Every finding on record at Prairieview at the Garlands

Based on observations, interviews, and record review, the facility failed to thoroughly assess, identify, treat, monitor, and implement adequate interventions to prevent the development and/or worsening of pressure ulcers for one of one (R7) resident reviewed for pressure ulcers. This failure resulted in R7 developing an unstageable pressure ulcer on the left heel, an open skin impairment to the sacral area, and a reddened area to the right upper, inner thigh.Findings include:R7 is an [AGE] year-old resident admitted to the facility on [DATE] with diagnoses, in part but not limited to heart disease, peripheral vascular disease, congestive heart failure, and cerebral infarction. MDS (minimum data set) dated 01/07/2026, indicates R7 is moderately cognitively impaired; and had no skin impairments upon admission.On 05/05/2026 at 9:20 AM, V2 (Director of Nursing) and V4 (Registered Nurse) were observed assessing the pressure ulcer on R7's left heel (back of heel). Sock was removed; there was no dressing covering the wound. V2 stated normally cream and gauze are placed on the wound but sometimes it's left open. The wound appeared red/pink and had yellow exudate in the middle (covering about 70% of wound). Wound was not measured at this time. V2 stated V22 (Wound Care Nurse) will come to the facility on Thursday or Friday of this week. The sock and shoe were placed back on; no wound dressing applied. V4 stated the wound dressing is changed twice a week and as needed during night shift.On 05/06/2026 at 10:24 AM, V14 (Registered Nurse), V12 (Certified Nursing Assistant), and V17 (Certified Nursing Assistant) assisted R7 to the bathroom for incontinent care. It was observed that there was an open skin impairment to the sacral area, measuring 2 cm (centimeters) x 1.5 cm, and a reddened area to the right upper, inner thigh measuring 1.5 cm x 1 cm. The open skin impairment on the sacral area was red with pink surrounding the opening and was non-blanchable; the patch of skin above the wound, extending upwards toward the back was red/purple in color. The reddened area on the thigh was a meaty red color, and the top layer of skin was no longer intact. V14 quietly exclaimed, Oh Sh** and stated they were unaware of this skin injury; V14 stated there are PRN (as needed) orders for barrier cream for the peri area; during this observation, cream was not present upon removal of the brief and cream was not placed when a new brief was placed, V14 confirmed they did not visualize cream during brief change.R7's record review of the Medical Inpatient History and Physical documentation obtained, upon admission, from an outside facility for care dated 03/01/2026 stated in part but not limited to, R7 admitted with a stage II sacral pressure injury to be treated with Medi honey and foam, and a left heel unstageable injury to be treated with foam; a wound consult recommended at this time.On 05/07/2026 at 10:30 AM, record review of the 03/13/2026 re-admission note in EHR (electronic health record) stated in part but not limited to, skin assessment done, buttocks intact, left heel with unstageable wound measuring 1.3 cm x 1cm. Care plan was not updated at this time.On 05/06/2026 at 12:08 PM, record review of Skin Assessment with Bath/Shower sheets from 01/26/2026 and 02/06/2026, no indications were documented about any skin impairments or changes to skin.All Skin Assessment with Bath/Shower sheets between 01/26/2026 and 04/21/2026 have no indication of sacral skin impairments and only 03/31/2026 and 04/21/2026 have mention of bandage and old skin impairment with circle indicators at the left heel.R7's record review of nursing notes entered by in-house nursing staff and an outside wound care nurse stated but not limited to:01/07/2026 written by V19 (Registered Nurse): Scalp: dry skin with dry, scabbed areas noted on top of head, left hand: 1.5 cm U-shaped skin tear, left elbow: small, scabbed area, no other skin issues noted01/11/2026 written by V21 (Registered Nurse): groin: redness with intact skin, buttocks/heels intact, no additional skin concerns01/16/2026 written by V22 (Wound Care Nurse): left hand skin tear (0.5 cm x 1 x 0 cm), dry and scabbed, groin, redness persists, treatment include initiating Lotrisone, Nystatin powder discontinued01/19/2026 written by V18 (Registered Nurse): groin redness with bleeding, buttocks with blanchable redness; moisture barrier applied, left heel deep tissue injury (DTI) identified and treated with normal saline cleanse, Betadine application and bordered dressing, heel protectors (booties) applied bilaterally.R7's record review of wound care progress notes indicated the DTI (deep tissue injury) to the left heel's progression fluctuated in measurements between 01/20/2026 - 02/27/2026, however the care plan initiated upon admission, 01/07/2026, states in part but not limited to: Potential/actual impairment to skin integrity related to: Fragile skin and incontinence was not updated to include a care plan for the DTI, when the DTI was identified on 01/19/2026.On 05/05/2026 at 1:30 PM, V2 was interviewed regarding wound care. V2 stated wounds are assessed and dressings are changed, daily, by in-house nurses on the night shift (7P-7A). V2 stated the expectation with any changes to wounds or previously intact skin should be brought to their attention, as soon as possible. V2 stated the expectation for skin assessment of residents is to assess the skin, upon admission and daily, report any changes to the wound care team and document these changes. V12 (Certified Nursing Assistant) and V13 (Certified Nursing Assistant) stated, in separate interviews, while providing showers to residents, shower sheets are completed to address any skin changes or abnormalities. These changes are then relayed to the nurse on duty and/or V2.On 05/06/2026 at 10:00 AM, V15 (MDS Coordinator) was interviewed regarding care plans and MDS (minimum data set) standards within the facility. V15 stated the expectation for care plans is for any member of the IDT (interdepartmental disciplinary team) to update care plans when any changes occur to the needs/requirements of the residents. V15 stated they initiate and finalize the initial MDS, and then the expectation is they are notified if/when any changes need to be made. Regarding initial MDS and care plan creation, V15 stated their procedure is to review the admission paperwork and medical records and the admission information from the facility staff to initiate these initial documents/plans. V15 stated the initial MDS created for R7 was based solely off the admission note from the facility staff that stated, skin was intact, and failed to include the information from the medical documents presented on admission. V15 stated the DTI that R7 is experiencing was facility acquired due to the admission note not referencing any redness to the area.On 05/06/26 at 4:30 PM, V22 (Wound Care Nurse) was interviewed regarding wound care. V22 stated their goal is to visit the facility, weekly, on Thursday or Friday, but there are some weeks they cannot make it or will try to come on the weekend. V22 stated they provide care to any skilled resident with a new wound and follow up with wound that the nursing staff request assistance with. V22 stated their expectation is for dressings to be done, according to the physician's orders, and that they are reached out to with concerns. V22 stated the expectations they have of facility staff are for the CNAs to do skin checks upon showering/bathing residents and for nurses to do their weekly skin checks. V22 stated their expectation if a wound is discovered without the ordered dressing in place would be to alert the appropriate staff and apply the treatment, according to the physician's orders.Record review of V22's initial wound care nursing note dated 01/16/2026 has no mention of issues with the heel or sacral area.Record review of V22's follow-up wound care nursing note dated 01/20/2026 gives measurements for the DTI to the left heel that was discovered on 01/19/2026 (1.5cm x 1.4cm x 0cm) but does not address the sacral redness noted on 01/29/2026 in V18's nursing note.On 05/06/26 at 4:40 PM, V18 (Registered Nurse) was interviewed regarding the nursing note entered on 01/19/2026 regarding R7's skin assessment. V18 stated the redness was on the sacrum and down to the buttocks. V18 stated they do not remember when they first noticed the redness. V18 stated wound care and V2 were notified at this time.On 05/06/26 at 4:55 PM, V19 (Registered Nurse) was interviewed regarding their admission nursing note on 01/07/2026. V19 stated they work night shifts only, one day per week, and does not recall performing this assessment. V19 stated they would have performed the assessment if it was not done on day shift, when assessments are typically performed.On 05/06/2026 at 1:10 PM, V20 (Medical Director) was interviewed and states that they oversee all residents in the facility and visit the facility 4 days per week (between themselves and their nurse practitioners). V20 stated they occasionally do skin assessments but don't like to double up with wound care. V20 stated they handle wound care prior to the contracted wound care team evaluating and then wound care team takes over all wound care. V20 stated the expectation is for in-house nurses to relay information to their team, unless it's a pressure injury. V20 stated they want pressure ulcers brought straight to wound care. V20 stated they are not aware of any redness to the sacral area until 05/06/2026 when contacted by facility staff. V20 stated that upon initial admission and re-admission, they review the admission note and all notes from previous facility/medical records to ensure orders and care plans are appropriate for the residents.Facility Policy titled, Wound Care dated 12/06/2022 states in part but not limited to:The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Verify that there is a physician's order for this procedure.Review the resident's care plan to assess any special needs of the resident.10. Place one gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water.Facility Policy titled, Skin Assessment dated 09/24/2020 stated in part but not limited to:On admission, the Nursing admission Assessment and the Braden Scale will be completed. The doctor will be notified of the treatment as needed.On admission, the admitting nurse will identify all skin issues including but not limited to: any discolored area, rashes, bruises, skin tears, pressure ulcers, tubes, open areas, including stage/classification of wound, quality of tissue and measurements.If a member is identified as high risk (score of 12 or less) for skin breakdown, the Braden Scale will be completed weekly times 4 weeks on admission.Upon identification of a pressure ulcer, the Braden Scale will be updated.The Wound Assessment Flow Sheet will be completed weekly or when a significant change is noted. The Care Plan will be updated and interventions carried out as indicated. Any pressure ulcer presenting as a Stage II or more will be seen by a Wound Care Specialist in consultation with the attending physician.The facilities' Prevention Protocol will be implemented on all residents identified at moderate to high risk (Braden score of 12 or below) and/or are identified to have co-morbidities that will impact skin integrity or impede the healing process. Prevention protocol may include:- Pressure reduction/relief- Skin careThe nurse will identify the necessary therapeutic interventions appropriate for the resident's individualized needs to reduce the risk of skin breakdown and/or treat existing wounds based on the member's clinical condition and risk factors.For those residents admitted with wounds, the nurse will notify the Director of Nursing/or designee who will follow the resident's progress weekly toward wound healing.If pressure ulcer occurs, the Director of Nursing/ or designee. It will be determined why the event was unavoidable, what clinical conditions and/or non-compliance issues contributed to the decline, and what all possible and appropriate interventions have been aggressively implemented but not changed the course of tissue decline. Document what new interventions (if any) are to be implemented and any education provided to the residents and family.The Director of Nursing and/or designee will make all changes to the MDS and implement a new care plan to reflect the individualized needs of the residents.Facility Policy titled, Care Plan Policy dated 12/06/2022 states in part but not limited to:3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.12. The interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the residents' conditionb. when the desired outcome is not metc. when the resident has been readmitted to the facility from a hospital stayd. at least quarterly, in conjunction with the required quarterly MDS assessment

