on 2/27/22. On 5/3/22 at 11:15 a.m., in an interview the Director of Nursing (DON) said the process for new admissions was for staff to do a full body assessment. If a wound was present, they are to contact the Physician and obtain orders for treatment. The DON said, I know wound care was a problem, it's my fault that it was missed for Resident #1. The DON confirmed Resident #1 did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed Resident #1 did not receive wound care during her 5 days stay in the facility. The DON said multiple balls were dropped with the same resident. The nurse should have initiated a treatment at the time of admission. 2. Review of Resident #2's clinical record showed an admitted [DATE]. Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment with a target date of 12/20/21documented the resident had intact skin and was at risk of developing pressure ulcers. The resident required extensive physical assistance of one person for bed mobility, transfer, and toileting. Resident #2 was always incontinent of bladder and bowel. The resident scored a 14 on the Brief Interview for Mental Status, indicating intact cognition. The care plan initiated 12/15/21 noted Resident #2 was at risk for skin breakdown related to diabetes, incontinence, use of anticoagulant, and impaired mobility. The goal was the risk for skin breakdown will be minimized. The interventions included: Complete weekly skin assessment, encourage/assist to turn and reposition as tolerated, monitor skin for signs of skin breakdown and off load heels as resident allows and monitor nutritional status and dietary needs, consult dietician as needed. On 2/23/22 the CRNP documented Resident #2 had a stage 1 pressure ulcer to the left heel and a suspected deep tissue injury to the right heel. The practitioner recommendations included, comprehensive skin and wound evaluation for bilateral heel pressure. Pressure reduction and turning precaution discussed with staff at time of recommendation and turning precautions discussed with staff at time of visit recommended. On 3/2/22 the CRNP documented the pressure ulcer to the left heel was a stage 2 and the right heel remained with a suspected deep tissue injury. The care plan was updated on 2/24/22 and documented Resident #2 had actual skin breakdown related to pressure with a stage 3 pressure ulcer on the right heel, a stage 3 pressure ulcer on the left heel and a stage 3 pressure ulcer on the sacrum. The interventions as of 2/24/22 included Podus boots (Positioning device to prevent and manage heel pressure) while in bed as tolerated, turn, and reposition during rounds, with care and as needed. The Certified Nursing Assistant (CNA) documentation for the month of March 2022 documented encourage/assist to turn reposition as needed. Did you turn and reposition? Yes, No. The form lacked documentation Resident #2 was encouraged and assisted to turn and reposition from 3/1/22 through 3/31/22. On 3/13/22, 3/17/22, 3/18/22, 3/25/22 and 3/27/22, the CNA documented NA [not applicable]. A review of the treatment administration record (TAR) documented a start date of 3/10/22 for the intervention to apply podus boots to bilateral feet while in bed as tolerated. The weekly skin evaluation dated 3/29/22 documented a pre-existing buttock wound. The skin evaluation showed no documentation of left and right pressure wounds on the heels or the sacrum. On 3/30/22 the CRNP documented Resident #2 had stage 3 pressure ulcer to the sacrum. The practitioner documented date wound acquired: Unknown. The CRNP ordered a specialty bed for the resident, and it is documented as implemented on 3/30/22. The CNA documentation for April 2022, showed no documentation Resident #2 was encouraged to turn and reposition as tolerated from 4/1/22 through 4/20/22. On 4/21/22 through 4/30/22 for all three shifts, staff entered NA [not applicable] 11 times. The form was left blank, making it impossible to determine if the resident was turned and repositioned nine times. The clinical record lacked documentation of when the wound was identified and treatment to that area until 3/30/22. On 4/4/22 at 9:00 a.m., in an interview with Certified Nursing Assistant (CNA) Staff H said when I change someone and I notice anything with the skin, I report it right away. I turn them every 2 hours and make sure they are dry. If they can't move themselves, I turn them, I have to move them. The CNA said she did