Every finding on record at Rehabilitation Center of Winter Park

Based on interview, and record review, the facility failed to notify and update the hospice provider regarding a fall for 1 of 1 resident reviewed for notification of change, out of a total sample of 5 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] for respite care. His diagnoses included dementia, Neurocognitive disorder, depressive disorder, and insomnia. Resident #1 was discharged home from the facility on 10/10/24. Review of resident #1's medical record revealed a late entry nursing progress note as well as a Situation Background Assessment and Recommendation (SBAR) note dated 10/08/24 at 4:15 AM. The notes showed resident #1 was found on the floor next to his bed, the facility Nurse Practitioner was notified on 10/08/24, and the document revealed the responsible party was not yet known, therefore not notified at that time. There was no documentation to show facility nurses contacted resident #1's hospice provider regarding the fall. On 1/13/25 at 12:32 PM, Registered Nurse (RN) A stated if a resident was on hospice services the facility process was to notify the physician, the representative, and the hospice service as a fall was a change in condition. On 1/14/25 at 12:28 PM, the interim Director of Nursing (DON) stated if a resident had a change in condition such as fall, then nursing was responsible for notifying the responsible party, the physician, and the contracted hospice. On 1/14/25 at 12:45 PM, the interim DON placed a telephone call to resident #1's hospice service. The Hospice Team Manager stated by phone that resident #1's wife called them on 10/10/24 at 10:21 AM, to report that her husband had a fall in the facility a few days before. The Hospice Team Manager stated the facility did not call or notify the hospice of resident #1's fall, instead it was his wife. On 1/14/25 at 12:50 PM, the interim DON validated there was no documentation in resident #1's medical record to show that resident #1's hospice service was notified of his change in condition regarding his fall on 10/08/24. The facility policy and procedure, Change in Condition revised 4/04/23, revealed a purpose to communicate changes in condition, regarding notification about changes in conditions as required. The policy Hospice Services with a revision date of 3/10/23 showed the facility will have an agreement with Hospice that includes the communication process for care of the resident including any changes in condition.

Based on observation, interview, and record review, the facility failed to ensure residents were provided necessary maintenance services to maintain a comfortable, homelike environment regarding functional television (TV) channels with audio, channel programming, and availability of remote controls for 4 rooms on the 100 unit, 6 rooms on the 200 unit and 1 room on the 300 unit, out of a total of 27 sampled rooms reviewed, (Rooms 111-B, 112-B, 114-A, 128-A, 128-B, 204-A, 207-A, 215-A, 215-B, 219-A, 219-B, 223-A, 230-A, 230-B, 301-A, and 301-B). Findings: 1. On 12/12/24 at 3:24 PM, during a tour of the 200-nursing unit, resident #3 in room [ROOM NUMBER]-A was laying in bed with the TV remote in his hand. He stated the TV channels were fuzzy and to make it worse it only got a handful of channels. He said he, reported it 2 times within the last week and a half. One maintenance guy came in and said it was the mount on the wall that holds the TV that was causing the problem something about the coax cable. He explained he repaired things, and knew that was not the issue. He said he informed the maintenance person and said, No one has come back since then to follow up or fix the issue. He stated when his roommate's television was on, it did not have any channels showing. Review of the work order report created on 11/13/24 for TV being fuzzy, and some channels not working had a status of completed on 12/11/24. A work order created on 11/22/24 for the resident having difficulty with his TV also had a status of completed on 12/11/24. Observations on 12/12/24 and 12/13/24 showed the TV channels continued to be fuzzy. On 12/12/24 at 3:31 PM, Licensed Practical Nurse (LPN) A stated she was aware that the TV for the A bed was not clear, and it had been verbally reported maintenance one day last week. On 12/12/24 at 3:39 PM, the Maintenance Director stated he was responsible for facility maintenance. He received work orders verbally, and on the computer, he checked the maintenance books on the units daily, and then took care of it. On 12/13/24 at 2:48 PM, the Maintenance Director stated we replace whatever TV was broken, or static coax cables, and explained they couldn't replace anything in the walls. He said they would have to contract out to a cable company for those repairs. He stated, they had not had to contract anything out to the cable company recently, within the last six months. On 12/13/24 at 3:25 PM, resident #3 in room [ROOM NUMBER]-A stated yesterday (12/12/24) confirmed they changed the TV and gave him a new TV. He stated the TV still had fuzzy channels, and now his remote control worked both his and his roommate's TV. He stated he could turn both TV's on, and off, as well as change the channels on both TV's. He stated he didn't get some TV channels. The Maintenance Director confirmed resident #3's TV channels were not clear, and his remote control did turn on, and off, and changed the channels on his TV. 2. On 12/12/24 at 3:27 PM, resident #4 in room [ROOM NUMBER]-B was observed laying in bed. He stated the TV didn't work when you turned it on. He proceeded to attempt to turn on his TV by pushing the button on the remote control to change the channels. The TV display showed a guide listing for the channels, however when he attempted to select several channels there were no visual images displayed for any of the channels selected, and there was no sound. 3. On 12/13/24 at 2:57 PM, A walk-through was conducted with the Maintenance Director, and the Administrator to inspect reported and completed TV and/or remote-control work orders. In room [ROOM NUMBER]-B the Maintenance Director confirmed there was only 1 remote control in the room to operate both residents' TVs. 4. On 12/13/24 at 3:06 PM, observations of room [ROOM NUMBER]-B with the Maintenance Director revealed the TV channels were fuzzy, and unclear for both TVs. There was only one remote control in the room for both residents. Closer observation showed a crossover of the one remote control, as it turned both TVs on, off, and changed channels. 5. On 12/13/24 at 3:08 PM, in room [ROOM NUMBER]-A the TV check by the Maintenance Director showed the picture on the TV channels was not clear. 6. On 12/13/24 at 3:10 PM, a TV check for room [ROOM NUMBER] revealed resident #6 in 128-B in bed watching TV. She stated her roommate did not have a remote control for her TV. The Maintenance Director searched and was not able to locate the remote control for the A bed. He validated there was no remote control for room [ROOM NUMBER]-A's television. Resident #6 stated her TV was currently playing on the antenna only. She stated it was the only way to see the channels clearly. She explained her husband worked with the cable company and he fixed her TV because all of her channels were fuzzy. She stated some channels did not even show up and she could not get any of the higher channels on the TV. Resident #6 then proceeded to switch her TV from antenna mode to the facility cable which revealed all channels were fuzzy as well as missed channels on the TV channel selection. She confirmed she had previously reported this concern to the facility. 7. On 12/13/24 at 3:15 PM, resident #7 in 204-A, stated the TV was loud, and the volume and TV channels were not responsive with the remote control. He stated it was not synced and it woke up his roommate with the loud volume. The Maintenance Director checked his TV and stated it was an issue with the guide setting. 8. On 12/13/24 at 3:17 PM, resident #8 in 207-A stated the TV did not pick up some of the channels. The Maintenance Director stated the TV needed to be reprogrammed. Further review of the facility work order report revealed there was a work order created on 10/24/24 for reprogramming resident #8's TV. The status showed completed on 11/06/24, however, the TV required frequent reprogramming. 9. On 12/13/24 at 3:23 PM, the Maintenance Director revealed the remote control for room [ROOM NUMBER]-A would turn on and off the TV for 215-B. Observation revealed neither TV had pictures displayed on the channels. 10. On 12/13/24 at 3:34 PM, in room [ROOM NUMBER]-A, resident #9 stated the remote control did not work properly. He stated if he turned on his TV with his remote control it would turn on both TVs in the room, his TV and the roommate's TV. The Maintenance Director confirmed both TVs in the room could be turned on and off from resident #9's remote control. 11. On 12/13/24 at 3:38 PM, the TV check with the Maintenance Director revealed both beds 230-A and 230-B's TV channels were unclear, the images were fuzzy as displayed on the TVs, and the remote controls turned on both A and B bed's TVs. 12. On 12/13/24 at 3:34 PM, in room [ROOM NUMBER]-A resident #10 stated when it rained all the channels went out and you couldn't see any channels on the TV. He stated when he turned on his TV it also turned on his roommate's TV and that woke him up. He said, I asked for a computer TV and they stated they can't do that because they would have to re-wire everything. The Maintenance Director confirmed 301-B had no remote control for the TV. On 12/13/24 at 3:45 PM, Maintenance Director confirmed it was not homelike, and not normal for TVs to be fuzzy, and not showing pictures on the channels. He stated each resident should have their own remote control. He said, The remote control for one resident's TV should not turn on or off the TV for the roommate. He stated he had not done any audits on the functionality of the TVs display of pictures, availability of channels, or checked to make sure each resident had their own remote control which operated their individual TV in the rooms. On 12/13/24 at 3:56 PM, the Administrator stated the TVs should work better, should not be fuzzy or have channels that the residents couldn't get. Review of the facility Work Order policy dated 4/01/22 showed that work orders should be completed in order to establish maintenance service and were addressed. Review of the Resident Rights Policy dated 4/01/22 revealed the purpose was to ensure the preservation of the resident's right to a dignified existence, with access to services inside and outside of the facility. The policy detailed that each resident had the right to a safe, clean comfortable, homelike environment with maintenance services to maintain a comfortable interior.

Based on interview, and record review, the facility failed to ensure baseline care plan summaries were reviewed with or a copy provided to the resident and/or the resident representative for 2 of 4 residents reviewed for baseline care plan, of a total sample of 10 residents, (#1, and #2). Findings: 1. Resident #1's electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses of cerebral infarction (stroke), hemiplegia, type 2 diabetes, speech and language deficits, abnormal posture, need for assistance with activities of daily living (ADLs). He resided in the facility for 10 days and was discharged on [DATE]. On 12/12/24 at 2:57 PM, Registered Nurse (RN) C stated the care plan was initiated upon admission, then Minimum Data Set (MDS) nurses completed the comprehensive care plan. She stated that resident #1 did not receive a baseline care plan from the nurse on admission and there were other people who had to sign off on it as well, as part of a team effort. RN C explained the resident was supposed to get a copy of the baseline care plan once it was finished. On 12/12/24 at 3:51 PM, Licensed Practical Nurse (LPN) B stated nurses completed the baseline care plans in the computer. She explained she thought the MDS nurse reviewed the care plans with residents and then gave them a copy once they were completed. On 12/13/24 at 12:26 PM, and 1:12 PM, the Director of Nursing (DON) stated the nurse who held the key was expected to do the initial admission assessment, and the nursing baseline care plan. She explained the care plan should be signed by the resident, family or representative, and a copy given to them. The DON conveyed the baseline care plan stayed with the admission packet and was placed with the admission paperwork for the clinical team to review in the morning. She stated the clinical team reviewed the packets in the morning for accuracy and completeness. Resident #1's EMR was reviewed with the DON which revealed there was no baseline care plan present for resident #1. The DON confirmed there was no baseline care plan scanned into the computer record for resident #1. On 12/13/24 at 5:15 PM, the Lead MDS Coordinator, stated nursing was responsible for the residents' baseline care plans, and it was a team effort to complete it. 12/13/24 at 5:20 PM, the DON provided a paper copy of resident #1's baseline care plan. The document revealed an admitted [DATE] with baseline care plan dated 10/29/24. The care plan included a summary of goals, interventions, physician orders, services, and treatments. Further review showed on page six under the section, Date reviewed with resident/representative, the line was blank with no date for review, signature, or provided copy of the baseline care plan summaries to the resident or the resident's representative. Review of resident #1's EMR revealed no documentation that the resident or the representative refused to review or sign the baseline care plan summary. 2. Resident #2's EMR showed the resident was admitted to the facility on [DATE], with a previous admission on 8/22/24. Diagnoses included subsequent fall with fracture, cognitive communication deficit, dementia, depressive disorder, and need for assistance with ADLs. Resident #2 resided in the facility for 26 days and was discharged on [DATE]. Review of the EMR for resident #2 revealed there was no baseline care plan summary for the admitted [DATE] and the medical record did not reveal documentation of a copy of the baseline care plan provided to the resident or the representative or their refusal to review and sign the baseline care plan summary. On 12/13/24 at 5:30 PM, the DON provided a copy of the baseline care plan summary for resident #2. The form presented by the DON was dated for the previous admission of 8/22/24, and page 6, the signature page for date reviewed with the resident or representative was not included. The DON stated nurses were responsible for the baseline care plans, and she was unsure if any audits or education had been completely recently regarding care plans. Review of the facility's Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates dated 4/1/22 showed the facility would provide the resident and their representative with a summary of the baseline care plan when requested and a written summary must be provided to the resident or representative by completion of the comprehensive care plan.

Based on interview, and record review, the facility failed to maintain complete, accurate, and readily accessible medical records for 2 of 2 residents reviewed for medical record review,of a total sample of 10 residents, (#1, and #2). Findings: 1. Resident #1 was admitted to the facilty on 10/28/24 with diagnoses of hypertension, muscle weakness, cerebral infarction (stroke), hemiplegia, cognitive and social or emotional deficit, and type 2 diabetes. Resident #1 remained in the facility for 10 days and was discharged on [DATE] Review of resident #1's medical record revealed resident #1's Admission Agreement paperwork was missing from the medical record and the baseline care plan for the admitted [DATE] had date discrepancies regarding the discharge plans section and incomplete documentation regarding no date or signature for review with the resident or representative for the baseline care plan summary. On 12/13/24 at 1:40 PM, the Director of Community Relations stated there was no scanned copy of the Admission Agreement in the computer for resident #1. On 12/13/24 at 1:44 PM, the Admissions Director stated she was unable to locate the signed admission agreement in the computer or in the record. She said, Don't know what happened there. On 12/13/24 at 4:20 PM, the Admissions Director explained the admission packet was, a part of the electronic medical record. She stated the main thing was getting the packet signed. She stated the timeframe for getting the admission packet paperwork completed, signed and into the medical record was 24-48 hours or longer if you have to contact the family for a signature if the resident was unable to sign. She stated it was important because it was the agreement between the resident and the facility for the services provided. The Admission Director confirmed she was responsible for the Admission Agreement and explained the packed contained information so the residents knew their rights and the protocols for the facility. On 12/13/24 at 5:20 PM, the Director of Nursing (DON) provided a copy of the resident baseline care plan which reflected an admitted [DATE], and a completion date of 10/29/24 with a staff signature. Discrepancies were noted on page 4 of the baseline care plan, which showed no date, and under the section for Discharge Plans, showed a location for transfer to another skilled facility with home health care. Review of a progress note by the Assistant Administrator dated 11/05/24 at 10:41 AM, revealed, Patient and family requested to transfer . Referral sent. A progress note by the Assistant Administrator dated 11/06/24 at 1:41 PM, showed she confirmed resident #1's transfer to the skilled nursing facility. Comparison of the progress notes dated 11/05/24 at 10:41 AM, and 11/06/24 at 1:41 PM, conflict with date of completion on the baseline care plan of 10/29/24. On 12/13/24 at 5:30 PM, the DON acknowledged that the copy of the baseline care plan summary was incomplete and stated nursing was responsible for baseline care plans. 2. Resident #2 was admitted to the facility on [DATE] with a previous admission on 8/22/24. She had diagnoses of fractured nasal bones, contusions-scalp, subsequent falls, chronic obstructive pulmonary disease, disorders of the brain, depressive disorder and hypertension. She resided in the facility for 26 days and was discharged on [DATE]. Record review showed resident #2's admission of 10/18/24 base line care plan summary was missing from the electronic record. On 12/13/24 at 1:08 PM, the DON reviewed resident #2's medical record and confirmed there were no scanned documents for the baseline care plan. On 12/13/24 at 5:30 PM, the DON provided a paper copy of the baseline care plan that showed the previous admitted [DATE], that was missing page 6 which contained the baseline care plan summary completion date, the date reviewed with resident or representative and staff signature. The DON stated this was all she could find. Review of the EMR did not reveal documentation of the resident or the representative refusing to review or sign the baseline care plan summary for 10/18/24 admission. Review of the Resident Rights Policy dated 4/01/22 revealed the purpose was to ensure the preservation for resident's right to a dignified existence, and communication with access to services inside and outside of the facility. Review of the facility Admission Agreement indicated the agreement contained the entire understanding between the facility and the resident and/or representative. The facility accepted the application for admission subject to the resident or representative executing consent for admission, and medical treatment. The resident and/or representative acknowledged that they had been fully informed, and signed their signature to indicate they executed the agreement on the date and year written. The Admission Policy dated 9/26/22, revised 5/15/23 showed the facility would provide admissions according to State and Federal regulations and no potential or current resident would be requested or required to waive their rights. Review of the signed job description dated 12/22/22 for Admission Director reflected advising residents and /or families of admission requirements as established by the facility, ensures proper completion, signing and distribution of paperwork, and ensure residents and families received the highest quality of service.

