Every finding on record at Rehabilitation Center of Lisbon

Based on observation, staff interview, clinical record review, and facility policy review, the facility failed to ensure that interventions to prevent falls were implemented for 1 of 6 residents reviewed for falls (Resident #52). The facility reported a census of 62 residents. Findings include: Review of the MDS assessment, dated 12/03/25, revealed that Resident #52 had a BIMS score of 15/15, which indicated intact cognition. The list of diagnoses included fracture and other multiple trauma, Cerebral Vascular Accident (CVA or stroke), muscle wasting and atrophy. Resident #52 required supervision or touching assistance with transfers and walking. Review of the Care Plan, revised on 12/19/25, revealed a Focus area for Resident #52's need for assistance with ADLs (activities of daily living) due to Type 2 Diabetes Mellitus, Chronic Kidney Disease (CKD), history of Transient Ischemic Attack (TIA or sudden stroke-like symptoms), and limitations due to history of fall with fracture and repair to left hip. Interventions dated 9/5/25 identified that Resident #52 required assistance of one staff member to transfer and one staff member assistance to walk to and from the bathroom using a wheeled walker and gait belt. Review of the Care Plan, revised on 9/08/25, revealed that Resident #52 was at risk for falls. The fall interventions included the following, in part: a. Do not leave unattended in wheelchair when in room. Date initiated: 10/09/25. b. Assist resident with ambulation and transfers as needed. Date initiated: 8/29/25. c. Sign in room to utilize call light. Date initiated: 10/22/25.Review of nursing progress Note, dated 12/05/25 at 3:24 PM, revealed that Resident #52 had an unwitnessed fall in room, when resident reported she self ambulated for a blanket and did not activate call light as Resident #52 thought she could do it by herself. An intervention identified reinforcing education to Resident #52 on utilizing the call light. During an observation on 1/11/26 at 1:16 PM, Resident #52 propelled self in wheelchair, through the hallway from the dining room into her room and took self into the bathroom, located inside resident's room. A sign noted to be hung on the wardrobe in Resident #52's room that instructed staff to not leave resident unattended in wheelchair in room. During an observation on 1/13/26 at 9:07 AM, Resident #52 propelled self in wheelchair from the dining room to her room. At 9:20 AM, Resident #52 noted to be in her bathroom. At 9:22 AM, Resident #52 observed ambulating independently from the bathroom, pushing wheelchair backwards, with hands on the seat and a stooped (bent forward) posture to her recliner where she then turned and sat self down. During an observation on 1/14/26 at 8:51 AM, Resident #52 sat in wheelchair unattended in her room and at 8:54 AM, transferred self from wheelchair into her recliner. During an interview on 1/14/26 at 2:13 PM, Staff D, CNA, reported that Resident #52 required assistance of 1 staff to transfer using a walker and gait belt. Staff D identified interventions to prevent Resident #52 from falling included have her call light in reach, and don't leave unattended in wheelchair in her room. During an interview on 1/21/26 at 3:39 PM, the Director of Nursing (DON) reported that fall interventions determined at the time of fall would be discussed in nursing meetings every week to ensure all interventions were care planned, implemented, and appropriate for each resident. The DON revealed an expectation that all fall interventions be implemented to prevent falls and injury. Review of the facility policy, titled Fall Occurrence, dated February 2024, revealed a Purpose Statement stating that it is the policy of the facility to ensure that residents are evaluated for fall risks and implement interventions to minimize risk for falls and/or risk for injury from falls. The policy listed the following procedures to follow, which included, Based on assessment, interventions are implemented and placed on the Care Plan.

Based on clinical record review, staff interviews and facility policy review the facility failed to administer medication as ordered to 3 out of 11 resident reviewed (Resident#4, Resident #9,& Resident #47).The facility reported a census of 62 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #4 dated 7/2/25, listed diagnoses of gastrointestinal hemorrhage (bleeding), Alzheimer's disease, anemia (lack of healthy red blood cells), heart failure, and orthostatic hypotension (low BP). The Brief Interview for Mental Status Score (BIMS) reflected 5 out of 15, which indicated severe cognitive impairment. Review of the resident's Care Plan for antidepressant medication use with goal target date 10/09/25 revealed the following intervention: Administer medications as ordered. The Progress Note for Resident #4 dated 9/17/25 at 8:40 AM revealed [Provider] notified of medication error. The Provider ordered give Midodrine (medication to treat low blood pressure)10 milligrams (mg) now and to check vitals every hour for 1 hour. The Progress Note for Resident #4 dated 9/17/25 at 8:52 AM reflected the facility contacted the daughter of Resident #4 regarding the medication error that happened that morning, resident was stable with plan to monitor and double dose of midodrine. The Incident Report Note for Resident #4 dated 9/17/25 at 3:06 PM explained Resident #4 received another resident's medications in error. The medication administered to Resident#4 included apixaban 5 milligrams (prescription blood thinning medication), pantoprazole 20 mg (medication to decrease stomach acid), amiodarone 200 mg (medication to treat irregular heartbeats), Zofran 4mg (medication to prevent nausea and vomiting), levothyroxine 50mcg (medication to treat underactive thyroid), senna-plus (stimulant laxative & stool softener medication), Wellbutrin XL 150 mg (antidepressant), clopidogrel 75mg (antiplatelet medication), escitalopram 20 mg, (antidepressant medication), ferrous sulfate 325mg (iron supplement), furosemide 40mg (diuretic medication), and losartan 50mg (used to treat high blood pressure). The Incident Report note revealed the following treatment provided: manual blood pressure (BP) every 1 hour for 8 hours, then every 4 hours for 5 hours. Midodrine increased to 10 mg 3 times a day for 9/17/25 only, then resume 5mg three times a day. The Medication Administration Record (MAR) dated 9/17/25, revealed Staff A, Licensed Practical Nurse (LPN) provided the morning medications to Resident #4. 