Every finding on record at Parkview Rehabilitation Center at Winter Park

Based on interview, and record review, the facility failed to accurately document Activities of Daily Living (ADLs) provided for 2 of 4 residents reviewed for ADLs, out of a total sample of 8 residents, (#1 and #2). Findings: 1. Review of resident #1's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 4/24/26. Her diagnoses included Alzheimer's disease, dementia, and cerebrovascular disease. Review of resident #1's Significant Change in Status Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 4/30/26 revealed a Brief Interview for Mental Status (BIMS) exam was not obtained because the resident was rarely or never understood. A Staff Assessment for Mental Status identified short- and long-term memory problems. The Functional Abilities assessment showed resident #1 was dependent on staff assistance for all ADLs and mobility functions; and was incontinent of bladder and bowel. Review of resident #1's Comprehensive Care Plan revealed a focus for ADL Self Care Performance revised on 4/24/26. Interventions for bathing, bed mobility, dressing, and toilet use identified resident #1 as totally dependent with the assistance of two staff. The care plan identified transfers required a mechanical lift with the assistance of two staff. Review of resident #1's Documentation Survey Report, which documented ADLs provided by the Certified Nursing Assistants (CNAs), for April 2026 revealed blank spaces with no ADL documentation for the following dates and shifts:7:00 AM though 3:00 PM: 4/06, 4/16, and 4/173:00 PM through 11:00 PM: 4/1611:00 PM through 7:00 AM: 4/01, 4/03 through 4/05, 4/07 through 4/10, and 4/12 through 4/15Review of resident #1's Documentation Survey Report for May 2026 revealed blank spaces with no ADL documentation for the following dates and shifts:7:00 AM though 3:00 PM: 5/22 3:00 PM through 11:00 PM: 5/16, 5/21, and 5/2211:00 PM through 7:00 AM: 5/1, and 5/04 through 5/21On 8/14/26 at 9:13 AM, during a telephone interview, CNA E stated resident #1 required total care and two-person assistance. CNA E indicated she typically documented ADL care provided to residents but had been unable to access the electronic medical record for a period of time. CNA E stated she was unaware of a form to document care while she did not have electronic access and instead kept track of the ADL care provided in a personal notebook. On 8/14/26 at 12:10 PM, the Director of Clinical Services stated CNA E was asked why ADLs were not documented for resident #1 during April and May 2026, and CNA E reported she did not have access to the electronic medical record. The Director of Clinical Services stated the Director of Nursing (DON) later restored CNA E's access in May. The Director of Clinical Services indicated CNA E reported the access problem to nurses and the Administrator (NHA) but there was no proof. 2. Review of resident #2's medical record revealed he was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 5/26/26. His diagnoses included periprosthetic fracture around internal prosthetic right knee joint, osteoporosis, dementia, contracture of the right hand, hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following a stroke. Review of resident #2's Significant Change in Status MDS assessment, with an ARD of 6/01/26, revealed a BIMS exam was not obtained because the resident was rarely or never understood. A Staff Assessment for Mental Status identified short- and long-term memory problems. The Functional Abilities assessment showed resident #2 was dependent on staff assistance for all ADLs and mobility functions and was incontinent of bladder and bowel. Review of resident #2's Comprehensive Care Plan revealed a Focus for ADL Self Care Performance revised on 6/16/26. Interventions for bathing, bed mobility, dressing, and toilet use identified resident #2 as totally dependent with the assistance of two-staff. The care plan indicated transfers required a mechanical lift with the assistance of two staff. Review of resident #2's Documentation Survey Report for July 2026 revealed blank spaces with no ADL documentation for the following dates and shifts:7:00 AM though 3:00 PM: 7/05, 7/14, and 7/243:00 PM through 11:00 PM: 7/03, 7/05, 7/11, 7/12, 7/17, 7/25, 7/26, and 7/2811:00 PM through 7:00 AM: 7/01, 7/02, 7/06, 7/07, 7/09 through 7/15, 7/17, 7/20, 7/21, 7/23 through 7/26, 7/28, and 7/31 Review of resident #2's Documentation Survey Report for August 2026 revealed blank spaces with no ADL documentation for the following dates and shifts:7:00 AM though 3:00 PM: 8/01 through 8/03, 8/07, 8/083:00 PM through 11:00 PM: 8/08 and 8/0911:00 PM through 7:00 AM: 8/04 through 8/09, 8/12, and 8/13 On 8/14/26 at 12:40 PM, the DON reviewed copies of the Documentation Survey Report for residents #1 and #2 and validated the medical records should contain documentation of ADLs provided to the residents. She confirmed the records were not accurate when ADLs were not documented.

Based on interview and record review, the facility failed to report an allegation of possible neglect for 1 of 2 residents reviewed for neglect, of a total sample of 8 residents, (#1).Findings: Review of resident #1's medical record revealed the [AGE] year-old female was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 4/24/26. Her diagnoses included Alzheimer's disease, dementia, and cerebrovascular disease. Review of resident #1's Significant Change in Status Minimum Data Set (MDS) assessment with Assessment Reference Date of 4/30/26 revealed a Brief Interview for Mental Status exam was not completed because the resident was rarely or never understood. A Staff Assessment for Mental Status identified short- and long-term memory problems. The MDS assessment showed no behavioral symptoms or rejection of care necessary to achieve goals for health and well-being. The Functional Abilities assessment showed resident #1 was dependent on staff assistance for all Activities of Daily Living, mobility functions; and was incontinent of bladder and bowel. Review of resident #1's Comprehensive Care Plan revealed a focus for risk for falls related to decreased mobility and dementia, initiated on 8/09/24 and revised on 4/24/26. Interventions included keeping the bed in a low position, cueing for safety awareness, and using a scoop mattress to establish the bed perimeter. Review of an SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 4/17/26 revealed resident #1 sustained a fall that afternoon. The form identified pain to the right and left trochanter (hip) and indicated marked localized bruising, swelling, or pain over joint or bone, with or without recent fall. The form documented, Resident was sitting on floor with her back on the O2 [oxygen] concentrator and her head leaning against the nightstand, feet placed under bed. Resident was not making any sounds. The physician was notified at 3:00 PM and ordered resident #1 transferred to the hospital for x-rays and evaluation. Review of resident #1's Progress Notes revealed a nursing note dated 4/17/26 which documented the resident was observed sitting on floor with her back against the oxygen concentrator and her head leaning on the nightstand. The note indicated the resident was assessed, placed on a mechanical lift pad, and lifted onto the bed. The nurse noted upon reassessment, resident #1 grimaced and made noise when her lower extremities were touched. The physician was notified and ordered the resident transferred to the emergency room for evaluation. Review of resident #1's hospital records revealed a History and Physical dated 4/17/26 documented the resident presented following a fall from the bed while being cleaned at the Skilled Nursing Facility. The fall was documented as witnessed. Resident #1 remained hospitalized until her return to the facility on 4/24/26. Review of resident #1's Progress Notes revealed a Focus Interdisciplinary (IDT) note dated 5/01/26 documented the IDT reviewed resident #1's fall and identifying it as a fall without injury. The noted documented the fall interventions were in place and effective and resident #1 had started hospice services upon her return to the facility on 4/24/26. On 8/13/26 at 12:42 PM, Licensed Practical Nurse (LPN) A stated resident #1 required total care and two-person assistance with turning, cleaning, and bathing. She stated the resident was unable to communicate her needs or use the call light. LPN A recalled on 4/17/26 resident #1's assigned Certified Nursing Assistant (CNA) reported the resident had fallen. LPN A explained she and LPN C went to the room and found resident #1 on the floor beside the bed. LPN A stated she was surprised when she was told resident #1 had fallen because the resident could not move independently. She recalled she thought, How in the heck this did happen? LPN A stated resident #1 grimaced when moved was subsequently sent to the hospital. According to LPN A, CNA B reported she was providing incontinence care to resident #1 by herself and, while turning the resident onto her side, the resident continued rolling and fell from the bed. LPN A recalled the bed was in a high position at the time of the fall. On 8/13/26 at 2:26 PM, LPN C stated CNA B was resident #1's assigned CNA on 4/17/26 and came to the nurses' station and reported resident #1 had fallen. LPN C indicated resident #1 required total care and was nonverbal. LPN C recalled CNA B reported she was changing resident #1, turned to obtain an item, and the resident fell during the process. LPN C confirmed CNA B was alone in the room while providing care to resident #1. LPN C stated she was not asked to provide a witness statement regarding the incident. On 8/13/26 at 3:04 PM, CNA D stated resident #1 required total assistance, could not communicate her needs, did not use the call light, and required two-person assistance throughout the time CNA D provided care to her. CNA D further stated resident #1 usually remained in whatever position staff placed her. On 8/14/26 at 10:29 AM, the Director of Rehabilitation stated resident #1's fall was discussed during the clinical meeting, and it was established that CNA B did not followed resident #1's plan of care. Review of the facility's Abuse Quality Assessment and Assurance (QA&A) Log for April 2026 revealed resident #1's incident on 4/17/26 was not included. Review of the Fall Management Guide for resident #1's 4/17/26 fall revealed the facility completed a root cause analysis. The identified root cause was, CNA providing care by herself, didn't have supplies readily accessible. The Action Plan documented resident #1 was sent to the hospital and the CNA was suspended pending investigation. The form documented the huddle was completed on 4/20/26 and was signed by the Administrator (NHA) on 4/22/26. An Event/Interview Statement from LPN A dated 4/17/26 was attached. No statement from CNA B was available with the investigation documentation. On 8/14/26 at 11:43 AM, during a joint interview with Regional Nurse Consultants (RNC) H and I, the Director of Clinical Services and the Director of Nursing (DON), resident #1's 4/17/26 fall was reviewed. The Director of Clinical Services stated the facility determined CNA B had provided care to resident #1 by herself despite having previously received education regarding two-person assistance. The Director of Clinical Services indicated CNA B was suspended on the day of the event pending investigation and was subsequently terminated. She stated the facility's response included staff re-education regarding bed mobility, two-person assistance, Kardex (CNA care plan) review, and abuse and neglect. The Director of Clinical Services stated the incident was reviewed during a call attended by facility and regional leadership. She stated the facility did not report the incident as possible neglect because resident #1 did not sustain an injury, the appropriate plan of care had been in place, and CNA B made the decision not to follow it. She stated they did not feel it was malicious intent of abuse or neglect and CNA B just made a very bad choice. The Director of Clinical Services further stated the decision whether to report the incident was ultimately the facility's decision. During the same interview, facility and regional leadership acknowledged resident #1 required transfer to a higher level of care and remained hospitalized for seven days following the fall. They acknowledged the facility failed to report the incident as possible neglect. Review of the facility's In-service Education Cover Sheet dated 4/17/26 revealed education provided following the incident included Bed Mobility, Always Do with Two, Reviewing Kardex and Abuse, Neglect and Exploitation. The documented objectives included, 2 people assist requires 2 people for care and Not providing residents who are 2 person(s) with 2 person(s) can be neglect and/or abuse. Review of the facility's policy titled Abuse & Neglect Prohibition, revised 10/24/22, revealed the facility would investigate any alleged abuse or neglect in accordance with state or federal law and report such allegations to the state as required by state and federal regulations.