Based on record review, and interview, the facility failed to notify a resident's Power of Attorney (POA) of changes in condition for 1 of 3 residents reviewed for change in condition, of a total sample of 5, (#1). Findings: Review of resident #1's medical record revealed their responsible party/durable POA was family member #1. Review of resident #1's Quarterly Minimum Data Set Assessment (MDS) dated [DATE] and Annual MDS dated [DATE] indicated she rarely/never understood regarding communication and a mental status examination should not be conducted. One of her diagnoses included unspecified dementia with unspecified severity. Review of resident #1's medical record revealed a nursing note dated 3/17/24 that the resident had a skin tear to the right forearm. There was no documentation about what caused this injury. There was no description of the size of the wound, nor its placement on the forearm. A nursing note dated 3/18/24 revealed a physician was made aware of the skin tear and treatment orders were obtained for the right forearm skin tear noted in the 3/17/24 nursing note. On 10/22/24 at 11:19 AM, the Director of Nursing (DON) reviewed resident #1's nursing note dated 3/17/24 that indicated a skin tear to her right forearm. She verified there was no documentation that resident #1's POA was notified of this injury. She said she did not know why the POA was not notified. Review of resident #1's medical record revealed a nursing note dated 4/13/24 which indicated resident #1 had bruises to the forehead and side of left eye. There was no documentation about what caused these injuries. There was no documentation with a description of the injury including the approximate size, shape, coloration of the bruising nor more detailed placement of location. It was documented the physician was notified. There was no mention the POA was notified. On 10/22/24 at 11:11 AM, the Assistant Administrator verified there was no documentation that resident #1's bruising to the forehead and side of left eye injuries from 4/13/24 were reported to her POA. Review of resident #1's record revealed a nursing note dated 5/09/24 that resident #1 was observed coughing, the physician was contacted, and new orders were received for a chest x-ray, 2 views. On 10/22/24 at 11:00 AM, the DON verified that there was no documentation that the POA was notified for this change in condition of resident #1 coughing as noted in the 5/09/24 nursing note nor notification of the follow-up order for a chest x-ray. Review of resident #1's medical record revealed a note dated 5/28/24 that resident #1's psychotropic medications were discussed among nursing staff and the psychiatric providers. There was a physician's order to change her Trazadone (antidepressant medication) to 50 milligrams (mg). Review of resident #1's treatment administration record indicated that 100 mg of Trazadone HCl was administered on 5/27/24 and the dose was decreased to 50 mg of Trazadone HCl, which was administered beginning on 5/28/24. On 10/22/24 at 10:49 AM, the DON verified there was no documentation that resident #1's POA had been notified of the Trazadone dosage decrease. Review of resident #1's record revealed a nursing note dated 7/11/24 that resident #1 had itchy skin due to little pink dots on back, buttocks, and front areas. The physician was notified and new orders were obtained for Permethrin External Liquid 1% (an insecticide). There was no mention resident #1's POA was notified. On 10/22/2024 at 10:48 AM, the DON verified it was not documented that resident #1's POA was notified of this change to using Permethrin External Liquid 1% medication for resident #1's rash. Review of the facility's change in condition policy, dated 4/01/22 included content in the procedure section that the facility would consult the resident's physician and if known, notify the resident's legal representative or an interested family member when there was an acute illness or a significant change in the resident's physical, mental or psychosocial status or a need to alter treatment significantly. Review of the facility's policy and guidelines for Abuse, dated 4/1/22 included content that injuries of unknown origin must be immediately investigated to rule out abuse and indicated Social Service staff or designee should keep in frequent contact with the resident and/or resident representative.

Based on record review, and interview, the facility failed to follow their policy and family member request to thoroughly investigate injuries of unknown origin for 2 of 3 residents reviewed for injuries of unknown origin, of a total sample of 5, (#1 and #4). Findings: 1. Review of resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] and Annual MDS dated [DATE] indicated she rarely/never understood regarding communication and a mental status exam should not be conducted. One of her diagnoses included unspecified dementia, with unspecified severity. Review of resident #1's medical record revealed a nursing note dated 3/17/24 that the resident has a skin tear to the right forearm. There was no documentation about what caused this injury. There was no description of the size of the wound, nor its placement on the forearm. On 10/22/2024 at 11:19 AM, the Director of Nursing (DON) reviewed resident #1's nursing note dated 3/17/24 that indicated a skin tear to right forearm. She verified that there was no documentation about how this injury occurred and there was no documentation of an investigation about how it occurred. On 10/22/2024 at 11:30 AM, the Administrator stated that he did not recall this situation regarding a skin tear documented in the 3/17/24 nursing note. He does not have any additional investigation documentation, and this injury of unknown origin was not reported to the State Agency,nor other required entities. Review of resident #1's medical record revealed a nursing note dated 4/13/24 which indicated resident #1 had bruises to the forehead and the side of her left eye. There was no documentation about what caused these injuries. There was no documentation about the approximate size, shape, coloration of the bruising nor more detailed placement of location. It was documented the physician was notified. On 10/22/2024 at 11:11 AM, the Assistant Administrator verified there was no documentation how resident #1's bruising to the forehead and side of left eye injuries occurred, and no documentation an investigation was performed to understand what caused resident #1's injuries of unknown origin observed by nursing staff on 4/13/24. The Assistant Administrator described resident #1 as combative toward staff who offered care in August of 2024 and received care planning at that time regarding such behavior. She confirmed there was no such documentation of any such behavior occurring on 4/13/24 when the bruising to the forehead and the side of left eye was noted in her record. She verified there was no witness to this injury when it occurred, and was unable to say how these injuries occurred. She verified there was no reporting about this injury to State Agency, nor other required entities. Review of resident #1's medical record revealed a nursing note dated 5/21/24 which indicated resident #1 had a skin tear to the right elbow. It described the resident moved her upper extremities frequently and hit the wall. There was no documentation about the size of the skin tear. Review of resident #1's medical record revealed a nursing note dated 5/26/24 that resident #1's family was concerned about the origin of the injury on her right elbow which was noted in the 5/21/24 nursing note. The facility described the wound as a tear and the family member was concerned it was instead a cut. The family requested an investigation about the origin of the injury, last week, but they had not been provided a follow-up response. On 10/22/24 at 11:06 AM, the Administrator and Assistant Administrator verified they were never notified by any staff that resident #1's family was concerned about the causation of the injury to resident #1's right elbow. They verified there was no witness to this injury and no follow-up investigation was documented about the injury to understand its causation or to implement interventions. They verified the injury was not reported to the State agency nor to other required entities. Review of resident #1's medical record revealed a nursing note dated 7/30/24 which indicated resident #1 had a skin tear to her right lower leg. There was no documentation about what caused this injury. There was no description of the size of the wound, nor its placement on the lower leg. On 10/22/24 at 10:35 AM, the Assistant Administrator verified there was no documentation about what caused the injury to resident #1's right lower leg which was observed 07/30/24, and said there was no additional documentation of an investigation having been done to understand what caused resident #1's injury. She verified the injury was not reported to the State Agency for possible abuse or neglect or to any other required entities. 2. Resident #4 was admitted to the facility on [DATE]. Her Quarterly MDS assessment dated [DATE] revealed she had a Brief Interview for Mental Status score of 2 out of 15 which indicated severe cognitive impairment. Review of resident #4's medical record revealed a nursing note dated 7/04/24 in which a nurse observed purplish, red internal bruising on resident #4's right and left hands and right lateral forearm. On 10/22/24 at 4:18 PM, the Assistant Administrator reviewed the investigation about bruising on resident #4's hands and right lateral forearm that was observed by the nurse on 7/04/24. No witnesses had noted when the injuries occurred. She explained they were believed to have been caused by blood draws for specimen collection that were done on 6/29/24. She said the blood draw company was contacted, but it did not have documentation of how many blood draws were attempted. Although the number of attempted blood draws was not verified by the blood draw company the Assistant Administrator verified there was no additional investigation, such as interviewing staff from various shifts or assessing other residents' skin who have severe cognitive impairment, to understand how the injuries occurred. She verified the injuries were not reported to the State Agency or other required entities for possible abuse or neglect. In a telephone interview on 10/23/24 at 1:34 PM, the blood lab draw Assistant Operations Manager verified there was no record of how many times a blood draw was attempted on resident #4, nor what site or sites on her body the specimen was collected from on 6/29/24. Review of the medical record revealed a Licensed Nurse Weekly Skin Observation dated 9/01/24 which indicated there were no skin issues. A nursing note dated 9/02/24 indicated the resident's family member observed bruising on the resident. The nurse indicated that on assessment a purplish bruise was noted on top of her right hand, the top of her left hand, the right wrist and left lower arm. There was no documentation about what caused these injuries, but the nurse documented the physician and Risk Manager were notified. On 10/23/24 at 9:13 AM, the Assistant Administrator confirmed the facility was aware resident #4's daughter had concerns that Certified Nursing Assistant (CNA) B abused her mother and the CNA was suspended while the facility investigated. The Assistant Administrator verified that as part of the facility's investigation regarding the abuse allegations from 9/02/24 the facility did not assess the skin of other severely cognitively impaired residents who were not able to self report but were provided care by the same staff to investigate if there were other injuries of unknown origin which could exist. Review of the facility's policy and guidelines for implementation, abuse policy, dated 4/01/22 included content regarding injuries of unknown origin. The document revealed it was the policy of the facility that reports of abuse (mistreatment, neglect, or abuse, including injuries of unknown source. ) were promptly and thoroughly investigated. Additionally, it noted that investigation of injuries of unknown origin or suspicious injuries must be immediately investigated to rule out abuse. The policy included examples of injuries, and remarked they were not limited to, bruising of the face, bruises of unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma.

Based on record review, and interview, the facility failed to report injuries of unknown origin in a timely manner per regulations for 2 of 3 residents reviewed for injuries of unknown origin, of a total sample of 5 residents, (#1 and #4). Findings: 1. Resident #4 was admitted to the facility on [DATE]. Her Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status score of 2 out of 15, which indicated severe cognitive impairment. Review of resident #4's medical record revealed a nursing note dated 9/02/24 by Registered Nurse (RN) A that the resident's family member observed bruising on the resident. The nurse indicated that upon assessment a purplish bruise was noted on top of the right hand, top of left hand, right wrist and left lower arm. There was no documentation about what caused these injuries, but the nurse documented she reported the concerns to the physician and the Risk Manager. In interviews on 10/22/24 at 4:36 PM, and on 10/23/24 at 9:14 AM, with the Administrator and the Assistant Administrator, the Assistant Administrator confirmed the facility was aware resident #4's daughter had concerns that Certified Nursing Assistant (CNA) B abused her mother and the CNA was suspended while the facility investigated. She acknowledged the facility did report the allegations but verified there was an over 24-hour delay in reporting to the State agency, and other entities per the regulations regarding the bruising injuries of unknown origin documented on the nursing note by RN A dated 9/02/24. The Administrator said he did not know why he didn't know about the bruising injuries earlier. He said the Director of Nursing (DON), at the time of the survey, now a former employee, was the Risk Manager at the time. Review of resident #4's medical record revealed a nursing note dated 7/04/24 in which the nurse observed purplish, red bruising on resident #4's right and left hands and right forearm. There was no documentation about what caused the injuries. On 10/22/24 at 4:18 PM, the Assistant Administrator reviewed the investigation about the bruising on resident #4's hands and right forearm that was observed by the nurse on 7/04/24. She acknowledged no witnesses were noted when the injury occurred. She explained it was believed to have been caused by blood draws for specimen collection that was done on 6/29/24. She said the blood draw company was contacted, but it did not have documentation of how many blood draws were attempted. Although the number of attempted blood draws by the blood draw company was not verified by the facility, the Assistant Administrator verified no additional investigation, such as interviewing staff from various shifts or assessing other residents' skin who had severe cognitive impairment, to understand how the injuries might have occurred was completed. There was no documentation that the facility notified the State agency nor other entities of the injuries of unknown origin or possible abuse/neglect. In a telephone interview on 10/23/24 at 1:34 PM, the blood lab draw Assistant Operations Manager verified there was no record of how many times a blood draw was attempted on resident #4, nor what from what site or sites on resident #4's body the specimen was collected from on 6/29/24. 2. Resident #1 was most recently admitted to the facility on [DATE] and discharged on [DATE]. Review of resident #1's Quarterly MDS assessment dated [DATE] and Annual MDS dated [DATE] indicated she rarely/never understood regarding communication and a mental status exam should not be conducted. One of her diagnoses included unspecified dementia, with unspecified severity. Review of resident #1's medical record revealed a nursing note dated 3/17/24 noting the resident had a skin tear to the right forearm. There was no documentation about what caused this injury. There was no description of the size of the wound, nor its placement on the forearm. A nursing note dated 3/18/24 revealed the skin tear was reported to the physician and treatment orders were given. On 10/22/24 at 11:19 AM, the Director of Nursing (DON) reviewed resident #1's nursing note dated 3/17/24 which indicated she had a skin tear to her right forearm. She verified there was no documentation about how the injury occurred nor was there documentation of an investigation about how it occurred. On 10/22/24 at 11:30 AM, the Administrator stated he did not recall the situation regarding resident #1's skin tear as documented in the 3/17/24 nursing note. The Administrator confirmed the facility did not have any additional investigation documentation and he confirmed the incident was not reported to to the appropriate entities or state agency for possible abuse or neglect. Review of resident #1's medical record revealed a nursing note dated 4/13/24 which indicated resident #1 had bruises to the forehead and the side of her left eye. There was no documentation about what caused these injuries. There was no documentation about the approximate size, shape, coloration of the bruising nor more detailed placement of location. It was documented the physician was notified. On 10/22/2024 at 11:11 AM, the Assistant Administrator verified there was no documentation how resident #1's bruising to the forehead and side of left eye injuries occurred, and no documentation an investigation was performed to understand what caused resident #1's injuries of unknown origin observed by nursing staff on 4/13/24. The Assistant Administrator described resident #1 as combative toward staff who offered care in August of 2024 and received care planning at that time regarding such behavior. She confirmed there was no such documentation of any such behaviors occurring on 4/13/24 when the bruising to the forehead and the side of left eye was noted in her record. She verified there was no witness to this injury when it occurred, and she was unable to say how these injuries occurred. She verified there was no reporting about this injury to the State Agency, nor other required entities. Review of resident #1's record revealed a nursing note dated 5/21/24 which indicated that resident #1 had a skin tear to the right elbow. It described the resident moved her upper extremities frequently and hit the wall. There was no documentation about the size of the skin tear noted. Review of resident #1's medical record revealed a nursing note dated 5/26/24 that resident #1's family was concerned about the origin of the injury on her right elbow which was also noted in the 5/21/24 nursing note. The nursing staff described the injury as a tear and the Power of Attorney (POA) was concerned it was more like a cut. The document indicated the POA requested an investigation to the Unit Manager about the origin of the injury, last week, but had not received a follow-up response. On 10/22/24 at 11:06 AM, the Administrator and Assistant Administrator verified they were not notified by any staff that resident #1's family was concerned about the causation of the injury on resident #1's right elbow. They verified there was no witness to this injury and no follow-up investigation was documented about this injury to understand its causation. They confirmed that this injury was not reported to the State agency or other required entities for possible abuse or neglect. Review of resident #1's record revealed a nursing note dated 7/30/24 that resident #1 had a skin tear to her right lower leg. There was no documentation about what caused this injury. There was no description of the size of the wound, nor its placement on the lower leg. On 10/22/24 at 10:35 AM, the Assistant Administrator verified there was no documentation about what caused the injury to resident #1's right lower leg which was observed 7/30/24, and said there was no additional documentation of an investigation or subsequent reporting for possible abuse or neglect having been done to understand what caused resident #1's injury. Review of the facility's abuse policy, dated 04/01/22 included content regarding injuries of unknown origin. In the reporting and response portion of the policy it indicated abuse allegations including (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source.) were reported per Federal and State law. The facility would ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source. were reported immediately, but not later than two hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials. in accordance with State law through established procedures. It stated the Administrator or designee would make an initial (immediate or within 24 hours) report to the State Agency. A follow-up investigation would be submitted to the State Agency within five (5) days. The Administrator/ Designee would notify the agency for Adult Protective Services, the Statewide Abuse Hotline, would utilize the State agency Nursing Home Reporting System for Immediate and 5 day reports, and would utilize the State agency Reporting System to submit the 15-day Adverse Report.