not know what the resident care plan was and said the nurse will tell me if she needed to do something specific for a resident. On 5/19/22 at 10:30 a.m., during an observation and interview, Resident #2 was sitting in her room in a wheelchair with nonskid socks on her feet and no leg rests on the chair. Resident #2 said she was aware of the wounds on her feet and buttocks and said, they get better then they get worse. Resident #2 said sometimes the staff change her when she is incontinent but not always. The resident said, I urinate a lot during the day and sometimes they only come 2 times a shift and they tell me they can't put me back to bed because I need to stay up in the wheelchair. Resident #2 said they put the boots on my feet sometimes but not always. Resident #2 said the staff did not always change her when she is wet. On 5/3/22 at 1:50 p.m., in an interview, the DON said Resident #2 did not have a specialty mattress in place to reduce pressure until after the sacral wound was identified. The DON said the facility did not have an official turning program to prevent or manage pressure ulcers. The DON said we tried the boots and turning and repositioning and then we put her on the air mattress on 3/30/22. The DON confirmed Resident #2 had 3 in house acquired pressure wounds.

Based on clinical record and policy review and staff interview, the facility failed to prevent terminal neglect, by not performing cardiopulmonary resuscitation (CPR) for 1 (Resident #1) of 3 residents sampled for neglect. Some 54 residents had full code status. Center for Clinical Standards and Quality/Survey & Certification (S&C) letter on Cardiopulmonary Resuscitation (CPR) in Nursing Home: ,[DATE]-NH, revised ([DATE]) includes the following: The American Heart Association (AHA) has established evidenced-based decision-making guidelines for initiating CPR when [MEDICAL CONDITION] occurs in or out of the hospital. AHA urges all potential rescuers to initiate CPR unless: 1) a valid DNR order is in place; 2) obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or 3) initiating CPR could cause injury or peril to the rescuer. AHA guidelines for CPR provide the standard for the American Red Cross, state EMS agencies, healthcare providers, and the general public. Facility policy should specifically direct staff to initiate CPR when [MEDICAL CONDITION] occurs for residents who have requested CPR in their advance directives, who have not formulated an advance directive, who do not have a valid DNR order, or who do not show AHA signs of clinical death as defined in the AHA Guidelines. The survey found Resident #1 was full code status and was found unresponsive in early morning hours of [DATE]. The staff nurse on duty did not perform cardiopulmonary resuscitation (CPR) or call [DATE]. The end result was the resident died . This failure was identified to be an immediate jeopardy. The immediate jeopardy started on [DATE] at 2:45 a.m. and was removed on [DATE] when the facility provided documentation the majority of the licensed nurses were properly trained on when to perform CPR. On [DATE] at about 11:15 a.m. the facility administrator was informed of the immediate jeopardy which began [DATE]. The findings included: 1. The facility's policy OPS300 Abuse Prohibition (revised on [DATE]) included the facility will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation. It continues that the facility will implement an abuse prohibition program through the following: Including Investigation of incidents and allegations; . The policy ends with Neglect is defined as the failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A review of the clinical record for Resident #1 revealed a physician's orders [REDACTED]. A Nurse Practitioner progress note dated [DATE] indicated the patient wanted to be changed from a Do Not Resuscitate (DNR) to a full code. A Care Plan Meeting Note dated [DATE] revealed the resident expressed desire to remain a full code. In an interview on [DATE] at 12:30 p.m., the Facility Administrator confirmed Resident #1 was a full code. In an interview on [DATE] at 12:34 p.m., The Director of Nursing confirmed Resident #1 was a full code. A nurse's note, dated [DATE] at 6:51 a.m., indicated the Staff went to check on him (Resident #1) at 2:45 a.m. resident had no pulse, no BP, and no respiration (cardiopulmonary arrest). Body very cool to touch. In an interview on [DATE] at 2:40 