Every finding on record at Prairie Vista Village

Based on clinical record reviews staff interview, and facility policy review, the facility failed to ensure that 1 out of 5 residents reviewed (Resident #36) for medications were provided with information, education regarding the risks and benefits of psychotropic medications or choice of alternatives and options. The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment of Resident #36, dated 5/3/26 documented diagnoses that included: Non-Alzheimer's dementia and mood disorder. The MDS coded Resident #36 took high-risk medications included, antipsychotic, antianxiety and antidepressants. The MDS recorded a Brief Interview for Mental Status (BIMS) score of 11, indicated moderate cognitive impairment. The Care Plan for Resident #36 initialed 7/3/24 relayed took psychotropic and anti-psychotic medications daily related to mood disorder and history of alcohol dependence.The Medication Administration Record (MAR) of Resident #36 for May 2026 documented orders for the following psychotropic medications.Olanzapine (antipsychotic) 10 milligram (mg), daily for delirium, agitation, dementing illnesses with behavioral symptoms, start date 7/31/24Olanzapine 5 mg as needed for delirium, agitation related to mood disorder for ninety days, start date 2/26/26Mirtazapine (antidepressant) 15 mg daily for sleep related, mood disorder, start date 2/19/26Trazodone (antidepressant) 75 mg nightly for sleep, start date 2/2/26Melatonin 5 mg daily for insomnia, start date 11/19/25A Psychoactive Medication Therapy Informed Consent form signed 2/20/26 was provided for Resident #35 signed by the representative and medical provider documented Olanzapine 5 mg had been prescribed for delirium, agitation for mood disorder. The facility could not provide any other consent forms.On 5/21/26 at 12:45 PM the Administrator relayed would be working on a plan in place to improve process for ensuring consent forms per new regulations.A policy titled Medication Regimen Reviews, revised 7/2024 documented, medication regimen and associated treatment goals involve collaboration with the resident (or representative), family members, and the interdisciplinary team (IDT), includes a review of the resident's or representative's stated preferences, the comprehensive care plans and information provided about the risks and benefits of the medication regimen.

Based on interviews, observation, clinical record review, and Iowa Physician Orders for Scope of Treatment, (I-POST) documents the facility failed to ensure consistency with process's to ensure clear direction with Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR) code status for 3 of 16 reviewed for Advance Directives (Resident #4, #36, #40) . The facility reported a census of 45 residents. Findings include:1.Resident #4 I-POST documented, Do Not Resuscitate (DNR) signed Resident #4 and by the medical provider with signature date [DATE]. Resident #4 Electronic Record Profile and Order Summary documented Code Status, CPR/Attempt resuscitation. 2.Resident #36 I-POST documented, DNR with signature date of [DATE]. Resident #36 Electronic Record Profile and order summary documented Code Status, DNR 3.Resident #40 I-POST documented, DNR with signature date [DATE]. Resident #40 Electronic Record Profile and order summary documented Code Status, DNR An observation on [DATE] and [DATE] revealed circled magnets on shared door of Resident #40 and Resident #36 , a green color to designate CPR and a red circle to designate DNR. On [DATE] at 2:00 PM Register Nurse (RN) Staff A explained all resident code status is revealed to staff by various methods included the binder with I-POST documents or the electronic record or could see a red magnet circle on the resident's door to indicate DNR or a green circle magnet to designate CPR. On [DATE] at 10:28 AM, Licensed Practical Nurse (LPN) Staff B relayed would go to the electronic record, the profile page and to the orders summary page for resident advance directives. Staff B relayed the magnets on residents' doors also reflected code status. Inquired about one green and one red magnet on shared room of Resident # 36 and #40. Staff B responded the green magnet referred to Resident #40 choice for CPR. On [DATE] at 11:55 AM the Administrator agreed code status for residents should be consistent to ensure residents wishes are followed. The Administrator relayed would correct discrepancies immediately.