Based on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice and the plan of care for 1 of 1 residents reviewed for IV care, of a total sample of 40 residents, (#510). Findings: Resident #510 was readmitted to the facility on [DATE] from an acute care hospital with diagnoses of acute respiratory failure, pleural effusion, pneumonia, and multiple sclerosis. Review of hospital records from her admission on 1/25/25 revealed she had a midline (IV) line in her right upper arm for administration of IV antibiotics. Resident #510's physican orders indicated she received two grams (gm) Ceftriaxone sodium solution daily beginning on 1/27/25 that was to continue until 2/21/25. A midline catheter is put into a vein by the bend in the elbow or the upper arm .midline catheter may allow you to receive long-term intravenous medicine or treatments, (retrieved on 2/14/25 from www.drugs.com). On 2/03/25 at 10:31 AM, resident #510 was alert and oriented, sitting up in her bed. She had a midline IV with a transparent dressing on her right upper arm. The dressing was dated 1/25/25 and the resident explained she got the IV when she was recently hospitalized . The Registered Nurse (RN) A was outside of the resident's room at that time. She entered the room and explained she was the Evening Supervisor. She confirmed the date on resident #510's midline IV dressing and acknowledged the dressing had not been changed in nine days. RN A explained the facility policy was for IV dressings to be changed at least every seven days or more if needed, and confirmed the dressing should have been changed. RN A explained IV dressing changes were important to prevent infection. and said the dressing should be changed immediately. On 2/03/25 at 1:30 PM, resident #510's assigned RN B confirmed that IV dressing changes should be at least every seven days. She acknowledged that resident #510's midline IV dressing should have been changed on 2/01/25 and explained dressing changes were important care in preventing infections and complications in IV lines. Review of resident #510's medical record revealed no documentation of IV site assessment, nor documentation of midline IV dressing changes from 1/25/25 to 1/31/25 on the Treatment Administration Record. Review of the medical record revealed no physician orders for IV site assessment or midline IV dressing changes. Review of resident #510's care plan revealed a focus for IV therapy related to Pneumonia Infection was initiated on 1/25/25. The care plan did not include interventions to assess the IV site. On 2/05/25 at 1:05 PM, Licensed Practical Nurse (LPN) C said she had worked at the facility for more than twenty years. She explained for residents with IV lines, their IV should be assessed for patency; for signs and symptoms of infection at insertion site; and nurses should change the transparent dressing every seven days and as needed to prevent infection or complications. On 2/05/25 at 3:21 PM, RN D, the Infection Preventionist explained for newly admitted residents with an IV line, nurses had twenty-four hours to change the dressing if needed and enter the appropriate orders for dressing changes every week and as needed. The Infection Preventionist stated the insertion site should be assessed for signs and symptoms of infection every shift. On 2/05/25 at 3:36 PM, the Director of Nursing (DON) explained the facility's protocol regarding IV dressing changes was that the dressing be changed every week, the site monitored for signs and symptoms of infection and that it was the responsibility of the assigned nurse to complete dressing changes. The DON acknowledged resident #510's IV dressing had not been changed as required and said that the expectation was for it to have been changed per protocol to prevent infection. On 2/5/25 at 3:50 PM, the Assistant Director of Nursing (ADON) said, nurses should monitor IVs every day, change the dressing every week and assess to prevent infection. She confirmed resident #510's midline dressing had not been changed per protocol and said, it should have been changed. On 2/6/25 at 10:02 AM, the Nursing Home Administrator stated even though he was not clinical he hoped the facility's protocol for IVs was followed. The facility's Policy and Procedures-Midline Catheter Dressing Change and Infection Prevention and Control Plan, revised on June 2024 indicated Sterile Dressing Change using Transparent dressing is performed upon admission and if transparent dressing is dated clean dry and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label. Review of the facility's Infection Control Policy revised June 2024 revealed, An Infection Prevention and Control Program (IPCP) [was] established and maintained to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Section 11-Prevention of Infection part d described, Important facets of infection prevention include instituting measures to avoid complications and educating staff and ensuring that they adhere to proper techniques and procedures.

Based on interview, and record review, the facility failed to assess the resident's condition and monitor and document for complications after dialysis treatments for one of three residents reviewed for dialysis, of a total sample of 40 residents, (#82). Findings: Resident #82 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease with dependence on renal dialysis. Review of the physician order summary for February 2025 revealed an order for hemodialysis on Tuesday, Thursday, and Saturday via a left upper arm fistula. Review of the medical record on 2/05/25 revealed no post-dialysis documentation of nursing Progress Notes from Thursday 1/30/25, Saturday, 2/01/25 or Tuesday, 2/04/25 to indicate post-dialysis nursing care or assessment was completed. On 2/05/25 at 5:37 PM, the Director of Nursing (DON) stated the facility completed the resident information with blood pressure on the top of the Dialysis Communication Form prior to the resident going for dialysis. She explained the dialysis center was supposed to fill out their section of the form but often did not. The DON continued that the staff nurse assessed and monitored the resident's condition when they returned from dialysis. They documented the resident returned then took their blood pressure. She added that the medical records staff checked the resident's Dialysis notebook the following day and followed up with the dialysis center to get any information regarding the resident's dialysis treatment. The DON indicated she or whoever she designated, the Infection Control nurse or the Staff Development Coordinator would also follow up with medical records to ensure they got the information from the dialysis center. The Infection Control nurse was present and acknowledged she had never been involved in the process of ensuring the information from the dialysis center was received. The Regional Nurse stated medical records did not check the resident's dialysis book daily and recommended an interview with the Medical Records Coordinator. On 2/05/25 at 6:05 PM, the Medical Records Coordinator stated last November the facility switched from more frequent record gathering to requesting information from the dialysis center on their resident's dialysis treatment monthly. She added, on Monday, 2/03/25, she requested dialysis records for all the facility residents who received dialysis from December 2024 and January 2025. The Medical Records Coordinator explained there had been a glitch in the system and the facility had not received December's records yet. On 2/06/25 at 2:13 PM, in an interview with the DON and the Regional Nurse B, the DON stated she would expect the nurse assigned to the dialysis resident's unit to document at a minimum, the resident returned from dialysis. The Regional Nurse added the DON should expect the resident's nurse to include the resident's vital signs as well and the DON agreed. They confirmed the documentation by the nurse should include if the resident was stable or not. The DON verified resident #82's scheduled days for dialysis were Tuesday, Thursday and Saturdays and confirmed there were no post-dialysis documentation of nursing Progress Notes from the recent dates of Thursday, 1/30/25, Saturday, 2/01/25 or Tuesday, 2/04/25. They acknowledged without the documentation there was no way to know if the resident received dialysis treatments on those days, their status or monitoring of their condition upon their return. The DON and Regional Nurse tried to locate the information in the resident #82's medical record but were unable to locate it. The Regional Nurse phoned the dialysis center to confirm resident #82 had received dialysis treatments on 1/30/25, 2/01/25, and 2/04/25. The DON and Regional Nurse agreed nursing staff needed to document when a resident went to dialysis, returned from dialysis, and that they were monitored for infection, bleeding at the dressing site and vital signs when the resident returned from dialysis. On 2/06/25 at 3:45 PM, the Regional Nurse stated the facility did not have a policy regarding batch orders for residents receiving dialysis treatments. The facility's policy entitled Dialysis dated June 2024 indicated its purpose was to monitor and care for hemodialysis residents in the skilled nursing center, and that the resident was to be monitored for bleeding, post-dialysis treatment. The policy detailed the resident was to be monitored for signs of dyspnea (trouble breathing), rales (crackles or high pitched lung sounds), jugular venous distention (bulging of neck veins) and occasional peripheral edema (swelling of extremities).

Based on observation, interview, and record review, the facility failed to ensure menu choices were met for 1 of 2 resident reviewed for food, of a total sample of 40 residents, (#99). Findings: Review of the medical record revealed resident #99, a [AGE] year old female was admitted to the facility on [DATE] from an acute care hospital. The resident's diagnoses included chronic heart failure, hypertension, type 2 diabetes mellitus with chronic kidney disease, Alzheimer's Disease, need for assistance with personal care, and moderate protein-calorie malnutrition. The Minimum Data Set Quarterly Assessment with an Assessment Reference Date of 1/08/25 noted during the look-back periods, resident #99 scored 0 out of 15 on the Brief Interview for Mental Status which indicated she was severely cognitively impaired. The assessment showed resident #99 required a therapeutic diet, and staff assistance to complete Activities of Daily Living (ADLs) including eating. The Order Summary Report showed resident #99 had active physician's orders that included, Multivitamins-Minerals once daily for nutritional supplement, protein drinks twice daily, Consistent Carbohydrate (CCHO) diet with fortified foods, fingerstick blood glucose monitoring as needed for diabetes mellitus, and encourage extra liquids to prevent/reduce the risk of infection for rehydration. The Comprehensive Care Plan included focuses for person-centered care, impaired communication and thought processes related to dementia, risk for pressure wounds related to incontinence, diabetes mellitus with a goal to have decreased disease process complications with an intervention to monitor nutritional status and appetite. Other care plans included dependence on staff to complete all activities and ADLs, risk for decreased nutritional status and dehydration related to protein-calorie malnutrition, diabetes mellitus, therapeutic diet, and low body mass index (BMI) with interventions to monitor diet tolerance and intake, supplements, and to provide food preferences and substitutions. On 2/04/25 at 10:42 AM, resident #99's daughter said she completed handwritten menu choice forms a week in advance, but the facility didn't provide what was requested. She explained they often brought sandwiches and cranberry juice that her mother didn't like, and staff just left them on the bedside table. An undated, unwrapped sandwich and a 4-ounce individual cranberry juice was observed on the resident's bedside table. Resident #99's daughter explained she was concerned because her mother didn't eat well, especially if she or her father weren't there for encouragement. She said she gave up asking staff for substitutions, and she brought snacks for her mother from home. The Kardex for Certified Nursing Assistants (CNA) noted staff were to assist resident #99 with meals, encourage fluids, and monitor her diet tolerance. On 2/06/25 at 12:22 PM, CNA I said the facility had cranberry juice and apple juice for residents. She explained resident #99 required staff assistance for her meals and the kitchen had her menu preferences that were provided on the meal tray. On 2/06/25 at 11:33 AM, the Certified Dietary Manager (CDM) explained she was newly hired and it was her fourth day on the job. She described the process for providing residents' menu choices was done via a handwritten form, and preferences were entered into the computer system. On 2/06/25 at 12:52 PM, resident #99 was observed sitting in a wheelchair in her room with her daughter. CNA I brought in the resident's lunch tray that included spaghetti covered with marinara tomato sauce. The lunch menu ticket included with the tray dated 2/06/25 read, (Fortified Food) Item(s) not specified, NO PREFERENCES, and a handwritten note that read, no tomato beside the item listed as spaghetti marinara. Resident #99's daughter said she completed menu selections a week in advance with notes. She checked the ticket and said she had written the note for no tomato sauce. Resident #99's daughter explained the resident didn't like any gravy or sauces, but her requests were always ignored. A short time later on 2/06/25 at 1:43 PM, the resident's daughter said she tried to remove the sauce because her mother wouldn't eat the spaghetti and barely ate from the other items on her tray. Two 64-ounce bottles of apple juice and strawberry juice were observed on the resident's dresser. The resident's daughter said she brought them in because staff only gave her mother cranberry juice that she wouldn't drink. The Nutrition Quarterly Note dated 1/03/25 included a plan of care update that read, . BMI : 22.5 indicates underweight . Nutritional interventions in place to promote PO [by mouth] intake . Preferences obtained and honored .will have PO intake greater than 50% at meals . On 2/06/25 at 1:43 PM, the CDM checked resident #99's lunch ticket and confirmed there was an advance request for no tomato/marinara sauce. She said the kitchen could and should have omitted the sauce, and explained the facility kept apple juice on hand. The CDM acknowledged all resident menu choices should be verified and updated to ensure they were honored. She explained she did not have computer access yet and could not verify how the previous CDM managed resident's menu preferences. The CDM stated it was important to provide correct menu choices for residents with items they liked to ensure they ate well. On 2/06/25 at 3:56 PM, the Nursing Home Administrator said the CDM reported to him, and he expected the Dietary Department to meet with residents and/or family representatives to obtain menu choices and update them regularly. He said the facility was working on the process with the new CDM to ensure accuracy. On 2/06/25 at 3:15 PM, Regional Nurse B said the facility did not have a written policy and procedure for how staff obtained resident menu preferences and choices. Review of the Facility assessment dated [DATE] noted all residents' dietary preferences were met daily per diet order and resident preferences.