2. The MDS for Resident#9 dated 10/22/25 listed diagnoses of osteoarthritis (OA) (degenerative joint condition causing bones to rub, leading to pain) anemia, Hypertension (high BP), and heart failure. The BIMS reflected a score of 14 out of 15, which indicated intact cognition. The Care Plan for Resident #9 initiated 8/20/25 directed staff to administer pain medication per physician orders. Review of Resident #9's December 2025 MAR revealed, Oxycodone tablet 10mg (opioid analgesic for moderate to severe pain) with directions to give one tablet by mouth every 6 hours as needed (PRN) for left shoulder pain (start date 2/12/25). Resident #9's December 2025 MAR further revealed, Morphine Sulfate (MS) Contin tablet 15 mg Extended Release (opioid pain medication) with directions to give one tablet by mouth two times a day for chronic left shoulder pain (start date 3/4/25). Resident #9's MS Contin was scheduled to be administered at 10:00 AM and 10:00 PM per the MAR. Continued review of the MAR revealed on 12/4/25, Staff A administered PRN Oxycodone 10mg to the resident at 7:44 AM, as well as at 10:27 AM. A dose of the medication had been administered by a different nurse on 12/4/25 at 5:41 AM. Review of Resident #9's Order Administration Notes revealed the following: a.12/4/25 at 5:41 AM: oxycodone 10 mg give 1 tablet by mouth every 6 hours PRN for left shoulder pain. b.12/4/25 at 7:43 AM oxycodone 10 mg give 1 tablet by mouth every 6 hours PRN for left shoulder pain. Ineffective with follow-up pain scale 7. c.12/4/25 at 7:44 AM: oxycodone 10 mg give 1 tablet by mouth every 6 hours PRN for left shoulder pain. The Incident Report-Medication Event Note dated 12/4/25 at 8:10 AM revealed the resident was ordered oxycodone 10mg administered, and medication was scheduled every 6 hours PRN. Description of medication incident revealed, PRN medication administered after only 2.5 hours from last dose. The note reflected Resident #9 did not display signs or symptoms of distress. The Provider ordered the nurse to give routine MS Contin at 10am and continue to give PRN oxycontin as prescribed. The MAR revealed on 12/4/25, Staff A, LPN, documented HO (hold see Progress Note) for the resident's 10:00 AM dose of MS Contin 15 mg. The Order Administration Note dated 12/4/25 at 10:27 AM revealed PRN oxycodone given instead of scheduled MS Contin. 10 AM MS Contin dose held per physician orders. The Incident Report-Medication Event note dated 12/4/25 at 11:28 AM revealed Oxycodone 10mg given instead of MS Contin 15mg. The employee file for Staff A, LPN included an Employee Warning Notice dated 9/8/25, which reflected violation pills were found at the table with the resident, nurse not in the area. The form reported the facility completed education before about not leaving meds in resident room or at the table. The form also stated it was the expectation that we watch all meds be taken to assure that the right resident takes the medication. The document signed by Staff A and the facility on 9/9/25. The Employee file failed to include an education/warning for Resident #4's medication error on 9/17/25. The Employee Warning Notice for Staff A dated 12/5/25 revealed: On 12/4/25 Staff A gave an as needed oxycodone to a resident without checking previous administration which ended up giving the resident the medication prior to the ordered time it was available. The warning identified the facility addressed there was no way [the nurse] looked at her MAR before she administered the medication or [Staff A] would have seen it was not time for the dose. During the same shift [Staff A] gave the same resident oxycodone in place of her mid-morning morphine sulfate ER. Demonstrating how she failed to follow the 5 rights of medication administration. The document revealed the nurse will be provided additional training. Signed by Staff A and the facility on Signed 12/17/25. On 1/21/26 at 11:52 PM, Staff B, Certified Medication Aide (CMA) reported she knew who a resident was by the picture on the MAR. She said if she ever questioned who a resident was, she would ask a coworker. Staff B reported the MAR told when the medications were due by the color of the medication on the screen. Staff B stated the color white meant the medication was not due yet, yellow meant it was time to give, green indicated the medication given, and pink color meant the medication was late. Staff B said the PRN medication would tell (staff) if was too soon to give. On 1/21/26 at 12:20 PM the Nurse Practitioner reported the staff follow up as needed with any medication errors. On 1/21/26 at 12:32 PM Staff C, LPN reported there were several ways to identify a resident. Staff used the photo in the MAR, the name, asked the resident, asked other staff, asked the resident their date of birth . Staff C, described the colors of the MAR and what each color meant. Yellow meant medications were due, green meant medication were given, red meant medications were past due. Staff C stated the PRN medication directed the staff if they were able to be given, or if it was too soon to give the medication. On 1/21/26 at 3:39 PM, the Director of Nursing (DON) reported she expected the nurses to check MAR and follow the 5 rights for all medication administration. The DON reported she provided education to Staff A before the incident with Resident #4 in September, when she observed Staff A left medications unattended on the table. The DON reported Staff A knew the expectations of the facility. On 1/21/26 at 4:23 PM the Administrator reported she expected the nurses to follow the physician's orders and give the right person the correct medication as the physician ordered. The facility provided a policy titled Medication Administration Medication Pass dated 5/2023 revealed, Read transcribed physician order on EMAR (electronic medication administration record): patient name, medication name, dosage, route and interval ordered. 3. Review of the MDS assessment dated [DATE] revealed that Resident #47 had a BIMS score of 10 out of 15, which indicated moderate cognitive impairment. The list of diagnoses included heart failure, End Stage Renal Disease (ESRD), Type 2 Diabetes Mellitus, and non-Alzheimer's dementia. Review of Resident #47's Census Report, revealed the resident was sent to the hospital on 1/3/26 with return on 1/5/26, was sent back to the hospital on 1/5/26 for less than 24 hours with return to facility on 1/6/26, and was sent to the hospital again on 1/6/26 until return to facility on 1/10/26. Review of the Hospital After Visit Summary, dated 1/04/26-1/05/26, revealed new orders to stop taking Jardiance (empagliflozin) (medication used to improve glucose control in Type 2 Diabetes Mellitus). Review of the MAR dated January 2026 lacked orders for Jardiance prior to hospitalization, and revealed the resident was ordered Farxiga (Dapagliflozin Propanediol) (medication used to improve glucose control in Type 2 Diabetes Mellitus) 5 milligrams (mg) with instructions to give 1 tablet by mouth in the morning, which was started on 7/10/25. Review of the nursing Progress Notes, between the dates of 1/05/26 and 1/15/26 lacked documentation of attempt to clarify the order from the hospital to discontinue Jardiance. Review of the Hospital Discharge summary, dated admission on [DATE] and dated discharge on [DATE], revealed orders to stop taking Farxiga (Dapagliflozin Propanediol) 5mg tablet. The MAR revealed that Farxiga (Dapagliflozin Propanediol) 5mg tablet was given 1/11/26 through 1/15/26, then discontinued on 1/15/26. Review of a nursing Progress Note, dated 1/15/26 at 3:11 PM, revealed an order to discontinue Resident #47's Farxiga. b. Review of the Hospital After Visit Summary, dated 1/05/26, following visit to Emergency Department, revealed an order to start taking amoxicillin-clavulanate (Augmentin) (antibiotic), with diagnoses urinary retention and acute cystitis (bladder infection) with hematuria (blood in the urine). Review of the Hospital Discharge summary, dated admission on [DATE] and dated discharge on [DATE], revealed orders to stop taking Amoxicillin-Clavulanate (Augmentin) 875-125mg and change order to Amoxicillin 875mg tablet (Amoxil) with instructions to take 1 tablet by mouth