Based on record review, and interview, the facility failed to remove an indwelling urinary (foley) catheter and collect a urine specimen in a timely manner which led to a delay in treatment for 1 of 2 residents reviewed for urinary catheters, of a total sample of 5 residents, (#1). Findings: Review of resident #1's Annual Minimum Data Set assessment dated [DATE] indicated she rarely/never understood regarding communication and a mental status exam should not be conducted. Her diagnoses included unspecified dementia, with unspecified severity. Review of resident #1's record revealed a nursing note dated 7/30/24 at 2:55 PM, that resident #1 was straight catheterized for urine with 600 cubic centimeters (cc) output due to no urine output. The physician was notified, and orders were received that day for a urinalysis with a culture and sensitivity and to place an indwelling foley catheter for three days pending the urinalysis results. Review of resident #1's medical record revealed a nursing note dated the next day on 7/31/24 at 8:08 AM, that a foley catheter had been placed. The note did not mention that a urine sample for urinalysis was collected. Resident #1 had a care plan for risk for urinary tract infection (UTI) and complications of indwelling foley catheter related to retention initiated on 7/31/24. The goal was for the risk for UTI and complications to be minimized with the use of current interventions through the next review. Interventions included check for catheter patency every shift and as needed and labs as ordered dated 7/31/24. Review of resident #1's Treatment Administration Record (TAR) revealed an order for foley catheter check for patency every shift and change as needed with a start date of 7/31/24 and was discontinued on 8/10/24. The order did not contain the direction for the removal of the catheter after three days as documented in a verbal order from the physician on 7/30/24. Also the TAR documentation showed there were two shifts the patency check was missing, one on 08/04/24 and again on 08/07/24, from the start of the order on 7/31/24 until the first shift of 8/10/24 when the catheter was discontinued. Review of resident #1's medical record revealed a nursing note dated 8/05/24 that the foley catheter had been removed, five days after it was inserted. This note conflicted with documentation by nurses on the TAR which on six shifts nurses documented they checked the patency of the foley catheter even though the nurse documented it was removed on 8/05/24. Nurses on 8/09/24 did not document the patency check on the TAR and instead documented 9- other/see Progress notes. Review of resident #1's medical record revealed a urinalysis lab report with a collection date of 8/05/24 at 6:45 AM, with results reported on 8/07/24, six days after the verbal order was initially received as noted by the nurse on 7/30/24. Review of resident #1's record revealed a physician's note dated 8/08/24 that the urine culture and sensitivity had been received, a urinary tract infection was diagnosed , and an antibiotic which the bacteria was sensitive to was ordered, nine days after the original order date for a urine analysis with culture and sensitivity. On 10/22/24 at 10:33 AM, the Director of Nursing (DON) acknowledged the urine collection for resident #1's urinalysis was not done until 8/05/24. She stated resident #1 should have been straight catheterized again on 7/31/24 in the morning for specimen collection for the urinalysis and culture and sensitivity, as it had not been collected on 7/30/24. The DON was unable to explain why it had not been done with the insertion of the foley catheter, nor why the order for the foley catheter did not specify it was for three days per the verbal order of the physician. She confirmed there was a delayed collection for the urinalysis and verified the foley catheter was in longer than three days. She verified the late urinalysis collection caused the ordered treatment (antibiotics) to be delayed.

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 3 of 6 residents reviewed for PASARR, of a total sample of 49 residents, (#90, #134, and #22). for 3 of 3 residents reviewed for PASARRs, out of a total sample of 47 residents, Findings: 1. Review of the medical record revealed resident #90 was originally admitted to the facility on [DATE] from the hospital, with a most recent readmission on 8/16/24. Her diagnoses included bipolar disorder, anxiety, major depressive disorder and psychoactive substance abuse with onset date of 6/29/23. Resident #90's 5-day Minimum Data Set (MDS) with an assessment reference date of 7/05/24 revealed the resident had a diagnosis of anxiety, depression, and bipolar disorder. The MDS assessment noted the resident was taking antianxiety and antidepressant medications. Review of resident #90's medical record revealed a care plan which indicated the resident was at risk for alteration in mood secondary to bipolar disorder, anxiety, and tended to have emotional outburst at times. The care plan also indicated the resident received antidepressants for depression. Review of the State of Florida Agency for Health Care Administration Preadmission Screening and Resident Review Level I screen dated 6/26/23 and signed by the admitting hospital Social Worker, Section I for decision making listed mental illness or suspected mental illness as Bipolar disorder and Substance abuse, but did not include diagnoses of anxiety and major depressive disorder. Section II of the decision making (Other Indications) did not indicate any functional limitations in major life activities such as interpersonal functioning, which would help to trigger additional screening for a Level II PASARR. On 8/28/24 at 11:20 AM, the Social Service Director stated she and the Director of Nursing (DON) were responsible to ensure the residents' Level I and Level II PASARRs were accurate and submitted timely. She also stated residents were to have Level I PASARRs submitted prior to admission, if a resident was diagnosed with a new mental illness diagnosis, or if there was a change in condition. The Social Service Director viewed resident #90's Level I PASARR dated 6/26/23 and verified the diagnoses listed were bipolar and substance abuse. The Social Service Director confirmed the resident had an additional diagnosis of anxiety disorder and major depressive disorder on 6/29/23 which was not included on the 6/26/23 Level I PASARR. She acknowledged a new Level I PASARR should have been submitted with the new diagnosis listed. On 8/28/24 at 3:40 PM, the DON stated she had been working at the facility for one year. She conveyed it was the Social Service Director's responsibility to oversee the PASARR process and make sure the facility was compliant. She specified when the Social Service Director was absent, it would be the DONs responsibility to ensure the PASARRs were accurate and submitted timely. She also stated a Level I PASARR was required prior to admission or when there was a new diagnosis. The DON verified resident #90 had a Level I PASARR submitted on 6/26/23 with bipolar and substance abuse diagnosis listed. She confirmed the resident had a new anxiety and major depressive disorder diagnosis on 6/29/23 but a new Level I PASARR was not submitted. The DON reiterated a new Level I should have been submitted but did not know why it was missed. 51023 2. Resident #134's medical record revealed he was admitted to the facility on [DATE] with diagnoses of severe protein-calorie malnutrition, muscle weakness, delusional disorders, psychotic disorder with delusions due to known physiological condition, dementia without behaviors, adult failure to thrive, and myocardial infarction type 2. The resident's PASARR form dated 6/09/23 was completed prior to admission to the facility. The form incorrectly indicated no diagnosis listed under Section IA Mental Illness or suspected Mental Illness. Under Section II, a secondary diagnosis of Dementia was listed. A Psychiatry evaluation note dated 7/03/23 revealed the resident had a diagnosis of delusional disorder, psychotic disorder, and dementia. Review of resident #134's physician medication orders revealed the resident was ordered Buspirone Hydrochloride (HCl) 5 milligrams (MG) for anxiety with a start date of 8/07/24, Seroquel 200 MG for psychotic disorder with delusions with a start date of 5/29/24, Depakote sprinkles 375 MG for mood disorder with a start date of 3/18/24 and ABH GEL 1 milliliter (0.5 MG Ativan / 25 MG Benadryl/ 0.5 MG Haldol) every 8 hours for agitation with a start date of 1/16/24. Review of resident #134's care plan dated 7/02/24 revealed focuses included history of refusing medications and activities of daily living care related to dementia/delusions, and being verbally and physically abusive to staff related to psychosis and cognitive status. Another focus listed that the resident was observed playing with feces, not easily redirected, hallucinations, anxious behaviors, naked, restless and easily agitated. He again was noted to be fighting staff and striking at staff when re-directed. Review of resident medical record revealed no updates had been made to the PASARR form to include these mental illnesses. 49840 3. Resident #22 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and convulsions. After admission the resident was newly diagnosed with psychotic disorder, major depression, and schizoaffective disorder Review of resident #22's Level I PASARR Screen dated 6/26/15, revealed no mental or intellectual diagnosis were indicated. There were no other PASARRs completed after admission. The MDS Quarterly assessment dated [DATE], revealed resident #22 had a Brief Interview for Mental Status score of 14 out of 15 which indicated she was cognitively intact. The assessment showed she did not show any moods or behaviors in the look back period but was actively taking antidepressants. Her active diagnoses included dementia, anxiety disorder, depression, psychotic disorder, and schizophrenia. Review of resident #22's order summary report dated 8/28/24, revealed she was took Donepezil for dementia, and Escitalopram to treat anxiety disorder and depression. The Medical record for resident #22 revealed she actively received psychiatric services once per week to treat anxiety and insomnia. A psychiatric note dated 8/13/24 revealed a recommendation for resident #22 to continue on Escitalopram for anxiety. Resident #22 had a care plan revised on 8/09/23 with a focus on her behavior of fixating on other resident's care, removing her dressings, removing her oxygen, and refusing medications as well as care. The goal of this care plan, with revision date 7/10/24, was for resident to show less behaviors. Interventions included behavior monitoring, medication administration, and psychiatric consult. She also had a care plan initiated on 5/08/23 to monitor antidepressant medication use. On 8/28/24 at 9:46 AM, the Social Service Director acknowledged the Level I PASARR for resident #22 was incorrect because she was admitted to the facility with several mental health diagnoses and other diagnoses were added later. She stated a PASARR audit had been initiated on 7/31/24 to identify and correct all PASARRs in the facility. The goal was to correct the PASARRs and then submit them for review. However, she said she went on medical leave after completing the audit and could not continue with the next step which would have been to submit them for review. She stated that the DON was the only other person qualified to complete and submit PASARRs in her absence. The Social Service Director revealed she had a conversation with the Regional Nurse Consultant about PASARRs still not being submitted. There was an active Performance Improvement Plan (PIP) for PASARRs that was presented to the Quality Assurance and Performance Improvement (QAPI) committee, but they had yet to meet to discuss the issue. On 8/28/24 at 9:54 AM, the Regional Nurse Consultant acknowledged she was aware of the delay with correcting and submitting PASARRs. She stated she was working with the Social Service Director to get them completed as soon as possible. She explained that the PIP for PASARRs was ineffective because there were no target dates for completion of the tasks identified in the plan and delegation of tasks should have been done when the Social Service Director was on medical leave to prevent delays. The facility PASARR policy dated 4/01/22 revealed it was the facility's policy to assure that all residents admitted to the facility receive a Pre-Admission Screening and Resident Review, in accordance with State and Federal Regulations. Furthermore, the facility must refer all level I and II residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon significant change in status assessment.

Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the policy and procedure, Quality Assurance and Performance Improvement (QAPI) dated 6/01/21, revealed the facility would take actions aimed at performance improvement and would measure the success of those actions and track performance to ensure that improvements were realized and sustained. The facility had deficiencies cited at F641 for accuracy of assessments and F693 for concerns with tube feeding per physician orders and standards of care during the previous recertification survey conducted 10/17/22 through 10/20/22. During this survey, the facility was found to be in noncompliance with F641 and F693. As a result of these repeat deficiencies, it was identified there was insufficient auditing and oversight to prevent the citation. On 8/30/24 at 2:20 PM, the Administrator stated the facility had a QAPI committee that met monthly. He explained the committee reviewed several areas which included reportable incidents, clinical metrics, care issues, grievances and survey activity to include deficiencies cited. He stated when an issue was identified, the QAPI committee would create a performance improvement plan to address the concern to bring it back into compliance. Concerns from the current survey were reviewed with the Administrator. He acknowledged there were repeat citations from the previous recertification survey and stated, The process failed.