Based on observation, interview, and record review, the facility failed to ensure scheduled medications were administered as per physician's orders and according to accepted professional standards of practice for 5 of 5 residents reviewed for medication administration, of a total sample of 9 residents, (#5, #6, #7, #8, & #9). Findings: On 8/08/24 at 12:07 PM, Licensed Practical Nurse (LPN) A was at her medication cart preparing medications. The LPN stated she was still giving her morning medications and had three more residents to give morning medications to. The 1st floor Unit Manager (UM), and Registered Nurse (RN) Supervisor were seen sitting at the nurse's station. LPN A stated the UM was aware she was still giving morning medications after 12:00 PM. On 8/08/24 at 12:34 PM, and at 12:40 PM, LPN A was still administering her morning medications. On 8/08/24 at 12:50 PM, the 1st floor UM stated staff had a four-hour window to administer morning medications as directed by the facility's medication administration schedule. The UM stated he did not know the facility's protocol if medications were administered out of that recommended timeframe. Review of the facility's undated Medication Administration Times revealed the following, one time a day: upon rising 6:00 AM to 10:00 AM. In the morning: 6:00 AM, in the afternoon: 12:00 PM to 5:00 PM or 2:00 PM. In the evening: prior to bed 6:00 PM to 10:00 PM. Two times per day: upon rising and prior to bed 6:00 AM to 10:00 AM and 6:00 PM to 10:00 PM. Review of the Medication Administration Audit Reports for the day shift on 8/08/24 revealed the following: Resident #5 received her scheduled morning medications late, between 11:58 AM to 12:16 PM, including Carvedilol 3.125 milligram (mg) twice daily for high blood pressure, and Eliquis 2.5 mg daily for clot prevention. Resident #6 received her scheduled morning medications late, between 12:19 PM to 12:34 PM, including Apixaban 5 mg every 12 hours for clot prevention, Amlodipine 5 mg daily for high blood pressure, Phenytoin 125 mg/5 milliliter (ml) give 8 ml twice daily for seizures, and Buspirone 5 mg twice daily for anxiety. Resident #7 received her scheduled morning medications late, between 12:36 PM to 12:40 PM, including Folic acid 1 mg daily. Resident #8 received her scheduled morning medications late, between 12:49 PM to 12:57 PM, including Apixaban 5 mg every 12 hours, Furosemide 40 mg daily, Diltiazem 120 mg daily, Losartan Potassium 25 mg daily, and Metoprolol extended release 50 mg daily for high blood pressure. Resident #9 received her scheduled morning medications late, between 12:41 PM to 12:47 PM, including Acetaminophen 325 mg- 2 tablets twice daily for pain, Furosemide 20 mg daily for congestive heart failure, Depakote 250 mg twice daily for mood disorder, Lisinopril 5 mg in the morning for high blood pressure, and Celebrex 200 mg daily for pain. On 8/08/24 at 12:29 PM, resident #5 stated she had just received her morning medications. The resident said only two nurses gave her medications on time, all the others gave them late. On 8/08/24 at 1:25 PM, the Assistant Director Of Nursing (DON) B stated the scheduled morning medication administration time was upon rising, and the window the medications were to be given was between 6:00 AM to 10:00 AM. She stated if medications were given after 11:00 AM, the medications were considered late. ADON B said the facility's protocol for late administration of medication was the nurse would notify the physician, and obtain orders as needed for the late medications. She stated the nurse should document the communication with the physician in the resident's electronic medical record (EMR). Review of medical records for residents #5, #6, #7, #8 and #9 revealed notification to the physician was not done until after the surveyor discussed the late medication administration with the facility. The policy Person- Centered Medication Administration Schedule adopted on 10/25/2021 and revised on 8/06/2024 read, Medications shall be administered according to established schedules.

Based on observation, interview, and record review, the facility failed to implement nutrition / hydration care plans that included physician orders for thickened liquids for 3 of 4 residents reviewed for dietary services, out of a total sample of 4 residents, (#4, #6, and #8). Findings: On 9/07/23 at 10:17 AM, Cook D stated residents' meal trays were prepared according to pre-printed diet slips that reflected the type of diet, required food texture, and consistency of fluids. She explained the kitchen stocked large, pre-mixed containers of mildly thickened water (nectar consistency) and moderately thickened water (honey consistency) from which kitchen staff dispensed the correct fluid into cups at mealtimes. Cook D stated if residents needed fluids between meals, nursing staff on the units would have to check diet orders in the computer to ensure they provided the right consistency. She stated nursing staff could come to the kitchen for pitchers of honey and/or nectar thickened water and keep them in the nourishment room refrigerators. Cook D selected diet slips for three residents who required thickened liquids for review, residents #4, #6, and #8. 1. Review of resident #8's medical record revealed he was admitted to the facility on [DATE], and most recently readmitted on [DATE]. His diagnoses included end-stage kidney disease with dependence on dialysis, type 2 diabetes, and schizoaffective disorder. The Minimum Data Set (MDS) Discharge-Return Anticipated assessment with assessment reference date (ARD) of 8/09/23 revealed resident #8 had short term memory problems and moderately impaired cognitive skills for daily decision making. He required supervision with eating and had a therapeutic diet. Resident #8's medical record included a care plan for risk for decreased nutritional status and dehydration, initiated on 7/07/23. The interventions included provide a controlled carbohydrate diet, encourage fluids, and monitor oral intake. Review of the Order Summary Report revealed a physician order dated 9/05/23 for a regular diet, regular texture, and mildly thick consistency fluids. On 9/07/23 at 10:30 AM, there was a white Styrofoam cup labeled with resident #8's room and bed number on his tray table. The 100 Unit Manager (UM) confirmed the cup was filled with regular water. On 9/07/23 at 10:50 AM, Certified Nursing Assistant (CNA) C confirmed resident #8 was on her assignment but she was not aware he required thickened water. She stated she usually asked the nurse if she had questions about residents' care needs. CNA C verbalized the importance of providing fluids of the correct consistency. She said, I know they might choke. On 9/07/23 at 1:05 PM, the 100 UM stated all staff should check care plans at the start of every shift as physician orders and nursing interventions could change. She validated it was important for staff to know what type of care their residents needed. The 100 UM stated to her knowledge, the kitchen sent thickened water to the units. She explained the night shift staff who filled resident #8's water cup early that morning should have obtained thickened water from the nourishment room. 2. Review of the medical record revealed resident #4 was admitted to the facility on [DATE]. Her diagnoses included cerebrovascular disease, dementia, generalized muscle weakness, and severe protein calorie malnutrition. The MDS Quarterly assessment with ARD of 7/09/23 revealed resident #4 had severely impaired cognitive skills for daily decision-making. She required extensive assistance from one person for eating, and had a mechanically altered diet-require change in texture of food or liquids (e.g., pureed texture, thickened liquids). Resident #4 had a care plan for risk for decreased nutritional status and dehydration initiated on 3/31/22. The goal was for the resident to tolerate her diet as ordered. The interventions were assist with meals as needed, provide diet as ordered, encourage oral fluids, and monitor oral intake. The care plan was revised on 3/04/23 to reflect thickened liquids as ordered. Review of resident #4's medical record revealed an Order Summary Report with a physician order dated 1/10/23 for meals with pureed texture and fluids of moderately thick consistency. A Nutrition Quarterly assessment dated [DATE] indicated resident #4 continued to experience difficulty swallowing and still required a pureed diet texture and fluids of moderately thick consistency. On 9/07/23 at 10:35 AM, resident #4 was in bed and there was no water on her tray table or bedside table. Registered Nurse (RN) A confirmed the resident did not have water at bedside and offered to get a cup of water from the nourishment room. She returned with a white Styrofoam cup and straw, stated it was regular water and ice, placed the straw in resident #4's mouth, and encouraged her to sip. RN A was prompted to pause and check the resident's diet order. On 9/07/23 at 10:43 AM, RN A checked the electronic medical record and validated resident #4 had a physician order for moderately thickened water. 3. Review of the medical record revealed resident #6 was admitted to the facility on [DATE] with diagnoses including dysphagia or difficulty swallowing, Alzheimer's Disease, and Chronic Obstructive Pulmonary Disease. The MDS Significant Change in Status assessment with ARD of 8/18/23 revealed resident #6 had severely impaired cognitive skills. He required supervision with assistance of one person for eating, and had a mechanically altered diet. Resident #6's care plan for risk for decreased nutritional status and dehydration was initiated on 4/13/22. The goal was the resident would tolerate his diet as ordered. The interventions included assist with meals as needed, provide diet as ordered, encourage oral fluids, and monitor for signs and symptoms of dehydration. Review of the Order Summary Report revealed resident #6 had physician orders dated 10/13/22 for a regular diet and fluids of mildly thick consistency, and 6/20/23 for Speech Therapy three times weekly for four weeks to address management of dysphagia. Review of a Speech Therapy Evaluation and Plan of Treatment dated 6/20/23 revealed resident #6 had mild to moderate dysphagia characterized by coughing during intake of thin liquids. The document read, [Patient] deficits impact airway protection and risk for aspiration pneumonia. The resident's Speech Therapy Discharge Summary dated 7/17/23 read, .continues with significant swallowing impairment impacting safety for tolerating thin liquids. He presents with decreased safety awareness. The recommendation on discharge was for resident #6 to remain on mechanical soft food texture with mildly thickened liquids to reduce his risk for aspiration. On 9/07/23 at 10:40 AM, RN A confirmed resident #6 should definitely have thickened liquids at bedside as she was certain he had difficulty swallowing. She checked the white Styrofoam cup on his tray table that was labeled with the resident's room and bed number. RN A removed the lid and stated it was regular water, not thickened water. On 9/07/23 at 10:43 AM, RN A checked the resident's electronic medical record and verified there was an order for mildly thickened liquids. On 9/07/23 at 10:48 AM, during observation of the 200 unit's nourishment room with RN A, there were no containers of thickened water noted in the refrigerator. There was one dry, unlabeled, empty pitcher on the counter. On 9/07/23 at 11:12 AM, the Rehab Program Manager was informed of concerns regarding residents #4, #6, and #8 who required thickened liquids, but instead were provided regular thin liquids by staff. He explained the correct consistency of fluids was important as there was the potential for respiratory complications related to aspiration and pneumonia. The Rehab Program Manager explained his expectation was nursing staff would follow therapy recommendations and physician orders to ensure residents' safety during consumption of food and fluids. On 9/07/23 at 12:25 PM, the Director of Nursing (DON) acknowledged it was concerning that three of three residents who represented both units were offered thin liquids, rather than thickened liquids as ordered. The DON stated her expectation was nursing staff would follow all physician orders, including diet orders, to meet the needs of the ten residents in the facility who required thickened liquids. She validated the correct consistency was important in decreasing aspiration risk for residents who had difficulty swallowing. The DON said, We don't want to cause harm. She stated she was not sure whether dietary staff delivered thickened water to the units or nurses retrieved pitchers from the kitchen. The facility's policy and procedure for Hydration Evaluation & Approaches revised on 2/19/11, indicated staff would observe care delivery to determine if the interventions identified in the care plan have been implemented. The document revealed staff would verify the correct type of fluid was provided to a resident with dysphagia.

Based on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) comprehensive assessments were completed timely for 1 of 4 residents reviewed for Resident Assessments from a total sample of 46 residents, (#311). Findings: Review of the medical record revealed resident #311 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included history of falls, fracture of the right arm and shoulder, delirium, and dementia. The MDS comprehensive admission assessment with Assessment Reference Date (ARD) 5/18/2023 showed staff documented the assessment was completed late on 6/05/2023. On 6/07/2023 at 4:20 PM, the Director of Nursing (DON) stated the facility had been short staffed for MDS Coordinators since approximately April 2023 when the full-time coordinator left. She said there was one part time person, and she was not working on 6/07/2023 or 6/08/2023. She explained the facility received additional support on occasion from a traveler MDS Coordinator. She said she was responsible for the department and an additional full-time nurse was planned to start soon. On 6/08/2023 at 1:52 PM, the DON checked the medical record and acknowledged resident #311's MDS admission assessment had been completed late. She said she had been informed by corporate management there were multiple late MDS assessments. Review of the MDS 3.0 Final Validation Report dated 6/05/2023 noted a message with resident #311's 5/18/2023 assessment that read, Assessment Completed Late . is more than 13 days after A1600 (entry date). The facility's policies and procedures dated 3/27/2018 titled, SHCO40001.01 Resident Assessment Process, read, 1. The facility conducts a comprehensive assessment {MDS, including Care Area Assessment (CAA)} to identify the resident's needs within 14 days after admission .

Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) quarterly assessments were completed timely for 3 of 4 residents reviewed for Resident Assessments from a total sample of 46 residents, (#74, #84, #103) Findings: 1. Review of the medical record revealed resident #74 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of pressure ulcer of the right heel, dysphagia (swallowing difficulty), presence of gastrostomy (tube feeding device), peripheral vascular disease (poor circulation to extremities), muscle contractures, dementia, depression, and malnutrition. Review of the MDS quarterly assessment with Assessment Reference Date (ARD) 5/24/2023 showed it was in progress and due for completion on 6/07/2023. 2. Review of the medical record revealed resident #84 was admitted to the facility on [DATE] from an acute care hospital and had diagnoses of repeated falls, viral hepatitis, severe kidney disease, heart disease, weakness, cognitive communication deficit, and difficulty in walking. Review of the MDS quarterly assessment with ARD 5/20/2023 showed it was in progress and due for completion on 6/03/2023. 3. Review of the medical record revealed resident #103 was admitted to the facility on [DATE] from an acute care hospital with diagnoses of liver transplant, renal dialysis dependence, kidney failure, history of falls, depression, anxiety, weakness, need for assistance with personal care, and anemia. Review of the MDS quarterly assessment with ARD 5/18/2023 noted it was completed late on 6/6/2023. Review of the MDS 3.0 Final Validation Report dated 6/06/2023 noted a message for resident #103's 5/18/2023 assessment that read, Assessment Completed Late . Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). On 6/07/2023 at 4:20 PM, the Director of Nursing (DON) stated the facility had been short staffed for MDS Coordinators since approximately April 2023 when the full-time coordinator left. She said there was one part time person, and she was not working on 6/07/2023 or 6/08/2023. She explained the facility received additional support on occasion from a traveler MDS Coordinator. She said she was responsible for the department and an additional full-time nurse was planned to start soon. On 6/08/2023 at 1:52 PM, the DON checked the medical record and acknowledged the MDS assessments were overdue and not completed yet, or had been completed late. She said she had been informed by corporate management there were multiple late MDS assessments. The facilities policies and procedures dated 3/27/2018 titled, SHCO40001.01 Resident Assessment Process, read, 13. The MDS completion date (Z500B) must be within 14 days of the Assessment Reference Date (ARD) (A2300) .

Based on observation, interview, and record review, the facility failed to accurately complete Minimum Data Set (MDS) assessment related to functional range of motion (ROM) for 1 of 1 resident reviewed for mobility, of a total sample of 46 residents, (#55). Findings: Resident #55, a 68- year-old female was admitted to the facility on [DATE] with diagnoses which included stroke, contractures of her left upper extremity, and generalized muscle weakness. The resident's admission, and modification to admission MDS assessment with Assessment Reference date of 2/24/23, revealed the resident's cognition was intact with a Brief Interview For Mental Status (BIMS) score of 13 out of 15. Resident #55 required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, personal hygiene, and required one person assistance for eating. The assessment indicated the resident had no impairment in functional limitation in range of motion of her upper and lower extremities. On 6/05/23 at 10:15 AM, resident #55 was sitting up in bed, her left hand was contracted, and the resident was not wearing a splint/brace. A palm guard was noted on the bedside table. Resident #55 stated she had two strokes and could not move her left arm or hand. On 6/07/23 at 12:56 PM, Licensed Practical Nurse (LPN) D confirmed the resident had a contracture of her left upper extremity and stated therapy had been working with the resident for the contracture, but the resident had been refusing splint placement. On 6/07/23 at 2:36 PM, the Rehab Program Manger stated resident #55 had a contracture of her left hand/arm, but the resident would not allow therapy to do much ROM and had refused all splinting. On 6/08/23 at 1:20 PM, the resident's clinical records were reviewed with the Regional Clinical Services Director, and she confirmed the resident's admitting diagnoses included contracture of her left upper extremity. On 6/08/23 at 1:43 PM, the Director of Nursing (DON) stated the facility had a part time MDS Coordinator who was currently unavailable. The resident's clinical records, her admission and modification of admission MDS assessments were reviewed with the DON. She stated the resident had limitation in her ROM due to the contracture. The DON acknowledged section G0400 on the Admission MDS assessment was not accurate. The Centers for Medicare & Medicaid Services Long-term Care Facility Resident Assessment Instrument 3.0 user's manual Version 1.17.1 dated October 2019, defines Functional limitation in range of motion as Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury. The manual indicated that assessment would be Coded 0 no impairment: if resident has full functional range of motion on the right and left side of upper/lower extremities. Resident #55 had contracture of the muscles of her left upper extremity, and contracture of unspecified joint.

Based on interview, and record review, the facility failed to review and revise care plans to meet the residents' need pertaining to activities for 3 of 3 cognitively impaired residents reviewed for activities, of a total sample of 46 residents, (#17 #20 #74). Findings: 1. 1. Resident #17, a [AGE] year-old female was admitted to the facility originally on 8/14/22 and readmitted on [DATE]. Her diagnoses included mood disorder, schizoaffective disorder, anxiety disorder. schizophrenia, dementia, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/18/23 revealed the resident's cognition was not assessed. The assessment revealed the resident required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 6/05/23 at 10:37 AM, and on 6/06/23 at 11:16 AM, resident #17 was lying on her back in a low bed. The resident did not respond when spoken to. The resident's television was not on, no music was playing, and no form of activity was noted for the resident. On 6/08/23 at 11:16 AM, the Activities Director stated care plans for activities were developed, reviewed/revised by the Activities Director. The resident's care plan for activities initiated on 8/22/22 and revised on 3/02/23 was reviewed with the Activities Director. She confirmed the goal of the care plan was for the resident to continue to make their choices regarding activities and express satisfaction on their activities of choice. Interventions included honor resident right to choose programs of own liking daily .including self-directed. Provide resident with alternative choices for self-directed/non- organized activities. Provide with a life enrichment programming calendar to encourage self-direction when choosing daily activities. The Activities Director stated the resident's cognition was moderately impaired. She acknowledged the care plan interventions were not individualized, or person centered since the resident could not do self-directed activities or choose activities from the activity calendar. 2. Resident #20, a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses which included dementia, generalized anxiety disorder, schizoaffective disorder, and major depressive disorder. Review of the resident's quarterly MDS assessment with ARD of 5/02/23, revealed the resident's cognition was rarely/never understood. The assessment revealed the resident required extensive assistance of two persons for transfers, dressing, toilet use, and personal hygiene. On 6/05/23 at 10:32 AM, and on 6/06/23 at 10:45 AM, resident #20 was lying in bed. There was no response when spoken to, and no activities were noted. The television was not on and there was no music playing in the room. On 6/06/23 at 4:16 PM, Certified Nursing Assistant (CNA) C stated resident #20 required total care for all her activities of daily living and could not make her needs known. On 6/07/23 at 1:03 PM, and at 2:28 PM, the Activities Director stated that a care plan for activities would be initiated as soon as a resident was admitted . She explained interventions initiated would be dependent on the MDS assessment. The Activities Director stated she conducted an audit in April 2023 to identify mental status and communication needs of residents. She noted resident #20 had severe cognitive impairment, was never /rarely understood. The resident's care plan for activities initiated 11/05/22 and revised on 11/09/22 was reviewed with the Activities Director. Interventions included, assist with arranging community activities, introduce to residents with similar background, interests, and encourage/facilitate interaction. The Activities Director said the care plan was not person centered or individualized since the resident was unable to do any self-directed activities or choose activities from the activity calendar. 3. Resident #74, an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included dementia, dysphagia, acute respiratory failure with hypoxia, and gastrostomy. Review of the resident's quarterly MDS assessment with ARD of 2/02/23 revealed the resident was rarely/never understood. Resident #74 was totally dependent on staff for bed mobility, transfers, toilet use, and required extensive assistance of two persons for dressing. On 6/05/23 at 10:32 AM, resident #74 was lying in bed, with her eyes closed. There was no response when spoken to. On 6/06/23 at 10:43 AM, the resident was lying in bed with her eyes open. There was no response when spoken to. The television was not on, no music or any other activities were observed in the resident's room. On 6/07/23 at 1:03 PM, and at 2:28 PM, the Activities Director stated she reviewed resident #74's care plan for activities on 5/30/23 , and no significant changes were identified so a revision of her activities care plan was not done. The residents' care plan for activities was reviewed with the Activities Director. She verbalized the resident's care plan was initiated prior to her hire date, and since she had been hired, she had not reviewed or revised the activities care plan. The care plan interventions included honor resident right to choose programs of own liking daily .including self-directed. Provide resident with alternative choices for self-directed/non- organized activities. Provide with life enrichment programming calendar to encourage self-direction when choosing daily activities. The Activities Director said the care plan was not person centered and individualized since resident #74 could not do self-directed activities or choose activities from the activity calendar. The facility policy Comprehensive Person-Centered Care Plans with revised date of 8/31/2022, and effective date of 10/24/2022, read, The center will develop a comprehensive person-centered care plan for each resident that is individualized and includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. the document indicated the care plan would be Reviewed and revised by the interdisciplinary team after each assessment .and as changes in the resident's care and treatment occur

Based on observation, interview, and record review, the facility failed to ensure an ongoing program of activities was provided for 3 of 3 cognitively impaired residents reviewed for activities, of a total sample of 46 residents, (#17 #20 #74). Findings: 1. Resident #17, a [AGE] year-old female was admitted to the facility originally on 8/14/22 and readmitted on [DATE]. Her diagnoses included mood disorder, schizoaffective disorder, anxiety disorder, schizophrenia, dementia, and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/18/23 revealed the resident's cognition was not assessed. The assessment revealed the resident required extensive assistance of two persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. On 6/05/23 at 10:37 AM, and on 6/06/23 at 11:16 AM, resident #17 was lying on her back in a low bed. The resident did not respond when spoken to. The resident's television was not on, no music was playing, and no form of activity was noted for the resident. Review of the resident's Point of Care Response History record from 5/10/23 to 6/07/23 revealed the resident refused one to one activities on 5/27/23. The records showed the resident actively participated in conversation and talking during activities on 5/09/23, 5/10/23, 5/11/23, 5/13/23, 5/15/23, 5/16/23, 5/17/23, 5/20/23, 5/25/23, and 5/27/23. Not applicable was selected for activities on 5/19/23,5/20/23, 5/25/23, and 5/26/23 2. Resident #20, a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses which included dementia, generalized anxiety disorder, schizoaffective disorder, and major depressive disorder. Review of the resident's quarterly MDS assessment with ARD of 5/02/23, revealed the resident's cognition was rarely/never understood. The assessment revealed the resident required extensive assistance of two persons for transfers, dressing, toilet use, and personal hygiene. On 6/05/23 at 10:32 AM, and on 6/06/23 at 10:45 AM, resident #20 was lying in bed. There was no response when spoken to, and no activities were noted. The television was not on and there was no music playing in the room. On 6/06/23 at 4:16 PM, Certified Nursing Assistant (CNA) C stated resident #20 required total care for all her activities of daily living and could not make her needs known. Review of the resident's Point of Care history log from 5/10/23 to 5/27/23 revealed no documentation for one to one activity visits. The log showed the resident actively participated in conversation and talking activities on 5/10/23, 5/11/23, 5/12/23, 5/16/23, 5/17/23, 5/23/23, 5/25/23, and 5/27/23. No other documentation could be identified regarding activities for resident #20. 3. Resident #74, an [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included dementia, dysphagia, acute respiratory failure with hypoxia, and gastrostomy. Review of the resident's quarterly MDS assessment with ARD of 2/02/23 revealed the resident was rarely/never understood. Resident #74 was totally dependent on staff for bed mobility, transfers, toilet use, and required extensive assistance of two persons for dressing. On 6/05/23 at 10:32 AM, resident #74 was lying in bed, with her eyes closed. There was no response when spoken to. On 6/06/23 at 10:43 AM, the resident was lying in bed with her eyes open. There was no response when spoken to. The television was not on, no music or any other activities were observed in the resident's room. Review of the resident's Point of Care record from 5/10/23 to 5/31/23 noted the resident refused one to one activity visit on 5/27/23. The record showed the resident actively participated in conversation and talking activities on 5/10/23, 5/11/23, 5/12/23, 5/13/23, 5/16/23, 5/17/23, 5/19/23, 5/23/23, 5/25/23, and 5/27/23. The activities staff had noted Observation on 5/09/23, and 5/19/23, and Not applicable was selected on 5/23/23, and 5/31/23. No additional documentation could be identified for activities for resident #74. Review of the Activities Calendar for January 2023 to June 2023 showed one-to-one visits were scheduled for every Monday and Thursday. Review of the one-to-one log revealed resident #17 was not on the log, resident #20 had one one-to-one visit on 1/12/23, and resident #74 had one one-to-one visit on 2/09/23. The Activities calendars, and the one-to-one logs were reviewed with the Activities Director. She acknowledged the documentation. On 6/07/23 at 1:03 PM, and on 6/08/23 at 11:00 AM, the Activity Director stated she conducted an audit in April 2023 to identify the mental status and communication needs of residents. She stated that from the audit, it was identified that residents #17, #20, and #74 had severely impaired cognition and the residents were never/rarely understood. She recalled that based on the audit, she had to revise the activities calendar and add activities for residents who were cognitively impaired. This included weekly one-to-one visits for all cognitively impaired residents on Mondays and Wednesdays, and sensory group activity twice monthly. She stated the one to one log was completed by the Activities Assistant, along with daily visits, which would be documented in the residents' Point of Care Response History. She acknowledged there was no documentation to confirm one-to-one visits were provided for the residents as scheduled on the activity calendars. The Activities Director stated that from documentation reviewed, weekly one-to-one visits were not done for residents #17, #20, and #74. The residents Point of Care Response History was reviewed with the Activities Director. She explained that morning rounds were conducted by the Activity Assistant, and they were directed to talk with residents, and read the daily news provided in Spanish and English. She explained that Active indicated the resident actively participated in the activity, and passive indicated staff performed the activity. The Activity Director explained passive response would apply to residents with severely impaired cognition. She stated residents #17, #20, and #74's cognition was severely impaired and they could not comprehend the news. She said the documentation on the Point of Care record indicated the residents actively participated in the task which was not correct. She noted the Activity Assistant should have selected, passive participation which would have been appropriate for residents #17, #20 and #74. The facility's policy Activity Program revised on 6/26/2018 indicated the facility would provide an ongoing program of activities designed to meet the interests and the physical, mental and psychosocial wellbeing of each resident.