Based on clinical health record review, facilty document review, resident interviews, staff interviews, and policy review, the facilty failed to ensure residents were free from exploitation for 2 of 45 residents reviewed for abuse (Residents #10 and #18). Staff E, Licensed Practical Nurse (LPN), stole resident pain medications and documented the medications were administered to the residents. These actions continued until Staff E was suspended and terminated. The facility reported a census of 45. Findings include: 1.The Minimum Data Set (MDS) Assessment completed on 4/5/26 revealed Resident #10 with a Brief Interview for Mental (BIMS) Status score of 15, indicating intact cognition. This score is consistent with the previous BIMS from past assessments. Per the MDS from 10/5/25, Resident #10 reported occasional pain which rarely interfered with sleep. Pain was rated at a 6 out of 10, with zero representing no pain and 10 representing the worst pain possible. The Care Plan, last revised on 4/21/26, noted Focus Areas related to pain due to history of muscle tear and osteoarthritis (joint disease related to wear and tear) of the knees. Interventions include contacting the physician as needed for pain medication adjustments, daily scheduled pain medications, which include the use of an opioid (narcotic pain medication). The Care Plan also noted Resident #10 is able to express themselves when in pain and in need of further interventions or repositioning. The September and October 2025 Medication Administration Record (MAR) included the following pain medications: A. Hydrocodone-Acetaminophen (Narco) one 10-325mg tablet administered three times daily, initiated on 6/9/25 B. Hydrocodone-Acetaminophen (Narco) one 7.5-325mg tablet administered one time daily during the evening mediation pass, initiated on 10/19/22 C. Acetaminophen two 325mg tablets administered as needed (PRN) for pain or temperature 100 or above, initiated on 11/4/18 D. Hydrocodone-Acetaminophen (Narco) one 7.5-325mg tablet administered PRN for pain, initiated on 10/19/22 The Nurse's Note from 9/29/25 at 7:09 PM summarized Resident #10 as alert and oriented. The resident is able to make their own decisions, communicates effectively, and able to make their needs known. Resident #10 sleeps thru the night. Chronic pain rating 7-8/10 and receives scheduled pain medications The Visit Summary Progress Note from 10/7/25, completed by the rounding Advanced Registered Nurse Practitioner (ARNP) noted no interval changes or acute concerns per nursing staff. Resident sleeping OK. No complaints of pain and no signs of such noted by staff. No changes to be made today, all chronic conditions are stable. Plan to revisit in 2 months, sooner PRN. Review of the September 2025 MAR revealed the following administration of the PRN Hydrocodone-Acetaminophen 7.5-325mg tablets. All of the PRNs listed were administered by Staff E, Licensed Practical Nurse (LPN), and no other staff members. A. On 9/2/25 at 1:08 PM; Pain rated at an 8 with the intervention documented as ineffective B. On 9/3/25 at 1:16 PM; Pain rated at an 8 with the intervention documented as effective C. On 9/4/25 at 12:52 PM; Pain rated at an 8 with the intervention documented as effective D. On 9/9/25 at 1:06 PM; Pain rated at an 8 with the intervention documented as effective E. On 9/10/25 at 1:03 PM; Pain rated at an 8 with the intervention documented as effective F. On 9/16/25 at 12:59 AM: Pain rated at an 8 with the intervention documented as effective G. On 9/16 25 at 11:33 PM; Pain rated at an 8 with the intervention documented as effective H. On 9/17/25 at 10:52 PM; Pain rated at an 8 with the intervention documented as effective I On 9/19/25 at 3:24 AM; Pain rated at an 8 with the intervention documented as effective J. On 9/21/25 at 1:21 PM; Pain rated at an 8 with the intervention documented as effective K On 9/23/25 at 12:21 AM; Pain rated at an 8 with the intervention documented as effective L. On 9/23/25 at 9:03 PM; Pain rated at an 8 with the intervention documented as effective M. On 9/29/25 at 9:40 PM; Pain rated at an 8 with the intervention documented as effective The Nurse's Note dated 9/4/25 at 12:56 PM documented Resident #10 complained of right leg pain at an 8 out 10. No further documentation identified in the clinical health record related to the other pain medication administration. No further explanation of pain location, how it affected sleep, use of non-pharmalogical interventions, or that the physician was notified due to consistent use of the PRNs. Review of the October 2025 MAR revealed the following administration of the PRN Hydrocodone-Acetaminophen 7.5-325mg tablets. All of the PRNs listed were administered by Staff E and no other staff members. A. On 10/6/25 at 10:27 PM; Pain rated at an 8 with the intervention documented as effective B. On 10/8/25 at 1:31 AM; Pain rated at an 8 with the intervention documented as effective C. On 10/9/25 at 12:44 AM; Pain rated at an 8 with the intervention documented as effective D. On 10/9/25 at 11:06 PM; Pain rated at an 8 with the intervention documented as effective E. On 10/13/25 at 10:13 PM; Pain rated at an 8 with the intervention documented as effective F. On 10/15/25 at 12:01 AM; Pain rated at an 8 with the intervention documented as effective G. On 10/16/25 at 12:55 AM; Pain rated at an 8 with the intervention documented as effective No further documentation identified in the clinical health record related to the PRN pain medication administration. No further explanation of pain location, how it affected sleep, use of non-pharmacological interventions, or that the physician was notified due to consistent use of the PRNs. Review of the November 2025 MAR revealed no PRN Hydrocodone-Acetaminophen 7.5-325mg was administered. Review of the December 2025 MAR revealed a PRN Hydrocodone-Acetaminophen 7.5-325mg tablet was administered on 12/28/25 at 2:20 AM. Pain was rated at a 7 with the intervention documented as effective. In an interview on 5/19/26 at 3:30 PM, Resident #10 reported chronic right leg pain due to ruptured quadricep muscle. A brace is worn to hold in place. Baseline pain level stated at a 7 out of 10. Schedule pain medications help keep pain manageable as does consistent medication times. Pain levels will drop down to a 4 after the medications. Resident #10 stated they are aware of the order for additional pain medication as needed. Resident #10 voiced no specific event or medical needs which would have resulted in increased pain or the need for additional pain medications. They typically do not ask for any PRN pain medications as the scheduled medications are effective. Resident #10 explained they are usually asleep by 9:00 PM and sleep through the night. If they do wake up during the night with pain, they are able to reposition themselves independently to alleviate the pain. Regarding the time frame from September to October 2025, Resident #10 unable to recall Staff E evaluating them for pain after falling asleep for the night. They do not recall asking Staff E for PRN pain medications. They do not feel Staff E brought pain medications and then took it away as they declined the intervention. During an interview on 5/20/26 at 2:23 PM, Staff A, Registered Nurse (RN), explained Resident #10 had both scheduled and as needed pain medications. Based on their nursing assessments, Staff A believes the resident's chronic pain is well managed with little to no use of PRN pain medications. Staff A does not recall the resident experiencing any acute episodes of increased pain. Resident #10 is fairly rigid with their schedule. They are typically in bed by 4:30 PM, asleep by 9:00 PM, and awake for the day at 4:00 AM. During the months of September and October, Staff A does not recall the resident voicing to them waking up in pain or needing any pain medications in the middle of the night. Staff A reported when Staff E worked the day shift, Resident #10 was given PRN medications more frequently. Staff A then noticed the same pattern when Staff E switched to the overnight shift. During an interview on 5/21/26 at 12:40 PM, Staff F, RN, acknowledged working with a Staff E at times. When this occurred, Staff E would prefer to manage the medication cart themselves rather than have a Certified Medication Aide (CMA) working alongside them. Staff E would explain they were used to giving medications themselves instead of CMAs. During an interview on 5/26/26 at 3:35 PM, Staff I, CMA, confirmed Staff E preferred to manage a medication cart themselves and not involve a CMA. During an interview on 5/27/26 at 9:30 AM, Staff J, CMA, note the amount of scheduled pain medications Resident #10 receives throughout the day. The resident will tend to request PRN pain medications during winter months or before/after riding the facility's bus for outside appointments. The ride tends to exacerbate pain. Staff J has seen Resident #10 experience more pain in the mornings right before getting up and moving for the day. 2.The MDS Assessment completed on 4/6/26 revealed Resident #18 with a BIMS score of 15, indicating intact cognition. This score is consistent with the previous BIMS from past assessments. Per the MDS from 8/23/25, Resident #18 reported occasional pain which rarely interfered with sleep. Pain was rated at a 4 out of 10, with zero representing no pain and 10 representing the worst pain possible. The Care Plan, last revised on 4/27/26, noted Focus Areas related to pain due to history of meniscus tear (knee injury), osteoarthritis, osteoporosis, and decreased mobility. Interventions include contacting the physician as needed for pain medication adjustments, use of scheduled opioid pain medication, and offering non-pharmacological pain interventions, such as distractions, 1:1 time. The September and October 2025 Medication Administration Record (MAR) noted the following pain medications: A. Hydrocodone-Acetaminophen one 5-325mg tablet administered two times daily, initiated on 12/4/23 B. Acetaminophen one 500mg tablet administered three times daily, initiated on 7/27/23 C. Acetaminophen two 325mg tablets administered as needed (PRN) for pain every 6 hours, initiated on 7/27/23 D. Hydrocodone-Acetaminophen one 5-325mg tablet administered PRN for pain every 4 hours, initiated on 12/4/23 The Nurse's Note from 8/12/25 at 9:00 PM noted Resident #18 went to orthopedics and received a right knee injection for pain relief. Resident to follow-up in three months for another injection. The Visit Summary Progress Note from 8/21/25, completed by the rounding Advanced Registered Nurse Practitioner (ARNP) noted no reports of pain and wearing a right knee brace for comfort/stability. Staff reporting no concerns. No acute medical needs identified. The Nurse's Note from 8/21/25 at 11:43 PM noted Resident #18 uses call light for assistance when needed. They generally sleep all night until 4-5:00 AM and will use call light for staff help. Resident able to make needs known. Review of the September 2025 MAR revealed the following administration of the PRN Hydrocodone-Acetaminophen 5-325mg tablets. All of the PRNs listed were administered by Staff E, Licensed Practical Nurse (LPN) and no other staff members. A. On 9/2/25 at 12:37 PM with no pain rating listed and the intervention documented as effective B. On 9/16/25 at 3:32 AM with no pain rating listed and the intervention documented as effective C. On 9/23/25 at 10:38 PM with no pain rating listed and the intervention documented as effective D. On 9/24/25 at 3:11 AM with no pain rating listed and the intervention documented as effective E. On 9/24/25 at 10:05 PM with no pain rating listed and the intervention documented as effective F. On 9/29/25 at 10:21 PM with no pain rating listed and the intervention documented as effective No further documentation identified in the clinical health record related to the PRN pain medication administration. No further explanation of pain rating or location, how it affected sleep, or use of non-pharmacological interventions. Review of the October 2025 MAR revealed the following administration of the PRN Hydrocodone-Acetaminophen 5-325mg tablets. All of the PRNs listed were administered by Staff E and no other staff members. A. On 10/6/25 at 11:17 PM with no pain rating listed and the intervention documented as effective B. On 10/9/25 at 3:46 AM with no pain rating listed and the intervention documented as effective C. On 10/10/25 at 3:11 AM A with no pain rating listed and the intervention documented as effective D. On 10/14/25 at 1:17 AM with no pain rating listed and the intervention documented as effective E. On 10/15/25 at 1:36 AM with no pain rating listed and the intervention documented as effective F. On 10/16/25 at 2:17 AM with no pain rating listed and the intervention documented as effective No further documentation identified in the clinical health record related to the PRN pain medication administration. No further explanation of pain rating or location, how it affected sleep, or use of non-pharmacological interventions. Review of the November and December 2025 MAR revealed no PRN Hydrocodone-Acetaminophen 5-325mg tablets were administered. During an interview on 5/21/26 at 11:21 AM, Resident #18 confirmed overall constant pain to their right knee. Medications help with the pain. In September/October, Resident #18 explained they were able to walk around, with a walker, and was not asking for any additional pain medications. Pain did not wake them up at night. Resident #18 does not recall Staff E asking them about pain nor waking up to check on them. The resident stated Staff E didn't do anything. During an interview on 5/21/26 at 12:40 PM, Staff F, RN, explained they had noticed Resident #18 taking pain pills during the night, which they felt was unusual for the resident. The pills were all administered by Staff E. The morning of 10/16/26 Staff F asked Resident #18 about pain management and how they slept. Staff F noticed they were given a pain pill during the night by Staff E. Resident #18 voiced sleeping fine and did not take any pain medications. After this conversation, Staff F alerted nursing administration about possible drug misappropriation. The facility document labeled Statement dated 10/17/25, detailed events from 10/26/25. Staff F noted Resident #18 was given PRN pain medication at 2:17 AM. Staff F also noted the resident received a PRN the previous three nights. Resident #18 denied receiving the medications during the night as well as any pain. Resident #18 stated they sleep through the night. Staff F then notified the Director of Nursing of these findings. The facility document labeled Admin Report-H.B dated 10/26/25, detailed the Facility Administrator's account of the events on 10/16/25. Clinical health record review revealed numerous occasions where PRN pain medications were administered to Residents #10 and #18 over the past three months. All on various shifts and almost all documented by Staff E. No other nurses, including those working the same shift and hall during Staff E's days off, documented the use of PRN pain medications. Staff E was adamant the residents asked for the medications. Staff E agreed to a drug test but stated they were taking prescription pain medications. Staff E agreed to bring a copy for the active prescription, which they did on 10/17/25. The facility document labeled Stmnt dated 10/17/25, detailed Staff G's account of the events on 10/16/25. Staff G talked with Resident #18 about needing any pain medications the night before. Resident #18 responded they never have any pain at night and doesn't need the pills. They have pain during the day when up. When Staff G asked about PRN medications during the night, Resident #10 replied they have been sleeping well without pain for quite some time and confirmed not receiving pain medications during the overnight hours. The facility documented labeled Admin Final Report detailed results of the facility investigation. The facility terminated Staff E on 10/24/25 due to creating an environment of suspicion and mistrust. Staff E continued to deny any wrongdoing but appeared to understand the reasoning. During an interview on 5/26/26 at 2:00 PM, the Facility Administrator explained nursing administration staff notified them of a possible situation the morning of 10/16/25. Staff E documented providing Residents #10 and #18 with PRN narcotic pain medications but residents denied receiving. Review of video footage from the overnight shift, Staff E seen obtaining resident pain medications and entering residents' rooms at the documented administration times. Since the medications were PRNs, residents would have had to notify staff of discomfort and asked for the medication. Video footage does not show Staff E or any other staff member entering resident rooms prior Staff E going in with pain medications. Reports did not show the residents utilized their call lights to alert staff they needed assistance prior to Staff E entering the rooms with pain medications. Staff E was contacted on 10/16/25 to discuss the situation further and to notify they were suspended until further notice. Staff E initially agreed to a drug test as requested by the facility. However after consulting with their attorney, Staff E declined. Staff E did submit their own drug test approximately 4 days later. On 10/24/25, Staff E was officially terminated. During an interview on 5/26/26 at 3:10 PM Staff H, CMA, confirmed working with Staff E during the overnight shifts a month or so prior to Staff E's termination. Staff H believed Staff E was completing more resident pain assessments when compared to other nurses. Thus administering more pain medications than others. Staff H noted it was not typical for other nurses to give Resident #18 PRN pain medications. During an interview on 5/27/26 at 9:30 AM, Staff J, CMA noted it was odd Resident #18 received PRN pain medications at night. During an interview on 5/27/26 at 10:00 AM, the Director of Nursing, DON, believed Resident #18's overall knee pain was a result of use throughout the day and not rest/non-use. The resident typically rate their pain at a 4-5 out of 10. If having a bad day, this may increase to an 8. The DON explained Staff F approached them the morning of 10/16/25 to discuss possible narcotic pain medication theft. After pulling reports, the only two residents with active PRN Hydrocodone-Acetaminophen orders were Residents #10 & #18. The report indicated Staff E was the only staff administering the medication. Both residents denied receiving the PRN pain medications. This furthered the need to conduct a more in-depth investigation. The Director of Clinical Services and the Facility Administrator were both updated and brought into the situation. The DON noted Staff E covered a variety of shifts throughout their employment. They estimate Staff E worked the day shift until August 2025. After this took a Social Services role but resigned the same day. Since this role was a salaried position, Staff E would not be able to supplement their income by picking up floor nursing shifts. The only nursing shifts available at this time were overnights, which Staff E took over approximately August 2025. The DON stated licensed nursing staff should be documenting and summarizing resident pain assessments. This could be done via the 72-hour Hot Charting for acute changes in the clinical health record. This would help determine trends and if the physician needs to re-evaluate medication management. Otherwise nursing should be alerting on-coming staff the use of PRN pain medications so they may follow-up with the resident During an interview on 5/27/26 at 2:10 PM, Staff G, Director of Clinical Services, described Resident #10 as medication focused and can talk to their pain and pain management. Resident #18 alert and oriented who wants to be involved with their cares and decision-making. Staff G explained Staff F had approached them as well as the DON regarding possible medication misappropriation by Staff E the morning of 10/16/25. They then discussed further with Residents #10 and #18 who both denied receiving pain medications the night before. Staff G was present when Staff E returned to the facility on [DATE] to discuss the situation in more detail. Staff E explained the residents do ask for their pain medications and that they know the residents. Staff E agreed to a drug test but explained they were taking prescription pain medications so the test would be positive. The policy Medications, revised 2/1/22, outlined the following: A. The program shall maintain a list of each tenant's medication and document the medication administered A. Medications and treatments shall be administered as prescribed by the tenant's physician, advance registered nurse practitioner, or physician's assistant. B. When a tenant requests a PRN medication, the licensed nurse or care partner will check the PRN medication record to identify the last time the medication was taken and when it can be taken again. The PRN sheet will identify the primary purpose of the medication C. After medication administration is complete, the licensed nurse will write down the time and the tenant's complaint on the PRN medication report. The policy Nursing Facility Abuse Preventions, Identification, Investigation, and Reporting, revised July 2024, outlined the following: A. Upon initial employment, staff training will include activities that constitute abuse, neglect, exploitation, and misappropriate of resident property B. Exploitation, as related to dependent adult abuse, defined as a caretaker knowingly obtains, uses, endeavors to obtain to use, or who misappropriates a dependent adult's fund, assets, medications or property with the intent to temporarily or permanently deprive a dependent adult of the use, benefit, or possession of the funds, assets, medications or property for the benefit of someone other than the dependent adult C. Resident much not be subjected to abuse by anyone, including but limited to, facility staff

