Every finding on record at Regents Park at Aventura

Based on observations, interviews, and record reviews, the staff failed to keep residents' information confidential at one of the two nursing stations on the second floor. As evidenced by an unattended computer with an open screen displayed a resident's confidential health care information at the 2 [NAME] Nursing station. There were 173 residents residing in the facility at the time of the survey. The findings include.Observations on 01/06/2026 at 12:56 PM revealed an unattended computer with the screen open displaying residents' health care information at the 2 west Nursing Station. (Photographic evidence). Interview on 01/07/2026 at 09:30 AM, Staff B, Licensed Practical Nurse (LPN), stated, I understood HIPAA (Health Insurance Portability and Accountability Act) as it is related to protecting the privacy of patient information. Patient confidentiality mean not discussing resident information over the phone and only sharing information with individuals who were authorized and listed in the chart. When walking away from a computer, I made sure it was not left open or visible to others and that any paperwork containing patient information was shredded once it was no longer needed. Review of the facility's policy and procedure titled HIPAA Policy: 11/2019: Examples of violations include, but are not limited to: 1. The intentional or negligent mishandling, altering, or destruction of confidential information or media/workstations that house such information.2. Leaving a secured application unattended while logged on.

Based on observations, record review, and interviews, the facility failed to provide adequate privacy during hygiene and catheter care for one resident (Resident #7) out of three residents sampled with an indwelling urinary catheter. Resident #7's roommate entered the room while Resident #7 was exposed. At the time of the survey, nine residents with an indwelling urinary catheter resided in the facility. The findings include. During an observation on November 5, 2025, at 9:45 AM, Staff A, Licensed Practical Nurse (LPN), performed hygiene care for Resident #7. The privacy curtain did not completely extend around the bed, leaving Resident #7 exposed. Additionally, the roommate entered the room while care was ongoing.In an interview conducted on November 5, 2025, at 12:33 PM, Staff A, LPN, was asked about the facility's protocol related to providing privacy during personal care. Staff A acknowledged, I was aware that the curtain did not extend around the resident, but I did not want to stop because I did not want the resident to refuse care.During an interview on November 5, 2025, at 12:51 PM, the Director of Nursing (DON) stated, Staff are to provide privacy to the best of their ability. Record review of a policy titled Promoting/Maintaining Resident Dignity date Implemented: 5/2020 date reviewed/revised: 4/2023 revealed Policy:It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.Compliance Guidelines:All staff members are involved in providing care to residents to promote and maintain resident dignity and respect residents' rights.

Based on observations, record review and interviews facility failed to provide appropriate catheter care to facilitate the flow of urine for one (Resident#7) out of three sampled residents who had indwelling urinary catheter, as evidenced by during catheter care Resident#7's indwelling urinary catheter drainage collection bag and tubing were positioned on top of bed with backflowing urine noted in the tubing. This deficient practice prevented the free flowing of urine that would be accumulated in the bladder causing discomfort and increasing the risk for catheter-associated urinary tract infections and other serious medical issues. There were nine residents with indwelling urinary catheters residing in the facility at the time of this survey.The findings include. During an observation on 11/05/25 at 9:45 AM, Staff A, a Licensed Practical Nurse (LPN), performed hygiene and catheter care for Resident #7. The urinary drainage bag and tubing noted with urine were positioned on the bed next to the resident's feet in level with the bladder, causing backflow of urine. (Photographic evidence). At 10:02 AM, Staff A, LPN lowered the drainage bag, opened the port, emptied the urine into a urinal, and closed the port without cleaning it.A review of Resident #7's demographic sheet revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following cerebral infarction affecting the left non-dominant side.A review of a Significant Change Minimum Data Set reference dated 9/13/25 indicated that Resident #7 had a Brief Interview for Mental Status score of 5 out of 10, suggesting severe cognitive impairment.A review of Resident #7's physician's order sheet revealed an order dated 10/28/25 to always keep the urine collection bag below the level of the bladder.On 11/5/25 at 12:33 PM Staff A, LPN stated: the urinary drainage collection bag should be placed in the dignity bag and hooked on the bed frame to help urine flow to prevent urine from going back into the bladder which can contribute to a Urinary Tract Infection (UTI). During care it is okay to leave the drainage bag on the bed because I wanted to prevent any trauma .That positioning could cause reflux due to the kinking; I am supposed to clean the port with an alcohol pad before and after draining the urine to prevent infection.On 11/05/25 at 12:03 PM, the Infection Control Preventionist revealed staff must ensure the urinary drainage bag does not touch the floor and must hang by gravity to maintain a good flow and prevent stasis, which can contribute to UTI due to backflow of urine. When emptying the urine bag, the exit port should be cleaned with soap and water before and after to prevent infection.During an interview on 11/05/25 at 12:51 PM, the Director of Nursing (DON) stated that the bag should remain below the level of the bladder to prevent urine reflux, which can cause a UTI. The staff left the urinary drainage collection bag on the bed during hygiene care to prevent any trauma. The DON noted that there was no facility policy regarding the correct positioning of the indwelling urinary catheter drainage bag and that it is common knowledge.