Based on observation, interview, and record review, the facility failed to ensure Oxygen (O2) therapy was administered at the correct flow rate per physician's order for 1 of 2 residents reviewed for oxygen, of a total sample of 46 residents (#104). Findings: Resident # 104 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), dementia, psychotic disorder with hallucinations, diabetes type II, major depressive disorder, and Alzheimer's disease. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 4/07/23 revealed the resident's cognition was severely impaired with a Brief Interview For Mental Status score of 03 out of 15. Resident #104 had total dependence on staff of two persons for transfers and required extensive assistance of two persons for bed mobility, toilet use, personal hygiene, and dressing. The assessment revealed the resident received oxygen therapy. Review of the resident's physician's order revealed an order dated 10/03/23 for oxygen at 2 Liters per minute (LPM) continuously via nasal cannula every shift for COPD. On 6/05/23 at 10:25 AM, and at 1:16 PM resident #104 was lying in bed on her back, O2 therapy was infusing at 3 LPM via nasal cannula. On 6/05/23 at 2:09 PM, Licensed Practical Nurse (LPN) A stated resident #104 was on 02 as needed. The resident's physician orders were reviewed with the LPN and revealed an order for 02 continuously at 2 LPM every shift. Observation of the O2 flow rate for resident #104 was conducted with LPN A. She confirmed O2 was infusing at 3 LPM instead of 2 LPM as ordered by the physician. The LPN stated O2 was adjusted by nurses and was checked during medication administration. She said she checked the resident's O2 therapy this morning, and thought it was on 2 LPM. On 6/05/23 at 2:13 PM, Unit A LPN/Unit Manager stated O2 administration was by physician order, and nurses should be checking O2 every shift. She stated the expectation was that O2 was to be administered per the physician's order. On 6/06/23 at 4:25 PM, the Director of Nursing (DON), said nurses were expected to follow the physician order for flow rate for residents on O2 therapy, and nurses were expected to check on the resident's O2 therapy every shift, or if there were any changes with the resident. The resident's care plan Oxygen therapy related to impaired gas exchange, COPD, initiated on 3/31/23 with revision on 4/17/23 interventions included Oxygen therapy as per MD (Medical Doctor) orders 5/23/23 Oxygen via nasal cannula 2 liters/COPD. The facility's policy Oxygen Administration revised on 5/22/2018 instructions included, Check physician's order Turn the unit on to the desired flow rate.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a physically and cognitively impaired resident from exiting the facility and failed to ensure staff responded timely to exit door alarms to ensure the safety of 1 of 4 residents reviewed for elopement of a total sample of 7 residents, (#1). While resident #1 was outside the facility unsupervised, there was a likelihood he could have fallen from his wheelchair, been accosted by unknown persons, or been hit by a car. On 7/11/22 at 4:36 AM, the facility failed to prevent resident #1, a physically and cognitively impaired resident, from exiting the facility unsupervised. The resident left the first floor unit unnoticed by staff as he self-propelled in his wheelchair approximately 120 feet from his room to the double fire doors that led to the lobby. He traveled an additional 33 feet through the lobby until he reached the main exterior exit door. He pushed on the doors for 15 seconds until they opened and an alarm activated. Facility staff did not respond to the door alarm, and resident #1 exited the building in his wheelchair. Once through the main doors, he turned left, opened a gate, and traveled approximately 47 feet down a moderately sloped ramp in the dark. Resident #1 left the ramp and came to a stop on a grassy [NAME], approximately 20 feet away from the road, where he was discovered 30 minutes later by his assigned nurse. The facility's failure to provide adequate supervision to a resident with identified risk for elopement and the failure of staff to respond to exit door alarms contributed to resident #1's elopement and placed all residents who wandered at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy which began on 7/11/22 and was removed on 7/13/22. Findings: Review of resident #1's medical record revealed the [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included Alzheimer's Disease, cognitive communication deficit, anxiety disorder, chronic obstructive pulmonary disease, and history of falls. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 4/12/22 revealed resident #1 ambulated with an assistive device and/or used a manual wheelchair. The document indicated the resident was alert and disoriented but could follow simple instructions. Review of the facility's Elopement Risk Screen assessments conducted on 4/13/21, 4/21/22, 5/3/22, 5/5/22, 7/11/22 and 7/18/22 revealed resident #1 was at risk of elopement. A psychiatric consult note dated 6/30/22 read, Patient lacks the capacity to make decisions related to his/her need for health care, or long-term placement. Due to cognitive impairment, the patient is unable to understand the nature, extent or probable consequences of not receiving medical care.unable to make rational evaluation of the burdens, risks, and benefits of treatments. Review of a nursing progress noted dated 4/13/22 at 10:00 PM showed the resident was wandered up and down the hallway. Another nursing progress note dated 4/13/22 at 11:54 PM, read the resident wandered, was looking and asking for exit door. A wander alert bracelet was placed to his left ankle after notification to the physician and the resident's daughter. The Minimum Data Set (MDS) Admission assessment with assessment reference date of 4/23/22 revealed resident #1 had a Brief Interview for Mental Status score of 9 which indicated moderate cognitive impairment. The MDS assessment showed resident #1 did not exhibit wandering behaviors in the lookback period. The document showed he required extensive assistance with transfers, bed mobility and locomotion, and supervision for walking in his room and the corridor. The MDS assessment revealed resident #1 had unsteady balance during transfers and walking but was able to stabilize himself without staff assistance, and used a wheelchair for mobility. Review of the medical record revealed resident #1 had a care plan for impaired cognitive function and impaired thought process, initiated on 4/13/22. The interventions directed staff to cue, reorient and supervise the resident as needed. A care plan for risk for elopement, initiated on 4/27/22 included goal that resident's safety will be maintained. The care plan interventions directed staff to offer pleasant diversions and structured activities. On 7/20/22 at 6:38 AM, Licensed Practical Nurse (LPN) H stated no code was required to open the fire egress door that led from the first floor unit to the lobby. He explained the door alarm would be activated by residents who wore electronic monitoring devices or if someone pushed on the fire egress doors until they opened. On 7/20/22 at 11:38 AM, Certified Nursing Assistant (CNA) I explained when activated, the fire egress door alarm could be heard in the unit as the noise was pretty loud. However, CNA I explained when she was inside resident rooms she could not hear the alarm. She stated if a resident exhibited exit seeking behavior, staff should notify the nurse, and stay near the resident to closely observe On 7/20/22 at 12:33 PM, CNA J explained resident #1 was transferred to the first-floor unit from the second-floor unit. She stated he was not appropriate for the first-floor unit which exited to the front doors. CNA J described it as a bad decision because the resident never stayed in his room. CNA J noted resident #1 had dementia and at times he could not be easily redirected. She stated staff could not hear the door alarm if they were inside rooms with the doors closed. On 7/20/22 at 1:23 PM, in a telephone interview, and on 7/21/22 at 3:24 PM in an in-person interview with the assistance of a translator, CNA B confirmed resident #1 was on his assignment on the night he eloped. CNA B recalled as he conducted resident care rounds, he last saw the resident in his wheelchair in the hallway. CNA B stated as he exited a resident's room, Registered Nurse (RN) A told him she could not find resident #1. CNA B stated he searched the first-floor unit and did not find the resident, so he went to the second-floor unit to continue searching, but did not see the resident anywhere. CNA B could not explain how the resident passed through two sets of doors without him hearing the alarms. CNA B stated when resident #1 was found in front of the facility in his wheelchair, he was barefooted and still wore an electronic monitoring device. On 7/20/22 at 1:52 PM, LPN C recalled she was seated in the library when RN A asked if she had seen resident #1. Although the library was located near the first-floor unit exit doors, LPN C stated she did not hear any alarms. LPN C stated she observed staff searching for the resident, but she did not hear any announcements made on the overhead paging system. LPN C stated she worked for a staffing agency and that was her first shift in the facility. She indicated she received a brief orientation at the beginning of her shift but did not remember receiving any information on elopement prevention. LPN C stated the facility's administration neither interviewed her nor asked for a written statement until earlier today. On 7/20/22 at 2:04 PM, in a telephone interview, RN A stated she was assigned to resident #1 on the night he got out of the facility, on 7/11/22 at approximately 4:45 AM. She stated she was familiar with this resident and had cared for him when he resided on the second-floor unit. She described him as confused, with memory problems. She indicated resident #1 could walk when he held onto the wheelchair for support, and she recalled he even pushed his overbed table at times as he walked. RN A validated resident #1 wandered inside the facility at times and she recalled he sometimes said, What am I doing here? and I want to go home. RN A explained on 7/11/22, she last saw resident #1 at approximately 4:30 AM. She recalled he was seated in his wheelchair in the hallway so she assisted him to his room and into bed. RN A stated she then went into another resident's room and when she exited that room at approximately 4:45 AM, she heard a door alarm. RN A stated she checked resident #1's room and noted he was not there. She explained she deactivated the alarms on both sets of doors and returned to the first-floor unit to search for the resident and to ask other staff if they had seen him. RN A indicated when she told CNA B, the assigned CNA, she could not find resident #1 his response was, Where can he go? He can't go anywhere. RN A stated after about 10 minutes she went outside through the main front lobby doors, turned right, searched the parking lot, and re-entered the facility through a side door. She explained all staff continued to search both floors of the facility but did not find resident #1. RN A stated she went back outside through the main front lobby doors and turned to the left and saw the resident in the grassy area near the front entrance. She recalled he was seated in his wheelchair and wore a long sleeve shirt and long pants, but no shoes or socks. RN A stated as she brought the resident back to the facility, he informed her he was going home. RN A confirmed resident #1 still wore his electronic monitoring device when found. RN A acknowledged she did not think about calling a Code Purple on the overhead paging system to alert all staff that a resident was missing. She confirmed she did not use the words missing resident when she alerted the other staff, rather she just asked if they had seen resident #1. RN A validated she did not do a head count of all residents and explained she was frightened. She said, It's a scary thing for a nurse when a resident cannot be found. On 7/20/22 at 3:00 PM, resident #1's elopement route was retraced. He left his room and self-propelled his wheelchair past the first-floor unit nurses' station, and traveled down the middle hall to the double fire doors that led to the lobby, a distance of approximately 120 feet from his room. Resident #1 pushed on the doors for 15 seconds until the magnetic lock released, and the door opened, activating the alarm. He then traveled an additional 33 feet through the lobby until he reached the main exterior exit door. He pushed on the doors for 15 seconds until they opened and activated a second door alarm. Resident #1 then exited the facility in his wheelchair, turned left, opened a gate, and traveled down a moderately sloped ramp in the dark. Resident #1 left the ramp and came to a stop on a grassy [NAME], approximately 20 feet away from the moderately-trafficked road in front of the facility. Hazards outside the facility included a nearby construction site and a retention pond containing water, in the park across the street. Resident #1 traveled a total distance of about 200 feet from his room to the point where he was discovered (as per facility's video recording). On 7/20/22 at 2:52 PM, the Director of Maintenance explained the fire egress doors between the first-floor unit and the lobby were protected by an electronic wander monitoring system. He stated these doors locked and alarmed only when an electronic monitoring device approached the sensor. He stated the main front lobby doors used to enter and exit the facility were locked at all times and also had an electronic wander monitoring system. The Director of Maintenance stated he checked the function of the electronic monitoring system every morning and did not identify any issues during the daily inspections prior to the elopement. On 7/20/22 at 3:56 PM, during an interview with the Administrator and Director of Nursing (DON), the DON recalled she received a telephone call from RN A on 7/11/22 at approximately 5:25 AM. She stated the RN informed her resident #1 got outside the facility but had been found and brought back inside. The DON stated to her knowledge, resident #1 had not previously shown exit seeking behaviors. She did not recall reports from staff regarding the resident expressing a desire to go home. The Administrator explained the facility's video camera footage provided a timeline of resident #1's elopement. He stated the video showed the resident exited the first-floor unit on 7/11/22 at 4:31 AM and RN A responded to the alarm 14 minutes later at approximately 4:45 AM. The Administrator explained RN A disabled the alarm and initiated a search, but did not follow the facility's policy and announce the missing resident on the overhead paging system or conduct a head count of all residents in the facility. A review of the facility's video recording on 7/21/22 at 11:04 AM, showed resident #1 in his wheelchair near the double exit doors with no staff visible on 7/11/22 at 4:31 AM. The resident pushed the handicap button on the main entrance door at 4:35 AM and exited the facility. At 4:40 AM-4:44 AM, cars can by seen driving by close to where the resident was situated. At 5:08 AM, RN A and CNA B were noted with the resident bringing him back to the facility. On 7/21/22 at 3:58 PM, in a telephone interview, resident #1's daughter stated her Dad sometimes said he wanted to go outside but he did not understand he could not go out by himself. She explained the facility had recently moved him from one floor to another, so he got confused and agitated after the change. On 7/21/22 at 6:51 AM, CNA D recalled the morning of the incident, she was in the hallway but could not recall whether she heard the door alarm or not. She explained she was not able to hear the door alarm if she was inside resident rooms. She stated she did not see the resident when he returned and did not hear any announcement on the overhead system. On 7/22/22 at approximately 4:25 PM, the Director of Maintenance explained the door alarms sounded by the door and at the nurse's station. He explained it was a loud noise that could be heard inside resident's rooms if the door was open but if the door was closed, you may not hear it. On 7/22/22 at 6:17 PM, in a telephone interview, resident #1's physician and Medical Director confirmed the facility contacted him after the elopement incident. He explained during the Quality Assurance Performance Improvement (QAPI) meeting, they reviewed the incident and discussed the implementation of a thorough search of the grounds. He noted resident #1 lacked insight and appeared he wanted to go home when he exited the facility. The physician acknowledged the resident had an electronic monitoring device based on exit seeking behaviors and elopement risk assessments. He indicated resident #1 was not tested for outside safety and should not have been outside of the building without supervision. Review of the policy and procedure Resident Elopement revised on 3/15/22 revealed the facility .strives to provide a safe environment and implements measures to minimize elopement. A resident who leaves a safe area may have the potential to experience heat or cold exposure, dehydration and/or other medical complications or environmental hazards such as bodies of water or busy roads. The policy's definition of elopement was. when a resident leaves the premises or a safe area without authorization .and/or necessary supervision. Review of the Facility Assessment Tool updated on 7/11/22 revealed the facility could care for residents who had behavioral issues and cognitive impairment. The document indicated the facility would identify hazards and risks and involve residents and their representatives in creating person-centered plans of care. Review of the immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 7/11/22 the facility staff ensured all residents were accounted for and residents with wander alert devices were in place and functioning * On 7/11/22 the resident was assessed by the physician and placed on one to one supervision. The resident's care plan and Kardex were reviewed and updated. * On 7/11/22 the facility's egress doors were checked to ensure they were in good working condition and were appropriately secured. Daily audits of doors continued. * On 7/11/22, the licensed nurse involved in incident received re-education on the elopement risk process and policy and procedure by the administrator and Assistant Director of Nursing. *On 7/11/22 an Ad Hoc QAPI meeting was held. *On 7/11/22 facility completed audit of elopement risk assessments for current residents and identified the need to add 4 more alerting devices. Care plans and Kardexes were reviewed of all residents triggered to be at risk for elopement. * On 7/11/22 facility audited elopement books to ensure pictures and demographic information were in place and accurate. * From 7/11/22 to 7/13/22, all staff were re-educated regarding elopement risk process, policy and procedure with Abuse, Neglect and Exploitation, with emphasis on supervision, overhead paging of Code Silver (facility's code for missing persons), responding to alarms and initiating a thorough search. In-service attendance sheets were provided for 7/11/22 and 7/12/22. Staff education was accompanied by a post-test and participation in Code Silver drills to validate understanding and competency. The passing rate of the test was 84%. * On 7/11/22, elopement drills were initiated on every shift. On 7/12/22, it was identified that one staff responded to the alarm and disengaged the alarm without doing a thorough search. The staff member was immediately reeducated and return demonstration done successfully. Twenty one drills were conducted between 7/11/22 to 7/17/22. Review of in-service attendance sheets revealed drills were conducted according to the action plan. Code drills were ongoing. * From 7/22/22 to 7/23/22 interviews conducted with staff representing all shifts included 9 CNAs, 1 LPN, 1 RN, 2 Housekeeping staff, 1 Laundry staff and 1 Dietary staff revealed staff participated in elopement drills, elopement education, door alarm procedures, and initiating thorough search. All staff were able to verbalize knowledge and understanding of the education provided after the IJ. The resident sample was expanded to include 3 additional residents at risk for wandering, and elopement. Observations, interviews and record review revealed residents #2, #3 and #7 had elopement risk assessments, appropriate care plans and demographic information placed in the elopement binders.