Based on clinical record review, facility record review, family interview, staff interviews, and policy review, the facility failed to provide services to protect the resident from accidents or hazards by not ensuring the correct mechanical lift sling was used resulting in the resident sliding out from the sling (Resident #7). The facility reported a census of 45. Findings include: The Minimum Data Set (MDS) Assessment completed 3/1/26 revealed Resident #7 was not able to complete a Brief Interview for Mental Status. The resident was noted to be severely cognitively impaired for daily decision making. Medical diagnoses include dementia with a weight of 147#. The MDS noted Resident #7 is dependent on staff for all transfers, such as chair/bed to chair The Care Plan with a Target Date of 8/29/26 noted Resident #7 is not able to complete self-cares due to dementia diagnosis. Interventions include the use of a mechanical lift with two staff members. This was initiated on 6/2/25. The intervention was updated on 4/8/26 to include the use of a medium/purple sling. The weight capacity of the medium sling is 125-200#. The Progress Noted dated 4/5/26 at 7:10 PM, documented Resident #7 had slid out of the mechanical lift sling. Upon arrival the nurse found the resident laying on her back on the floor. No signs or symptoms of pain or injury. The undated Root Cause Analysis of the incident identified the incorrect mechanical lift sling size had been used during the transfer. Staff did not verify the correct sling size needed for the resident. During a family interview on 5/20/26 at 1:00 PM, Resident #7's spouse noted they were present during the incident. They explained staff was in the process of lifting the resident up out of the wheelchair when they slipped through the bottom of the sling. During an interview on 5/20/26 at 1:32 PM, Staff C, Certified Nursing Assistant (CNA), confirmed they were present during the incident where Resident #7 was being transferred from a wheelchair to the bed. The mechanical lift sling used was the one that had been in use during the day and already in place in the wheelchair. While in the beginning stages of lifting the resident in the air, the Staff C noted Resident #7 was a little restless and grabbing onto the sling itself. The next thing they knew, the resident had slid out of the sling and landed on their buttocks. Staff C reported all the sling loops were hooked correctly. Staff C believed the resident had been sitting too high up in the sling. During a follow-up interview on 5/26/26 at 4:00 PM, Staff C explained the color of the [NAME] around the outside edges of the sling indicates the size of the sling. Staff C could not recall what size of sling was used at the time of the incident. During an interview on 5/21/26 at 11:10 AM, Staff D, Registered Nurse, confirmed they were the nurse responding to the incident involving Resident #7. Based on their observations and staff explanation, the resident slid out of the sling, buttocks first, through an opening that was created when the leg straps were crossed and hooked up to the mechanical lift. Staff D believed the sling used for the transfer was too big for the resident. After providing medical care, Staff D inspected the sling. The straps & loops were all intact. There were no frayed edges or loose stitching. Staff D believed the color of the mechanical lift (Hoyer) was green, which indicate a large sized sling (weight capacity of approximately 200-275#). The sling was immediately removed from the resident's room and taken out of service. During an interview on 5/21/26 at 3:00 PM, the Director of Nursing (DON) explained they were not on site at the time of the incident. However, the DON did see the sling the next day at the nurses station where it was placed after the incident. The DON confirmed the color of the sling was not purple (indicating medium size). They stated it may have been green. The DON reported Resident #7 has always utilized a medium sized sling for mechanical lift transfers. The facility utilizes Pocket Care Plans for staff to refer to for resident care information. These are updated anywhere from 1-3 times per week and available to staff on a daily basis. Once updated, outdated Pocket Care Plans are not kept. During an interview on 5/26/26 at 12:00 PM, the Director of Clinical Services provided a summary of the facility's investigation of the incident. Resident #7 had moved their leg while in the mechanical lift sling and repositioned themselves. This then led to the resident sliding out the opening, which was larger than usual due to the incorrect sling sized being used. During a follow-up interview on 5/27/26 at 2:50 PM, the DON explained Pocket Care Plans list all resident using a mechanical lift and the resident's current sling size. This process had been in place prior to Resident #7's incident. Staff should be referring to these to ensure the correct size is being used. The policy Lifting Machine, Using a Mechanical, revised July 2024, noted the following: 1. Select sling size that is appropriate for the resident's size and task 2. Double check the sling and machine's weight limit against the resident's weight 3. Visually check the sling size the ensure it is not too large or too small just prior to attaching sling straps to the mechanical lift

Based on observations, policy review, and staff interview the facility failed to serve food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness during one of one meals observed. Facility staff also failed to cover facial hair (beard) while preparing food. The facility reported a census of 43 residents. Findings include: Observations revealed the following: a. On 5/19/25 at 10 AM, Staff A, [NAME] was in the kitchen shredding pork for the lunch meal, Staff A had facial hair of full beard without any coverage of the beard. b. On 5/21/25 at 11:15 AM, Staff B, [NAME] was in the kitchen preparing food for the lunch meal. Staff B had facial hair of beard without any coverage of the beard. c. On 5/21/25 with lunch service starting at 12 PM, Staff C, Dietary Aide prepared plates of food for the residents, by lifting up the plates from the counter and placed her thumb onto the eating surface of the plate prior to placing food on the plate. Staff C then proceeded to touch door handles, counters, scoops, and slips of paper and then proceeded to serve more plates of food, touching the eating surface of the plates with her thumb. Additionally, Staff C removed 4 bowls from the cupboard, by placing her fingers inside the bowls, and then served soup in the bowls to residents. A facility policy Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices dated October 2018 revealed hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linen, employees must wash hands before coming in contact with any food surfaces, and during food preparation as often as necessary to prevent contamination when changing tasks. On 5/21/25 at 2 PM, the Dietary Manager (DM) stated her expectation for dietary staff to wear covering over their beard when in the kitchen. Additionally, the DM stated expectation for staff to not touch the eating surface of plates and bowls with bare hands when serving food.

Based on observation, staff interview, and policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 39. Findings include: 1. Observation of the kitchen on 05/13/24 at 10:01 AM revealed the refrigerator contained the following items; a bag of open to the air, unsealed, undated ham slices sitting in a pool of what appeared to be its own juices. A container of whipping cream that was open to the air, with no label to indicate when it had been opened. A Sealed, unlabeled, undated bag of an unknown food product. Observation on 05/13/24 at 10:09 AM revealed the walk-in freezer contained the following items: Two bags of what appeared to be hamburger patties that lacked labels, dates, and were not sealed. One bag of what appeared to be meat chunks that lacked labels, dates, and was not sealed. One bag of sealed meat products that lacked a label. Observation on 05/14/24 at 12:08 PM of Staff A, dietary aide, preparing and serving food without performing hand hygiene, while wearing gloves, and without using serving utensils or changing gloves. In an interview on 05/15/24 at 10:13 AM with Staff B, who indicated gloves should not be worn during food service, staff should avoid direct contact with a person's food, and staff should perform hand hygiene before and after dining service, and as needed during service. In an interview on 05/15/24 at 03:09 PM the Culinary Director stated her expectations are that staff should wash their hands before service, after service, and if their hands are visibly soiled. Staff should avoid direct contact with food by using serving utensils such as spoons and tongs. Review of policy titled Food Receiving and Storage, revised in 2018, stated All foods stored in the refrigerator or freezer will be covered, labeled, and dated. Opened containers must be dated and sealed or covered during storage. 34817 2. Observations of the breakfast meal service on 5/14/24 revealed the following: At 08:13 AM , Staff A, dietary aide, wore gloves as she checked the temperature of food in the warming table in the Rehab dining room. Staff A opened a cabinet, then picked up serving utensils and scooped food into a bowl and onto a plate. Staff A continued to wear the same gloves as she picked up a donut, then placed the donut on the plate. Staff A then picked up menu slips that dropped off the counter, and placed the menu slips back on the counter. Staff A removed her gloves. At 08:17 AM, Staff A continued to scoop food onto plates, donned a pair of gloves, and reached into a bread sack with her gloved hand and removed a slice of bread. Staff A touched multiple surfaces with her gloved hand including menu slips, plates, and utensils for serving food, as well as touched donuts with the same gloves during meal service. The food was delivered to a residents in the dining room.