Based on observation, interviews and record review the facility failed to protect Resident #1's right to be free from Neglect by the facility's staff. Certified Nursing Assistants (CNAs), (Staff A) and (Staff B) failed to safely transfer Resident #1 from her bed to the chair with a Mechanical Lift. The facility neglected to effectively inspect and operate the Mechanical Lift in a safe manner during the transfer of Resident #1. This failure to operate the mechanical lift in a safe manner on [DATE] at 9:57 AM Staff A and Staff B who reported that during the transfer the Mechanical lift kept rising and when Staff B grabbed the lift pad to stop it from going higher Resident #1 suddenly fell from the Mechanical lift and landed face down on the floor sustaining injuries to her head. Resident #1 expired at the hospital approximately four hours later. There were 60 residents residing in the facility that required use of a mechanical lift for transfer. Refer to F 689, F 867, and F 908. The findings included: Review of the facility policy and procedures titled Abuse, Neglect, Exploitation, Mistreatment and Injury of Unknown Injury revision date [DATE] states: It is the policy of the facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. During a focused tour on [DATE] starting at 8:50 AM on the 2nd and 3rd floor units; there were 4 mechanical lifts on the 2nd floor unit and 4 mechanical lifts on the 3rd floor unit. The most recent inspection stickers were dated [DATE], [DATE], [DATE] (Photos available) Review of the Mechanical Lift Preventative Maintenance Log documented the lifts were inspected for safety and functioning by maintenance staff on [DATE] and [DATE]. The lifts were inspected after the incident on [DATE]. and on [DATE] the medical equipment company inspected the mechanical lifts. Review of the Mechanical Lift training/Competency revealed Certified Nursing Assistant (Staff A) completed training on [DATE], [DATE] and [DATE]. Staff B completed training on [DATE], [DATE] and [DATE]. All other nursing staff completed training on [DATE]-[DATE], [DATE]-[DATE] and [DATE]-[DATE]. Review of the Abuse, Neglect and Exploitation In-serviced revealed the most recent training for all staff at the facility was completed [DATE]-[DATE]. Review of the medical records for Resident # 1 revealed the resident was admitted to the facility on [DATE], readmitted on [DATE]. Clinical diagnoses included but not limited to: Chronic Obstructive Pulmonary Disease (COPD), Chronic, and Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #1 was discharged on [DATE]. Review of the Physician's Orders Sheet for [DATE] revealed Resident #1 had orders that included but not limited to: order dated [DATE]: Transfer to [local hospital], Diagnosis: Fall/head trauma, order dated [DATE]- Recommend use of mechanical lift with nursing as needed. Medications included: Singular Tablet 10 Milligram (MG) -Give 1 tablet enterally at bedtime for COPD. Prednisone tablet 10 mg-give 1 tablet enterally one time a day related to COPD. Xanax Oral Tablet 0.5 MG -Give 1 tablet enterally one time a day related to anxiety disorder. Record review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented the Brief Interview for Mental Status Score was unable to determine. Section E for Behaviors documented no behaviors exhibited. Section GG for Functional Abilities documented resident had Impairment on both sides of upper and lower extremities, dependent for transfer from chair to bed. Section K for Nutritional Status documented the resident weighed 100 pounds and is 60 inches in length, no unknown weight loss/gain. Section J for Health Conditions documented no shortness of breath, no falls since admission or readmission. Section N for Medications documented the resident was taking antianxiety medications. Section O for Special Treatments documented the resident was on oxygen therapy. Section P for Restraints documented the resident did not used any physical restraints or alarms. Record review of Resident # 1's Care Plans Dated [DATE] revealed: Resident#1 has a self-care deficit and needs staff assistance to perform and complete Activities of Daily Living (ADL's) secondary to: impaired mobility and dementia. Resident requires total assistance with all ADL functions. Interventions Included: mattress with bilateral side rail as recommended by manufacture. Recommend use of mechanical lift with nursing, bed to chair transfer as needed. Splint/Brace Bilateral hand rolls on at all times, may be remove for skin check and range of motion. Adaptive devices - Hip abductor brace/wheel on after morning care, off at nighttime. Observe for decline from current function and report if identified. Praise all attempts to complete tasks no matter how small. Review of the Director of Nursing (DON) incident note on [DATE] timestamped 09:57 documented: Called to resident's room by assigned CNA upon entering the room the resident was observed on the floor lying next to bed and mechanical lift machine behind her, on assessment resident observed with an open area to nose bridge and with a split to upper left area of lips and bleeding from her mouth profusely. Pressure and ice applied; no other physical injuries were noted at this time. The resident was transferred back to bed with assist of 3 staff members, Head of bed elevated, head turned to the side to allow blood to run out freely. Blood pressure ,d+[DATE], heart rate 72, respirations 20, temperature 98.1, oxygen saturation 97% on nasal cannula. Neurological checks initiated. When asked what happened the CNA's stated while transferring the resident from the bed to the Geri chair with the use of a mechanical lifter with the assistance of two staff members, the machine went up abruptly too quick, the resident shift causing the machine to tilt and the resident slide out, unable to catch the resident on time she fell and her head hit the floor, nursing staff were called to the room immediately Nurse Practitioner was made aware of the resident clinical condition, order received to send the resident to the Hospital via 911, Diagnosis: Fall. 9:59 AM, 911 was called report given, nursing staff and respiratory team remains at the resident's bedside for close monitoring; 10:26 AM 911 arrived with three (3) personnel and took over however was not able to take resident to the hospital because their transportation broke down and they had to call for backup transportation. 10:46 AM the resident transferred to the Hospital accompanied by six (6) 911 attendants. Call placed to the hospital report given to emergency room nurse. Review of the nursing progress notes for Resident #1 dated [DATE] timestamped 14:00 documented: Call placed to the Hospital to check on the resident. Spoke with the emergency room nurse who stated that the resident had expired. Review of the Agency for Healthcare Administration (AHCA) immediate and five-day report revealed the reports were submitted timely. Date/Time of Incident: [DATE] 11:00 AM; Type of Incident: Neglect; Description of Incident: On [DATE] at 11:00 AM [Investigator from local community-based agency] came to the facility and met with the Administrator and DON regarding an allegation of neglect from an unknown caller received stating Resident #1 was raised six (6) feet high in the lifter then fell and hit her head and was transferred to the hospital where she expired. A comprehensive investigation was conducted which included medical record review, safety inspection of the mechanical lift, and staff interviews. On [DATE] at approximately 8:30 AM, a Detective from the local Police Department Criminal Investigations Division met with the Administrator and stated the medical examiner determined the cause of [Resident #1's] death was blunt force trauma due to an accident. Upon conclusion of the investigations, it appeared that during the transfer with the mechanical lift CNA, [Staff A], while trying to move the foot of the machine may have inadvertently pushed the remote with her body causing the lift to extend resulting in CNA [Staff B], reaching out to hold the lifter pad in attempt to keep the resident safe which caused the pad to tilt resulting in the resident accidentally falling from the lift. Our investigation concluded the neglect was unsubstantiated. facility's protocol was followed for mechanical transfer. Review of the adverse incident report revealed the report was submitted timely on [DATE]. The adverse report concluded CNA [Staff A] may have inadvertently push the remote with her body as she was moving the lift, which cause the lift to continue to rise in the air prompting CNA [ Staff B] to grab onto the resident's lift pad causing the resident to fall. Interview on [DATE] at 12:58 PM the Maintenance Director stated: Currently there are nine (9) Mechanical lifts in the facility, we had 3 lifts on each floor (2nd and 3rd floor) for a total of 6, 1 in the maintenance area (Lift #846) that was involved in the incident with the resident and 2 new mechanical lifts that are now on the floor, one additional mechanical lift on each floor, for a total of 9. The most recent inspection for all the mechanical lifts started on [DATE] to [DATE]. The inspection date posted on the lifts are [DATE]. Prior inspections of the lifts were completed on [DATE] and [DATE].(medical equipment representative completed inspections after incident on [DATE]) On [DATE] at 11: 00 AM the Maintenance Director stated he started at the facility in mid-[DATE], he received training on [DATE] on the mechanical lifts from the representative from the medical equipment company, the training was about how to inspect the parts on the mechanical lifts to make sure they are in working order, all parts are clean and well maintained, this is to be completed monthly. If a part is broken or not working correctly on the mechanical lifts, they are not repaired they are replaced. What we do is we take the mechanical lift that is not functioning correctly off of the floor, order the needed part or parts, replace the part when received, inspect the mechanical lift for proper functioning and then we put the lift back on the floor for use. [Company Names] are the manufacturers of the 9 lifts that we have at the facility, currently they are all working/functioning correctly. Lift #846 (the mechanical lift involved in the incident with the resident) is not on the floor at this time, we have the lift stored in the maintenance area as instructed by the management. This Surveyor verified lift #846 is in working order and stored in maintenance room though observation and staff demonstration of the lift operating correctly. Interview on [DATE] at 11:07 AM the Medical Equipment Company Representative stated: I have been selling medical supplies and equipment for thirty (30) years, the medical equipment company is my company, I am a licensed Durable Medical Equipment company (DME) licensed and regulated by AHCA. Any equipment we sell to the facilities, we make sure we familiarize ourselves with the manuals and operating instruction. For mechanical lifts, manufacturers usually suggest preventative maintenance which may include cleaning lifts, detecting wear and damage monthly, lubricating the lift, and performing regular maintenance. The facility is currently checking the lifts monthly and my company oversees the facility's maintenance program. Approximately every six (6) months, during the monthly maintenance, and at any time if there is an issue with the lifts. If there is an issue with a mechanical lift, the maintenance team calls my company and order the parts needed for the repair and use the company personnel if needed for additional instructions on replacing the mechanical lifts parts. The parts on the mechanical lifts are never repaired they are always replaced if they are not functioning correctly. When I came to the facility on [DATE] I completed a visual inspection of all the mechanical lifts at the facility, I ran the lifts through their paces (extended the arm to its maximum height and depth), the mechanical lifts at the facility are electrical, they either work or they do not work, there is no in-between. The only parts that can truly malfunction is the remote-control button not working, or the lever that moves the lift up and down (actuator) stops moving. The levers and the remote controls on the mechanical lifts are the additional areas I checked on [DATE]. The operating instructions are the same for all three of the manufacturers of the mechanical lifts the facility has in stock and are currently using. I am a provider for all types of medical equipment, mechanical lifts, electrical beds, etc. When I train the facility staff, I ask them to put the mechanical lifts through its paces-make sure that all functioning parameters are working correctly-lifts opens and closes, goes up and down, brakes on the wheels locks and unlocks correctly etc. The evaluation of the training is on a pass or fail scale. The training I provide to the maintenance staff is completed/conducted in a very relaxed atmosphere and is very hands on, with live inspections and questions and answers in real time that must be answered and understanding verbalized before we move on to another area of the training. For example, for the mechanical lifts- the wheels (Caster Base) the training would be to visually inspect there are no missing wheels, casters, no debris, casters are attached correctly smooth, swivel and roll. The boom (Overhead bar) and mast (main pole)-visual inspections-Check the hardware and hangings for wear, make sure the boom is centered. Hanger bar-check the hooks, check the connection to the boom. Actuator assembly (motor)-inspect the hardware connected to the other parts of the machine, check for wear and deterioration (any loose parts). Lastly put the mechanical through its paces (up and down to its maximum level using the remote control) to ensure the lift is fully functional. As a vendor for all the medical equipment it is my job to be familiar with all the manufacturer manuals and pass on the information about the equipment to the facilities I work with, obviously the facility develops their own standards and policies and procedures for their staff to follow. Interview on [DATE] at 1:28 PM CNA, Staff B, (7:00 AM to 3:00 PM shift), 3rd floor stated I was one of the CNAs involved in the incident with the resident. I have been working here for over [AGE] years, I do this work because I love this work. On that particular morning after the resident received morning care I called the other CNA, [Staff A] for assistance with the transfer of the resident using the mechanical lift, we did our color code for the hook up of the lift pad and used a medium lift pad, upon hooking the pad to the lift [Staff A] came to the side where I was after hooking up the pad to the lift, myself and Staff A elevate the mechanical lift over the bed a little bit, checked the lift pad to make sure it was secure by pulling on it, [Staff A] pulled the lift out from over the bed a little bit then opened the legs of the lift for balance, [Staff A] held on to the lift and I held on to the lift pad on the side while [Staff A] continued to pull the mechanical lift out from over the bed at a safe height, the lift started to go up in the air, I held unto the pad on the side tighter, the pad tilted away from me to the opposite side with the resident inside and the resident fell out of the lift pad onto the floor at the side of the bed. I ran to call the nurse while [Staff A] stayed with the resident. I saw blood on the floor, the resident was bleeding from somewhere on the head, I just saw blood. The Licensed Practical Nurse (LPN), [Staff C] came and started her assessment on the resident and stated she needed help to get the resident into the bed. Myself [Staff A] and LPN, [Staff C] picked the resident up together and placed the resident in bed. At that time several nurses came into the room to help with the resident, and I went out of the room. On [DATE] the same day I received an in-service and several times after, the most recent was this morning on the mechanical lifts-operation, safety, how to use-what size lift pad the resident requires, get the correct size pad, make sure the mechanical lift is functioning correctly-check to make sure the battery is charged, use the remote control to make sure the lift goes up and down, emergency button is working-turn the lever and the weight of the resident will lower the lift on one machine, on the other machine pull up the emergency button and the lift is lowered back down with the resident. Since the incidents I have had several random observations completed by nurses and the charge nurses to make sure I am doing my transfers correctly. The feedback I have received so far, is that I am doing my transfers correctly. Interview on [DATE] at 2:15 PM CNA, Staff A (7:00 AM to 3:00 PM shift), 3rd floor stated: I have been working at this facility for two years. I was one of the CNAs involved in the incident with the resident. On [DATE] in the morning I was called by CNA [Staff B] to assist her with a mechanical lift transfer for [Resident #1], I went to the room, she had already checked the lift pad and the lift, I was operating the lift, while CNA [Staff B] was tending to the resident, I press the remote to start lifting the resident up from the bed, I started to move the resident towards the Geri chair in the lift, I started to pull the machine towards me and I may have accidentally press on the remote control, I was moving the machine towards me to turn and I did not notice the lift was going up, CNA [Staff B] grabbed the resident and the lift pad, I never saw the resident falling out of the lift pad, I noticed the resident on the floor, there was blood on the floor and on the resident's head on the side and her nose was bleeding. CNA [Staff B] went out of the room to call the nurse for assistance, I stayed in the room. LPN [Staff C] came to the room and assessed the resident, all three of us work together to put the resident back in bed. At that time several staff came into the room to help, and I left the room. I have been observed completing transfers with other staff by the Director of Nursing (DON), Assistant Director of Nursing (ADON) and several other nurses. Also, I have been retrained several times since the incident about the mechanical lift. mechanical lifts-operation, safety, how to use-what size lift pad the resident requires, get the correct size pad, make sure the mechanical lift is functioning correctly-check to make sure the battery is charged, use the remote control to make sure the lift goes up and down, emergency button is working-turn the lever and the weight of the resident will lower the lift on one machine, on the other machine pull up the emergency button and the lift is lowered back down with the resident. Interview on [DATE] at 2:30 PM LPN Staff C, stated: I was the nurse that the CNAs [Staff B] came and got to check on the resident, I went into the room, the resident was lying on the floor, there was blood on her face and head, I turned the resident on the side on the floor, I grabbed a sheet and with the help of the other two CNAs [Staff A and Staff B] we placed the resident into the bed. I activated the rescue team-call for additional help, the assigned nurse for the resident came in the room, I called 911, other nurses were in the room helping with the assessment/care of the resident, another nurse called the physician, orders were received to transfer the resident to the hospital. I cleaned the resident's face, the blood was coming from a laceration on the nose and left upper lip, gauze was placed and pressure applied to help stop the bleeding, the resident's head was elevated in the bed, the respiratory therapist applied oxygen to the resident via non-rebreather bag, the resident had an order for continuous oxygen via nasal cannula and an enteral tube. I left the room when the rapid response team came in the room to get the paperwork ready for the resident's transfer. Rescue arrived, and started working on the resident, trying to put an IV (Intravenous line) on the resident, I'm not sure why, they stayed in the room for about 15 to 20 minutes with the resident before transporting the resident out of the facility. An additional rescue team showed up with the gurney for transport and took the resident out of the facility. At the time of the transport, the resident was alive and being taken care of by the rescue team. The same day [DATE] I received in-service on mechanical lift-safety, how to use, make sure battery is charge, we have electric and battery-operated mechanical lifts, make sure the base of legs are open for balance during transfer, lift pad is in good conditions, check the wheels that they can lock and unlock, how and when to use the emergency button to stabilize and lower the lift, do not grab onto the resident. The DON, and the lift technician provided the in-services, and I have received several in-services since the incident. After the incident I was observed by the ADON and nurse manager during a transfer of a resident with a CNA, it has to be two people for lift transfers at all times. The Kardex task list have the information on what size mechanical lift pad to use for transfer for the resident, the lift pads range from small to extra-large. The lift pads are in the laundry department in the morning, once the residents are in bed at night, the lift pads are taken to the laundry to be washed. In the back of the pad the size is written on it and there is a color code circle for each size. Interview on [DATE] at 7:22 AM the Administrator (NHA) stated: I have been working at this facility for 3 weeks, this incident occurred on my second day of work at the facility. The DON alerted me that an incident has taken place with the resident, I went to the room, the resident was on the bed, they were several nursing staff in the room providing care while waiting for 911 rescue to arrive, the rescue truck broke down in front of the facility, so they had to call for another rescue to arrive. It took approx. 20 minutes for the second rescue to arrive, the resident left the facility alive, she was bleeding from the laceration on her lip. I did a follow up call to the resident's daughter after learning about the resident's death at the hospital and I called the resident's daughter with the DON present after the resident left the facility. I called maintenance to inspect the lift involved, Interviewed the two CNAs involved, and started a root cause analysis report about the incident. The next day the medical equipment vendor came to the facility and conducted training and competencies with maintenance staff and some nurses and CNAs and inspected all the Mechanical lifts to make sure they were functioning correctly. We completed mechanical lift competencies with the two CNAs involved in the incident and then continued with the other nursing staff. During an interview on [DATE] at 7:41 PM, with the ADON, DON/QAPI/Risk Manager; the DON stated that on [DATE] in the morning at around 9:55 AM, we got a call from the nurse manger to come to the 3rd floor, I went to the resident's room, I saw the resident in the bed receiving care from staff, they were trying to stop the bleeding from the nose and the mouth, the Mechanical lift was in the room on the side of the bed, I asked the staff what happened, everyone was busy working on the resident. CNAs [Staff B] explained to me she and another CNA [Staff A] were transferring the resident from the bed to the Geri-chair, she was guiding the resident and CNA [Staff A] was operating the lift. She noticed the lift started moving upwards and she grabbed onto the lift pad, the resident flipped out of the lift pad and fell to the floor. The DON stated: The mechanical lift was extended to its highest when I went into the room and the bar that the sling hooks onto was above my head, I am 5 feet 9 inches tall. [Staff A] and [Staff B] were so devastated, and I really could not get any more information from them at that time. I made sure rescue was on the way, rescue arrived at the facility, they wanted to know what happened to the resident, we explained about the fall, they took over the care of the resident, they placed a Nonrebreather mask on the resident, they could not take the resident right away because the rescue truck broke down at the facility, about 20 minutes later another rescue team came and took the resident to the hospital, the resident's daughter was called, we informed her of what happened. At that point the resident's oxygen saturation was fluctuating and her vitals were not stable. We started to do in-services right away with the CNAs and nurses on the 3rd floor, checked the machine right away for functioning, the maintenance director did not find any issues with the machine, but we removed the lift from the floor, the same day we started training and completing competencies for nurses and CNAs on mechanical lift transfers and was able to complete all nursing staff by [DATE]. Currently we are conducting weekly random competencies on every shift for nurses and CNAs, this is being conducted by myself (DON), ADON, unit managers and supervisors. As the risk manager on [DATE] we started an investigation to see if any staff had issues with the mechanical lifts prior to that day. We interviewed the two CNAS involved, [Staff A] and [Staff B] again that day, we had them walk us through the steps of what happened to see if they were following the facility policies and protocols. We discovered the machine was not the issue and one of the CNAs [Staff B] was the one that cause the incident by the way she grabbed onto the lift pad. I filed a neglect report based on the report from [local community-based agency] on [DATE] and completed the five-day investigation and submitted the reports timely. The adverse report was submitted on [DATE] after we completed our investigation. Our investigation concluded the neglect was unsubstantiated. Facility protocol was followed for mechanical transfer. The adverse report concluded CNAs [Staff A] may have inadvertently push the remote with her body as she was moving the lift, which cause the lift to continue to rise in the air prompting CNA [Staff B] to grab onto the resident's lift pad causing the resident to fall to the floor. Our last Quality Assurance and performance Improvement (QAPI) meeting was on [DATE], usually our QAPI meeting is the last Thursday of the month, and the last meeting prior to the [DATE] meeting was on [DATE]. We discussed all of our deficiencies from the AHCA recertification survey exit date [DATE], interventions were put in place, education was provided to the resident about why sharp razors cannot be kept at the bedside, we educated and retrained nursing staff, housekeeping, rehabilitation staff and other staff that visit resident's room about when doing rounds to check for any safety issues and report it to the nurse or nurse managers if any issues are found. Education was provided to residents and their family verbally about safety issues with razors and other items brought in the facility from outside. The QAPI meeting on [DATE] we discussed noncompliance regarding repeated deficiencies. We discussed the incident that occurred with Resident#1, investigated the root cause analysis of the incident, set goals for Education and competency for the nursing staff about safely completed mechanical lift transfers without any incident, Implemented a Performance Improvement Plan (PIP)and put a system in place for reporting findings from the PIP. Review of the facility's immediate Jeopardy Removal Plan included: [DATE]-Competency/training Mechanical Lift operations completed for CNAs Staff A and Staff B [DATE]-Medical Equipment Company checked all mechanical lifts to make sure they were functioning properly; no areas of concern were reported. [DATE]-Safe Handling policy for Mechanical lifts were reviewed with DON, ADON, NHA, Unit Managers, attendees were documented on the [DATE] QAPI sign in sheet. [DATE]-Reviewed Federal reports reviewed AHCA Immediate, Five- day and Adverse Incident Report-the reports were submitted timely. [DATE]-[DATE]-Safe and Proper Handling of Mechanical lifts training/competencies-completed for all nurses and CNAs. [DATE]-Reviewed interviews for alert residents and family interviews for alert residents about safety and abuse/neglect. [DATE]-Abuse and Neglect policy reviewed and revised [DATE], revisions were implemented in the employee training section. [DATE] New Abuse Investigate Protocol checklist was implemented, DON. ADON, NHA, SSD were in- serviced on the new form. [DATE]-In service on Abuse, Neglect and Exploitation was completed for all staff at the facility. [DATE]-The sixty (60) residents requiring Mechanical lift for transfers, care plans were reviewed.