p.m., Registered Nurse (RN) Staff A said she was aware Resident #1 was a full code. She said on [DATE] at 12:20 a.m. she gave the resident some pain medication. At 2:45 a.m., she found Resident #1 cold and hard as a rock. She felt cardiopulmonary resuscitation (CPR) was not needed due to patient condition and the patient was at the end of life. RN Staff A said he was receiving pain medication every 6 hours and that's what they do at the end of life. She said she called the son soon after the resident was found. The body was released to the funeral home at 6:45 a.m. She said she forgot to call the doctor and inform him of the resident's condition, that she withheld CPR, or to obtain an order to release the body to the funeral home. On [DATE] at 4:36 p.m., Resident #1's physician said he should have been notified immediately and CPR should have been performed. A review of facility policy NSG208 Cardiac and/or Respiratory Arrest (revised [DATE]) indicated If a patient does not have a DNR order, CPR/AED (automated external defibrillator) certified staff will initiate CPR/AED and emergency medical services (EMS) will be activated. On [DATE] at 3:30 p.m., the Director of Nursing (DON) said she was notified via telephone by RN Staff B of Resident #1's passing and CPR was not performed despite a full code status. She immediately suspended RN Staff A and began a corrective action plan. She confirmed RN Staff A should have performed CPR, contacted the resident's physician and called [DATE]. She said nurses and certified nursing assistants, full-time, part-time, and PRN (as needed) were educated on [DATE] through [DATE] on policy and procedure for CPR. By [DATE], 56 of the 73 nursing employees participated in the drill. This removed the immediacy. The training would continue as needed. The facility identified the incident as an event that needed to be looked at in their quality assurance and performance improvement (QAPI) plan. The facility put systems in place which will be on-going and monitored monthly. The Ad-Hoc Performance Improvement Meeting of [DATE] detailed the facility's corrective action plan. The plan included audits of advanced directives, physician orders, and care plans. They would conduct reviews of deaths over previous 90 days and going forward for 90 days. Staff would be in-serviced. Mock codes would be conducted. The survey verified the corrective actions were put in place: audits were completed, deaths were reviewed, in-services and mock codes were conducted. The facility actions removed the immediate jeopardy as of [DATE] when most of the licensed nurses were educated and participated in a mock code drill. This verification lowered the scope and severity to D. Refer also to F678 and F835.

Based on staff interview and clinical record review, the facility failed to provide basic life support for 1 (Resident #1) of 2 full code residents of 3 residents sampled. Full-code refers to having all resuscitative efforts implemented in the event of cardiopulmonary arrest. There were some 54 residents with full code status. Center for Clinical Standards and Quality/Survey & Certification (S&C) letter on Cardiopulmonary Resuscitation (CPR) in Nursing Home: ,[DATE]-NH, revised ([DATE]) includes the following: The American Heart Association (AHA) has established evidenced-based decision-making guidelines for initiating CPR when [MEDICAL CONDITION] occurs in or out of the hospital. AHA urges all potential rescuers to initiate CPR unless: 1) a valid DNR order is in place; 2) obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or 3) initiating CPR could cause injury or peril to the rescuer. AHA guidelines for CPR provide the standard for the American Red Cross, state EMS agencies, healthcare providers, and the general public. Facility policy should specifically direct staff to initiate CPR when [MEDICAL CONDITION] occurs for residents who have requested CPR in their advance directives, who have not formulated an advance directive, who do not have a valid DNR order, or who do not show AHA signs of clinical death as defined in the AHA Guidelines. The survey found Resident #1 was full code status and was found unresponsive in early morning hours of [DATE]. The staff nurse on duty did not perform CPR or call [DATE]. The end result was the resident died . This failure was identified to be an immediate jeopardy. The immediate jeopardy started on [DATE] at 2:45 a.m. and was removed