Based on observation, interview and record review, the facility failed to prevent an avoidable fall for 1 of 13 residents reviewed for falls out of a total sample of 47 residents, (#235). This failure resulted in resident #235 falling from her bed and sustaining injury and subsequent death. On [DATE] at approximately 5:45 AM, an agency staff, Certified Nursing Assistant (CNA) E provided incontinence care to resident #235 without assistance. CNA E rolled the resident onto her left side, to secure the incontinence brief and the resident fell out of bed onto the floor, face first. The resident was transferred to the hospital where she was intubated and admitted to the intensive care unit. She was diagnosed with a severe head wound, brain bleed and brain shift. The resident was admitted to Hospice on [DATE] and died on [DATE]. The facility's failure to prevent an avoidable fall resulted in serious harm. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to a D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Resident #235 was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included stroke, type 2 diabetes, heart failure, [CONDITION(S)], and right side craniotomy in 2012. A craniotomy is the surgical removal of part of the brain from the skull to expose the brain for surgery. (www.hopkinsmedicine.org [DATE]) The Admission Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident's cognition was severely impaired. Review of the Activities of Daily Living (ADL) section of the assessment indicated the resident required extensive assist of 2 staff persons for Bed Mobility, and Toilet use. The assessment showed the resident required extensive assistance of 1 staff person for Dressing, Eating and Personal Hygiene. The resident was totally dependent upon staff for Transfers, Locomotion and Bathing. Review of the facility's Fall Risk Evaluation dated [DATE] revealed a score of 16 and deemed the resident at high risk for falls. A score of 10 or greater indicated High risk for falls. The evaluation noted the resident was disoriented at all times, was bedbound, incontinent and had decreased muscular coordination with jerking and unstable movements. Review of the resident's medical record revealed a care plan for falls related to weakness, decreased mobility and stroke. A nursing care plan for ADL self care performance deficit was initiated on [DATE]. The interventions noted the resident required extensive assistance of 1 staff person for personal hygiene and extensive assistance of 2 staff persons for bed mobility. The care plan indicated resident #235 required extensive assist for toilet use but did not define the number of staff members required for this task. Review of the CNA care plan/Kardex revealed instructions to assist with toileting as needed and provide extensive assistance with toileting, but the Kardex did not indicate the number of staff required. A review of the nursing progress note dated [DATE] at 6:00 AM by Registered Nurse (RN) I read, At 5:50 AM CNA notified nurse that resident is on the floor face down. Nurse went to resident's room and verified observation. Staff assisted resident to supine position. Head to toe assessment completed, bleeding noted to top of the forehead, staff applied pressure on site, and covered with dressing. Vital signs obtained. Upon Interviewing CNA, CNA explained during AM [morning] care, CNA changed the patient's brief and turned her on left side lying position the patient tipped over the bed onto the floor. The note indicated resident #235 responded to pain but was nonverbal. RN I received an order to transfer the resident to the hospital for further evaluation. A review of the hospital records dated [DATE] noted that upon arrival to the Emergency Department the resident had laceration to her forehead and was minimally responsive. She was intubated and a Computerized Tomography (CT) scan of the brain showed acute intracranial bleed. A hospital progress note on [DATE] at 2:01 PM read, patient with poor prognosis due to .acute bleed, not operative candidate, palliative care consulted. On [DATE] the resident was transferred to Hospice and died [DATE]. A telephone interview was conducted with the resident's son on [DATE] at 10:25 AM. He said he spoke to the resident regularly on the phone and last spoke to her a day before the fall. We were laughing and bringing up old times. She was talking away. He said he saw his mother in the hospital on [DATE] and she was on a ventilator. He described the cut and stitches on her face from the fall. He said she was unresponsive and could not squeeze his hand. He stated the doctor told him that she had a massive brain bleed with brain shifting and there was nothing they could do. He said they were informed on [DATE] that she was dying. He said his mother passed away on [DATE] and the death certificate noted acute head trauma with brain bleed. On [DATE] at 10:03 AM, resident #235's fall was discussed with the facility's Administrator and Director of Nursing (DON). They stated the fall occurred in the morning of [DATE] at the time of shift change. They explained the staff assigned to the resident's care was from a staffing agency, CNA E. The DON said on [DATE] at approximately 5:50 AM, CNA E informed the nurse the resident had fallen from the bed on to the floor. The nurse assessed the resident and called 911 to transport the resident to the hospital. The DON explained that CNA E should have requested help before she provided care to the resident. She said CNA E told her, I just did not ask for any help. The DON said the resident's level of care assistance was on the Kardex but CNA E did not look at it. When asked how agency staff would be made aware to access the Kardex, the DON replied, It is kind of a given. Although the DON said CNA E did not look at the Kardex, she acknowledged that training to use the Kardex was not included in agency staff's orientation. On [DATE] at 9:41 AM, CNA E was interviewed by phone. She said she was out of the country and the phone signals were not very good. CNA E said she worked with a staffing agency. She explained she was asked to work at the facility on the 3 PM to 11 PM shift on [DATE] as the facility was short staffed. She said she started her shift at 4 PM and worked until 11 PM but she was not assigned to resident #235. She was then asked to work a double shift and agreed to work 11 PM to 7 AM. She recalled she was assigned 12 to 14 residents, including resident #235. She noted at approximately 4 AM she started to do her final rounds. She stated resident #235 was in a 3-person room and she first provided care to the other 2 residents in the room. She remembered before she started care for resident #235, she went out into the hallway to find help. She recalled CNA L was working in the same hallway and she asked CNA L for help. CNA L was with another resident and told her to wait. CNA E did not explain why she asked CNA L for assistance with resident #235 but stated she proceeded to provide ADL care, including incontinence care as resident #235 was wet and had a bowel movement. She said she changed the resident's bed linen, her gown and the incontinence brief as they were wet and soiled. She said she first secured the resident's incontinence brief, with the tab/tape on her left hip. She then turned the resident toward her, onto the resident's left side to secure the right side tab and that's when the resident fell out of bed. She said it happened so quickly that she did not have time to prevent the fall. CNA E stated, When it's morning and it's getting close to 7 AM, we need to change the residents' before the next shift comes in. We cannot leave them with their briefs wet or soiled. CNA E stated she immediately informed the nurse and 911 was called. She explained she returned to the facility on [DATE] at approximately 8 PM and spoke to the DON about the fall. The CNA was again asked why she provided care to resident #235 by herself but the phone disconnected. The surveyors were not able to contact CNA E by phone again and an email was sent on [DATE] at 11:19 AM. In response to the email, the CNA replied that she was not aware whether the resident required 1 or 2-person assist for toileting care and mobility as she was not able to access the resident's care plan/Kardex. She explained she was not educated by the facility on how to use the tablet to access the resident Kardex. A review of the facility's investigation and Root Cause Analysis revealed, The assigned CNA did not review the resident Kardex nor ask for assistance with bed mobility. The facility failed to identify that agency staff did not have access to the Kardex and were unable to review the residents' care needs. The investigation also did not identify the omissions on resident #235's nursing care plan and CNA Kardex for the number of staff required to safely provide care. During a telephone interview on [DATE] at 10:22 PM, CNA L stated she had worked at the facility for several years and had taken care of resident #235 in the past. She said the resident was a 2 person assist for all ADLs including incontinence care. CNA L explained resident #235 was confused and did not move her arms or legs much. She added the resident was not aggressive or resistive to care. CNA L remembered working on [DATE] on the 11 PM to 7 AM shift. She recalled CNA E, an agency staff, was assigned to resident #235. Contrary to CNA E's statement, CNA L said CNA E never asked her for help with resident #235's care. CNA L stated she was coming out of room 134 when she heard that a resident had fallen. She explained CNAs were provided training on how to use the tablets and access the Kardex but was not aware if agency staff were included in the training. On [DATE] at 8:11 PM, Registered Nurse (RN) I stated he worked on the 11 PM to 7 AM shift when the resident fell from bed. He recalled resident #235 was confused and did not resist care. He said she was bed bound and required assistance of 2 staff persons for bed mobility and transfers. RN I explained he usually changed the resident's gastrostomy tube dressing at midnight and she would either be sleeping or just about to fall asleep. He recalled she had weakness to one side of her body but both sides of the body were weak and that one side was more pronounced. In regard to bed mobility, RN I said to turn and reposition her would take a lot of effort. It would be hard to turn her from her back onto her side. He remembered on [DATE], that it was the first time he had worked with CNA E. He explained on the morning of [DATE] at approximately 6:00 AM, CNA E informed him that resident #235 fell . He described CNA E as panicked and crying when she told him the resident fell . He said he entered resident #235's room and was shocked when he saw the resident on the floor face down and bleeding. RN I stated he assessed the resident and her level of consciousness was definitely different. She was moaning and more disoriented and not verbal. He stated prior to the fall the resident was able to answer verbal commands. He said she was bleeding from her forehead and described the wound as a deep skin tear. He said the other nurse, RN K put a dressing on her forehead wound and helped him put her back in bed. He added, I really don't know how to describe it. He said he was concerned for the resident as she did not give him a verbal response, just moaned. He did neurological checks while waiting for paramedics to arrive and the resident's heart rate was high, 104 beats per minute. He said he was concerned that she might be bleeding in her brain. He said in the past, he helped CNAs with the resident's care as she required 2 person assist with care. He recalled CNA E never asked or help or verbalize any problems using the tablet to check the resident's care needs. He said he did not remember seeing CNA E use the tablet to access the resident's Kardex. He did not answer when asked if CNA E had been trained to use the tablet to access the resident's Kardex. On [DATE] at 3:37 PM, agency CNA Q described resident #235 as immobile with left sided weakness. She added the resident was a 2 staff person assist for repositioning and incontinence care as she was weak and heavy. She said she was given access to the electronic Kardex but did not receive any formal training. She explained if agency staff did not know how to use the electronic Kardex, the other aides would show them, if they were available. On [DATE] at 5:28 PM, agency CNA R stated she had worked at this facility intermittently over the past 2 months. She could not recall any formal training on the use of the facility's electronic Kardex. I asked one of the girls how to use the system. On [DATE] at 5:46 PM, agency CNA S, stated she worked occasionally at the facility since [DATE]. She recalled she received brief verbal instructions from a nurse on how to access the resident Kardex. CNA S described the process as a little difficult and the nurse instructed her to ask one of the other CNAs if she had any trouble. On [DATE] at 3:17 PM, the Care Plan Coordinator reviewed and discussed resident #235's MDS assessment, nursing care plans and CNA Kardex. She stated the resident's MDS Admission Assessment showed the resident required extensive assistance by 2 staff persons for Bed Mobility and Toilet Use. The Care Plan Coordinator explained the Kardex provided information on how to safely care for residents and therefore needed to be accurate. At this time, she was informed resident #235's care plan and Kardex were missing specifics on how many staff were required to provide incontinence care. The Toileting section for both the Care Plan and the Kardex read, Extensive assist with -- persons assist. The CPC stated, for toileting, it should say 2 person assist, for both the Care Plan and Kardex. She said if information was missing, staff were expected to go to the nurse for that. The Care Plan Coordinator stated she was not aware of the omission until now and it was also missed in review of the care plan and Kardex during investigation of the fall. A review of the resident #235's ADL flow sheets showed that contrary to directions on the MDS Admission Assessment, the flow sheet for [DATE] showed care related to bed mobility for 47 of 81 shifts was provided by 1 staff instead of 2. For 33 of 54 shifts, toileting/incontinence care was provided by 1 staff person instead of the required 2. From [DATE]st to [DATE]rd, 2021, the ADL flow sheet noted that for 4 of 7 shifts, CNAs documented only 1 staff person performed toileting/incontinence care. Toileting/Incontinence care for resident #235 required staff to turn and reposition the resident in bed, hence assistance of 2 staff for Bed Mobility during this task. The Care Plan Coordinator did not provide an answer as to why only 1 CNA performed bed mobility and incontinence care according to the flow sheet. On [DATE] at 3:39 PM, the Assistant Director of Nursing (ADON) stated she was responsible for staff training. She explained the facility CNAs were trained how to access and to follow the resident Care Plans and Kardex starting at orientation. She added that agency staff also received orientation, but did not provide any details on how agency staff were educated on the use of the electronic Kardex. She said the facility had documentation of the agency CNAs' orientation however, at the time of exit, the ADON did not provide any agency staff training. On [DATE] at 6:17 PM, CNA O stated that sometimes when residents were first admitted , the Kardex may indicate the resident needed 2 staff person assistance with ADL tasks. She explained that as the resident's abilities improved with therapy, she would determine if the resident could manage with less assistance, of 1 staff person. On [DATE] at 3:28 PM, the facility's Medical Director stated he was aware of resident #235's fall. He said the facility had falls with injury in the past but not like this. He acknowledged it was the facility's responsibility to ensure that staff were doing what they were supposed to be doing and to train and educate the staff. The facility's Immediate Jeopardy Removal Plan included the following immediate actions the facility implemented, which the survey team verified: *On [DATE] 89 resident care plans/Kardexes were audited for assistance needed for bed mobility to ensure assistance needed was accurate and complete. 20 Care plans and Kardexes updated to reflect accurate level of assistance for bed mobility. *Education began on [DATE] through [DATE] for both licensed and non-licensed staff that included agency staff on following the care plan and Kardex. 32 CNAs, 9 LPNs and 15 RNs for a total of 56 staff members and 8 agency CNAs received education prior to resident contact. *On [DATE] a text blast was sent out at 6:22 PM to a total of 56 staff, with regards to following the Kardex related to Bed Mobility. *On [DATE] Ad Hoc QAPI meeting was conducted on [DATE] with the Medical Director, Administrator, DON and 5 other team members to review the plan of action. *On [DATE] Ad Hoc QAPI meeting via phone and reviewed education and audits. No further recommendations made. *On [DATE] education validation competency audits completed by Management Team. *On [DATE] audits of Kardexes and Plan of Care for bed mobility were completed by the DON for 5 residents. These 5 residents were 1 staff person assist for Bed mobility and 4 of the 5 residents were at risk for falls. *On [DATE] Ad Hoc QAPI meeting with the Medical Director, Administrator, DON and 5 other team members. At this meeting no other recommendations were determined. *On [DATE] Ad Hoc QAPI meeting was conducted with the Medical Director, Administrator, DON and 5 other team members. The QAPI members determined that an audit of Care Plans/Kardexes were required with regards to accuracy of ADLs. *On [DATE] the audits conducted by the MDS Coordinator of all current 82 residents regarding accuracy of resident Care Plans/Kardexes, specifying how many staff were required to provide safe care to the residents. This audit identified that 4 Care Plans/Kardexes required to be updated as follows: a. 1 resident's Bed Mobility was updated from limited assist of 1 staff to supervision of 1 staff. b. 1 resident had Bed Mobility updated for extensive assist by 1 staff to extensive assist with 2 staff. c. 1 resident had Bed Mobility updated for supervision of 1 staff to extensive assist with 1 staff. d. 1 resident had Transfers updated from dependent of 1 or 2 staff to extensive assist by 2 staff. *On [DATE] audit of residents at risk falls was completed by the DON. 25 fall risk residents were identified and fall risk interventions updated. *On [DATE]/ education to Licensed Nurses and CNAs with regards to missing ADL assistance, utilization of 2 staff members and documentation. *On [DATE] the MDS coordinator was educated on ensuring accuracy of resident Care Plans/Kardexes. *Newly hired staff and agency staff will receive the education as part of their new hire and agency orientation process.