Based on clinical record review, staff interviews, and policy review, the facility staff failed to follow the Care Plan to properly transfer a resident as directed in the resident's care plan for 1 of 4 residents sampled for transfers and falls (Resident #22). The facility reported a census of 39 residents. Findings include: The Quarterly Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #22 had diagnoses of orthostatic hypotension, non-Alzheimer's dementia, and tremors. The resident had a Brief Interview for Mental Status score of 4, which indicated severely impaired cognition. The MDS revealed the resident required partial to moderate assistance for transfers. The MDS recorded the resident had no falls. The Quarterly MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 4, indicating severely impaired cognition. The resident required substantial to maximum assistance for transfers. The MDS indicated the resident had a fall without injury since the prior assessment. The Care Plan revised 9/1/22 revealed the resident at risk for major injury related to falls due to weakness and impaired gait and balance. The staff directives included to transfer the resident with assistance of one and a gait belt, and ensure the resident wore proper footwear. The Care Plan revised 2/29/24 revealed staff directives to use an EZ stand lift and assistance of two staff for all transfers except toileting. Use a front wheeled walker and assistance of one staff and a gait belt as tolerated for toileting, and use the EZ stand to toilet PRN (as needed). A Fall Risk assessment dated [DATE] revealed the resident at risk for falls. Incident Reports revealed the following: a. On 1/9/24 at 6:20 AM, resident on floor on his knees and bent at waist with torso and head on his mattress. Certified Nursing Assistant (CNA) stated the resident's legs buckled while she transferred the resident from the bed to his wheelchair. Resident #22 reported the same story. Gait belt not in use. Resident only had socks on, no shoes on. No injuries. Resident assisted into wheelchair by two staff. Education provided to CNA on proper footwear during transfers and to use a gait belt. b. On 3/20/24 at 4:20 PM, CNA stated resident lowered to the floor during a stand pivot transfer (SPT) from the recliner to his wheelchair. The recliner moved during the transfer. Staff did not use the EZ stand lift or two staff for transfer. The Progress Notes revealed the following: a. On 1/9/24 at 6:20 AM, resident on floor on his knees and bent at waist with torso and head on his mattress. CNA stated the resident's legs buckled while she transferred the resident from the bed to his wheelchair. Resident #22 reported the same story. Gait belt not in use. Resident only had socks on, no shoes on. No injuries. Resident assisted into wheelchair by two staff. Education provided to CNA on proper footwear during transfers and to use a gait belt. b. On 3/20/24 at 8:16 PM, called to resident's room at approximately 4:20 PM. The resident sat on floor in front of his recliner. CNA in room at time of the incident. CNA reported the resident slid out of recliner onto the floor. The Physical Therapy (PT) discharge summary dated 2/23/24 revealed PT recommended EZ-stand and assistance of two staff for transfers to improve ease of transfers on the resident and staff. Resident able to transfer using grab bars in the bathroom with assistance of one staff as he tolerated. In an interview 5/16/24 at 9:55 AM, the Director of Nursing (DON) reported a fall packet filled out by the nurse whenever a resident had a fall. A risk watch put in place and an intervention added to prevent further falls. The DON completed investigation on how and why the fall occurred. Information shared at staff huddle held daily to go over new information and things the staff needed to know. The DON confirmed Resident #22 had falls. Therapy got involved to help with strengthening and to determine best transfer status. Resident #22 used a SPT for toileting otherwise staff used an EZ stand lift for transfers (to/from bed, chair. wheelchair). The DON checked the resident's Care Plan in the electronic health record and confirmed Resident #22 transfer status changed to using an EZ stand started on 2/24/24. The DON reported a pocket care plan for staff to use kept in a binder at the nurse's station. The MDS nurse updated the pocket care plan. The DON stated she expected staff used a gait belt for all transfers on residents who required assistance of one staff. In an interview 5/16/24 at 9:45 AM, Staff C, CNA, and Certified Medication Aide (CMA) reported she obtained a pocket care plan from the nurse's station and used the pocket care plan to know how a resident transferred. In an interview 5/16/24 at 10:33 AM, Staff D, MDS nurse stated she updated the pocket care plan as soon as she got notification for updates. Staff D stated the EHR care plan updated weekly. She only kept the current pocket care plans. Former pocket care plans not kept. The pocket care plan included information such as how a resident transferred. Resident #22 transfer status changed 2 weeks ago and he now used an EZ stand lift for all transfers, but prior to this time staff used an EZ stand lift PRN. In an interview 5/16/24 at 10:50 AM, the DON reported Staff E was the CNA involved when Resident #22 had a fall on 3/20/24. In an interview 5/16/24 at 10:52 AM, Staff F, CNA, reported she used a pocket care plan to know how a resident transferred. She recalled Resident #22 transferred with assistance of one staff but it depended on the day. A gait belt used if a resident required assistance of one staff. Staff F reported she believed the pocket care plan showed Resident #22 required assistance of one staff. On the day of his fall (1/9/24) she assisted resident and his knees buckled, he went down on his knees by the bed. She called for the nurse. Staff F stated she believed she used a gait belt when she transferred the resident, but the incident happened awhile ago. In an interview 5/16/24 at 11:10 AM, Staff G, Licensed Practical Nurse (LPN) reported Resident #22 had falls. Interventions in place included to ensure his bed in lowest position and a mat on the floor by the bed. Therapy did an evaluation on him. When Resident #22 had a fall (1/9/24) he was not wearing gripper socks or shoes. She gave the CNA education at that time to use a gait belt whenever she transferred the resident and ensure he had proper footwear on. Resident #22 currently used an EZ stand and assistance of two staff for transfers. Previously he required assistance of one staff and use of a gait belt. In an interview 5/16/24 at 11:20 AM, Staff E, CNA, reported she looked at the pocket care plan to know how a resident transferred. The pocket care plan included the number of staff needed for transfers and any equipment needed. Staff E stated Resident #22 used a walker and assistance of two staff. They used an EZ stand PRN. Staff E reported the resident use to walk but he hadn't walked in awhile. On the day when he had a fall and she worked (3/20/24), the resident was a SPT. She placed his wheelchair by him and locked the brakes. She was transferring him from his chair to the wheelchair. His feet started sliding after he stood up. She lowered him to the floor and called for the nurse. He didn't have any injuries. She didn't realize his transfer status had changed. She didn't check the care plan or she would have had two staff assistance during this transfer. Staff E reported she worked agency for 8 months at the facility, then signed on as an employee. She had 1 hour of orientation when she first started working at the facility as agency. When she was hired to work at the facility as an employee she completed paperwork but did not receive any formal training. In an interview 5/16/24 at 12:25 PM, the DON reported they have done audits on falls and if staff are following the care plan as to how they are supposed to transfer a resident. A comprehensive person-centered care plan policy revealed the care plan included measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs, and implemented for each resident. Care plans are revised as information about the residents and the residents ' conditions change.

Based on observations, staff interviews, clinical record review and facility policy review the facility failed to follow infection control guidelines for 2 out of 3 residents observed (Resident #3 and Resident #6). Observations revealed that hands were not sanitized or washed and proper technique was not used when performing incontinence/peri cares on Resident #3 and Resident #6. The facility reported a census of 45 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #3 to include non-Alzheimer's dementia and need for help with personal care. The MDS documented the resident required extensive assist of 1 for toilet use. The Care Plan for Resident #3 with a Focus Area dated 2/6/20, directed staff that this resident was at risk for UTI (Urinary Tract Infection) and had a history of UTIs. On 7/27/23 at 1:00 p.m., the Director of Nursing (DON), assisted Resident #3 to ambulate into her room with a gait belt and a 4 wheeled walker. The DON asked the resident if she needed to use the restroom and she stated that she did. When questioned, the DON stated Resident #3 required assistance with using the toilet PRN (as needed). The DON donned gloves then pulled down the resident's pants and adult pull-up briefs. The DON then removed the pad that was in her pull up briefs and discarded it. The DON then put on new gloves, grabbed a new pad, grabbed the wipes, and brought the wipes over to the resident. She then placed the pad in the adult pull-up brief and assisted the resident to stand. The DON used a wipe down each side of her groin, and then one for down the middle, then used a wipe to wipe down between her buttocks, and then one for each side of her buttocks. The DON discarded the wipes as she went then she pulled up this resident's pants, flushed the toilet and threw away the gloves. The DON tightened the resident's gait belt and assisted the resident to ambulate to her recliner and positioned items within resident's reach. The DON put the gait belt around her shoulder and waist and fastened it. The DON then gathered up the garbage, grabbed a new garbage bag and placed it into the trash can. The DON then washed her hands, took off the gait belt, hung it on the wall and left the room. Following the incident, questioned the DON if she should have washed or sanitized her hands. She stated yes she should have. She added that she should have washed or sanitized them after she removed the dirty pad and before she put on new gloves. 2. The MDS dated [DATE], documented diagnoses for Resident #6 included CVA (Cerebrovascular Accident) and disorder of bone density. The MDS documented the resident required extensive assist of 2 staff for toilet use. The Care Plan for Resident #6 with a Focus Area revised on 6/16/22, directed staff that this resident had functional bladder incontinence related to CVA. An intervention dated 6/16/22, directed staff to monitor for signs and symptoms of UTI. On 7/31/23 at 11:15 p.m. observed Resident #6 sitting on the toilet waiting for assistance to get cleaned up after using the toilet. Staff A, Certified Nurse Aide (CNA) washed her hands and applied gloves. Staff A wiped this resident in front peri area, hips and groins, using separate wipes for each swipe. She then assisted the resident to stand with a gait belt and wiped down her backside. Staff A removed the glove she had used to wipe down resident's skin and told the resident she had a large bowel movement. Staff A pulled up the resident's briefs then assisted her to transfer to her wheelchair as she pulled the chair closer. Staff A then removed the other glove, discarded it into the trash and washed her hands. When questioned Staff A if she felt she did peri care correctly she stated that she should have sanitized her hands after she removed her gloves. On 7/31/23 at 1:00 p.m., the Infection Preventionist, Registered Nurse (RN), stated that she knew there had been a couple of issues with the facility's peri care during the survey. She stated that she was planning on doing audits anyway, as the facility had a couple of concerns overall regarding residents having diagnoses of UTIs, so she was planning on scheduling and doing the audits herself. On 7/31/23 at 2:30 p.m. the Administrator acknowledged that there were issues with peri care and infection control. A list provided by the facility of residents diagnosed with UTI's dated from 5/1/23 to 7/31/23, revealed 4 residents were diagnosed with UTI's during the 3 month period. An undated blank Peri-care on Toilet Skills Checklist (peri care audits), revealed the following procedure was to be completed by staff that were being audited: Procedure: Knock on resident's door, address resident by name, introduce yourself, explain procedure and gather supplies- Place barrier (towel) on surface to set supplies on. 1. Wash cloths, peri wash or wipes 2. Small garbage bag ( for soiled clothing/wash cloths) 3. Hand towel 4. Gloves 5. Brief or pull ups if applicable 6. Barrier cream/ointment, if applicable 7. Hand Sanitizer -Provide privacy, wash and dry hands, put on gloves. -Assist resident by toilet and pull down slacks, remove soiled incontinent product if applicable. -Remove gloves, sanitize hands, and re-glove. Make sure gait belt is tucked around resident's waist -Allow resident time to urinate or defecate -Begin your peri-care if was incontinent. (You must stand in front of resident) -Wipe abdomen horizontally, change cloth surface with each swipe, or one wipe, one swipe -Wipe thighs in downward motion and inner thighs, change cloth surface with each swipe, or one wipe, one swipe -Wipe off each side of groin in a downward motion, change cloth surface with each swipe, or one wipe, one swipe -Females: Gently spread the labia and wipe down one side and then the other, wipe front to back. Change cloth surface with each swipe, or one wipe, one swipe -Males: Gently grasp shaft of penis and hold upward. Retract foreskin, if present, and wash head of penis in circular motion moving away from urethral meatus. Wipe shaft of penis in gentle downward motion. Wipe scrotum, cleaning upper portion and then underlying area. Wipe pubis area. Change cloth surface with each swipe, or one wipe, one swipe -Remove gloves, sanitize hands -Reapply gloves -In an upward motion, wipe back of thighs, buttocks, and anus. Change cloth surface with each swipe, or one wipe, one swipe -Remove gloves, sanitize hands -Reapply gloves -Apply barrier cream/ointment to pubis area if applicable. Remove gloves and fasten brief, pull up slacks. -Wash hands -Offer water. Ask if there is anything they need -Place call light within reach -Clean and put equipment away -Report any unusual observations A Handwashing/Hygiene policy revised August 2019, directed staff as follows: The facility considered hand hygiene the primary means to prevent the spread of infections. The Policy documented the following: Policy Interpretation and Implementation 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 4. Triclosan-containing soaps will not be used. 5. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and/or posted throughout the facility. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: When hands are visibly soiled; and After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after coming on duty; - Before and after direct contact with residents; - Before preparing or handling medications; -Before performing any non-surgical invasive procedures; -Before and after handling an invasive device (e.g., urinary catheters, IV access sites); -Before donning sterile gloves; -Before handling clean or soiled dressings, gauze pads, etc.; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with a resident's intact skin; -After contact with blood or bodily fluids; -After handling used dressings, contaminated equipment, etc.; -After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; After removing gloves; -Before and after entering isolation precaution settings; -Before and after eating or handling food; -Before and after assisting a resident with meals; and -After personal use of the toilet or conducting your personal hygiene. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used: Before aseptic procedures; when anticipating contact with blood or body fluids; and when in contact with a resident, or the equipment or environment of a resident, who is on contact precautions. 11. Wearing artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities, and is prohibited among those caring for severely ill or immunocompromised residents. The Infection Preventionist maintains the right to request the removal of artificial fingernails at any time if he or she determines that they present an unusual infection control risk. Procedure: Equipment and Supplies 1. The following equipment and supplies are necessary for hand hygiene: Alcohol-based hand rub containing at least 62% alcohol; running water; soap (liquid or bar; anti-microbial or non-antimicrobial); paper towels; trash can; lotion; and non-sterile gloves. Washing Hands: 1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands. 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. 3. Rinse hands with water and dry thoroughly with a disposable towel. 4. Use towel to turn off the faucet. 5. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis. Using Alcohol-Based Hand Rubs 1. Apply generous amount of product to palm of hand and rub hands together. 2. Cover all surfaces of hands and fingers until hands are dry. 3. Follow manufacturers' directions for volume of product to use. Applying and Removing Gloves 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene.