on [DATE] when the facility's documentation showed the majority of the licensed nurses were properly trained on when to perform cardiopulmonary resuscitation. On [DATE] at about 11:15 a.m. the facility administrator was informed of the immediate jeopardy which began [DATE]. The findings included: 1. A review of the clinical record for Resident #1 revealed, on [DATE], a physician's orders [REDACTED]. A Nurse Practitioner progress note, dated [DATE], indicated the patient wanted to be changed from a Do Not Resuscitate (DNR) to a full code. The Care Plan Meeting Note dated [DATE] revealed the resident expressed desire to remain a full code. On [DATE] at 12:30 p.m., the Administrator confirmed Resident #1 was a full code. On [DATE] at 12:34 p.m., the Director of Nursing confirmed Resident #1 was a full code. A nurse's note, dated [DATE] at 6:51 a.m., indicated the Staff went to check on him (Resident #1) at 2:45 a.m. resident had no pulse, no BP, and no respiration (cardiopulmonary arrest). Body very cool to touch. On [DATE] at 2:40 p.m., Registered Nurse (RN) Staff A said she was aware Resident #1 was a full code. She said on [DATE] at 12:20 a.m. she gave the resident some pain medication. At 2:45 a.m., she found Resident #1 cold and hard as a rock. She felt cardiopulmonary resuscitation (CPR) was not needed due to patient condition and the patient was at the end of life. RN Staff A said he was receiving pain medication every 6 hours and that's what they do at the end of life. She said she called the son soon after the resident was found. The body was released to the funeral home at 6:45 a.m. She said she forgot to call the doctor and inform him of the resident's condition, that she withheld CPR, or to obtain an order to release the body to the funeral home. A review of correspondence from the Physician On-Call service revealed the facility's Director of Nursing (DON) called the physician to inform him of Resident #1's death at 8:11 a.m. On [DATE] at 4:36 p.m., Resident #1's physician said he should have been notified immediately and CPR should have been performed. The physician said he was notified several hours after the resident expired. The physician stated, it would be kind of quick for a deceased person to be cold and hard as a rock that soon after dying. (The time from the last medication to finding the resident unresponsive was 2 hours and 25 minutes.) 2. On [DATE] at 3:30 p.m., the Director of Nursing (DON) said she was notified via telephone that Resident #1 passed and CPR was not performed despite a full code status, she immediately suspended RN Staff A and began a corrective action plan. She said nurses and certified nursing assistants, full-time, part-time, and PRN (as needed) were educated on [DATE] through [DATE] on policy and procedure for CPR. As of [DATE], 56 of the 73 nursing employees participated in the drill. This removed the immediacy. The training would continue as needed. The facility identified the incident as an event that needed to be looked at in their quality assurance and performance improvement (QAPI) plan. The facility put systems in place which will be on-going and monitored monthly. The Ad-Hoc Performance Improvement Meeting of [DATE] detailed the facility's corrective action plan. The plan included audits of advanced directives, physician orders, and care plans. They would conduct reviews of deaths over previous 90 days and going forward for 90 days. Staff would be in-serviced. Mock codes would be conducted. The survey verified the corrective actions were put in place: audits were completed, deaths were reviewed, in-services and mock codes were conducted. The facility actions removed the immediate jeopardy as of [DATE] when most of the licensed nurses were educated and participated in a mock code drill. This verification lowered the scope and severity to D. Refer also to F600 and F835.