every 12 hours. Review of the MAR, dated January 2026, revealed an order for Amoxicillin-Clavulanate (Augmentin) 875-125mg, with instructions to give one tablet by mouth two times a day for seven days for UTI was started on 1/06/26, held while in the hospital 1/07/26-1/09/26, resumed on 1/10/26 and discontinued on 1/12/26. The MAR revealed an order for Amoxicillin 875mg, with instructions to give 1 tablet every 12 hours for UTI for 4 administrations was started on 1/14/26 and completed on 1/16/26. Review of a nursing Progress Note, entered on 1/14/26 at 10:34 AM, revealed that Resident #47's Provider was in the facility for post-hospital visit and reviewed orders for Amoxicillin-Clavulanate (Augmentin) 875-125mg. The Provider gave new order to give additional doses of Amoxicillin 875mg every 12 hours for 4 administrations. c. Review of the Hospital Discharge summary, dated admission on [DATE] and dated discharge on [DATE], revealed orders to hold Resident #47's order for Furosemide (Lasix) (used to remove excess fluid and treat high blood pressure) 60 mg, until Provider restarts, due to low blood pressure. Review of the MAR, dated January 2026, revealed an order for Furosemide 60 mg, with instructions to give 60 mg by mouth in the morning related to Chronic Systolic Heart Failure. The order for Furosemide 60 mg started on 1/06/26. Furosemide continued to be given on and after 1/11/26. d. Review of the Hospital After Visit Summary, dated 1/04/26-1/05/26, revealed new orders to start the medication, Midodrine (proamatine) (used to treat low blood pressure upon standing) 5 mg, with instructions to take 1 tablet by mouth three times a day for 30 days for a diagnosis of syncope (fainting). Review of a nursing Progress Note, entered on 1/14/26 at 10:34 AM, revealed that Resident #47's Provider was in the facility for post-hospital visit and added parameters to the Midodrine, instructing to hold the medication if systolic blood pressure is greater than 140. Review of the MAR dated January 2026 revealed an order for Midodrine 5 mg, with instructions to give 1 tablet by mouth three times a day for syncope for 30 days, started on 1/05/26. The MAR lacked parameters to hold medication if systolic blood pressure is greater than 140. The Midodrine was given three times a day between 1/14/26 and 1/20/26 without ensuring Resident #47's blood pressure was within parameters. Review of Resident #47's Medical Records lacked documentation of blood pressures checked three times a day to ensure blood pressure was within parameters and Midodrine was safe to administer. During an interview on 1/21/26 at 12:21 PM, a Provider for Resident #47 reported that there had been some medication errors involving Resident #47 upon his return from the hospital. The Provider stated that there was error with the Farxiga and that Augmentin had not been switched to Amoxicillin as indicated in the hospital discharge summary. The Provider stated that in response, ordered additional doses of Amoxicillin to ensure resolution of UTI and discontinued the Farxiga and Tramadol. The Provider reported that orders were given on 1/14/26 to add parameters to the medication, Midodrine, to hold if systolic blood pressure is greater than 140. The Provider was unable to find that blood pressures were being checked prior to medication administration and stated they would follow up with the facility to ensure this was implemented. The Provider stated that no negative outcomes had been observed as a result of medication errors. During an interview on 1/21/26 at 1:17 PM, Staff C, Licensed Practical Nurse (LPN), reported that Resident #47's Midodrine was supposed to have parameters to hold if systolic blood pressure is greater than 140 and informed that she was unable to find that parameters had been added to the medication order. During an interview on 1/21/26 at 1:52 PM, Staff B, Certified Medication Assistant (CMA), reported that Resident #47's Midodrine order did not have parameters to hold or require check of blood pressure prior to administration. Staff B stated she wondered about the medication hold parameters, due to other residents on this medication requiring blood pressure checks, but thought that the doctor didn't need that for Resident #47. During an interview on 1/21/26 at 3:39 PM, the DON stated that medication errors related to Resident #47's Farxiga, Tramadol, and Amoxicillin were identified during Provider visit (1/124/26) and that the error to implement Midodrine parameters was identified on 1/21/26. The DON revealed an expectation of nursing staff to transcribe and follow Provider orders and expected that nursing staff use an audit/double noting system to ensure implementation of orders. Review of the facility provided Incident Report Medication Event Note dated 1/14/26 at 9:30 AM, revealed a medication event which identified that Resident #47 had orders to hold Lasix until seen by Provider and to stop Augmentin 875-125mg BID x7days and start Amoxil 875mg one tablet by mouth every 12 hours and that the incident was related to communication with pharmacy. The Report documented that Resident #47's family and Provider were notified of incident on 1/14/26. The facility provided a policy titled Medication Administration Medication Pass dated 5/2023. Listed the purpose: To safely and accurately prepare and administer medication according to physician order and patient needs. The procedure directed: Open MAR to patient record and review physician medication order against medication label Administer medication in accordance with frequency prescribed by physician - identify patient. Administer medication according to specific procedure such as oral, topical, injection, etc.

Based on observation, staff interview, and policy review the facility failed to use appropriate personal protective equipment (PPE) when laundering soiled items. The facility reported a census of 61 residents. Findings include: During an observation on 12/11/24 at 8:09 AM Staff B, laundry aide, put on gloves and took plastic laundry bags out of bins and placed them onto the sorting counter. She then failed to put on a gown, sorted the linens, and placed them into bins. She then tossed the plastic bags in the garbage. Staff B cleaned the counter and performed hand hygiene. In an interview on 12/11/24 at 8:03 AM the Environmental Supervisor explained soiled laundry arrived in plastic bags in a covered yellow cart. The laundry then got sorted into bins. She explained items from isolation rooms go into a separate red bin. Staff wore a gown and goggles when handing isolation laundry. She noted no PPE is worn during sorting of general soiled laundry aside from gloves. In an interview on 12/12/24 at 9:06 AM the Administrator/Infection Preventionist explained she expected staff to put on an apron or gown when handling laundry from an isolation room. She noted she was not sure what PPE was required when handling general soiled laundry and stated the Environmental Supervisor would know. She acknowledged she was unaware of the need for staff to wear a gown when handling any soiled laundry. The facility policy titled Infection Prevention and Control Program (IPCP) Guidelines, revised 9/22 educated staff hand washing facilities as well as appropriate personal protective equipment (i.e. gloves and gowns) are available in the laundry area for workers to wear while sorting linens.