Based on observation, interview, and record review the facility failed to have a properly functioning lock for the drawer containing the residents' emergency supply of controlled substances. This failure has the potential to affect all residents in the facility. The findings include: On 2/18/25 at 10:45 AM, during medication room inspection, the drawer containing the emergency supply of controlled substances was opened without a key. The lock was not functioning as intended. On 2/18/25 at 10:45 AM, V3 Registered Nurse stated, I have not checked or accessed this drawer in a long time. The document Ekit Contents showed the drawer contained, but not limited to, fentanyl patches, morphine, and oxycontin (all Schedule II narcotic pain medications.) On 2/19/25 at 9:33 AM, V2 Director of Nursing stated controlled substance have to be double locked. V2 said the controlled substance boxes, within the locked drawer, have a keyed lock but they are not affixed to the cabinet. V2 said controlled substances are double locked because they are more likely to be diverted compared to other medications. V2 said the emergency supply of narcotics are available for all residents to be used. V2 said if a provider order a controlled substance for a resident, the emergency supply would be used until pharmacy could deliver the regular supply. The facility's policy Controlled Substances (Revision 12/6/22) showed The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications . The facility's policy does not show controlled substances must be separately locked from non-controlled medications in a permanently affixed container.

Based on observation, interview, and record review the facility failed to administer insulin according to manufacturer's instructions. This applies to 1 of 2 residents reviewed for insulin administration in the sample of 20. The findings include: R4's Admission Record (Face Sheet) showed a current/recent admitted [DATE]. R4's face sheet showed a diagnosis of Diabetes Type II. R4's Order Summary Report as of 2/19/25 showed an order for 7 units of rapid-acting insulin (a medication to control blood sugar in diabetic patients) to be given at mealtime, if the resident eats his meal. The order showed the insulin was to be dispensed via a prefilled insulin pen. On 2/18/25 at 11:59 AM, V3 Registered Nurse (RN) began preparation of R4's insulin pen. V3 removed the pen's cap, attached a needle, dialed in 2 units, held the pen horizontally, and depressed the plunger. The needle cap remained in place and the tip of the needle was not visible through the opaque cap (a drop of insulin was not visible at the tip of the needle). V3 then dialed in 7 units of insulin, entered R4's room, wiped is abdomen with alcohol, removed the needle cap, then injected the insulin. V3 held the insulin plunger for less than 2 seconds, removed her thumb from the plunger, held the needle in his skin for less than 4 seconds, then removed the needle from his abdomen. The rapid acting insulin manufacturer's instructions (revision 2/2023) showed, after the needle is attached, small amounts of air may collect in the pen and to ensure proper dosing, Turn the dose selector to select 2 units. Hold the pen with the needle pointing up. Tap the top of the pen gently a few times to let any air bubbles rise to the top. Hold the pen with the needle pointing up. Press and hold in the dose button until the dose counter shows '0' .A drop of insulin should be seen at the needle tip. If you do not see a drop of insulin repeat steps . The instructions showed, following the priming of the pen, the desired insulin dose should be dialed in and the needle injected into the skin. The instructions continued, once the needle is injected the dose button should be pressed and when the insulin dial reads zero, the dose button should continue to be pressed and the needle left in the skin for a slow 6 count. The manufacturer instructions stated if the 6 count is not done with the dose button pressed, the full dose of insulin may not be administered. On 2/19/25 at 9:33 AM, V2 Director of Nursing stated, nursing staff should be following manufacturer's instructions. V2 said the purpose of priming the insulin pen is to ensure there are no air bubbles and the resident receives their full dose of insulin. V2 said the purpose of keeping the dose button pressed is to ensure the resident receives their full dose of insulin.

Based on observation, interview, and record review the facility failed to ensure a resident was safely transferred who has a history of multiple falls. This applies to 1 of 8 residents (R13) reviewed for safety in the sample of 8. The findings include: R13's face sheet shows she is an [AGE] year old female with diagnoses including repeated falls, dementia, Alzheimer's and hypertension. On 4/22/24 at 9:28 AM, V4 (RN) said R13 is a very high fall risk and has increased weakness. On 4/22/24 at 12:55 PM, R13 was wheeled to her room. V5 and V6 (Both Certified Nursing Assistant's) lifted R13 with the gait belt and transferred her to the bed. R13 was leaning back and unable to stand upright. The back of her heels were on the floor with her feet and toes pointed upwards. A mechanical lift sling was hanging on her bathroom door. On 4/22/24 at 1:00 PM, V5 (CNA) said R13 is alert to self, confused and transfers with two person assist. On 4/22/24 at 1:28 PM, V2 (DON) said R13 is alert to person only and is high fall risk. She has had multiple falls and requires substantial assistance with transfers. She used to be able to bear weight and walk and has had a decline with increased weakness. Some days staff use the mechanical stand lift to transfer her when she is weak. Staff should ensure a resident is able to stand and bear weight when transferring. On 4/23/24 at 8:58 AM, V3 (MDS Nurse) said R13 has a history of multiple falls. She is getting weaker, and she will need to be re-assessed for her transfer status. R13's Fall Risk Evaluation dated 1/2/24 shows she is HIGH Risk for falls. The facility's Incident Accident Reports provided on 4/22/24 shows R13 had seven falls in the last four months on (1/8/24, 1/17/24, 1/18/24, 2/3/24, 2/5/24 and 3/30/24). The facility's Safe Lifting and Movements of Residents Policy dated 2022, states, In order to protect the safety and well-being of staff and residents. and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following .weight bearing ability .