Based on observation, interview and record review, the facility failed to ensure the oxygen concentrator was clean for 1 of 2 residents reviewed for respiratory care out of 6 residents receiving oxygen via oxygen concentrator in a total sample of 47 residents, (#28). Findings: On 7/18/21 at 12:04 PM, resident #28 was lying in bed. She received oxygen (O2) via concentrator. The air intake area on back of the concentrator was completely covered with dust. The O2 tubing bag was dated as changed on 7/12/21. On 7/20/21 at 1:52 PM, Registered Nurse (RN) J said she checked the concentrator to ensure it was set at the right flow rate. She added the tubing was changed weekly on the 11 PM to 7 AM shift. She said nurses were responsible for the cleanliness of the concentrators and washing of the air filters. The Infection Control Preventionist (ICP) was present and explained that an outside service came to check the filters. When both RN J and ICP observed resident #28's oxygen concentrator, they both acknowledged the exterior air intake area of the oxygen concentrator was covered with dust. On 7/20/21 at 5:15 PM, the Maintenance Supervisor noted the air intake of the concentrator was covered in dust when he observed resident #28's oxygen concentrator. He said the concentrator was one of two rented machines and an electrical inspection was done April 2021. He opened the internal filter which was dated 5/15/19. He said he contacted the manufacturer and the internal filter should have been changed every 2 years and acknowledged it should have been changed 2 months ago. On 7/21/21 at 1:30 PM, the air intake vent of the concentrator for resident #28 remained covered with dust. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the oxygen concentrator manufacturer's manual noted, Periodically use a damp cloth to wipe down the exterior case of the .device. The facility policy and procedure for Oxygen Administration via Concentrator last revised on 4/24/18 did not have any procedures for cleaning the concentrator.

Based on observation, interview, and record review, the facility failed to provide adequate activities of daily living (ADL) care for 1 of 2 dependent residents of a total sample of 47 residents, (#74). Findings: Resident #74 was readmitted to the facility from an acute care hospital on 3/25/21. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's significant change Minimum Data Set (MDS) assessment with Assessment Reference Date 7/1/21 revealed no history of rejection of care. Her Brief Interview for Mental Status (BIMS) score was 5/15 which indicated she was severely cognitively impaired. The resident required extensive assistance of 1 staff with her personal hygiene and was totally dependent on staff for bathing. The resident's care plan for ADL self-care performance deficit revised on 7/8/21 noted interventions that included, Bathing: The resident needs limited assistance on staff for personal hygiene This care plan contradicted the most recent MDS assessment that noted she needed extensive assistance. 07/21/21 at 12:31 PM, the MDS Coordinator acknowledged the ADL care plan was not updated after the most recent significant change MDS assessment was completed. She said resident #74 had a decline and now needed extensive assistance for personal hygiene. On 7/18/21 at 11:25 AM, resident #74 was lying in bed. Her fingernails were dirty with brownish/orange colored debris under the nails. Resident #74 was observed again on 7/18/21 at 12:30 PM eating lunch while in bed and her fingernails remained dirty with orange/brown residue noted under the nails. On 7/18/21 at 3:45 PM, resident #74 was resting in bed and her fingernails remained the same. On 7/19/21 at 12:25 PM, resident #74 was sitting up in bed eating lunch with her fingers and her fingernails remained dirty with brownish/orange residue present under nails and around the cuticles. The Director of Nursing (DON) walked into the room and observed the resident eating her lunch with dirty hands/fingernails. The DON said they used to have wipes for residents to use prior to eating to clean their hands. On 7/20/21 at 12:05 PM, the resident was lying in bed with untouched lunch tray on the over-bed table. Certified nursing assistant (CNA) A was in the room and acknowledged the resident's dirty hands and fingernails with orange/brown residue under the nails. The CNA did not offer to clean the resident's hands/nails and said that the resident was too drowsy to eat at this time. On 7/20/21 at 12:30 PM, the resident's assigned CNA B was at the bedside and acknowledged the resident's hands/fingernails were dirty. The CNA said she wiped the resident's hands earlier today with a washcloth but did not clean under her fingernails. She explained she did not know when they did nail care at this facility as this was her first day working here. On 7/20/21 at 1:47 PM, the DON acknowledged residents #74's hand/fingernails were dirty and said the staff should have cleaned them during ADL care and prior to meals. The DON added that CNAs should not have to be instructed to do nail care as it was part of their job duties. The facility's policy for Fingernail Care dated 4/10/2019 read, The purpose of the care of fingernails promotes circulation to the hands and helps prevent small tears around the nails that could lead to infections Clean under the fingernails with an orange stick

Based on observation and interview, the facility failed to ensure the upright freezer was maintained in a clean and sanitary condition to prevent the potential of cross contamination of stored frozen food items in 1 of 1 freezer. Findings: On 7/17/21 at 10:52 AM, the six door upright freezer had a red liquid spilled on the floor of the middle bottom door. A ready to eat turkey pot roast and another ready to eat roast were stored on the floor of the freezer directly on top of the spill. At the time of the observation, the Certified Dietary Manager acknowledged the red liquid spill and the food stored on the floor on top of the spill. There was no rack to keep the food items from being in direct contact with the bottom floor of the freezer and in contact with the spill.