Based on observation, interview, and record review, the facility failed to treat residents who required assistance with meals in a dignified and respectful manner for 1 of 1 residents reviewed for dignity, of a total sample of 49 residents, (#42). Findings: Review of resident #42's medical record documented she was readmitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), aphasia (comprehension and communication disorder), stroke, and contracture of right hand. Review of the Quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 6/02/24 revealed resident #42's Brief Interview for Mental Status was not obtained because she was rarely or never understood. The MDS showed she was dependent of staff for most Activities of Daily Living. Review of the Follow Up Question Report for August 2024 revealed resident #42 was dependent for eating. On 8/26/24 at 8:43 AM, Certified Nursing Assistant (CNA) K stated resident #42 was not interviewable and she was, a feeder. On 8/27/24 at 4:50 PM, CNA H explained this was her first time caring for resident #42. She shared resident #42 did not talk and said, She is a feeder too. When asked why she referred to resident #42 as a feeder she stated that was the term they used. On 8/29/24 at 3:40 PM, CNA J stated although she had not been assigned to resident #42, she knew whoever was assigned to her had to assist her to eat because she was, a feeder. On 8/29/24 at 11:49 AM, the Keys Unit Manager (UM) stated CNAs should refer to residents who needed assistance to eat, as dependent diners. She indicated it was not appropriate to refer to the residents as feeders. She said it was, not politically correct and was a dignity issue. On 8/30/24 at 10:00 AM, the Director of Nursing (DON) stated residents who required assistance with meals were called dependent diners, not feeders. Later at 12:28 PM, the DON explained a checklist was used to validate CNAs competencies for tasks such as eating and swallowing. She stated they also reviewed the facility's Resident Rights policy with the CNAs. During the exit conference on 8/30/24 at approximately 4:10 PM, the Resident Council President stated she had heard the CNAs refer to some residents as feeders before which she had brought to staff attention. She indicated this was, demeaning and demoralizing. Review of the CNA's job description revealed CNAs were to provide, Care in a manner that protects and promotes Resident Rights, dignity, self-determination and active participation . Refers to residents by proper names unless residents request otherwise. Avoids use of all pet names . Review of the facility's policy and procedure titled Resident Rights dated 4/01/22 revealed a purpose to preserve every resident's right to a dignified existence. The document indicated it was the facility's policy to, . treat each resident with respect and dignity and care for reach resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on observation and interview the facility failed to provide a sanitary, comfortable and homelike interior for one out of 10 residents reviewed for environment, of a total sample of 42, (#126). Findings: Resident #126 was admitted to the facility on [DATE] with diagnoses which included left leg above the knee amputation, other abnormalities of gait and mobility and the need for assistance with personal care. On 8/26/24 at 8:53 AM, resident #126 was observed in his room, alert and oriented, sitting up in his wheelchair eating breakfast. He indicated the bedside commode next to his table had not been emptied for two days. When he lifted the lid of the commode, there was a foul odor and a large amount of feces and urine were observed. He explained he asked the staff that morning during breakfast service to empty it but was told it was not their job. On 8/26/24 at 1:30 PM, observation of the bedside commode in resident #126's room revealed it remained dirty with a foul odor in the room and still had not been emptied. A few minutes later, outside the resident's room, Certified Nursing Assistant (CNA) B, stated she had not been asked by resident #126 to empty his bedside commode. She stated that resident #126 used the bathroom and not the bedside commode. The next day, on 8/27/24 at 10:19 AM, resident # 126 was again observed sitting in his wheelchair in his room with assigned CNA A present. The bedside commode was in the same place beside his bedside table and the odor of old feces and urine continued to be present in the room. CNA A opened the bedside commode and verified it was dirty with old feces and urine. CNA A stated she was not aware of the commode being full and said the resident did not tell her it needed to be emptied. CNA A explained she had noticed the odor in the room, but thought the odor came from the resident after he soiled himself, so she took him to the shower room. On 8/27/24 at 4:33 PM, assigned Licensed Practical Nurse (LPN) D, confirmed she was aware of resident #126's dirty bedside commode and had directed the CNA yesterday to empty it. She stated she did not realize the CNA yesterday had not emptied it. She indicated she also asked the assigned CNA the present morning to empty the commode because resident #126 again mentioned it had not been emptied for two days. LPN D confirmed it was part of the CNA's responsibility to empty the commode. On 8/30/24 at 9:12 AM, the Director of Nursing stated it was the responsibility of any staff to check and empty the commodes and urinals. She continued, it was not acceptable for resident #126 to have a dirty commode for such a long time without it neither being checked nor emptied. The undated facility's Job Description for CNAs under the section of Specified Duties indicated CNAs were responsible for maintaining a safe, clean, orderly and pleasant physical environment throughout the facility. The duties described CNAs were to assist in keeping a clean, orderly area, and were involved in cleaning equipment. The facility's policy and guidelines for implementation on Resident Rights- Safe/Clean/Comfortable Homelike Environment dated April 1st, 2022, stated it was the policy of the facility to provide a safe, clean comfortable homelike environment in such a manner to acknowledge and respect resident rights.

Based on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for eating assistance for 1 of 3 residents reviewed for nutrition, of a total sample of 49 residents, (#42). Findings: Cross Reference F550 Review of resident #42's medical record revealed she was readmitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), aphasia (comprehension and communication disorder), stroke, and contracture of right hand. On 8/27/24 at 5:26 PM, resident #42 was observed in bed, wearing a splint on her right arm and her both of her hands were contracted. Review of the Quarterly MDS assessment with Assessment Reference Date (ARD) of 6/02/24 revealed resident #42's Brief Interview for Mental Status was not obtained because she was rarely or never understood. The MDS incorrectly showed she needed partial/moderate assistance for eating. Review of the previous Quarterly MDS assessment with ARD dated 3/02/24 also showed resident #42 needed partial/moderate assistance for eating. Review of the Certified Nursing Assistant (CNA) Kardex dated 8/30/24 revealed for eating, resident required extensive assistance by one staff for participation to eat. Review of the Follow Up Question Report from 5/26/24 to 6/02/24 in which CNA responses were recorded for Activities of Daily Living (ADL) abilities revealed resident #42 was dependent on staff for eating 16 of 19 times, (with three responses recorded as not applicable or refused). Review of the Follow Up Question Report from 2/25/24 to 3/02/24 in which CNA responses were recorded for ADL abilities revealed resident #42 was dependent on staff for eating on 6 out of the 7 days. CNAs documented 8 times out of the 13 documented responses that resident #42 was dependent on staff or needed maximum assistance from staff to eat, (with six responses recorded as not applicable). Resident #42 had a Care Plan for ADL Self Care Performance Deficit dated 10/23/23. Interventions included for eating resident required extensive staff assistance from one staff for participation to eat. An additional Care Plan for Risk for Malnutrition dated 10/25/23 included an intervention for staff to, Provide adequate supervision/assistance as indicated with meals, supplements and snacks. On 8/30/24 at 10:51 AM, the MDS Lead explained she verified the medical record and conducted interviews with staff and residents to complete the MDS assessments. She indicated section GG was completed in collaboration with therapy and nursing. She validated resident #42's Quarterly assessments for March and June 2024 showed the resident required partial/moderate assistance for eating. She indicated she could not tell when the change from partial to dependent occurred as the information was collected during the lookback period through review of documentation and interviews. She mentioned any MDS coded incorrectly would require revision. She stated accuracy of the MDS assessment was important so staff could take proper care of the resident. She indicated they used the Resident Assessment Instrument (RAI) as their guide to complete the MDS assessment. Review of the Resident Assessment Instrument instructions for Section GG read, Code 03, Partial/moderate assistance: if the helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Code 01, Dependent: if the helper does ALL of the effort. Resident does none of the effort to complete the activity; or the assistance of two or more helpers is required for the resident to complete the activity. Review of the facility's policy and procedure titled Resident assessment dated [DATE] read, The facility will conduct an initial and periodic comprehensive, accurate assessment of a resident's functional capacity which will include needs, strengths, goals, life history and preferences utilizing the RAI. It also included, The assessments will be conducted by individuals with the knowledge to complete an accurate assessment of relevant care areas and knowledgeable about the resident's status, physical, mental and psychological needs, strengths and areas of decline.

Based on interview and record review, the facility failed to request a Preadmission Screening and Resident Review (PASARR) level I and level II evaluations for 2 of 6 residents reviewed for PASARR,of a total sample of 49 residents, (#100, and #93). Findings: 1. Review of the medical record revealed resident #100 was admitted to the facility on [DATE] from the hospital. Her diagnoses included psychosis and major depressive disorder. Resident #100's Quarterly Minimum Data Set (MDS) with an assessment reference date of 8/02/24 revealed the resident had diagnoses of depression and psychotic disorder. The Quarterly assessment also noted the resident had severely impaired cognitive skills for daily decision making. Review of resident #100's medical record revealed her care plan noted the resident had alteration in thought processes related to psychosis and major depressive disorder. On 8/28/24 at 11:13 AM, the Social Service Director accessed resident #100's Level I PASARR dated 7/30/21, (prior to admission), in the medical record and confirmed it noted a Level II evaluation was required because there was a diagnosis or suspicion of a serious mental illness. The Social Service Director acknowledged she could not locate the Level II PASARR and did not know if one was submitted. She also acknowledged the resident should have had the Level II PASARR prior to admission and did not know why there was not one submitted. On 8/28/24 at 3:17 PM, Director of Nursing (DON) stated she had been working at the facility for 1 year. She conveyed it was the Social Service Director's responsibility to oversee the PASARR process and make sure the facility was compliant. She specified when the Social Service Director was absent, it would be the DONs responsibility to ensure the PASARRs were accurate and submitted timely. She acknowledged a Level I PASARR was required prior to admission and a Level II be submitted when triggered. She confirmed resident #100's Level I PASARR dated 7/30/21 prior to admission triggered a Level II evaluation to be submitted. The DON conveyed she was unable to locate it or know if she had one submitted. She reiterated the Level II should have been submitted in July 2021 prior to the resident being admitted to the facility and was unsure how it was missed. Review of resident #100's PASARR re-submitted on 8/28/24 after it was brought to the Social Service Director's attention noted a Level II evaluation was required because there was a diagnosis or suspicion of a serious mental illness. 2. Review of the medical record revealed resident #93 was admitted to the facility on [DATE] from the hospital. His diagnosis included severe dementia with agitation, bipolar disorder, depressive episodes, anxiety disorder, psychosis, and insomnia. Resident #93's Quarterly MDS with an assessment reference date of 6/14/24 revealed the resident had a diagnosis of anxiety disorder, bipolar, psychotic disorder, and schizophrenia. The Quarterly MDS noted the resident received antipsychotic, antianxiety, and antidepressant medications. The Quarterly MDS assessment also noted the resident scored 3 out of 15 on the Brief Interview for Mental Status that indicated he had severe cognitive impairment. Review of resident #93's medical record revealed his care plan noted the resident had cognitive impairment related to schizophrenia, bipolar, general anxiety disorder, and major depressive disorder. On 8/28/24 at 11:30 AM, the Social Service Director stated it was her and the DONs responsibility to ensure the residents' Level I and Level II PASARRs were accurate and submitted timely. She also stated residents were to have Level I PASARRs submitted prior to admission, if a resident was diagnosed with a new mental illness, or if there was a change in condition. The Social Service Director confirmed resident #93 was admitted on [DATE] but was uncertain if a Level I PASARR was submitted prior to admission since she was unable to locate it. She acknowledged the resident's diagnoses included anxiety disorder, bipolar disorder, depressive disorder, insomnia, psychosis, and severe dementia agitation. She also acknowledged a Level I PASARR should have been submitted prior to admission to the facility. On 8/28/24 at 3:25 PM, the DON stated it was the Social Service Director's responsibility to oversee the PASARR process and make sure the facility was compliant with the regulations. She specified when the Social Service Director was absent, it would be the DONs responsibility to ensure that PASARRs were accurate and submitted timely. She also confirmed a Level I PASARR was required prior to admission. She confirmed resident #93 was admitted to the facility on [DATE] and was unable to determine if a Level I PASARR was submitted prior to admission. She acknowledged the Level I should have been submitted prior to admission and was unsure why it was not completed. Facility policy dated 4/01/22 read, It is the facility's policy to assure that all residents admitted to the facility receive a Pre-Admission Screening and Resident Review, in accordance with State and Federal Regulations.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for a resident with diabetes for 1 of 5 residents reviewed for high-risk medications, of a total of 49 residents, (#571). Findings: Review of resident #571's medical record revealed she was readmitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, lupus, and congestive heart failure. Review of resident #571's Admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 8/04/24 revealed a Brief Interview for Mental Status score of 15 out of 15, which indicated intact cognition. The assessment showed resident #571 received insulin injections. Review of resident #571's physician orders dated 8/20/24 showed medication orders dated the same day for Steglatro 5 milligrams (mg) daily, 24 units of Insulin Glargine two times a day and 10 units of Insulin Lispro with meals for diabetes. Review of resident #571's medical record revealed a comprehensive care plan for diabetes was not developed for the resident after the completion of the admission MDS assessment. On 8/30/24 at 10:51 AM, the MDS Lead explained her responsibilities included to oversee the MDS assessments and development of care plans. Later at 1:41 PM, the MDS Lead indicated the comprehensive care plan included medications and diagnoses. She stated resident #571 had been, in and out of the hospital, since she was admitted to the facility, therefore, a full care plan was not done. She validated a care plan for diabetes was not developed until 8/28/24 and indicated a full care plan should had been developed when the admission MDS assessment was completed. She explained the care plan painted the picture of the resident's needs. She said, It should have been done but it was missed. Review of the facility's policy and procedure titled Resident assessment dated [DATE] read, The results of the assessment will be used to develop, review and revise the resident's comprehensive care plan.

