Every finding on record at Regents Park of Winter Park

Based on observation, interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI) program failed to identify a repeated deficiency and area of systemic non-compliance with Intravenous (IV) catheter care. The deficient practice had the potential to affect more than a limited number of residents by not ensuring consistent monitoring and follow-up of identified problems. Findings: Review of the facility's survey history revealed repeat deficiency concerns for IV catheter care. The survey history revealed the facility was issued a Centers for Medicare & Medicaid Services (CMS) Enforcement that included F694 Parenteral/IV Fluids during the 10/23/24 recertification survey and again during the current recertification survey.On 6/04/26 at 5:45 PM, the facility's Administrator discussed the facility's QAPI program. The Administrator was unable to show evidence the facility had a Process Improvement Plan (PIP), or current audits in effect for parenteral/IV fluids. The Administrator acknowledged the facility had received a citation for parenteral/IV fluids during the last recertification survey but give an explanation for the repeat concerns with IVs.From 6/01/26 to 6/04/26, a recertification survey was conducted, and deficient practice was again identified for F694 Parenteral/IV Fluids.The facility did not implement an ongoing, systematic QAPI program to ensure that identified problems were corrected and prevented from recurring. The failure of the facility to maintain complete monitoring documentation and address repeated deficiencies demonstrated the QAPI program was not effective.Review of the facility's undated standards and guidelines titled, 2026 Quality Assurance & Performance Improvement Plan read, it was designed to establish and maintain an organized facility-wide program that is data-driven and utilizes a proactive approach to improving quality of care and services throughout the facility. The document listed multiple objectives of the QAPI Plan which included to address gaps in system or processes and multiple goals of the QAPI Plan which included no previously cited tags in the past three (3) years.

Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection and prevention control program to provide a sanitary environment to prevent the development and transmission of communicable diseases and infections related to laundry services in one of one laundry room of the facility. Additionally, the facility failed to ensure staff implemented and adhered to infection prevention and control practices for transmission based, and enhanced barrier precautions for a midline intravenous (IV) catheter for one of two residents reviewed for IV antibiotics, of a total sample of 38 residents, (#128, and #127). Findings: 1. On 6/04/26 at 12:06 PM, a laundry room tour with the Housekeeping Manager revealed wet floors with standing water between two large washers. The Housekeeping Manager said the floor had been like this for a few days now. He said he was not sure if it was coming from the washer and needed to call the vendor. Broken tiles were on the floor, which the Maintenance Director explained he was aware of. The Housekeeping Manager said there may be an issue with the bleach dispensing into the wash. He explained there may be something stuck in the tubing because the Laundry Attendant told him that the linen did not smell right but he needed to call the vendor. He indicated there was no alarm or alert on the screen of the washer that let them know if there was a problem with the bleach or detergent. The manager said he assumed it was cleaning the laundry because the vendor checked it. The Housekeeping Manager said they had a contract with a company to provide that service, and they came monthly and as needed to check that everything was working. He said he had a manual for the washers but did not have it close by. An Air Conditioner (AC) vent located above the clean linen area was not covered and visible dust was observed blowing through the vent. He confirmed the AC vent needed a cover. (Photographic evidence obtained) On 6/04/26 at 12:41 PM, the Infection Preventionist (IP) acknowledged the issues observed in the laundry room with the Housekeeping Manager could cause cross contamination. The IP acknowledged she was responsible for ensuring the laundry room followed infection control standards for proper handling and sanitization of everything that came through the laundry room for cleaning and sanitization. She confirmed staff should not rely on their sense of smell to determine if the laundry was properly sanitized. On 6/04/26 at 1:56 PM, a second tour of the laundry room was conducted with the Maintenance Director and the IP. The Maintenance Director said he thought the water leak was coming from the washer, but he was not previously aware of this issue. A few minutes later at around 2:03 PM, Laundry Attendant E was folding clean linen and shook a bed sheet without wearing a gowns or gloves. When she shook the sheet, it touched her chin, clothing and upper chest. The IP acknowledged this could lead to cross contamination and said staff should hold the linen away from their face and avoid shaking linens. The facility's undated policy on Infection Control- Linen Management states It is the policy of the facility to ensure that linens are handled in a way to prevent cross contamination and the spread of infection in accordance with State and Federal Guidelines. The procedure showed clean linens were to be kept covered and protected from dust, should not come into contact with staff clothing and laundry equipment should be properly maintained according to the manufacturer's instructions. 2. Review of resident #128's medical record revealed she was admitted to the facility on [DATE] with diagnoses including acute pyelonephritis (kidney infection), bacteremia (bacteria in the blood), urinary tract infection, extended spectrum beta lactamase (ESBL) resistance and dementia. Hospital paperwork dated 5/28/26 showed an Infectious Disease consult for ESBL Klebsiella bacteremia originating from a urinary source. The consult noted left sided pyelonephritis, and the bacteria were susceptible to ertapenem, which was ordered. Extended spectrum beta lactamase ESBL–producing Enterobacterales are resistant to common antibiotics and require complex treatment. These organisms, including Klebsiella pneumoniae, can cause urinary tract and bloodstream infections, leading to increased morbidity and hospitalization (retrieved from CDC on 6/05/26). Physician orders dated 5/31/26 directed Ertapenem sodium 1 gram, reconstituted, to be administered intravenously daily for seven days. The resident's care plan included IV access for ESBL bacteremia and the need for contact isolation. On 6/01/26 at 10:44 AM, a Social Service Assistant entered resident #118's room without donning personal protective equipment (PPE), despite signage indicating contact isolation. PPE was present outside the room. On 6/01/26 at 10:52 AM, Licensed Practical Nurse (LPN) B confirmed resident #128 remained on contact isolation for ESBL and had a midline catheter. On 6/01/26 at 10:57 AM, the Social Service Assistant acknowledged she did not don PPE before entering the resident's room. She explained she was not aware the resident was on contact isolation and did not notice the contact isolation sign before going into the room. On 6/04/26 at 12:30 PM, the Director of Nursing (DON) acknowledged the Social Service Assistant did not don PPE before entering resident #128's room. The DON stated all staff were educated upon hire and yearly about transmission based precautions and infection control. She said staff were expected to adhere to those precautions. Review of the undated policy titled Central Venous Catheter Access and Maintenance revealed the intent is to ensure appropriate infection control prevention and control measures were taken to prevent the spread of infection. 3. Resident #127 was admitted on [DATE] with diagnoses which included cerebrovascular disease, urinary tract infection, chronic sinusitis, pneumonia, and dementia without behavioral disturbances. Review of the resident's discharge hospital paperwork dated 5/26/26 reveled the resident was treated for chronic sinusitis, and urinary tract infection. On 6/01/26 at 12:21 PM, resident #127 was in bed with a single lumen midline IV to her left upper arm. The resident did not have any signage or instructions related to transmission based precautions outside of the room that indicated if PPE was needed. Review of resident's clinical record revealed no physician orders related to transmission based precautions, isolation or enhanced barrier protection. On 6/3/26 at 12:23 PM, the Infection Preventionist (IP) stated any resident who was admitted to the facility with an IV line such as a midline should be placed on enhanced barrier precautions due to it being a potential portal of entry for infections. The IP confirmed resident #127 did not have an order for enhanced barrier precautions but should have. Review of the undated facility policy titled Central Venous Catheter Access and Maintenance revealed the intent was to ensure appropriate infection prevention and control measures were taken to prevent the spread of infection.

Based on interview, and record review, the facility failed to inform and provide written information to residents and/or their representatives about their right to accept or refuse medical or surgical treatment and to formulate an Advance Directive (AD) for five dependent residents' representatives, (# 1, # 11, #12, #15, and #116) and 15 residents able to make their own decisions for healthcare, (#1, #4, #5, #6, #7, #8, #10, #11, #12, #13, #15, #16, #57, #108, and #116), of a total sample of 38 residents. Specifically, the facility failed to ensure residents or their representative acknowledged receipt of verbal and written information about AD and failed to ensure AD acknowledgment forms were complete. Findings: 1. Resident #1 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of lung, secondary malignant neoplasm of bone, pneumonia, and chronic obstructive pulmonary disease with exacerbation. Review of the Minimum Data Set (MDS) assessment with assessment reference date (ARD) of [DATE] indicated he had a BIMS of 12 out of 15, which meant his cognition was moderately impaired. Review of resident #1's care plan showed an intervention dated [DATE] to discuss AD with the resident and/or appointed health care representative. Review of the AD acknowledgement form revealed the form was incomplete with no date or signatures to indicate the resident/resident representative acknowledged receipt of written information about their right to accept or refuse medical surgical treatment and formulate an AD. 2. Resident #15 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, schizoaffective disorder bipolar, and chronic obstructive pulmonary disease. Review of the MDS with ARD dated [DATE] indicated she had a BIMS of 2 out of 15, which meant her cognition was severely impaired. Review of resident #15's care plan showed an intervention dated [DATE] to discuss AD with the resident and/or appointed health care representative. Review of the AD acknowledgement form revealed the form was incomplete with no date or signatures to indicate the resident/resident representative acknowledged receipt of written information about their right to accept or refuse medical surgical treatment and formulate an AD. 3. Resident #116 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (brain dysfunction), hemiplegia and hemiparesis, type 2 diabetes mellitus, major depressive disorder, and dysphagia (trouble swallowing). Review of the MDS with ARD of [DATE] indicated she had a BIMS of 03 out of 15, which meant her cognition was severely impaired. Review of resident #116's care plan showed an intervention dated [DATE] to activate resident's AD as indicated, provide AD education and materials including state forms provided, and allow opportunities for expression of feelings and ask questions. There was no mention to provide the same materials to the resident representative and resident #116 was unable to make her own decisions. Review of the AD acknowledgement form revealed the form was incomplete with no date or signatures to indicate the resident/resident representative acknowledged receipt of written information about the right to accept or refuse medical surgical treatment and formulate an AD. 4. Resident #11 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbances, brief psychotic disorder, respiratory failure and cerebrovascular disease. The admission MDS assessment dated [DATE], revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) and was severely impaired related to cognitive skills for daily decision making. Review of the AD acknowledgement form revealed the form was incomplete and had no resident nor representative signature acknowledging they had been informed in writing of their rights and rules regarding decisions for medical care. 5. Resident #12 was admitted to the facility on [DATE] with diagnoses of stroke, metabolic encephalopathy, both hands were contracted, and she had aphasia (difficulty speaking). The MDS assessment dated [DATE] indicated she had unclear speech, had a BIMS of 6/15, meaning impaired cognition therefore she was unable to make her own healthcare decisions. Review of resident #12's care plan showed an intervention dated [DATE] to discuss AD (to decide if the resident would be revived in case of an emergency) with the resident's family. The Electronic Medical Record revealed the resident had a blank AD form in her chart, with no date, signatures, or indication of code status. [DATE] at 10:25 AM, the Administrator provided documentation dated [DATE] that showed the facility sent an e-sign readmission Agreement for AD to resident #12's guardian. The Administrator stated the form was not returned. On [DATE] at 1:30 PM, the Social Services Assistant explained if residents were confused or unable to talk, they contacted the family to confirm for AD to determine if they would like to be Full Code or Do Not Resuscitate. She said they attempted to contact the family until they got in communication and documented the attempts in the progress notes. On [DATE] at 1:54 PM, the 200-hallway Unit Manager stated when a new admission came in, the facility used the code status off the hospital paperwork until they contacted the family or guardian, and they made a note in the chart. She commented that staff attempted to get a hold of resident #12's family three times, and they followed up with code status wishes in the care plan meetings. The facility was unable to provide any progress notes to indicate any further attempts had been made to contact resident #12's representative regarding AD. On [DATE] at 9:43 AM, the Social Services Director discussed code status review, and said if a resident was confused, they tried to document if a family member didn't answer. She explained her assistant followed up with guardians they were unable to get in touch with. On [DATE] at 10:18 AM, Licensed Practical Nurse C said she left a voicemail with the Power of Attorney, tried to contact someone else on the emergency contact list, and noted it in the chart if a resident's representative didn't answer. Additionally, a review of the AD acknowledgment forms for residents #4, #5, #6, #7, #8, #10, #13, #16, #57, and #108 revealed the forms were incomplete. Specifically, responses were missing for questions pertaining to AD, and all applicable checkboxes had been left blank. The questions and checkboxes included whether the resident/resident representative had or had not chosen to formulate and issue any Advanced Directives. On [DATE] at 1:18 PM, the Director of Nursing (DON) said she was responsible for checking charts and verifying orders for newly admitted residents. She explained at morning meetings they went over the admission checklist and made sure there were consents, and orders, then followed up on those at the care meetings. The DON remarked it was important to document the initiation of care, and that the family was contacted. She confirmed the admission Coordinator was to follow up if they were unable to reach the guardian. The facility's Advance Directives Policy revised [DATE] indicated the admitting nurse should verify the resident's code status upon admission with the resident/resident representative to determine resident wishes for medical intervention should their heart stop beating or they stop breathing. This step was to ensure the facility honored the resident's right to decide whether to prolong life in accordance with federal and state regulations.

Based on interview, and record review, the facility failed to ensure completion and accuracy of Level I Preadmission Screening and Resident Reviews (PASARRs) on admission, and/or failed to make referrals for newly evident or possible mental disorders, to evaluate the need for specialized mental health services or alternate placement for 7 of 7 residents reviewed for PASARR, of a total sample of 38 residents, (#4, #6, #7, #8, #10, #62, and #66). Findings: 1. Review of the medical record revealed resident #4 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, anxiety, major depressive disorder, obsessive-compulsive disorder (OCD) and paranoid schizophrenia. Review of the State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review (PASARR) Level I screen dated 1/22/25 and signed by the admitting hospital Social Worker, revealed Section I for decision making listed mental illness or suspected mental illness as bipolar disorder and schizoaffective disorder. A psychiatry evaluation note dated 5/07/26 revealed the resident was on medication to treat and manage mental health diagnoses. This included the medication Buspirone for anxiety, Fluvoxamine for OCD, Trazodone for depression and Lyrica and Zyprexa for schizophrenia. Review of the resident's medical record revealed no updates had been made to the PASARR form to include these mental illnesses. 2. Review of the medical record revealed resident #6 was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, dementia with agitation, and brief psychotic disorder. The resident's PASARR form dated 5/04/26 was completed prior to admission to the facility. The form incorrectly indicated no diagnoses listed under Section IA, Mental Illness or suspected Mental Illness. A psychiatry evaluation note dated 5/12/26 revealed the resident had a diagnosis of brief psychotic disorder and suffered from psychotic symptoms that were not consistent and long lasting. The note indicated the disturbance was not attributable to the physiological effects of a substance or another medical condition. Review of resident #6's medical record revealed no updates had been made to the PASARR form to include these mental illnesses. 3. Resident #8 was re-admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy (brain dysfunction), alcoholic liver cirrhosis of liver with ascites, bipolar disorder, major depressive disorder, generalized anxiety disorder and post-traumatic stress disorder (PTSD). Review of the most recent Minimum Data Set (MDS) quarterly assessment with assessment reference date (ARD) of 5/07/26 revealed the resident had a Brief Interview for Mental Status (BIMS) Score of 15 out of 15 which indicated her cognition was intact. The MDS listed anxiety disorder, depression, bipolar disorder and PTSD as active diagnoses listed under Psychiatric/Mood Disorders. A review of the PASARR Level I Screen for Serious Mental Illness (SMI) and/or Intellectual Disability or Related Conditions (ID) For Medicaid Certified Nursing Facility revealed resident #8 was screened by the facility's current MDS/Resident Assessment Coordinator on 7/25/25 but did not include the diagnoses of depression nor PTSD. 4. Resident # 62 was re-admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes, acute kidney failure, paranoid schizophrenia, bipolar disorder, anxiety disorder, autistic disorder, major depressive disorder and PTSD. Review of the most recent MDS quarterly assessment with ARD of 3/11/26 revealed the resident had a BIMS score of 13 out of 15 which indicated her cognition was intact. The MDS listed anxiety disorder, depression, bipolar disorder, schizophrenia and PTSD as active diagnoses listed under Psychiatric/Mood Disorders. A review of the PASARR Level I Screen revealed resident #62 was screened by a Registered Nurse from the facility on 5/08/24 but the screen did not include the diagnosis of PTSD. On 6/03/26 at 4:58 PM, the MDS/Resident Assessment Coordinator acknowledged resident #8 and #62's Level I PASARRs did not include the correct and most recent mental illnesses and needed to be updated. 5. Resident #66 was re-admitted to the facility on [DATE] with diagnoses that included fibromyalgia, major depressive disorder, and Parkinson's disease. Review of the most recent MDS quarterly assessment with ARD of 4/09/26 revealed the resident had a BIMS score of 13 out of 15, which indicated her cognition was intact. A review of the PASARR Level I Screen for SMI and/or ID or Related Conditions for Medicaid Certified Nursing Facility revealed resident #66 was screened by the hospital on 8/02/25 but the diagnosis of major depressive disorder was not checked and sections I.A. and I.B on page 2 of 5 were blank. 6. Resident #7 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, diabetes, stroke, and congestive heart failure. Review of resident #7's electronic medical record revealed a PASARR Level I screen dated 11/19/25 completed at the hospital that indicated she had diagnosis of bipolar disorder. The facility completed another PASARR Level I screen on 4/17/26 that included diagnoses of anxiety and depression but omitted bipolar disorder. The MDS assessment dated [DATE] revealed resident #7 had a BIMS score of 15 out of 15, which indicated she was cognitively intact. The assessment detailed the resident required moderate to substantial assistance from staff, and diagnoses listed were depression and bipolar disorder. Review of resident #7's current physician orders showed she took Depakote for depression and anxiety, also used to treat bipolar disorder. A psychiatry note dated 5/22/26 indicated the resident went through a period of depression, had little appetite, low energy, and psychomotor changes. 7. Resident #10 was admitted to the facility on [DATE] with diagnoses of stroke, depression, and bipolar disorder. Review of resident #10's electronic medical record revealed a PASARR Level I screen dated 4/24/26 with all of the diagnoses left blank. The MDS assessment with ARD 4/29/26 indicated the resident had a BIMS score of 14 out of 15, which meant she was cognitively intact. The assessment showed her left side was paralyzed, she required substantial assistance with activities of daily living, and she had diagnoses of bipolar disorder and anxiety. Review of resident #10's current physician orders revealed the medication Depakote for diagnosis of seizures, Trazadone for depression, and Ativan for anxiety. The resident's most recent psychiatry note dated 5/12/26, indicated she was having trouble sleeping, and the facility adjusted her medications. On 6/03/26 at 11:55 AM, the MDS Coordinator said the facility had not yet submitted the PASARR screens for residents #4, #6, #8, #62, #7, and #10, because they were reviewing them for accuracy. She explained after the screens were corrected and submitted, they would put the information in the care plan and determine if the residents needed any additional psychiatry services. On 6/03/26 at 1:30 PM, the Social Services Assistant stated she and the Social Services Director conferenced with psychiatry and were updated if the resident had a new mental health diagnosis via email. She did not say why the PASARR level I's were not correct for residents #4, #6, #8, #62, #7, and #10. On 6/04/26 at 1:42 PM, the Director of Nursing (DON) stated she and the MDS Coordinator were responsible for PASARR screens, and explained the Social Services Department reviewed them. She said they checked the diagnoses when the resident came from the hospital to ensure they were accurate. The facility PASARR policy (undated) revealed the facility had a guideline to ensure all residents admitted to the facility received a Pre-admission Screening and Resident Review, in accordance with State and Federal Regulations. The document described the facility was obligated to coordinate the Level I and II PASARRs into the care plan to ensure residents received the appropriate psychiatry services. The policy indicated the facility was responsible to make sure people with intellectual disabilities or serious mental illnesses had access to the appropriate level of care.