Based on interview, record review, and review of the facility's policies, the facility failed to immediately notify a resident's family representative of an unwitnessed resident fall for 1 of 3 sampled residents, (1). Findings: Review of resident #1's record revealed he was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Review of the nursing progress notes dated 12/5/20 at 10:51 AM Occurrence note read: At 8:30 AM, CNA (Certified Nurse Assistant) notified nurse upon entering residents room, resident was observed laying on the floor at the left side of the his bed near wheelchair. Nurse verified findings. When interviewing resident, resident was unable to provide statement due to dementia. Head to toe assessment completed. Skin assessment completed, no skin tears or abrasions noted. ROM (Range of motion) demonstrated to both upper and lower extremities. No complaints nor signs/symptoms of pain/discomfort noted at this time. Upon room assessment, floors were wet from spilt milk under patient but clutter free, ample lighting in room. Resident was wearing no-skid shoes, Staff assisted resident onto wheelchair then back to bed. Neurological (Neuro) checks in progress. Vital signs WNL (Within Normal Limits.) Call light within reach, Bed is in lowest position, will continue to monitor for any changes. Notified MD (name), no new orders. There was no documentation that the nurse notified the resident's family representative of the fall. On 12/17/20 at 3:30 PM, the Director of Nursing (DON) stated the record did not reflect the family was notified of the fall. The DON stated she spoke to the nurse caring for the resident and the nurse stated she tried to call the family on 12/05/20 several times but was unsuccessful. The DON added the nurse did not document the telephone call attempts of 12/05/20. The DON said the nurse called the family on 12/06/20 when the resident had a different occurrence of a significant change with loss of consciousness. Review of the facility protocol titled Change In Contrition Guideline, read, The facility must inform the resident, consult with the resident's physician and notify the resident's family member or legal representative when there is a change requiring notification . Example situation requiring notification include: 1. An accident involving the resident which: a. Resulting in injury, b. Potential to require physician intervention.

Based on observation, interview and record review, the facility failed to provide a safe and sanitary environment in the laundry department to prevent cross-contamination and spread of infection. Findings: On 01/07/2020 at 11:15 AM, tour of the laundry clean linen room revealed a black [NAME]et hanging outside, at the top of the storage locker. On 01/07/20 at 11:22 AM, laundry aide A stated, It's the employee locker and I put my purse and stuff in there not allowed to have food in here. On 01/07/20 at 11:30 AM, the housekeeping director stated that the lockers were already in the clean linen room when he came to the facility, and was not aware they were being used as personal lockers. He said there should not be a personal [NAME]et on the locker. He stated the only thing he has ever seen in the lockers were extra linens like towels and table clothes. The housekeeping director opened the lockers and found an employee's black print with blue handle purse, and a white Styrofoam cup with straw and plastic lid on the shelf with linen. There were also resident gowns, clothing, wash cloths, pads, and blankets wrapped in plastic in the storage locker. The housekeeping director stated that the drink, [NAME]et, purse and cup should not be there. He stated that education was done every month for infection control in the laundry. On 01/08/20 at 4:52 PM, the director of nursing stated the expectation was that employees do not keep personal belongings stored in the laundry clean linen room. Review of provided education for laundry aide A noted education for infection control, dated 10/01/19, as well as signature page for infection control overview and policy displaying the prevention and spread of infection specific to environmental service employees signed and dated 06/20/19. Review of the facility policy for infection control read, This facility's infection control policies and practices apply equally to all personnel The objectives of our infection control policies and practices are to: Prevent, detect, investigate, and control infections in the facility.

Based on observation, record review and interview the facility failed to assess residents for the type of mechanical lift to be used for safe transfers for 1 of 5 sampled residents, (#1). Findings: Resident #1 was a [AGE] year old female with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] noted that the resident's cognition was severely impaired with inattention and disorganized thinking. The resident required total assistance with transfers with the help of 2 staff members and extensive assistance for locomotion both on and off the nursing unit. The resident was not steady with surface to surface transfers such as wheelchair to bed and was only stable with human assistance. The quarterly MDS assessment dated [DATE] noted that the resident remained total assistance of 2 staff for transfers, but had a decline in locomotion. The resident now required total assistance with locomotion for both on and off the nursing unit. A review of the resident's care plan noted that the resident required a mechanical lift for transfers but it did not specify what type of mechanical lift to be used. On 8/9/19 at 11:44 AM, the Care Plan Coordinator stated that the facility did not specify the type of mechanical lifts on the care plan. She stated that the certified nursing assistants (CNAs) knew which type of mechanical lift to use. She added that the CNAs were responsible for checking the electronic kardex to see which type of lift to be used for the resident. Review of the resident #1's electronic Kardex noted only 'mechanical lift' and did not specify what type of lift the CNAs should have used when transferring. On 8/9/19 at 5:07 PM, the Director of Nursing (DON) stated that resident #1 had consistently used a sit to stand lift but she could not provide any documentation that identified that resident #1 required a sit to stand lift. Review of the medical record and the facility's investigation revealed that on 7/2/19 at approximately 6 PM there was an incident/fall with resident #1 while staff transferred her with the sit to stand lift. CNA #A and CNA #B were attempting to transfer resident #1 from her wheelchair to the bed with the sit to stand lift. As the resident was being lowered to the bed the lift stopped working mid transfer. At that moment the resident slipped/fell while still being supported by the sling. The resident was still holding on to the lowering arms of the sit to stand lift. The CNAs manually lowered the resident to the floor by releasing the straps on the sling. The CNAs then used a total mechanical lift to transfer the resident from the floor to the bed. The CNAs did not report the incident/fall to the charge nurse. The next morning on 7/3/19 at 7:47 AM, a nursing progress note indicated the resident was complaining of pain to her right leg. The nurse noted that the resident's right knee was painful to touch and she observed swelling of the right foot. The resident was given medications for pain. The advance registered nurse practitioner (ARNP) and medical doctor were both notified and orders for x-rays were obtained. The resident's leg and foot were x-rayed on 7/3/19 at 7:37 PM, 12 hours post fall incident. The results of the x-rays were not available for another 12 hours after the x-rays were taken on the morning of 7/4/19, showing mild displaced oblique extra articular [MEDICAL CONDITION] femur. On 7/4/19 at 10 AM, the ARNP was notified of the x-ray report. Resident #1 was transferred to the hospital on [DATE] at 1:30 PM, approximately 43 hours post fall incident. A hospital X-ray report of 7/4/19 at 3:27 PM read, right femur, Acute, comminuted distal fracture, with 2 cm posterior and 0.3 CM medial displacement of the distal fragment. On 8/9/19 at approximately 11 AM, CNA #A stated that she was working on 7/2/19 and had transferred resident #1 from the chair to the bed. She stated that while the resident was being transferred, the sit to stand lift stopped working. CNA #A indicated she pushed and pushed the red emergency stop button and then manually lowered the resident to the floor by slacking the sling cords/strap's length. She said they manually released the sling straps to lower the resident to the floor. When asked why the bed was not lowered so the resident could have been placed in bed rather than the floor, CNA #A did not provide an answer. On 8/9/19 at 2:07 PM, CNA #B stated that she assisted CNA A with resident #1's transfer using the sit to stand lift on the evening of 7/2/19. She explained that CNA #A was operating the lift while she provided support of the resident. She confirmed that as they were lowering the resident to the bed, the lift stopped working. As the sit to stand lift malfunctioned, the resident slipped in the sling. CNA #B re-enacted the scene. The CNA showed that the resident was still holding on to the lowering arms of the lift then her buttocks went back in rapid motion toward her heels. CNA #B stated the residents butt was lower than the edge of the bed and that is why the resident could not be placed into the bed. CNA #B stated the resident was lowered to the floor. Then she and CNA #A rolled the resident back and forth and placed a total mechanical lift sling under her. They then transferred the resident from the floor to her bed using a total mechanical lift. CNA #B stated they tried to tell the resident's direct care nurse but she was on break. The CNAs did not explain why they did not report this incident to the nurse at the end of their shift. The nursing staff were not aware of the incident and the resident was not assessed for injuries. Review of the sit to stand lift's operating manual revealed that two types of slings, a Standing Sling or a Transfer Sling, could be used with the lift. The manual noted that both slings were required to have a safety strap. The safety strap was attached to either sling and it fastened with Velcro in front of the resident while the sling straps were attached to the lift. The purpose of the safety strap was to ensure the sling was positioned correctly around the resident's back/torso and it prevented the resident from slipping in the sling. On 8/30/19 at 3:23 PM, CNA #B described the sling that had been used for resident #2 when the sit to stand lift stopped working and the resident fell . She said that the sling used was a regular sling that looped around the resident's back. CNA #B indicated the sling did not have a Velcro support strap. On 8/30/19 at 4:55 PM, the DON described the sit to stand lift and the loop sling. Her description was similar to the standing sling but there was no Velcro closure support strap. She indicated the lift and the slings had been in the facility for several years and believed that the sling did not have the support strap. On 8/30/19 at 3:59 PM, the physical therapist (PT) stated that he had worked at the facility for 8.5 years. He stated that the process for assessing residents and lifts had changed. He stated that when the facility was under the previous management company, the nurses would assess the type of lift needed for a resident with input from therapy staff. He further explained that if a resident was on therapy case load, then therapy staff would provide a recommendation if the resident required a mechanical lift for transfers. However, if the resident was not on therapy or had not been on therapy in the past quarter, then nursing would do the assessment for the mechanical lift. The PT added that with the new management company from 1 year ago, recommendations on how residents were to be transferred and lifts to be used were given upon being discharged from therapy. The PT stated that residents were screened by therapy upon admission and then on a quarterly basis to assess for any changes. However, therapy did not give any recommendations for transfers based on the screen. The facility provided resident #1's therapy notes from (YEAR) showing that the resident used a sit to stand lift. The facility could not provide any assessments since (YEAR) on the resident's transfer status or whether the resident could still be transferred safely using the sit to stand lift. On 8/9/19 at 1:08 PM, CNA #C stated that she checked the Kardex or asked the nurse to find out if residents required the total mechanical transfer lift or sit to stand for transfers. She stated that one of her residents was previously transferred with a sit to stand lift but the resident could no longer hold on to the lowering arms/hand grips. Now the resident required a total mechanical lift transfer. She said that the resident had a change in condition and had been using a total mechanical lift for a week. The resident's Kardex was reviewed with CNA C. The kardex showed that the resident required a mechanical lift but it did not specify whether to use a total mechanical lift or a sit to stand lift. CNA #C stated, that needs to be changed as the resident now needs a total mechanical lift. On 8/30/19 at 4:53 PM, a meeting was held with the Administrator, DON and Nurse Consultant to review the facility's investigation of the fall. The administrator stated that after he interviewed CNA A and CNA B on 7/5/19, the sit to stand lift was taken out of service. He said the lift was reviewed/tested by the in-house maintenance staff and a manufacturer representative and they did not find any problems with the lift. The sit to stand lift however was no longer in the facility. The Administrator stated that they no longer had the sit to stand lift in the facility that was used to transfer resident #1. He did not explain why the sit to stand was no longer in the facility. The DON confirmed that the nurses performed the assessment for the mechanical lifts. She stated that the assessments were completed using electronic forms but she was not able to access the assessments since the changes in the management company one year ago. The DON could not provide any current assessments showing the types of mechanical lifts to be used for resident transfers.