Based on observations, interviews and record review the facility's Certified Nursing Assistants (CNAs), (Staff A) and (Staff B) failed to ensure Resident #1 was safely transferred from the bed to the chair with a mechanical lift. The facility failed to effectively inspect, complete accurate safety check and maintain the mechanical lift to ensure it is safely operating during the transfer of Resident #1. This failure to ensure the mechanical lift is operating in a safe manner resulted in Resident # 1 falling from the mechanical lift on [DATE] at 9:57 AM while Certified Nursing Assistants (CNAs) Staff A and Staff B were transferring Resident #1 from bed to chair, Staff A and Staff B reported that during the transfer the mechanical lift kept rising and when Staff B grabbed the lift pad to stop it from going higher, Resident #1 suddenly fell from the lift and landed face down on the floor sustaining injuries to the head. Resident # 1 expired at the hospital approximately four (4) hours after the fall. There were 60 residents residing in the facility that required use of a mechanical lift for transfer. Refer to F 600, F 867, and F 908. The findings included: Review of the facility policy and procedures titled Safe Resident Handling Transfers revision date ,d+[DATE] states: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and policies. Compliance guidelines: 3. Mechanical lifting equipment or other approved transferring aids will be used based on the residents' needs to prevent manual lifting except in medical emergencies. 4. Mechanical lifts may include equipment such as full body lifts, sit to stand lifts, or ceiling track mounted lifts. 6. The staff will inspect the equipment prior to use to ensure functionality and will alert maintenance or other designee if the equipment is not functioning properly. 7. Damaged, broken, or improperly functioning lift equipment will not be used and tagged out according to facility policy. 8. The facility will ensure there are appropriately amounts of varying sizes of slings to accommodate residents and that residents will be measured correctly as per manufacturer's instructions on proper sling size. 9. Ensure that the sling designed for the lift is utilized with that specific lift. 10. Two staff members must be utilized when transferring residents with a mechanical lift 11. Staff will be educated on the use of safe handling/ transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. 12. The staff must demonstrate competency in the use of the mechanical lifts prior to use and annually with documentation of the competency placed in their education file. 14. Resident lifting and transferring will be performed according to the resident/s individual care plan. Review of the facility policy and procedures titled Accidents and Incidents dated [DATE] states: It is the policy of the facility to report accidents and incidents in accordance to state and federal regulations. Procedure: 1. The facility will ensure that: a. The resident environment remains as free from accident hazards as is possible; and b. Each resident receives adequate supervision and assistance devices to prevent accidents. 2. The facility will provide an environment that is free from accidents hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes: a. Identify hazard (s) and risk(s). b. Evaluating and analyzing hazard(s) and risk(s). c. Implementing interventions to reduce hazard(s) and risk(s); and d. Monitoring for the effectiveness and modifying interventions when necessary. On [DATE] during a focused tour starting at 8:50 AM on the 2nd and 3rd floor units, revealed four mechanical lifts on the 2nd floor unit and four mechanical lifts on the 3rd floor unit with inspection stickers dated [DATE], [DATE], [DATE] (Photos available) Review of the Mechanical Lift preventative maintenance log documented the lifts were inspected for safety and functioning by maintenance staff prior to [DATE] on [DATE]. The lifts were inspected after [DATE] on [DATE] and [DATE]. Review of the Mechanical Lift training/Competency revealed Certified Nursing Assistant (Staff A) completed training on [DATE], [DATE] and [DATE]. Staff B completed training on [DATE], [DATE] and [DATE]. All other nursing staff completed training on [DATE]-[DATE], [DATE]-[DATE] and [DATE]-[DATE]. Review of the Agency for Healthcare Administration (AHCA) immediate and five-day report revealed the reports were submitted timely. Date/Time of Incident: [DATE] 11:00 AM; Type of Incident: Neglect; Description of Incident: On [DATE] at 11:00am, a [community-based agency investigator] came to the facility and met with the Administrator and DON regarding an allegation of neglect from an unknown caller received stating [Resident #1] was raised six (6) feet high in the lifter then fell and hit her head and was transferred to the hospital where she expired. A comprehensive investigation was conducted which included medical record review, safety inspection of the mechanical lift, and staff interviews. On [DATE] at approximately 8:30 AM a Detective from the local Police Department Criminal Investigations Division met with the Administrator and stated the medical examiner determined the cause of [Resident #1's] death was blunt force trauma due to an accident. Upon conclusion of the investigations, it appeared that during the transfer with the mechanical lift CNA, Staff A, while trying to move the foot of the machine may have inadvertently pushed the remote with her body causing the lift to extend resulting in CNA, [Staff B], reached out to hold the lifter pad in attempt to keep the resident safe which caused the pad to tilt resulting in the resident accidentally falling from the lift. Our investigation concluded the neglect was unsubstantiated; the facility's protocol was followed for mechanical transfer. Review of the adverse incident report revealed the report was submitted timely on [DATE]. The adverse report concluded CNAs [Staff A] may have inadvertently push the remote with her body as she was moving the lift, which cause the lift to continue to rise in the air prompting CNA [Staff B] to grab onto the resident's lift pad causing the resident to fall. Review of the medical records for Resident # 1 revealed the resident was admitted to the facility on [DATE], readmitted on [DATE]. Clinical diagnoses included but not limited to: Chronic Obstructive Pulmonary Disease (COPD), Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #1 was discharged on [DATE]. Review of the Physician's Orders Sheet for [DATE] revealed Resident #1 had orders that included but not limited to: order dated [DATE]- Transfer to [ local hospital], Diagnosis: Fall/head trauma, order dated [DATE]- Recommend use of mechanical lift with nursing as needed. Medications included: Singulair Tablet 10 Milligram (MG) -Give 1 tablet enterally at bedtime for COPD. Prednisone tablet 10 mg-give 1 tablet enterally one time a day related to COPD. Xanax Oral Tablet 0.5 MG -Give 1 tablet enterally one time a day related to anxiety disorder, Record review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented the Brief Interview for Mental Status Score was unable to determine. Section E for Behaviors documented no behaviors exhibited. Section GG for Functional Abilities documented resident had Impairment on both sides of upper and lower extremities, dependent for transfer from chair to bed. Section K for Nutritional Status documented resident weighed 100 pounds and is 60 inches in length, no unknown weight loss/gain. Section J for Health Conditions documented no shortness of breath, no falls since admission or readmission. Section N for Medications documented the resident was taking antianxiety medications. Section O for Special Treatments documented the resident was on oxygen therapy. Section P for Restraints documented the resident did not used any physical restraints or alarms. Record review of Resident #1's Care Plans dated [DATE] revealed: Resident#1 has a self-care deficit and needs staff assistance to perform and complete Activities of Daily Living (ADL's) secondary to: impaired mobility and dementia. Resident requires total assistance with all ADL functions. Interventions Included: Mattress with bilateral side rail as recommended by manufacture. Recommend use of mechanical lift with nursing, bed to chair transfer as needed. Splint/Brace Bilateral hand rolls on at all times, may be remove for skin check and range of motion. Adaptive devices - Hip abductor brace/wheel on after morning care, off at nighttime. Observe for decline from current function and report if identified. Praise all attempts to complete tasks no matter how small. Review of the Director of Nursing (DON) incident note on [DATE] timestamped 09:57 documented: Called to resident's room by assigned CNA upon entering the room the resident was observed on the floor lying next to bed and mechanical lift machine behind her, on assessment resident observed with an open area to nose bridge and with a split to upper left area of lips and bleeding from her mouth profusely. Pressure and ice applied; no other physical injuries were noted at this time. The resident was transferred back to bed with assist of 3 staff members, Head of bed elevated, head turned to the side to allow blood to run out freely. Blood pressure ,d+[DATE], heart rate 72, respirations 20, temperature 98.1, oxygen saturation 97% on nasal cannula. neurological checks initiated. When asked what happened the CNA's stated while transferring the resident from the bed to the chair with the use of a mechanical lifter with the assistance of two staff members, the machine went up abruptly too quick, the resident shift causing the machine to tilt and the resident slide out, unable to catch the resident on time she fell and her head hit the floor, nursing staff were called to the room immediately. Nurse Practitioner was made aware of the resident clinical condition, order received to send the resident to the hospital via 911, Diagnosis: Fall. 9:59 AM, 911 was called report given, nursing staff and respiratory team remains at the resident's bedside for close monitoring, 10:26 AM 911 arrived with three (3) personal and took over however was not able to take resident to the hospital because their transportation broke down and they had to call for backup transportation. 10.46 AM the resident transferred to the hospital accompanied by six (local emergency rescue) attendants. Call placed to the hospital report given to emergency room nurse. Review of the nursing progress notes for Resident #1 dated [DATE] timestamped 14:00 documented: Call placed to the hospital to check on the resident. Spoke with the emergency room nurse who stated that the resident had expired. Interview on [DATE] at 12:58 PM the Maintenance Director stated: Currently there are nine Mechanical lifts in the facility, we had three lifts on each floor (2nd and 3rd floor) for a total of six; one in the maintenance area (Lift #846) that was involved in the incident with the resident and two new mechanical lifts that are now on the floor, one additional mechanical lift on each floor, for a total of nine The most recent inspection for all the mechanical lifts started [DATE] to [DATE]. The inspection date we posted on the lifts are [DATE]. Prior inspections of the lifts were completed on [DATE]. (the medical equipment company did a visual inspection) Interview on [DATE] at 11:00; the AM the Maintenance Director stated he started at the facility in mid-[DATE], he received training on [DATE] on the mechanical lifts from the representative from medical equipment company, the training was about how to inspect the parts on the mechanical lifts to make sure they are in working order, all parts are clean and well maintained, this is to be completed monthly. If a part is broken or not working correctly on the mechanical lifts, they are not repaired they are replaced. We take the mechanical lift that is not functioning correctly off of the floor, order the needed part or parts, replace the part when received, inspect the mechanical lift for proper functioning and then we put the lift back on the floor for use. [Company name] are the manufacturers of the nine lifts that we have at the facility, currently they are all working/functioning correctly. Lift #846 (the mechanical lift involved in the incident with the resident) is not on the floor at this time, we have the lift stored in the maintenance area as instructed by management. This surveyor verified lift #846 is in working order and stored in maintenance room though observation and staff demonstration of the lift operating correctly. Interview on [DATE] at 11:07 AM the medical equipment company representative stated: I have been selling medical supplies and equipment for thirty (30) years, the medical equipment company is my company, I am a licensed Durable Medical Equipment company (DME) licensed and regulated by AHCA. Any equipment we sell to the facilities, we make sure we familiarize ourselves with the manuals and operating instruction. For mechanical lifts, manufacturers usually suggest preventative maintenance which may include cleaning lifts, detecting wear and damage monthly, lubricating the lift, and performing regular maintenance. The facility is currently checking the lifts monthly and my company oversees the facility's maintenance program. Approximately every six (6) months, during the monthly maintenance, and at any time if there is an issue with the lifts. If there is an issue with a mechanical lift, the maintenance team calls my company and order the parts needed for the repair and use the company personnel if needed for additional instructions on replacing the mechanical lifts parts. The parts on the mechanical lifts are never repaired they are always replaced if they are not functioning correctly. When I came to the facility on [DATE], I completed a visual inspection of all the mechanical lifts at the facility, I ran the lifts through their paces (extended the arm to its maximum height and depth), the mechanical lifts at the facility are electrical, they either work or they do not work, there is no in-between. The only parts that can truly malfunction is the remote-control button not working, or the lever that moves the lift up and down (actuator) stops moving. The levers and the remote controls on the mechanical lifts are the additional areas I checked on [DATE]. The operating instructions are the same for all three of the manufacturers of the mechanical lifts the facility has in stock and are currently using. I am a provider for all types of medical equipment, mechanical lifts, electrical beds, etc. When I train the facility staff, I ask them to put the mechanical lifts through its paces-make sure that all functioning parameters are working correctly-lifts opens and closes, goes up and down, brakes on the wheels locks and unlocks correctly etc. The evaluation of the training is on a pass or fail scale. The training I provide to the maintenance staff is completed/conducted in a very relaxed atmosphere and is very hands on, with live inspections and questions and answers in real time that must be answered and understanding verbalized before we move on to another area of the training. For example, for the mechanical lifts- the wheels (Caster Base) the training would be to visually inspect there are no missing wheels, casters, no debris, casters are attached correctly smooth, swivel and roll. The boom (Overhead bar) and mast (main pole)-visual inspections-check the hardware and hangings for wear, make sure the boom is centered. Hanger bar-check the hooks, check the connection to the boom. Actuator assembly (motor)-inspect the hardware connected to the other parts of the machine, check for wear and deterioration (any loose parts). Lastly put the mechanical through its paces (up and down to its maximum level using the remote control) to ensure the lift is fully functional. As a vendor for all the medical equipment it is my job to be familiar with all the manufacturer manuals and pass on the information about the equipment to the facilities I work with, obviously the facility develops their own standards and policies and procedures for their staff to follow. Interview on [DATE] at 1:28 PM CNA, Staff B, 7:00 AM to 3:00 PM shift, 3rd floor stated: I was one of the CNAs involved in the incident with the resident. I have been working here for over [AGE] years, I do this work because I love this work. On that particular morning after the resident received morning care I called the other CNA, [Staff A] for assistance with the transfer of the resident using the mechanical lift, we did our color code for the hook up of the lift pad and used a medium lift pad, upon hooking the pad to the lift [Staff A ] came to the side where I was after hooking up the pad to the lift, myself and [Staff A] elevate the mechanical lift over the bed a little bit, checked the lift pad to make sure it was secure by pulling on it, [Staff A] pulled the lift out from over the bed a little bit then opened the legs of the lift for balance, [Staff A ] held on to the lift and I held on to the lift pad on the side while [Staff A ] continued to pull the mechanical lift out from over the bed at a safe height, the lift started to go up in the air, I held unto the pad on the side tighter, the pad tilted away from me to the opposite side with the resident inside and the resident fell out of the lift pad onto the floor at the side of the bed. I ran to call the nurse while [Staff A] stayed with the resident. I saw blood on the floor, the resident was bleeding from somewhere on the head, I just saw blood. The Licensed Practical Nurse (LPN), [Staff C] came and started her assessment on the resident and stated she needed help to get the resident into the bed. Myself, [Staff A] and LPN, [Staff C] picked the resident up together and placed the resident in bed. At that time several nurses came into the room to help with the resident, and I went out of the room. On [DATE] the same day I received an in-service and several times after, the most recent was this morning on the mechanical lifts-operation, safety, how to use-what size lift pad the resident requires, get the correct size pad, make sure the mechanical lift is functioning correctly-check to make sure the battery is charged, use the remote control to make sure the lift goes up and down, emergency button is working-turn the lever and the weight of the resident will lower the lift on one machine, on the other machine pull up the emergency button and the lift is lowered back down with the resident. Since the incidents I have had several random observations completed by nurses and the charge nurses to make sure I am doing my transfers correctly. The feedback I have received so far, is that I am doing my transfers correctly. Interview on [DATE] at 2:15PM CNA, [Staff A] 7:00 AM to 3:00 PM shift, 3rd floor stated: I have been working at this facility for two years. I was one of the CNAs involved in the incident with the resident. On [DATE] in the morning I was called by CNA [Staff B] to assist her with a mechanical lift transfer for [Resident #1], I went to the room, she had already checked the lift pad and the lift, I was operating the lift, while CNA [Staff B] was tending to the resident, I press the remote to start lifting the resident up from the bed, I started to move the resident towards the Geri chair in the lift, I started to pull the machine towards me and I may have accidentally press on the remote control, I was moving the machine towards me to turn and I did not notice the lift was going up, CNA [Staff B] grabbed the resident and the lift pad, I never saw the resident falling out of the lift pad, I noticed the resident on the floor, there was blood on the floor and on the resident's head on the side and her nose was bleeding. CNA [Staff B] went out of the room to call the nurse for assistance, I stayed in the room. LPN [Staff C] came to the room and assessed the resident, all three of us work together to put the resident back in bed. At that time several staff came into the room to help, and I left the room. I have been observed completing transfers with other staff by the Director of Nursing (DON), Assistant Director of Nursing (ADON) and several other nurses. Also, I have been retrained several times since the incident about the mechanical lift. mechanical lifts-operation, safety, how to use-what size lift pad the resident requires, get the correct size pad, make sure the mechanical lift is functioning correctly-check to make sure the battery is charged, use the remote control to make sure the lift goes up and down, emergency button is working-turn the lever and the weight of the resident will lower the lift on one machine, on the other machine pull up the emergency button and the lift is lowered back down with the resident. Interview on [DATE] at 2:30PM LPN Staff C, stated: I was the nurse that the CNAs [Staff B] came and got to check on the resident, I went into the room, the resident was lying on the floor, there was blood on her face and head, I turned the resident on the side on the floor, I grabbed a sheet and with the help of the other two CNAs Staff a and [Staff B] we placed the resident into the bed. I activated the rescue team-call for additional help, the assigned nurse for the resident came in the room, I called 911, other nurses were in the room helping with the assessment/care of the resident, another nurse called the physician, orders were received to transfer the resident to the hospital. I cleaned the resident's face, the blood was coming from a laceration on the nose and left upper lip, gauze was placed and pressure applied to help stop the bleeding, the resident's head was elevated in the bed, the respiratory therapist applied oxygen to the resident via non-rebreather bag, the resident had an order for continuous oxygen via nasal cannula and an enteral tube. I left the room when the rapid response team came in the room to get the paperwork ready for the resident's transfer. Rescue arrived, and started working on the resident, trying to put an IV (intravenous line) on the resident, I'm not sure why, they stayed in the room for about 15 to 20 minutes with the resident before transporting the resident out of the facility. An additional rescue team showed up with the gurney for transport and took the resident out of the facility. At the time of the transport, the resident was alive and being taken care of by the rescue team. The same day [DATE] I received in-service on mechanical lift-safety, how to use, make sure battery is charge, we have electric and battery-operated mechanical lifts, make sure the base of legs are open for balance during transfer, lift pad is in good conditions, check the wheels that they can lock and unlock, how and when to use the emergency button to stabilize and lower the lift, do not grab onto the resident. The DON, and the lift technician provided the in-services, and I have received several in-services since the incident. After the incident I was observed by the ADON and nurse manager during a transfer of a resident with a CNAs, it has to be two people for lift transfers at all times. The Kardex task list have the information on what size mechanical lift pad to use for transfer for the resident, the lift pads range from small to extra-large. The lift pads are in the laundry department in the morning, once the residents are in bed at night, the lift pads are taken to the laundry to be washed. In the back of the pad the size is written on it and there is a color code circle for each size. Interview on [DATE] at 7:22AM Administrator (NHA) stated: I have been working at this facility for 3 weeks, this incident occurred on my second day of work at the facility. The DON alerted me that an incident has taken place with the resident, I went to the room, the resident was on the bed, they were several nursing staff in the room providing care while waiting for 911 rescue to arrive, the rescue truck broke down in front of the facility, so they had to call for another rescue to arrive. It took approximately 20 minutes for the second rescue to arrive, the resident left the facility alive, she was bleeding from the laceration on her lip. I did a follow up call to the resident's daughter after learning about the resident's death at the hospital and I called the resident's daughter with the DON present after the resident left the facility. I called maintenance to inspect the lift involved, Interviewed the two CNAs involved, and started a root cause analysis report about the incident. The next day the medical equipment vendor came to the facility and conducted training and competencies with maintenance staff and some nurses and CNAs and inspected all the mechanical lifts to make sure they were functioning correctly. We completed mechanical lift competencies with the two CNAs involved in the incident and then continued with the other nursing staff. We had a Quality Assurance and performance Improvement (QAPI) meeting to review our findings and set goals for compliance. Currently trainings and competencies are ongoing, we are conducting random observations of staff performing mechanical lift transfers with residents and we are going to continue to monitor the progress through QAPI. The staff and team are very receptive to the trainings and competencies that we have put in place. The purpose of the QAPI is having a forum where the interdisciplinary (IDT) team have an opportunity to bring issues to the team so we can rectify and implement interventions, put a plan in place, measure interventions through audits for effectiveness and revise plans and interventions as needed. Interview on [DATE] at 7:41 PM with the ADON, DON/QAPI/Risk Manager; the ADON stated I started working at the facility in [DATE]. The DON stated she has been working at the facility since 2013. On [DATE] in the morning at around 9:55AM, we got a call from the nurse manger to come to the 3rd floor, I went to the resident's room, I saw the resident in the bed receiving care from staff, they were trying to stop the bleeding from the nose and the mouth, the mechanical lift was in the room on the side of the bed, I asked the staff what happened, everyone was busy working on the resident. CNA [Staff B] explained to me she and another CNA [Staff A] were transferring the resident from the bed to the Geri-chair, she was guiding the resident and CNA [Staff A] was operating the lift. She noticed the lift started moving upwards and she grabbed onto the lift pad, the resident flipped out of the lift pad and fell to the floor. The DON stated: The mechanical lift was extended to its highest when I went into the room and the bar that the sling hooks onto was above my head, I am 5 feet 9 inches tall. Staff A and Staff B were so devastated, and I really could not get any more information from them at that time. I made sure rescue was on the way, rescue arrived at the facility, they wanted to know what happened to the resident, we explained about the fall, they took over the care of the resident, they placed a Nonrebreather mask on the resident, they could not take the resident right away because the rescue truck broke down at the facility, about 20 minutes later another rescue team came and took the resident to the hospital, the Resident's daughter was called, we informed her of what happened. At that point the resident's oxygen saturation was fluctuating and her vitals were not stable. We started to do in-services right away with the CNAs and nurses on the 3rd floor, checked the machine right away for functioning, the maintenance director did not find any issues with the machine, but we removed the lift from the floor, the same day we started training and completing competencies for nurses and CNAs on mechanical lift transfers and was able to complete all nursing staff by [DATE]. Currently we are conducting weekly random competencies on every shift for nurses and CNAs, this is being conducted by myself (DON), ADON, unit managers and supervisors. As the risk manager, on [DATE] we started an investigation to see if any staff had issues with the mechanical lifts prior to that day. We interviewed the two CNAS involved, [Staff A] and [Staff B] again that day, we had them walk us through the steps of what happened to see if they were following the facility policies and protocols. We discovered the machine was not the issue and one of the [Staff B] was the one that cause the incident by the way she grabbed onto the lift pad. I filed a neglect report based on the report from [community-based agency] on [DATE] and completed the five-day investigation and submitted the reports timely. The adverse report was submitted on [DATE] after we completed our investigation. Our investigation concluded the neglect was unsubstantiated. Facility protocol was followed for mechanical transfer. The adverse report concluded CNA [Staff A] may have inadvertently push the remote with her body as she was moving the lift, which cause the lift to continue to rise in the air prompting CNA [Staff B] to grab onto the resident's lift pad causing the resident to fall to the floor. The QAPI meeting on [DATE] we discussed noncompliance regarding repeated deficiencies. We discuss the incident that occurred with [Resident#1], investigated the root cause analysis of the incident, set goals for education and competency for the nursing staff about safely completed mechanical lift transfers without any incident, implemented a Performance Improvement Plan (PIP)and put a system in place for reporting findings from the PIP. The QAPI committee members are Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Infection Prevention, Maintenance Director, Registered Dietitian, Activities Director, Social Services Director, Admission Director, Maintenance Director, Housekeeping Director and Department Heads/Representatives. The purpose of QAPI is to identify any potential risk, trends, risk factors to patients and try to prevent it from happening by coming up with interventions and a plan to prevent and minimize any safety concerns. Interventions and plans are monitored for effectiveness though audits, in-services, and feedback from staff. The facility's immediate jeopardy removal plan included: [DATE]-Lift #846 was inspected and found to be functioning correctly, currently not being used on the floor, stored in the maintenance room (photo available with inspection dates). [DATE]-Competency/training Mechanical Lift operations completed for CNAs Staff A and Staff B. [DATE]-[DATE]-Safe and Proper Handling of mechanical lifts training/competencies-completed for all nurses and CNAs. [DATE]-ADHOC Quality Assurance and Performance Improvement (QAPI) meeting on Mechanical lift transfers completed with the QAPI team. [DATE]-Safe Handling policy for mechanical lifts were reviewed with DON, ADON, NHA, Unit Managers, attendees were documented on the [DATE] QAPI sign in sheet. [DATE]-Medical Equipment Company checked all mechanical lifts to make sure they were functioning properly; no areas of concern were reported. [DATE]-Monthly Maintenance Mechanical lift logs completed on [DATE], and [DATE] by Maintenance Director. [DATE]-Residents' Kardex audited/updated for mechanical lift pad sizes [DATE]-Mechanical sling size assessment for the 60 residents using mechanical lifts were completed by Unit Managers. [DATE]-[DATE]-Safe and Proper Handling of Mechanical lifts training/competencies-completed for all nurses and CNAs. [DATE], [DATE], [DATE]-Weekly Maintenance Mec [TRUNCATED]