Based on observation, interview, and record review, the facility failed to provide appropriate care consistent with professional standards of practice, and treatment to promote healing of a sacral pressure ulcer (PU) for 1 of 4 residents reviewed for pressure ulcers, of a total sample of 42 residents, (#42). Findings: Resident #42 was readmitted to the facility on [DATE] with a diagnosis of dysphagia (trouble swallowing) following unspecified cerebrovascular disease, end stage renal disease, need for assistance with personal care, aphasia (difficulty speaking), and unspecified protein-calorie malnutrition. Review of the Minimum Data Set quarterly assessment, with Assessment Reference Date 6/02/24 revealed resident # 42's Brief Mental Status score was 3 out of 15 which indicated severe cognitive impairment. The assessment indicated she had no behaviors or refusal of care and was dependent on staff to roll from left to right. Further review of the assessment showed resident #42 required substantial assistance for personal hygiene; was at risk for developing pressure ulcers, but did not have any pressure ulcers or injuries, or other skin problems at the time of the assessment. On 8/27/24 at 4:22 PM, resident #42 was observed lying on a low air loss mattress with her eyes opened. She did not respond to questions. Review of the Weekly Skin Observations dated 7/06/24 to 8/16/24 showed resident # 42 had no skin issues. On 8/23/24 the Weekly Skin Observation revealed resident #42 had a dialysis port on her right upper chest and an opened area on her buttocks. Review of a change in condition note for 8/23/24 (a late entry dated 8/27/24) revealed, The symptom, sign, change I called about is the following: Left buttocks skin impairment; open area noted. This change started 08/23/2024. Review of the Wound Physician progress note dated 8/23/24 revealed a sacral PU that measured 6 x 3 x 0.3 centimeters (cm) with necrotic adipose (fat tissue) exposed, scant amount of serous drainage, with no odor. The wound bed contained 26-50 % epitheliazation (new layer of skin cells). necrosis 20%, epithelial 30%, dermis 50%. Wound orders included Xeroform, and cover with border dressing every day, as needed. Recommendations included a low-air-loss mattress, float heels, and apply pressure ulcer precautions. Review of the Treatment Administration Record for the month of August 2024 revealed wound treatment per the Wound Physician's orders commenced 8/27/24, three days after the wound was initially found. The physician's order was started on 8/27/24, three days after the Wound Physician's consultation on 8/23/24 with wound orders, which read, Wound #1 Sacral, Cleanse wound Normal Saline Solution. Apply Xeroform, cover with border dressing. Per the medical record, a care plan for resident #42's skin/wound was also not initiated until 8/27/24 for the pressure ulcer to her sacrum. A Stage 3 pressure ulcer is a Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss, (Retrieved on 9/06/24 from the CMS Appendix PP Manual). On 8/29/24 at 11:49 AM, the [NAME] Unit Manager (UM), stated the facility had a Wound Care Nurse whose sole task was wound care. Once they were notified, about wound care orders, the UM said she assumed they were handled by the Wound Care Nurse whom she said recently resigned. The UM was unsure of when she last checked resident # 42's bottom and had not seen any skin impairments. The UM validated there was no documentation after she saw resident #42's bottom. She recalled she had learned sometime before Friday 8/23/24, the Wound Care Physician needed to see resident #42 but could not recall how she learned of it. The UM stated she saw two residents on [NAME] Unit with the Wound Care Physician on Friday 8/23/24 and one of them was resident #42. She stated the Wound Care Physician debrided resident #42's wound and, placed a pressure gauze or something, then he covered the wound. The UM explained the Wound Care Physician would have given orders later with his consult note however, she found out later that the Wound Care Physician had left the note somewhere on the nurses' station desk. She confirmed the physician orders for resident #42 wound care were not entered or started until 8/27/24, three days after the wound was found and the Wound Physician consulted on the resident's wound. The UM stated it was fair to say resident #42 had not received wound care for a few days and she validated the physician orders were not followed. On 8/30/24 at 11:51 AM, RN L, the former Wound Care Nurse, stated via telephone, she did not recall if she had seen resident #42 or if she had any skin breakdown. Review of Policy and Procedures, Skin Integrity, dated 7/05/23 revealed the objective was to decrease the prevalence and incidence of residents who developed pressure injuries and provide a guideline for optimal care to promote healing to residents with all identified alterations in skin integrity.

Based on observation, interview, and record review, the facility failed to provide appropriate care for a resident on tube feedings in relation to feeding rate and time for 1 of 1 resident reviewed for tube feedings, of a total sample of 49, (#48). Findings: Resident #48 was readmitted to the facility on [DATE] from an acute care hospital with diagnoses that included metabolic encephalopathy, diabetes mellitus type II, moderate protein-calorie malnutrition, anemia in chronic kidney disease, dysphagia, and vascular dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident #48 was severely cognitively impaired and was dependent on staff for all care. Resident #48 had diagnoses listed for aphasia (lost or impaired speech), malnutrition, and gastrostomy status. Services received included feeding tube care and wound care for a stage 3 pressure ulcer. The assessment also indicated he received hospice services. Review of resident #48's order summary report dated 8/28/24 revealed an order for nothing by mouth (NPO) as of 8/07/24. He also had a tube feeding order for Glucerna 1.2 kilocalorie (kcal) to be given daily via percutaneous endoscopic gastrostomy (PEG) tube and feeding pump at a continuous rate of 75 milliliters (ml)/ an hour (hr) for 20 hours. The tube feeding was to be turned off at 10:00 AM and turned back on at 2:00 PM daily. A PEG tube is a tube that allows you to receive nutrition through your stomach if you have difficulty swallowing or can't get enough nutrition by mouth, (retrieved on 9/10/24 from www.clevelandclinic.org). On 8/27/24 at 9:55 AM, resident #48 was in bed with eyes closed and head of bed elevated. He was connected to a feeding pump that was actively running and the feeding bag was labeled Glucerna 1.2 kcal at 75 ml/hr. There was 900 ml out of 1000 ml still left in the bag and the pump was running at a rate of 60 ml/hr. On 8/27/24 at 4:40 PM, resident #48 was in bed with eyes closed and tube feeding turned off. Licensed Practical Nurse (LPN D), stated the tube feeding for resident #48 had been stopped later than 10:00 AM due to staff being busy. She said he was supposed to have a 4-hour break after 20 hours of continuous feeding, so she had a timer going to start the next feeding. LPN D said the facility allowed for medications to be administered 1 hour before or 1 hour later than scheduled to accommodate delays in administration. She acknowledged the feeding was late because it had been stopped at 11:30 AM and it was now 4:20 PM (more than two hours past the scheduled restart time). When questioned about the rate at which the feeding was running, LPN D confirmed the resident had an order to run the feeding at a rate of 75 ml/hr. Review of resident #48's medical record revealed a Mini Nutritional Assessment was completed by the Regional Dietician (RD) on 8/14/24 which recommended continuing Glucerna 1.2 kcal via feeding pump at a rate of 75 ml/hr continuously for 20 hours. Resident #48 had a care plan initiated on 8/09/24 that addressed feedings and skin integrity. Interventions included administer feedings via gastric tube as ordered and encourage good nutrition and hydration to promote healthier skin. On 8/28/24 at 3:17 PM, resident #48's tube feeding was still running at rate of 60 ml/hr. LPN D was asked why the resident's tube feeding was running at 60 ml/hr instead of the physician ordered rate. She stated when she hung the feeding bag, she turned on the machine and that was the rate that was preset. She acknowledged when a resident received an order for tube feeding, the nurse was responsible for hanging the feeding and setting the rate on the feeding pump. LPN D explained for resident #48 she was not the original nurse who received the order so she did not set up the pump. She said she hung the feeding, then turned on the machine but did not verify the rate. LPN D confirmed she had received education on tube feeding care from the facility. On 8/28/24 at 5:23 PM, LPN I, stated she cared for another resident with tube feeding orders. She stated she did not always compare the rate on the feeding pump with the physician order because she knew the resident's orders very well. On 8/28/24 at 5:29 PM, the LPN Unit Manager (UM) for the Keys unit, confirmed resident #48 had physician orders for tube feeding to run at a rate of 75 ml/hr starting at 2:00 PM and ending at 10:00 AM the following day. She said nurses could stop and start the feeding up to 1 hour before or 1 hour after if they were busy, but if there was a longer delay they would need to document the reason and contact the physician. The UM stated it was the nurses' responsibility to verify the order in the medical record, and set the rate on the feeding pumps per the physician order. On 8/28/24 at 5:51 PM, the Director of Nursing (DON) said the expectation was for nurses to follow physician orders when administering enteral (tube) feedings. All nurses received competencies on tube feeding when they were hired. She further explained if the nurse had to delay the feeding for any reason, they should document in the medical record and call the physician. On 8/29/24 at 11:04 AM, the Registered Dietitian explained if a resident was on the incorrect rate for a prolonged period it could cause unintentional weight loss, a calorie deficit, and poor wound healing. The expectation was for nurses to follow the physician orders. Review of the facility's Enteral Feeding policy dated 1/01/22, revealed the licensed nurse was responsible to assure patency of the feeding tube, administration of nutritional products and medications per physician's orders, assessment of the tube and skin site, and documentation of the enteral feeding process. The purpose of this policy was to ensure the safe and effective administration of enteral formulas and medications.

Based on interview, and record review, the facility failed to ensure the manufacturer's specifications regarding the preparation and administration of an over-the-counter medication was followed to ensure accurate and safe administration of medication for 1 of 1 residents reviewed for dialysis, of a total sample of 49 residents, (#18). Findings: Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pulmonary edema, acute and chronic respiratory failure, lupus, end stage renal disease, congestive heart failure, hypertension, dependence on renal dialysis. Review of resident #18's physician orders revealed an order for Diclofenac Sodium External Gel 1 % (Topical) dated 7/26/24. The order indicated the nurse was to apply to neck topically four times a day for pain. Diclofenac is a Nonsteroidal anti-inflammatory drug (NSAID), people who use NSAIDS such as topical Diclofenac may have a higher risk of having a heart attack or stroke than people who do not use these medications. These events happen without warning and may cause death. You should always use the dosing card to measure out the correct dose of Diclofenac. For the upper body area use 2 grams, (retrieved from www.mayoclinic.org on 8/30/24). Monitor renal function in patients with renal impairment. Avoid use of Diclofenac Sodium gel in paitents with advanced renal disease, (retrieved from www.drugs.com on 9/11/24). On 8/29/24 at 5:29 PM, Licensed Practical Nurse (LPN) M stated resident #18 received Diclofenac topical gel for pain. When asked how she administered the medication to the resident she replied, I squeeze some into a plastic medication cup to take to her room. When asked how much she put in the cup she said about a fourth of the cup. She confirmed she was not aware the medication required a dose in grams and it should be measured prior to use. On 8/29/24 at 5:56 PM, LPN G explained if she was going to administer Diclofenac topical gel, she would remove the tube and squeeze some gel into a little medication cup and take it to the resident's room. When asked if she knew the medication had dosing instructions for upper and lower body parts, she confirmed she was not aware of that and did not know it should be measured before it was put on the resident. On 8/30/24 at 9:03 AM, the Director of Nursing stated Diclofenac topical gel had a dosing stick for nurses to measure the dose of medication. She explained if the dose was not included in the order, pharmacy would usually let us know. She stated the order should have a specific dose to administer. She said, It can't be 2-4 grams because a nurse could not make the determination of how much to apply. The dose should be clarified by the nurse when it is not included in the order. On 8/30/24 at 9:32 AM, the Consultant Pharmacist stated, typically the order would have a dose specified, and it would have an amount in grams. If we were dispensing the medication, we would send a fax to the facility to clarify that dose. She explained Diclofenac gel was an over the counter medication so the pharmacy did not supply it to the facility, instead it was in the facility stock. The Pharmacist explained a fax should have been sent to the facility for clarification of the dose, but she explained she could do not confirm whether this process was done. She confirmed if the resident who received the Diclofenac topical gel received dialysis and the dose was not measured, the resident could be at risk for increased side effects of the medication because their kidneys were already compromised. The facility policy, Physician Medication Orders dated 4/01/22 indicated orders for medication must include the name and strength of the drug, quantity or specific duration of therapy, and the dosage and frequency of administration.

Based on observation, interview, and record review, the facility failed to ensure residents were able to call for staff assistance through a call bell system for 2 of 2 residents reviewed for call bells, of a total sample of 49 residents, (#71 and #95). On 8/26/24 at 8:59 AM, residents #71 and #95 were observed in their shared room, each lying in their own bed, each, awake and alert. Resident #71 was asked if staff responded in a timely manner when he activated his call bell, and the resident responded, I don't even have a call bell. At that moment, resident #71's roommate, resident #95 stated, Neither do I. Upon observation, both residents' call bells were noted to be attached by a hook to the wall behind the head of their beds, which was out of reach for both residents. Resident #71 was asked what would he do if he needed help, he replied, Yell, I guess. A few minutes later assigned Registered Nurse (RN) E was asked to come to the room. She confirmed the call bells were attached to the walls out of reach of both residents. RN E stated there was no reason the residents should not have their call bells in reach. The nurse then unhooked the call bell from the wall and handed the call bells to each resident. Review of #71's medical record revealed he was admitted on [DATE] with diagnoses including type 2 diabetes mellitus with neuropathy, morbid obesity, repeated falls, dementia, muscle weakness and anxiety disorder. The resident's mobility status revealed he was dependent on staff to roll side to side, as well as a two person assist with a mechanical lift for transfers. Review of #95's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic kidney disease stage 3, cognitive communication deficit, type 2 diabetes, orthostatic hypotension and muscle weakness. The resident's mobility status revealed he needed supervision to roll side to side, as well as a minimum assist of one person with transfers. Review of the facility's call bell policy dated 4/01/22 titled, Call Bells revealed that, . all residents are to have access to call bells at all times, even if it is generally believed that the resident is unable to use it. Staff are expected to be as vigilant as possible in keeping the call bell within reach of the residents. The call system must be accessible to the residents while in their bed.