Based on record review, observation and interview the facility failed to ensure that pain management is coordinated, by the interdisciplinary team, to address pain being experienced by Residents #181 and #184 of 2 sampled residents; and that hospice care services are coordinated with the facility, to address the palliative needs of Resident #142 of 1 sampled resident. This impacted 3 (Residents #142, #181 and #184) of 45 sampled residents. The findings include: 1. Resident #181 was admitted to the facility on [DATE]. Her hospital records documented she was treated for [REDACTED]. A CT SCAN of the pelvis, dated 9/11/12, documents "Hip pain, possible fracture; severe chronic [MEDICAL CONDITION] changes are again seen in both hips with remodeling and bilateral aceabula protrusio. No fracture." Physical Therapy Treatment notes from the hospital, dated 9/13/12, at 4:05 p.m., noted "Pain Evaluation, Pain Scale Used: Linear Pain Rating Scale; Pain Location: Lower Extremity; Pain Side: Bilateral; Pain Level: 9; Pain Type: Constant; Pain Quality: Aching; Action to Pain: Patient pre-medicated by nursing. and Fear from falling and pain is affecting patient's overall functional mobility. Patient unable to progress to sitting today secondary to pain. Recommend that patient may benefit from routine pain medications to improve mobility." Occupational Therapy Treatment notes from the hospital, dated 9/12/12, at 1:00 p.m., documented "Pain Evaluation, Pain Scale Used: Wong Baker Pain Scale; Pain Level 9 with movement and ROM (range of motion; Action to Pain: Nurse notified." A Pain Evaluation form completed by the facility on date of admission, 9/16/12, documented "without pain, no program needed. " Physician orders, dated 9/17/12, documented "Pain Management, [MEDICATION NAME] 325 mg, 2 tablets PRN (as necessary) every 6 hours for mild pain" and orders dated 9/19/12 documented "[MEDICATION NAME] HCL 50 mg every 6 hours for pain." Upon interview with the use of an interpreter, on 10/2/12 at 11:55 a.m., Resident #181 stated she always had pain in her left leg and does not get relief from pain medication. Resident #181 was observed in bed, lying on her back, on 10/2/12, at 3:30 p.m. and 10/3/12 at 4:00 p.m. Upon interview at these times, the resident stated that she had pain in her left leg. The Care Plan, dated 9/16/12, noted "Pain/Potential for pain related to: (no entry)", with goal "Will be free from signs and symptoms of pain such as facial grimacing, moaning or crying." Interventions include "Monitor pain on a scale of 0-10, administer pain medication per physician orders, and note the effectiveness. Notify MD if pain not reduced. Assist to reposition for comfort." A Physical Therapy Evaluation (PT) form, dated 9/17/12, documented "Pt (Patient) was referred to PT secondary to pneumonia and acute [MEDICAL CONDITION]. Pt had recent fall after which she required assistance for all mobility and presents with retropulsion and significant fear of falling. Patient currently requires Maximum/Total assistance for all transfers and is grossly resistant to all activity. Pt also presents with severe pain in left lower leg secondary to [MEDICAL CONDITION]." A Physical Therapy Weekly Progress Summary form, dated 10/1/12, notes "She has made slow but steady progress despite apprehensive and anxious because of fear. Nursing medicates resident for pain prior to treatment. Reports decreased pain during sessions." An Occupational Therapy Evaluation form dated 9/17/12 documented "Pain Score 10/10, Describe: facial grimacing and moaning, Relieved by: medication; Activity Tolerance: Poor." An Occupational Therapy Weekly Progress Summary form, dated 9/24/12, notes "Meds (medications) given prior to therapy to decrease anxiety and pain" and on 10/1/12 state "Nursing aware of pain. Meds given prior to session to decrease anxiety." At 9:00 a.m. on 10/4/12 the surveyor approached Staff F to do a Medication Observation. Staff F stated that Resident #181 was in therapy and she would like to wait to administer the medications until the resident was done. Staff F approached the surveyor at 9:30 a.m. and stated "The resident is still in therapy and I would like to give her the medications there (in therapy)." During the medication observation, the nurse stated "she (the resident) is requesting a pain medication, so I will give that too." Resident #181 was observed, on 10/4/12, at 9:35 a.m., receiving occupational/physical therapy. The resident was in a sitting position. Resident #181 had facial grimacing and was complaining of left leg pain and her left hand/arm was shaking violently. The nurse administered medications to the resident, at this time, which included 1 tablet of [MEDICATION NAME] 50 mg; and the nurse stated "This should give her some relief" (referring to the pain medication [MEDICATION NAME]). Three therapists were present at this time. Interview of Director of Rehabilitation, on 10/4/12, at 12:00 p.m., stated that a Broda chair was being initiated