Based on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F689-Free of Accident Hazards/Supervision/Devices. As evidenced by: F689 was cited during a complaint survey ending 12/14/23 when the facility failed to provide adequate supervision and additional interventions to ensure the safety of vulnerable residents and to prevent repeated falls that resulted in injuries and during the recertification survey with exit dated 08/21/24 razors were observed on Resident #382 's nightstand The findings included: Record review of the facility's survey history revealed, during a recertification conducted on July 29, 2024, through August 1, 2024, at the facility, F689-Free of Accident Hazards/Supervision/Devices was cited as the facility failed to ensure resident's room was free of accident hazards (razors at bedside) for 1 of 40 sampled residents (Resident #382). Review of the facility policy and procedures titled Quality Assurance and Performance Improvement (QAPI) dated 09/10/2021 states: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Interview on 9/19/24 at 7:22 AM the Administrator (NHA) stated: I have been working at this facility for 3 weeks, this incident occurred on my second day of work at the facility. On 8/30/24 we had a Quality Assurance and performance Improvement (QAPI) meeting to review our findings and set goals for compliance. Currently trainings and competencies are ongoing, we are conducting random observations of staff performing mechanical lift transfers with residents and we are going to continue to monitor the progress through QAPI. The staff and team are very receptive to the trainings and competencies that we have put in place. The purpose of the QAPI is having a forum where the interdisciplinary (IDT) team have an opportunity to bring issues to the team so we can rectify and implement interventions, put a plan in place, measure interventions through audits for effectiveness and revise plans and interventions as needed. Interview on 9/19/24 at 7:41 PM the Director of Nursing (DON)/QAPI revealed the last Quality Assurance and performance Improvement (QAPI) meeting was on 8/30/24, usually our QAPI meeting is the last Thursday of the month, the last meeting prior to the 8/30/24 meeting was on 8/26/24. On 08/26/24 we discussed all of our deficiencies from the AHCA recertification survey exit date 8/1/24, interventions were put in place, education was provided to the resident about why sharp razors cannot be kept at the bedside, we educated and retrained nursing staff, housekeeping, rehabilitation staff and other staff that visit resident's room about when doing rounds to check for any safety issues and report it to the nurse or nurse managers if any issues are found. Education was provided to residents and their family verbally about safety issues with razors and other items brought in the facility from outside. The QAPI meeting on 08/30/24 we discussed noncompliance regarding repeated deficiencies. We discuss the incident that occurred with Resident#1, investigated the root cause analysis of the incident, set goals for Education and competency for the nursing staff about safely completed Mechanical lift transfers without any incident, implement a Performance Improvement Plan (PIP)and put a system in place for reporting findings from the PIP. The QAPI committee members includes the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Infection Prevention, Maintenance Director, Registered Dietitian, Activities Director, Social Services Director, Admission Director, Maintenance Director, Housekeeping Director and Departments Heads/Representatives. The purpose of QAPI is to identify any potential risk, trends, risk factors to patients and try to prevent it from happening by coming up with interventions and a plan to prevent and minimize any safety concerns. Interventions and plans are monitored for effectiveness though audits, in-services, and feedback from staff.

Based on observation, interview and record review, it was determined that the facility failed to store prepare, distribute and serve food in accordance with professional standards for food service safety that potentially effects 164 of the facility residents. The findings included: 1) During the initial kitchen/food service observation tour conducted on 07/29/24 at 9:00 AM and accompanied with the facility's Food Service Director (FSD), the following were noted: (a) A large section of the ceiling (8 feet) was noted to be dripping heavily on to the floor area in front of food production table/surfaces and reach-in refrigerators (3). The floor covered in a large area of contaminated water. It was noted that staff were walking through the water and cases of recent food deliveries were also in contact with the water. The FSD stated that the dripping ceiling water was from broken air-conditioning pipes and had been an issue for the past 2 weeks. The surveyor requested that the cases of food be moved to a safe area and the floor area closed off from staff traffic. (b) Observation of the dry food/disposable goods storage area noted that soiled staff clothing and soiled freezer jackets were hung directly on clean storage shelves and in contact with clean disposable goods. The surveyor requested to the FSD to remove the clothing items from the clean storage room. (c) Observation of the walk-in refrigerator #1 noted a 10-pound commercial package of Macaroni Salad. Further observation noted that the commercial container failed to have a stamped expiration date. The surveyor requested the FSD to contact the company to determine the expiration date and provide the documentation. (d) Observation of the food preparation area noted a large electrical box (2 X 3') of which the surface was rust laden. The surveyor requested the FSD to contact the maintenance department to remove the rust from the exterior. (e) Observation of the dairy dish room area noted that racks (3) of soiled resident dishes from the breakfast meal were being stored in a clean area. The surveyor discussed with the FSD that there was potential of cross contamination form soiled dishes to clean food preparation equipment and requested the racks be moved to the soiled area of the dish room. (f) Food utility carts and food transportation carts (3) were noted to have storage shelves that were heavily soiled and areas on black mold type matter. The surveyor discussed with the FSD that the carts need to be properly cleaned and sanitized prior to continued use. (g) Numerous adaptive eating dishes (5 -3-compartment and wide lip plates) were noted to have exteriors that were heavily stained yellow and brown, The surveyor requested that the plates be discarded from continued use. (h) Observation of the walls and floors of the food production area were noted to be heavily soiled and/or had broken tiles (10). The surveyor discussed with the FSD the walls and floors were not being properly cleaned on a daily basis and that maintenance be contacted for tile repair. (i) Observation of a ceiling vent located next to the 3-compartment sink was noted to have an exterior with a heavy build-up of condensation that was dripping down onto the floor area and clean food production and preparation equipment. The FSD stated that the vent and ceiling issues been reported for weeks to the administration without repair. (2) During a second observation of the lunch meal on 07/29/24 at 11:30 AM accompanied with the FSD, the following were noted: (k) Dietary staff were noted to be handling and bagging clean resident silverware in an unsanitary manner. Specifically, a large dish rack of silver was being stored next to the food tray line. Staff were noted to be handling the clean silverware by the food contact stem resulting in potential contamination. The surveyor discussed that all silverware is to be store in containers with the stem handles in the upright position. The surveyor requested that the silverware be rewashed and sanitized and stored in the regulatory requirement. 3) During a third observation of lunch in the main kitchen and accompanied with the Food Service Director on 07/29/24 at 12:15 noted: (a) Temperatures of hot and cold foods on the tray assembly line were tested with the facility's calibrated digital thermometer. The testing revealed that hot foods were not being held at the regulatory temperature of 135 degrees F or greater and cold foods were not being held at the regulatory temperature of 41 degrees F or below: Italian Baked Chicken (30 portions) = 125 degrees F Beef Liver Platter (6 portions) = 60 degrees F Garden Pasta (10 portions) = 45 degrees F [NAME] Slaw (10 portions) = 40 degrees F Orange Juice/Cranberry Juice (30 portions) = 50 degrees F Nectar Thickened Milk (8 portions) = 50 degrees F 4) Fourth observation of the breakfast meal conducted in the main kitchen on 07/30/24 at 6:45 AM and accompanied with the Food Service Director (FSD), noted: (a) Approximately 25 pounds of bagged raw chicken was noted thawing in a large pan that in the cook's sink with running water. Further observation noted that only the hot water valve was open and running onto the raw chicken. A temperature conducted by the Food Service Director was noted to be recorded at 105 degrees F. It was immediately discussed with the FSD that the regulatory requirement is for the water to be running at 70 degrees F or below. The bagged chicken was noted to be almost defrosted and not cold to the touch. The surveyor requested to the FSD that the chicken not be utilized for the lunch meal on 07/30/24. The FSD informed the surveyor that all of the raw chicken was discarded. (b) Temperatures of hot and cold foods on the tray assembly line were tested with the facility's calibrated digital thermometer. The testing revealed that hot foods were not being held at the regulatory temperature of 135 degrees F or greater and cold foods were not being held at the regulatory temperature of 41 degrees F or below; the following was noted: Pureed Oatmeal = 120 degrees F Fortified Oatmeal = 120 degrees F Pureed Eggs = 135 degrees F Pureed Tropical Fruit Salad = 60 degrees F Mechanical Soft Tropical Salad = 60 degrees F (c) Observation of the Meat Dishwashing Room noted that the exterior of ceiling vent located in the middle of the dish washing room was noted to have a heavy accumulation of condensation. Further observation noted that the condensation was dripping down on to clean food transportation carts and clean resident dishes. The surveyor informed the FSD that there was potential for contamination and no carts or dishes should be allowed under the dripping vent and that maintenance department be contacted to resolve the issue immediately. (d) Rodent traps (4) were noted to be located throughout kitchen in food areas. During a discussion with the FSD at the time of the observation she reported to not have knowledge if there was a rodent issue. (e) Flying insects (4) were noted in food production and serving areas of the main kitchen. The surveyor requested the FSD to notify administrator to contact their pest control company for servicing. 5) During a fifth observation conducted in the main kitchen on 07/31/24 at 11:30 AM and accompanied with the Food Service Director (FSD) noted: (a) Temperatures of hot and cold foods on the tray assembly line were tested with the facility's calibrated digital thermometer. The testing revealed that hot foods were not being held at the regulatory temperature of 135 degrees F or greater and cold foods were not being held at the regulatory temperature of 41 degrees F or below, the following was noted: Tossed Salad (8 portions) = 58 degrees F (b) Pan of powdered thickener (2 pounds) failed to be documented with a date.