Based on clinical record review, policy review, and staff interview, the facility failed to carry out physician's orders for 2 of 24 residents reviewed (Resident #13 and #14). The facility reported a census of 58 residents. Findings: 1. The Minimum Data Set (MDS) Assessment Tool, dated 10/13/22, listed diagnoses for Resident #13 included Type 2 diabetes, chronic kidney failure, and history of stroke. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, dressing, toilet use, and personal hygiene, and total dependence of 1 staff for bathing. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 8 out of 15, indicating a moderate cognitive impairment. A Physician Order, dated 6/2/21, directed staff to notify the Physician if the resident's blood sugar reads below 60 milligrams per deciliter (mg/dl) or above 450 mg/dl. The facility lacked documentation of a Physician notification for a blood sugar reading of 488 mg/dl on 11/5/22. A Physician Order, dated 7/28/22, directed staff to hold 10 units of Novolog (insulin) if the resident's blood sugar is below 150 mg/dl. A 11/15/22 Incident Report-Medication Event 24 hour Follow-Up Progress Note indicated the resident received 10 units of Novolog after a blood sugar result of 99 mg/dl. The resident became lethargic. A second blood sugar resulted in a reading of 43 mg/dl. The resident required an emergency 1 gram injection of glucagon. 2. The MDS Assessment Tool, dated 12/2/22, listed diagnoses for Resident #14 included chronic heart failure, morbid obesity, and a surgical wound. The MDS documented the resident required extensive assistance of 2 staff for bed mobility, transfers, walking, and toilet use. Also extensive assistance of 1 staff for dressing, and personal hygiene. The MDS listed the resident's BIMS score as 12 out of 15, indicating a moderate cognitive impairment. A Physician Order, dated 10/14/22, directed staff to weigh Resident #14 daily and notify the Physician of weight gain of 3 lbs (pounds) in one day, or 5 lbs in one week. A review of the clinical health record lacked a documented daily weight on: 10/16/22, 10/19/22, 10/20/22. 10/22/22, 10/24/22, 10/26/22, 10/29/22, 10/30/22, 10/31/22, and on 11/7/22. A review of the clinical health record lacked documentation of a physician notification for a 3 lbs one day weight gain for the following days: a. On 11/4/22 weight of 307.2 lbs, 11/5/22 weight of 316.8 lbs. - gain of 9.6 lbs b. On 11/10/22 weight of 311.6, 11/11/22 weight of 315 - gain of 3.4 lbs c. On 11/13/22 weight of 315.6, 11/14/22 weight of 319.6 - gain of 4 lbs d. On 11/19/22 weight of 320.2, 11/20/22 weight of 325 - gain of 4.8 lbs A Daily Skilled Progress Note, dated 11/25/22, revealed the resident began to become confused and experienced shortness of breath during therapy. The resident started use of oxygen after a pulse oximeter reading of 71%. Hospital records, dated 11/27/22, revealed weight gain, shortness of breath, and hypoxia (low oxygen level) the reason for admission. A review of the clinic record indicated on 11/25/22 the residents weighed 322.2 lbs. At readmission on 11/28/22 the resident weighed 300.8 lbs. During an interview on 12/8/22 at 9:29 AM, Staff A, Certified Nursing Assistant (CNA) stated the resident's weight should be taken daily. Staff A stated the Unit Nurse is informed of the weight and completes the documentation. During an interview on 12/8/22 at 9:36 AM, Staff B, CNA stated the resident's weight should be taken daily. Staff B stated the Unit Nurse is informed of the weight and completes the documentation. Staff B denied being aware that the resident gained weight, but the nurse will ask for a reweigh if needed. During an interview on 12/8/22 at 11:35 AM, Staff C, Registered Nurse (RN) stated the resident is weighed daily, and if there is a weight gain of 3 lbs in one day, or 5 lbs in a week the Physician is to be notified. Staff C stated she would document the weight gain and notification of the physician with a progress note in the Electronic Health Record (EHR) During an interview on 12/8/22 at 2:28 PM, the Director of Nursing (DON) stated she would expect the nurse to call the Physician any time a resident has a result within an order's specific parameters. The DON stated the staff should have notified the Physician of Resident #13 11/5/22 blood sugar reading of 488 mg/dl as the order stated to notify the physician of a result above 450 mg/dl. The DON stated the staff should have notified the physician of Resident #14's one day weight gain of 3 pounds or more as the order started to notify the physician of a weight gain of 3 pounds or more in one day. The DON stated she would expect the staff to document all physician notifications in a progress note in the EHR. The facility policy, revised date of 4/2012, titled Family and Physician Notification Relating to Accident or Change in Medical Condition directed staff to immediately notify the physician of any change in the resident's medical condition; and to document the change.

Based on clinical record review, staff interviews and Nurse Practitioner interview the facility failed to provide timely assessment and interventions for the necessary care and services, to maintain the residents' highest practical physical well-being. Clinical record review revealed the Nursing Staff did a thorough assessment, but failed to administer oxygen as conditions warranted and failed to consult the resident's physician in a timely manner which delayed treatment and eventual hospitalization for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 52 residents. Findings Include: According to Resident #1's Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 indicating a severely impaired cognitive status. Resident #1 required extensive assistance with transfers, ambulation, dressing, toilet use and personal hygiene needs. Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on [DATE] at 11:05 a.m., Staff A, Certified Nurse Aide (CNA), stated on [DATE] at around 2:30 p.m. she was passing ice on [NAME] Hall. As she entered room [ROOM NUMBER] she saw Resident #1 laying prone on her bathroom floor. Resident #1 had been incontinent of bowel and bladder and her pants were pulled down to her ankles. Staff A called for help and Staff B, CNA responded. Resident #1 was agitated, confused and not talking. Soon Staff C, Licensed Practical Nurse (LPN), Staff D, LPN and Staff E, Registered Nurse (RN) arrive. Staff D begins assessing Resident #1, checking her vital signs as Staff A and Staff B begins cleaning her up. Staff A stated she suggested calling Emergency Medical Services (EMS), which was quickly denounced by Staff D as she stated no, Resident #1 is a Do Not Resuscitate (DNR) status. Staff A stated she was confused with the response. When Resident #1 was sat up, her oxygen levels dropped and Staff C suggested using oxygen. Staff D stated no, we can't do that without an order. Resident #1 was eventually lifted into her wheelchair and then lifted into bed. About 30 minutes into the event, Staff E checked Resident #1's code status and discovered she was a Full Code. At this time EMS was called and Resident #1 transferred by ambulance to the emergency room (ER). In an interview on [DATE] at 11:15 a.m., Staff B, CNA, stated on [DATE] it was a normal day on [NAME] Hallway and she and Staff A were doing shift tasks, when Staff A called for assistance in room [ROOM NUMBER]. Staff B stated she entered the room and found Resident #1 laying on the bathroom floor with her pants pulled down and incontinent of bowel and bladder. Staff B stated Staff C, Staff D and Staff E arrived and started assessing Resident #1 as Staff A and Staff B