this date to help relieve resident's pain when sitting. She stated that both the Physical (PT) and Occupational Therapists (OT) were aware of the resident's pain. The Director of Rehabilitation stated "I hope that nursing gives the resident pain medication before therapy." Two therapists were present during this interview, one from PT and one from OT. Review of the September 2012 Medication Administration Record (MAR) records documented that Tylenol 325 milligram (mg) two tablets was administered 5 times from 9/17/12 through 9/30/12; and that [MEDICATION NAME] 50 mg 1 tablet was administered 12 times during this 14 day time period. Pain medication, either Tylenol or [MEDICATION NAME], was given prior to therapy, at 8:00 a.m., 8:30 a.m., or 9:00 a.m., 5 times, during this 14 day time period. Review of the October 2012 MAR revealed the following: On 10/1/12 [MEDICATION NAME] 50 mg (and no Tylenol) was given once at 6:30 a.m. for general pain at a level of "5" moderate/severe. On 10/2/12 [MEDICATION NAME] 50 mg (and no Tylenol) was given at 6:00 a.m. and at 12:00 p.m. and at 5:30 p.m. for general pain at a level of "5" moderate/severe. On 10/4/12 [MEDICATION NAME] 50 mg was documented as given at 9:30 a.m. for Left leg pain at a level of "6" moderate/severe. This medication was observed by the surveyor and 3 therapists as being given at 9:35 a.m. in the therapy room located on the C wing of the North Unit. Resident #181 was observed in the therapy department at 9:00 a.m., on 10/4/12, and a medication observation was performed at 9:35 a.m. by the surveyor. Resident #181 was observed lying on her back in bed, at a 30 degree angle, at 10:00 a.m. on 10/5/12. When approached the resident stated "I am sick. " When asked what was wrong, she stated "Pain leg" and pointed at her left leg. When asked if she got a pill for the pain, she said "yes. " Review of the MAR at this time documented that Resident #181 had received [MEDICATION NAME] 50 mg (no time listed) based on a new physician's orders [REDACTED]." The MAR documented that Resident #181 received [MEDICATION NAME] 50 mg at 6:00 a.m., 10/5/12, for "Level 5" (moderate to severe) left leg pain, and no response to the medication was listed on the MAR; and Tylenol 325 mg 2 tabs was administered at 12:30 a.m. (10/5/12) for "#6" for moderate/severe L leg pain. Physician orders [REDACTED]. " In addition, the MAR states that Tylenol (for mild pain) was given to the resident on 10/4/12 at 1945 (7:45 p.m.) for "5" moderate/several L leg pain.. Further review of the medication administration records revealed that Tylenol 325 mg 2 tabs po is documented as being administrated for a pain rating of "3" (moderate) and "5" (moderate/severe) 5 times on the September 2012 MAR and 2 times on the October 2012 MAR. There was no indication, in the medical record, that the physician was contacted regarding pain not being relieved by [MEDICATION NAME] and that there were no specific orders for pain medication to be given for moderate to severe pain or for " breakthrough pain " . Interview with the Assistant Director of Nursing on 10/5/12 at 12:00 p.m. revealed that she was unaware that the resident was not receiving pain medication prior to therapy in the morning and she was unaware that Tylenol was being given to the resident to relieve moderate to severe pain (rather than mild pain as ordered by the physician). During an interview with Resident #181's physician, on 10/5/12, at 2:15 p.m. The Administrator was present at this time and the physician consented to be on speaker phone. The physician acknowledged that he had given orders for Tylenol on admission and added the [MEDICATION NAME] medication a few days later due to complaints of pain not being relieved by the Tylenol. He stated that the facility never advised him that the resident was experiencing pain that was not being relieved by [MEDICATION NAME]. He stated "I have not been called regarding pain, PT (Physical Therapy) reports that the resident has hesitation and anxiety and [MEDICAL CONDITION], pain management was not a main complaint. " Interview of the Director of Rehabilitation, Physical Therapist and Occupational Therapist, on 10/5/12, at 2:30 p.m., revealed that they were unaware that the resident was not receiving pain medication prior to therapy treatments in the morning although their therapy notes indicated that nursing administers pain medication prior to therapy treatment. 