Based on interview and record review the facility failed to transcribe a resident's admission medication orders in a manner to prevent a significant medication error. This failure resulted in R1 developing hypotension (low blood pressure) and dizziness after receiving eight (8) doses of a diuretic medication (water-pill), one pill per day, from [DATE]-[DATE], instead of PRN (as needed), as shown per R1's hospital discharge orders. This failure applies to 1 of 6 residents (R1) reviewed for medication administration and significant medication errors in the sample of 6. The findings include: A facility incident report dated [DATE] showed R1 was admitted to the facility on [DATE], from a local hospital. The report showed R1 began complaining of dizziness on [DATE]. The report showed R1's Metolazone (diuretic medication) was entered incorrectly as scheduled, instead of daily as needed, for weight gain greater than 5 pounds. Physician notified and order received for STAT labs and to push fluids . R1's hospital History and Physical report dated [DATE] showed R1 had a significant history of CHF (congestive heart failure), dilated cardiomyopathy, and hypertension (high blood pressure). The report showed R1's blood pressure as ,d+[DATE]. R1's hospital discharge orders dated [DATE] showed R1 was admitted to the facility with a physician order for Metolazone (diuretic medication) 5mg (milligrams): Take one tablet by mouth daily, as needed, for a weight gain greater than 5 pounds. A facility's physician order for R1, dated [DATE], showed the Metolazone medication was incorrectly ordered as Metolazone oral tablet 5 mg: Give 1 tablet by mouth one time a day (at 9:00 AM) for edema/weight gain. R1's [DATE] Medication Administration Record showed R1 was administered Metolazone, 5 mg (1 tablet) daily, from [DATE]-[DATE]. R1's progress note dated [DATE] showed R1 was assessed by staff due to her complaint of dizziness. R1's blood pressure was checked. R1 was hypotensive with a blood pressure of ,d+[DATE]. R1 was given fluids. R1's physician was notified. During this incident, R1's medications were reviewed. R1's Metolazone medication was found to have been incorrectly transcribed/ordered by the facility. On [DATE] at 10:25 AM, V8 (Family of R1) stated, I was there (on [DATE]) when (R1) had an episode but, she also had a similar episode the day before ([DATE]) where (R1) got pale, her blood pressure dropped, and she felt faint. My sister was there for that one. When I was there, it all happened so quick. It was kind of a frantic scene. (R1) suddenly got pale, felt faint, and her blood pressure dropped. I was scared. I thought she was going to die. She thought she was going to die. (R1) kept trying to tell us no CPR, so we didn't do CPR (cardiopulmonary resuscitation) if it came to that. Staff came running in. They laid her flat. They tried to get her to drink water. That's when they found the medication error. I am just so thankful she survived. I saw my dad die. I couldn't go through that again. R1's Weights and Vitals Summary record for [DATE] was reviewed. It showed R1 did have an episode of hypotension on [DATE] at 11:30 AM, as reported by V8 (Family of R1). R1's blood pressure dropped to ,d+[DATE] at that time. No progress notes or other documentation was noted related to R1's symptoms and hypotension on [DATE]. On [DATE] at 9:54 AM, V1 Administrator stated she did not know R1 had an episode of hypotension and dizziness on [DATE]. On [DATE] at 12:00 PM, V2 Director of Nursing stated the facility has a double check process in place to ensure a new admission's medication orders are transcribed correctly from the resident's hospital discharge medication orders. V2 stated, The nurse that admits the resident, transcribes the admission medication orders into the computer, from that resident's hospital discharge orders. The oncoming night nurse is supposed to double check to make sure the orders were entered correctly. Unfortunately, in (R1's) case, that did not happen. (V5 Registered Nurse/RN) incorrectly transcribed (R1's) Metolazone order. The night nurse that took over for (V5) didn't double check (R1's) admission orders. V2 stated she did not know R1 had an episode of hypotension and dizziness on [DATE]. On [DATE], two attempts to contact V5 RN, via phone, for an interview were unsuccessful. V1 Administrator stated V5 was no longer employed by the facility. On [DATE] at 10:45 AM, V6 (Pharmacist) stated, Metolazone is a medication used to help residents, with CHF, get rid of extra fluid. I see here in the computer that (R1's) admission order for Metolazone was sent us (from the facility) with an order for the medication to be given daily, not PRN (as needed). It wasn't transcribed correctly. If the medication is not given as ordered, it can cause dehydration, low blood pressure, and possibly cause someone to pass out. I see she (R1) is also on Lasix (another diuretic medication). If someone is on both Metolazone and Lasix, it can be potentially dangerous for someone if not given correctly. On [DATE] at 11:02 AM, V7 (R1's Physician) stated, (R1) was seen by cardiology in the hospital. She has bad CHF. She was supposed to get the Metolazone PRN, not daily. If the medication is not given correctly, it can cause dehydration, low blood pressure, and feeling faint. If not treated, it could cause someone to pass out and become unresponsive. The facility's Medication on Admission, Readmission, and Discharge policy dated [DATE] showed, Medication orders upon admission, readmission, and discharge in skilled nursing are to be entered by the admission nurse, verified by the physician, pharmacy and oncoming nurse for the next shift . The oncoming nurse for the next shift reviews the medication orders entered in the electronic medical record to prevent medication errors .

Based on observation interview, interview, and record review the facility failed to ensure enhanced barrier precautions were implemented and failed to change gloves and perform hand hygiene during incontinence care in a manner to prevent cross contamination. This has the potential to affect all 15 residents residing in the facility. The findings include: 1. The facility's Resident Census and Condition Report (CMS 672) dated May 22, 2023, shows a resident census of 15. On May 23,2023 at 09:16 AM, V2 Director of Nursing (DON) said the facility has no residents on transmission based precautions (TBP) or enhanced barrier precautions (EBP). V2 said there is no specific facility policy on enhanced barrier precautions. The facility's Matrix dated May 22, 2023 shows R12, R14, and R15 have urinary indwelling catheters and R2 and R11 have pressure wounds. On May 23.2023 at 01:40 PM, V2 said the facility has not updated their transmission based precautions to include enhanced barrier precautions. V1 Administrator said they recall hearing about EBP but have not implemented the precautions at the facility. V2 said EBP would apply to residents with urinary catheters or wounds. V2 said the facility has 5 residents that have catheters and/or wounds. V2 said staff should wear gown and gloves when providing care for residents on EBP. The CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) dated July 12, 2022, shows: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and/or Infection or colonization with an MDRO. 34506 2. R67's Admission Record shows he was admitted to the facility on [DATE], with diagnoses including sepsis and urinary tract infections. On May 22, 2023, at 10:10 AM, V4 and V5 CNAs (Certified Nursing Assistants) transferred R67 from his wheelchair to his bed. There was a large amount of stool noted to the back of R67's pants. V5 removed R67's soiled pants and folded the soiled brief down in between R67's legs. V5 then touched R67's knees and the safe transfer belt. V4 wiped R67's front peri area then touched R67's body to help him to turn to his side. V5 then wiped R67's buttocks, there was stool noted to V5's right pointer finger glove. V5 then touched the wipes container and R67's call light. There was no glove change or hand hygiene performed by V4 or V5. 3. R8's Admission Record shows she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and history of falling. R8's MDS (Minimum Data Set) dated March 20, 2023, shows R8 is frequently incontinent of urine and always incontinent of stool. On May 22, 2023, at 12:55 PM, V5 CNA folded R8's incontinence brief down, in between her legs. V5 wiped R8's front peri area, then turned R8 onto her side in order to wipe R8's buttocks. V5 did not change her gloves or perform hand hygiene. 4. R13's MDS dated [DATE], shows he is always incontinent of bowel and bladder. On May 22, 2023, at 10:51 AM, V4 and V5 placed R13 onto the toilet. There was stool noted in R13's incontinence brief. V5 removed the soiled incontinence brief and placed a new brief around R13's legs. V5 then touched R13 to help him to stand. V4 wiped the stool from R13's buttocks, then pulled the new clean incontinence brief up, touched R13's body, and touched R13's wheelchair. There was no glove change or hand hygiene performed by V4 or V5. On May 23, 2023, at 1:50 PM, V8 CNA said gloves should be changed before you touch clean items. The facility's Handwashing/Hand Hygiene policy dated December 6, 2022, shows, This facility consider hand hygiene the primary means to prevent the spread of infections. Use an alcohol based hand rub; or alternatively, soap and water for the following situations: before and after direct contact with residents, before and after handling an invasive device, and before handling clean or soiled dressings. Before moving from a contaminated body site to a clean body site during resident care, after contact with a resident's intact skin.

Based on observation, interview and record review the facility failed to provide ADL (activities of daily living) assistance for residents' requiring assistance for incontinence care for 4 of 11 residents (R11, R3, R9, R8) reviewed for ADLs in the sample of 11. The findings include: 1. R11's Admission Record form showed R11 was admitted to the facility on [DATE], with diagnoses including altered mental status, dementia, and Alzheimer's disease. R11's resident assessment dated [DATE], showed R11 required the extensive assistance of staff for toileting and repositioning. The assessment showed R11 was incontinent of bowel and bladder. On May 22, 2023, at 9:26 AM, R11 was asleep, seated in a recliner in a room. An odor of stool was noted in R11's room. On May 22, 2023, at 10:31 AM, R11 remained asleep in the recliner in her room. An odor of stool remained in R11's room. On May 22, 2023, at 11:13 AM, R11 remained asleep in the recliner in her room. An odor of stool remained in R11's room. On May 22, 2023, at 11:50 AM, V4 Certified Nursing Assistant (CNA) and V5 CNA entered R11's room to provide cares. V4 and V5 assisted R11 out of her wheelchair, to the toilet, via a mechanical lift. As R11 stood in front of the toilet, V5 CNA began removing R11's brief. As V5 removed the brief, a large amount of mushy, liquid stool, fell out of the brief onto the floor, Stool was noted leaking out of the brief, onto R11's inner thighs. R11's entire buttock area was covered with a large amount of stool. R11's buttocks were reddened. V5 CNA stated, We got (R11) up around 7:30 AM this morning. We did incontinence care at that time (4.5 hours prior). 2. R3's current care plan showed R3 was cognitively impaired with diagnoses of dementia, aphasia, and intracerebral (brain) hemorrhage. R3's resident assessment dated [DATE], showed R3 was totally dependent on staff for cares/ADLs. The assessment showed R3 was incontinent of bowel and bladder. On May 22, 2023, at 9:35 AM, R3 was seated in a wheelchair in the activity room. A mechanical lift, cloth sling was noted underneath R3 in the wheelchair. On May 22, 2023, at 10:30 AM, R3's family wheeled R3 out of the activity room, down to her room for a visit. On May 22, 2023, at 11:05 AM, R3's family wheeled R3 into the dining room, where facility staff were seated. On May 22, 2023, at 12:13 PM, R3 remained in the dining room as facility staff fed her lunch. On May 22, 2023, at 1:15 PM, R3 remained in the dining room, asleep in her wheelchair. On May 22, 2023, at 2:00 PM, V4 and V5 CNAs wheeled R3 into her room to provide cares. R3 was transferred to her bed by V4 and V5 CNAs. V4 removed R3's incontinence brief. R3's brief was saturated with urine and a small amount of stool. R3's buttocks were reddened with visible creases indented in the skin of her buttocks from the mechanical lift cloth sling R3 was sitting on. V4 CNA stated, I got (R3) up around 6:30 AM this morning and did incontinence then (7.5 hours prior). She was the first one I got up. I haven't done incontinence care on her since then. On May 23, 2023, at 8:24 AM, V3 Registered Nurse stated, Residents should be repositioned every 2 hours. Residents should be checked for incontinence every 2 hours and cleaned up when needed. 34506 3. R9's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, and hematuria. R9's MDS (Minimum Data Set) dated March 2, 2023, shows he requires total assistance with toilet use, personal hygiene, bed mobility, and transferring. R9 is always incontinent of bowel and bladder. R9's Care Plan shows he has an ADL (Activities of Daily Living) self care performance deficit related to Alzheimer's, dementia. R9 is dependent on staff for repositioning, turning in bed, personal hygiene and oral care. On May 22,2023, R9 was observed sitting in a tall back recliner at various times from 9:30 AM-1:13 PM. On May 22, 2023, at 1:13 PM, V4 and V5 CNA (Certified Nursing Assistant) transferred R9 from the recliner to the bed. There was urine and stool in R9's incontinence brief. There were creases on R9's buttocks from sitting in the recliner. V4 said that R9 has been up in the recliner since 6:30 AM. 4. R8's Face Sheet shows she was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease and history of falling. R8's MDS dated [DATE] shows she requires extensive assistance with bed mobility and transferring. R8 requires total assistance for toilet use and personal hygiene. R9's Care Plan shows she has bladder incontinence related to activity intolerance, confusion, dementia, urinary tract infection, and impaired mobility. Clean peri-area with each incontinence episode. On May 22, 2023, R9 was observed sitting in her high back recliner at various times from 9:29 AM-12:55 PM. At 12:55 PM, V4 and V5 transferred R9 into bed. R9's incontinence brief was saturated with urine and creases were noted to R9's skin on her upper legs and buttocks. There was stool noted to R9's buttocks. V4 said that R9 has been up and in her high back recliner since about 7:30 AM. On May 23, 2023, at 1:50 PM, V8 CNA said incontinence care and repositioning should be done at lease every two hours in order to protect residents skin. The facility's Activities of Daily Living policy dated December 6, 2022, shows, Residents will be provided with care, treatment and services as appropriated to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The facility's Perineal Care Policy dated December 6, 2022, shows, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.