began cleaning Resident #1 up. Staff D stated something like she had a stroke. Someone asked if we needed to call 911 and Staff D stated no, she is a DNR. Staff C then asked if they should get oxygen on her. Staff D again said no, noting they would need to get a Physician Order. Staff B stated the oxygen saturation level was in the eighties. Staff B stated Resident #1 was not responding and was lifted off the floor and into bed. Staff E, RN finally left to check Resident #1's code status and returned stating Resident #1 was a full code. EMS was called and Resident #1 sent out to the hospital. Staff B stated this was the first time she had ever seen a nurse not provide basic care, but notes other nurses were found to be much more responsive to medical emergencies. In an interview on [DATE] at 2:45 p.m., Staff C, LPN, stated she was a Traveling Nurse and had just contracted with the facility. Staff C stated on [DATE] she was orientating when a call came asking for assistance in room [ROOM NUMBER]. By the time she arrived there were ,d+[DATE] Aides and Staff D, LPN taking vital signs. Resident #1 seemed a little responsive in the beginning, but then started to decline. Resident #1's pulse oxygen level was down to 82% and Staff C stated let's get some oxygen on her and Staff D said no, we need an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . At some point early on someone was asking what Resident #1's code status was. Staff D stated she was a DNR. Staff C stated she offered to go check, but Staff D was adamant Resident #1 was a DNR. Later on, Staff E checked and Resident #1 was a Full Code. Staff C stated she then called 911, the physician and family. In an interview on [DATE] at 3:21 p.m., Staff D, LPN, stated on the afternoon of [DATE] she was summoned to Resident #1's room. Resident #1 was lying face down with her brief and pants down to her ankles. Resident #1 had been incontinent of bowel and bladder. Resident #1 was semi responsive, agitated and restless. Staff got her rolled over and attempted to get her vital signs. Resident #1 vaguely responded to her name. Within ,d+[DATE] minutes Resident #1 was breathing fine and her pupils equal and reactive to light. They sat her up and oxygen saturation levels fell from 92% to 85%. Staff C asked about getting her some oxygen and Staff D stated that we needed an order. Staff D stated she was wrong about that, but Resident #1 was not in any respiratory distress. They were able to get Resident #1 cleaned up and up into her bed. Staff D stated she thought Resident #1 was a DNR. Someone went and checked and reported she was a Full Code. Staff D stated at that time the physician was called and an order received to have Resident #1 sent out for evaluation. Staff D stated she also called the family. Staff D claimed there was no significant delay in treatment as they were just getting done with Resident #1 when it was discovered she was a Full Code. In an interview on [DATE] at 12:50 p.m., the Director of Nursing (DON) stated she expected during a medical emergency nurses know their residents' Code Status. CNA's will page for a nurse, who will complete an initial assessment, attend to the residents needs and ensure the residents safety. If the resident is a full code and needs Cardiopulmonary Resuscitation (CPR) the nurse and others will initiate the CPR immediately and call 911. The physician and family will be notified as time and personnel allow. If the resident is a DNR, the nurse would provide an assessment, treat and care for the resident's immediate needs and ensure safety. The physician and family will be notified to determine further treatment, Emergency Medical Service (EMS) involvement, hospitalization , etc. The DON stated that using oxygen during a medical emergency is at the discretion of the nurse and does not require a Physician Order. The same applies for calling EMS for residents who are Full Code to prevent any delay in treatment and care. Residents who are DNR would be provided first aide, but family would be notified to determine EMS involvement or hospitalization decisions. The DON stated she was at the facility when Resident #1 had her fall and was called to the room and arrived after Resident #1 in bed. Vital signs were checked and oxygen saturation levels were between 95% and 97%. The DON stated she asked whether the Nursing Staff knew the resident's Code Status at which time Staff D stated she was a DNR. Staff E then looked and said Resident #1 was a Full Code. At that time EMS was notified. The DON stated Staff C later asked whether a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff C stated Staff D said we couldn't give oxygen without an order. The DON clarified that an order was not necessary during an emergency. The DON stated after reviewing the events, staff education was provided to her nurses. According to the Nurse Staff Education bullet points included: a. Always check Code Status in any emergency situation. b. If someone's oxygen levels fall dangerously low and is not coming up, apply oxygen as this is a nursing judgement. Orders can be written later. A nurse is only allowed to give 2 liters per minute without an order in emergency situations. c. If someone is a DNR and found unresponsive, always call the Power of Attorney (POA) to clarify what they would like done. According to Progress Notes dated [DATE] at 2:55 p.m., Resident #1 was discovered laying face down in her bathroom with her brief and pants pulled down. Resident #1 was incontinent of bowel and bladder and was minimally responsive and restless, she responded minimally to her name, but did not speak. Resident #1 was unable to roll onto her back without staff assistance when making attempts to move and reposition. She was not able to focus on a person talking to her and her eyes noted to be rolling back and to the right, pupils sluggish with light stimuli. Resident #1 not able to follow finger with eyes and her left side of face noted to be drooping, left arm/hand flaccid, minimal movement to left foot/toes. Resident #1 is unable to perform grips/push/pulls upon request, but mobility intact to right arm and legs with no shortening or rotation to lower extremities. No verbalizations of pain, noted grimace and frown to face. Resident unable to respond to simple questions or commands and unable to open her eyes on her own. Resident #1 has history of strokes. Possible stroke at this time. (Staff D believes Resident #1 is a DNR). According to Progress Note dated [DATE] at 3:20 p.m. written by Staff D, physician notified of possible stroke and orders obtained to have transported via ambulance to hospital. (Resident #1 is found to be a Full Code). According to Progress Note dated [DATE] at 3:25 p.m. written by Staff D, Resident #1's family notified of fall and possible stroke. In an interview on [DATE] at 4:32 p.m., the Nurse Practitioner (NP), stated in general, residents with embolic strokes do much better if they can get to an emergency room or hospital quickly. The sooner the better. The NP noted she had not seen Resident #1 since her hospitalization on [DATE] and was unaware of her current condition. According to the Hospital Admission Records dated [DATE], Resident #1 was admitted into an intensive care unit due to ischemic stroke. In a follow up interview on [DATE] at 2:40 p.m., the Director of Nursing (DON) was asked if she felt Staff D acted appropriately following Resident #1's fall. The DON stated she believed Staff D acted appropriately in the management of Resident #1's care and given the resident's condition following the fall, believed taking 25 minutes to call an ambulance was appropriate.