Based on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, orderly, and comfortable interior on the facility's first floor, second floor residential units, third floor residential units, maintenance department, and laundry area. The findings included: During the initial resident screenings conducted by the surveyors on 07/29/24 to 7/30/24 and environment rounds conducted on 07/31/24 and 08/01/24 accompanied with the facility's Director Of Housekeeping and Corporate Director of Housekeeping, the following were noted: 1) First Floor: Hallway - Ceiling mounted air -conditioning vents (4) noted to be covered with condensation and dripping onto hallway floor near skilled therapy department. Maintenance Department - During the 08/01/24 tour it was noted that the entry door to the room was proper fully open and no staff within the room and area. Noted that residents have access to hallway where the maintenance department is located, and the room was noted to be full of leaning and poisonous chemical as well as numerous sharp tools. 2) Second Floor (East & [NAME] Nursing Units) East & [NAME] Nurses Station - station floor heavily soiled and areas of dried black matter. Furniture and storage cabinets were dust laden. room [ROOM NUMBER] - The privacy curtain (A-bed) did not provide full privacy for the resident, and exterior of foot of the bed (A-bed) was in disrepair. Room # 214 - The privacy curtain (B-bed) did not provide full privacy for the resident, and rooms windows (2) covered with green type algae. room [ROOM NUMBER] - The privacy curtain (B-bed) did not provide full privacy for the resident, and offensive triune odor throughout the room. room [ROOM NUMBER] - Large black stains on the room ceiling tiles (3). room [ROOM NUMBER] - Bathroom toilet requires recaulking to the floor, bathroom paper towel dispenser to working, room windows covered with green type algae. Exterior of bathroom entry door damaged and in disrepair, resident dentures on overbed table, and resident toothbrushes and combs in sink and not in personal protective containers. room [ROOM NUMBER] - Bathroom entry door exterior damaged and in disrepair, and bathroom toilet seat loose. room [ROOM NUMBER] - Room floor was soiled and numerous black stains, and wall a/c vent soiled and molded. room [ROOM NUMBER] - Room floor was soiled, exterior of bathroom toilet was soiled, and full urinal container on room floor. room [ROOM NUMBER] - Bathroom emergency call bell wrapped around wall handrail., wall mounted air-conditioning vent leaking steadily onto to the room floor, and the privacy curtain (B-bed) did not provide full privacy for the resident. room [ROOM NUMBER] - Wall air-conditioning vent leaking and condensation steadily dripping onto the room floor. room [ROOM NUMBER] - Bathroom entry door exterior was damaged and in disrepair. room [ROOM NUMBER] - Strong urine odor throughout the room, and bathroom entry door exterior was aged and in disrepair. room [ROOM NUMBER] - Room floor soiled, room entry door exterior was damaged and in disrepair, and no pull cord to over-bed light (A-bed). room [ROOM NUMBER] - Room entry door damaged and in disrepair (sharp exposed edges. room [ROOM NUMBER] - Bathroom emergency call cord wrapped around wall handrail. East Community Shower - Stall #2 had broken wall and floor tiles (5), and privacy curtain soiled with black matter. West Community Shower Room - rusted plumbing pies coming from floor. Biohazard Room - entry door damaged and in disrepair. 3) Third Floor: room [ROOM NUMBER] - Bathroom paper towel dispenser not working and would not dispense paper towels. room [ROOM NUMBER] - Bathroom paper towel dispenser not working and would not dispense paper towels. room [ROOM NUMBER] - Privacy curtain (Bed -B) too short to promote privacy for the resident. room [ROOM NUMBER] - Privacy curtain (Bed -B) too short to promote privacy for the resident. room [ROOM NUMBER] - Privacy curtain (Bed -B) too short to promote privacy for the resident. 4) Laundry Room: During the observation tour it was noted that a Laundry Aide (Staff H) was sitting directly on a clean linen shelf drinking a beverage. The clean linen folding table was noted to have a phone charging on top of the table and along with beverage containers (3), soiled food containers (2) and staff personal items (purses). Numerous ceiling tiles (3) located in the washroom area were noted to be stained brown in color. 5) During an interview conducted with the Housekeeping Director and Corporate Housekeeping Director following 08/01/24 tour it was noted that the is a Maintenance/Housekeeping Logbook located at the 2 nurses station on the second floor and 1 on the third-floor nurses station. Staff are required to log any housekeeping/maintenance issues. The logs are to be viewed during the day by housekeeping and maintenance staff for repairs/cleaning. Further stated that staff are not documenting housekeeping/maintenance issues into the logbooks.

Based on observation, interview, and record review, it was determined that portion sizes documented on the approved menu were not followed and potentially effected 88 of the facility residents with physician ordered Regular diet. The findings included: During the observation of the lunch meal in the main kitchen on 07//31/24 at 11:45 AM, it was noted that the entree serving of roast turkey appeared insufficient. Further observation noted that all of the individual portions of Roast Turkey (approximately 40) located in steam table appeared insufficient. A review of the facility's approved menu for the lunch meal of 07/31/24 noted documentation that a minimum 3-ounce portion of Roast Turkey was to be served. A portion of the Roast Turkey that was plated to be served was selected by the surveyor to be weighed by the Food Service Director (FSD). The turkey portion weighed on the facility's calibrated food scale was recorded at 2.46 ounces. The surveyor reviewed the approved lunch menu with the FSD that indicated a requirement of 3 ounces minimum turkey portion. It was then requested that a portion scale be utilized on the tray line to ensure that the portion size of 3 ounces was being followed.

Based on observations, interview and record review the facility failed to follow facility policy for 2 out of 31 residents on Enhanced Barrier Precautions (EBP) Residents #177 and #69 as evidenced by no isolation gowns at the residents' doors and failed to ensure that food trash/soiled residents food trays are covered during transportation. The findings included: Review of the facility's policy titled, Enhanced Barrier Precautions with a revised date of 04/01/24 included in part: EBP is intended for nursing homes to prevent the spread of novel or targeted Multi-Drug Resistant Organism (MDRO)s when resident have an infection or colonization with a MDRO or if the resident has a wound or indwelling medical device, regardless of MDRO infection or colonization. Review of the Center for Disease Control (CDC) guidelines documented, in part, that for residents on EBPs that PPE (gowns and gloves) are to be located at the residents' doors. The CDC website is CDC_Implementation_Of_Personal_Protective_Equipment_(PPE _Use_In_Nursing_Homes_To_Prevent_Spread_Of_Multidrug-resistant_Organisms_(MDROs). 1) On 07/29/24 at 12:15 PM an observation was made of Resident #177 lying in bed, resident has EBP sign on door and above her bed, there were no isolation gowns in the room. On 07/29/24 at 3:50 PM a second observation was made of Resident # 177 lying in bed awake, resident has EBP sign on door and above her bed, there were no isolation gowns in the room. During an interview conducted on 07/29/24 at 3:55 PM with Staff M Registered Nurse/Unit Manager (RN/UM) in Resident #177's room, she acknowledged the resident was on EBP for a wound, when asked where the PPE is kept, specifically the gowns, she said they are right next to the inside of the door to the room and as she pointed the area next to the door, she said they must have run out. When asked where additional isolation gowns are kept, she said they are at the nursing station. When asked to show surveyor the extra isolation gowns at the nursing station, she leads the surveyor to the nursing station at the other end of the hallway where they were out of gowns and handed the surveyor off to Staff H Registered Nurse (RN) who proceeded down another hallway almost to the very end across from room [] to an unlocked storage room with the extra isolation gowns. Staff H RN said the room is normally locked. 2) On 07/29/24 at 11:50 AM an observation was made of Resident #69 lying in bed with tube feeding bottle full and not infusing, the resident has EBP sign on door and above her bed, there was no isolation gowns in the room. 3) On 07/30/24 at 9:55 AM an observation was made of an uncovered meal tray cart containing 10 dirty trays being pushed through the hallway on the 3rd floor by Staff I Dietary Aide. During an interview conducted on 07/30/24 at 10:00 AM with Staff I Dietary Aide who reported she has worked at the facility for [AGE] years. When asked if she normally pushes a meal tray with dirty trays uncovered down the hall, she said no, but someone must have thrown the cover away.

Based on observation, interview, and record review, it was determined that the facility failed to provide necessary care and services so that activities of daily living do not diminish for 1 (Resident #64) of 5 sampled resident for nutrition review for independence in self-feeding and 1 (Resident #177) of 1 sampled resident for daily dental care. The findings included: 1) Observation of the breakfast meal on 07/31/24 at 7:45 AM noted breakfast tray delivered to the room of Resident #64. Mechanical Soft tray served and set up on overbed table in front of resident. Resident not positioned and noted to be in almost a lying position in front of the meal tray. Resident noted to be attempting to feed self with hands and spilling foods on chest/gown. Resident unable to reach beverages on tray and could not drink liquids (juices, milk, coffee) provided on the meal tray. Resident noted with no supervision or assistance from staff during the entire meal observation and consumed less than 50% of the meal and 0% of fluids. Review of Resident #64's clinical records on 07/31/24 noted the following: Revealed the resident was admitted [DATE]. Diagnoses included: Sepsis (4/15/24), Acute Respiratory failure (4/15/24), Diabetes Mellitus type 2 (DM2), Dysphagia, Alzheimer's Disease and Anemia, Review of Resident # 64's Weight History noted steady weight loss: 07/24/24 = 156 pounds 05/29/24 = 159 pounds 04/13/24 = 161 pounds 04/04/24 = 169 pounds BMI (Body Mass Index) = 21.8 Height = 71 inches Review of the quarterly MDS dated [DATE] documented in section C for cognitive pattern a Brief Interview of Mental status (BIMS) score of 5 out of 15 suggests severe cognitive impairment Section D for Mood documented no mood and section GG for functional abilities documented the resident requires assistance with meals. review of Progress Note dated 7/16/24 documented a weight of 156 pounds, triggers for significant weight loss, =7.8% (13.2 pounds) BMI = 21.8 denotes health range for height. Nutritional Risk assessment dated [DATE] noted: Less (<) Supervision with Meals /Pocketing holding foods in mouth. 41837 2 Record review for Resident #177 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Encounter for Other Orthopedic Aftercare and Unspecified Dementia. Review of the Minimum Data Set for Resident #177 dated 07/20/24 revealed in Section C a Brief Interview of Mental Status score of 6 indicating severe cognitive impairment. On 07/29/24 at 12:15 PM an observation was made of Resident # 177 lying in bed sleeping with top denture out of mouth on top of bedspread, bottom denture with greenish brown on them were in clear plastic container with opaque liquid covered with a lid (Photographic Evidence Obtained). On 07/29/24 at 3:50 PM an second observation was made of Resident # 177 lying in bed awake with top denture and bottom denture (bottom denture still with greenish brown on them) were in clear plastic container with opaque liquid covered with a lid. During a side-by-side observation conducted on 07/29/24 at 3:50 PM with Staff M Registered Nurse/Unit Manager (RN/UM) who was asked about the dentures for Resident #177, she said the Certified Nurse Aides (CNA) take the dentures out at night and put them in the resident's mouth in the morning. When asked if they are cleaned, she said yes, the CNAs clean the dentures. When asked about Resident #177's dentures in the cup at the bedside, she said it might be some adhesive residue and a denture tablet that turned the adhesive green. When asked if she would wash the bottom denture, she did so in the bathroom and the greenish-brown film came off easily with a toothbrush.

Based on observations, interviews, and record reviews the facility failed to ensure resident's room free of accident hazards (razors at bedside) for 1 of 40 sampled residents (Resident #382). The findings included: Review of the facility's policy/procedure titled, Safety Awareness (Sharp Objects) dated 03/01/21 included in part: To ensure the safety and well-being of residents, staff, and visitors by regulating the possession and use of sharp objects and razors within the nursing home facility. For the safety of all individuals within the nursing home, the possession and use of sharp objects and razors by residents are strictly regulated. Sharp objects and razors pose a significant risk of injury and must be managed according to the guidelines outlined below: Definitions: Razors: Bladed instruments used for shaving or cutting hair. Guidelines: 1. Prohibited items: Residents are not permitted to possess or use sharp objects or razors independently within the nursing home. Sharp objects and razors include, but are not limited to, knives, scissors, razors (both disposable and electric), needles and other similar items. 2. Storage and Access: All sharp objects and razors must be securely stored in designated areas, accessible only to authorized staff members. Record review for Resident #382 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Sequelae of Unspecified Cerebrovascular Disease and Hemiplegia Affecting Left Nondominant Side. Review of the Minimum Data Set for Resident #382 dated 06/08/24 revealed in Section C a Brief Interview of Mental Status score of 14 indicating a cognitive response. Review of the Physician's Orders for Resident #382 revealed an order dated 05/30/24 for Clopidogrel Bisulfate (Plavix) Tablet 75 MG Give 1 tablet by mouth one time a day for blood clot prevention related to Cerebrovascular Disease. Review of the Care Plan for Resident #382 dated 06/12/24 with a focus on the resident at risk for bleeding and easy bruising related to medication regimen. The goal was for the resident to be free from signs/symptoms of bleeding through the next review date. The interventions included: Give medications as ordered. Observe closely for signs/symptoms of bleeding. Provide a safe environment On 07/29/24 at 10:17 AM an observation was made in Resident #382's room on nightstand of safety razor. (Photographic Evidence obtained). The resident was not in the room. On 07/30/24 at 9:40 AM an observation was made of Resident #382 sitting in wheelchair in room with no razor on the nightstand. During an interview conducted on 07/30/24 at 9:40 AM with Resident # 382 who was in his room and asked about a razor seen the day before on his nightstand, he said someone must have come in and took it. The resident proceeded to show the surveyor the drawers in the nightstand by opening each one, in the drawers were approximately 6 to 8 safety razors. When asked if he uses razors, he said yes almost every day. During an Interview conducted on 07/31/24 at 4:00 PM with the Director of Nursing (DON) who stated residents can only have razors to shave, and then the razors need to be disposed of immediately in sharp container. During an interview conducted on 07/30/24 at 9:00 AM with Staff J Licensed Practical Nurse (LPN) who stated she has worked at the facility for 3 years. When asked if residents can have razors at the bedside, she said residents can be provided with a razor, but it must be disposed of after use in sharps container.