Based on observation, interview and record review the facility failed to ensure residents were treated in a dignified manner during dining for three of 11 residents (R11, R3, R9) reviewed for dignity in the sample of 11. The findings include: 1. On May 22, 2023, at 12:16 PM, R11 was seated in the dining room. V5 Certified Nursing Assistant (CNA) stood next to R11, feeding R11 soup. 2. On May 22, 2023, at 12:20 PM, R3 was seated in the dining room. V7 CNA stood next to R3, feeding R3 soup. 34506 3. On May 22, 2023, at 12:37 PM, R9 was seated in the dining room. V5 CNA was standing next to R9 while she was feeding him soup and his main meal. 4. On May 23, 2023, at 12:10 PM, V9 CNA was on her cell phone in the dining room while feeding R11. At 12:25 PM, V9's cell phone was sitting next to her on top of the table while she was still feeding R11. On May 23, 2023, at 8:24 AM, V3 Registered Nurse stated, Staff are not to be standing when feeding residents. Staff are to be face-to-face with residents. It's a dignity issue. Per our policy, staff are not to be standing. On May 23, 2023, at 1:50 PM, V8 CNA said staff should be sitting down while feeding residents so that they are able to face the residents and see eye to eye. V8 said cell phones should not be used while feeding residents. The facility's Assistance with Meals policy dated December 6, 2022, shows, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: not standing over residents while assisting them with meals.

Based on observation, interview, and record review, the facility failed to ensure peri care was provided in a manner to prevent urinary tract infections and failed to maintain a urinary drainage bag below the level of the bladder for two of five residents (R9, R15) reviewed for incontinence care and catheter care in the sample of 11. The findings include: 1. R9's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, hematuria, and dementia. R9's MDS (Minimum Data Set) dated March 2, 2023, shows he is always incontinent of bowel and bladder. R9's Care Plan shows he is totally dependent on staff for personal hygiene and oral care. On May 22, 2023, at 1:13 PM, V4 and V5 CNAs (Certified Nursing Assistants) transferred R9 from his recliner to his bed. R9 had urine and stool in his incontinence brief. V5 CNA wiped the stool from R9's buttocks but did not clean the urine from R9's front peri area. On May 23, 2023, at 1:50 PM, V8 CNA said residents peri areas should be washed from front to back. The facility's Perineal Care policy dated December 6, 2022, shows, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Wash perineal area starting with urethra and working outward .continue to wipe the perineal area including the penis, scrotum and inner thighs. Wash and rinse the rectal area thoroughly. 2. R15's Admission Record shows he was admitted to the facility on [DATE], with diagnoses including urinary retention, gross hematuria, cognitive communication deficit, and acute kidney failure. R15's Care Plan dated April 25, 2023, shows R15 has a urinary catheter and to position catheter bag and tubing below the level of the bladder and away from entrance room door. On May 22, 2023, at 1:24 PM, V4 and V5 CNAs transferred R15 from his wheelchair to the toilet. V5 lifted R15's urinary drainage bag above the level of his bladder while he was sitting in the wheelchair. There was urine in R15's urinary drainage bag and in the tubing of the urinary catheter. On May 23, 2023, at 1:50 PM, V8 CNA said the urinary drainage bag should be kept below the level of the resident's bladder, so urine doesn't flow back and cause infection. The facility's Indwelling Catheter Protocol dated October 24, 2018, shows, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview and record review the facility failed to ensure pressure injury treatments and interventions were in place for 3 of 3 (R11, R2, R9) residents reviewed for pressure injuries in the sample of 11. The findings include: 1.R11's Admission Record form showed R11 was admitted to the facility on [DATE], with diagnoses including altered mental status, dementia, and Alzheimer's disease. R11's Skin/Wound note dated March 22, 2023, showed a new open wound was found to R11's sacral/coccyx area, measuring 3.0 cm (centimeters) x 0.3 cm. R11's Skin/Wound note dated May 22, 2023, showed, Skin remains fragile. Coccyx area remains with superficial open area, (Stage) 2. R11's current care plan showed, Keep skin clean and dry .Follow facility protocols for treatment of injury .Cleanse open area to sacrum, pat dry, apply Mepilex (foam) dressing, change dressing every 3 days and prn (as needed) until healed. On May 22, 2023, at 9:26 AM, R11 was asleep, seated in a recliner in a room. An odor of stool was noted in R11's room. On May 22, 2023, at 10:31 AM, R11 remained asleep in the recliner in her room. An odor of stool remained in R11's room. On May 22, 2023, at 11:13 AM, R11 remained asleep in the recliner in her room. An odor of stool remained in R11's room. On May 22, 2023, at 11:50 AM, V4 Certified Nursing Assistant (CNA) and V5 CNA entered R11's room to provide cares. V4 and V5 assisted R11 out of her wheelchair, to the toilet, via a mechanical lift. As R11 stood in front of the toilet, V5 CNA began removing R11's brief. As V5 removed the brief, a large amount of mushy, liquid stool, fell out of the brief onto the floor, Stool was noted leaking out of the brief, onto R11's inner thighs. R11's entire buttock area was covered with a large amount of stool. No dressing was noted to the circular reddened area to R11's coccyx area. No dressing was noted in R11's soiled incontinence brief. R11's buttocks were reddened. V5 CNA stated, We got (R11) up around 7:30 AM this morning. We did incontinence care at that time (4.5 hours prior). She doesn't have a dressing to her bottom. She doesn't need one. On May 23, 2023, at 8:24 AM, V3 Registered Nurse (RN) stated, (R11) has a stage 2 (pressure injury) to her coccyx .She is to have a foam dressing over her coccyx wound. It gets changed every 3 days and as needed. If the dressing is missing or has fallen off, staff are to tell the nurse so we can apply a new one. To help her wound heal, she is on a low air loss mattress, has a dressing to her coccyx, reposition her every 2 hours, and make sure her skin is kept clean and dry. No one told me yesterday that (R11) did not have a dressing over her coccyx wound. 2.R2's Wound Progress Note dated May 10, 2023, showed R2 had an unstageable pressure injury to her left heel and a stage 2 pressure injury to her right heel. R2's left heel pressure injury measured 3.5 cm x 4 cm x 0.4 cm. R2's right heel pressure injury measured 0.7 cm x 0.4 cm x 0.2 cm. R2's physician progress note dated May 1, 2023, showed, Needs offloading boots on at all times. On May 22, 2023, at 9:36 AM, R2 was seated in a wheelchair in her room. Gauze dressings were noted to both of R2's heels. No offloading boots were noted to R2's feet. On May 22, 2023, at 10:05 AM, R2 remained seated in a wheelchair in her room. No offloading boots were noted to R2's feet. The facility's Prevention of Pressure Injuries policy dated December 6, 2022, showed, Clean promptly after episodes of incontinence. Use facility-approved protective dressings for at risk individuals, Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. 34506 3. R9's Face Sheet shows he was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, hematuria, and dementia. R9's MDS (Minimum Data Set) dated March 2, 2023, shows R9 requires total assistance with bed mobility and transferring. R9's Scale for Predicting Pressure Injury Risk dated May 23, 2023, shows R9 is high risk for developing pressure injuries. R9 Order Summary Report dated May 23.2023 shows an order for low air loss mattress dated June 18,2021. R9's Care Plan shows R9 has a potential for pressure injury development related to history of skin breakdown and limited mobility. R9 has a history of pressure injuries to his buttock. Intervention for low air loss. On May 22, 2023, at 1:13 PM, R9 was transferred into his bed. R9 had an air mattress pump to the foot of his bed and the pump was shut off. On May 23, 2023, at 2:03 PM, the mattress pump was shut off again. V4 CNA stated she thought the air mattress (pump) was on.