Based on observation, record review, resident and staff interviews the facility failed to identify an environmental hazard when they left a shower chair unlocked while a resident showered. The staff member stepped away from Resident #11 to obtain a towel, the resident attempted a self-transfer, and fell when the shower chair rolled away. The fall resulted in a right [CONDITION(S)] for 1 of 2 residents reviewed for accidents. (Resident #11). The facility reported a census of 50 residents. Findings Include: Resident #11's Minimum Data Set (MDS) assessment dated [DATE] showed the resident required assistance of one staff for bathing. The MDS identified the resident with a Basic Interview for Mental Status (BIMS) score of 12 indicating the resident had mildly impaired cognitive skills. The MDS also showed the resident with diagnoses of Non-Alzheimer's Dementia, Muscle Weakness, and other abnormalities of gait and mobility. The Care Plan with a revision date of 2/17/21 showed Resident #11 with a Focus Area in regards to Activities of Daily Living (ADL's) noting the resident with the potential for alteration in functionality related to activity intolerance that is exacerbated by his dementia, anxiety and dyspnea (problem breathing) with his [CONDITION(S)] (COPD) that is potentiated by his anxiety. The resident has a chronic cough. Due to his multiple co-morbidities including Diabetes, hypertension (high blood pressure) and above mentioned diagnosis, and use of psychoactive medications, he is at risk for decline in ADL/mobility independence. The Care Plan directed staff to provide assistance of one with bathing and showering as an intervention for Resident #11. The Progress Note dated 4/29/21 at 2:45 p.m., titled Incident Report stated the Nurse summoned to the shower room, where upon entering noted the resident lying on the floor of the shower, under the shower head, on his left side with his knees bent and the resident holding them with his hands. The shower floor wet and the water to the shower turned off with the resident lying naked with no shoe covers, there was a towel placed under his head. The Certified Nursing Assistant (CNA) assisting Resident #11 with a shower stated the resident was sitting on the shower chair that was not locked and washing himself under the shower head. The CNA stated he went around the corner of the shower room to obtain more towels and he noted the resident was grabbing the grab bar affixed to the wall and at the sink to the left of the shower and he attempted to stand up unassisted and lost his balance. The resident went to sit on the shower chair which rolled away from the resident and he fell to the floor, landing on his right hip and right side. The CNA stated the resident did not hit his head or lose consciousness and independently rolled from his right side to his left and immediately reported pain. The Progress notes during the assessment of Resident #11 The Progress Note revealed Resident #11 was sent to the emergency department. The History and Physical from a hospital admitted d 4/29/21 revealed right intertrochantric (hip) fracture. The notes from the physician revealed Resident #11 presented to the emergency room after a fall in the shower. Resident #11 reported pain is 10 out of 10. (Pain scale rating 1-10 with a 1 indicates mild pain to a 10 severe pain). During an observation on 5/11/21 11:49 a.m., Resident # 11 propelled self to the dining room in the wheelchair with upper extremities. During an observation on 5/12/21 at 8:38 a.m., surveyor viewed the [NAME] shower room, the towel cabinet is in a separate area from the shower in the room. The towel cabinet was 12 steps from the shower head area and on the other side of the south wall of the shower. During an interview on 5/12/21 at 10:02 a.m., Resident # 11 stated he recalled the fall he had in the shower. I was in the shower and the chair I was in got loose underneath me and I slipped right underneath it and fell . I had lot of pain on a scale of 1-10, I would rate it a 10. Resident #11 reported still having a lot of pain and continue to rate it at a 8 out of 10. During an interview on 5/12/21 at 10:01 a.m., with Staff G, Certified Nursing Assistant (CNA) and Staff H, CNA stated they would never leave a resident unattended in the shower to get towels from the cabinet and always have the brakes locked on the shower chair. During an interview on 5/12/21 at 10:47 a.m., Staff E, Registered Nurse (RN) stated on 4/29/21 Staff F, Certified Nursing Assistant/Certified Medication Aide (CNA/CMA) summoned her to the [NAME] shower room. She observed Resident #11 in the shower laid out on the wet floor with legs drawn up to his chin. Resident #11 appeared alert and verbal. Staff F, CNA/CMA told Staff E, RN Resident #11 was in the shower chair with the brakes unlocked and he had gone around the corner to get some towels. He came back and Resident #11 stood, attempted to grab onto the shower bar and sink and fell . Staff E, RN stated I will probably get in trouble for telling you this but Staff F, CNA/CMA should have had the brakes on the shower chair and should never have left him unattended to get the towel. During an interview on 5/12/21 at 1:51 p.m., Staff F, CNA/CMA stated on 4/29/21 he gave Resident #11 a shower. Staff F reported Resident #11 sat on the shower chair with the brakes unlocked. Staff F reported he went around the corner of the shower to get towels and left Resident #11 unattended. Resident #11 attempted to stand to wash his bottom and lost his balance as he attempted to sit back down. The shower chair rolled out from under him. Staff F stated we have iphones and can look up the Kardex which tell you exactly what type of assistance the resident needs. Staff F stated he could see Resident #11 when he went to get a towel. The Surveyor asked to clarify the location of the towels in reference to where the towels were located. Staff F reported, well, you got me there I could not see him the whole time. Staff F stated he did go over to the cabinet to grab towels and did not have his eyes on the resident. Staff F confirmed when he went over to grab the towels is when the resident fell . During an interview on 5/12/21 at 2:04 p.m., the Director of Nursing (DON) stated the Kardex is what is on the Care Plan. The DON stated would expect staff to follow what is on the Kardex which is on the iphone they carry with them and flows directly from the Care Plan. Staff F should have followed the Care Plan and provide assist if that is what it says for Resident # 11. In a follow-up interview on 5/12/21 at 3:13 p.m. Staff F, CNA/CMA reenacted Resident #11 fall on 4/29/21 in the [NAME] shower room. Staff F stated I left him out of sight for a few seconds to grab the towels out of the cabinet to put on the floor and the chair. I did leave him unattended to grab the towels. He should have been supervision with the shower when he fell . In another follow-up interview on 5/12/21 at 4:17 p.m. with Staff F, CNA/CMA stated he could not recall where the privacy curtain on the shower was located at the time of the fall. He did loose sight of the resident when he was getting the towels out of the cabinet but then when coming back he could see out of the corner of his eye the resident was standing and he rushed to get to the resident but he fell any way. The Administrator provided a statement dated 5/13/21 stated we do not have a bathing policy. Staff are trained on how to bath a resident in their CNA course and after they are hired. We expect staff to provide individualized cares tailored to each resident's needs and preferences. The shower chair noted with a label from Direct Supply with a Model #VL SC17 P FRSB. The Manual provided by the facility during the IDR entitled Operation Instructions directed under the Operating Information: Showering - Transfer user into the chair. Move user into shower area and lock casters.