Based on observation, interview, and record review, the facility failed to adhere to accepted standards of practice for intravenous (IV) catheters, including midlines for 1 of 2 residents reviewed for IV antibiotics, of a total sample of 38 residents, (#128). Findings: 1. Review of resident #128's medical record revealed she was admitted to the facility on [DATE] with diagnoses including acute pyelonephritis (kidney infection), bacteremia (bacteria in the blood), urinary tract infection, extended spectrum beta lactamase (ESBL) resistance and dementia. Hospital paperwork dated 5/28/26 showed an Infectious Disease consult for ESBL Klebsiella bacteremia originating from a urinary source. The consult noted left sided pyelonephritis, and the bacteria were susceptible to ertapenem, which was ordered. Extended spectrum beta lactamase (ESBL)-producing Enterobacterales are resistant to common antibiotics and require complex treatment. These organisms, including Klebsiella pneumoniae, can cause urinary tract and bloodstream infections, leading to increased morbidity and hospitalization (retrieved from CDC on 6/05/26). Physician orders dated 5/31/26 directed Ertapenem sodium 1 gram, reconstituted, to be administered intravenously daily for seven days. On 6/01/26 at 10:52 AM, Licensed Practical Nurse (LPN) B confirmed resident #128 had the midline IV catheter but had no physician orders for midline catheter monitoring or dressing changes. On 6/03/26 at 9:02 AM, LPN A was preparing Ertapenem Sodium reconstituted 1 gram (gm) in a 100 milliliter (ml) bag to be administered IV. LPN A set the dial flow rate to 100 ml/hour. After the nurse completed administration and disposed of used supplies including her PPE, LPN A verified the pharmacy administration instructions written on the IV bag. LPN A acknowledged she had set the flow rate incorrectly and the rate should have been 200 ml/hour instead of 100 ml/hour. She explained the IV antibiotic should run for a total of 30 minutes and the previous flow rate of 100 ml/hour would have run over an hour. LPN A could not say why she set the rate incorrectly and acknowledged she should have verified the pharmacy instructions and physician's order before setting the flow rate. On 6/04/26 at 12:30 PM, the Director of Nursing (DON) acknowledged resident #128 did not have orders related to monitoring and maintaining the midline catheter until after the start of survey. She explained the facility process was for the admitting nurse to enter the orders for the IV. She said a second check was performed during their clinical meeting on Monday morning to make sure all associated orders were in the resident's chart. The DON acknowledged she was aware LPN A administered the IV antibiotic for resident #128 at the incorrect rate. She stated the pharmacy determined the rate at which the antibiotics should be run based on multiple factors and nurses were expected to read and follow those instructions. Review of the undated policy titled Medication Administration revealed medications were to be verified before administration. Verification of the medication included reviewing the medication name and label.

Based on interview, and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice that accounted for residents' experiences and preferences to mitigate triggers to avoid re-traumatization of the resident, for 2 of 2 residents diagnosed with Post Traumatic Stress Disorder (PTSD), of a total sample of 38 residents, (#8, and #62).Findings: 1. Resident #8 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction), alcoholic liver cirrhosis with fluid buildup, bipolar disorder, major depression, anxiety, and PTSD. The most recent Minimum Data Set (MDS) quarterly assessment with an Assessment Reference Date (ARD) of 5/07/26 showed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, intact cognitive function. The MDS listed PTSD as an active diagnosis for resident #8 under psychiatric or mood disorders. On 6/01/26 at 1:32 PM, resident #8 stated she did not sleep well and sometimes had nightmares. Review of psychiatrist progress notes from 2/26/26, 5/26/26, and 5/07/26, included, The history suggests that this patient has suffered from significant trauma resulting into nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one month(s) and have occurred without any substance use or organic brain pathology Care Plan for PTSD diagnosis: Trauma: Reports childhood emotional, physical and sexual abuse by family members Triggers: Male resident resembling father, trauma related nightmares, Care Plan: Started Prazosin, increased Sertraline refer to psychotherapy, staff to use trauma informed approach, monitor distress around triggers. A review of resident #8's Comprehensive Care Plan showed a focus for a risk for trauma related to medical settings but did not include a care plan that listed her specific trauma triggers. On 6/03/26 at 10:25 AM, resident #8's assigned Certified Nursing Assistant (CNA) F said the resident needed minimal assistance with activities of daily living, and she was not aware of any special care or instructions when caring for resident #8. CNA F explained as she reviewed the Kardex on her computer that there were special instructions for resident #8. On 6/03/26 at 10:45 AM, resident #8's assigned Registered Nurse (RN) D said the resident refused medication at times and preferred going outside to smoke. He said he did not know of any special instructions or precautions for resident #8 care. 2. Resident #62 was admitted to the facility on [DATE] with health diagnoses that included Type 2 diabetes, acute kidney failure, paranoid schizophrenia, bipolar disorder, anxiety disorder, autistic disorder, major depression, and PTSD. The most recent MDS quarterly assessment with an ARD of 3/11/26 showed the resident had a BIMS score of 13 out of 15, meaning her cognition was mostly intact. The MDS listed PTSD as an active diagnosis under psychiatric or mood disorders. A psychiatrist's note from 3/10/26 documented, The history suggests that this patient has suffered from significant trauma resulting into nightmares, flashbacks, and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to the patient. The symptoms have lasted for more than one month[s] and have occurred without any substance use or organic brain pathology Care Plan for PTSD diagnosis: Trauma: Being stabbed by niece at age [AGE] Triggers: Discussing past trauma, Care Plan: monitor for nightmares or emotional triggers maintain supportive environment. Review of resident #62's Comprehensive Care Plan revealed the resident had a risk for emotional distress related to a history of abuse, PTSD, and trauma. However, the care plan did not include her triggers and did not reflect the psychiatrist's suggestions. On 6/01/26 at 3:25 PM, resident #62 was upset and stated she did not want to leave her room while it was being deep cleaned. She said she had trouble sitting near another resident in the dining room who coughed a lot. On 6/03/26 at 10:25 AM, the assigned CNA F said she knew the resident who was able to communicate her needs. CNA F stated she was not aware of any special instructions or precautions for the resident. On 6/03/26 at 10:45 AM, resident #62's assigned RN D said he would check her medications and lithium level labs whenever she showed certain behaviors, but he did not know of any other special care instructions or precautions to take around her. On 6/03/26 at 3:38 PM, in a joint interview, the Social Services Director (SSD) and Social Services Assistant (SSA) said the SSA completed the Trauma-Informed Care Assessment for new or returning residents. They explained, if psychiatric services were needed, a referral was made, and they followed the psychiatrist's recommendations. The SSD said she reviewed care plans but was unsure about trauma-informed care plans. She said their department completed assessments, and the MDS team helped with care planning. On 6/03/26 at 3:58 PM, the MDS Coordinator said the User Defined Assessment (UDA) for trauma was completed by the SSD, and she helped with it. She explained that no specific triggers were added to care plans because residents often did not talk about them. She said she was not the only one responsible, as the whole Interdisciplinary Team (IDT) worked on care planning. On 6/03/26 at 4:10 PM, in a joint interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), SSD, and MDS Coordinator, the DON said the IDT was responsible for trauma-informed care plans. She said there was poor communication between the psychiatrist and the team, which caused the triggers listed in the psychiatrist's notes to be missed. After comparing the psychiatrist's notes for residents #8 and #62, to their mutual care plans, the DON agreed the care plans were not resident centered. The DON said she expected better communication so the staff could avoid triggers for residents with PTSD. On 6/04/26 at 9:18 AM, in a joint interview with the Psychiatric Advance Practice Registered Nurse, and DON, they agreed that trauma-informed care plans should include the resident's triggers and steps for staff to prevent re-traumatization. She said all staff should know this information and that she expected the team to read her notes but confirmed their communication had broken down. The facility's Trauma-Informed Care policy, revised 7/27/22, indicated the facility would provide care that met professional standards, respected culture and preferences, and avoided triggers or re-traumatization. The guidelines said that even if a trauma survivor did not want to share their history, the facility should still try to identify triggers and create care plan steps to reduce or remove them.

Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from neglect to prevent a fall with major injury (#3); and neglected to implement care directives to promote safety during a transfer procedure, (#2), for 2 of 7 residents reviewed for mechanical lift use, out of a total sample of 8 residents. On 11/22/24 at approximately 5:00 PM, the facility failed to prevent resident #3, a vulnerable, physically impaired resident, from suffering a fall and fracture. The resident's plan of care indicated she required assistance from two staff members for transfers with a full body mechanical lift, but her assigned Certified Nursing Assistant (CNA) attempted the task single-handedly. During the transfer between the shower chair and her bed, one of the sling's loops detached from the lift while the resident was suspended in the air, and she fell to the floor. Resident #3 landed on her head and back, suffered excruciating pain, and was hospitalized with diagnoses of blunt head trauma and a fracture of the sacrum or tailbone. On re-admission to the facility, resident #3 complained of acute left hip pain, and after three weeks of persistent pain, she was subsequently diagnosed with a left hip fracture and required re-hospitalization . After the fall, resident #3 developed a fear of using the mechanical lift and chose to remain in bed, which affected her quality of life by limiting participation in her usual routine and activities of choice. On 12/10/24 at approximately 11:00 AM, the facility failed to ensure staff accessed and implemented the plan of care for resident #2, a physically impaired resident, to promote his safety during a mechanical lift transfer. The resident's assigned CNA neglected to review the CNA care plan or kardex prior to the procedure and attempted to transfer him from the bed to a chair with a sit-to stand lift, instead of a full body lift as required. Resident #2 had noticeable weakness and poor balance, but the CNA did not pause the transfer to validate his transfer status and thereby placed him at high risk for an adverse outcome as he was unable to stand. The facility's failure to provide appropriate care and services for mechanical lift transfers contributed to resident #3's fall and fracture and placed resident #2 and all 48 residents who required mechanical lifts for transfers at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on 11/22/24. The facility's Director of Nursing and Regional Nurse Consultant were notified of the Immediate Jeopardy on 12/13/24 at 3:05 PM, and provided the Immediate Jeopardy templates. The Immediate Jeopardy was determined to be removed on 12/11/24 after verification of the immediate actions implemented by the facility. The scope and severity of the deficiencies was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy. The census at the start of the survey was 105. Findings: Cross reference F689 and F726. 1. Review of the medical record revealed resident #3, a [AGE] year-old female, was admitted to the facility on [DATE]. She was transferred to the hospital on 11/22/24, readmitted on [DATE], and returned to the hospital on 12/12/24. Her diagnoses included multiple sclerosis, breast cancer, secondary bone cancer, muscle contractures of her left hip, both knees, and right ankle, muscle wasting and atrophy of the shoulders, post-fall sacral fracture, and a left hip fracture. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 10/23/24 revealed resident #3 had functional limitation in range of motion due to impairment of all extremities and used a wheelchair for mobility. Resident #3 was dependent on staff for transfers between the chair and bed, and into and out of the shower. The MDS Discharge assessment-return anticipated, with ARD of 11/22/24, revealed resident #3 had an unplanned discharge to an acute care hospital on 11/22/24. The MDS assessment indicated she had one fall since admission/entry, re-entry, or the prior assessment, which resulted in a major injury. Review of the medical record revealed resident #3 had a care plan for activities of daily living (ADL) self-care performance deficit related to multiple sclerosis, impaired mobility, and contractures. The document was created on 4/03/15 and revised on 2/23/24. The goal was resident #3 would have her ADL needs met by staff. The interventions included instructions for CNAs to perform chair/bed and shower transfers with a total body mechanical lift operated by two staff. A care plan for risk for complications of osteoporosis with a history of a fracture, initiated on 4/03/15 and revised on 11/28/24, revealed a goal that resident #3 would remain free of injury. The interventions included educate the resident and caregivers on safety measures needed to reduce the risk for falls and report signs of a fracture and pain to the physician. Review of the CNA care plan or kardex for resident #3 revealed instruction for two CNAs to perform transfers with a full body mechanical lift. On 12/10/24 at 3:02 PM, the facility's Administrator and Director of Nursing (DON) discussed resident #3's fall. The Administrator explained the incident investigation showed resident #3's assigned CNA performed a mechanical lift transfer without assistance, which was contrary to the facility's policy. The Administrator verified the facility therefore substantiated the incident as neglect. The DON stated she interviewed CNA A by telephone on the day of the incident and had her come into the building the following day to do a re-enactment and demonstrate how the resident fell . She stated CNA A confirmed she performed the mechanical lift transfer by herself and admitted to not following her training. On 12/10/24 at 10:10 AM, resident #3 verified she fell from the mechanical lift when her CNA attempted to transfer her from the shower chair to her bed. She stated the CNA was the only staff present at the time. Resident #3 said, It was not the first time that only one CNA picked me up in the lift. I did not realize it was wrong then, but now I know it is supposed to be two people. Resident #3 stated since the fall she was fearful of using the lift and now had significant left hip pain with movement. On 12/10/24 at 4:02 PM, CNA B stated she often assisted CNA A to transfer resident #3 with the mechanical lift on shower days. She recalled on the day the resident fell ; she assisted CNA A to transfer her from the bed to the shower chair. CNA B stated she did not accompany them to the shower room, but told CNA A to call her when they were finished so she could assist with transferring resident #3 back to bed. CNA B stated she left to provide care for her assigned residents and when the dinner meal cart arrived, she started to distribute trays. She explained she did not see when CNA A and resident #3 returned from the shower room, and CNA A never asked her to help to transfer the resident back to bed. CNA B stated she was in the unit's day room when CNA A shouted her name three times from resident #3's doorway. She stated CNA A appeared very upset and when she ran to the room to check what happened, she saw resident #3 on the floor. CNA B stated all CNAs were aware a mechanical lift transfer required two people, but CNA A decided to do the wrong thing. In interviews on 12/10/24 at 10:00 AM, and 12/12/24 at 10:45 AM, the Cambridge Unit Manager (UM) confirmed resident #3 required a full body mechanical lift for transfers. She explained the resident fell from the lift on 11/22/24 when the assigned CNA performed a transfer by herself, although the task required two staff. The UM stated resident #3 was hospitalized after the fall, and was diagnosed with a sacral fracture. She confirmed the resident complained of increased pain since re-admission to the facility and now requested almost daily doses of the pain medication Oxycodone, a significant increase compared to before the fall. The UM stated x-rays done yesterday showed resident #3 had a left hip fracture so she was sent to the hospital this morning for evaluation. On 12/13/24 at 9:57 AM, in a telephone interview, resident #3's daughter confirmed since her mother fell during a mechanical lift transfer, she had been experiencing significant pain with movement, particularly when she rolled from side to side. The resident's daughter stated her mother was again in the hospital with a newly diagnosed left hip fracture that likely occurred at the time of the fall from the lift, although it was not diagnosed then. She explained her mother was not a good surgical candidate at this time as she was compromised by multiple clinical conditions including metastatic cancer and multiple sclerosis. Resident #3's daughter acknowledged the combination of the improbability of surgery, increased pain, and fear of using the lift would create limitations that negatively impacted her mother's quality of life. She said, I think they could have done a better job assessing her pain and addressing the cause. I am upset. 2. Review of the medical record revealed resident #2, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included seizures, muscle wasting and atrophy of both shoulders, unsteadiness on his feet, abnormal posture, and cervical spine fusion. Resident #2 had a nursing care plan created on 10/27/24 for ADL self-care performance deficit related to generalized weakness. An intervention dated 11/24/24 instructed CNAs to perform transfers between the bed and wheelchair and into and out of the shower with a total body mechanical lift operated by two staff. Review of the kardex for resident #2 revealed the instruction for two CNAs to transfer him between the bed and chair with a full body mechanical lift. On 12/10/24 at 9:50 AM, CNA C stated resident #2 was scheduled for a shower today and she would transfer him from his bed to the shower chair with a mechanical lift. A sit-to-stand lift was noted in the hallway near the resident's door. On 12/10/24 at 11:00 AM, CNA C stated she was ready to transfer resident #2 with assistance from CNA E. The sit-to-stand lift remained outside resident #2's door so CNA C was prompted to check the care directives regarding the resident's transfer needs. She reviewed the nursing care plan for risk for falls, but did not check the care plan for ADLs or view the Kardex with specific transfer instructions. On 12/10/24 at 11:02 AM, CNA C placed the sit-to-stand lift at resident #2's bedside and CNA E assisted with positioning the resident into a seated position on the side of the bed. He was not able maintain an upright position and rocked backwards and fell to the side without CNA E's support. CNA C explained before the resident went to the hospital, he did not use a lift as he was able to stand for transfers with the assistance of two people. She stated since re-admission, he was much weaker and required a mechanical lift. CNA C stated this was her first attempt to get the resident out of bed since his return from the hospital. As CNA C continued to position resident #2 in the sit-to-stand lift for the transfer, CNA E expressed concern, pointed to the lift, and said, Maybe this is not good for him. Staff were aware of the resident's extreme weakness and obvious inability to even sit, and neither CNA stopped the procedure to verify his transfer requirements or report concerns to a nurse. The transfer with the sit-to-stand lift was averted when CNA C discovered the lift's battery was dead. On 12/11/24 at 9:56 AM, the Therapy Director was informed staff attempted to transfer resident #2 from his bed to the shower chair with a sit-to-stand mechanical lift. She reviewed his Physical Therapy notes and explained the resident required maximum assistance for transfers and it was determined that the full body mechanical lift was the appropriate type for CNAs to use. She was informed CNA C mentioned that prior to his hospitalization , the resident could do stand and pivot transfers with two staff. The Therapy Director reiterated resident #2 required maximum assistance for transfers and for the safety of staff and the resident, a full body mechanical lift was the only recommended transfer method. On 12/12/24 at 12:19 PM, the facility's Medical Director stated he was very familiar with resident #3's medical issues which included multiple sclerosis and breast cancer with bone metastasis. He explained recent diagnostic tests showed metastatic lesions in both hips. The Medical Director stated the CNA's decision to transfer the resident by herself was inexcusable as she was very frail and already at high risk for fractures due to her diagnoses. He stated his expectation was for all staff to handle resident #3 delicately, like an egg. The Medical Director confirmed he was made aware CNAs attempted to transfer resident #2 with the wrong type of mechanical lift a couple days ago, because they did not check the care directives. He stated he was dumbfounded as all staff were re-educated on transfers with mechanical lifts after resident #3 fell a few weeks ago. The Medical Director emphasized the importance of CNAs following care directives to ensure residents were transferred appropriately and safely. Review of the facility's policy and procedures for the prohibition of Abuse, Neglect and Exploitation, revised on 11/16/23, revealed the facility would protect the health, welfare, and rights of each resident. The policy defined neglect as failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The document indicated the facility would provide ongoing oversight and supervision of staff to ensure the abuse and neglect prohibition policy was implemented. Review of the policy and procedures for Comprehensive Care Plans, revised on 7/27/22, revealed the facility would develop and implement a comprehensive care plan to meet residents' needs according to assessment findings and identify services to be furnished to attain the highest practicable well-being. Review of the facility's policy and procedures for Safe Resident Handling/Transfers, revised on 11/29/22, revealed the facility would ensure residents were handled and transferred safely to minimize risks for injury and promote a safe, secure and comfortable experience for the resident. The guidelines revealed the interdisciplinary team (IDT) would evaluate and assess each resident's mobility needs to determine the type of lifting equipment or other transferring/handling aids to be used. The document read, Two staff members must be utilized when transferring residents with a mechanical lift.Staff members are expected to maintain compliance with safe handling/transfer practices.Resident lifting and transferring will be performed according to the resident's individual plan of care. The resident sample was expanded to include five additional residents who required a full body mechanical lift for transfers. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 11/22/24, the evening shift Nursing Supervisor immediately placed the mechanical lift and sling out of service. * On 11/22/24, the CNA who failed to follow correct procedure for use of mechanical lift using two staff members was immediately suspended. * On 11/22/24, the Weekend Nursing Supervisor began education and skills validation with 13 of 24 CNAs duty on the day, evening and night shifts. * On 11/23/24, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the facility's Administrator, Director of Nursing, and Medical Director to review the initial incident. * On 11/24/24 through 11/25/24, the Therapy Director completed resident transfer status evaluations on current residents. Any updates were placed in the kardex and care plans. * On 11/24/24 through 11/25/24, the MDS coordinator completed care plan/kardex reviews to ensure appropriate transfer status was on care plan/kardex for current residents. * On 11/25/24, the MDS Coordinators completed a quality review of current residents for MDS accuracy related to transfer status. Corrections were made as identified. Quality reviews were then completed on current resident care plans and kardexes to ensure accurate transfer status were listed. Corrections were made when identified. * On 11/23/24, the Maintenance Director inspected all mechanical lifts and slings for any malfunctions and no concerns were identified. * On 11/23/24 through 11/27/24, current nursing staff were educated on mechanical lift usage and competencies were performed by the Director of Nursing, Staff Development Coordinator, and Nurse Managers. Occupational and Physical Therapy staff were educated on mechanical lift usage. Of 91 total nursing staff, 80 total current nursing staff received education, and 11 total nursing staff members were to receive education prior to next shift worked. Of 27 total Occupational and Physical Therapy staff, 26 total current therapy staff received education, and 1 total therapy staff member was to receive education prior to next shift worked. There are no contracted licensed nurses or CNAs currently on staff. Any contracted nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet. * On 11/24/24 through 11/27/24, current facility staff were educated on abuse, neglect and exploitation by the Administrator, Director of Nursing, Staff Development Coordinator, and Nurse Managers. Of 171 total staff, 171 current staff received education. There are no staff members who require education prior to next shift worked, and no contracted licensed nurses or CNAs on staff. Any contracted nurses or CNAs who are placed at the facility on assignment in the future will receive the above education prior to starting their shift through an agency orientation packet. * On 11/23/24, an Ad Hoc QAPI meeting was completed with the Medical Director, Administrator, and DON. The topics of the incident, abuse and neglect, use of mechanical lifts, mechanical lift competencies, updating care plans/kardex, and following care plans/kardex were discussed. * On 11/25/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, Staff Development Coordinator, IDT members, and Nurse Managers to review the 4-Point Plan and Investigation. * On 11/26/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT members to include the Director of Rehabilitation, to review the 4-Point Plan, Root Cause Analysis, and progression of investigation. * On 12/07/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT team to include the Director of Rehabilitation, to review the 4-Point Plan progress, quality reviews, and conclusion of investigation. * On 12/10/24, the Unit Manager corrected the assigned CNA on the proper way to transfer resident #2 and showed her the transfer status on the kardex. The CNA was suspended pending investigation and re-educated on checking the kardex prior to transfers. * On 12/10/24, nursing staff re-education on how to view kardex for transfer status was initiated with return demonstration required. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift. * On 12/10/24, nursing staff competencies were initiated by the Director of Nursing or designees. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift, by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift. * On 12/11/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to discuss areas of concern that were identified during the complaint survey that started on 12/10/24 and additional steps the facility is taking to re-educate staff. * On 12/12/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to go over kardex education, discuss quality monitoring tools, root cause of concerns, and clarify areas of concerns. Interviews conducted on 12/13/24 with 19 total facility staff who represented the nursing, therapy, and housekeeping departments revealed they were knowledgeable of the facility's policy and procedure to prohibit abuse and neglect. Interviews conducted with nursing staff, including 12 CNAs, two Registered Nurses, and two Licensed Practical Nurses, revealed they received education on the Safe Resident Handling/Transfers policy and procedures, and the requirement to access and review the nursing care plan or CNA kardex as appropriate, to identify the type of mechanical lift and number of staff required for transfers. Staff validated they performed return demonstrations.