Based on observation, interview and record review the facility failed to ensure the availability of routine medications to enable continuity of care for a newly admitted resident (#4), resulting in resident leaving the facility Against Medical Advice (AMA). The facility also failed to administer medications as ordered, resulting in resident (#12) receiving incorrect medication, for 2 of 2 residents reviewed for medication administration, of a total sample of 12 residents. Findings: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included cellulitis of the right lower limb, acute respiratory failure with hypoxia, pneumonia, chronic lung disease, and tobacco use. She was promptly discharged , Against Medical Advice (AMA), the next day on 4/10/24 at 2:00 PM. Review of the medical record for resident #4 revealed she had a Brief Interview for Mental Status Score (BIMS) of 15/15 which meant she was cognitively intact. Review of the Order Summary Report revealed resident #4 had 12 routine medications ordered on 4/10/24. Further review of the Medication Administration Record (MAR) revealed resident #4 never received 8 of the 12 routine medications scheduled for twice a day while at the facility. Some of the medications not given included Calcium-Vitamin D for supplementation, Fenofibrate for cholesterol, Prednisone for swelling, Trelegy Ellipta Inhaler for asthma, Amoxicillin for cellulitis of right lower limb, Lisinopril for hypertension, Verapamil for hypertension and chest pain, and Gabapentin for nerve pain. On 6/24/24 at 10:31 AM, in a phone interview with resident #4, she confirmed she was admitted to the facility from the hospital around 3:00 PM on 4/09/24, due to an infection of her right lower limb that required skilled nursing care. She said the facility did not have any of her evening medications and was told by staff they were working on getting the ordered medications from the pharmacy. Furthermore, on the morning of 4/10/24, she asked her husband to bring her own home medications to the facility because the facility still did not have them for her to take. When the facility found out she had her home medications, she was told by a nurse and the Director of Nursing (DON), she could not have her home medications at the bedside due to safety concerns. Resident #4 said she was very upset and decided to leave AMA that same day at around 2:00 PM. Review of Progress Notes for resident #4 revealed on 4/10/24 at 10:53 AM, the Unit Manager (UM) and DON were notified resident #4 was observed with her home medications at the bedside and was encouraged to allow nursing to secure the medications until she was discharged home. The note described resident #4 had refused the education and told staff she was leaving AMA at 02:00 PM that day. An entry at 1:11 PM revealed resident #4 told the Advanced Practice Registered Nurse (APRN) she would be leaving the facility AMA and would get her medications from the pharmacy. On 6/24/24 at 2:41 PM, Registered Nurse (RN) A, revealed on the morning of 4/10/24 resident #4 told her she had not received some of her medications that morning so she left AMA that afternoon. RN A stated they were trying to get the pharmacy to deliver the medications but were having issues with the orders. She further explained when a resident arrived from the hospital, they waited to receive the medication orders, then the pharmacy would deliver to the facility at 6:00 AM and 2:00 PM. The facility had an automated medication dispensing cabinet, which the nurses were allowed to pull certain medications from if available. She said for resident #4, there were some medications they pulled from the automated medication dispensing cabinet but had to wait on the others. On 6/24/24 at 3:10 PM, RN B said she did not remember resident #4 but based on the time of her admission, she would have been on shift. She stated when a resident arrived at the facility, medications were not always available right away and the pharmacy delivered them early in the morning. She further explained the facility had a automated medication dispensing cabinet, but not all nurses had access to it. On 6/24/24 at 3:52 PM, the DON stated she did not remember resident #4. She explained the facility had asked the hospital to medicate the residents prior to the transfer to the facility due to the pharmacy cutoff of 5:00 PM. She said they had an automated medication dispensing cabinet machine but there were certain medications that needed a prescription or a pharmacy code to be taken out of the machine. She also stated there were occasions when the pharmacy would deliver medications at 3:00 AM. A short time later at 5:29 PM, the DON reported that based on review of the MAR and progress notes for resident #4, she was unsure why her evening medications on 4/09/24 and some of her morning medications on 4/10/24 were not given. There was no documentation in the medical record to explain why the medications were still not available. She explained that their admissions process was to obtain medication orders as soon as the resident arrived at the facility. If there were any issues with obtaining the medications from the pharmacy, a call should be made to the doctor and a note would be written in the medical record. Regarding residents bringing medications from home, the DON explained in situations where the facility had made every attempt to obtain the medication from the pharmacy, the resident was allowed to bring medications from home, but nursing staff would need to administer and store the medications based on the facility policy. 2. Resident #12 was admitted to the facility on [DATE] with diagnoses that included muscle wasting and atrophy, history of transient ischemic attack (TIA), stroke affecting left side, and type II diabetes. Review of the medical record for resident #12 revealed he had a BIMS of 12/15 which indicated mild cognitive impairment. On 6/25/24 at 9:39 AM, RN C was observed in the hall at the medication cart administering medications to resident # 12. She performed hand hygiene and proceeded to administer Refresh Tears eye drops in both of his eyes. Then she pulled out a medication cup and added one tablet of Amlodipine 5 milligram (mg), one tablet of Metformin 500 mg, and one tablet of Vitamin C. RN C handed the medications to resident #12 and he took them with a sip of water. Review of resident #12's medical record revealed he had an order for Cholecalciferol (Vitamin D-3)125 micrograms (5000 UT) one tablet given daily. Resident #12 did not have a physician's order for Vitamin C. On 6/25/24 at 11:00 AM, RN C was notified by the DON she had incorrectly administered Vitamin C instead of Vitamin D as ordered by the physician to resident #12. RN C explained she was not resident #12's usual nurse since she worked at the facility on an as needed basis. The DON stated the process for reporting medication errors was to complete an incident report, contact the physician, and monitor the resident for any adverse reaction. Review of the policy and procedure for Administering Medications, revised 6/18/24, revealed a protocol that the individual administering the medication must check the label to verify the right medication, right dosage, right time, and right method of administration before giving the medication.

Based on observation, interview, and record review, the facility neglected to determine appropriate size slings for full body mechanical lifts; neglected to assess and dispose of damaged lift slings and ensure compatibility of slings with lifts per manufacturers' recommendations, for 14 of 15 residents reviewed for accidents, (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15); and neglected to conduct a post fall assessment for injury prior to lifting resident from the floor for 1 of 15 residents reviewed for accidents (#1) of a total sample of 42 residents who required mechanical lifts for transfers. On [DATE] at approximately 1:15 PM, resident #1 fell during a transfer from a recliner chair to her bed with a full body mechanical lift. The Certified Nursing Assistants (CNAs) who performed the task failed to inspect the sling prior to use and did not notice one of the loops had frayed edges. Resident #1 fell headfirst from the sling while she was suspended above the floor when the frayed loop that secured one corner of the sling detached from the lift. The CNAs did not immediately notify the assigned nurse of the fall with possible head injury. Instead, they lifted resident #1 by her arms and legs and transferred her from the floor to her bed without any interventions to prevent further injury. The resident quickly exhibited signs and symptoms of respiratory distress, decreased blood pressure, heart rate and respiratory rate. Emergency Medical Services was alerted and resident #1 was transferred to an ambulance at approximately 1:38 PM. The resident's heart stopped while she was in the vehicle in the facility's parking lot. She received cardiopulmonary resuscitation (CPR) for approximately 60 minutes and there was a reasonable likelihood she could have experienced severe pain and/or further injuries including organ damage and fractures before she was pronounced dead at the hospital. The facility's failure to conduct mechanical lift evaluations and provide safe and appropriate equipment placed all residents who required a mechanical lift for transfers at risk for serious injury/impairment/death and resulted in Immediate Jeopardy starting on [DATE]. These failures contributed to the injury and subsequent death of resident #1 and resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was ongoing as of the survey exit on [DATE]. Findings: Cross reference F689, F726, F835 and F908 Resident #1, a [AGE] year-old female was admitted to the facility from the hospital on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Cauda-Equina Syndrome occurs when the nerves located at the base of the spinal column are compressed, often from an injury. It can cause pain, weakness and incontinence and can lead to permanent paralysis (retrieved on [DATE] from https://my.ClevelandClinic.org/health/diseases/ -cauda-equina-syndrome). The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1 was initially hospitalized for a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The form indicated she was not ambulatory, was not weight bearing on both legs and required assistance of two persons for transfers. Review of resident #1's medical record revealed a Baseline Care Plan dated [DATE]. The document indicated resident #1 was at risk for falls related to [CONDITION(S)] and weakness and needed assistance with activities of daily living. However, the baseline care plan did not mention resident #1 needed a full body mechanical lift for transfers. Her functional abilities, weight bearing status, devices used, and special instructions were not listed on the care plan. Review of the facility Policy and Procedures Care Plans-Baseline dated [DATE] revealed the admitting nurse would review the attending physician's order and implement a nursing care plan to ensure the resident's immediate care needs were met. An Admission Nursing Data Collection form dated [DATE] indicated resident #1 was unable to ambulate and required total assistance of two staff persons for transfers. The assessment revealed the resident used a wheelchair, but no other supportive or assistive devices were listed. Review of resident #1's medical record revealed a Physical Therapy Plan of Care which showed she was on therapy caseload from [DATE] to [DATE]. The document indicated the resident did not use a mechanical lift in the past, present, nor would require one in the future. The physical therapy assessment revealed resident #1 required maximum assistance by two staff for bed to chair transfers and her plan of care indicated she was dependent for all physical effort required for chair to bed transfers. She had a short-term goal to transfer safely from all locations with maximum assistance of two staff. Review of the Section GG- RN Assessor form dated [DATE] revealed she was not assessed for transfers between a bed and a chair due to medical conditions or safety concerns. Review of resident #1's Order Summary Report dated [DATE] revealed physician's orders dated [DATE] for [MEDICATION(S)] 5 milligrams once daily for a heart condition, and full resuscitation status. The document did not reveal any physician's orders for use of mechanical lift or any specification for method of transfer. [MEDICATION(S)] is a drug used to thin your blood and prevent clots. Use of the drug increases your risk of severe or fatal bleeding (retrieved on [DATE] from www.drugs.com). Review of the Task List Report dated [DATE] revealed tasks assigned to Certified Nursing Assistants (CNA) who cared for resident #1 from [DATE] to [DATE]. The document did not include any instructions on the level of assistance required for resident #1's transfers or information on the method of transfer. An Exception Report dated [DATE] at 1:28 PM revealed Licensed Practical Nurse (LPN) C was called to resident #1's room by a CNA. Resident #1 was noted to be unresponsive with shallow breathing, blood pressure of ,d+[DATE] [mm Hg], heart rate of 59 [beats per minute] and respirations of 13 [breaths per minute]. The report indicated the CNA informed LPN C the resident had fallen out of the mechanical lift. The documentation revealed it was unknown if the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Witness statements from CNAs A and B revealed during a transfer to bed using the mechanical lift, resident #1 fell out of the sling. The report read, They were not sure what resident hit during her fall. In telephone interviews on [DATE] at 4:55 PM and 6:15 PM and on [DATE] at 2:16 PM, CNA B stated CNA A assisted her to transfer resident #1 from the bed to the chair with the full body mechanical lift on Monday, [DATE]. She stated earlier that day CNA A assisted her to transfer resident #1 from the bed to the reclining chair with the same mechanical lift and sling. She said during the morning transfer they used the blue attachment loops to secure the sling to the lift. She recalled they selected the blue loops for the morning transfer as they were more appropriate for placing the resident in an upright position in the chair. She noted for the afternoon transfer they agreed to use the green attachment loop on the sling for a flatter position to place her in bed. CNA B did not recall if the top green attachment loop was frayed. She explained while CNA A lifted the resident above the recliner with the mechanical lift, she pushed it out of the way towards the wall. CNA B acknowledged she did not hold the guide straps of the sling, and said it was not necessary until the end of the transfer. She remembered that as CNA A moved the mechanical lift towards the bed, the resident suddenly screamed, and she heard her hit the floor. I heard the resident cry out. It happened so fast. I didn't really see how it happened. Too fast to do anything. She wasn't close enough to hit any furniture or the bed. She hit the ground. Her shoulder and head were on the ground and her legs were still in the sling. The left shoulder loop had pulled off. CNA B said she told CNA A they had to get the resident up off the floor. She explained while resident #1 cried out they picked her up by her arms and legs and lifted her from the floor to the bed. CNA B explained she knew they should not pick resident #1 up, but she was crying, and we panicked. On [DATE] at 12:45 PM, LPN C recalled she had just exited another resident's room when CNA B told her resident #1 fell out of the sling. LPN C stated she entered resident #1's room and observed the resident in bed. She said, Her head was bent down and a little limp. LPN C stated resident #1 exhibited respiratory distress. She stated LPN E called 911 while LPN D assisted her to obtain resident #1's vital signs. On [DATE] at 1:09 PM, LPN D described resident #1's blood pressure and respirations as very low. LPN D said, Her face was making grimacing like she was in pain. She stated LPN C placed an oxygen mask on resident #1, but they were unable to obtain a reading for her oxygen saturation. LPN D stated emergency responders arrived soon after and transported resident #1 to the hospital. On [DATE] at 5:12 PM, the Director of Nursing (DON) stated she was called to the room by LPN C and informed resident #1 fell to the floor. She explained resident #1 was in bed, with her head slumped to the right. The DON demonstrated the resident's position by dropping her chin towards her chest and leaning her head to the right in an unnatural position. The DON stated she was later informed by a staff member that emergency personnel were observed attempting to resuscitate resident #1 inside the ambulance in the parking lot. On [DATE] at 10:58 AM, during a telephone interview, the Medical Director noted it was important for staff to follow facility procedures and stressed the importance of educating all staff to promote resident safety. The Medical Director was not aware CNAs A and B had picked resident #1 from the floor and put her into bed before she was assessed for injury by a nurse or other clinician. He indicated CNAs should not have attempted to move resident #1 after she fell . Review of the local Fire Rescue Patient Care Record dated [DATE] revealed emergency personnel arrived at resident #1's bedside at 1:46 PM. A few minutes later at 1:51 PM they initiated CPR as resident #1 was pulseless and unresponsive. The document indicated nursing home staff reported the resident was dropped from a mechanical lift during a transfer back to bed and facility staff confirmed she fell on her head. The form noted staff were uncertain if the resident had a pulse or was breathing when they lifted her back into bed. Review of the hospital record dated [DATE] at 2:05 PM, revealed resident #1 was unresponsive with CPR in progress when she arrived. Resuscitation attempts were unsuccessful, and the physician noted her time of death was [DATE] at 2:36 PM, approximately one hour after she fell from the sling. On [DATE] at approximately 11:40 AM, inspection of the mechanical lift and sling used for resident #1 was conducted with the Maintenance Director and Regional Nurse Consultant (RNC). The sling had 3 different colored attachment loops at each of the 4 corners of the sling. The green, upper left attachment loop was damaged, with frayed edges and loose strands of thread. Photographic evidence obtained. The RNC validated slings should never be used in that condition and should be discarded if damaged. He was not able to verbalize the facility's process for inspection of slings to ensure safety. On [DATE] at 12:00 PM, resident #4 was seated in a recliner chair with a mechanical lift sling underneath her body. The sling had a frayed green loop connector on the right upper corner. On [DATE] at 12:25 PM, resident #4's assigned nurse, agency LPN L stated she was not aware the resident's sling had a frayed loop, and she was unsure what should be done with it. She stated she did not receive education on slings during her orientation to the facility and used her knowledge to decide which sling to use. On [DATE] at 12:34 PM, resident #4's assigned CNA F stated she was aware the resident's sling had a frayed attachment loop. She explained, I knew this loop was a little frayed, but I was not going to use that loop. She stated she selected the size of slings by looking at residents to judge their size. CNA F stated, if the sling did not fit, she would pick another one. In interviews on [DATE] at 2:15 PM, and [DATE] at 5:12 PM, the DON recalled she performed an audit to ensure no other slings were damaged and acknowledged her audit did not identify the frayed loop connector in current use for resident #4. She said she did not know if agency staff were trained to select the correct sling size for residents who required mechanical lift transfers. She explained the current process for determining the appropriate size sling was by . eyeballing the resident. The DON acknowledged this was not an accurate method to determine the correct sling size. Review of the medical records for residents #4, #5, #6,#7, #8, #9, #10, #11, #12, #13, #14, and #15 revealed no instructions for staff concerning mechanical lift sling size use prior to the incident on [DATE]. Review of residents #6, #7, #8, #9, #13 and #14s' medical record revealed the plans of care did not include use of mechanical lifts for transfers. On [DATE] at 4:02 PM, CNA K noted the residents' appropriate sling size was not always noted in the plans of care. She explained she relied on nurses for direction on selecting the appropriate size sling. On [DATE] at 4:04 PM, CNA O said he would use any sling with any lift, as no one told him differently. On [DATE] at 5:37 PM, the RNC confirmed the facility used various brand slings, not those necessarily recommended by the manufacturers of the mechanical lifts. He stated it was a marketing approach to void warranties if specific brands were not used. He acknowledged the facility did not have a system in place to monitor the condition of mechanical lift slings and indicated the facility did not have an assessment process related to mechanical lift use, determination of sling size, nor a process to make this information available to staff via care plans and CNA task lists. Review of the mechanical lift User Instruction Manual Hoyer HPL700 (retrieved on [DATE] from www.joerns.com) revealed warnings related to not lifting a patient unless trained and competent to do so, not using a sling unless it was recommended for use with the lift, always checking the sling was suitable for the particular patient and of the correct size and capacity, never using a sling which was frayed or damaged, and always fitting the sling to the patient according to the user instructions. In bold writing, the manual warned that their brand slings and lifts were not designed to be interchangeable with another manufacturer's product's. The manual read, Using other manufacturer's products on Hoyer products is potentially unsafe and could result in serious injury. It recommended daily inspection of slings for fraying or other damage and instructed users not to use a sling if damaged or worn. On [DATE] at 12:43 PM, in a telephone interview, the lift's Health Care Product Support Team member for the brand of mechanical lift used for resident #1 during her fall, stated if their sling was used with another company's mechanical lift, it was possible the sling could slide off the spreader bar hook and lead to an accident. On [DATE] at 2:53 PM, in a telephone interview, the sling's Customer Service Representative for the brand of sling used for resident #1 during her fall, confirmed it was against the company's recommendations to use their slings with other manufacturer's lifts. She explained their slings were safety tested and approved for use only with their brand lifts. She confirmed use of incompatible lifts and slings could cause injury to patients and the user would be liable for the outcome. She said, I don't know what could happen. The customer service representative explained selection of the appropriate size sling for a patient was important. She stated the company recommended patients be measured to identify the appropriate sling, not chosen solely by the patient's weight. Review of the facility's policy for Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property dated [DATE] noted Neglect means the failure of the center, its associates or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility's procedures for Lifting Machine, Using a Portable dated [DATE], revealed the purpose to help lift residents, promote comfort and maintain good body alignment while the resident is being moved. The procedure did not include instructions for staff on how to select the correct sling for the lift. The document provided no directions regarding staff responsibilities during transfers or the frequency and method of inspecting slings for wear and tear. Review of the job description for the Staff Development coordinator with effective date of [DATE] revealed essential duties included implementing job skills training for CNAs, maintenance of records for staff development and reporting to appropriate department managers and Administrator any staff who failed to attend required education programs. Review of the Facility Assessment Tool updated on [DATE] revealed the facility was able to care for residents with mobility, falls with injury prevention and transfer needs. The document indicated the facility would attempt to acquire information and training on equipment needed to ensure staff are able to provide appropriate care and services. The document revealed the facility reviewed resident needs with physicians and educated staff on the use of specialized equipment. The assessment noted staff completed annual competencies on transfers, use of mechanical lifts, and accident prevention. Physical equipment such as mechanical lifts and slings were part of a preventative maintenance program that ensured the equipment functioned properly.