Based on observations, interviews, and record review the facility failed to monitor weights and identify weight loss in a timely manner for 1 of 10 residents sampled for nutrition (Resident #162). The findings included: Review of the facility's policy titled, Weights (Nutrition) dated 03/01/21 included in part the following: It is the policy of the facility to obtain a weight on all residents at set time intervals and per resident need (daily, weekly, monthly). All residents will be weighed within 24 hours of admission or re-admission and weekly thereafter for an additional 3 weeks, for a total of 4 weeks. The dietician will determine which residents have had a significant weight change (>/= 5% loss/gain in 1 month and /or >/= 10% loss/gain in 6 months) and a clinical nutrition weight evaluation note will be written in the EMR (Electronic Medical Record). Record review for Resident #162 revealed the resident was originally admitted to the facility on [DATE] with diagnoses that included: Cerebral Atherosclerosis, Type 2 Diabetes Mellitus, Mild Protein-Calorie Malnutrition, Chronic Viral Hepatitis C, Dysphagia Oropharyngeal Phase, and Dementia. Review of the Minimum Data Set for Resident #162 dated 07/19/24 revealed in Section C a Brief Interview of Mental Status score of 99 indicating the resident was unable to complete the interview. Review of the Residents weights revealed the following: On 04/24/24 the resident weighed 175 pounds. For the week of 04/28/24 to 05/04/24 there was no weight for the resident. On 05/06/24 the resident weighed 170.4 pounds. For the week of 05/12/24 to 05/18/24 there was no weight for the resident. For the week of 05/19/24 to 05/25/24 there was no weight for the resident. On 05/30/24 the resident was transferred to the hospital. On 06/06/24 the resident was readmitted to the facility. On 06/07/24 the resident weighed 158 pounds. On 06/10/24 the resident weighed 156.6 pounds. On 06/17/24 the resident weighed 153 pounds. For the week of 06/23/24 to 06/29/24 there was no weight for the resident. For the week of 06/30/24 to 07/06/24 there was no weight for the resident. On 07/08/24 the resident weighed 140 pounds. On 07/15/24 the resident weighed 135.8 pounds. In summary this indicated the resident did not have a weekly weight for 5 weeks. This also indicated the resident had lost 18 pounds (a significant weight loss of 11.4%) from 06/07/24 to 07/08/24. Review of the Nutritional Risk Evaluations for Resident #162 revealed the resident had a Nutritional Risk Evaluation completed on 06/07/24 and 07/19/24. This indicated there was no Nutritional Risk Evaluation completed in a timely manner after resident had a significant weight loss on 07/08/24 of 11.4%. During an interview conducted on 07/31/24 at 12:00 PM with Staff D Registered Dietician (RD) revealed she has worked at the facility for 3 years. When asked about weights, she said the residents are weighed on admission, then weekly for 4 weeks, then monthly. She said if the resident is having weight loss during the weekly weights, the resident would continue on with weekly weights until the resident no longer had weight loss and the weight was stable. When asked about significant weight loss, she said a significant would be greater than 5% in 1 month (30 days), or greater than 7% in 3 months (90 days), or more than 10% in 6 months (180 days). When asked who is responsible for making sure the weights are obtained and entered int the residents EMR (Electronic Medical Record), she said she is ultimately responsible. When asked if there is any issue with obtaining the weights, she said they have a good system in place to get the weights for residents. When asked about Resident #62, she acknowledged the resident had weight loss, a significant weight loss and they had missed some of the weekly weights.

Based on observations, interviews, and record reviews the facility failed to ensure medications secured in med room for one of two med rooms observed and failed to secure medication for 3 of 40 sampled residents (Resident #136, Resident #120, and Resident #382.) The findings included: Review of the facility's policy titled, Labeling of Medications Storage of Drugs and Biologicals with an implemented date of 11/28/19 included in part: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations. 1 On 07/30/24 at 3:55 PM Staff H Registered Nurse (RN) lead surveyor to show where additional isolation gowns were kept, she entered an unlocked room containing multiple over the counter medications including Acetaminophen, zinc, aspirin, Vitamin B12, and ferrous sulfate, in an unlocked treatment cart in the unlocked medication room containing Hydrocortisone Acetate 1%, and in an adjoining room inside the unlocked medication room was another room with the door wide open and no lock on the door, with various creams, ointments and solutions for wound care. During an interview conducted on 07/30/24 at 3:55 PM with Staff H RN who acknowledged the room should be locked. The RN stated it is normally locked. The wound care nurse entered the medication room and was asked if this was her treatment cart, she said yes. When asked if it is normally left unlocked when unattended, she said no, she had been cleaning the cart at the end of her shift and went to throw out some garbage and must have forgotten to lock the cart and also forgot to make sure the medication room was locked. 2 Record review for Resident #120 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Wedge Compression Fracture of Second Thoracic Vertebra Initial Encounter for Closed Fracture, Unspecified Fracture of Upper End Left Humerus Initial Encounter for Closed Fracture and Cough Unspecified. Review of the Minimum Data Set (MDS) for Resident #120 dated 06/19/24 revealed in Section C a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. On 7/29/24 12:15 PM an observation was made of Resident #120 sitting in wheelchair near bed, on overbed table in front of resident was Biotene dry mouth lozenges. On 7/30/24 10:04 AM a second observation Resident #120 in bed with Biotene dry mouth lozenges on overbed table next to resident. During an interview conducted on 07/29/24 at 12:15 PM with Resident #120 who was asked about the Biotene dry mouth lozenges on her overbed table, she said she uses them at least once a day sometimes twice a day, the medications make her mouth dry. During an interview conducted on 07/30/24 at 10:05 AM with Staff H Registered Nurse (RN) who was asked if resident can have medications at the bedside, she said no. Staff H RN stated: unless the family brought medication in and we did not find it, we are constantly checking to see if residents have medications at the bedside. During a side-by-side observation with Staff H, RN who acknowledged the Biotene dry mouth lozenges on overbed table next to Resident #120. She said the resident should not have them and we can do a self-administration evaluation and call the doctor to see if he wants to order the Biotene for the resident. 3 Record review for Resident #136 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Legal Blindness as Defined in USA, Type 2 Diabetes Mellitus with Unspecified Diabetic Retinopathy without Macular Edema, Chronic Kidney Disease Stage 3 Unspecified. Review of the MDS for Resident #136 dated 07/01/24 revealed in Section C a BIMS score of 15 indicating a cognitive response. In Section H for Urinary continence was documented as always. Review of the Care Plan for Resident #136 dated 07/11/24 with a focus on the resident a has impaired vision and is at risk for decline in visual status. Related to: Diabetic Retinopathy and Legally Blind. The goal was for the resident to maintain self-identity and dignity daily through the next review date. The interventions included: Anticipate and meet needs. Attempt to keep personal belongings in the same and easy access location. Keep room and hallway free of hazardous objects and clutter On 07/30/24 at 9:20 AM an observation was made of Resident #136 lying in bed and on the overbed table was Emergen C vitamin C gummies, vitamin C lozenges, Vicks vapor ointment (Photographic Evidence Obtained). During an interview conducted on 7/30/24 at 9:25 AM with Resident #136 who was asked about the medications at the bedside she said they are vitamin C and are like candy. Takes them when she thinks to, and she said she keeps them all on the bedside table. She said nursing has seen them and has no issue with them. During an interview conducted on 07/30/24 at 9:35 AM with Staff J Licensed Practical Nurse (LPN) who stated she has worked at the facility for 3 years. When asked if residents can have medications at the bedside, she said they can self-administer medications if assessed and meds are kept locked at the bedside and there is a care plan. When a side-by-side observation was made in the room of Resident #136, the LPN acknowledged the medications and said, I thought they were candy. During an interview conducted on 07/30/24 at 9:37 AM with Staff K Registered Nurse/Unit Manager (RN/UM) who stated she has worked at the facility for [AGE] years. When asked if residents can keep meds at the bedside, she said residents should not have meds unlocked at the bedside, they need to be assessed to self-administer, and if it is okay for the resident to self-administer, then the meds need to be locked. When asked if Resident #136 was assessed to self-administer medications, she said no. During an interview conducted on 07/30/24 at 9:45 AM with Staff L Certified Nursing Assistant (CNA) who stated she has worked at the facility for 4 months. When asked if residents can have meds at the bedside, she said no, if she sees meds at the bedside, she calls for the nurse to tell them. 4 Record review for Resident #382 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Unspecified Sequelae of Unspecified Cerebrovascular Disease and Hemiplegia Affecting Left Nondominant Side. Review of the MDS for Resident #382 dated 06/08/24 revealed in Section C a BIMS score of 14 indicating a cognitive response. On 07/29/24 at 10:17 AM an observation was made in Resident #382's room on nightstand of safety razor, Asper creme, Tums, and 3% Hydrogen peroxide (Photographic Evidence obtained). The resident was not in the room. On 07/30/24 at 9:40 AM an observation was made of Resident #382 sitting in wheelchair in room with no medications or razor on the nightstand. During an interview conducted on 07/30/24 at 9:40 AM with Resident # 382 who was in his room and asked about the Tums and Asper creme at the bedside that was not there today, he said someone must have come in and took it because they are always there. He said the Tums he takes because he has a lot of gas. The resident proceeded to show the surveyor additional medications he had in his nightstand drawer, including Omega 3 Fish oil capsules, and Centrum Men 50 multi-vitamins also noted in the drawers were approximately 6 to 8 safety razors. When asked if he uses razors, he said yes almost every day.

Based on observation, interview, and record review, it was determined that the facility failed to prepare food in a form to designed to meet the individual needs for 31 residents out of which eight included eight sampled residents (Resident #6, Resident #22, Resident #50, Resident #111, Resident #118, Resident #144, Resident #154, Resident #177), and failed to provide 43 residents with physician ordered Mechanical Soft that included sampled Resident #161. The findings included: Review of the facility's Approved Diet Manual (2019) on 07/30/24 noted the following: * Dysphagia Pureed Diet: The diet is used for severe chewing and/or swallowing problems. All foods are pureed to stimulate a a food bolus , eliminating the whole chewing phase. All foods must be the consistency of moist mashed potatoes and/or pudding like consistency. * Mechanical Soft Diet: The diet is used for individuals with mild and/or pharyngeal phase dysphagia. Foods that are difficult to chew are chopped, ground, shredded, cooked, or altered to make them easier to chew. Allfoods that are hard to chewy should be avoided. All protein foods (meats, poultry/fish) must be very tender , chopped or ground, and well moistened. 1) During the observation of the lunch meal of in the main kitchen on 07/29/31 at 11:45 AM , it was noted that the 1/3 sized steam table pan of pureed Cilantro Rice appeared to have lumps and pieces. During the observation the surveyor requested to taste the pureed rice mixture and it was noted that there were small pieces of rice in the pureed mixture and the rice was not of a smooth consistency. The FSD and the cook ( staff ) declined to taste the pureed rice to confirm the surveyors findings . Interview with the cook at the time of the observation noted to state no specific training on the preparation of pureed foods and further stated that he does not taste test the various pureed mixtures to ensure a smooth pureed consistency. The surveyor requested the rice be pureed to he required smooth consistency prior to serving residents with physician ordered pureed diet. 2) During the observation of the breakfast meal in the main kitchen on 07/30/24 at 7 AM, the surveyor requested a taste test of the pureed eggs. The taste test again noted small pieces of egg with the pureed mixture. Interview with the cook at the time of the observation again noted that the pureed foods are not taste prior to serving to ensure a smooth pureed consistency. * Review of the facility's Diet Census Form dated 07/29/24 noted that there were currently 31 facility resident's with physician ordered Pureed Diet, which included Sampled Resident's #6, #22, #50, #111, #118, #144, #154, and #177. 41837 2 Record review for Resident #161 revealed the resident was admitted to the facility on [DATE] with a Principle Diagnosis of Cerebral Ischemia Review of the Physician's Orders for Resident #161 revealed an order dated 04/11/24 for NAS (No Added Salt) diet, Mechanical Soft texture, thin consistency. On 07/29/24 at 1:05 PM an observation was made of Resident #161 sitting in 3rd floor dining room with large piece of chicken , rice, zucchini, roll and piece of chocolate cake, on the meal ticket was regular mechanical soft, ground Italian baked chicken (Photographic Evidence Obtained). On 07/29/24 at 5:55 PM an observation was made of Resident #161 eating in 3rd floor dining room, on her plate was a slice of vegetable quiche, sauteed spinach, dinner roll, spice pears, baked onion soup. meal ticket stated regular mechanical soft. During an interview conducted on 07/31/24 at 12:00 PM with Staff D Registered Dietician (RD) who was asked about a mechanical soft diet, she said the meat would be ground. When asked about Resident #161, would a whole chicken breast be acceptable for the resident with the mechanical soft diet, she said no, it should be ground. When shown the picture of chicken with meal ticket for Resident #161, the RD stated that is not good. In summary the reviewed diet census for the facility on 07/29/24 and it was noted that there were currently 43 residents with physician ordered mechanical soft diet, of the 43 residents it included Resident #161.

Based on observations, interviews, and record reviews, the facility failed to develop and implement an effective Quality Assurance and Performance Improvement Program (QAPI) with appropriate plans of action. The facility failed to regularly review and analyze data and act on available data to make improvements regarding 4 out of 4 federal repeated deficiencies (F550, F761, F812 and F867). The findings included: A review of the facility QAPI Plan (no date) revealed the following: We will set short-term achievable goals in quarterly increments to allow review of our progress towards our annual long-term goal. We will continually monitor to sustain the goals we have met. Each Performance Improvement Project subcommittee will utilize Root Cause Analysis and the Plan, Do, Study, Act (PDSA) cycle of improvement to improve existing processes. Data will be collected during this process and then analyzed to determine the effectiveness of change. Upon conclusion of each Performance Improvement Project, the subcommittee will provide the QAPI Committee with a summary report, analysis of activities, and recommendations. A review of the last recertification survey dated 03/02/23 revealed that the facility was cited for the following deficiencies: F550 under Resident Rights, F761 under Pharmacy Services, F 812 under Food and Nutrition Services, and F867 under Quality Assurance Performance Improvement. During the QAPI review conducted with the Administrator on 08/01/24 at 9:20 AM, she stated that they meet monthly and review past deficiencies from prior surveys. They will start a QAPI and will reevaluate after the first three months. If a QAPI is not meeting its set goal, it will investigate the root cause analysis and change the action plans until it meets the goal rate, usually at 100%. When asked about the repeated deficiency of F812, the Administrator said that they had identified the condensation issue in the central kitchen but had yet to have a chance to start a QAPI. She discussed sanitation concerns and staff education completed by the kitchen manager but could not provide this Surveyor with any tracking and trending QAPI. Continuing the interview on 08/01/24 at 10:00 AM with the facility's Administrator, she stated that they had issues regarding F550 and staff standing over residents during dining in the last survey. This was resolved, and they do not have any QAPI regarding dignity during dining. She further stated that all department heads were responsible for monitoring dignity during dining and reporting to her. The Administrator reported that she has identified medication at the bedside and that residents are ordering medications online. She has been doing her own monitoring and rounds with other staff members but was not able to provide this Surveyor with the QAPI paperwork regarding tracking and trending on any medications at the bedside or medication rooms not locked.