Based on observation, interview, and record review, the facility failed to follow its policies and procedures and accepted standards of practice to prevent an avoidable fall from a full body mechanical lift (#3); and ensure use of the appropriate type of mechanical lift to meet assessed needs (#2), for 2 of 7 residents reviewed for mechanical lift use, out of a total sample of 8 residents. On 11/22/24 at approximately 5:00 PM, the facility failed to prevent resident #3, a vulnerable, physically impaired resident, from suffering a fall and fracture. The resident's plan of care indicated she required assistance from two staff members for transfers with a full body mechanical lift, but her assigned Certified Nursing Assistant (CNA) attempted the task single-handedly. During the transfer between the shower chair and her bed, one of the sling's loops detached from the lift while the resident was suspended in the air, and she fell to the floor. Resident #3 landed on her head and back, suffered excruciating pain, and was hospitalized with diagnoses of blunt head trauma and a fracture of the sacrum or tailbone. On re-admission to the facility, resident #3 complained of acute left hip pain, and after three weeks of persistent pain, she was subsequently diagnosed with a left hip fracture and required re-hospitalization . After the fall, resident #3 developed a fear of using the mechanical lift and chose to remain in bed, which affected her quality of life by limiting participation in her usual routine and activities of choice. On 12/10/24 at approximately 11:00 AM, the facility failed to ensure staff accessed and implemented the plan of care for resident #2, a physically impaired resident, to promote his safety during a mechanical lift transfer. The resident's assigned CNA neglected to review the CNA care plan or kardex prior to the procedure and attempted to transfer him from the bed to a chair with a sit-to stand lift, instead of a full body lift as required. Resident #2 had noticeable weakness and poor balance, but the CNA did not pause to validate his transfer status which thereby placed him at high risk for an adverse outcome as he was unable to stand. The facility's failure to adhere to plans of care related to providing the required number of staff to operate a mechanical lift and failure to use the appropriate type of lift contributed to resident #3's fall and fracture, and placed resident #2 and all 48 residents who required mechanical lifts for transfers at risk for serious injury/impairment/death. These failures resulted in Immediate Jeopardy starting on 11/22/24. The facility's Director of Nursing and Regional Nurse Consultant were notified of the Immediate Jeopardy on 12/13/24 at 3:05 PM, and provided the Immediate Jeopardy templates. The Immediate Jeopardy was determined to be removed on 12/11/24 after verification of the immediate actions implemented by the facility. The scope and severity of the deficiencies was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy. The census at the start of the survey was 105. Findings: Cross reference F600 and F726. 1. Review of the medical record revealed resident #3, a [AGE] year-old female, was admitted to the facility on [DATE]. She was transferred to the hospital on 11/22/24, readmitted on [DATE], and returned to the hospital on 12/12/24. Her diagnoses included multiple sclerosis, breast cancer, secondary bone cancer, muscle contractures of her left hip, both knees, and right ankle, muscle wasting and atrophy of the shoulders, post-fall sacral fracture, and a left hip fracture. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 10/23/24 revealed resident #3 had clear speech, was able to express her ideas and wants, and had no comprehension issues. The resident's Brief Interview for Mental Status (BIMS) score was 15/15 which indicated she was cognitively intact. The MDS assessment revealed resident #3 exhibited no behavioral symptoms and did not reject evaluation or care that was necessary to achieve her goals for health and well-being. She had functional limitation in range of motion due to impairment of all extremities and used a wheelchair for mobility. Resident #3 was dependent on staff for transfers between the chair and bed, and into and out of the shower. The MDS Discharge assessment-return anticipated, with ARD of 11/22/24, revealed resident #3 had an unplanned discharge to an acute care hospital on 11/22/24. The MDS assessment indicated she had one fall since admission/entry, re-entry, or the prior assessment, which resulted in a major injury. Review of the medical record revealed resident #3 had a care plan for activities of daily living (ADL) self-care performance deficit related to multiple sclerosis, impaired mobility, and contractures. The document was created on 4/03/15 and revised on 2/23/24. The goal was resident #3 would have her ADL needs met by staff. The interventions included instructions for CNAs to perform chair/bed and shower transfers with a total body mechanical lift operated by two staff. A care plan for risk for complications of osteoporosis with a history of a fracture, initiated on 4/03/15 and revised on 11/28/24, revealed a goal that resident #3 would remain free of injury. The interventions included educate the resident and caregivers on safety measures needed to reduce the risk for falls and report signs of a fracture and pain to the physician. Review of the CNA care plan or kardex for resident #3 revealed the instruction for two CNAs to perform transfers with a full body mechanical lift. Review of the Physical Therapy Plan of Care dated 9/25/24 revealed resident #3 was referred for therapy services to address further deterioration in range of motion of her hips, knees, and ankles. The document indicated she required total assistance for transfers and got out of bed three times weekly to a high-back recliner wheelchair. The Initial Physical Therapy assessment showed resident #3 was dependent on staff for transfers and read, Resident does none of the effort to complete the activity.assistance of 2 or more helpers is required for the resident to complete the activity. A Situation, Background, Appearance, Review and Notify (SBAR) Communication Form dated 11/22/24 revealed resident #3 had a fall and complained of level 10/10 pain in the back of her head. The document indicated RN D notified the resident's primary care clinician and her daughter of the accident. Review of a Narrative Note written on 11/22/24 by Registered Nurse (RN) D, the 3:00 PM to 11:00 PM Nursing Supervisor, revealed resident #3 fell while being transferred from the chair to her bed with a full body mechanical lift, and was sent to the hospital. Review of the Order Recap Report for November and December 2024 revealed resident #3 had a physician order with an effective date of 11/22/24, to send her to the Emergency Department for evaluation after a fall. Review of the hospital record revealed resident #3 had computed tomography (CT) scans of her head, neck, and spine on 11/22/24 for complaints of a headache and neck pain after a she fell out of [mechanical] lift. The result showed no acute intracranial abnormality, but the resident had a small scalp contusion on the left side of the back of her head. A CT scan of the lumbar spine, dated 11/22/24, was done for a complaint of back pain, and the result showed resident #3 sustained an acute fracture along the anterior sacrum at the S2 level. An x-ray of her pelvis done on 11/22/24 was described as a significantly limited evaluation that could not exclude an acute impacted left hip femoral neck fracture. A follow-up CT scan for further evaluation was recommended by the radiologist. Review of the CT scan of the resident' pelvis dated 11/22/24 showed no acute abnormality. The hospital record included resident #3's History & Physical dated 11/23/24, which showed assessment findings including fall from a mechanical lift, lower back pain, headache, blunt head trauma, and acute closed fracture of the anterior sacrum. Review of the Admit/Readmit Screener & Baseline Care Plan dated 11/27/24 revealed on re-admission to the facility from the hospital, resident #3 was alert and oriented to person, place, time, and situation. The document showed resident #3 reported she had experienced frequent, moderate left hip pain over the last five days and the nurse noted the resident said, My left hip hurts. The document revealed the resident described her hip pain as worse with movement and alleviated by the pain medication Oxycodone. The Order Recap Report for November and December 2024 included orders dated 11/27/24 to re-admit resident #3 for long term care services and observe for pain every shift. Resident #3 had physician orders dated 11/28/24 for two tablets of Acetaminophen (pain reliever) 325 milligrams (mg) every four hours as needed for mild pain, Baclofen (muscle relaxer) 10 mg once daily for back pain, and Oxycodone (Opioid pain reliever) 5 mg as needed for pain. Review of a Health Note dated 11/28/24 revealed resident #3 was assessed by a clinical provider on re-admission to the facility. The note indicated she had acute pain due to trauma and complained of left hip pain with movement. A Skin/Wound Note dated 12/02/24 revealed resident #3 continued to complain of pain with left hip movement. Review of the medical record revealed a physician order dated 12/10/24 for diagnostic x-rays of the resident's left ankle, and both femurs (thigh bones) for report of pain. A Radiology Results Report dated 12/11/24 revealed resident #3 had x-rays of her left ankle, left hip, and right hip. Interpretation of the x-rays showed the resident had a fracture at the upper end of her left femur. Review of an SBAR Communication Form revealed resident #3's primary care clinician was notified of her left hip fracture on 12/12/24 at 6:20 AM. The form indicated the facility received an order to send the resident to the hospital Emergency Department via emergency medical services. On 12/10/24 at 10:00 AM, the Cambridge Unit Manager (UM) confirmed resident #3 fell from the full body mechanical lift and sustained a sacral fracture. She stated after completing the resident's shower, CNA A transported her back to her room in the shower chair. The UM explained CNA A used the mechanical lift to transfer the resident from the chair to her bed, noted one of the straps on the sling came loose, and had to lower her to the ground. The UM confirmed transfers with full body mechanical lifts required two staff members to be present. On 12/10/24 at 10:10 AM, resident #3 verified she fell from the mechanical lift during a transfer between the shower chair and her bed. She stated the CNA was the only staff member in the room at the time. Resident #3 used her hand to demonstrate that she was above the current height of the bed. She said, I was up in the air. I suddenly, quickly fell flat to the floor. I hit the back of my head and back. I was shocked. I did not realize what happened because it was so fast. She stated she felt as if she slipped out of the sling. The resident stated she was in a lot of pain after she landed on the floor. She explained she still had pain whenever she rolled from one side to another, especially on the left side. Resident #3 expressed fear of using the mechanical lift since the incident and stated in the three weeks since her fall, she got out of bed only once with assistance from two or three strong men, who transported her to a doctor's appointment. She confirmed she had not been transferred by CNAs since she fell . The resident stated before the incident, she enjoyed getting out of bed on some days, just to get into her wheelchair and move around the room. On 12/10/24 at 10:48 AM, Physical Therapy Assistant (PTA) F explained resident #3 was going to be transferred from her bed to the wheelchair for the first time since re-admission. She stated she would be present to reassure resident #3 during the procedure. PTA F confirmed resident #3 complained of pain in her left hip during morning care, and she positioned her legs with a pillow to relieve the pain. On 12/10/24 at 10:52 AM, CNAs C and E placed the sling underneath resident #3 in bed and attached the loops to the spreader bar of the full body mechanical lift. During the transfer procedure, the resident complained of left hip pain and had an apprehensive expression. When resident #3 was seated in the wheelchair, CNA E repositioned her left leg and foot and the resident cried out, grimaced, and continued to tell staff her left hip hurt. On 12/10/24 at 3:02 PM, the Administrator confirmed the facility's incident investigation showed resident #3 fell during a mechanical lift transfer performed by CNA A. She verified CNA A did not follow the facility's policy and procedures for mechanical lift transfers which indicated these types of transfers always required two staff members. On 12/10/24 at 3:37 PM, RN D verified she was the evening shift Nursing Supervisor on 11/22/24. She recalled she was on the Bristol unit at about 5:00 PM when someone urgently grabbed her and said she was needed on the Cambridge unit. RN D stated she rushed to the room as directed and saw resident #3 on the floor near the foot of her bed. She stated the mechanical lift was at the foot of the roommate's bed and the shower chair was close to the door. RN D explained it appeared as if CNA A had rolled the lift across the room with the resident in it. She stated the sling was on the floor under the resident who still had towels wrapped around her body. RN D stated she assessed resident #3, noted she was in pain, and discovered a lump on the back of her head. She confirmed she arranged for the resident to go to the hospital for further evaluation. On 12/11/24 at 10:27 AM, the Therapy Director validated for at least the last three years, resident #3 was dependent on two staff for transfers as she required a full body mechanical lift. The Therapy Director stated the resident enjoyed therapy sessions and usually came to the gym. She was informed resident #3 was now fearful of the mechanical lift and chose to remain in bed. The Therapy Director reviewed resident #3's treatment notes and confirmed she did not see documentation regarding any treatments in the gym since the fall. The Therapy Director confirmed resident #3 sometimes liked to get out of bed and propel herself in the wheelchair in her room. On 12/12/24 at 10:45 AM, the Cambridge UM explained prior to her fall from the mechanical lift, resident #3 had chronic pain issues related to her metastatic cancer, but her pain levels worsened after the fall. The UM reviewed the resident's Medication Administration Record (MAR) for October through December 2024 and confirmed the document showed increasing pain levels and more frequent use of Oxycodone for pain management. She verified prior to the fall from the mechanical lift, resident #3 requested only one dose of Oxycodone 5 mg in October 2024 and three doses in November 2024. The UM stated after the fall, the resident received Oxycodone on 11/30/24 for a pain level of 8. She verified the MAR showed in December 2024 resident #3 received Oxycodone 5 mg almost daily, as eight doses were administered over a 10-day period for pain levels that ranged from 4 to 8 on a 0 to 10 scale. On 12/12/24 at 12:19 PM, the facility's Medical Director stated the Administrator and Director of Nursing (DON) informed him of resident #3's fall from the mechanical lift. He described the CNA's decision to utilize the mechanical lift without assistance as inexcusable since she was frail and already at high risk for fractures due to her diagnosis of metastatic bone cancer. On 12/13/24 at 9:57 AM, in a telephone interview, resident #3's daughter stated during the weeks since re-admission from the hospital her mother experienced significant pain. She explained every time staff rolled her mother from side to side, she screamed or cried out in audible distress. The resident's daughter stated the facility eventually did x-rays and discovered her mother had a left hip fracture. She stated she visited her mother in the hospital early this morning and the orthopedic surgeon explained hip replacement/repair surgery was the solution, but not currently a realistic option, due to her mother's multiple health issues. The resident's daughter said, She's fine if she's not rolling or they're not transferring her, but that would make her be in bed all the time, and mostly in the same position. She is very nervous about the lift now.combination of fear and pain. She explained before the fall, her mother did things around her room, went to the therapy gym, and occasionally attended bingo with her roommate. The daughter acknowledged there would be restrictions on her mother's usual activities if she could not have surgery and had to remain in bed. She acknowledged her mother's contractures made positioning for diagnostic tests challenging, and the orthopedic surgeon felt the left hip fracture was related to the fall from the mechanical lift on 11/22/24 but was not diagnosed at that time. 2. Review of the medical record revealed resident #2, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included seizures, muscle wasting and atrophy of both shoulders, unsteadiness on his feet, abnormal posture, and cervical spine fusion. Review of the MDS Medicare 5-day assessment with ARD of 11/25/24 revealed resident #2 had functional limitation in range of motion due to impairment of one lower extremity. The MDS assessment indicated the resident was dependent on staff for transfers between the bed and wheelchair. Resident #2 had a nursing care plan created on 10/27/24 for ADL self-care performance deficit related to generalized weakness. An intervention dated 11/24/24 instructed CNAs to perform transfers between the bed and wheelchair and into and out of the shower with a total body mechanical lift operated by two staff. A care plan for risk for falls and fall related injury, created on 10/27/24 had the goal that resident #2's risk for falls and injuries would be minimized. The interventions included assist with transfers as needed, cue for safety awareness, and encourage use of the call light for assistance with standing/transferring. Review of the kardex for resident #2 revealed the instruction for two CNAs to perform transfers with a full body mechanical lift was noted in the section for ADL Level of Assistance. Review of the Physical Therapy Evaluation & Plan of Treatment dated 12/03/24 revealed at baseline, resident #2 required maximum assistance from two staff for transfers. He was referred to physical therapy due to exacerbation of decreased strength, functional mobility, and transfer ability, and reduced ADL participation. The document indicated his static sitting balance was poor and he was unable to maintain balance without moderate to maximal assistance. The evaluation showed the resident had intermittent, aching right knee pain, at a level 5/10. Review of the Occupational Therapy Evaluation & Plan of Treatment dated 12/03/24 revealed resident #2 had reduced bilateral upper extremity strength, reduced safety awareness, and decreased activity tolerance. The evaluation indicated the resident had poor sitting balance at baseline. On 12/10/24 at 11:00 AM, CNA C stated she was ready to get resident #2 out of bed and into the shower chair to transport him to the shower room. A sit-to-stand lift, instead of the full body lift noted in the medical record, was in the hallway outside the resident's room. CNA C was prompted to check the electronic kardex regarding the resident's transfer status. She accessed the nursing care plan instead of the kardex and reviewed an intervention for fall prevention related to encouraging the resident to use his call light to obtain assistance with standing and transferring. After reading the nursing care plan, CNA C stated the resident was able to stand for transfers. A few minutes later on 12/10/24 at 11:02 AM, CNA C placed the sit-to-stand lift at resident #2's bedside and assisted by CNA E, she initiated the transfer procedure. With substantial effort, both CNAs assisted resident #2 to sit on the side of his bed with his feet dangling above the base of the lift. The resident exhibited extreme weakness and poor balance as he repeatedly rocked backwards and from side to side. Due to his poor trunk control, CNA E had to keep her left hand and arm on or around the resident's shoulders to prevent him from falling as he could not support himself in a sitting position. CNA C explained resident #2 was weaker since his recent re-admission from the hospital. Next, she placed the sling behind the resident's upper back and under his arms and attached it to the lift. CNA E positioned the resident's arms and hands to hold on to the frame of the lift while CNA C instructed him to position his feet on the platform in preparation to stand. The resident attempted to follow the instruction but as he gripped the lift tightly with both hands, he continued to sway backwards and to the side. CNA E expressed concern, pointed to the lift, and said, Maybe this is not good for him. However, CNA C persevered. She pressed the button on the remote to lift resident #2 from his seated position but was not able to perform the transfer with the inappropriate lift as the battery was dead. CNA C left the room to retrieve another battery while CNA E returned resident #2 to a supine position in bed. A couple minutes later, CNA C stood at the nurses' station while the Cambridge UM looked at the computer screen. On 12/10/24 at 11:08 AM, CNA C walked towards resident #2's room with a full body mechanical lift. The Cambridge UM was informed CNAs C and E had been about to transfer resident with the wrong type of lift as the staff did not check the kardex for instructions prior to the task. On 12/11/24 at 2:46 PM, the Clinical Reimbursement Director confirmed it was very important for CNAs to follow the care directives developed by members of the interdisciplinary team (IDT) based on their assessment findings. She verified on admission on 10/28/24, resident #2's baseline care plan showed he was not able to stand. The Clinical Reimbursement Director reviewed the resident's comprehensive care plan and kardex and validated both documents showed the intervention for two staff to transfer him with a total mechanical lift. She stated resident #2 was never assessed as appropriate for sit-to-stand lift transfers. On 12/11/24 at 9:56 AM, the Therapy Director stated resident #2's re-admission evaluation by Physical Therapy on 12/02/24 showed he still required maximum assistance for transfers. She explained through a collaborative process, it was determined that CNAs should use the full body mechanical lift to transfer resident #2. The Therapy Director validated use of a sit-to-stand lift was not an appropriate choice for this resident. She explained the facility's goal was to promote safety for residents and staff, and the transfer attempted by CNAs C and E would not have been safe for resident #2 or the CNAs. On 12/12/24 at 12:19 PM, the Medical Director was informed of concerns related to the likelihood of an adverse outcome for resident #2 when staff attempted a mechanical lift transfer without accessing care directives and selected the wrong type of lift. The Medical Director confirmed the resident's attending physician had already made him aware of the issue and he was dumbfounded. Review of the facility's policy and procedures for Safe Resident Handling/Transfers, revised on 11/29/22, revealed the facility would ensure residents were handled and transferred safely to minimize risks for injury and promote a safe, secure and comfortable experience for the resident. The document indicated mechanical lifts were a safer alternative to manual lifting for staff and residents. The guidelines revealed the IDT would evaluate and assess each resident's mobility needs to determine the type of lifting equipment or other transferring/handling aids to be used. The document read, Two staff members must be utilized when transferring residents with a mechanical lift.Resident lifting and transferring will be performed according to the resident's individual plan of care. Review of the Facility Assessment Tool, dated 7/29/24, revealed facility staff would provide general care and services such as assistance with mobility and fall prevention. The document indicated the facility would offer specific care including bathing, showers, and transfers, and person-centered care such as the prevention of abuse and neglect and identification of risks and hazards. The resident sample was expanded to include five additional residents who required a full body mechanical lift for transfers. Review of immediate actions to remove the Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: * On 11/22/24, the evening shift Nursing Supervisor immediately placed the mechanical lift and sling out of service. * On 11/22/24, the CNA who failed to follow correct procedure for use of mechanical lift using two staff members was immediately suspended. * On 11/22/24, the Weekend Nursing Supervisor began education and skills validation with 13 of 24 CNAs duty on the day, evening and night shifts. * On 11/23/24, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the facility Administrator, Director of Nursing, and Medical Director to review the initial incident. * On 11/24/24 through 11/25/24, the Therapy Director completed resident transfer status evaluations on current residents. Any updates were placed in the kardex and care plans. * On 11/24/24 through 11/25/24, the MDS coordinator completed care plan/kardex reviews to ensure appropriate transfer status was on care plan/kardex for current residents. * On 11/25/24, the MDS Coordinators completed a quality review of current residents for MDS accuracy related to transfer status. Corrections were made as identified. Quality reviews were then completed on current resident care plans and kardexes to ensure accurate transfer status were listed. Corrections were made when identified. * On 11/23/24, the Maintenance Director inspected all mechanical lifts and slings for any malfunctions and no concerns were identified. * On 11/23/24 through 11/27/24, current nursing staff were educated on mechanical lift usage and competencies were performed by the Director of Nursing, Staff Development Coordinator, and Nurse Managers. Occupational and Physical Therapy staff were educated on mechanical lift usage. Of 91 total nursing staff, 80 total current nursing staff received education, and 11 total nursing staff members were to receive education prior to next shift worked. Of 27 total Occupational and Physical Therapy staff, 26 total current therapy staff received education, and 1 total therapy staff member was to receive education prior to next shift worked. There are no contracted licensed nurses or CNAs currently on staff. Any contracted nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet. * On 11/24/24 through 11/27/24, current facility staff were educated on abuse, neglect and exploitation by the Administrator, Director of Nursing, Staff Development Coordinator, and Nurse Managers. Of 171 total staff, 171 current staff received education. There are no staff members who require education prior to next shift worked, and no contracted licensed nurses or CNAs on staff. Any contracted nurses or CNAs who are placed at the facility on assignment in the future will receive the above education prior to starting their shift through an agency orientation packet. * On 11/23/24, an Ad Hoc QAPI meeting was completed with the Medical Director, Administrator, and DON. The topics of the incident, abuse and neglect, use of mechanical lifts, mechanical lift competencies, updating care plans/kardex, and following care plans/kardex were discussed. * On 11/25/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, Staff Development Coordinator, IDT members, and Nurse Managers to review the 4-Point Plan and Investigation. * On 11/26/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT members to include the Director of Rehabilitation, to review the 4-Point Plan, Root Cause Analysis, and progression of investigation. * On 12/07/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT team to include the Director of Rehabilitation, to review the 4-Point Plan progress, quality reviews, and conclusion of investigation. * On 12/10/24, the Unit Manager corrected the assigned CNA on the proper way to transfer resident #2 and showed her the transfer status on the kardex. The CNA was suspended pending investigation and re-educated on checking the kardex prior to transfers. * On 12/10/24, nursing staff re-education on how to view kardex for transfer status was initiated with return demonstration required. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift. * On 12/10/24, nursing staff competencies were initiated by the Director of Nursing or designees. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift, by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift. * On 12/11/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to discuss areas of concern that were identified during the complaint survey that started on 12/10/24 and additional steps the facility is taking to re-educate staff. * On 12/12/24, an Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to go over Kardex education, discuss quality monitoring tools, root cause of concerns, and clarify areas of concerns. Interviews conducted on 12/13/24 with 16 facility staff including 12 CNAs, two Registered Nurses, and two Licensed Practical Nurses who represented all shifts revealed they were knowledgeable of the facility's mechanical lift transfer policy and the requirement to access and review the nursing care plan or CNA kardex as appropriate, to identify the type of mechanical lift and number of staff required for transfers. Staff validated they performed return demonstrations.