Based on interview and record review, the facility failed to prevent an avoidable fall with subsequent death for 1 of 15 residents reviewed for accidents with injury; and failed to identify safety hazards related to use of mechanical lifts and slings for 14 of 15 residents reviewed for accidents, (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) of a total sample of 42 residents requiring mechanical lifts for transfers. On [DATE] at approximately 1:15 PM, resident #1 fell during a transfer from a recliner chair to her bed with a full body mechanical lift. The Certified Nursing Assistants (CNAs) who performed the task failed to inspect the sling prior to use. They did not notice one of the loops had frayed edges. Resident #1 fell headfirst from the sling while she was suspended above the floor when the frayed loop that secured one corner of the sling detached from the lift. The CNAs did not immediately notify the assigned nurse of the fall with possible head injury. Instead, they lifted resident #1 by her arms and legs and transferred her from the floor to her bed without any interventions to prevent further injury. The resident quickly exhibited signs and symptoms of respiratory distress, and decreased blood pressure, heart rate and respiratory rate. Emergency Medical Services (EMS) was alerted and resident #1 was transferred to an ambulance at approximately 1:38 PM. The resident's heart stopped while she was in the vehicle in the facility's parking lot. She received Cardiopulmonary Resuscitation (CPR) for approximately 60 minutes and there was reasonable likelihood she could have experienced severe pain and/or further injuries including organ damage and fractures before she was pronounced dead at the hospital. The facility's failure to prevent an avoidable fall and identify safety hazards related to use of mechanical lifts placed all residents who required mechanical lifts for transfers at risk for serious injury/impairment/death and resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was ongoing as of the survey exit on [DATE]. Findings: Cross reference F600, F726, F835, and F908 Resident #1 was admitted to the facility on [DATE] with diagnoses including end stage kidney disease, type 2 diabetes, [CONDITION(S)]. [CONDITION(S)] occurs when the nerves located at the base of the spinal column are compressed, often from an injury. It can cause pain, weakness and incontinence and can lead to permanent paralysis (retrieved on [DATE] from https://my.clevelandclinic.org/health/diseases/ -cauda-equina-syndrome). The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1 was hospitalized for a primary diagnosis of pneumonia, was alert and oriented and had fair rehabilitation potential. The form indicated she was not ambulatory, was not weight bearing and required assistance of 2 staff persons for transfers. Review of the Order Summary Report revealed resident #1 had physician orders dated [DATE] for physical therapy, occupational therapy to evaluate and treat as indicated. The resident had orders dated [DATE] for full resuscitation status. The Admission Nursing Data Collection form dated [DATE] revealed the resident was oriented to person, place, time, and situation. She required total assistance of two people for transfers, and required extensive assistance of two persons for bed mobility, and she was unable to walk. Review of resident #1's Baseline Care Plan completed on [DATE] included a care plan for falls related to end stage kidney failure and weakness. The goal was to decrease risk factors for fall related injury. The Physical Therapy Plan of Care dated [DATE] reflected the resident's rehab potential was good due to demonstration of higher functional level compared to current condition. The document showed she was motivated to return to her daughter's home. Review of the Exception Report dated [DATE] revealed Licensed Practical Nurse (LPN) C was called to resident #1's room by CNA B. Resident #1 was noted to be lying in bed and was unresponsive. The report read, Per CNAs resident had fallen out of [mechanical] lift. The resident had shallow breathing and her vital signs were below normal levels. Her blood pressure was ,d+[DATE] [mm Hg], pulse was 59 [beats per minute] and respiratory rate was 13 breaths per minute. The report indicated it was unknown if she had a head injury but her neurological checks were abnormal. CNAs A and B explained the resident fell out of the sling during a transfer from the recliner chair to her bed and the CNAs were unsure what the resident hit during the fall. Review of the local Fire Rescue Patient Care Record revealed paramedics arrived at the facility on [DATE] at 1:46 PM. The Clinical Impression section of the form indicated a primary impression of [CONDITION(S)] and a [MEDICATION(S)] injury associated with a fall from 4 feet. The resident's acuity was determined to be critical. The EMS note indicated they arrived at the resident's bedside and found her pulseless and not breathing with an oxygen mask in place. The nursing home staff informed them the resident was dropped from a mechanical lift while staff attempted to transfer her back to bed. The document read, When asked if [patient] fell on her head, staff replied yes. The resident was quickly moved to EMS stretcher and high-quality CPR (cardiopulmonary resuscitation) was initiated and continued until she was transferred to the care of emergency department (ED) personnel at the hospital. The Emergency Department Clinical Summary Final Report dated [DATE] indicated the resident arrived at the ED on [DATE] at 2:07 PM with CPR in progress, and continued by ED staff. The resident's time of death was called by the physician on [DATE] at 2:36 PM. In response to a telephone call made on [DATE] at 1:30 PM, resident #1's daughter stated her mother had only been at the facility a few days when she received a call that she fell from the mechanical lift. The daughter said she was concerned whether her mother was aware she was falling. She was always worried about falling, that was her biggest fear. She recalled the facility staff told her, her mother was not conscious, and they called the paramedics. She said when she got to the hospital her mother had already died . The daughter spoke about being with her mother the evening before the incident and had told her she would come back the next day. She said, I saw her the night before and she was fine and looking forward to coming home soon. This is horrific. I just want this to be over. During telephone interviews on [DATE] at 4:55 PM, and on [DATE] at 2:16 PM, CNA B said she took care of resident #1 only one time and that was on [DATE]. CNA B recalled resident #1 was alert and oriented and was fully engaged in conversation with her during morning care. She stated later that day at approximately:30 PM, CNA A informed her the resident wanted to go back to bed. She noted the resident was in her room seated in the recliner with the same sling under her that was used in the morning. CNA B explained they decided to use the green attachment loops to connect the sling to the mechanical lift as this would place the resident in a flat position. CNA B recalled CNA A was at the controls of the lift. She said, I made sure the attachment loops on my side were connected properly. I did not remember the attachment loop being frayed either in the morning or afternoon. She remembered CNA A raised resident #1 up above the recliner and I pushed the chair towards the wall. As CNA A moved the lift towards the bed, CNA B stated she heard the resident scream and saw her fall. She explained the attachment loop at the top of the left side of the sling detached from the lift. CNA B said, I heard when she hit, but I am not sure if it was her shoulder or head that hit the floor. She recalled the resident was crying and they panicked and picked her off the floor and lifted her back to bed. She said, We did not use the sling to pick her up. [CNA A] got the resident by the upper body, and I got the bottom. She stated after resident #1 was in bed, she ran to alert LPN C. On [DATE] at 4:15 PM, CNA A said she and CNA B took resident #1 out of bed and put her in the recliner chair to go to [CONDITION(S)] in the morning of [DATE]. She noted about 1:15 PM, LPN C told her resident #1 had returned from [CONDITION(S)] and requested to go to bed. She remembered she got the mechanical lift and took it to resident #1's room. She recalled CNA B hooked the green attachment loop to the hooks on the mechanical lift and checked to make sure they were secure. She indicated she operated the lift and raised the resident up and CNA B moved the recliner chair out of the way. CNA A stated, as she was moving resident #1 to the bed, the attachment loop by the resident's head slid off the hook and she fell head first on the floor. She reported she and CNA B picked the resident up off the floor, put her on the bed and then CNA B went to get the nurse. On [DATE] at 12:45 PM, LPN C recalled she had just exited another resident's room when CNA B told her resident #1 fell out of the sling. LPN C stated she entered resident #1's room and observed the resident in bed. She said, Her head was bent down and a little limp. LPN C stated resident #1 exhibited respiratory distress. She stated LPN E called 911 while LPN D assisted her to obtain resident #1's vital signs. On [DATE] at 1:09 PM, LPN D described resident #1's blood pressure and respirations as very low. LPN D said, Her face was making grimacing like she was in pain. She stated LPN C placed an oxygen mask on resident #1, but they were unable to obtain a reading for her oxygen saturation. LPN D stated emergency responders arrived soon after and transported resident #1 to the hospital. On [DATE] at 5:12 PM, the Director of Nursing (DON) stated she was called to the room by LPN C and informed resident #1 fell to the floor. She explained resident #1 was in bed, with her head slumped to the right. The DON demonstrated the resident's position by dropping her chin towards her chest and leaning her head to the right in an unnatural position. The DON stated she was later informed by a staff member that emergency personnel were observed attempting to resuscitate resident #1 inside the ambulance in the parking lot. On [DATE] at 10:58 AM, during a telephone interview, the Medical Director noted it was important for staff to follow facility procedures and stressed the importance of educating all staff to promote resident safety. The Medical Director was not aware CNAs A and B had picked resident #1 from the floor and put her into bed before she was assessed for injury by a nurse or other clinician. He indicated CNAs should not have attempted to move resident #1 after she fell . On [DATE] at 11:30 AM, the mechanical lift and sling used during resident #1's fall were inspected with the Director of Maintenance and the Regional Nurse Consultant (RNC). The mechanical lift was noted to be Brand A HPL700 and the sling was noted to be Brand B R111. The Director of Maintenance stated the lift had no mechanical defects when checked after the incident. The sling was noted to be frayed on one of the green attachment loops. The fraying was obvious and thread strands were coming off the main part of the attachment loop connection. This was the attachment loop that disengaged from the lift's hook. Photographic evidence obtained. The RNC said a sling should not be used in this condition and it should have been discarded. On [DATE] at 11:38 AM, the RNC acknowledged prior to this incident, the facility staff had not been educated to inspect the slings. On [DATE] at 12:00 PM, resident #4 was seated in a recliner chair with a mechanical lift sling underneath her body. The sling had a frayed green loop connector on the right upper corner. Photographic evidence obtained. On [DATE] at 12:34 PM, CNA F stated she placed the sling under resident #4 prior to transferring her to the recliner chair. She said, I do inspect the sling before I use it. I knew this loop was a little frayed, but I was not going to use that loop. On [DATE] at 12:25 PM, resident #4's assigned nurse, agency LPN L stated she was not aware the resident's sling had a frayed loop, and she was unsure what should be done with it. She stated she did not receive education on slings during her orientation to the facility and used her knowledge to decide which sling to use. In interview on [DATE] at 5:12 PM, the DON recalled she performed an audit to ensure no other slings were damaged and acknowledged her audit did not identify the frayed loop connector in current use for resident #4. She said she did not know if agency staff were trained to select the correct sling size for residents who required mechanical lift transfers. She explained the current process for determining the appropriate size sling was by . eyeballing the resident. The DON acknowledged this was not an accurate method to determine the correct sling size. Review of the medical records for residents #4, #5, #6,#7, #8, #9, #10, #11, #12, #13, #14, and #15 revealed no instructions for staff concerning mechanical lift sling size use prior to the incident on [DATE]. Review of residents #6, #7, #8, #9, #13 and #14s' medical record revealed the plans of care did not include use of mechanical lifts for transfers. On [DATE] at 4:02 PM, CNA K noted the residents' appropriate sling size was not always noted in the plans of care. She explained she relied on nurses for direction on selecting the appropriate size sling. On [DATE] at 4:04 PM, CNA O said he would use any sling with any lift, as no one told him differently. On [DATE] at 9:10 AM, the Staff Development Coordinator (SDC) explained an experienced facility CNA would orient the agency CNA and complete a competency checklist. The SCD acknowledged she did not have a completed skills checklist for CNAs A and B. Review of the User Instruction Manual for the Brand A HPL 700 mechanical lift revealed a statement on the front page that noted the lift was only compatible with certain slings. DO NOT use a sling unless it is recommended for use with the lift. Always check the sling is suitable for the particular patient and is of the correct size and capacity. NEVER use a sling, which is frayed or damaged. On [DATE] at 12:43 PM, in a telephone interview, the Health Care Product Support Team member for the brand of mechanical lift used for resident #1 during her fall, stated if their sling was used with another company's mechanical lift, it was possible the sling could slide off the spreader bar hook and lead to an accident. On [DATE] at 5:37 PM, the RNC validated the facility had been combining slings and mechanical lifts of different brands to transfer residents, contrary to manufacturers' recommendations and had purchased slings that were not approved brands. The RNC confirmed the facility did not have systems in place prior to the fall incident to monitor the condition of the slings, ensure residents were appropriately measured and weighed to identify the correct sling size, or provide the information for direct care staff.