Based on record review, observation and staff interview the facility failed to assess bed side rails for usage and obtain consents for 3 of 7 residents reviewed (resident #47, #26 and #51). The facility reported a census of 60 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool for Resident #47 with a completion date of 6/23/19, identified [DIAGNOSES REDACTED]. The MDS documented the resident needed extensive assistance of two person for bed mobility, transfers, ambulation, personal hygiene and toilet use. The MDS documented the resident's Brief Interview for Mental Status (BIMS) score as 0 which indicated severe cognitive impairment. During an observation on 7/1/19 at 10:25 a.m., noted the resident's bed with half upper side rail/hand grip bars on both sides of the bed. Review of the clinical record revealed the lack of a side rail assessment or signed consent form for the use of bed rails. On 7/2/19 an unsigned Bed Rail Assessment Tool dated 7/1/19 was found in the Electronic Health Record (EHR) and added to the care plan as a focus area with a revision date of 7/1/19. 2. The MDS assessment tool for Resident #26 with a completion date of 5/10/19, identified [DIAGNOSES REDACTED]. The MDS documented the resident needed extensive assistance of two staff for bed mobility, and toileting. The MDS documented the resident needed extensive assistance of one for personal hygiene. Ambulation did not occur during the MDS assessment period. The MDS documented the resident's Brief Interview for Mental Status (BIMS) as 9 out of 15 indicating moderate cognitive impairment. During an observation on 7/1/19 at 2:00 p.m., noted the resident's bed with upper half side rail/hand grip bars on both sides of the bed. Review of the clinical record revealed the lack of a side rail assessment or signed consent form for the use of bed rails. On 7/2/19 an unsigned Bed Rail Assessment Tool dated 7/1/19 found in the EHR and added to the care plan as a focus area with a revision date of 7/1/19. During an interview on 7/2/19 at 9:00 a.m., the Director of Nursing (DON) stated they had done verbal side rail consents in the past and she would try to find that documentation. Documentation was not provided. In an interview on 7/1/19 at 10:15 a m., Staff B, Registered Nurse (RN), stated she completed the assessments yesterday. Staff B acknowledged that prior to 7/1/19 the resident did not have a consent or assessment for use of the rails. 3. The MDS assessment with a reference date of 6/10/19 revealed Resident #51 with a BIMS score of 13 indicating no cognitive impairment. The resident required limited assistance of 1 staff for bed mobility and assistance of 1 staff for transfers. The MDS listed [DIAGNOSES REDACTED]. An observation on 6/30/19 at 4:33 p.m. revealed Resident #51's bed with 2 bed rails in an upright position at the head of the bed. Review of Resident #51's care plan with a revision date of 6/3/19 revealed the use of bilateral grab bars to aid with bed mobility. Further review of Resident #51's care plan with revision date of 6/21/19 revealed that resident with grab bars to her bed to help her get in and out of bed safely. Clinical record review on 7/1/19 at 9:54 a.m. revealed Resident #51's chart lacked a signed informed consent by the resident or the resident's representative discussing the risks and/or benefits of the use of bed rails. During an interview on 7/2/19 at 10:10 a.m., Staff B confirmed that the facility had not completed a consent prior to use of bed rails for Resident # 51. Staff B stated that the side rail assessment is a newer assessment and has been overlooked at times.

Based on record review and staff interview, the facility failed to notify the Long Term Care (LTC) State Ombudsman's office of the hospitalization of 4 out of 4 residents reviewed (#47, #30, #39, and #52). The facility reported a census of 60 residents. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] for Resident #47 identified [DIAGNOSES REDACTED]. A Brief Interview for Mental Status documented the resident with a score of 0 which indicated severe cognitive impairment for decision-making. A review of the nurse's progress notes in the clinical record revealed the resident transferred to the hospital via ambulance on 5/7/19 and per daughter would be having surgery on 5/8/19. The resident returned to the facility on [DATE]. A review of the Ombudsman notification list for the dates of the hospital admission/transfer out of facility 5/7/19 revealed the resident's name not documented on the monthly notification list. A Notice of Transfer Form stamped as Faxed documented the Ombudsman notified of Res. #47's transfer on 7/1/19. 2. Review of the medical record for Resident #30 revealed the resident discharged from the facility on 5/2/19 and hospitalized . The clinical record lacked documentation of notification to the LTC Ombudsman that Resident #30 had discharged to the hospital as required by federal regulation. Record review of Resident # 30's progress notes on 7/1/19 revealed that resident was transferred out of the facility to the hospital on [DATE] via ambulance at 2:02 p.m. and admitted . During an interview on 7/1/19 at 10:14 a.m., Staff A, Activity Coordinator, questioned if Resident #30's hospitalization on [DATE] had been reported to the Long Term Care Ombudsman. Staff A reviewed the form that is mailed monthly to update the Ombudsmen's office of facility discharges and stated that Resident #30's name was not listed for (MONTH) 2019. During an interview on 7/1/19 at 10:45 a.m., Staff A stated she had completed the Ombudsmen notification for Resident #30's transfer to hospital on [DATE]. She provided an updated roster for the Ombudsman's notification list that included Resident # 30's name on it with a discharge to hospital date of 5/2/19. 3. Review of the medical record for Resident #39 revealed the resident discharged from the facility on 4/22/19 and hospitalized . The clinical record lacked documentation of notification to the LTC Ombudsman that the resident discharged to the hospital as required by federal regulation. Record review of Resident # 39's progress notes on 7/1/19 revealed that resident transferred out of the facility to the hospital on [DATE] via ambulance at 4:27 a.m. and admitted . During an interview on 7/1/19 at 10:14 a.m., Staff A questioned if Resident #39's hospitalization on [DATE] had been reported to the Long Term Care Ombudsman. Staff A reviewed the form that is mailed out monthly to update the Ombudsmen's office of facility discharges and stated that Resident #39's name was not listed for (MONTH) 2019. During an interview on 7/1/19 at 10:45 a.m., Staff A stated she had completed the Ombudsmen notification today for Resident #39's transfer to hospital on 4-22-19. She provided an updated roster for the Ombudsman's notification list that was faxed out 7/1/19. The list included Resident # 30's name on it with a discharged to hospital date of 5/2/19. 4. Review of the MDS for resident #52 dated 3/3/19 showed resident discharged from facility on 3/3/19. Review of the progress notes revealed resident discharged to hospital on [DATE]. In review of the facility documentation showed no discharge notice sent to the Office of the State Long-Term Care Ombudsman for the hospital discharge on 3/3/19. Facility documentation showed Office of the State Long-Term Care Ombudsman office notified on 7/1/19 for the 3/3/19 hospital discharge after surveyor requested information on discharge notifications. In an interview on 7/1/19 at 10:10 a.m., Staff A stated the facility did not notify the State Long-Term Care Ombudsman office of the resident's hospital discharge on 3/3/19.