Based on record review, observation, document review, and staff interview the facility failed to ensure the staff received adequate training for the use of assistive devices to prevent accidents for one of four residents reviewed (Resident #20) requiring mechanical lift transfers. The facility reported a census of 40 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #20 dated 01/13/23 documented a Brief Interview for Mental Status (BIMS) as 12 indicating some cognitive impairment. The MDS documented diagnoses of atrial fibrillation, heart failure, thyroid disorder, arthritis, cerebrovascular accident, and hemiplegia or hemiparesis. The MDS documented admission to the facility on [DATE]. In an interview on 02/13/23 at 01:40 PM, Resident #20, stated she started slipping out of the lift and ended up on the floor. Resident #20 stated she wasn't hurt from the fall but the incident scared her. Resident #20 stated her back hurt from laying on the floor for so long. Resident #20 stated she laid on the floor for a long time about half an hour. Resident #20 stated the staff were rough when turning her to get her back in the sling. Resident #20 stated she is hard to turn on the floor. Resident #20 stated she was not currently in pain. Observation on 02/13/23 at 01:55 PM of the mechanical sit to stand lift, Invacare Reliant 350, utilized to transfer Resident #20 by Staff C and Staff D. During transfer Staff C (CNA) and Staff D (CNA) applied transport sling around back of Resident #20. Transport sling then applied to attachment points on lift. Transport sling applied on outside of lift on the left side of sling by Staff C. Transport sling applied on the inside of the lift on the right side of the sling by Staff D. In an interview on 02/13/23 at 01:56 PM, Staff C, stated transport sling should have been applied on both sides of the lift on the outside of the lift. Staff C stated she did not look at how Staff D applied sling prior to transfer. Staff C stated Staff E trained the proper way to apply sling to lift. In an interview on 02/13/23 at 01:56 PM, Staff D, stated she started less than 6 months ago. Staff D stated the sling was not applied properly. In a review on 02/15/23 at 02:20 PM of manual for Invacare Reliant 350 mechanical lift indication of lift sling application to outside of arms of lift at attachment points when used to transfer individuals. In an interview on 02/13/23 at 12:05 PM, Staff A (DON), stated the pocket care plan contains the type of lift to be utilized and the therapy department decides the size of sling to use on each resident. Staff A stated therapy completes an evaluation on everyone that enters the facility for transfer needs. Staff A said therapy sends communication to nurse, then nurse updates pocket care plan, then Staff G would update care plan. Staff A stated pocket care plans are audited weekly. Staff A stated therapy was notified of need to evaluate Resident #20 after being lowered to the floor. Evaluation was completed by Staff F (Physical Therapy) and it was determined the previous toilet sling was too big and new sling was ordered. Staff A stated Staff E (Physical Therapy) ordered previous toilet sling and Staff F ordered current toilet sling. Staff A stated current sling just arrived a week ago. Staff A stated the expectation is the facility staff to be trained by the therapy department and facility staff to train any agency staff that will utilize the lifts. In an interview on 02/14/23 at 10:40 AM, Staff F, stated when a change in ability to transfer is noted in a resident an order is written to be seen by the therapy department. Staff F stated at that time resident with change in ability to transfer would be evaluated and recommendations are sent to the nursing department. Staff F stated at that time, training for staff that work at the facility would begin. Staff F stated a log has not been kept with staff that have been trained on the new sling but 2 or 3 had been trained. Staff F stated evaluation of Resident #20 was completed and at that time it was determined that the previous sling size was too big. Staff F stated the previous sling was a size large. Staff F stated that is when she spoke with Staff L (Medical Records) about buying a new sling. In an interview on 02/14/23 at 11:20 AM, Staff H (Administrator), stated the expectation of the facility is a log of staff that are trained at the facility is to be kept. Staff H stated it was reported to him that purchase of a new sling that was similar to previous but size medium would be required as the previous sling was too big. In an interview on 02/15/23 at 8:00 AM, Staff A stated document titled Fall Checklist is completed with all falls that occur at the facility. In an interview on 02/15/23 at 2:00 PM, Staff B, ADON stated a document titled Fall Checklist completed for 72 hours after fall. Staff B stated contents of Fall Checklist are entered into progress notes for fall assessment. Staff B stated Fall Checklist is thrown away after all contents are entered and 72 hours are completed. In an interview on 02/15/23 9:30 AM, Staff I (CNA), stated January 10 2023 was the first day she worked at the facility. Staff I stated Staff J (CNA) stated this was a new sling for toileting use only for Resident #20 and instructed Staff I how to apply the sling. Staff I stated sling was applied by Staff J. Staff I stated Resident #20 was taken to the toilet and was going to be transferred to the bed when Resident #20 started slipping down in the sling. Staff I stated both Staff J and Staff I noted Resident #20 buttocks slip down in the sling. Staff I stated the transfer was stopped and Resident #20 was lowered to the floor with the hoyer mechanical lift. Staff I stated Resident #20 did not appear to be in pain. Staff I stated Resident #20 would verbalize if she was in pain. Staff I stated Resident #20 seemed scared. Staff I stated Staff J called on the radio for nurse as soon as Resident #20 was lowered to the floor. Staff I stated the nurse came very quickly may have been just outside of the resident's door when the incident happened. Staff I stated Resident #20 did not hit anything on the way to the floor in the sling. Staff I stated Resident #20 was not on the floor long, maybe 10 minutes. Staff I stated that the nurse completed the assessment of resident #20 on the floor prior to moving to bed. Staff I stated the non-toilet sling was used to transfer Resident #20 to the bed from the floor. In an interview on 02/15/23 at 09:40 AM, Staff J, stated on 01/10/23 Resident #20 was part of Staff J's assignment that day. Staff J stated she was working with Staff I when the incident occurred with Resident #20 being lowered to the floor. Staff J stated this was the first time that she had used this sling. Staff J stated she was trained with demonstration by Staff E who was the head of physical therapy at the time and the person who ordered the toilet sling. Staff J stated both she and Staff I were using the hoyer lift with the toilet sling to transfer Resident #20 that morning to the toilet. Staff J stated Resident #20 transferred to the toilet that morning without difficulties. Staff J stated when transferring Resident #20 to bed from the toilet both Staff I and Staff J noticed Resident #20 buttocks slid down in the sling. Staff J said at that point when Resident #20 slid, Staff J grabbed the abdominal support belt that was around Resident #20 on the sling and supported Resident #20 to the floor with Staff I working the hoyer. Staff J stated Resident #20 did not hit anything on the way to the floor. Staff J stated the nurse completed assessment prior to moving Resident #20 to the bed. Staff J stated Resident #20 remained on the floor for 10 minutes. Staff J stated Resident #20 was transferred to the bed with the regular hoyer sling not the toilet sling. Staff J stated she asked Resident #20 if she was okay or in any pain. Staff J stated Resident #20 said she wasn't in pain but that she was a little scared. Staff J stated Resident #20 was laughing a little and asked if the rest of the staff were okay. Staff J stated Resident #20 said they did not want to use that sling anymore. In an interview on 02/15/23 at 02:37 PM, Staff K (RN), stated on 01/10/23 two Certified Nursing Assistants (CNA) were transferring Resident #20 with the new sling for use on the toilet. Staff K said the two CNA's called for a nurse over the radio and she entered Resident #20's room. Staff K stated she completed fall assessment while Resident #20 remained on the floor. Staff K stated there were no abnormal findings from the assessment. Staff K stated Resident #20 was not in pain. Staff K reported Resident #20 was laughing and making jokes while lying on the floor. Staff K stated Resident #20 was turned and regular sling was applied and the new toilet sling was removed. Staff K stated Resident #20 remained on the floor for no more than 5 minutes. Staff K stated Staff A was notified and at that point Staff K reported Staff A said she would notify the family during the care conference that was going to occur that morning. In a review on 02/15/23 at 04:00 PM, of Physical Therapy / PT Evaluation and Plan of Treatment revealed the following. 1. Document signed by Staff F with entry date 01/11/23, Staff report uncomfortable using hoyer lift with patient and Patient presents with increased difficulty using hoyer sling for toileting. Patient experienced an episode of sliding through a hoyer sling requiring staff to lower the patient to the floor. Therapy referral to determine safest options for transfers. In a review on 02/15/23 at 04:00 PM, the Physical Therapy / Therapy Progress Report revealed the following. 1. Document signed by Staff E with entry date 11/23/22, Patient family is concerned with patient posture is not completely upright with EZ-Stand lift and are requesting trials of Hoyer lift to promote transfers with less joint pain. Progress and response to treatment: Patient is making consistent progress towards reaching ST and LT goals, Maximum improvement is yet to be attained and anticipated improvement is attainable within current POT duration. Family is now requesting trial of a Hoyer lift for transfers. Initial trial completed this date. Patient is unsure of her preference. Will continue trials. In a review on 2/15/23 at 04:00 PM, Physical Therapy / Discharge Summary revealed the following. 1. Document signed by Staff E with Entry date 11/30/22, Trials of Hoyer Lift with toileting sling. Patient prefers continued use of EZ-Stand mechanical lift rather than transition to Hoyer lift. Facility is purchasing another style of toileting sling that is a universal fit and should fit the model of Hoyer lift we have. Nursing will trial the new sling with the patient and proceed with transfers per patient preference after trial of new toileting sling. In a review on 2/15/23 at 04:00 PM, the Physical Therapy Treatment Encounter Note(s) revealed the following. 1. Document signed by Staff F with entry date 01/26/23, Admin plans to order new toileting sling for patient. Updated patient and family on decision to order new sling with everyone in agreement to plan. Will hold therapy until a new sling arrives. 2. Document signed by Staff F with entry date 01/24/23, Trialed putting hoyer sling under patient while patient sitting in recliner as an option for using during toileting. However, as the patient would have to undress prior to using the toilet, the patient would be at an increased risk of skin tears applying and removing sling. Recommending ordering medium dress toileting high sling for the patient. Also discussed with the patient using a commode with the patient refusing use of the commode due to fear of tipping over in it. Patient refused to trial use of the commode with the therapist. Staff updated in findings. 3. Document signed by Staff F with entry date 01/20/23, Located mesh hoyer sling with commode opening for patient. Determine correct size for the patient. Trialed use of hoyer sling with patient transferring from chair to bed, bed to toilet, toilet to bed and bed to chair with A x 2. Patient unable to assist and remains in supine position requiring dependent A x 2 to get into sitting position to get onto toilet and into chair. Patient reports comfort with trial but is ergonomically unsafe for staff to utilize with the patient. Further sling trials required to determine the safest option for the patient. 4. Document signed by Staff F with entry date 01/17/23, Reviewed manual for new sling and found sizing chart to determine most appropriate sling for patient to ensure safety. Measurements taken as follows with patient seated in chair: hip to knee 24 in, shoulder width 17 in, hip to waist 9.5 in, hip to hip 20 in, waist circumference 50 in. Patient most recent weight was 193 lbs. Per sizing guide patients' current size large sling is too big and the patient requires a smaller sling size. Discussed this with Staff L as well as the likely need for a commode to transfer patient. 5. Document signed by Staff E with entry date 11/30/22, Reviewed mechanical lift options and patient prefers the EZ-Stand Mechanical lift option. Patient is willing to trial a different toileting sling for the Hoyer lift if the facility is able to obtain one. Nursing staff is aware. Call out to the patient's son to update. Patient will continue to utilize EZ-Stand Mechanical Lift for now. Nursing will follow up per Hoyer options. PT DC'd this date. 6. Document signed by Staff E with entry date 11/28/22, Reviewed mechanical lift options with patient following last session trial with Hoyer lift with toileting sling. Patient reports the Hoyer sling was too complicated and she prefers the EZ-Stand mechanical lift at that time. Communicated Hoyer lift trial with DON and discussed sling options. Will forward link to optional sling for DON to research. 7. Document signed by Staff E with entry date 11/23/22, Discussed opinions with patient utilizing a Hoyer for toileting. Staff recommends continuation of EZ-Stand. Discussed family plan for patient to try Hoyer with patient. Patient reports she is not sure she will like Hoyer. Patient reported fear of using Hoyer. Reviewed process for Hoyer transfer and demonstrated per online video. Patient agreeable to trial. Worked with CNA for a transfer trial. Difficulty placing the patient far enough back before sitting. Determined with current sling, leg straps should hook onto green loops and head straps should hook onto the farthest away loop to increase sitting support. Patient reports a comfortable transfer, not sure how she will like it on a continual basis. 8. Document signed by Staff E with entry date 11/22/22, Investigation of facility purchase of a toileting sling for our current Hoyer. Sling found in storage. Follow up is required of DON/ADON as to proper sling for Hoyer Brand. Will follow up tomorrow and contact the patient's son and begin trials with the patient, if patient remains agreeable. Discussion this date with the patient regarding sling and process for use for toileting. Patient is agreeable to trial at this time. Review of risk and benefits of Hoyer vs EZ-Stand mechanical lift. 9. Document signed by Staff E with entry date 11/18/22, Patient completed EZ-Stand transfers with no grimacing or VC's of Left shoulder pain until patient questioned her and then patient reported yes, it hurts. Unable to describe type or intensity or location. Discussed options of Hoyer vs EZ-Stand for transfers. Patient reports she does not want to use a Hoyer lift if she has to use a bedpan. Patient's son called during the session and discussed current transfers, patient display and verbalization of pain, and report of not wanting the Hoyer if it includes use of bedpan. Patient's son states the facility administrator explained to him that the facility has a Hoyer and it can be used for bathroom transfers.