Based on interview and record review the facility failed to ensure two residents (R1, R2) received the correct dosages of physician prescribed medication. This failure resulted in R1 receiving 17 additional doses of an anti-depressant medication which contributed to R1 being hospitalized for a mental status change. This applies to 2 of 4 residents (R1, R2) reviewed for medication errors in the sample of 4. The findings include: 1.) R1's nursing progress notes show she was admitted to the skilled unit of the facility on 11/17/22. Her face sheet shows she had diagnoses including: major depression, anxiety, and a history of falls. R1's nursing progress note for 12/11/22 at 6:15 PM, shows R1 was having increased confusion and poor balance and gait. R1's progress note written and signed by V5 (Nurse Practitioner) on 12/12/22 states, Patient {R1} is being seen because she is more confused her balance is off/Hx TIA and MI. Referred to see patient by RN secondary to increased confusion, and unsteady gait over her stay at the skilled facility .Patient has been treated for a UTI (Urinary Tract Infection). Patient's husband is requesting patient to be seen by neurology. R1's nursing progress notes for 12/15/22 at 12:11 PM, states, Member noted with altered mental status, unable to follow commands and increased confusion noted. POA (V9- R1's Power of Attorney/spouse) agreed to send member out to {local community hospital} for further evaluation. R1's Neurology consult report from a local community hospital show that R1 presented to the emergency roiagnom on [DATE] for complaints of altered mental status and generalized weakness that began a couple days prior to presentation. R1's nursing progress note dated 12/16/22 at 8:05 AM, shows that the facility was contacted by V10 (R1's daughter) while she was in the hospital to clarify the correct dosage of R1's Wellbutrin. R1's nursing progress note on 12/16/22 at 1:07 PM, written by V4 (Registered Nurse/RN) shows R1 was admitted to the hospital and V7 was contacted by her regarding R1's Wellbutrin order. R1's 12/21/22 physician progress note written by V11 (R1's primary physician) states, Patient was seen secondary to follow-up hospital admission patient was sent secondary to some neurologic symptoms of unbalance. Patient excellently (sic) did take extra Wellbutrin. That was decreased in the hospital. Patient's back to normal self. R1's 12/7/22 nursing progress note signed by (V3 Registered Nurse/RN) at 3:00 PM, shows R1 went to a psychiatry appointment on 12/7/22 and returned with an order for Wellbutrin (anti-depressant) 300 MG (milligrams) PO (by mouth) BID (two times a day). A Physician Progress note, and prescription written by V7 (Psychiatrist) for R1 on 12/7/22 states, Wellbutrin 300 mg Xl #30 take 1 tab po daily. In V7's progress note there was an arrow pointing up, in front of the medication change, meaning to increase the dose to 300 mg. That order was then incorrectly transcribed and entered into R1's 12/1/22-12/31/22- Medication Administration Record (MAR) on 12/7/22 as the following: Wellbutrin XL 300 mg tablet Give 1 tablet BID at 7:00 AM and 7:00 PM. R1 had an active order for buproprion 200 mg (generic medication for Wellbutrin) to be given at 8:00 PM prior to the medication increase, and that order was not discontinued when the new order was received. R1's MAR shows she ultimately received 500 mg more per day of the Wellbutrin/buproprion from 12/8/22 until 12/15/22 when she was sent to the hospital for increased confusion. R1 received a total of 8 extra doses of the bupropion 200 mg. and 7 extra doses of the Wellbutrin 300 mg which was verified on 1/3/23 with V2 (Director of Nursing) On 1/3/23 at 8:45 AM, V4 (RN) said she was made aware of the medication error for R1 while R1 was in the hospital. She said the facility was contacted by V10 to clarify the medication dosage for R1's Wellbutrin. When the facility began reviewing R1's physician orders it was discovered, and she then contacted V7 to report the medication error. V4 said R1 was experiencing more confusion but it was assumed to be from a urinary infection that R1 was treated for. On 1/3/23 at 9:00 AM, V5 (Nurse Practitioner) said she was made aware of R1's Wellbutrin medication error. She said the high end range of Wellbutrin is 450 mg per day and an overdose or too much of this medication can cause seizures and lethargy. V5 said she does not understand why the medication error was not caught sooner. On 1/3/23 at 11:00 AM V2 (Director of Nursing) said V3 incorrectly transcribed R1's Wellbutrin and as a result R1 received an extra 500 mg of the medication per day for 8 days. On 1/3/23 at 11:21 AM, V1 (Administrator) said we understand the importance of what has occurred, and disciplinary actions are being taken against V3. On 1/3/23 at 3:00 PM, V7 (Psychiatrist) said he did see R1 and prescribed her Wellbutrin 300 mg per day. He was notified by a nurse at the facility of the medication error when R1 was in the hospital. V7 said the maximum dose of Wellbutrin XL is 450 mg and by R1 receiving 800 mg a day (almost triple) his prescribed amount, with the other medications she was at an extreme risk of having a seizure. He said this was a very significant error to occur because of the risk to her. V7 said he never got a straight answer on how this error could have occurred and why it wasn't caught for 8 days by anyone from the facility or pharmacy. He said he feels this was a very significant medication error and had it went on longer the chances are high that R1 would have had a seizure. He also said he believes this was a major contributing factor as to why R1 became so confused and weak. On 1/4/23 at 8:16 AM, (V9/R1's spouse and POA) said that his wife has had urinary tract infections in the past and it has never caused her as much confusion as her saw in her after she started receiving the increased Wellbutrin. V9 said, I am not a doctor and can't say for sure that the extra medication is what caused her increased confusion, but I have never seen her like that from a UTI. V9 said the family was told by the psychiatrist that this amount of medication was almost 3 times what he prescribed and could have caused a seizure. On 1/4/23 at 8:23 AM, V10 (R1's daughter) said she learned about the medication error when her mom (R1) was in the hospital. She said when the nurses at the hospital were reviewing R1's medication orders they discovered then the Wellbutrin was a high dose. She said the hospital decided to hold the medication and slowly bring it back down to the correct dosage. V10 said she had some concerns about her mom's confusion at the facility after the Wellbutrin order was changed, but when she tried to discuss it with staff it was dismissed as she has good days, and she has bad days. She said she does not believe that was entirely accurate and she feels R1's confusion and weakness became far worse after she started receiving the wrong dose of the Wellbutrin. The facility's Illinois Department of Public Health- Initial and Final Report completed by V1 (Administrator) shows it was identified on 12/16/22 that R1 had sustained a medication error at the facility, and she received Wellbutrin 300 mg bid and Wellbutrin 200 mg instead of the prescribed order being Wellbutrin 300 mg daily. 2.) R2's electronic medical record and face sheet shows he was admitted to the skilled unit of the facility on 7/6/22 and had diagnoses including: Parkinson's Disease, dementia and gait and mobility issues. R2's discharge medication records from a local hospital dated 7/6/22 show R2 should receive Carbidopa-levodopa (a medication for Parkinson's disease) 25-250 mg 1 tablet TID (three times a day) 7:00 AM, 5:00 PM, and 9:00 PM and 1/2 tablet at 11:00 AM. R2's nursing progress notes show he was admitted to the facility on [DATE] by V3. R2's physician order sheet shows the order for his Carbidopa-levodopa was entered as the following: Carbidopa-Levodopa Tablet 25-250 MG give 0.5 tablet by mouth once a day, and a second order for the same dosage to be given 3 times a day was also entered. R2's 7/1/22-7/31/22 MAR shows he received the incorrect dosage of Carbidopa-levodopa 1/2 tablet instead of 1 tablet TID from admission on 7/6/22 until 7/29/22 for a total of 69 doses when it should have been 1 full tablet. R1's nursing progress note for 7/29/22 at 6:08 PM, states, while in member's room, ready to administer medications, member's son noted that one of the pills of the Carbidopa-levodopa was not the correct dose, it was only 1/2 tablet. Member's son stated that Carbidopa-levodopa at {5:00 PM} time frame was to be a whole tablet. Orders were checked from hospital and it was noted that that the member should be receiving 1 whole tablet 3 times a day and 1/2 tablet at 11:00 AM. On 1/3/23 at 10:20 AM, V5 (Nurse Practitioner) said she was aware of the medication error for R2's Carbidopa-levodopa and as a result R2 received less of the medication. She said she does believe R2 was having some increased Parkinson's symptoms as a result of this medication error and that is how it was caught, but she cannot say for certain. On 1/3/23 at 11:30 AM, V3 (RN) said V3 was aware of R2 having a medication error and receiving less then prescribed Carbidopa medication. She said R2 did show signs of increased Parkinson's symptoms in the time frame when the medication error occurred, and he became more sluggish. A Medication Error report was completed by the facility on 7/29/22 for R2 which shows he received the incorrect dosage of his Carbidopa from admission on 7/6/22 until it was discovered by his son on 7/29/22. The facility provided Administering Medication policy revised on 12/6/22 states, Administering Medications Policy Statement Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with the Prescriber orders, including any required time frame.