Based on observation, interview, and record review, the facility failed to validate that Certified Nursing Assistants (CNAs) possessed and demonstrated appropriate competencies and skills to meet identified needs based on assessments, and followed directives in the plans of care for 2 of 7 residents reviewed for mechanical lift transfers, out of a total sample of 8 residents, (#2 and #3), and for all residents who required assistance with transfers. Findings: 1. Review of the medical record revealed resident #3, a [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included multiple sclerosis, breast cancer, secondary bone cancer, muscle contractures of her left hip, both knees, and right ankle, and a post-fall sacral fracture. Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 10/23/24 revealed resident #3 had a Brief Interview for Mental score of 15/15, which indicated she had no cognitive impairment. The MDS assessment showed the resident had functional limitation in range of motion due to impairments of all extremities and used a wheelchair for mobility. She was dependent on staff for transfers between the bed and wheelchair and into and out of the shower. The document showed she had no falls since admission/entry, re-entry, or the prior assessment. Resident #3 had a nursing care plan initiated on 4/03/15 for activities of daily living (ADL) self-care performance deficit related to multiple sclerosis, impaired mobility, and contractures. The goal was staff would anticipate and meet her ADL needs. An intervention dated 2/12/24 instructed CNAs to perform chair/bed and shower transfers with a total body mechanical lift operated by two staff. Review of the CNA care plan or kardex for resident #3 revealed the nursing care plan intervention regarding transfers was transcribed accurately. The instruction for two CNAs to perform transfers with a full body mechanical lift was noted in the section for ADL Level of Assistance. Review of a Narrative Note dated 11/22/24 revealed resident #3 fell during a mechanical lift transfer between the chair and her bed. The progress note indicated she was transferred to the hospital where she was diagnosed with a sacral fracture and blunt head trauma. On 12/10/24 at 10:10 AM, resident #3 verified she fell from the mechanical lift when her CNA attempted to transfer her from the shower chair to her bed. She stated the CNA was the only staff present at the time. Resident #3 said, It was not the first time that only one CNA picked me up in the lift. I did not realize it was wrong then, but now I know it is supposed to be two people. On 12/10/24 at 3:02 PM, the facility's Administrator and Director of Nursing (DON) discussed resident #3's fall. The Administrator explained the incident investigation showed resident #3's assigned CNA did not ask for assistance and used the mechanical lift to perform the transfer by herself. The Administrator stated according to CNA A, the loop of one shoulder strap detached from the lift and she had to lower resident #3 to the floor. The DON recalled she interviewed CNA A who admitted she performed the mechanical lift transfer without the help of another CNA. The DON stated she reminded CNA A she participated in skills fair competencies a few days before which included training on the requirement for two staff to perform all mechanical lift transfers. The DON stated since resident #3's fall, she and the Unit Managers (UMs) conducted random surveillance of staff during mechanical lift transfers to ensure there were two CNAs present. Review of the post-incident Staff Education Summary (undated) revealed licensed nurses, CNAs, and therapy staff completed mechanical lift training with required competencies, and audits would be done to ensure compliance. The document indicated education for CNAs included instructions to .review the transfer status of their assigned residents to ensure that no changes have occurred. They were reminded to look at the kardex. 2. Review of the medical record revealed resident #2, a [AGE] year-old male, was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included seizures, muscle wasting and atrophy of both shoulders, unsteadiness on his feet, abnormal posture, and cervical spine fusion. Review of the MDS Medicare 5-day assessment with ARD of 11/25/24 revealed resident #2 had functional limitation in range of motion due to impairment of one lower extremity. The MDS assessment indicated the resident was dependent on staff for transfers between the bed and wheelchair. Resident #2 had a nursing care plan created on 10/27/24 for ADL self-care performance deficit related to generalized weakness. An intervention dated 11/24/24 instructed CNAs to perform transfers between the bed and wheelchair and into and out of the shower with a total body mechanical lift operated by two staff. Review of the CNA care plan or kardex for resident #2 revealed the nursing care plan intervention regarding transfers was transcribed accurately. The instruction for two CNAs to perform transfers with a full body mechanical lift was noted in the section for ADL Level of Assistance. On 12/10/24 at 11:00 AM, CNA C stated she was ready to get resident #2 out of bed and into the shower chair to transport him to the shower room. A sit-to-stand lift, instead of the full body lift noted in the medical record, was in the hallway outside the resident's room. CNA C was prompted to check the electronic Kardex regarding the resident's transfer status. She logged into the resident's electronic medical record and noted two buttons, side by side, for the care plan and kardex. CNA C selected the care plan button which pulled up the detailed nursing care plan. She scrolled through the focus areas and interventions and stopped at the nursing care plan for risk for falls, which indicated resident #2 should be encouraged to use his call light to obtain assistance with standing and transferring. After CNA C read the nursing care plan she incorrectly stated the resident was able to stand for transfers. She did not review the nursing care plan for ADLs that included transfer instructions or select the kardex tab with specific transfer instructions for CNAs. On 12/10/24 at 11:02 AM, CNA C entered resident #2's room and explained he was recently readmitted from the hospital. She stated before the resident went out to the hospital, he was able to stand up and transfer with the assistance of two staff, not a mechanical lift, but was now too weak to do this. CNA C stated this was her first attempt to get the resident out of bed after re-admission. She stood at resident #2's bedside, and assisted by CNA E, initiated the sit-to-stand lift procedure. Although resident #2 exhibited extreme weakness and poor balance, neither CNA stopped the procedure to review the kardex or report concerns to a nurse. As she prepared to lift the resident from the edge of the bed to a standing position, CNA C discovered the lift's battery was dead. On 12/10/24 at 11:08 AM, the Cambridge UM confirmed resident #2 should be transferred with a full body mechanical lift. When she explained CNA C misunderstood the transfer instructions, she was informed CNA C did not verify the resident's required transfer method in the kardex prior to attempting the task. On 12/10/24 at 11:21 AM, the Regional Nurse Consultant, Clinical Reimbursement Director, DON, and the Cambridge UM were informed CNA C had to be prompted to check the care plan prior to transfer, and when she accessed the electronic plan of care, she reviewed the nursing care plan rather than kardex. They were told the CNA did not accurately identify the location of resident #2's transfer instructions. The Clinical Reimbursement Director interjected that to her knowledge, CNAs should not have access to the nursing care plan. On 12/10/24 at 11:24 AM, the Clinical Reimbursement Director reviewed resident #2's care directives on the tablet used by CNA C. She verified there were two possible sources of information available to CNAs, the nursing care plan and the kardex. On 12/11/24 at 2:46 PM, the Clinical Reimbursement Director acknowledged she was now aware CNAs had access to the detailed nursing care plan as well as the kardex. She explained the kardex was a simplified version of the care plan and contained specific, task-oriented instructions for CNAs. She confirmed the comprehensive care plan had extensive interventions for all disciplines. The Clinical Reimbursement Director stated it was very important for CNAs to follow the care directives included in the kardex. She reviewed resident #2's care plans and stated he always required a full body mechanical lift since admission and had never been deemed appropriate for a sit-to-stand lift or other type of transfer. On 12/13/24 at 12:31 PM, the DON stated after resident #3's fall from the mechanical lift during a transfer attempted by a single CNA, the facility verbally re-educated staff on neglect related to failure to follow resident care instructions. She acknowledged staff were not required to complete a post-test or any other activity to validate comprehension of the education provided. The DON stated CNAs were told to look at kardexes prior to caring for residents. She confirmed the facility's management team did not require demonstration of this skill nor identify that CNAs had issues with locating or using the kardex. The DON said, We had no idea that a care plan tab was there. Not sure why it was not mentioned to me if others knew it was there. She stated her understanding was all new CNAs were taught about the kardex and required to demonstrate its use in orientation. The DON explained the Staff Educator, who no longer worked at the facility, was responsible for educating CNAs on the kardex, so she could not say why the care plan tab went unreported. On 12/12/24 at 12:19 PM, the facility's Medical Director confirmed he was aware of the concerns related to CNAs' failures to adhere to protocols for use of mechanical lifts and verification of transfer status in the plan of care. He stated he was surprised, especially about the incident with resident #2 since staff were re-educated after resident #3's fall. The Medical Director was informed of concerns related to CNAs' knowledge regarding accessing the kardex. He stated there was apparently additional work to be done to ensure staff cared for residents according to instructions in the plan of care. Review of a Competency Validation form for CNA A (dated 11/20/24) revealed she demonstrated competency in the use of a mechanical lift for transfers. The form listed indications for the use of a total lift and cautions including use number of staff designated to safely complete the transfer [and] report any resident change in condition to your supervisor. However, there was no checklist attached to the validation form to show CNA A performed all required steps of the procedure. Review of Competency Validation forms for CNA C (dated 11/20/24) and CNA E (dated 11/24/24) revealed both staff demonstrated competency with use of the mechanical total or full body lift. The attached step-by-step checklist did not show a requirement for CNAs to check the kardex and verify transfer instructions prior to using the lift. Review of the Skills Fair November 2024 packets for CNAs A, C, and E revealed the topics included stand and pivot transfers with the assistance of one or two staff and transfers with a full body or total lift. None of the packets contained a competency checklist for use of the sit-to-stand mechanical lift. The job description for Certified Nursing Assistant, dated April 2020, revealed essential duties and responsibilities included .transfer residents, utilizing appropriate assistive devices. The job description for the Director of Nursing, dated August 2021, revealed the DON would manage the overall operations of the Nursing Department to ensure excellent care for all residents. The DON's essential duties and responsibilities included staff training and staff development, ensuring the provision of appropriate departmental in-service education programs, and direct the performance and delivery of nursing and resident care services. Review of the Facility Assessment Tool, dated 7/29/24, revealed facility staff would provide general care and services such as assistance with mobility and fall prevention. The document indicated the facility would offer specific care including bathing, showers, and transfers, and person-centered care such as the prevention of abuse and neglect and identification of risks and hazards. The Facility Assessment Tool revealed education and/or in-services for CNAs would be provided annually, semi-annually, and as needed on topics including activities that constitute neglect. Nursing staff would demonstrate competency in person-centered care and ADLs at the time of hire, semi-annually, and as needed.

Based on interview, and record review, the facility failed to immediately notify the physician and resident representative of a change in condition regarding a fracture for 1 of 2 residents reviewed for falls, out of a total sample of 8 residents, (#3). Findings: Review of the medical record revealed resident #3, a [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included multiple sclerosis, breast cancer, secondary bone cancer, muscle contractures of her left hip, both knees, and right ankle, and a post-fall sacral fracture. Review of the Order Recap Report for the period 11/01/24 to 12/31/24 revealed an order from resident #3's attending physician, dated 12/10/24, for x-rays of her left ankle and both hips. Resident #3's Radiology Results Report revealed x-rays of her left ankle, left hip, and right hip were done on 12/11/24 at 6:10 PM. Interpretation of the x-rays by a radiologist showed the resident had a fracture at the upper end of the left femur or thigh bone. The document was electronically signed by the radiologist on 12/11/24 at 8:28 PM. Review of a Situation, Background, Appearance, Review and Notify (SBAR) Communication Form revealed resident #3's primary care clinician was notified of her left hip fracture on 12/12/24 at 6:20 AM, approximately 12 hours after the test was completed. The SBAR form indicated the facility received an order to send the resident to the hospital Emergency Department via emergency medical services. Review of Progress Notes revealed no documentation on 12/11/24 by resident #3's assigned nurse, Registered Nurse (RN) G, regarding the completion of her x-rays or acknowledgement of the results. A Narrative Note dated 12/12/24 at 6:20 AM, indicated the Director of Nursing (DON) notified an Advanced Practice Registered Nurse of the x-ray results of a left hip fracture and she received an order to send resident #3 to the hospital for evaluation. The note revealed the DON informed RN G of the order and tasked him with notifying the resident's representative, her daughter. On 12/12/24 at 10:28 AM, the Cambridge Unit Manager (UM) confirmed resident #3's radiology results were available since about 8:30 PM on 12/11/24 but the physician was not notified until the next morning, 12/12/24, at about 6:20 AM. She explained the radiology provider usually faxed radiology reports to the facility and would call to make verbal notification if there was a positive result. The UM stated the physician on call, the resident, and the representative should immediately be notified of abnormal findings. She confirmed the assigned nurse did not enter any documentation in the medical record on the x-ray technician's visit or any follow up related to obtaining or viewing the results. The UM stated she was not aware of the finding of a left hip fracture until the DON informed her earlier this morning. On 12/12/24 at 12:19 PM, the facility's Medical Director verified his expectation was nurses would immediately notify the ordering physician regarding a positive or abnormal diagnostic test result. On 12/13/24 at 9:06 AM, the DON validated resident #3's x-ray result of a left hip fracture was available to nurses on 12/11/24 at 8:28 PM when the document was uploaded to the electronic medical record. She explained in the early morning on 12/12/24, she was at home reviewing residents' test results, new physician orders, and the 24-hour report when she noted the radiology report that showed resident #3 had a left hip fracture. The DON stated she realized the physician had not been notified so she called the facility and discussed the result with RN G. She confirmed she expected nurses to monitor for pending diagnostic test results at the beginning of the shift, during the shift, and prior to leaving. The DON stated resident #3's physician and daughter should have been notified of her condition immediately after the x-ray results were available. On 12/13/24 at 2:59 PM, RN G confirmed he was assigned to resident #3 on 12/11/24. He explained he worked on the 3:00 PM to 11:00 PM and the 11:00 PM to 7:00 AM shifts. RN G verified the x-ray technician completed the resident's x-rays at 6:19 PM according to his personal nursing report sheet. He stated the radiology provider did not call the facility, and he did not check the electronic medical record for the results during his 16-hour shift. RN G explained sometimes the Nursing Supervisor would check for pending test results, but he was not aware of resident #3's results until the DON called him on 12/12/24 in the early morning while he was passing morning medications. RN G acknowledged he should have checked for the result during his shifts. He said, It was my responsibility. I was supposed to follow up. Review of the facility's policy and procedure for Notification of Changes, implemented in November 2020, revealed the facility would promptly inform the resident, consult the physician, and notify the resident's representative when there was a change in condition such as an accident, significant change in physical status, or the need to alter treatment or initiate a new treatment.

Based on interview, and record review, the facility failed to honor resident's right to choose their preferred bathing preferences for 1 of 4 residents reviewed for choices, of a total sample of 41 residents, (#78). Findings: Review of the medical record revealed resident #78 was admitted to the facility on [DATE] from the hospital. Her diagnosis included left lower extremity cellulitis, gangrene, dementia, and diabetes. Resident #78's Nursing Admit/Readmit screener dated 7/30/24 revealed the resident's preference for bathing was a shower on scheduled shower days during the day shift. Resident #78's Medicare 5-day Minimum Data Set (MDS) assessment with an assessment reference date of 8/1/24 revealed the resident scored a 3 out of 15 on the Brief Interview for Mental Status, which indicated severe cognitive impairment. The MDS assessment also indicated resident #78 required substantial/maximal assistance with bathing. Resident #78's Certified Nursing Assistant (CNA) Kardex, with admitted [DATE], noted the resident preferred showers on Mondays and Thursdays in the evening. A review of resident #78's medical record revealed an activity of daily living self-care performance deficit care plan was initiated on 10/13/24 and revised on 8/01/24 that noted the resident needed supervision/touch assistance with showers. The bathing task report for resident #78 showed she received only four showers from between 8/01/24 to 9/30/24 and once on 10/07/24. The report noted the resident instead received bed baths on 17 of 24 scheduled shower days since admission. On 10/20/24 at 12:44 PM, resident #78 stated she got bed baths but preferred showers. She conveyed she had told the staff she preferred showers, but they just washed her in the bed. Resident #81's daughter was present and agreed with her mother. The daughter stated she asked the facility to shower her mother on Monday and Thursday evenings. On 10/23/24 at 11:52 AM, the Bristol Unit Manager (UM) stated that CNAs must check the shower book to see who got a shower. The CNA was required to let the primary nurse know if a resident refused a shower. A progress note should be written by the nurse when a resident refused a shower. The UM accessed resident #78's medical record and confirmed the Kardex and the nursing admission assessment, indicating the resident's bathing preference was showers. She confirmed the Kardex listed shower preference for Mondays and Thursdays in the evenings. On 10/23/24 at 2:16 PM, the Director of Nursing accessed the resident's bathing task report. She acknowledged the resident received only five showers in the past 67 days, on 8/01/24, 8/19/24, 9/05/24, 9/30/24, and 10/07/24, with one day documented as refused to bathe and another scheduled day with no documentation. The DON expressed that the resident's choices were not honored and that resident #78 should have received showers instead of bed baths. She acknowledged the importance of ensuring the resident received her preferred means of bathing, as it was the resident's right.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services according to professional standards for monitoring and management of an intravenous (IV) therapy site for 1 of 1 residents reviewed for IV access, of a total sample of 41 residents, (#168). Findings: Review of the electronic medical record for resident #168 revealed she was admitted to the facility on [DATE], with diagnoses of displaced closed fracture of left femur, history of falling, diabetes, muscle weakness, abnormalities of gait, mobility and urinary tract infection. On 10/20/24 at 11:51 AM, observation of resident #168 while laying in bed, revealed an peripheral intravenous central catheter (PICC) line with no date in her left upper arm. A PICC line is a long thin tube that is inserted through a vein in the arm which is passed through to larger veins near your heart, used to give medications, (retrieved from www.mayoclinic.org on 11/04/24). Review of resident #168's medical record identified a completed IV insertion form dated 10/16/24 at 11:02 AM, with reason for visit showing new order for PICC line, inserted in the left arm. A completed IV insertion form dated 10/18/24 at 12:01 PM, with reason for visit listed as consult and note documented, Pt mid [midline] clogged/Unclogged . Further review of the medical record revealed there was no physician order for insertion, monitoring or flushing of the PICC line on 10/15/24, 10/16/24 or 10/17/24 documented on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). The medical record showed shortly thereafter a weekly skin evaluation form dated 10/16/24 at 1:05 PM, did not list the PICC line in the left arm and resident #168 baseline careplan revealed no problem, goal or interventions for a left arm PICC line or IV therapy site. IV therapy management for nurses includes verifying physician orders, monitoring, inspecting, and flushing the IV catheter, (retrieved on 11/04/24, from https://www.ncbi.nlm.nih.gov/books). Review of resident #168's medical record identified a physician order to start Meropenem-Sodium Chloride (antibiotic) IV Solution 500 milligrams (mg)/50 milliliters (ml) every 12 hours for sepsis on 10/16/24. Review of the MAR for resident #168 showed multiple nurses administered Meropenem-Sodium Chloride IV medication on 10/16/24 at 9:00 AM, and 9:00 PM, for a total of five doses over two shifts with no physician orders for monitoring management or flushing the PICC line site. On 10/22/24 at 10:50 AM, the 200 hallway Unit Manager (UM) stated resident #168 should have normal saline flushes every shift, before and after IV antibiotic administration. She continued, the IV dressing change was after 24 hours and weekly after insertion, as well as monitoring of the IV therapy site every shift. She validated resident #168 did not have any of those physician orders. She stated the admission nurse was responsible for putting in the orders and the check system for new physician orders was completed the next day by the clinical team which consisted of the Unit Managers, Assistant Director of Nursing and the Director of Nursing. She acknowledged resident #168 did not receive the proper monitoring or sufficient care or service for IV therapy. On 10/22/27 at 2:07 PM, the Director of Nursing stated the initial nurse was supposed to add orders for changing the IV dressing, inspecting the site, and flushes. She stated IV sites were monitored and flushed every shift and confirmed the check system for new physician orders was reviewed by the nurse management clinical team daily. Review of the policy and procedure for Intravenous Therapy dated 8/02/22 revealed the facility should adhere to accepted standards of practice regarding infusion practices, IV sites should be checked every four hours or as per facility protocol, and nurses should confirm patency of the IV site per flushing protocols. Review of the policy for Flushing Midline and Central Line IV Catheters dated May 2022 showed Midline and Central Line IV catheters will be flushed to maintain patency .