Based on observation, staff, resident interviews, and clinical record review the facility failed to prevent the development of a pressure wound for 1 of 1 resident reviewed (Resident # 14). The resident required extensive assistance of 1 staff for dressing. When staff donned the resident's shoes and failed to adjust them properly in the back, this caused the back of the shoe to rub and apply pressure and friction on the skin over the resident's Achille's tendon and heel bone. On 8/7/21, staff identified and documented a Stage II pressure ulcer to the resident's left heel that measured 2.5 centimeters (cm) by 1 cm by 0.3 cm. By 10/11/2021, the area had increased slough and drainage and had developed into a Stage 3 pressure sore. The facility reported a census of 33 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. According to the Minimum Data Set assessment tool dated 10/3/21, Resident #14 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident scored 15 of 15 possible points on the Brief Interview of Mental Status (BIMS) test, which meant the resident demonstrated intact cognitive abilities. The MDS also documented the resident required extensive assist of 1 staff for dressing and had a Stage III pressure ulcer. The MDS showed facility staff provided pressure ulcer/injury care, applications of ointments/medications other than to feet, and application of dressings to feet (with or without topical medications - a pressure wound treatment to the foot). The Care Plan (CP) dated 8/7/21 documented Resident # 14 had a Stage 3 pressure area on the left inner heel from his new shoes. The Care Plan directed staff to use a shoe horn when putting on the resident's shoes to help prevent the back of the shoe from bending down and causing skin problems. The CP also directed staff to administer pain medication as ordered. The Nurse's Note dated 8/7/21 documented a Stage II pressure ulcer to the resident's left heel that measured 2.5 centimeters (cm) by 1 cm, with a depth of 0.3 cm. The Wound/Skin sheet dated 8/7/21 identified a Stage II pressure ulcer to the resident's left heel that measured 2.5 centimeters (cm) by 1 cm by 0.3 cm. The Physician's Assistant note dated 08/10/21, documented the wound measured 0.8 cm by 2.5 cm and was 90 % covered in yellow slough. The note documented the resident described the wound site as tender. The note continued to reflect chronic [CONDITION(S)]. The Physician's Assistant note dated 09/21/21, documented the wound measured 0.8 cm by 2 cm 90 % covered in yellow slough. The note documented the resident described the wound site as tender with direct pressure. The Nurses Note dated 10/11/2021 at 10:15 AM, revealed staff informed the Primary Care Provider of a weekly skin assessment due to ulcer on left heel: 2.5 cm x 1.5 CM x 0.1 cm in depth and Stage 3 due to granulation. Informed PCP that our Wound Nurse Consultant is scheduled to see Resident # 14 - No New orders at this time. The Patient Order Sheet dated 10/11/21, documented a full thickness, Stage 3 pressure area on the left heel that measured 1 cm long by 2 cm wide with undetermined depth and moderate drainage. Observation on 10/13/21 07:45 AM revealed the resident's inner left Achilles area wound was approximately 1 cm x 2 cm and 0.4 cm deep, with rolled looking edges. The area appeared clean and pink in color. During an interview on 10/11/21 at 2:45 PM, Resident # 14 reported the back of his shoe folded over and rubbed on the heel area which caused the wound. In a subsequent interview on 10/13/21 at 07:43 AM, Resident # 14 reported his heel does hurt when it is touched and when air gets to it. On 10/13/21 at 07:55 AM, the MDS Coordinator/Wound Nurse, verified staff failed to put the resident's shoes on correctly and it caused the pressure wound. At 2:52 PM, the MDS nurse reported any skin area is preventable if we know it is happening. During another interview on 10/14/21 at 09:44 AM, Resident # 14 stated he lets staff know if the wound hurts. Resident # 14 continued it hurts when I bump it, and also overnight it hurts if it rubs on the cushion that staff put under my legs. He added it [CONDITION(S)] some when the nurses are doing the treatment. The resident stated the pain gets to a 3 on a 0-10 pain scale (0 = nothing, 10 = the worse pain ever). Resident # 14 revealed staff administer scheduled acetaminophen and he will get an extra one sometimes. At 09:49 AM, the resident reported it took a few days for the wound to open. He reported he kept trying to get the Certified Nurses Aids to pull the back up on the shoes because it was hurting him. The resident confirmed the back of the shoe remained folded over when he had them on for a few days before the staff addressed his concerns. In an interview on 10/14/21 at 10:05 AM, Staff C CNA reported Resident #14 told them he felt something wrong in the shoe. She added she always tried to get the back of the new shoes up because they were stiff compared to the older shoes. On 10/14/21 at 11:59 AM, Staff B CNA, reported the only thing she knew is that he told us after we put both of the shoes on to make sure the back was up and in the right spot. During an interview 10/14/21 at 12:03 PM, the Director of Nursing (DON), confirmed the pressure ulcer developed from the resident's new shoes. The DON could not remember whether or not Resident # 14 complained about the new shoe placement on the back of his foot for a few days before the staff found the pressure ulcer. The DON verified Resident # 14 as alert, oriented, and communicated his needs. When asked, the DON replied her expectation would be that the facility does what it can to prevent pressure ulcers from developing.

Based on observations and policy review, the facility failed to follow sanitary practices for storage of food on five items observed on 2/2 passes through the kitchen. The five items were open and not dated. One food item was observed to be open to air under vent in dry storage on 2/2 of the kitchen passes. Four out of six frying pans were observed to be covered in blackened debris on the inside of the pan. Findings Include: 1. Upon initial kitchen tour on 1/21/20, at 8:18 a.m., the following items found undated in the walk-in freezer: a. One bag of diced pepperoni. b. One bag of diced sausage. c. One bag of bacon open/unsealed and exposing the food to air. d. One bag of two hamburger patties. e. One bag of two chicken breasts. f. One bag of potato bites. g. One bag of unidentified breaded food open/unsealed and exposing the food to air 2. Upon a follow-up visit to the kitchen on 1/22/20 at 7:48 a.m., observed items in the walk-in freezer still undated: a. One bag of diced pepperoni. b. One bag of diced sausage. c. One bag of unidentified breaded food remained open. 3. During the initial tour of the kitchen on 1/21/20 at 8:18 AM, revealed the following: a. Four out of six frying pains with black charred debris on the inside of the pans. b. The unit kitchenette had rotting wood and mold under the steamtable. During an interview on 1/23/20 at 2:08 p.m., the Dietary Manager (DM) stated that she expected all opened items should be dated and then sealed or closed. At the time, the DM disposed of opened and undated items. The DM reported she planned to submit a work for maintenance to repair the wood under the steamtable. Review of a policy entitled Dating and Labeling of Food stated: All prepared foods that are stored will be properly dated to ensure food safety. Make sure you are using the First in, First Out System. (FIFO). Procedure for when to date mark instructed: a. If an opened food item is not used within 24 hours. b. The food requires refrigeration. c. A commercially-prepared item is opened. d. When a ready-to-eat food item is stored regardless of temperature. e. When potentially hazardous foods are stored. Review of policy for How to Store Refrigerated Food Properly to Prevent Cross Contamination revealed: a. Always cover food to protect it. b. Label and date all food.

Based on observation, staff interviews and review of facility policy, the facility failed to serve and maintain food temperatures for all entrees served to residents during the lunch meal service on 1/21/2019 at 11:59 AM. The facility reported a census of 37 residents. Findings include: During an observation on 1/21/2019 at at 12:25 p.m., Staff B, Dietary Aide added a second pan of chicken to the steam table. Staff A, Cook continued to serve food without checking the temperature of the pan of chicken. At 12:35 PM, Staff A, stated she had served the last plate of food for residents in the dining room. Staff A checked temperatures of remaining food in the steamtable, which revealed the following temperatures: a. Chicken - 110 degrees Fahrenheit (F), noting Three residents received chicken from the second pan. b. Hamburger Patty - 103 degrees F, with one resident receiving a hamburger patty. During an interview 1/23/20 at 9:48 a.m., Staff B, Dietary Aide stated that she took chicken from the hot box in the kitchen and placed in the pan on the steam table to be served. Staff B stated that chicken should be 165 degrees F in the pan and then 145 degrees F when served to the resident. Review of Temperature Log policy revealed that all food, once taken out of the oven and placed in the steam table are checked for temperature by a Dietary Aide or Cook, noting hot food temperatures need to be 145 degrees F or above.