Based on interview and record review the facility failed to ensure medication orders were correctly transcribed and clarified for 2 of 4 residents (R1, R2) reviewed for pharmacy services in the sample of 4. The findings include: 1.) R1's nursing progress notes show she was admitted to the skilled unit of the facility on 11/17/22. Her face sheet shows she had diagnoses including: major depression, anxiety, and a history of falls. R1's Physician Progress note, and prescription written by V7 (Psychiatrist) for R1 on 12/7/22 states, Wellbutrin 300 mg XL #30 take 1 tab po daily. In V7's progress note there was an arrow pointing up, in front of the medication change, meaning to increase the dose to 300 mg (from 200mg). R1's 12/7/22 nursing progress note signed by (V3 Registered Nurse/RN) at 3:00 PM, shows R1 went to a psychiatry appointment on 12/7/22 and returned with an order for Wellbutrin (anti-depressant) 300 MG (milligrams) PO (by mouth) BID (two times a day). That order for Wellbutrin was then transcribed and sent to pharmacy by V3. The order was then put into R1's 12/1/22-12/31/22- Medication Administration Record (MAR) on 12/7/22 as the following: Wellbutrin XL tablet Give 1 tablet BID at 7:00 AM and 7:00 PM. R1 had an active order for buproprion 200 mg (generic medication for Wellbutrin) to be given at 8:00 PM prior to the medication increase, and that order was not discontinued when the new order was received. R1's Medication Administration shows she ultimately received 500 mg more per day of the Wellbutrin/buproprion from 12/8/22 until 12/15/22 due to the transcription error. On 1/3/23 at 11:00 AM, V2 (Director of Nursing) said V3 incorrectly transcribed R1's Wellbutrin order which was sent to pharmacy and ultimately resulted in R1 receiving more of the medication. V2 said nurses should clarify any discrepancies in orders with the physician and pharmacy should contact the facility as well. Pharmacy is also expected to send irregularity reports or call with questions about a resident's medication order. On 1/3/23 at 11:30 AM, V3 said she did incorrectly transcribe R1's medication order for Wellbutrin. V3 said she thinks it happened because the order was confusing to her, but she did not call V7 to clarify the order. On 1/3/23 at 12:42 PM, V6 (Director of Pharmacy) said the pharmacy did receive the order for R1's Wellbutrin change on 12/7/22. They did not fill the order that day because it triggered an alert in their system for a dosage too high. He said it is documented in their computer system that the facility was faxed and called on 12/7/22 and again 12/8/22 and they were told by an unnamed nurse from the facility that R1's order for the Wellbutrin was clarified by V7 and they could send the medication out that day. On 1/3/23 at 3:00 PM, V7 (Psychiatrist) said his order for R1's Wellbutrin should have been for her to receive 300 MG total per day. He said no one called him from the facility or from pharmacy to clarify the medication order. He said the maximum dosage of this medication would be 450 mg and this should have been triggered by the pharmacy also to clarify the dosage. 2.) R2's electronic medical record and face sheet shows he was admitted to the skilled unit of the facility on 7/6/22 and had diagnoses including: Parkinson's Disease, Dementia and gait and mobility issues. R2's discharge medication records from a local hospital show R2 should receive Carbidopa-levodopa (a medication for Parkinson's disease) 25-250 mg 1 tablet TID (three times a day) 7:00 AM, 5:00 PM, and 9:00 PM and 1/2 tablet at 11:00 AM. R2's nursing progress notes show he was admitted to the facility on [DATE] by V3 (RN). R2's physician order sheet shows the order for his Carbidopa-levodopa was entered as the following: Carbidopa-Levodopa Tablet 25-250 MG give 0.5 tablet by mouth once a day, and a second order for it to be given 3 times a day was also entered. R2's 7/1/22-7/31/22 MAR shows he received the incorrectly transcribed dosage of Carbidopa-levodopa 1/2 tablet instead of 1 tablet TID from admission on 7/6/22 until 7/29/22. On 1/3/23 at 10:20 AM, V5 (Nurse Practitioner) said she was aware of the transcription error for R2's Carbidopa-levodopa and as a result R2 received less of the medication for quite a while. On 1/3/23 at 11:21 AM, V1 (Administrator) said the facility is aware of the 2 medication transcription errors made by V3 for R1 and R2. V1 said disciplinary measures have been initiated for V3. On 1/3/23 at 11:30 AM, V3 said she did transcribe R2's medication order incorrectly. It should have been for 1 tablet 3 times a day and 1/2 tablet at 11:00 AM and she wrote it for 1/2 tablet 4 times a day. V3 said she believes this mistake could have been avoided if someone else double checked R2's admission orders. She said she does not recall pharmacy ever contacting her to clarify R2's medication order. On 1/3/23 at 12:42 PM, V6 (Director of Pharmacy) said the pharmacy did receive the orders for R2's Carbidopa-levodopa on 7/6/22. The pharmacy called back to the facility on [DATE] and spoke with V3 for clarification about the medication orders for R2. He said it is documented in their computer that V3 told the pharmacy staff that 1/2 tablet TID and 1/2 tablet at 11:00 AM was the correct order and they sent out the medication. The facility provided pharmacy services and procedures manual titled Physician/Prescriber Authorization and Communication of orders to pharmacy with a revised date of 1/1/12 states, Facility should verify transfer/transition and admission orders with the resident's Physician/Prescriber before they are communicate to the Pharmacy. The same policy in section 6.3 states Facility should contact Physician/Prescriber when staff is notified by Pharmacy of an order requiring clarification.

Based on observation, interview and record review, the facility failed to perform hand hygiene and change their gloves in a manner to prevent cross contamination for two of eight residents (R7,R10) reviewed for infection control in the sample of eight. The findings include: 1. R7's Admission record shows he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's Minimum Data Set, dated dated dated [DATE] shows R7 is not cognitively intact. R7 requires total assistance of two staff members for toileting and personal hygiene. R7 is always incontinent of bowel and bladder. R7's Care Plan initiated on 4/23/2020 shows, member has bladder incontinence. Needs assistance with toileting. At risk for urinary tract infection and skin breakdown to buttocks and peri area. On 6/21/22 at 1:00 PM, V4 and V5 CNA (Certified Nursing Assistants) used a mechanical lift to assist R7 to stand up in front of the toilet. V4 removed R7's urine saturated brief. V4 touched R7's body to assist him into a sitting position and touched the mechanical lift sling without washing her hands or changing her gloves. There was a strong urine smell. R7 had a bowel movement in the toilet. V4 stood R7 up via the mechanical lift. V5 cleansed the stool from R7's buttocks, put lotion on R7's buttock and legs, and touched R7's clean incontinence brief without changing his gloves or performing hand hygiene. The facility's Standard Precautions Policy revised on 10/24/16 shows, Standard precautions will be used to minimize the spread of infectious diseases. The facility's Handwashing policy dated 10/24/16 shows, To ensure good hand washing techniques are used according to CDC (Centers for Disease Control) guideline and to thoroughly cleanse the hands with friction, soap and water. Wash hands: After touching blood, body fluids or objects contaminated by blood or body fluids. Do this even if you were wearing gloves. The facility's Incontinence Care Policy dated 5/22/17 shows, Change gloves after cleaning peri-area. 2. On 06/21/22 at 12:32 PM, V4 and V5, CNAs (Certified Nursing Assistants) were observed assisting R10 to bed and then with incontinence care. V5 wiped R10's backside with his gloved hands, and with no glove change or hand hygiene performed, finished putting a clean brief on R10, and adjusted her blankets and pillows. On 06/21/22 12:48 PM, V3, Registered Nurse (RN) removed R10's coccyx dressing and while using the same gloves, V3 proceeded to clean R10's coccyx area, then applied a new dressing. V3 removed her contaminated gloves and carried them out of the room with her down the hall to the dining room where she threw the gloves away. On 06/22/22 at 10:32 AM, V5 said he washes his hands and applies gloves before incontinence care. V5 said during incontinence care one should clean the peri area from front to back, change gloves, clean up any stool, change gloves, then apply the brief and change gloves. The facility's Incontinence Care Policy dated 5/22/17 shows, Change gloves after cleaning peri-area. On 06/22/22 at 10:38 AM, V3 said gloves are applied and she removes the dressing and clean gloves are applied and then the clean dressing is applied. V3 said the purpose of changing gloves after removing the dressing is to keep the wound clean. R10's Minimum Data Set (MDS) dated [DATE] shows R10 has severe cognitive impairment and is completely dependent on staff for her personal hygiene needs and requires extensive assistance with toilet use. R10's Order Summary Report dated 6/22/22 shows an order to apply protective [MEDICATION(S)] dressing to coccyx/sacral blanchable redness, change every three days and as needed for protective dressing. R10's Care Plan initiated 5/21/22 shows R10 has actual impairment to skin integrity on coccyx/sacral area related to fragile skin. The facility's Standard Precautions Policy revised on 10/24/16 shows, Standard precautions will be used to minimize the spread of infectious diseases.