2. Resident #184 was admitted to facility on 9/17/12. A Pain Evaluation form, dated 917/12, states "admitted with no complaint of pain. " Interdisciplinary (Nursing) Progress Notes for the time period 9/17/12 through 10/2/12 contain no complaint of pain. Physician order [REDACTED]. " A Care Plan, dated 9/17/12, noted "Pain/Potential for pain, with a goal stating "Will be free from signs and symptoms of pain such as facial grimacing, moaning, or crying, target date 12/16/12. " Interventions include the following: "Administer Pain medication as per MD orders and note the effectiveness. Notify MD if pain not reduced. Give PRN Meds (medications) for breakthrough as per MD orders and not effectiveness. Notify MD if pain not reduced. Document/report complaints & non-verbal signs of pain." A Physical Therapy (PT) Evaluation, dated 9/18/12, documented "Pain, 7/10, dull pain on thighs relieved by medication. " A PT Weekly Progress Summary documented "9/25/12 Patient continues to complain of coccyx pain. Even though she has been educated about the use of donut when sitting (puts more pressure), patient likes to use it and states it relieves her pain a little bit. Pt has been hesitant to request pain medicine even though she has been encourage to do it PRN." and "10/2/12 Continues to complain about 'tailbone' hurting and use of donut when in bed and in chair." An Occupational Therapy Evaluation (OT), dated 9/18/12, notes "Pain, 7/10, hips ache relieved by Tylenol. " An OT Weekly Progress Summary documented "9/25/12 Resident complaint pain rated 9/10. Nursing notified and pain medication given with good result 4/10 during treatment continue per Doc to maximize functional ADL (Activities of Daily Living) independence, decrease pain and functional mobility." and "Due to increased c/o of pain (coccyx) 9/10 OT/Nursing agreed for medicine to be administered 30 minutes prior to treatment. Resident reports pain level decrease to 4/10 after meds." A Speech Therapy Weekly Progress Summary form dated 9/25/12 noted "Pt. (patient) has been seen 5-6 times a week to increase cognitive-linguistic skills. Pt. frequently requests to be laid down in her bed - c/o (complains) her tailbone hurting often. Frequently have to redirect pt. to stay up in her chair until she is seen by therapy. Pt. usually lies in bed until lunchtime and then is up for noon meal and therapies." Upon interview, on 10/2/12, at 9:00 a.m., Resident #184 was lying in bed in her room and stated "I have pain in my tail bone. I fell and hit it before I came here. Nothing will relieve the pain. I tell the staff that I have pain but nothing relieves it. I have the pain all the time. I sometimes use that pillow (pointing to a " donut ' shaped pillow lying on a chair next to her night stand). The pillow was observed to be out of reach for the resident. When asked if she received any pain for the medication, the resident stated " It does not help. Resident #184 was observed lying in bed at 1:00 p.m. .on 10/3/12 lying in her bed. When asked how she felt, she said "very good today"; and her tail bone was bothering her and that is why she had to lay down in bed. The resident was smiling and said she was glad to see me. The resident was observed, on 10/4/12, at 11:50 a.m., sitting in a wheelchair in her room. Upon interview at this time Resident #184 said that her tail bone was paining her and she needed to go to bed to get some relief. The resident appeared restless and facial grimacing was observed. When asked if she got any pain medication, Resident #184 stated they already gave me my pills this morning. The resident reach for the call light to obtain staff assistance. Review of the Medication Administration Record (MAR), on 10/4/12, at 12 p.m., revealed that no pain medication (Tylenol) was administered this date and the last time Tylenol was administered was recorded as 9/23/12 at 2:30 p.m. There is no order for any type of pain medication to be administered on a continuum. Interview of Director of Rehabilitative Services, on 10/4/12, at 12 p.m., stating that Resident #184 has mentioned her tail bone hurting in PT and OT and wants to use a foam ring ("donut") brought from home when sitting (in chair) and lying in bed even though therapy has not recommended the use of the pillow due to the possibility of decreasing circulation to the area. The Director of Rehabilitation continued to state that Resident #184 has recently experienced a