Based on observation, clinical record review and staff interview, the facility failed to follow infection control practices in order to prevent the spread of infection for one of two residents observed with oxygen use. (Resident #35) The facility census was 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #35 had [DIAGNOSES REDACTED]. The plan of care dated 8/1/18 included a focus area of weakness needed assistance with all aspects of activities of daily living (ADL's) and hospice level of care. The Care Plan included interventions of oxygen as ordered. Observation on 11/13/18 at 12:27 p.m., revealed Staff A Certified Nurse Aide, CNA brought the resident to the dining room. Staff A left the portable oxygen tank at one side of the table and moved the resident to the opposite side of the table. Observation revealed the oxygen tubing and cannula dropped on the floor while Staff A let go of the tubing to move the resident. Staff A proceeded to move the portable oxygen tank beside the resident and placed the contaminated nasal cannula into the resident's nares. During interview on 11/13/18 at 12:35 p.m., the Director of Nursing (DON) stated staff should clean the cannula off with alcohol before placing into resident nares, if the nasal cannula touched the floor.

Based on clinical record review and staff interview, the facility failed to notify the Ombudsman regarding two of two resident transfers from the facility to the hospital. (Resident #17 & #18) The facility census was 33 residents. Findings include; 1. The Minimum Data (MDS) assessment dated [DATE], documented Resident #17 had [DIAGNOSES REDACTED]. The clinical record review revealed the following transfers out to the hospital and admitted back to the facility without Ombudsmen notification: a. Transferred out 6/4/18 admitted back 6/7/18 . b. Transferred out 7/23/18 admitted back 7/27/18. c. Transferred out 8/18/18 admitted back 8/24/18. 2. The MDS assessment dated [DATE], identified Resident #18 had [DIAGNOSES REDACTED]. The census list dated 11/14/18, revealed the resident transferred out to the hospital on [DATE], 9/20/18 and 10/8/18 without Ombudsmen notification. During interview on 11/14/18 at 10:53 a.m., the Social Service Director acknowledged she did not notify the Ombudsman of transfers to the hospital.

Based observation, facility policy review and staff interview, the facility failed to ensure resident food items were properly dated when open and failed to ensure dietary staff utilized proper hand washing while utilizing the dish machine. The facility census was 36 residents. Findings include: 1. During tour of the kitchen on 8/21/17 at 8:17 a.m., the following resident food items failed to have an open date: 1 opened bag garlic bread 1 opened bag sausage 1 opened bag of egg patties 1 opened bag of berries 1 opened bag of cauliflower 1 opened bag of hush puppies The Dating and Labeling Food Policy (undated) instructed for all prepared foods that are stored will be properly dated to ensure food safety. 2. Observation on 8/21/17 at 11:25 a.m., revealed Staff B, dietary cook, handled soiled dishes, then went on to put away clean dishes without washing their hands. At 11:40 a.m., Staff B placed soiled dishes into the dishwasher and went on to put away clean dishes without washing their hands. At 11:45 a.m., Staff B loaded soiled dishes into the dishwasher and went on to put away clean dishes without washing their hands. During interview on 8/24/17 at 8:45 a.m., Staff A, dietary cook and dietary manager in training, stated all staff must wash their hands after handling soiled dishes and before handling clean dishes.

Based on clinical record review and staff interview, the facility failed to provide an individual form and clinical rationale for continued use of psychotropic medications for 2 of 6 residents reviewed (Residents #5 & #9) The facility census was 32 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #5 had a [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. The Note To Attending Physician/Prescriber dated 1/26/17, requested a review of the Zoloft and Wellbutrin. The physician signed the document for a decrease in Zoloft. The physician did not address each medication for a gradual dose reduction or a rationale for the continued use of the medications. The Medication Administration Record [REDACTED]. The Note To Attending Physician/Prescriber dated 8/12/17, requested a review of Wellbutrin, Depakote, Lexapro, and Ativan The physician signed the document no change to all the above. The physician did not address each medication for a gradual dose reduction or a rationale for the continued use of the medications. 2. The MDS assessment dated [DATE], documented Resident #9 had [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED] The Note To Attending Physician/Prescriber dated 1/24/17 requested a review of the Remeron. The physician signed the form on 1/26/17 and checked the other box that directed to write the new order below. The physician wrote no new orders in the pharmacist section not in the Physician/Prescriber Response section. During interview on 8/24/17 at 11:30 a.m. the director of nursing stated she did not know if the nurses wrote in that section but agreed the physician must put their response in the physician section.

Based on clinical record review and staff interview, the facility failed to follow the planned restorative programs for seven of 7 residents reviewed. (Residents #1, #2, #5, #6, #7, #8, #9). The facility census was 31 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The 5/25/16 Care Plan documented the resident did not walk and relied on staff to cue or remind him/her to participate in the restorative program as recommended. The 7/19/16, revised restorative recommendation included the following: a. While seated, extend the lower extremities 10 to 15 times each 1 to 3 times a week. b. Upper extremity exercises on the Nu Step machine for 3 to 5 minutes as tolerated 1-3 times a week. c. 10 repetitions with yellow t-bands for each upper extremity 1-3 times a week. The June 2016 Documentation Survey Report revealed the resident had not participated in the Nu Step upper extremity exercise from June 1 -9, 2016. The August 2016 Documentation Survey Report revealed the resident attempted to participate in the restorative program on August 4, and August 23, 2016. 2. The MDS assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. The Care Plan dated 3/3/16, instructed staff to offer restorative exercises as recommended. The 7/14/16 revised restorative recommendation included the following: a. 5-10 lengths on the parallel bars with minimal assist and a gait belt 3 times a week. b. 15 repetitions of marching, knee extension, ankle pumps, hip adduction with pillow, hip abduction with orange band while seated. The August 2016 Documentation Survey Report revealed the resident attempted to participate in the restorative program on August 4, 5, 22 and 23, 2016. 3. The MDS assessment dated [DATE], documented Resident #7 had [DIAGNOSES REDACTED]. The 3/9/16 revised Care Plan indicated the resident would participate in the restorative program as recommended. The 10/28/14 revised restorative recommendation included the following: a. 15 minutes on the Sci Fit Bike. b. 10 repetitions of marching, knee extension, ankle pumps and hip adduction while seated 3 times a week. c. 10 repetitions of neck/cervical flexion/extension and side to side rotation 3 times a week. d. 2 to 3 minutes stretching of both hamstrings 3 times a week. The June 2016 Documentation Survey Report revealed the resident had not participated in the lower extremity exercises from June 1- 9, 2016. The August 2016 Documentation Survey Report revealed the resident attempted to participate in the restorative program on August 12 and 19, 2016. 4. The MDS assessment dated [DATE], documented Resident #8 had [DIAGNOSES REDACTED]. The 7/27/16 revised Care Plan indicated the resident would participate in the restorative program as recommended by therapy. The 8/11/16 restorative recommendation included the following: a. 15-20 minutes on the Sci Fit Bike 3 times a week. b. 15 repetitions of standing marching, hip extension, hip abduction and heel raises to both legs 3 to 4 times a week. c. 2 sets of 10 repetitions of elbow flexion/extension, shoulder flexion/extension, scapular abduction/adduction, shoulder elevation/rolls/squeezes 3 to 4 times a week. The August 2016 Documentation Survey Report revealed the resident attempted to participate in the restorative program on August 19 and 23, 2016. 5. The MDS assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. The 5/11/16 revised care plan intervention directed staff to offer the resident restorative program as therapy recommended. The Restorative Recommendation dated 10/6/15, included the following 3 times weekly: - sci fit bike level one 10 minutes, three times a week. - seated marching knee extensions, ankle pumps, hip adduction with pillow, hip abduction, and knee flex times fifteen repetitions. - stand at side of bar 3 times 45 seconds up to 60 seconds as able. The August 2016 documentation survey report revealed the resident attempted to participate in restorative on August 8 and lacked documentation of any other participation for the month of August for all recommended exercises. 6. The MDS assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. The 6/15/16 care plan intervention indicated the resident was in a restorative program as therapy recommended. The Restorative Recommendation dated 7/18/16, included the following 3 times weekly: - standing with gaitbelt, marching, hip extension, hip abduction times 10 repetitions. - seated 2 bound bar flexion, chest press, elbow flexion/extension with hand over hand with assist of 2 times 10 reps. - pullies 5-8 minutes as tolerated. The August 2016 documentation survey report lacked documentation of participation for all recommended exercises. 7. The MDS assessment dated [DATE], documented Resident 9 had [DIAGNOSES REDACTED]. The revised care plan intervention dated 4/13/16, directed staff to offer restorative program as recommended by therapy. The Restorative Recommendation dated 8/4/16, included the following 3 times weekly: - seated knee flexion/extension, hip flexion/marching, ankle pumps 2 times 15 reps bilateral lower extremities. - standing to side of parallel bars 3 times 30 -60 seconds per tolerance with minimal assist and gaitbelt - bilateral upper extremities shoulder flexion/extension/adduction/abduction, elbow flexion/extension. Active range of motion 2 times 10 reps. The August 2016 documentation survey report lacked participation for bilateral upper extremity exercises. The nursing rehab for lower extremities and standing exercises revealed the resident unable to perform the exercises on August 4, 19, and 23 and lacked other documentation of participation for the month of August. During interview on 8/24/16 at 2:15 p.m. the Administrator revealed the restorative aide (RA) recently went from RA to Medical Records, therefore the restorative program was temporarily suspended until another RA could be hired to fill the void. During interview on 8/24/16 at 2:50 p.m., Medical Records staff revealed they had previously acted as the restorative aide until starting their new role in Medical Records on August 2, 2016. Medical Records staff stated they were actively searching for a replacement to fill the RA role because residents were not currently getting the restorative exercise as planned.