Based on interview and record review the facility failed to offer both pneumonia vaccines [pneumococcal conjugate vaccine (PCV13) and pneumococcal polysaccharide vaccine (PPSV23)] for 1 of 5 residents (R2) reviewed for vaccines in the sample of 8. The findings include: R2's Admission Record dated 6/22/2022, shows R2 was admitted on [DATE]. On 6/22/2022 at 2:14PM, V1 Administrator said R2 was not offered either of the pneumonia vaccines because he was hospice. On 6/22/2022 at 2:14PM, V2 Director of Nursing said R2 was not offered either of the pneumonia vaccines. The facility's Pneumococcal Vaccine policy dated 1/24/2021 states All residents in the facility will be offered the pneumococcal vaccine on admission or soon afterwards.

Based on observation, interview, and record review, the facility failed to ensure a catheter bag remained below the level of the bladder for 1 of 1 resident (R10) with a history of Urinary Tract Infections (UTIs) reviewed for catheters in the sample of 8. The findings include: On 06/21/22 at 12:32 PM, V4 and V5, CNAs (Certified Nursing Assistants) were observed assisting R10 to bed and then with incontinence care. R10 had a urinary catheter leg bag attached to her right thigh which did not allow gravity to drain the urine into the bag as it was at the same level as R10's bladder. The bag and tubing contained cloudy, orange urine. Care was completed and V4 and V5 left the room. R10's Admission Record (dated 6/22/22) shows R10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R10's Care Plan (initiated 5/6/22) shows R10 has a Urinary Tract Infection and R10 has an indwelling catheter related to [CONDITION(S)] and retention of urine .Position catheter bag and tubing below the level of the bladder. R10's Minimum Data Set (MDS) dated [DATE] shows R10 has severe cognitive impairment and is completely dependent on staff for her personal hygiene needs and requires extensive assistance with toilet use. On 06/22/22 at 09:25 AM, V4 and V5 both said the catheter drainage bag should be below the bladder and a leg bag should be changed to a regular drainage bag if the resident is in bed to prevent the urine from flowing back into the bladder to prevent [CONDITION(S)]. On 06/22/22 at 11:47 AM, V2, Director of Nursing (DON), said she doesn't know why R10 has a leg bag instead of a regular drainage bag for her catheter. V2 said R10 had a [CONDITION(S)] last month. V2 said R10 has a history of chronic UTIs and was admitted to skilled nursing for the [CONDITION(S)]. The facility's Indwelling Catheter Protocol (created/revised 10/24/18) shows 3. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on observation, interview and record review the facility failed to ensure opened, refrigerated foods were labeled and dated. The facility failed to ensure dry storage scoops were stored outside of the dry storage containers. These failures have the potential to affect all 19 residents in the facility. The findings include: The CMS 672 form (Centers for Medicare and Medicaid Services Resident Census and Conditions Report) dated September 7, 2021 showed 19 residents in the facility. On September 7, 2021 from 9:00 AM-9:45 AM, an initial tour of the facility's main kitchen was completed by this surveyor and V9 Chef. On September 7, 2021 at 9:15 AM, 20 small individually poured, plastic containers of salad dressing were located on a tray in the kitchen's pastry cooler. None of the containers were labeled with the date they were poured/prepared or the name of the items. When V9 was asked what was in the containers, V9 stated, These are single serve salad dressings for the salads we serve. On September 7, 2021 at 9:18 AM, a metal rectangular container of cooked spiral-shaped noodles was noted in the smaller cooler next to the prep table in the kitchen. The container was not labeled with the date or time the noodles were prepared. V9 Chef stated, All foods opened or cooked must be covered and dated before placed in the coolers for storage. On September 7, 2021 at 9:21 AM, a large plastic scoop laid in a large plastic container, directly on top of uncooked brown rice. V9 Chef stated, That scoop is not supposed to be laying in the food. On September 7, 2021 at 9:27 AM, 2 large rectangular trays of cooked wild rice and 1 large tray of cooked macaroni and cheese were noted in one of the large coolers in the kitchen. The trays of rice and macaroni and cheese were not covered with any type of covering and were open to air. All three trays were not labeled with a dates or times the foods were cooked/prepared. On September 7, 2021 at 9:30 AM, an opened cardboard box filled with [NAME] was noted in one of the large coolers in the kitchen. The bottom of the cardboard box of [NAME] was saturated with water as the box was sitting on a tray with water in it. On September 8, 2021 at 9:35 AM, V10 Dietary Manager stated all food for the residents in the facility is prepared in the main kitchen of the facility and brought up to the floor to the residents. V10 stated, Vegetables should not be sitting in wet cardboard boxes. Individual, single serving-sized containers of salad dressing should be dated and labeled with the date they were prepared. Foods that have been opened should be dated and labeled before placed in the cooler. On September 8, 2021 at 11:00 AM, V9 Chef was preparing the pureed lunch. V9 used a plastic scoop to remove powdered thickener from a large plastic container. After using the scoop, V9 placed the scoop back in the container, directly on top of the powdered thickener. V9 then closed the lid on the container of thickener. The facility's Food Expiration Dates policy dated January 15, 2015 showed, All prepared foods will be covered with plastic wrap and must be labeled and dated . The facility's kitchen Dating and Labeling Items policy dated June 17, 2006 showed, All food items that will not be stored in their original container or have been opened, will be labeled and dated according to IDPH (Illinois Department of Public Health)/Lake County policies. All labels will include the item name, date, time, discard date and the initials of the person who labeled the item .

Based on interview and record review the facility failed to ensure their Infection Preventionist completed specialized training in infection prevention and control. The facility failed to ensure their Infection Preventionist performed monitoring and surveillance of infection control in the facility. These failures have the potential to affect all 19 residents in the facility. The findings include: The CMS 672 form (Centers for Medicare and Medicaid Services Resident Census and Conditions Report), dated September 7, 2021 showed 19 residents in the facility A facility letter dated February 8, 2021 showed V8 Licensed Practical Nurse (LPN) was named the Interim Infection Preventionist (IP) of the facility. On September 7, 2021 at 12:46 PM, V1 Administrator stated, We currently have no staff here that has completed the specialized training in infection control for the Infection Preventionist role. (V8 LPN/Interim IP) is acting as our Infection Preventionist but has not completed the training. I had an old ADON (V12/Previous Assistant Director of Nursing/DON) that had completed the infection control training, but he left in June 2021 . On September 8, 2021 at 10:07 AM, V8 LPN/Interim IP stated, As you know, we have skilled care, independent living, and assisted living as a part of our community here. My primary role is that I oversee the Wellness Center for independent living and the home care department in our community. My office is across the street in another building. I am not here (skilled care floor of the facility) much. In February 2021, (V11 Chief Operating Officer) asked me to take over as the interim Infection Preventionist when (V12) stepped down as Director of Nursing and became the Assistant Director of Nursing. (V12 previous ADON) had the certification and specialized training for the Infection Preventionist role but he left the company in June 2021. I was told I needed specialized education for my role as the Infection Preventionist, but I just started working on the training on September 7, 2021 (yesterday). I am on the skilled care floor for about an hour in the mornings to attend the morning staff meeting and then I go back to my main job. I don't track or trend infections or compile infection control data on the skilled floor. I don't do anything with outbreaks on the floor. I don't do any infection control education with the staff here. I will come over and help test staff for COVID-19 if there is an outbreak. I am not a member of the Quality Assurance team over here . The facility's Infection Preventionist policy dated February 4, 2019 showed, POLICY: Designated team member to develop practical methods of preventing and controlling the spread of infectious diseases, typical within a specific population, including staff, members, and visitors .DUTIES: .2. Monitor unit for signs and symptoms of illness. 3. Collect, compile and report on data related to infectious outbreak .

Based on interview and record review the facility failed to ensure all staff were testing for COVID-19 following an outbreak. This applies to all residents residing in the facility. The findings include: The facility's Resident & Census report dated September 7, 2021 shows 19 residents residing in the facility. V13's (Certified Nursing Assistant-CNA) testing spreadsheet for COVID-19 shows on 8/8/2021 he tested positive for COVID-19. V14's (CNA) testing report for COVID-19 showed she was not tested until 8/16/2021 (8 days later). On September 8, 2021 at 8:41 AM, V1 (Administrator) said all staff should be tested after an outbreak. I'm not sure what happened with V13 not being tested right away. The Lake County Health Department COVID-19 testing recommendations effective August 17, 2021 states, Outbreak testing for positive cases facility wide testing within 3 days of 1st positive case .IDPH updated Interim Guidance for Nursing Homes and other Long Term Care Facility incorporating COVID-19 vaccination The facility's COVID-19 testing Guidance & Plan policy dated June 2020 states, The purpose is to offer proper guidance and plan for Member and Team Member testing for COVID-19, as directed by IDPH If there is one confirmed COVID-19 case accompanied by one suspected case we will notify Lake County Health Department and initiate OUTBREAK protocol .