Based on observations, interviews and record review the facility failed to treat residents in a dignified manner who wear adult briefs for 2 out of 40 sampled residents (Residents #72 and Resident #136 and failed to ensure that residents are treated in a dignified manner with bedding while in bed for 1 out of 40 sampled residents (Resident #154) and failed to treat residents in a dignified manner during dining observation (Resident #6). The findings included: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity During Mealtimes dated 03/2020 included in part the following: 8. Ensure the resident receives the proper tray. 11. Allow adequate time that resident requires to complete meal. Do not rush. 12. Allow resident time needed to complete as much as desired of the meal. Review of the facility's policy titled, Promoting/Maintaining Resident Dignity with a revised date of 04/2023 included in part the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. 1)Record review for Resident #72 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Polyneuropathy Unspecified, and Benign Prostatic Hyperplasia Without Lower Urinary Tract Symptoms, Urinary Tract Infection Site Not Specified. Review of the Minimum Data Set for Resident #72 dated 07/11/24 revealed in Section C a Brief Interview of Mental Status score of 14 indicating a cognitive response. Review of the Care Plan for Resident #72 dated 04/18/24 with a focus on the resident has a self-care deficit and needs staff assistance to perform and complete ADL's secondary to: decreased mobility, incontinence status and polyneuropathy. The goal was for the resident to show improvements in his ADL functions with assistance through the next review date. The interventions included: Provide assistance only in the areas difficult for the resident. Allow the resident to do for self as much as possible. Setup needed basic items, washcloth, soap/water, towel, comb, etc. and keep within easy reach daily and as needed. Shower and/or shampoo hair according to patient preference as scheduled and PRN. Review of the Care Plan for Resident #72 dated 04/18/24 with a focus on the resident is at risk for alteration in skin integrity due to decreased mobility, medication side effects and incontinence status of bowel and bladder functions. The goal was for the resident's skin will remain intact through next review date. The interventions included: Apply skin moisturizer/barrier creams after incontinence care. Avoid massage over bony prominences. Change promptly when wet or soiled. Incontinence care - manage moisture. Review of the Care Plan for Resident #72 dated 04/18/24 with a focus on the resident is incontinent of bowel and bladder functions related to decrease mobility. The goal was the resident will be kept clean and dry as possible by next review date. The interventions included: Check every 2-3 hours for wetness/soiling and change promptly. Cue/check and assist to the bathroom/bedpan/urinal upon waking, before and after each meal, at HS (bedtime) and PRN (as needed). During an interview conducted on 07/29/24 at 11:05 AM with Resident #72 who stated staff sometimes take their time coming when he calls for assistance, by the time they come he cannot hold it and cannot help but soil himself. They always help him when he is soiled, it depends on who is working and where he is at, it may take an hour or so. The resident said he has to wear 2 diapers, or he would go all over the place, because he cannot hold his urine. The resident pulled his shirt up and his pants down to show the surveyor how he has to wear 2 diapers, the diapers were taped together to fit the resident who had a large waist. When asked if he was made to wait in a wet diaper, he said the diaper holds the urine and he need two of them or it (the urine) would go all over the place. The resident said sometimes he wets himself in the dining room. 2 Record review for Resident #136 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Legal Blindness as Defined in USA, Type 2 Diabetes Mellitus with Unspecified Diabetic Retinopathy without Macular Edema, Chronic Kidney Disease Stage 3 Unspecified. Review of the MDS for Resident #136 dated 07/01/24 revealed in Section C a BIMS score of 15 indicating a cognitive response. In Section H for Urinary continence was documented as always. Review of the Care Plan for Resident #136 dated 07/11/24 with a focus on the resident a has impaired vision and is at risk for decline in visual status. Related to: Diabetic Retinopathy and Legally Blind. The goal was for the resident to maintain self-identity and dignity daily through the next review date. The interventions included: Anticipate and meet needs. Attempt to keep personal belongings in the same and easy access location. Keep room and hallway free of hazardous objects and clutter Review of the Care Plan for Resident #136 dated 07/11/24 with a focus on the resident is incontinent of bowel and/or bladder as evidence by: Always incontinent. The goal was for resident to be kept clean and dry as possible by next review. The interventions included: Allow resident enough time for B and B needs. Apply skin moisture barrier post incontinence care. Avoid a hurried, judgmental manner. Check every 2-3 hours for wetness/soiling and change promptly. During an interview conducted on 07/30/24 9:25 AM with Resident #136 who said some staff have her wear 2 pampers to catch her urine because she has urine problems. When asked if this is something she requests, she said no, it what the staff do, some staff put 1 pamper on her and some put 2. When asked if she is wet in only 1 brief what happens, she said they just remove the one that is wet 49060 3) Record review for Resident #154 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease, Anxiety Disorder, and History of Falling. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #154 had a Brief Interview for Mental Status (BIMS) of 99, which indicated that she was rarely/never understood. Review of Section GG revealed that Resident #154 was dependent on the staff to be transferred from the chair to her bed and for all her activities of daily living (ADLs). During the facility's second-floor tour on 07/29/24 at 10:56 AM an observation was conducted of Resident #154's room. Upon entering the room, it was noted that all three beds in the room were without sheets or blankets. In addition, there were two large clear plastic bags filled with linens (unsure if the linens were soiled) located on the floor near the bathroom. Further observation revealed Resident #154 was in her bed without any sheets or a blanket. Resident #154 was dressed; she was on her right side in a fetal like position, which gave the appearance that she was cold. An interview was conducted on 07/31/24 at 9:50 AM with Staff C, Certified Nursing Assistant (CNA). She stated that she has worked at the facility for [AGE] years. Staff C noted that Resident #154 is dependent on staff for all her ADLs, and she is unable to transfer from her wheelchair to the bed on her own. Staff C acknowledged that she was working on Monday (07/29/24) and Resident #154's room was part of her assignment. However, Staff C stated that on Monday, another CNA (Staff F) assisted her with the room (removal of the linens from the beds) and provided care for Resident #154. Staff C stated that she asked Staff F if she had finished with Resident #154's room, and Staff F stated yes. However, Staff C noticed that the surveyor had gone into Resident #154's room. Then, Staff C went into the room and realized that the beds did not have any sheets on. In addition, she observed Resident #154 in her bed without sheets or a blanket, and the dirty linens were in bags on the floor near the bathroom. She also stated that she would never leave her residents in their beds without sheets or a blanket because it is not per policy. An interview was conducted on 08/01/24 at 10:24 AM with Staff F, CNA. She stated that she has worked at the facility for [AGE] years. She noted that she worked on Monday (07/29/24) however, was not assigned to Resident #154's room, but was helping Staff C with her assignment. Staff F acknowledged that on Monday she provided care for Resident #154 and removed the soiled linens. She stated that she left Resident #154 in her bed and the soiled linens for Staff C to finish because Staff C mentioned that she was coming right back. She stated that Staff C had gone to fill the water jug dispenser. Staff F was asked if leaving the resident in the bed without sheets was part of the care, she stated that it depends on the situation. She stated that if the staff is coming right back to finish the resident's care, then it is okay to leave the resident on the bed without linens. 40153 4) Record review revealed that Resident #6 was readmitted to the facility on [DATE] with diagnoses of Type 2 Diabetes, Hypokalemia, and Hyperlipidemia. The 5-day Minimum Data Set, dated dated dated [DATE] 24 revealed that Resident #6 had a Brief Interview for Mental Status (BIMS) of 99, which indicated that she rarely/never understood. In an observation conducted on 07/31/24 at 8:35 AM, Resident #6 was noted in her bed with her breakfast tray untouched at the bedside. The breakfast tray was observed with regular pureed nectar thickened liquids, pureed apple cinnamon French toast, pureed oatmeal cereal, cranberry juice, and apple sauce. No staff were noted in the room to help Resident #6 with her breakfast tray. At 9:03 AM (about 30 minutes later), Staff B, Certified Nursing Assistant (CNA), was observed entering Resident #6's room and coming out with the breakfast tray in her hands 4 minutes later. The tray was observed with 100% of the French toast consumed and 25% of the oatmeal consumed. In an interview conducted on 07/31/24 at 10:57 AM, Staff B stated that she is not familiar with Resident #6, that she is new to her, and that she has not worked with her in the past. She said that she only picked up the tray from Resident #6's room and did not assist Resident #6 with her breakfast tray. Staff B reported that Staff A, a Certified Nursing Assistant (CNA), assisted Resident #6 with her breakfast meal. In an interview conducted on 07/31/24 at 11:05 AM with Staff A, she stated that she was assigned to Resident #6 this morning, but she was busy feeding two other residents who needed assistance during dining. Staff A further said that Staff B fed Resident #6 her breakfast meal. In an interview conducted on 08/01/24 at 10:30 AM with the facility's Administrator, she was told of the findings. 01948 5) During the observation of the breakfast meal on 08/31/24 at 8:15 AM on the 2 East Unit the surveyor was attempting to identify resident's who had not yet received a breakfast meal tray. Specifically resident rooms [] for 6 residents. The surveyor asked the LPN medication nurse ( Staff N) who was in the hallway during the observation stated aloud if the residents have not received the breakfast meal it is because they are feeders another CNA (Staff L ) who was located in the area; also stated aloud in the hallway to the nurse that she was correct and said the residents are. feeder. residents are feeders. The surveyor informed the staff that identifying residents as feeders is a dignity issue and to please refer to the residents as requiring assistance with eating.

Based on observation, interview and record review the facility failed to ensure a thermometer was in the ice cream box. This has the potential to affect 154 out of 171 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the facility's Dietary Food Storage Policy and Procedure (no written date) documented: Policy: It is the policy of the facility to provide care and services related to the storage of food in the dietary department in accordance to State and Federal regulation; Procedure: 10) Freezer temperatures will remain below 0 degrees Fahrenheit (F); 11) The use of a thermometer, which shows that the proper temperature is being maintained will be used. Initial kitchen observation of the ice cream box with the Food Service Director (FSD) on 2/27/2023 at 6:54 AM revealed the thermometer missing and two frozen water bottles in the bottom of the ice cream box. Interview with the FSD on 2/27/2023 at 6:55 AM. He stated, The thermometer should be in there and the water bottles should not be in there.

Based on observations, record reviews, and interviews, the facility failed to ensure residents are treated with respect and dignity for three residents (Resident #87, Resident #104, Resident #143) out of three residents who were observed during dining, as evidenced by staff members were observed standing while feeding residents. This deficient practice has a potential to affect 24 residents who need assistance with eating of the 154 resident who eat orally. The findings included: 1) During observation on 02/27/2023 at 08:24 AM, Resident #87 was in bed, alert. The Certified Nursing Assistant (CNA), Staff D sanitized her hands then proceeded to set up the resident's breakfast tray, the resident's bed was in a low position and Staff D, CNA was standing up while feeding the resident. When the surveyor asked Staff D if this was how she usually positioned herself to help residents who needed assistance with eating, she stated sometimes this is how I feed the residents, standing up. On 02/28/2023 at 08:09 AM, Resident #87 was observed in bed, alert, the bed was in low position and the breakfast tray already served. Staff E, CNA was assisting the resident, she verbalized to resident what she was going to be doing and when the resident asked what was for breakfast Staff E let the resident know what was on her tray. Staff E washed her hands, then she proceeded to help the resident with breakfast and remained standing while feeding the resident. Record review of Resident #87's Minimum Data Set (MDS)-Quarterly, admitted : 09/02/2023 revealed: Section C for Cognitive Status with a Brief Interview of Mental Status (BIMS) score of 11 out of 15 indicating the resident is moderately impaired cognitively. Section G for Functional Status documented for eating that the resident requires total dependence with one-person to physically assist. Section I - Active Diagnosis indicated: Parkinson's disease, Malnutrition (protein, calorie), risk of malnutrition. Review of Resident #87's physician's orders revealed order dated 2/10/2023 for Speech Therapy clarification order: Speech Therapy Skilled services 3 times per week for 90 days for dysphagia treatment, therapeutic trials . mastication exercises . Review of tasks for Activities of Daily Living (ADL) indicated for Eating Resident #87 required total assistance .Full staff performance .Eating Support provided. One-person physical assist. Review of the Nutrition/Dietary Note dated 6/3/2022 revealed that Resident #87's appetite is good, requires assistance with meals. Snack accepted. Resident has own teeth with some missing. No reports of difficulty chewing or swallowing. Resident need for assistance due to vision impairment . Resident is able to feed self slowly however assistance is provided with every meal and supplements/nourishment. During an interview on 03/01/2023 at 02:43 PM, Staff D, CNA stated: when I feed a resident, I wash my hands and introduce myself, then I state that I am here to assist with breakfast, I offer the breakfast, and if their head is low, I let them know that I am going to raise their head then I present what is on the tray. I honor their desires for what they would like to eat or drink, then I sit down close to the residents' bed to feed them. She continued and stated, the day that you were here, what happened was that I know that I am supposed to pull up a chair and sit close to the resident to feed her, I am sorry, I thought you were going to interview her, and I did not use the chair but after you left. 2) On 02/27/2023 at 08:05 AM, Resident #104 was observed in bed alert and noted with all teeth missing. The bed was elevated with bilateral rails up, there was a chair at the bedside. The CNA, Staff A was observed standing up while feeding the resident. On 02/28/2023 at 08:14 AM, Resident #104 was observed in bed, breakfast was served and Staff B, CNA was standing up while feeding Resident #104. On 03/01/2023 at 11:53 AM, observed CNA, Staff C setting up the lunch tray for Resident #104, Staff C lowered the bed's side rail, lowered the bed, and continued setting up the resident's tray. Staff C began feeding resident while standing up. After the surveyor asked if this was how she usually assisted residents with feeding, Staff C proceeded to get a chair, sat down, and continued to feed Resident #104. Review of Resident #104's Minimum Data Set (MDS)-Quarterly, admitted : 10/01/2019 revealed in Section C for Cognitive Status a BIMS score of 99 meaning the resident was unable to complete the interview. Section G- Functional Status indicated for eating that the resident required extensive assistance with one-person to physically assist. Section I for Active Diagnosis indicated the resident has Non-Alzheimer's Dementia, Anemia, Coronary artery disease (CAD) and Hypertension. Section O- for Special Treatments, Procedures and Programs indicated the resident received Occupational Therapy, Therapy start date- 05/26/2022 and therapy end date-06/24/2022, Training and Skill Practice In: Eating and/or swallowing-0 minutes. Review of physician orders for Resident #104 revealed that the resident had an order dated 12/2/2022 for head of bed elevated at all times every shift and an order dated 12/2/2022 for aspiration precaution every shift. Review of Resident #104's Care Plan with start date 12/29/2022 and target completion date 1/6/2023 revealed that Resident #104 has self-care deficit and needs limited to total staff assistance to perform and complete Activities of Daily Living's secondary to her impaired mobility .Osteoporosis, Dementia, Hypothyroidism and Anemia . Diet with interventions as follows: My chewing/swallowing status is: Impaired, My diet order: Mechanical Altered, Requires Assistance with Meals. Review of tasks for Activities of Daily Living (ADL) revealed for Eating-total assist - full staff performance, one-person physical assist. Interview with Staff A, CNA on 03/01/2023 at 02:51 PM, when asked about the facility's protocol when feeding a resident; Staff A stated when assisting a resident with feeding, I introduce myself, I let them know what I am doing, I proceed with the feeding after set up, I am usually at bedside, facing her frontwards with the tray on the table, I was standing up at the time you were in the room. If I am in the dining, I am in eye level with them, and [Resident's #104] bed was up high when you were in the room. On 03/02/2023 at 09:12 AM during an interview with Registered Nurse (RN) Unit Manager for 2 East-, when asked about overseeing the CNAs, she stated I oversee the floor, when the trays comes to the floor, nurses passes them to the CNAs, we serve the residents who are independent with eating first, and lastly, we serve the ones that need assistance with eating as they require more time, we give them their meal and assist them at that time. We do respect their dignity by knocking on doors, washing hands, and when it comes to feeding them, we pull up a chair and sit next to them after positioning them. We give them time to eat, and the CNAs speak to them as they are giving them their meal, and telling them what they are doing. With residents with impaired vision, definitely they have to say what they are giving them. When I am on the floor, I make rounds to make sure that they are correctly positioned. 31581 3) Observation of Resident # 143 on 3/01/2023 at 12:42 PM revealed the resident sitting up in bed with the television on, the Certified Nursing Assistant (CNA), Staff H was noted standing by his bedside and feeding the resident lunch. The lunch tray consisted of a NCS (No Concentrated Sweets) diet, Mechanical soft texture with regular chicken noodle soup, chopped chicken fricassee with gravy, steamed rice, par sliced carrots, pineapple tidbits and apple juice. During an interview with Staff H, CNA on 3/01/2023 at 12:46 PM. Staff H stated, I always stands up to feed the resident because it is more comfortable for me. I didn't know I was supposed to sit down while feeding the resident. Review of the Demographic Face Sheet for Resident # 143 documented the resident was admitted on [DATE] with a diagnosis of diabetes mellitus, paraplegia, dysphagia, atherosclerotic heart disease and hypertension. Review of the Minimum Data Service (MDS) Annual assessment dated [DATE] for Resident #143 documented the resident's Breif Interview of Mental Status (BIMS) Summary Score was 07 out of 15, indicating the resident has cognitive impairment. Section G for functional status indicated the resident required total dependence with one person physical assist for adls (activities daily living) and eating. Interview with Staff I, a Licensed Practical Nurse (LPN) on 3/02/2023 at 10:50 AM. Staff I stated, He requires total care for adls and feeding. If the patient is in the bed, we position the patient in the bed at eye level. Talk to the patient and acknowledge whatever is on the plate. We are to sit down at the bed side by the patient, not standing up to feed the patient. Interview with Staff J, a CNA on 3/02/2023 at 11:07 AM. Staff J stated, I sit down when I feed him and I adjust the table to feed him. Interview with Staff K, a Registered Dietitian (RD) on 3/02/2023 at 11:48 AM. Staff K stated, He has to be fed and is on a NCS diet, Mechanical soft texture with thin liquids. Interview with the Director of Nursing (DON) on 3/02/2023 at 1:50 PM. The DON stated, He is total dependence for adls and feeding. The expectation is for the staff to sit down and feed the resident. They are to provide dignity and be face to face. Record review of the facility's policy Promoting/Maintaining Resident Dignity During Mealtimes Policy and Procedures issued 3/2020 documented: Policy-It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights or each resident; Policy Explanation and Compliance Guidelines: 1) All staff members involved in providing feeding assistance to residents promotes and maintains resident dignity during mealtimes, 5)All staff will be seated, while feeding a resident.