Based on clinical record review, facility call light log review, staff, resident and family interviews, the facility failed to answer resident call lights in a timely manner in order to meet resident needs for nine of nine residents. ( Resident #1, #2, #3, #4, #5, #6, #7, #8 & #9) The facility census was 31 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. The MDS assessment indicated the resident required extensive assistance for transfers and toilet use. The Individual Call light Report for 7/23/16 through 8/24/16 documented 48 occurrences where it took staff greater than 15 minutes to respond to the resident's call light. During interview on 8/22/16 at 1:45 p.m., the resident stated it takes 30-40 minutes for the call light to get answered. 2. The MDS assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. The MDS assessment indicated the resident required extensive assistance for bed mobility and was dependent for transfers and toilet use. The Individual Call light Report for 7/23/16 through 8/24/16 documented 49 occurrences where it took staff greater than 15 minutes to respond to the resident's call light. During interview on 8/24/16 at 9:40 a.m., the resident voiced call lights have taken 40 minutes to get answered. The resident stated staff will come into the room and shut off the call light and say they will be back. 3. The MDS assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. The MDS indicated the resident required extensive assistance for bed mobility, transfers and toileting. The Individual Call light Report for 7/23/16 through 8/24/16 documented 6 occurrences where it took staff greater than 15 minutes to respond to the resident's call light. During interview on 8/24/16 at 7:45 a.m., the residents family member stated call lights can take longer than 15 minutes to get answered. 4. The MDS assessment dated [DATE], documented Resident #9 had [DIAGNOSES REDACTED]. The MDS assessment indicated the resident required extensive assistance for bed mobility, transfer and toileting. The Individual Call light Report for 7/23/16 through 8/24/16 documented 35 occurrences where it took staff greater than 15 minutes to respond to the resident's call light. 5. The MDS assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance for all activities of daily living (ADLs). The Individual Call light Report for 7/23/16 through 8/24/16 documented 35 occurrences where it took staff between 15 minutes and 1 hour to respond to the resident's call light. During interview on 8/23/16 at 10:00 a.m., the residents family member revealed staff frequently took more than 15 minutes to answer the call light and they visited on a daily basis and knew of multiple times where it took 45-50 minutes for a respond. 6. The MDS assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required the extensive assistance for all ADLs. The Individual Call light Report for 7/23/16 through 8/24/16 documented 47 occurrences where it took staff between 15 minutes and 1 hour to respond to the resident's call light. During interview on 8/24/16 at 1:05 p.m., the residents spouse revealed they visited on a daily basis and stated 2 or 3 weeks ago they complained that it took too long for staff to respond to the call light. The spouse stated the nurse took the complaint checked the call log and verified it had taken 47 minutes to respond. Further investigation revealed that about 3 weeks before the interview, the call log documented 4 separate incidents where the response time had taken 50, 52, 29 and 48 minutes respectively. 7. The MDS assessment dated [DATE], documented Resident #3 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required the extensive assistance for all ADLs. The Individual Call light Report for 7/23/16 through 8/24/16 documented 50 occurrences where it took staff between 15 minutes and 1 hour to respond to Resident #3's call for help. During interview on 8/24/16 at 11:00 a.m., the resident revealed on 8/23/16, she/he had to sit on the toilet for 20 minutes after she/he called for assistance. 8. The MDS assessment dated [DATE], documented Resident #7 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had urinary and bowel incontinence and required the extensive assistance for all ADLs. The Individual Call light Report for 7/23/16 through 8/24/16 documented 32 occurrences where it took staff between 15 and 54 minutes to respond to the resident's call light. During interview on 8/24/16 at 10:15 a.m., the resident revealed call light response times was sometimes delayed due to the overnight shift typically having one staff on each hall 9. The MDS assessment dated [DATE], documented Resident #8 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had occasional urinary incontinence and required the limited assistance for all ADLs. The Individual Call light Report for 7/23/16 through 8/24/16 documented 11 occurrences where it took staff between 15 minutes and 32 minutes to respond to the resident's call light. During interview on 8/24/16 at 11:33 a.m., the Administrator and nurse consultant verified call lights had been an issue and they were aware some call lights were not being answered in a timely manner.

Based on observation, clinical record review and facility policy review, the facility failed to ensure staff completed adequate perineal care after an incontinent episode for one of four resident observed during personal cares. (Resident #4) The facility census was 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance for transfers and toilet use. Observation on 10/6/15 at 7:00 a.m., revealed Staff A, certified nurse aide, CNA and Staff C, CNA assisted the resident with cares. Observation revealed the resident was incontinent of urine. Staff assisted the resident to the bathroom. Staff A used perineal disposable wipes to cleansed across the resident's abdomen and right and left groin utilizing the same side of the disposable wipe. Staff A cleansed down the center front area and failed to cleanse the residents penis. The facility policy for Perineal Care dated 2015, identified the use of disposable wipes and instructed for female or male residents to not reuse the same wipe. The policy instructed staff to retract foreskin on males if uncircumcised and to wash the perineal area inclusive of the penis, scrotum and groin.

Based on observation, clinical record review and staff interview, the facility failed to ensure staff utilized proper technique when providing catheter care after an incontinent episode for one of four resident observed during personal cares. (Resident #6) The facility census was 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. The plan of care dated 10/6/15, documented the resident had an indwelling Foley catheter. Observation on 10/6/15, at 9:15 a.m., revealed Staff B, certified nurse aide, CNA and Staff C, CNA transferred the resident to bed for cares. Observation revealed the resident had an indwelling Foley catheter and was incontinent of bowel. Staff B utilized a disposable wipe to cleanse the residents abdomen and utilized another wipe in a back and forth direction when cleansing the residents vaginal area. Observation revealed Staff B used the same surface of the cloth for the vaginal area. Observation revealed Staff B informed the Registered Nurse in the room of a red tinged color on the wipe when near the area of the indwelling catheter. Staff B cleansed the catheter entrance into the bladder opening twice utilizing the same side of the disposable wipe. Staff positioned the resident on to their side as Staff B cleansed the residents right and left buttock using the same side of the disposable wipe. Staff B obtained another disposable wipe and cleansed the residents right and left hips using the same side of the wipe. Staff B cleansed the residents rectum using the same surface of the wipe three times. Record review revealed on 10/7/15, the resident's urine specimen laboratory results returned with a [DIAGNOSES REDACTED]. During interview on 10/7/15 at 2:45 p.m., the Administrator, Nursing Consultant and Director of Nursing revealed the need for further perineal care education.

Based on record review and staff interviews, the facility failed to provide adequate supervision to protect against hazards from self and interventions to prevent further falls from occurring for 1 of 4 residents reviewed (Resident #1). Resident #1 had a known history of falls. The resident had a fall on 6/15/15 and had no interventions implemented. The second fall on 6/24/15 resulted in a fracture hip. The facility identified a census of 32 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 6/18/15. The MDS identified the resident had a [DIAGNOSES REDACTED]. The MDS reflected the resident had a Brief Interview for Mental Status (BIM) score of 6. A score of 6 identified the resident had a severe memory problem. The assessment reflected the resident required limited assistance of 1 staff person for transfers, ambulation, and toilet use. A Self-Report form dated 7/2/15 from the facility, reflected the resident arrived to the facility after having a fall event at an assisted living apartment during the month of June, 2015. The Fall Risk Assessment form dated 6/11/15 identified a score of 19 for the resident. A score 10 or higher represented the resident at risk for falling. The Nursing Documentation and Fall Assessment Form dated 6/15/15 reflected the resident sitting on the floor in the middle of the room. The resident first stated of retrieving the television remote control and then stated twisted the foot and losing balance. The resident denied any injuries and stated not to tell anyone because it would delay in her/him going home. A facsimile (fax) to the physician dated 6/15/15 reported finding the resident sitting on the floor in the middle of the room. The resident could not state how the fall occurred and gave 2 different stories. Neurological checks completed without abnormality and no apparent injuries noted. The resident stood without difficulty. The Care Plan dated 6/22/15 failed to address the resident at risk for falling. The Care plan did not address the fall on 6/15/15 and any interventions implemented. A Fall Event Review Tool dated 6/15/15 identified an unknown sequence of events for a fall. The Tool showed an intervention to educate nurses on protocol. The Nursing Documentation and Fall Assessment Form dated 6/24/15 identified the resident did not have normal range of motion to the right leg and hip with a referral to the nursing notes for a timeline of events. A Physician's Telephone Order dated 6/24/15 directed the staff to send the resident to the hospital by ambulance due to right hip and thigh pain with external rotation. The Progress Notes/Nurses Notes reflected the following: On 6/13/15 at 1:19 p.m. a nurse passing the room noticed the resident standing beside the bed, attempting to move the bedside table. The nurse asked if the resident needed assistance where the resident stated the nurse could go as he/she could do it herself. The nurse left the room and watched at the door to see if the resident needed more assistance. On 6/15/15 at 1:51 p.m. the resident continues to do things and will not ask for assistance. On 6/15/15 3:12 p.m. the resident continues to refuse assistance when needed with the resident stating of needing no help. The nurse educated the resident on the need for assistance to avoid any falls or injuries, but the resident disagreed. On 6/15/15 at 7:53 p.m. the nurse found the resident standing at the back door stating of wanting to go outside. The nurse accompanied the resident who ambulated back to the room with a steady gait. On 6/15/15 at 10:54 p.m. the nurses sent a fax to the physician related to the resident found on the floor. See fall assessment form. On 6/16/15 at 11:04 p.m., the resident got up several times with reminders to use the call light. The resident is pleasantly confused at times. On 6/17/15 at 9:00 a.m. a Medicare meeting reported Occupational Therapy recommended supervision with all cares. A meeting with the family noted and possible long term care required due to the resident ' s confusion. Therapy felt the resident will not be safe at home. On 6/22/15 at 11:35 a.m. a nurse escorted the resident and reminded the resident for the need to have staff ambulate with her/him. The nurse will remind the team to check on the resident at frequent intervals. On 6/24/15 at 7:00 a.m. staff called the nurse to the room and found the resident sitting on the floor by the bed. The resident stated she/he was making the bed when the 'leg gave out'. The resident moved the left leg and foot without pain. When moving the right knee, the resident immediately complained of right thigh pain. The right leg did not exhibit external rotation or shortening. Assisting the resident to stand, the resident yelled out in pain and did not put the right foot to the floor. After placement in bed the right leg showed external rotation and shortening. The resident complained of severe pain in the right hip and thigh. The resident transferred per ambulance to the hospital for evaluation of a possible right hip fracture. A review of the physician ' s History and Physical Consultation dated 6/24/15 reflected the pelvis and right hip x-ray identified a right hip fracture. The consultation reflected the plan would be to obtain medical clearance and await surgical fixation and stabilization of the right hip. During an interview on 7/18/15 at 1:15 p.m. the Director of Nursing (DON), Registered Nurse, reported at the time of the first fall they were working on the whole aspect of falls, prevention and interventions. The DON agreed the resident's Care Plan failed to identify the falls and interventions. The Fall Event Review Tool dated 6/15/15 showed to educate nurses on protocol meant to observe, document non-compliance and behaviors. The DON stated the facility tries to not use alarms for residents as the facility is trying to go alarm free. During an interview on 8/18/15 at 3:32 p.m. the MDS Coordinator/Care Planner reported the facility may have educated the staff to remind the resident to use the call light. The Care Plan coordinator stated she noted no other interventions, such as frequent checks as implemented for safety. The MDS Coordinator agreed the resident's BIM score identified the resident with a severe memory loss, thus education to the resident did not help. After the second fall (6/24/15), she put Comfort Rounds into Place. Comfort Rounds, undated, noted to offer comfort rounds at least every 2 hours (more often if indicated). The checklist showed what to mark (position, toileting, and personal items) for every hour of the day.