Based on observation, interview, and record review the facility failed to implement infection control policies and recommendations from the Center for Disease Control (CDC) regarding staff donning personnel protective equipment (PPE) when entering a Person Under Investigation (PUI) for COVID-19 resident rooms. These failures have the potential to affect all 19 residents in the facility. The findings include: The CMS 672 form (Centers for Medicare and Medicaid Services Resident Census and Conditions Report), dated September 7, 2021 showed 19 residents in the facility 1. The facility's Daily Census report printed September 7, 2021 showed R218 was listed as a Person Under Investigation (PUI) for COVID-19 due to being a new admission and was on droplet isolation precautions. On September 7, 2021 at 10:40 AM, the door to R218's room was open with a Droplet Isolation sign adhered to the door. An isolation cart with PPE (personal protective equipment) was placed in the hallway, right next to R218's door. V4 Physical Therapist (PT) was seated in a chair in R218's room, directly next to R218 (less than 6 feet), providing therapy services. V4 wore an isolation gown, gloves, face shield, and surgical mask. V4 was not wearing a N95 mask. On September 7, 2021 at 11:04 AM, V6 Certified Nursing Assistant (CNA) knocked and entered R218's room wearing a surgical mask, isolation gown, and face shield. V6 was not wearing an N95 mask. A Droplet Isolation sign remained on R218's door. On September 7, 2021 at 12:08 PM, V7 Occupational Therapist knocked and entered R218's room wearing a surgical mask, isolation gown, and face shield. V7 was not wearing an N95 mask. V7 sat down in a chair directly next to R218 (less than 6 feet) and began providing therapy services. A Droplet Isolation sign remained on R218's door. On September 7, 2021 at 12:26 PM, V2 Director of Nursing (DON) knocked and entered R218's room to administer medications to R218. V2 wore a KN95 mask, an isolation gown, gloves, and face shield in R218's room. V2 did not wear an N95 mask. A Droplet Isolation sign remained on R218's door. On September 7, 2021 at 12:46 PM, V2 DON denied any shortage of N95 masks in the facility. When V2 DON was asked about her KN95 mask, V2 stated, I buy my own masks, so I use what I order personally. I have never been fitted for a N95 mask here at the facility. I was gone on the day they did the fit testing. On September 7, 2021 at 12:50 PM, V1 Administrator stated. For PUI residents on droplet isolation, staff are to wear N95 masks, gowns, gloves, and face shields when in those rooms. The facility's 14 Day Quarantine PPE Requirements When Entering the Room form (undated) showed staff must wear an N95 mask, face shield or goggles, clean gloves, and an isolation gown when in the room. The CDC's preparing for COVID-19 in nursing homes last updated March 29, 2021 showed, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown: Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (healthcare professional) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents . 2. On September 8, 2021 at 10:51 AM, a droplet/contact isolation sign was posted on R68's door. V7 (Occupational Therapist) placed a gown on and entered her room wearing a surgical mask. At 11:06 AM, V7 left R68's room with her surgical mask on. V7 said R68 is on quarantine for 14 days because she is a new admission. V7 said staff can enter a droplet/contact room with a surgical mask, gown and gloves. V7 said they have to wear a N95 mask only if the resident has COVID-19. On September 8, 2021 at 12:45 PM, V5 (Certified Nursing Assistant-CNA) donned a gown and placed a N95 mask over her surgical mask and entered R68's room. The facility's Person Under Investigation list provided on 9/8/2021 shows R68 is on droplet/contact precautions.

Based on interview and record review the facility failed to offer both pneumonia vaccines (pneumococcal conjugate vaccine (PCV13) and (Pneumococcal [MEDICATION(S)] vaccine (PPSV23)) for four of five residents (R1, R8, R11, R14) reviewed for vaccines in the sample of 13. The findings include: On September 7, 2021 at 12:50 PM, V2 Director of Nursing (DON) stated residents are screened for and offered both pneumonia vaccines (pneumococcal conjugate vaccine (PCV13) and Pneumococcal [MEDICATION(S)] vaccine (PPSV23)) upon admission to the facility and annually. R1's Admission Record showed R1 was admitted to the facility on [DATE]. R1's electronic medical record was reviewed and showed R1 consented to receiving the PPSV23 vaccine on February 21, 2020. R1's medical record showed no documentation of R1 ever receiving the PPSV23 vaccine or being screened for/offered the PCV13 vaccine. On September 8, 2021 at 11:03 AM, V1 Administrator stated she was unable to find documentation showing R1 received the PPSV23 vaccine in the facility. V1 also stated she was unable to find documentation showing R1 was screened for/offered the PCV13 vaccine. R8's Admission Record showed R8 was admitted to the facility April 3, 2020. R8's electronic medical record was reviewed and showed no documentation of R8 being screened for/offered either the PCV13 or PPSV23 vaccines. On September 8, 2021 at 11:03 AM, V1 Administrator stated she was unable to find documentation showing R8 was ever screened for/offered either pneumococcal vaccine. R11's Admission Record showed R11 was admitted to the facility on [DATE]. R11's electronic medical record was reviewed and showed R11 was not screened for the PCV13 vaccine until September 8, 2021. R11's medical record showed no documentation of R11 being screened for/offered the PPSV23 vaccine. On September 8, 2021 at 11:03 AM, V1 Administrator stated she was unable to find documentation showing R11 was ever screened for/offered the PPSV23 vaccine. R14's Admission Record showed R14 was admitted on [DATE]. R14's electronic medical record was reviewed and showed no documentation of R14 being screened for/offered either the PCV13 or PPSV23 vaccines. On September 8, 2021 at 11:03 AM, V1 Administrator stated she was unable to find documentation showing R14 was ever screened for/offered either pneumococcal vaccine. On September 8, 2021 at 11:03 AM, V1 Administrator stated the nurse that admits each resident is responsible for screening that resident for both pneumococcal vaccines during the admission process. V1 stated the Director of Nursing is responsible for double-checking to make sure each resident was screened for/offered both pneumococcal vaccines. The facility's Pneumococcal Vaccine policy dated January 24, 2021 showed, All residents in the facility will be offered the pneumococcal vaccine on admission or soon afterwards. The Center for Disease Control and Preventions' website titled Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal [MEDICATION(S)] Vaccine Among Adults Aged >[AGE] years: Updated Recommendations of the Advisory Committee on Immunization Practices dated November 22, 2019 showed under summary, .the Advisory Committee on Immunizations Practices (ACIP) recommended [PCV13] in series with [PPSV23] for all adults aged > 65. The same website showed under What are the Implications for Public Health Practice that, Shared clinical decision-making is recommended regarding administration of the PCV13 to person aged >65 .

Based on record review and interview, the facility failed to follow its transfer policy using the sit to stand lift device. This applies to one (R1) of three residents reviewed for falls during transfer using the mechanical lift. This failure resulted in one resident (R1) falling during a transfer using the mechanical lift that resulted in a dislocated left shoulder. The findings include: The facility's preliminary Incident Report Investigation (IRI) dated 5/24/14 showed that E6 (Certified Nursing Assistant) was transferring R1 from the toilet to the wheelchair via sit to stand machine. While E6 was wiping R1, the resident started sliding down from the lift. E6 was not able to hold the resident up and R1 fell to the floor. The Incident/Accident Report dated 5/24/14 at 11:42 AM showed that E7 (Registered Nurse) responded to the emergency call light in R1's room. E7 observed R1 semi lying on the bathroom floor with E6 holding her back. The report showed that R1 was alert, coherent and complaining of left shoulder pain. The facility's final IRI report dated 5/28/14 showed that during care in the resident's bathroom, the CNA stated that R1 slid from the sit to stand lift and both R1 and E6 fell to the floor. R1 complained of left shoulder pain and the affected area was immobilized. Paramedics were called and R1 was transported to the local hospital ER (emergency room ). The hospital X-Ray report showed that R1 sustained an interval reduction of the shoulder joint dislocation. R1 was returned to the facility the same day with left shoulder immobilizer in place. Furthermore, the report concluded that during the investigation, the CNA did not follow procedure according to the resident's care plan (2 person assist) or the facilities policy (2 persons will be present during the use of a lift at all times). R1's annual and quarterly MDS (Minimum Data Sheet) dated 11/25/13 & 2/25/14 respectively showed under Section G: Functional Status; B. Transfer - 3/3 (Extensive assistance with Two plus persons physical assist. During interviews with E3 (Certified Nursing Assistant), E4 (Certified Nursing Assistant) and E5 (Registered Nurse) on 6/4/14 between 10:40 AM to 2:45 PM, the staff said that when transferring residents using mechanical lifts such as sit to stand and total lift, there should be 2 staff present at all times. The facility policy and procedure titled, "Use of Lifts," effective 4/13/11, required, "3. Two staff members will be present during use of lift at all times."