Based on review of the Facility Assessment and staff interview, the facility failed to complete a thorough evaluation of the resident population, identify required resources and staffing levels needed to provide the necessary care and services needed for residents. The facility reported a census of 60. Findings include: A review of the Facility Assessment on 7/1/19 at 4:15 p.m. with a completion date of 2/25/19 and a revision date of 6/5/19 revealed a two page document that lists the various departments throughout the facility but does not evaluate the resident population and identify resources needed to provide the necessary person-centered care and services the residents require. During an interview on 7/1/19 at 4:15 p.m., the Administrator verified the document was the Facility Assessment. She stated they completed the first assessment last year when they had just opened with a smaller population and had revised it this year in February.

Based on observation, clinical record review and staff interview, the facility failed to ensure one of two residents observed during transfer was transferred in a safe and comfortable manner. (Resident #5) The facility census was 33 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #5 required extensive assistance for bed mobility, transfers, toileting, and did not ambulate. The assessment showed the resident had moderately impaired cognitive skills and was frequently incontinent with bladder and bowel function. The MDS assessment documented the resident had [DIAGNOSES REDACTED]. The Care Plan initiated on 1/8/18, showed the resident had a self care deficit related to impaired mobility. The intervention showed the resident did not ambulate and required the easy stand (Sarah Lift) with assistance of 2 staff for transfers. Observation on 3/26/18 at 9:55 a.m., showed Staff B, certified nurse aide, CNA and Staff C, CNA transferring the resident with a stand lift (EZ Way Smart Stand) from the bed to the bathroom. The resident barely held on to the handles of the stand lift, thus staff repeated over a few times for the resident to hold on and replaced the resident's hand onto the stand handle. Staff moved the stand with the resident hanging on, knees well bent, shoulders and arms pulling upwards. The resident groaned out loud once wheeled into the bathroom and until seated on the toilet. After cares were completed the resident stood, half bent with the lift. The resident's arms were pulled upward, the harness pulled up under the resident's armpits, and the shoulders pulled outward, with the elbows parallel to the shoulders. Staff transferred the resident with the stand into the wheelchair and wheeled the resident next to the bed. Staff transferred the resident back into the stand, lifted in the same manner and position, transferring the resident from the wheelchair to the bed. Observation on 3/27/18 at 12:32 p.m., revealed Staff B and Staff I, CNA, transferred the resident with same stand lift to the wheelchair for lunch. Staff sat the resident up at the edge of the bed. When standing the resident with the lift, the harness loop strap fell out of the notch, so the resident leaned to the right side and slumped downward. The resident gave a small yell out, and both staff quickly put their hands on the resident's backside and moved the resident back onto the bed. Staff I looked at the Consultant Nurse in the room and asked if they needed to use the Hoyer. The Consultant Nurse did not answer the question. The resident called out and said they were tired. Staff placed the resident back into the lift stand. The resident's hands did not grasp the stand bars fully. The resident hung downward, with bent knees, and with their arms and shoulders being pulled upward, at a parallel level. Staff transferred the resident in the lift to the wheelchair. Staff wheeled the resident to the bedside and transferred with the stand lift to the bed, in the same manner. Observation on 3/28/18 at 10:35 a.m., Staff D, CNA and Staff B transferred the resident with the stand lift from the wheelchair to the bathroom. The resident moaned out during most of the transfer. The resident's body hung low, arms were pulled upward, pulling on the harness belt, under her armpits, in an uncomfortable position. The Director of Nursing (DON) watched the transfer. During interview on 3/28/18 at 10:40 a.m., the director of nursing reported after observing the transfer, the resident looked uncomfortable, looked to have some pain and the stand transfer looked unsafe. The DON commented the stand lift did not look appropriate in transferring the resident.

Based on observation, clinical record review and staff interview, the facility failed to ensure staff utilized proper infection control technique after one resident had an incontinent episode. (Resident #7) The facility census was 33 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #7 required extensive assistance for bed mobility, transfers and toileting and was frequently incontinent with bladder functions. Observation on 3/26/18 at 12:44 p.m., showed Staff A, certified nurse aide, CNA and Staff B, CNA transferring the resident from the recliner to the wheelchair with the residents entire bottom of the pants wet with urine. After cares was completed staff transferred the resident back onto the soiled blue cushion in the wheelchair. Staff failed to disinfectant the soiled cushion before transferring the resident. During interview on 3/28/18 at 3:11 p.m., Staff H, CNA reported if a cushion was soiled the cushion should be cleansed before a resident was transferred back into the wheelchair. During interview on 3/28/18 at 4:10 p.m., the director of nursing, DON reported a soiled cushion should be disinfected prior to use.

Based on observation, dietary menu review and staff interview, the facility failed to ensure staff was properly trained to assist one resident (Resident #183) at meal time. The facility census was 33 residents. Findings include: 1. The facility Diet Type Report dated 3/26/18, documented Resident #183 was on a general diet. During meal observation on 3/26/18, Staff J, Door Greeter was assisting Resident #183 during the meal service by placing her hand on the residents and assisting the resident to physically to bring their hand up to the mouth to feed self. During entrance conference on 3/26/18 at 8:55 a.m., with Administrator stated they do not use Paid Nutritional Assistants at the facility. During interview on 3/26/18 at 3:19 p.m., the Director of Nursing stated Staff J was the receptionist and was not a Certified Nurse Aide, CNA and did not have a nursing license. During interview on 3/28/18 at 11:28 a.m., Staff J stated she was aware she was not supposed to put the food in the residents mouth, but could encourage the resident to eat. Staff J could hold the drink so the resident could drink from a straw. Staff J stated she probably should not be feeding hand over hand. Staff J stated she was not certified to feed and was not aware of even doing it just probably a habit. During interview on 3/28/18 at 12:33 p.m., the Director of Nursing stated non-certified or non-licensed staff should not be doing hand over hand when feeding resident and can not physically feed the resident.

Based on clinical record review and staff interview, the facility failed to complete a timely admission assessment for one of twelve residents reviewed. (Resident #1) The facility census was 33 residents. Findings include: 1. Record review revealed Resident #1 was initially admitted on [DATE], but was discharged to the hospital on [DATE] and re-admitted on [DATE]. The CMS (Center for Medicare Services) Submission Report MDS (minimum data set) 3.0 NH Final Validation Report revealed the resident assessment was completed late: assessment completion date was more than 14 days after the assessment reference date. Completion date was 3/26/2018. During interview on 3/28/18 at 3:35 p.m., the MDS Coordinator revealed the discharge assessment was late due to a Registered Nurse (RN) was not available to sign the assessment even though was completed on time. The admission assessment was still not complete due to she was busy with other tasks. During interview on 3/29/18 at 7:15 a.m., the Director of Nursing stated she would expect the MDS assessments to be completed on time and they use the Resident Assessment Instrument Manual (RAI) as direction per federal regulation. Review of the RAI OBRA - required Assessment Summary provided by the facility revealed an admission assessment should be completed no later than 14th calendar day of resident's admission. Discharge assessment should be completed 14 calendar days after the discharge date .