cognitive decline and is reluctant to take pain medication, because she states it does not work. Resident #184 was observed 10/5/12, at 10:00 a.m., lying on her bed and stated "I am not feeling good today" and continued to state that her "tail bone hurts a lot today" and "I am using my pillow now. " There is no documentation that: n the physician was notified regarding the resident's complaint of pain. n that the interdisciplinary care plan was followed n that the resident's pain was reassessed, status [REDACTED]. n that the interdisciplinary team revised the plan of care to address the unrelieved pain. 3. Resident #142 is a Long Term Care resident receiving Hospice services. He was admitted to the facility, on 1/05/12, as private pay, but soon became hospice certified. He has services from AVOW Hospice beginning 12/02/11, when he was at the Assisted Living Facility. During a family interview, on 10/02/12, at 11:00 a.m., the resident's wife reported chooses to hire a private duty care giver to give her husband the 1 to 1 special care that the Nursing Assistants ( NA) do not have time to provide from the facility. The family member feels she needs to have private care giver to ensure that oral care tasks are done daily. Review of the AVOW physician care plan reflects Social Services 1 time a month; Chaplain 1 X a month, Home Health Aid (HHA) 5 times a week and skilled nursing 1 X week and as needed. On 10/03/12, at 11:30 am, a massage therapist was observed leaving Resident #142's room. She stated the private duty aid was with him and she would come back later in the week. During an interview, on 10/03/12, at 1:30 p.m., with unit manager reporting she has asked about hospice services, but does not know what care hospice delivers. She confirmed that private care giver has given the assistance with eating and assists facility staff to provide care. During an interview with AVOW Hospice nurse, on 10/05/12, at 12:30 p.m., revealed HHA was started due to his skin integrity issues. She stated she spoke to the facility Minimum Data Set (MDS) staff today and was told about the next care plan scheduled for 10/17. She stated the interdisciplinary care team will discuss the need for HHA. She stated "in speaking with his wife, the family wanted to keep the private companion who had been with him at the ALF." The AVOW nurse was under the impression that the care giver was assisting him with his meals and not providing care. Observations during the 5 days of the survey, the private duty companion assisted Resident #142 with eating breakfast and lunch. Observations revealed the care giver got the resident out of the bed to have lunch on the deck outside. Observations revealed the resident has a good relationship with his companion as he smiled and answered the care givers questions. Interview with private duty, on 10/03/12, at 9:00 a.m. confirmed he is paid privately though a home health agency for the daily care he provides Resident #142 from 9:00 a.m. to 11:00 a.m. and 12:00 p.m. to 2 p.m., five days a week. He reported that he is a companion and does not do care. Observation on 10/03/12, at 1:10 p.m. revealed Resident #142 and care giver coming in from outside. A facility Nursing Assistant (NA) A pushed a lift into Resident #142's room. The private duty and NA transferred the resident to the bed. The private duty stated that he repositions Resident #142 in the bed and makes sure to change position every 2 hours. Interview with NA (A), on 10/03 at 1:50 p.m., confirmed 2 people are need to the lift. She confirmed the private duty assisted her with the transfer. Interview with NA (B) NA assigned to Resident #142, on 10/05/12, at 11:45 a.m., revealed the private duty provides personal care to the resident. She confirmed the private duty assists with the resident's oral care and hygiene. Interview with MDS staff on 10/05/12 at 11:30 am that she was not aware that hospice was providing a Home Health Aid 5 times a week since 7/25/12 and what services were provided. She confirmed that Resident #142 had a private care giver (companion) 5 days a week, but had no indication of what he did while he was with the resident. Review of the facility care plan documented Resident #142 is receiving Hospice services. The care plan for self care deficit is not specific on who provide bath and showers, total assistance with grooming needs, comb hair, wash face, hands, oral hygiene and shaving as needed.