Based on observation, interview, and record review, the facility failed to provide adequate supervision to maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision and failed to respond appropriately to a door alarm for 1 of 15 residents reviewed for elopement, of a total sample of 15 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was reasonable likelihood he could have fallen, become lost, been accosted/harmed by a stranger or been hit by a car. On 7/25/24 at approximately 5:15 AM, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. The facility was unaware of resident #1's whereabouts until staff located him across from an assisted living facility (ALF) approximately 0.2 miles away at 5:53 AM. The facility failed to ensure resident #1 was adequately supervised and failed to monitor the front lobby door to ensure vulnerable residents did not exit the facility without knowledge. There was a total of 15 residents who were identified as at risk for elopement. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy. The Immediate Jeopardy began on 7/25/24 and was removed on 7/26/24. The scope and severity of the deficiency was decreased to a D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. Findings: Resident #1 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses t included encephalopathy, unspecified dementia, heart failure, type 2 diabetes mellitus, adult failure to thrive and depression. Review of the Minimum Data Set quarterly assessment with assessment reference date of 7/07/24 revealed resident #1 had a Brief Interview for Mental Status score of 03/15 which indicated he had severe cognitive impairment. The document indicated resident #1 used a wheelchair for mobility and was able to propel his self independently. The assessment did not indicate resident #1 wandered or exhibited other behaviors during the look-back period but used a wander/elopement alarm daily. Review of physician orders revealed a current active order for electronic wander bracelet dated 11/20/23. Review of the psychiatric progress notes revealed resident #1 was recently seen by the provider on 4/03/24, 4/24/24, 5/29/24, 6/19/24 and 7/03/24. Each progress note indicated resident #1 had a history of exit-seeking behavior, was cognitively impaired with poor long-term and short-term memory, lacked insight concerning matters of self and lacked judgement regarding everyday activities. Review of the medical record revealed elopement risk evaluations dated 11/20/23, 12/04/23, 12/11/23, 12/20/23 and 3/04/24 indicated resident #1 was at risk for elopement. An elopement risk evaluation dated 5/03/24 indicated resident #1 was not at risk for elopement. Review of progress notes revealed resident #1 was considered to be at high risk for elopement on 11/20/23 and a wander bracelet was placed on his right arm. A progress noted dated 5/03/24 read, Resident elopement risk performed, no longer risk for elopement. [Electronic wander bracelet] removed. A care plan for elopement risk initiated 11/20/23 indicated resident #1 was at risk for elopement. Interventions included use of wander bracelet, check placement every shift, place resident information in elopement risk notebook, monitor for exit seeking behaviors and use verbal cues to redirect. The care plan was resolved on 5/03/24, when the electronic wander bracelet was removed and was reinitiated 7/25/24. Review of the Treatment Administration Record for May, June and July 2024 revealed staff continued to document on placement and function of the electronic wander alarm bracelet even though it had been removed on 5/03/24. In a phone interview on 8/07/24 at 6:23 AM, Certified Nursing Assistant (CNA) F verified resident #1 was on her assignment on 7/25/24. She recalled providing care to resident #1 with the assistance of another CNA between 4:00 and 4:30 AM. CNA F stated she then went to get another resident dressed for an appointment. She recalled as she escorted the other resident to the transportation pick-up area, Licensed Practical Nurse (LPN) D told her, Make sure you close that door so he [resident #1] can't get out. CNA F stated she closed the door and proceeded to the transportation area. On 8/06/24 at 5:37 AM, CNA B confirmed she assisted CNA F with providing care for resident #1 and then went back to her assignment. She recalled as she came out of a resident room around 5:00 AM, she saw resident #1 at the nurse's station with CNA A. CNA A informed her resident #1 was walking in the hallway without his wheelchair. CNA B stated she stayed with resident #1 while CNA A retrieved a wheelchair from the dayroom. She stated she went back to her assignment and did not see resident #1 again until after the event. She stated she did not hear an alarm go off and did not know the resident was missing until LPN D asked her to look for him. On 8/06/24 at 5:28 AM, CNA A stated she was not assigned to resident #1 but she saw him standing at the nurse's station. She asked CNA B to help her locate a wheelchair for resident #1. She explained she located a wheelchair in the day room, and they assisted the resident to sit in the chair. CNA A then went back to her assignment. She recalled LPN D later asked her if she knew where resident #1 was, so she started looking for him. She went up front and saw one of his shirts on the ground outside. She went back into the building and headed toward the back to see if she could find him. On 8/06/24 at 11:16 AM, LPN D - stated she saw resident #1 at the nurse's station between 5:00 - 5:10 AM. She recalled CNA F needed to escort another resident to the transportation area and asked LPN D if resident #1 was going somewhere as he was not usually up so early. LPN D stated she told CNA F to just close the doors when she went through, and LPN D continued her rounds. LPN D recalled at approximately 5:30 AM she came out of a resident's room and no longer saw resident #1 at the nurse's station. She stated she started looking around the unit for him and asked other staff to assist. LPN D reported Registered Nurse (RN) C called her and told her about the shirt found outside. LPN D stated she went outside with RN C and RN E to search for resident #1. She explained RN E located him between the two parking lots at the adjacent assisted living facility and they escorted him back into the facility through the back entrance. On 8/06/24 at 11:45 AM, RN E stated she was doing rounds and went to the unit resident #1 was on at approximately 5:00 AM on 7/25/24. She recalled seeing him in a wheelchair in front of the nurse's station. RN E reported she sat at the nurse's station to complete some documentation. She explained she left the unit at approximately 5:20 AM to go to the other unit but could not recall whether resident #1 was still near the nurse's station. She stated LPN D called her a short time later and asked if resident #1 followed her to the other unit. RN E informed LPN D he had not followed her and was not on that unit. RN E stated she told the staff to search for resident #1 and a code for missing resident was paged overhead. She recalled hearing the front door alarm as she was headed back to resident #1's unit. RN E stated when she entered the front lobby she saw RN C at the front door. RN C informed her resident #1 may have gone outside because they found a shirt on the ground that belonged to him. RN E stated she proceeded out the front door and walked down the pathway to the parking lot to search for resident #1. She recalled LPN D was ahead of her and when they reached the employee parking lot, RN E stated she got in her car to drive up toward the ALF to see if he was further up the road. She stated she saw resident #1 his wheelchair under a lamp post across from the ALF parking lot next to the enclosed retention pond. RN E stopped her car and called LPN D as she wheeled resident #1 back toward the facility. RN E reported RN C and LPN D took the resident back inside the facility as she retrieved her car. She explained he was placed on one-to-one supervision, and she applied a wander alarm bracelet on his ankle. RN E could not recall if resident #1 had a wander alarm bracelet previously. During a phone interview on 8/06/24 at 9:09 AM, RN C stated she was at the nurse's station around 5:00 AM the morning of 7/25/24. She recalled resident #1 wanted to use the phone. RN C asked resident #1 if he could make his call a little later and he agreed. She stated she left to use the restroom before she began to pass medications. RN C recalled LPN D was near resident #1 when she left. As she returned down the hallway approximately 10 minutes later, she heard a door alarm coming from the front lobby. RN C explained she entered the lobby and went to the front door. She recalled she pulled the door toward herself to ensure it was engaged and looked out the glass door. RN C stated it was dark outside and she did not see anyone, so she turned off the alarm and returned to her work station. She explained she did not think about the alarm again until later when LPN D came to her and asked if she had seen resident #1. She then remembered the front door alarm and went back to the front lobby with CNA A. RN C stated she held the front door open while CNA A went outside. She recalled the CNA found a shirt on the ground which she recognized as the shirt resident #1 had on his lap in the wheelchair. RN C stated she told the CNA to come back inside and she paged overhead for LPN D and RN E to come to the front lobby. She explained the three of them went out together to search for resident #1. She reported that RN E located him and returned him to facility through the back entrance. RN C expressed she felt CNA F and LPN D should have provided closer supervision for resident #1. She explained CNA F told LPN D to watch resident #1 while she escorted a resident to the transportation area. RN C stated LPN D told CNA F to just shut the doors to the unit when she went out. RN C acknowledged when she heard the door alarm, she did not go outside to search, nor did she notify any other staff of the alarm and instead she turned it off and returned to her duties. On 8/06/24, resident #1's wife confirmed she was notified her husband eloped from the facility. She stated she was not sure how he managed to get outside. She explained they had been married for [AGE] years and had always been together. Resident #1's wife stated she was concerned he got out of the facility unsupervised, but she was looking forward to taking him home. On 8/06/24 at 12:06 PM, the Director of Nursing (DON) acknowledged resident #1 had history of elopement but had a decline in mobility in May 2024. She explained he was assessed at that time and was not considered an elopement risk. She clarified the wander/elopement alarm bracelet was removed and the care plan was resolved at that time. The DON recalled he progressed approximately 4-6 weeks later with improved mobility but did not exhibit any exit-seeking behaviors. She explained resident #1 regularly accompanied his wife to the front door, kissed her before she left and returned to his room without incident. The DON reported she was not aware of any exit-seeking behavior. In a meeting with the Administrator, DON and Regional Nurse Consultant (RNC) on 8/07/24 at 10:58 AM, the Administrator stated the Quality Assurance and Performance Improvement (QAPI) Committee met and reviewed the event and investigation. She stated the committee identified RN C should have opened the door and looked outside when she responded to the door alarm and should have notified staff of the alarm. The Administrator acknowledged staff should have been more aware of resident #1's movement through the facility. She stated the committee noted several areas of opportunity for improvement and began education on several topics which included abuse and neglect, elopement standards and guidelines, accuracy of documentation, increased supervision and appropriate response to door alarms. The Administrator stated the QAPI Committee conducted a root cause analysis and determined the facility failed to respond appropriately to a door alarm and failed to provide appropriate supervision. Review of the policy and procedure Elopements and Wandering Residents revised 3/16/23 revealed an elopement occurred when a resident left the premises or a safe area without authorization and/or necessary supervision to do so. The document indicated that alarms were not a replacement for necessary supervision. Staff were directed to be vigilant in responding to alarms in a timely manner. On 8/07/24, resident #1's likely elopement route was retraced. He exited the facility's front lobby door and wheeled himself in the dark along an uneven sidewalk with four-inch curbs, from the front door to the parking lot. Resident #1 proceeded through the parking lot and down a paved driveway approximately 0.2 miles to an adjacent ALF. He was located under a lamp post across the street from the ALF's front parking lot next to a fenced retention pond. Along the route, he passed several metal drainage grates, a drainage ditch with water, a downed lamp post with exposed wires and two parking lots with dumpsters and electrical equipment. Historical weather data revealed on the morning resident #1 eloped, 7/25/24, the temperature at 5:53 AM was 78 degrees Fahrenheit and mostly cloudy. Sunrise occurred at 6:44 AM, (retrieved on 8/07/24 from www.wunderground.com). Review of the Facility Assessment Tool revealed the facility accepted and could care for residents with psychiatric and mood disorders including psychosis, impaired cognition, depression, anxiety, and behaviors that needed intervention. The document indicated the facility provided person-centered care which included identifying and implementing interventions to help support individuals with cognitive impairment. Review of corrective measures to remove Immediate Jeopardy implemented by the facility revealed the following, which were verified by the survey team: *On 7/25/24 at 5:30 AM, resident #1 was discovered to be missing and the facility implemented its elopement policy and procedures. *On 7/25/24 at 5:53 AM, resident #1 returned to the facility with facility staff. He was assessed on return to the facility and had no injuries. A head count was conducted to verify the safety of all residents. The required notifications were made to the physician and family. Resident #1 was placed on 1:1 supervision. *On 7/25/24, resident #1 was re-evaluated for elopement risk and the elopement risk care plan was re-initiated due to his increased risk. *On 7/25/24, the facility re-evaluated all residents' elopement risk and identified a total of 15 residents as at risk for elopement. The elopement risk binders were reviewed to ensure they contained photos and demographic information for all identified residents. *On 7/25/24, electronic wander alarm bracelets were checked for all residents identified as at risk for elopement. *On 7/25/24, the Maintenance Director checked all doors and alarms center wide for proper functioning. No issues were identified. *From 7/25/24 to 7/26/24, all staff were re-educated on the elopement policy to include elopement standards and guidelines, providing appropriate supervision for residents with wandering or exit seeking behaviors, appropriate response to door alarms and elopement risk binders. Staff were also educated on entering/exiting the facility through designated doors. As of 7/30/24, 100% of staff members received elopement education and participated in elopement drills. *From 7/25/24 to 7/26/24, the facility completed 6 elopement drills to cover all 3 shifts with satisfactory staff response documented on elopement drill worksheets. *On 7/26/24 at 8:50 AM, the facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting and conducted a root cause analysis. The committee reviewed recommendations to develop a plan for correction to include education, post-testing, drills and audits. The ad hoc QAPI committee including the Medical Director (via telephone) approved the recommendations. *On 7/26/24 at 5:00 PM, the facility held an ad hoc QAPI meeting to evaluate the actions taken which included education, elopement drills and increasing volume on alarm annunciators. The ad hoc QAPI committee including the Medical Director approved the current plan and recommendations for continued education and auditing. Interviews were conducted from 8/06/24 to 8/08/24 with 23 staff members (9 CNAs representing all shifts, 1 receptionist, 1 RN, 5 LPNs representing all shifts, 1 therapist, 3 environmental services staff and 3 dietary staff). Staff interviews revealed they were knowledgeable of the elopement policy and procedures, appropriate response to alarms and supervision of all residents to include those at risk for elopement. The resident sample was expanded during the survey to include 12 additional residents. Observations, interviews, and record reviews conducted revealed no concerns related to elopement risk evaluations, care plans and physician orders for residents #4 through #15.

Based on observation, interview, and record review, the facility failed to provide care and services to identify, monitor and treat pressure injuries for 2 of 3 residents reviewed for pressure ulcers, of a total sample of 45 residents, (#214 and #17). The facility's failure to evaluate alterations in skin integrity and implement appropriate treatments timely resulted in actual harm. Resident #214 was identified to have 2 new facility acquired pressure ulcers/injury identified 15 days after being admitted to the facility. The resident had one stage II pressure wound on her left buttock and an unstageable pressure wound on her sacrum. The facility failed to identify the wounds at an early stage and failed to implement timely treatment and preventable measures. Findings: Pressure ulcers happen when you lie or sit in one position too long and the weight of your body against the surface of the bed or chair cuts off blood supply. If found early there is a good chance they will heal in a few days with little fuss or pain. Without treatment they can get worse. The most important thing to do with any pressure sore is to stop the pressure. If you spend a lot of time in bed, try to move at least every two hours. Stage 2: Skin is broken , leaves an open wound. The sore may ooze clear fluid or pus and it is painful. Stage 3:The sore has gone through the second layer of skin into the fat tissue. It looks like a crater and may have a bad odor. Stage 4: The sore is deep and big. You may be able to see tendons, muscles and bone. Unstageable: is when you can't see the bottom of the sore, so you don't know how deep it is. It can only be staged once it is clean out. (Web MD at www.webmd.com, retrieved 3/24/23) Resident #214 was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included cerebral infarction, altered mental status, type 2 diabetes, and dementia. The resident's quarterly Minimum Data Set (MDS) assessment dated , 2/26/23 indicated the resident had severe cognitive impairment and was rarely or never understood. The resident required total dependence of two staff persons for bed mobility, transfers, toilet use, and total dependence of one person for dressing, eating and personal hygiene. She was bed or chair bound and always incontinent of bowel and bladder. The assessment indicated the resident had no pressure ulcers but was at risk for developing pressure ulcers. Review of the resident's medical record revealed a care plan initiated on 2/22/2023 for wound risk with interventions to assist to turn/reposition as needed. A care plan for Activities of Daily Living (ADL) initiated on 2/22/2023 included an intervention that resident was totally dependent on staff for ADL's. Review of the Order Summary Sheet dated 2/22/2023 showed an order for Skin Checks Every Shift for 3 days to end on 2/25/2023. There was no evidence in the medical record to show the resident's skin checks were completed every shift for three days. There was only one Weekly Skin Check form completed on 2/22/23 that noted no skin impairment. There were no other skin assessments found. Review of a Skin and Wound Evaluation form completed on 3/09/23 showed the resident now had two wounds, a Stage 2 to her left buttock and an unstageable wound to her sacrum. The Stage 2 left buttock pressure wound measured 2.6 centimeters (cm) by 1.0 cm with light serosanguinous exudate. The unstageable sacrum pressure wound measured 5.8 cm by 4.9 cm and 2.0 cm deep. with 100% slough and moderate serosanguinous exudate. A care plan for actual wound initiated the same day, on 3/9/23, noted the resident had an actual wound on her sacral area and left gluteus. Interventions included for the Certified Nursing Assistant (CNA) to encourage/remind/assist to turn/reposition as needed, pressure reducing mattress, and nursing to monitor wound weekly. An incontinence care plan implemented on 3/13/2023 noted nursing should observe condition of skin with each incontinent episode. On 3/14/23, the unstageable sacrum measured 6.2 cm, by 4.9 cm, and 1.8 cm in depth. The wound was 20% granulation and 80% slough with moderate serosanguinous exudate and noted the wound dressing was saturated. On 3/14/23 at 1:26 PM, CNA N stated she tried to reposition her residents but, we cannot always do it every two hours but I try. When there are only four of us, it is hard to do everything that we need to do for the residents. On 3/15/23 at 4:04 PM, the Assistant Director of Nursing (ADON) verified resident #214 was admitted three weeks ago with intact skin and now had 2 acquired pressure ulcers. On 3/16/23 at 1:45 PM, the Director of Nursing (DON) stated she did wound rounds with the ADON and Unit Manager on Tuesdays. She said she tried to spot check the residents at least weekly to make sure they were getting turned and repositioned. She stated her expectation was that the residents get turned every 2 hours. She acknowledged the skin checks for resident #214 were not done which would have identified areas of concern before they developed into actual pressure wounds. On 3/15/23 at 11:44 AM, in a telephone interview, the resident's daughter-in-law stated the family was very distressed the resident had two pressure ulcers. She said she had never had a pressure ulcer before and it had not even been a few weeks before she got the wounds. She recalled the facility just put the resident on the air mattress a few days ago. She stated the family was praying the wounds get better quickly because the resident did not need another infection. 2. Resident #17 was admitted to the facility on [DATE] and readmitted from an acute care hospital on 1/27/23 with diagnoses of acute embolism and thrombosis of right iliac vein, pyelonephritis, low back pain, malignant neoplasm of bladder. The resident's quarterly MDS assessment dated [DATE] revealed he had moderate cognitive impairment with a Brief Interview for Mental Status score of 10/15. The assessment noted he required extensive assistance of two staff for bed mobility and transfers and extensive assistance of one person for dressing, toileting, personal hygiene and eating. He had an indwelling urinary catheter and was always incontinent of bowel. He had occasional moderate pain and was admitted with an unstageable pressure ulcer. The Skin and Wound Evaluation dated 1/31/23 indicated the resident was readmitted from the hospital with an unstageable pressure ulcer to his sacrum that measured 3.8 cm in length by 2.8 cm in width and 1.8 cm deep with 80% slough and light serosanguinous exudate. On 3/15/23 the wound measured 4.3 cm by 3.7 cm, and 1.7 cm deep with 80% slough and moderate serosanguinous exudate with surrounding tissue erythema. Review of the weekly skin checks noted the resident's skin assessments were done on 2/06/23, 2/13/23 and 3/06/23. No other weekly skin checks could be located. There were no weekly skin assessments done on 2/20/23 or 2/27/23. On 3/16/23 at 1:45 PM, the DON stated her expectation was that skin assessments be done weekly and acknowledged the skin checks were missed for resident #17. The Wound Prevention and Treatment Overview Policy and Procedure, dated October 2021 read: Review skin integrity on a weekly basis as a proactive approach enabling the facility staff to identify possible changes in skin integrity/condition. The Registered Nurse job description read: Ensures that resident are handled properly, specifically lifting, turning , moving, positioning. Observes and reports the presence of pressure areas and skin breakdowns to prevent ulcer. The CNA job description read: Turns and repositions residents. Observes and reports the presence of pressure areas and skin breakdowns to prevent ulcer.