Based on record review and interview, the facility failed to ensure a resident's clinical record contained documentation that the resident was provided with written information regarding the right to formulate an advanced directive for three (Resident # 133, Resident #143, Resident #122) out of seven residents whose clinical records were triggered and reviewed for written evidence of provision of information regarding formulating an advanced directive. There were a total of 171 residents residing in the facility at the time of this survey. The findings included: Record review of the facility's Advanced Directives Policy and Procedures dated 3/01/2021 documented: Policy-It is the policy of this facility to honor Advance Directives in accordance to State and Federal regulations; Procedure: 4) The facility will provide each adult individual, at the time of the admission as a resident, with written information concerning the nursing home's policies respecting advance directives and provide documentation of the existence of an advance directive within the medical record. 1) Record review of Resident # 133's demographic face sheet noted admitted was 10/28/2022. Review of Resident # 133's clinical record showed no written documentation related to advance directives. On 3/03/2023 at 1:26 PM, the Social Services Director was asked about the advance directives for Resident #133. The Social Services Director stated, His responsible party sent via email to the facility the Durable Power of Attorney but never signed the document. We have been trying to get the document signed but she won't sign the form. We don't have any advance directives for this resident. 2) Record review of Resident #143's demographic face sheet noted admitted was 9/13/2021. Review of Resident # 143's clinical record showed no written documentation related to advance directives. On 3/03/2023 at 1:31 PM, the Social Services Director was asked about the advance directives for Resident #143. The Social Services Director stated, We don't have any advance directives for this resident. 3) Record review of Resident #122's demographic face sheet noted admitted was 7/17/2020. Review of Resident #122's clinical record showed no written documentation related to advance directives. On 3/03/2023 at 1:32 PM, the Social Services Director was asked about the advance directives for Resident # 122. The Social Services Director stated, We don't have any advance directives for this resident.

Based on observation, interview and record review the facility failed to implement infection control procedures related to the cleaning and disinfecting of a multi-person use glucose monitor on the facility's 3rd floor A side for one (Resident #108) out of six residents with glucose checks assigned to License Practical Nurse, Staff A. This deficient practice has the potential to increase the likelihood for cross contamination and increased risk for exposure to blood borne pathogen through contaminated equipment and supplies. There were 36 residents residing in the facility that required blood glucose checks. The findings included: On 11/4/21 at 8:45 AM, during observation Staff A, License Practical Nurse (LPN) was observed performing blood sugar check for Resident # 108. Staff A did not clean and disinfect the glucometer before and after usage. On 11/4 21 at approximately 8:50 AM, Staff A was asked about the facility's policy and procedure related to the disinfecting of the glucometer. Staff A acknowledged that she did clean and disinfect the glucometer before and after use when apprised of the above observation during blood glucose check for Resident #108. Review of Resident #108 clinical face sheet revealed the resident was admitted to facility on 1/7/2021. Review of the Brief Interview of Mental Status ( BIMS) 99 indicating the resident is cognitively impaired. Clinical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 108 clinical records revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the scheduled assignments revealed Staff A, LPN was assigned to complete six blood glucose checks that included Resident #108. Review of training records revealed the last annual blood borne pathogen, biomedical waste and hazard communication awareness training completed by Staff A, LPN was on 2/8/21. Review of the facility's policy and procedure titled: Glucometer Machines issued 6/2013,did not include disinfecting of glucometer. On 11 4/21 at 10:22 AM, during an interview Staff B, Registered Nurse (RN) unit manager revealed the nurses are supposed to clean the glucometer before and after using it. One machine is used for all residents on the floor, and they should use bleach wipes or alcohol wipes after each resident. On 11/04/2021 at 10:30 AM, the Director of Nursing, Assistant Director of Nursing and the Administrator in Training were informed of the concerns identified related to Staff A, LPN failure to disinfect the multi person glucometer before and after blood glucose check was performed for Resident #108. The DON stated the nurses required to disinfect the glucometer before and after each use. On 11/ 04 /21 at 12:56 PM record review facility's Glucose monitoring owner's manual Ultra Track Pro. Titled take care of your meter and strip. Line #1 to avoid the meter and strips from getting dirt, dust, or other contaminants, please wash and dry your hands thoroughly before used. To clean the meter exterior wipe with cloth, moisten with tap water our mild clean agent, then dry the device with soft dry cloth, do not flush with water. Record review facility's document tiled policy and procedure on cleaning re-usable equipment dated on 09/01/2110. Policy: Re-usable medical equipment will be clean with CDC approved /recommended germicidal wipes to maintain infection protocol. Policy and Procedure titled: Glucometer Machines revision / effective date June 2013/2013 indicated, Glucometer must be cleaned prior and after each use using EPA (Environmental Protection Agency)approved wipes. Review of the facility's document titled, Infection Control Policies and Practices indicated that the primary purpose of this facility's infection control policies and practices are to establish a system for preventing, identifying, reporting, investigating, and controlling infection communicable diseases for all residents, staff, volunteers, and other individuals providing services. On November 4, 2021 at 4:25 PM, the Director of Nursing, The Assistant Director of Nursing/ Infection Preventionist and the facility's Administrator was notified that ongoing Immediate Jeopardy existed for infection control related to failure to disinfect the multi person use glucometer before and after use. The facility's Immediate Jeopardy Removal Plan that was submitted on 11/05/2021 related to the immediate jeopardy indicated: Immediate Removal Action Plan: A new training /competency checklist and a compliance audit tool were created on 11/4/2021 by the Director of Nursing including the steps that need to be implemented to reduce the risk for transmission of blood borne pathogens. The policy for the glucometer machine was also updated on 11/4/2021 by the Director of Nursing to provide a standardized process for cleaning of glucometers, to ensure patient safety and reduce the risk of cross contamination. A copy of updated policy and procedures and the new training competency checklist was placed on each medication cart. On 11/4/2021 at 2:50 PM reeducation provided by the ADON (Assistant Director of Nursing)/ Infection Preventionist to license nurse Staff A and B regarding the appropriate steps for cleaning the glucometer before and after use. Both licensed nurses successfully completed the new training/competency. A face to face in-service was initiated at 3:30 PM by the Clinical Nursing staff utilizing the new competency checklist. The 7-3 shift licensed nurse and the oncoming 3:00 PM to 11:00 PM shift nurses were reeducated and completed the competency as a return demonstration of the in-service provided. The licensed practical nurses were also educated to follow manufacture's guidelines regarding the contact time of the disinfecting product. The license nurses will keep glucometer wet for maximal kill time indicated on disinfecting agent product label. Around 5:00 PM the DON reviewed the list of diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No residents on her assignment noted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 11/4/2021 the licensed nurses on 11:00 PM to 7:00 AM shift were reeducated at the beginning of their shift by the RN Nurse supervisor. On 11/4//2021 around 6:30 PM AD Hoc Quality Assurance members present Director of Nursing, Social Service Director, Assistant Don /Infection Control nurse, Three Unit Managers, Corporate Risk Manager, Activity Director, MDS Coordinator. The meeting chaired by the Administrator. Medical Director participates via phone. Unit managers for all three units reached out to some of the nurses to come in for the training. Around 8:00 PM several others licensed nurses were reeducated by the DON and infection the Infection Preventionist Nurses. They also completed the training /competency checklist successfully. The nurse manager or supervisor on each unit will review the schedule daily to ensure all licensed nurses have received the training and complete the competency. Any clinical nursing staff identified by the nurse manager who has not received the training will be training by the infection Preventionist or designee. Newly hired clinical nursing staff will receive training during their general orientation. For compliance monitoring, the DON ADON/ infection Preventionist or designee will complete the facility glucometer cleaning observation/ compliance audit tool observing license nurses cleaning the glucometer to ensure that the license nurses follow the facility infection Control policy and procedures. The Infection Preventionist, ADON or designee will have daily rounds and observe the infection control practice of the areas listed above to ensure the staff follow the facility infection control guidelines. For staff who failed their observation to be immediately reeducated and required to complete the training /competency checklist. The infection Preventionist /designee will observe at least four nurses cleaning the glucometer each unit weekly times four weeks then monthly times two months. Findings will be reported at the monthly QA/Risk management meeting until substantial compliance has been determined by the Quality Assurance Performance Improvement (QAPI) committee to ensure compliance has been achieved when completing the quality systems reviews. Facility's alleged compliance dated November 5th, 2021, signed. Review of the in-service sign in sheets provided by the facility revealed licensed nurses received training related to infection control that focused on the glucometers on 11/04/2021. Verification of the removal plan revealed, the facility implemented new training competency checklist, created audit tool that included steps that need to be implemented to reduce the risk of transmission of blood borne pathogens.: The documentation revealed : On 11/4/21 Licensed Nurses presentation on the 7:00 AM to 3:00 PM shift, 3:00 PM to 11:00 PM shift and 11:00 PM to 7:00 AM shifts received reeducation and completed return demonstration competency checks. Review of documentation provided revealed on 11/4/21, Staff A, LPN and Staff B, RN/Unit Manager received education from and corrective action from the ADON/Infection Preventionist. As of 11/5/21 the facility had completed the training and competency checks for 42 of 48 Licensed Nurses currently employed in the facility. The remaining 6 will be trained on next scheduled work day. Review of the in-service sign in sheets provided by the facility revealed licensed nurses received training related to infection control that focused on the glucometers on 11/04/2021. The sign in sheets revealed 25 licensed nurses and 17 Registered Nurses received training on 11/04/2020 related to training titled: Blood Borne Pathogens/ Cleaning and disinfecting of the Glucometer before and after use & cleaning re-usable equipment. Observation revealed the updated Glucometer use policy and procedure revealed the revised policy and competency checklist was located in the front of the narcotic book on the med carts. The revised policy titled: Glucometer Machines issued with revision date 11/4/2021 indicated to follow manufacture's guidelines for cleaning and disinfecting of glucose meters. Specific guidelines for glucose meters may vary with the manufacture. Keep glucometer wet for maximal kill time indicated on disinfecting agent product label. Record review It is the policy of the facility to clean and disinfect multi-patient use blood glucose meters. Resident transmission of blood -borne pathogens is a well-known risk when using lancets, needles, and syringes. Blood glucose monitors that are shared among residents must be cleaned and disinfected between each use.

Based on observation, interview, and record review the facility failed to ensure that the resident environment was hazard-free and maintained safe due to the use of electrical extension cords, electrical plate covers and adapters and using the overhead light fixture for electrical appliances. The improper use of electrical devices has the potential to overload and overheat the circuit increasing the potential for fire. Appliances plugged into overhead fixtures have the potential to cause entanglement or tripping. The findings include: Observation on 04-04-11 at 11:25am in room 207A revealed that there was a six socket plate cover over the electrical wall socket which had a white cord plugged into it along with the oxygen concentrator. On 04-04-11 at 11:28am observation in room 201 revealed a white extension cord was used to plug in a small white refrigerator. There was a nebulizer machine that was plugged into the overhead light switch located above the residents' bed. On 04-04-11 at 3:15pm during a resident interview room 209 was observed to have a television is plugged into a white extension cord that leads to the electrical socket. On 04-05-11 at 8:30am it was observed in room 204 that there was a six socket plate cover over the electrical socket. There was a wheel chair plugged into it with the battery charging. There was also a television is plugged in to one of the six sockets. On 04-06-11 a tour beginning at approximately 8:55am revealed that the rooms on the second floor in the West and East sections had either a plate cover, extension cord or the overhead light fixture plug used for refrigerators, nebulizers, oxygen concentrators, cell phones, clocks or televisions. The following observations were made: Room 201 had a nebulizer machine plugged into the overhead light fixture and a refrigerator that was plugged into an extension cord. Room 202 had the nebulizer machine plugged into the overhead light fixture. There was a six socket plate cover with two televisions, a clock, a small refrigerator and the wheel chair plugged into it. Room 203 had a nebulizer plugged into the overhead light fixture. Room 204 had a three socket adapter and a brown extension cord in use. Room 207 had a six plate socket cover with the television and oxygen concentrator plugged into it. Room 209 had an electrical extension cord used for the television. Room 210 had the nebulizer machine plugged into the overhead light fixture. Room 216 had the bed plugged into the overhead light fixture. Room 218 had a six socket plate cover with a refrigerator, television, and converter box plugged into it. Room 219 had the cell phone plugged into the overhead light fixture. Room 220 had a six socket plate cover which the television and cell phone had plugged into it. Room 222 had a three socket adapter with the television, electrical clock and refrigerator plugged into it. Room 224 had a three socket adapter with the television, electrical clock and refrigerator plugged into it. Also there was a six socket plate cover with the bed and the air mattress plugged into it. Room 230 had a six socket plate cover with the television, an air freshener, refrigerator and electrical clock plugged into it. Room 233 had a three socket adapter located behind the nightstand with the oxygen concentrator, nebulizer machine and electrical clock plugged into it. Room 241 had a six socket plate cover with two televisions plugged into it. Room 246 had a nebulizer machine plugged into the overhead light fixture. Room 247 had a six socket plate cover with two televisions plugged into it. Room 248 had a six socket plate cover with two televisions plugged into it. Room 253 had a six socket plate cover with two televisions plugged into it. On 04-07-11 at 10:10am interview with the maintenance director revealed that the plugs in the building were discussed and they would be removed.