Based on interview and record review, the facility failed to refer a resident with newly evident mental illness diagnoses for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 1 resident reviewed for PASARR, out of a total sample of 45 residents, (#27). Findings: Review of the medical record revealed resident #27 was readmitted to the facility on [DATE] with diagnoses including orthostatic hypotension, chronic obstructive pulmonary disease, type 2 diabetes and chronic respiratory failure. The resident had previous admissions from 8/21/19 to 9/13/19, and 4/02/22 to 4/19/22. Review of the Minimum Data Set Quarterly assessment with assessment reference date of 2/07/23 revealed resident #27 had a Brief Interview for Mental Status score of 12 which indicated she had moderate cognitive impairment. The document noted her active diagnoses included anxiety disorder, depression, psychotic disorder and schizophrenia. Review of resident #27's medical record revealed a psychotropic medication use care plan, initiated on 11/06/22, which indicated she received antidepressant, antianxiety and antipsychotic medications. The care plan included an intervention for psychological services as ordered and as needed. Review of resident #27's electronic medical record revealed diagnoses of generalized anxiety disorder with an onset date of 8/21/19, major depressive disorder with an onset date of 8/21/19, unspecified psychosis with an onset date of 8/21/19, and schizoaffective disorder with an onset date of 4/15/22. The record contained an updated Level I PASARR screening form dated 11/04/22 which did not indicate the resident had a mental illness (MI) or suspected MI. The record did not contain a Level II PASARR screening form to address these diagnoses. On 3/15/23 at 12:31 PM, the Social Services Director (SSD) stated the admissions department obtained PASARR forms from the hospital prior to admitting residents. She explained the nursing team would review each completed PASARR form during the daily clinical meeting. The SSD stated a Registered Nurse would have to complete a new PASARR form if indicated. She clarified she did not have the qualifications to update an incorrect PASARR form. On 3/15/23 at 12:46 PM, the Director of Nursing (DON) stated she was responsible for updating incorrect PASARR forms. She reviewed resident #27's Level I PASARR form and acknowledged the document was inaccurate. The DON explained the PASARR form should have been updated to reflect the resident's MI diagnoses. She validated the facility did not refer resident #27 for a Level II PASARR screening as required, based on her diagnoses.

Based on observation, interview, and record review, the facility failed to implement the plan of care and follow physician orders for 1 of 2 residents reviewed for tube feeding management out of a total sample of 45 residents, (#2). Findings: Review of the medical record revealed resident #2 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of quadriplegia or paralysis of all extremities, gastrostomy tube, gastroesophageal reflux disease, and brain disorder. A gastrostomy tube or G-tube is a feeding tube that is inserted directly into the stomach through a surgical incision in the abdominal wall. A feeding tube is necessary if someone has difficulty swallowing as it allows the person to receive adequate nutrition, hydration, and medication (retrieved on 4/03/23 from www.my.clevelandclinic.org). Review of the Minimum Data Set Annual assessment dated [DATE] revealed the resident had short and long-term memory loss, was totally dependent on two staff for activities of daily living, and required a feeding tube for nutrition. Review of the Enteral Feeding care plan revealed a focus of nutritional risk, nothing by mouth, and a G-tube as the only means of nutrition, hydration, with dependence on staff for intake. The interventions directed nurses to administer enteral feedings and water flushes as medically prescribed. Review of physician orders revealed an order dated 3/11/23 for Jevity 1.5 tube feeding continuously at 50 milliliters per hour for 24 hours. An order dated 12/06/22 indicated the tube feeding spike set was to be changed every 24 hours and as needed. The tube feeding spike set is used to access a sterile, pre-filled tube feeding formula by piercing the seal on the container (retrieved on 4/03/23 from www.med.virginia.edu). On 3/12/23 at 4:17 PM, resident #2's Jevity 1.5 tube feeding infused as ordered. The tube feeding container was dated 3/11/23 and the tube feeding spike set was dated 3/09/23. On 3/12/23 at 4:22 PM, in a joint observation with Licensed Practical Nurse Supervisor O, she confirmed resident #2's tube feeding spike set was dated 3/09/23. She validated the date on the tubing indicated it was changed three days ago and said, It is supposed to be changed every 24 hours. She stated nurses were responsible for following the physician's order to change the tube feeding spike set, and explained it was to be changed at least daily during the 3:00 PM to 11:00 PM shift. On 3/13/23 at 5:05 PM, the Director of Nursing (DON) stated her expectation was nurses would follow the physician's order regarding changing the tube feeding spike set. She explained nurses should verify the order and ensure they had all necessary equipment to complete the task. The DON confirmed all nurses received education regarding tube feeding care and services, and she acknowledged she was ultimately responsible for the Nursing department. The facility's Medication Administration Enteral Tubes Policy dated January 2023 read, The nursing care center assures the safe and effective administration of enteral formulas and medications. Election of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the residents' condition, in consultation with the physician, dietitian and pharmacist. 3. Enteral formulas, equipment, route of administration, and rate of flow are selected based on an assessment of the resident's condition and need. The manufacturer's instructions for the tube feeding spike set read, . 13. Discard after 2 hours of initial usage.

Based on observation, record review, and interview, the facility failed to provide podiatry services for 1 of 3 residents reviewed for Activities of Daily Living (ADLs), out of a total sample of 45 residents, (#44). Findings: Review of the medical record revealed resident #44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of encephalopathy or brain disorder, lack of coordination, chronic respiratory failure, and osteoarthritis of his left shoulder. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] revealed a Brief Interview for Mental Status score of 2 out of 15 which indicated severe cognitive impairment. The MDS assessment showed the resident required extensive assistance to total dependence on staff for ADLs including hygiene and bathing. Review of the resident's care plan for ADLs revealed interventions to provide assistance as indicated. The medical record included a physician order dated 2/07/23 that read, Podiatry services as needed. On 3/12/23 at 10:45 AM, resident #44 was in bed with his feet uncovered. The toenails on both the right and left feet were long, and some toenails grew downwards and curved underneath his toes, while others were approximately half inch long, discolored, thick, brittle, and/or splitting. On 3/13/23 at 5:05 PM, the Director of Nursing (DON) stated the facility's practice was to have the podiatrist visit weekly to evaluate and treat the residents whose names were placed in a designated podiatry book at the nurses' station. The DON explained the Social Services Director (SSD) would follow up. On 3/14/23 at 10:54 AM, the SSD explained her responsibilities included advocacy for residents to assist them with obtaining ancillary services such as podiatry care. She stated nurses would enter the name of any resident who needed to be seen by the podiatrist into the book on the unit. She stated the podiatrist visited the facility either once weekly or once every two weeks. The SSD stated she was never made aware of any concerns regarding resident #44 requiring arrangements for podiatry services. On 3/14/23 at 11:47 AM, Licensed Practical Nurse (LPN) Supervisor O stated toenail care was included in normal ADL care, but there were exceptions. She explained residents' names would be added to the podiatry list if they were diabetic, if Certified Nursing Assistants (CNAs) reported toenails were too thick for them to cut, or if a podiatry visit was requested by the resident or a family member. LPN Supervisor O confirmed weekly skin checks conducted by nurses included monitoring of residents' feet. On 3/14/23 at 12:25 PM, resident #44 validated his toenails were too long and he wanted them to be cut, but he had not yet been seen by a podiatrist. Review of the 100-Unit Podiatry book revealed the names of residents to be seen by the podiatrist with dates visits were requested between 4/11/22 and 2/28/23, with the last date a resident was seen noted as 3/06/23. Resident #44's name was not listed in the Podiatry book to indicate he required a visit from the podiatrist. On 3/14/23 at 12:52 PM, CNA Q stated residents' feet were to be washed and socks changed every day. She explained if she noticed a resident with long toenails, she would notify the nurse. On 3/16/23 at 9:58 AM, the DON removed the sock from resident #44's right foot and confirmed the second toenail was one centimeter (cm) long. She said,It's a little long. He can use a visit with the podiatrist. She proceeded to remove the sock from the resident's left foot and validated the second and third toenails were curved underneath the toes. The DON stated the resident's toenails measured one cm and had jagged edges. She said, If he is not on the list for the podiatrist, I will see about him being put on the list to be seen by the podiatrist. The facility's Process / Guidance for ADL assistance (undated) revealed staff would provide assistance with ADLs per plan of care or CNA care plan, to include assistance with routine hygiene, grooming, and nail care. Review of the Facility assessment dated [DATE] showed the facility would provide general care and services including ADL care. The document read, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies Staff type 3.1.Medical/Physician Services (e.g., Medical Director, Attending Physician, Physician Assistant, Nurse Practitioner, Dentist, Podiatrist, ophthalmologist).

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate services to prevent further decrease in range of motion related to application of hand splints for 2 of 2 residents reviewed for limited range of motion, out of a total sample of 45 residents, (#53 and #83). Findings: 1. Review of the medical record revealed resident #53 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Alzheimer's disease, paralysis affecting right dominant side, contractures of the right hand, left hand, right lower leg, and right elbow, muscle contractures at multiple sites, lack of coordination, and muscle wasting atrophy. A contracture is a fixed tightening of muscle, tendons, ligaments or skin. It prevents normal movement of the associated body part. (retrieved on 4/03/23 from www.medlineplus.gov). The Minimum Data Set (MDS) Quarterly assessment with assessment reference date (ARD) of 12/07/22 indicated the resident had short and long-term memory deficit. Resident #53 was totally dependent on staff for all activities of daily living (ADLs) including bed mobility, transfers, dressing, toilet use, and personal hygiene. On 3/12/23 at 11:49 AM, resident #53 was noted to have contracted right and left hands, but no splints in place. Review of the medical record showed a physician order dated 9/03/21 for restorative nursing as needed. Review of the resident's care plan for range of motion included interventions for bilateral palm guard splints as tolerated, right elbow extension splint as tolerated, and observe and report any decline in range of motion. On 3/13/23 at 5:54 PM, and 3/14/23 at 12:16 PM, resident #53 was observed without splints, braces, rolled washcloths, or carrot-shaped soft splints in her hands. On 3/14/23 at 12:33 PM, Registered Nurse (RN) L confirmed resident #53's hands were contracted and she did not have any type of splinting device applied. He said, She should have something in her hands. RN L was unsure if resident #53 received range of motion services from restorative nursing staff or therapy staff. On 3/14/23 at 12:52 PM, Certified Nurses Assistant (CNA) Q explained she usually applied residents' splints and range of motion exercises were done by restorative nursing staff. During review of resident #53's electronic CNA care plan or Kardex she noted there were no directions or instructions regarding range of motion or hand splints for the resident. CNA Q referenced the Kardex and said, Not here. On 3/15/23 at 11:52 AM, Licensed Practical Nurse (LPN) Supervisor O stated either the assigned CNA or therapy staff applied residents' palm guards and visually checked to make sure palm guards were provided. On 3/14/23 at 11:54 AM, the Director of Nursing (DON) stated initially therapy staff screened residents for contractures, then they would make recommendations or design a program for the resident. She stated interventions and orders depended on the results of therapy screenings and recommendations. On 3/14/23 at 12:46 PM, Occupational Therapist F explained resident #53 was to have two palm guard finger separators, one for each hand, and one elbow splint for the right arm, applied daily for four hours. She stated the resident was on the Restorative Nursing Program (RNP), but she was unsure if nursing staff were documenting on provision of restorative care and services. Occupational Therapist F provided a copy of the recommendation for therapy request for orders dated 10/6/22, restorative maintenance recommendations dated 11/22/22, and Occupational Therapy treatment note dated 12/07/22 that indicated all caregivers were trained and gave 100% return demonstration on proper technique and steps for application of splints. She provided a copy of the splinting program form dated 12/08/22 with in-service training signature page showing eleven signatures, orthotic needs, treatment notes and splinting program forms dated 12/08/22, and therapy recommendation for restorative functional maintenance program dated 1/20/23. She stated therapy recommendations were given to the DON and the Unit Managers. On 3/14/23 at 3:44 PM, the Administrator stated there was no documentation of concerns or Performance Improvement Plans (PIPs) related the RNP in the facility's Quality Assessment and Assurance (QAA) book. The Administrator and the DON stated the issue was discussed in an Ad Hoc QAA committee meeting outside of the scheduled monthly meeting. The Administrator explained the DON had not provided any documentation of the discussions so that it could be placed in the QAA book. The DON provided a Quality Assessment & Performance Improvement Plan form with a start date of 1/16/23. However, the document did not include information regarding an Ad Hoc meeting regarding the facility's RNP. The DON then provided the facility's Ad Hoc Meeting Restorative Plan. She stated they used a list of the residents on restorative therapy as their audit tool. No actual audit forms were completed and the DON did not provide any audit tool report. The DON stated there were no audits for Certified Nursing Assistants (CNA) inservice or audits for restorative nurse documentation. Review of the facility's restorative Nursing Programs and Guidelines with revision date October 2017 revealed The facility provides Restorative Nursing Programs that involve interventions to improve or maintain the optimal physical, mental and psychological functioning Combinations to consider that may enhance the Restorative nursing Process: Passive range of Motion (PRPM) + Splint/Brace Assist Review of the facility Process and Procedure no date showed Overview: The Contracture Prevention and Management (Splinting/Bracing) Program is designed to promote optimal improvement, preserve function, and minimize deterioration within the limits of the normal aging process and/or a recognized disease process. 46665 2. Review of the medical record revealed resident #83 was admitted [DATE] and readmitted to the facility on [DATE] with diagnoses including contracture of left hand, contracture of muscle of left hand, contracture of left knee, stroke due to occlusion or stenosis of right middle cerebral artery, and hemiplegia and hemiparesis to the left non-dominant side. The MDS quarterly assessment with ARD 12/04/2022 identified the resident scored 14 out of 15 on the Brief Mental Status Interview (BIMS), that indicated the resident was cognitively intact, did not reject care necessary for health and well-being, and was totally dependent on staff for activities of daily living (ADL). The MDS assessment indicated resident #83 did not receive splint or brace assistance during the look back period. The resident's orders included occupational therapy to be provided 5 times per week from 11/11/2022 to 12/21/2022 for contracture of the left hand and splint management. The resident's care plan included an intervention, Wrist-Hand-Finger-Orthosis (splint device) to left upper extremity as tolerated, initiated 6/06/2022, and revised 3/11/2023. The Kardex for Certified Nursing Assistants (CNA) to identify resident care information indicated resident #83's daily care required, Wrist-Hand-Finger-Orthosis (splint device) to left upper extremity as tolerated. The Kardex did not show the splint was being put on or taken off by staff. On 3/12/2023 at 11:03 AM, resident #83 was observed lying in bed awake. The resident's left wrist was bent towards her arm and there was no splint in place. On 3/12/2023 at 4:16 PM, the resident was observed lying in bed awake. Her left wrist was bent towards her arm without a splint on. Resident #83 said staff applied a splint to her left wrist, every once in a while. She explained she preferred having the splint on because it helped with pain. The resident made a grimacing expression while putting her hand on her left wrist. She said she was having a muscle contraction and it was, very painful. On 3/13/2023 at 8:51 AM, the resident was observed lying in bed with her eyes closed. The resident's left wrist did not have a splint in place. On 3/13/2023 at 5:27 PM, a splint was observed sitting on the overbed table next to the resident. The resident stated staff had not applied the splint to her left wrist all day. On 3/14/2023 at 8:46 AM, the resident explained since she had not been wearing the splint, she had experienced increased muscle spasms in her left wrist. She recalled the splint was missing a few weeks prior, and she told staff she was willing to purchase a new one. She said the splint was eventually found in a drawer and had been used once. She explained she sometimes had pain from muscle spasm in the left wrist from 8 to 10 on the 1-10 pain scale. On 3/14/2023 at 9:18 AM, CNA C said she regularly had resident #83 on her assignment. She said CNAs did not put on or take off the splint for the resident because therapy staff did it. 03/14/2023 at 10:24 AM, Certified Occupational Therapy Assistant (COTA) E said he was familiar with resident #83 and acknowledged the resident used a splint. He explained splints were used to prevent decline and maintain range of motion (ROM). He explained if a splint was not used to manage a contracture, the contracture could worsen. On 3/14/2023 at 10:34 AM, Occupational Therapist (OT) F explained resident #83 had used a splint for contractures and did very well in therapy while tolerating the splint about 4-5 hours at a time. She said the resident seldom refused the splint and it needed to continue to be put on daily by nursing staff after skilled therapy discontinued for functional maintenance. She said nurses and CNAs were supposed to put on and take off the splint for 4-6 hours a day. She said contractures usually worsen when not used daily because tissues and ligaments can shorten causing increased pain and reduced joint mobility. She conveyed it was very important for resident #83 to continue splint therapy to maintain range of motion and prevent decline. On 3/14/2023 at 11:20 AM, the Director of Nursing (DON) said after therapy was completed, some residents transition to restorative nursing for ROM and splinting treatment and services. She explained therapy completed the plan of treatment and the directions should be shown on the CNA Kardex to complete daily resident tasks. She said resident #83's program should show up on the CNA software like other tasks for the CNA to sign off and document as completed. She said she was aware of problems with CNAs not completing restorative tasks for ROM and splints since January 2023. She said she was going to look at the problem again to, revamp.

Based on observation, and interview, the facility failed to provide services to prevent complications from a gastronomy tube for 1 of 2 residents observed for enteral feeds, out of a total sample of 45 residents, (#214). Findings: Resident #214 was admitted to the facility 2/22/23 with diagnoses to include dysphagia, gastrostomy status, and type 2 diabetes. The resident's quarterly Minimum Data Set (MDS) assessment dated , 2/26/23 indicated the resident was severely cognitively impaired and was rarely or never understood. The assessment revealed the resident did not have any behaviors and was totally dependent on staff persons for activities of daily living. On 3/13 /23 at 12:30 PM, the resident was observed lying in bed with the tube feeding infusing. The head of the bed was not elevated and the resident lay flat in bed. Registered Nurse (RN) L confirmed the head of the resident's bed was not elevated and the tube feed was infusing. He stated the head of the bed should have been elevated at least 30-45 degrees. On 3/13/23 at 3:55 PM, the resident was again observed lying flat in bed with the tube feed running. The head of the bed was not elevated and the resident was lying flat. The MDS nurse confirmed the head of the bed was flat and the tube feeding was infusing. She stated the head of the bed should have been elevated to prevent the resident from aspirating the feed. She was not aware which staff left the head of bed down. On 3/14/23 at 1:26 PM, Certified Nursing Assistant (CNA) N stated she always raised the head of the bed for a resident with tube feedings when the feed was infusing. The resident's care plan for tube feeding dated 3/13/23 included an intervention to elevate the head of bed during administration of feeding or medication administration.

Based on observation, interview, and record review, the facility failed to ensure intravenous (IV) dressing was changed as ordered for 1 of 1 resident reviewed for IV therapy, of a total sample of 45 residents, (#269). Findings: Resident #269 was admitted to the facility on [DATE] with diagnoses including infection and inflammatory reaction due to other cardiac and vascular devices, cardiac pacemaker and other bacterial infections of unspecified site. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 3/08/23 revealed resident #269 had a Brief Interview for Mental Status score of 13 out of 15 which indicated she was cognitively intact. She did not exhibit any behavioral symptoms and did not reject care that was necessary to achieve her goals for health and well-being. The document revealed resident #269 had a diagnosis of wound infection and received IV antibiotics. A care plan for IV Medications was initiated on 3/03/23 and revised 3/11/23. The care plan indicated resident #269 received IV antibiotics for a pacemaker site infection. Interventions included to Check dressing at site daily, change per facility policy/MD orders. Review of resident #269's electronic medical record (EMR) revealed a physician order dated 3/03/23 which instructed licensed nurses on the evening shift to change IV dressing every 7 days and as needed for soiling and/or dislodgement. Review of the Medication Administration Record (MAR) for March 2023 revealed Registered Nurse (RN) B documented he had changed the IV dressing during the evening shift on 3/11/23. On 3/12/23 at 11:39 AM, resident #269 was observed in bed with head of bed elevated watching television. An IV medication bag was hanging from the IV pole but not connected. Resident #269 stated she was receiving an antibiotic due to an infection at her pacemaker site. She lifted her sleeve to show the IV insertion site on her left arm. The area was covered with a transparent dressing dated 3/02/23. Resident #269 stated the dressing had not been changed since her admission to the facility. On 3/12/23 at 11:55 AM, Licensed Practical Nurse (LPN) A observed resident #269's IV dressing and verified it was dated 3/02/23. She reviewed resident #269's EMR and reported the dressing was scheduled to have been changed 3/11/23. LPN A acknowledged 7 days from date on IV dressing would have been 3/09/23. She could not explain why it was scheduled for 3/11/23 or why it had not been changed as ordered. On 3/14/23 at 9:53 AM, the Director of Nursing (DON) stated the purpose of the IV dressing was to hold the IV in place and keep the insertion site clean to prevent infection. She reviewed resident #269's EMR and acknowledged the IV dressing should have been changed every 7 days according to the physician order. The DON reported she spoke with RN B who should have changed the dressing on the evening shift of 3/11/23. Per the DON, he was apologetic and confirmed he had not changed the IV dressing as ordered. She was unable to explain why the IV dressing change was scheduled for 3/11/23 instead of 7 days from date on IV dressing which was 3/09/23. The facility's policy and procedure for Dressing Change for Vascular Access Devices dated February 2016 indicated the purpose was to prevent local and systemic infection related to the IV catheter. The policy read, Central venous access device and midline dressing changes will be done at established intervals . transparent semi-permeable membrane dressings are changed every 7 days and [as needed].

Based on observation, interview, and record review, the facility failed to develop and implement a safe discharge plan to ensure a resident would not be discharged to an unlicensed group home for 1 of 4 sampled residents, (#1). The facility's failure to develop a safe/reasonable discharge plan to meet the resident's care needs and have a process in place to assess the safety of the discharge location resulted in psychosocial harm to resident #1. Based on the resident's severe cognitive impairment and inability to express his response, and using the reasonable person concept, the resident would experience anxiety, agitation, distress, and depressed mood when discharged to an unlicensed group home that was unsafe and incapable of meeting his needs. Findings: Resident #1 was admitted to the facility on [DATE] and readmitted from acute care hospital on 1/13/23 with diagnoses of metabolic encephalopathy, acute respiratory failure, stroke, Parkinson's disease, dysphagia, cognitive communication deficit, lack of coordination, unsteadiness on feet, neurocognitive disorder with Lewy bodies, and depression. Lewy body dementia is a brain disorder that can lead to problems with thinking, movement, behavior, and mood. Visual hallucinations, or seeing things that are not there, are a common symptom, and tend to happen early on (https://www.alzheimers.gov/alzheimers-dementias/lewy-body-dementia). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview of Mental Status (BIMS) score of 2 which indicated severe cognitive impairment. The resident had inattention and disorganized thinking. His overall presence of behavioral symptoms impacted self and others and put self and others at significant risk for physical injury. Resident #1 required extensive assistance with bed mobility, transfers, locomotion on/off unit, dressing, toilet use, personal hygiene and total dependence on staff for bathing. The assessment noted the resident was always incontinent of bladder and bowels. The MDS assessment dated [DATE] showed resident #1 received antipsychotic and anticoagulant medications in the last 7 of 7 days, received antianxiety medications in the last 3 of 7 days, and received antidepressant medications in the last 6 of 7 days. Review of resident #1's individualized plan of care documented the resident/responsible party wished for long term care placement. The care plan noted the resident had PTSD (post traumatic stress disorder) and could be aggressive/combative, had impaired cognitive function related to dementia and severely impaired cognition. He was at risk for falls related injury due to unsteady gait, aggressive/combativeness behaviors, psychotropic medication use and was an elopement risk. Review of the medical record showed resident #1 had falls at the facility on 12/9/22, 1/12/23 which resulted in head/abrasion, and 1/16/23. He had episodes of wandering on 12/12/22 when he pressed the exit door's handle bar for 15 seconds then exited the building and sat on the grass for 10 minutes. Staff were present during the time. The attending physician's progress note dated 1/19/23 read, The patient is s/p [status post] hospital secondary to AMS [altered mental status] .patient's prognosis is poor due to advance age and comorbidities. A decline in health wouldn't be unexpected. The attending physician note did not include any information regarding discharge planning. On 1/24/23 at 10:35 AM, resident #1 was observed walking in the unit's hallways without his walker. He had one to one staff supervision by Certified Nursing Assistant (CNA) A. She followed the resident and reminded him to use his walker and re-directed him from going into other residents' rooms. The resident was confused with poor eye contact and not able to answer interview screening questions. On 1/24/23 at 10:40 AM, the resident's assigned Licensed Practical Nurse (LPN) B stated the resident had one to one staff supervision for frequent falls, wandering and history of aggressive behavior. On 1/24/23 at 11 AM, the Social Services Director (SSD) said the resident's discharge hearing was set for 2/20/23. She explained that when resident #1 was first admitted , the plan was for him to go home and then it became apparent he was going to need long term care. She verbalized she became aware that his family wanted long term care when they started the Medicaid application process on 11/8/22 and acknowledged they did not want him discharged from the facility. She indicated the resident's wife would not be able to manage him at home and his daughter had young children to care for. The SSD reported the facility had used an agency to find the facility the resident was slated to be discharged to. She said she thought it was a licensed Assisted Living Facility (ALF) but was notified by the resident's daughter that it was an unlicensed group home. The SSD stated, we were not able to find any other nursing homes or ALFs that would accept him and that is why we chose a group home. When asked about documentation of discharge plans, the SSD stated she had not documented any discharge planning in resident #1's medical record and only had emails regarding her communication with the daughter. She did not explain if the facility had a system in place for assessing the safety of the resident's discharge location. The SSD stated they relied on the agency to provide them locations for resident to be discharged . An attempt was made to locate the facility on the website which revealed there was no license for this provider under Adult Family Care or Assisted Living Facility (ALF). On 1/24/23 at 11:49 AM, the facility's Administrator said she spoke to the resident's daughter when the discharge notice was given on 12/13/22. She indicated the family did not like the facility the resident would be discharged to but she explained to them it was the only facility that would accept him. The Administrator did not explain if they determined the group home was a safe setting for the resident to be discharged to or if his care needs could be met. She stated, we just went by what the agency told us. She could not provide any documentation of any discussions or assessments to determine the receiving facility was safe for the resident's discharge. Review of the facility's Care Plan/Interdisciplinary Team Note dated 11/30/22 showed the team met to review the resident's plan of care with the resident's wife and daughter. The documentation did not include which disciplines attended the meeting or any discussion of discharge plans. On 1/24/23 at 1:03 PM, a telephone interview was conducted with resident #1's wife and his daughter. Both the wife and daughter were emotional and cried as they explained they were informed by the Administrator on 11/29/22 that he would be discharged from the facility. The wife explained he had 3 falls which ended up with him going to the hospital and when they changed his medications, he went into downward spiral. The daughter stated, dad was such a good person prior to his hospitalization and does not deserve to be treated like this. They both said they wanted him to remain at the facility and spoke about the improvement in his behaviors. He is happy here and loves the people. The wife added, his Elder Care physician felt it was better for her husband to remain at the facility. The daughter said she visited the receiving facility the day after being informed her dad would be discharged and she had many concerns. She explained she saw medications were not locked, constant supervision was not provided, the entire back yard was full of big pieces of metal junk, the girl working there was not a certified care giver or nurse, there were no handicap showers or restrooms, and they had 4 men crammed into 1 room with 4 twin beds. She said it was the most atrocious place and so unsafe. The daughter recalled she phoned the Administrator the next day on 12/1/22, to inform her the facility was in a high crime area and described the unsafe setting with lots of clutter and tripping hazards. She said she also informed the Administrator the facility was not licensed. She said the Administrator responded by telling her, this was the only facility that agreed to take him and he would have to go their or home with your mom. She said she tried to explain to the Administrator her mom was elderly, had health issues and would not be able to care for her father. The resident's wife and daughter cried throughout the interview and expressed how sad and helpless they felt with his pending discharge. The daughter conveyed she sent the SSD an email on 12/5/22 describing the group home's unsafe and deplorable conditions and that it was an unlicensed facility. She said the only response she received from the SSD was for her to speak to the Administrator. She said she gave the facility a list of acceptable nursing homes with secure dementia units but the facility did not provide any alternatives other than the unlicensed group home or her mother's home. On 1/24/23 at 12:43 PM, Physical Therapist (PT) C said he worked with resident #1 regularly and could not get him to do anything safely. He explained the resident was easily startled and it was difficult to keep him calm and safe. He said the resident would not remember to use a walker and would just push it aside which made his walking unsafe. PT C noted he was not involved in the discharge planning process for resident #1 and indicated, the resident has become comfortable here and is not being as aggressive with people. On 1/24/23 at 3:27 PM, the Director of Therapy said the resident required a facility that offered 24-hour supervision such as an ALF with memory care unit. She noted the resident was very aggressive initially and said he was not displaying aggressive behaviors as much now. She explained he required 1-2 staff for all his care needs due to his behaviors. She said she was not aware he was being discharged to an unlicensed group home and reported, he needs more supervision and assistance. On 1/24/23 at 1:36 PM, Occupational Therapist (OT) D explained she worked with resident #1 and it was very difficult to get him to do his activities of daily living or go to the bathroom safely as he did not understand verbal cues. OT D said she was not involved in his discharge planning. She stated, an unlicensed group home would not be appropriate for him. He has no recollection, no cognition of what he is doing and needs constant supervision. He is not capable of attending to any activity because he cannot process what is going on. On 1/24/23 at 1:58 PM, the resident's regularly assigned nurse, LPN F said she was not involved in his discharge planning process. She noted he was on one to one supervision for wandering behaviors and history of aggression. She explained the resident could not follow any directions and required constant supervision 24 hours a day, 7 days a week. She reiterated the resident was not capable of doing anything independently. On 1/24/23 at 2:01 PM, resident #1's assigned Certified Nursing Assistant, (CNA) G spoke about the assistance the resident required. She explained she had to brush his teeth, wash and dress him, and assist with feeding meals. She conveyed he was on one to one supervision due to falls, constant wandering and need for frequent redirection. On 1/24/23 at 5:17 PM, Psychiatric Advance Practice Registered Nurse (APRN) H stated another provider group was now attending to resident #1. She said she saw him until the end of December 2022 and did not remember the facility discussing any discharge plans. She explained, the resident does wander and does not like to be re-directed. He would need a memory care unit at a nursing home or ALF. On 1/24/23 at 6:21 PM, the Director of Nursing (DON) verified the facility did not document team meeting notes regarding discharge planning for resident #1. She said, when he first came to us, he was extremely combative, impulsive, and aggressive which was all part of his dementia. We put him on one to one supervision 1 week after his admission and he remains on one t one because he tries to go outside, into other resident rooms and if we try to deter him, then he becomes combative. The staff stay next to him to ensure his safety. He is not able to participate in any activities for more than a few minutes. The DON added, she was not involved in any discussions regarding sending resident #1 to an unlicensed group home. She explained, he would need to be where he could have 24 hour 7 days a week supervision by staff who are trained in caring for residents with behaviors. The DON reviewed the care plan meeting notes from 11/30/22 and verified she was not involved in the discharge planning process for resident #1. She confirmed there was no documentation in the resident's medical record about discharge to a group home or the family's objection. On 1/25/23 at 12:24 PM, APRN I returned phone call made on 1/24/23. She stated she worked with the physician who specialized in memory care and had been doing visits with resident #1 via telehealth since 11/14/22. She explained she had seen the resident 6 times, with the last visit on 1/6/23. She noted they had been adjusting the resident's medication for behaviors which initially were aggressive and combative. We have made significant medication changes and each time he is doing much better. The APRN validated the facility had not contacted or involved her in the discharge planning process. She added that coordination with the facility had been difficult to complete and receive the report sheets for resident #1's mood, vital signs, and behaviors. We have to call the facility nurse to obtain needed information prior to our visit. She said she was aware of resident #1's pending discharge hearing and sent the facility a letter on 1/24/23 that read, it is in our medical opinion that he stays here and not locate to a different facility because it would likely cause exacerbation of his disease and worsen his behaviors. She added that a group home would not be a good option for resident #1. Review of the facility's policy & procedure Resident/Family Care & Services (Discharge Planning) effective February 2021 read, The Social Services Department works with the interdisciplinary team to assist the resident/resident representative with discharge process. Discharge planning begins at admission and throughout the continuum of care. The discharge plan is reviewed & re-evaluated at each of the resident's schedule care plan meetings. The Director of Social Services or designee is responsible for coordinating the discharge planning process .The facility must ensure that the transfer of discharge is documented in the resident's medical record and appropriate information is communicated to receiving health care institution or provider . The Social Services Director Job Description undated read, The Social Services Director is responsible for initiating and maintain a comprehensive social services program within the facility .Attends and participates in the IPOC meetings with emphasis on medically related social services including Discharge Planning .Develops and maintains resources for discharge planning information. Serves as primary resident/patient/family liaison regarding communications and development of interdisciplinary treatment and/or discharge plan .