Based on observation, interview, and record review, the facility failed to ensure nursing staff were competent in evaluating residents for the appropriate type of mechanical lift, selecting sling size to maintain safety, ensuring compatibility of slings with lifts, and identifying issues with the integrity of slings, for 14 of 15 residents reviewed for accidents, (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15): and failed to ensure CNAs did not move a resident after a fall before being assessed for injury by a clinician for 1 of 15 residents reviewed for accidents, (#1) of a total sample of 42 residents. On [DATE] at approximately 1:15 PM, resident #1 fell during a transfer from a recliner chair to her bed with a full body mechanical lift. The Certified Nursing Assistants (CNAs) who performed the task failed to inspect the sling prior to use. They did not notice one of the attachment loops had frayed edges. Resident #1 fell head first from the sling while she was suspended above the floor when the frayed attachment loop that secured one corner of the sling detached from the lift. The CNAs did not immediately notify the assigned nurse of the fall with possible head injury. Instead, they lifted resident #1 by her arms and legs and transferred her from the floor to her bed without any interventions to prevent further injury. The resident quickly exhibited signs and symptoms of respiratory distress, and decreased blood pressure, heart rate and respiratory rate. Emergency Medical Services (EMS) was alerted and resident #1 was transferred to an ambulance at approximately 1:38 PM. The resident's heart stopped while she was in the vehicle in the facility's parking lot. She received Cardiopulmonary Resuscitation (CPR) for approximately 60 minutes and there was reasonable likelihood she could have experienced severe pain and/or further injuries including organ damage and fractures before she was pronounced dead at the hospital. The facility's failure to conduct mechanical lift evaluations, provide safe and appropriate equipment, and ensure staff were competent in all aspects of mechanical lift transfers placed all residents who required a mechanical lift for transfers at risk for serious injury/impairment/death and resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was ongoing as of the survey exit on [DATE]. Findings: Cross Reference F600, F689, F835, F908 Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)] occurs when the nerves located at the base of the spinal column are compressed, often from an injury. It can cause pain, weakness and incontinence and can lead to permanent paralysis retrieved on [DATE] from https://my.clevelandclinic.org/health/diseases/ -cauda-equina-syndrome). The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1 was hospitalized for a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The form indicated she was not ambulatory, was not weight bearing to both legs and required assistance of 2 persons for transfers. Review of the Order Summary Report revealed resident #1 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Nursing Data Collection form dated [DATE] revealed the resident was oriented to person, place, time, and situation. She required total assistance of two people for transfers, and required extensive assistance of two persons for bed mobility, and she was unable to walk. Review of resident #1's Baseline Care Plan completed on [DATE] included a care plan for falls related to end stage kidney failure and weakness. The goal was to decrease risk factors for fall related injury. The Physical Therapy Plan of Care dated [DATE] reflected the resident's rehab potential was good due to her demonstration of higher functional level compared to current condition. The document showed she was motivated to return to her daughter's home. Review of the Exception Report dated [DATE] revealed Licensed Practical Nurse (LPN) C was called to resident #1's room by CNA B. Resident #1 was noted to be lying in bed and was unresponsive. The report read, Per CNAs resident had fallen out of [mechanical] lift. The resident had shallow breathing and her vital signs were below normal levels. Her blood pressure was ,d+[DATE] [mm Hg], pulse was 59 [beats per minute] and respiratory rate was 13 breaths per minute. The report indicated it was unknown if she had a head injury but her neurological checks were abnormal. The report noted CNAs A and B explained the resident fell out of the sling during a transfer from the recliner chair to her bed and the CNAs were unsure what the resident hit during the fall. Review of the local Fire Rescue Patient Care Record revealed paramedics arrived at the facility on [DATE] at 1:46 PM. The Clinical Impression section of the form indicated a primary impression of [CONDITION(S)] and a [MEDICATION(S)] injury associated with a fall from 4 feet. The resident's acuity was determined to be critical. The Emergency Medical Services (EMS) note indicated they arrived at the resident's bedside and found her pulseless and not breathing with an oxygen mask in place. The nursing home staff informed them the resident was dropped from a mechanical lift while staff attempted to transfer her back to bed. The document read, When asked if [patient] fell on her head, staff replied yes. The resident was quickly moved to EMS stretcher and high-quality CPR (Cardiopulmonary Resuscitation) was initiated and continued until she was transferred to the care of Emergency Department (ED) personnel at the hospital. The Emergency Department Clinical Summary Final Report dated [DATE] indicated the resident arrived at the ED on [DATE] at 2:07 PM with CPR in progress, and ED staff continued. The resident's time of death was called by the physician on [DATE] at 2:36 PM. During telephone interviews on [DATE] at 4:55 PM and [DATE] at 2:16 PM, CNA B stated she worked for a staffing agency and was assigned to the facility for the past three months. She stated the day of the incident,[DATE] was the first time she was assigned to care for resident #1. CNA B recalled resident #1 was alert and oriented and was fully engaged in conversation with her during morning care. She stated later that day at approximately:30 PM, CNA A informed her resident #1 wanted to go back to bed. She stated the resident was in her room seated in the recliner with the same sling under her that was used in the morning. CNA B explained they decided to use the green attachment loops to connect the sling to the mechanical lift as this would place the resident in a flat position. CNA B stated CNA A was at the controls of the lift. I made sure the attachment loops on my side were connected properly. I did not remember the attachment loop being frayed either in the morning or afternoon. CNA B stated CNA A raised resident #1 up above the recliner and I pushed the chair towards the wall. She said when CNA A moved the lift towards the bed, she heard the resident scream and saw her fall. CNA B explained the attachment loop at the top of the left side of the sling detached from the lift. When the resident fell , she was partially out of the sling. CNA B said, I heard when she hit, but I am not sure if it was her shoulder or head that hit the floor. She recalled the resident was crying and they panicked and picked the resident off the floor and lifted her back to bed. She said, We did not use the sling to pick her up. [CNA A] got the resident by the upper body, and I got the bottom. CNA B stated after resident #1 was in bed, she ran to alert Licensed Practical Nurse, (LPN) C. CNA B did not recall getting any education about mechanical lifts during her three months working in the facility and only received education on the day after the incident. CNA B stated she did not know what size sling they used to transfer resident #1 nor if it was the correct size. On [DATE] at 4:15 PM, CNA A stated she worked for a staffing agency and had worked four to five days weekly at the facility since [DATE]. She confirmed she assisted CNA B with resident #1's transfer on [DATE]. She stated she and CNA B hooked the green attachment loop to the hooks on the mechanical lift and checked to make sure they were secure. She recalled that when she moved the lift that held resident #1 towards the bed, the loop by the resident's head slid off the hook. She said the resident fell head first on the floor and they quickly picked her up and put her on the bed. On [DATE] at 12:50 PM, and [DATE] at 1:40 PM, LPN C stated resident #1 returned from [CONDITION(S)] on [DATE] about 1:00 PM. LPN C recalled resident #1 asked to go back to bed and CNAs A and B were instructed to transfer resident #1 from the recliner to the bed. LPN C stated soon after, CNA B informed her the resident fell . LPN C recalled she went to the room and saw the resident was in the bed. LPN C said, Her head was bent down and a little limp. She noted the resident's respirations were labored, her eyes were closed, and she did not open her eyes when spoken to. LPN C stated EMS was notified and arrived at the facility quickly to transport her to the hospital. She explained CNAs should leave a resident who fell on the floor and call the nurse to assess. She said she did not ask the CNAs how resident #1 got in the bed. On [DATE] at 1:10 PM, agency staff, LPN D stated she was at resident #1's bedside with LPN C until EMS arrived. LPN D explained she rarely helped with mechanical lift transfers. She reported she had not received any education from the facility on use of mechanical lifts nor selection of slings until [DATE], the day after resident #1 fell . She noted the facility had different lifts for different sized residents, and staff should be able to use any of them. On [DATE] at 2:20 PM, and [DATE] at 5:12 PM, the Director of Nursing (DON) stated she was called to resident #1's room and was told the resident fell to the floor. The DON recalled the resident was lying in bed and demonstrated the resident's head to be in an awkward position, with her chin to her chest. The DON stated she was later informed by another staff member that EMS personnel were attempting to resuscitate resident #1 in the ambulance in the facility's parking lot. On [DATE] at 3:40 PM, CNA G stated she worked the 3 PM to 11 PM shift the day resident #1 fell from the lift, [DATE]. CNA G expressed concerns about the agency CNAs using the mechanical lifts. The agency CNAs provide good care, but I feel they could use more training in mechanical lifts. On [DATE] at 12:25 PM, CNA F stated she also worked for a staffing agency and stated she never received education on policy and procedure for mechanical lift transfers until after resident #1 fell from the mechanical lift sling. On [DATE] at 9:10 AM, Staff Development Coordinator (SDC) stated CNAs from staffing agencies were given a tour of the facility and education on abuse, neglect, and misappropriation policy before the start of their first shift. The SCD stated she also provided staffing agency CNAs with a list of the administrative staff with phone numbers. She explained an experienced facility CNA would orient the agency CNA and complete a competency checklist. The SCD acknowledged she did not have a completed skills checklist for CNAs A and B. On [DATE] at 12:15 PM, resident #5 explained she was advancing from a full body to a standing lift. She recalled one day CNA B and another CNA attempted to get her up with a standing lift. Resident #5 said, I was nervous because it just did not feel right, they tried several times. She remembered CNA B eventually told the other CNA to stop, and they left to get a therapist to assist. On [DATE] at 8:30 AM, CNA I stated she had oriented staffing agency CNAs in the past but did not recall being given a skills checklist to use with them. On [DATE] at 8:40 AM, staffing agency CNA H stated she was never required to complete a skills checklist when she started working at the facility. She remembered only getting a paper with phone numbers. On [DATE] at 4:02 PM, CNA K stated sometimes the sling size was in the computer and sometimes it was not. She stated she would ask a nurse for information on sling size for new residents. She was taught to inspect the mechanical lift slings after resident #1's fall. The job description for the Director OF Nursing (DON) effective [DATE] revealed he/she will evaluate performance and provide feedback . conduct regular rounds to monitor delivery of care. The job description for Staff Developer-RN effective [DATE] revealed the primary function of this position was to recruit and train associates. The SDC was expected to monitor and guide these positions and maintain educational record documentation.

Based on interview and record review, the facility failed to effectively use its resources to identify safety hazards related to the use and maintenance of mechanical lifts and slings; and failed to ensure staff were knowledgeable of mechanical lift transfer techniques, selection of appropriate size slings and the need to inspect equipment and report issues immediately for 14 of 15 residents reviewed for accidents and mechanical lift use, (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14 and #15); and failed to develop and/or implement policies and procedures to ensure the safety of all residents who required mechanical lifts for transfers. On [DATE] at approximately 1:15 PM, resident #1 fell during a transfer from a recliner chair to her bed with a full body mechanical lift. The Certified Nursing Assistants (CNAs) who performed the task failed to inspect the sling prior to use and did not notice one of the loops had frayed edges. Resident #1 fell headfirst from the sling while she was suspended above the floor when the frayed loop that secured one corner of the sling detached from the lift. The CNAs did not immediately notify the assigned nurse of the fall with possible head injury. Instead, they lifted resident #1 by her arms and legs and transferred her from the floor to her bed without any interventions to prevent further injury. The resident quickly exhibited signs and symptoms of respiratory distress, and decreased blood pressure, heart rate and respiratory rate. Emergency Medical Services was alerted and resident #1 was transferred to an ambulance at approximately 1:38 PM. The resident's heart stopped while she was in the vehicle in the facility's parking lot. She received cardiopulmonary resuscitation for approximately 60 minutes and there was a reasonable likelihood she could have experienced severe pain and/or further injuries including organ damage and fractures before she was pronounced dead at the hospital. The facility's failure to conduct mechanical lift evaluations and provide safe and appropriate equipment placed all residents who required a mechanical lift for transfers at risk for serious injury/impairment/death and resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was ongoing as of the survey exit on [DATE]. Findings: Cross reference F600, F689, F726 and F908. Review of the facility's incident investigation revealed the Risk Management and Quality Assessment and Assurance committee met on [DATE] to review resident #1's fall from the mechanical lift. The committee's Performance Improvement Plan indicated the administrative team including the Administrator, Director of Nursing (DON), and the Medial Director determined the factors that contributed to resident #1's fall were Possible cardiac event, involuntary movements due to anxiety, agency staff. The facility's root cause analysis concluded the resident's preexisting medical condition was the cause of her fall. In an interview conducted on [DATE] between 5:12 PM and 5:40 PM, the facility's DON, Administrator and Regional Nurse Consultant (RNC) discussed resident #1's fall, transfer to the hospital, and unexpected death on [DATE]. On [DATE] at approximately 5:15 PM, the DON confirmed she was involved in the facility's incident investigation and root cause analysis. She stated the facility identified the causative factors for resident #1's fall as improper positioning in the sling and agitation. She explained although the resident fell from the sling while suspended above the floor, she did not necessarily hit her head and furthermore, her actual cause of death was determined to be cardiac arrest. The DON did not respond when asked to clarify the causative relationship between a cardiac event and the sling's loop detaching from the mechanical lift during a transfer. On [DATE] at approximately 5:22 PM, the administrative team was informed observations of slings and mechanical lifts, interviews with equipment manufacturers and staff, and review of medical records revealed significant concerns. They were informed the survey team observed a sling with an obviously frayed loop that was still in use; noted no procedures existed either before or after the incident to ensure slings were thoroughly and regularly inspected; discovered no assessment process to identify the appropriate size sling for each resident per manufacturers' recommendations, and staff were not provided with essential information via physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at approximately 5:27 PM, the DON stated the Therapy department conducted evaluations related to residents' transfer status. She was informed the Rehab Director indicated his department did not have anything to do with mechanical lift and sling size assessments. The DON then explained the Nursing department was responsible for decisions related to mechanical lift use. When asked how the facility determined the correct size and type of sling to be used for each resident, and how this information was transmitted to staff, the DON said, I size up the sling by eyeballing the resident. She acknowledged that method did not ensure accuracy and appropriateness and confirmed after the incident the facility implemented new procedures to select slings based on a resident's weight. However, the DON stated the facility had not included manufacturers' recommendations to measure the length of the resident's torso in addition to weight in the new procedure. She confirmed these details were important as weight only did not reflect other factors such as height and body type. The DON validated the required size of the sling should be placed on the CNA task list because they performed mechanical lift transfers but explained this was not done. On [DATE] at approximately 5:32 PM, the Administrator stated she was also the facility's Risk Manager. She defended the facility's determination that resident #1's anxiety prior to the transfer was a contributing factor to her fall from the mechanical lift. She acknowledged she was not aware of any concerns related to the condition of mechanical lift slings and compatibility issues between the different brands of slings and lifts. On [DATE] at 5:37 PM, contrary to the DON's statement, the RNC explained the facility's investigation showed no evidence resident #1 was agitated during the transfer procedure or that she exhibited behaviors which would have put her at risk for falling out of the sling. The RNC validated the facility had been combining slings and mechanical lifts of different brands to transfer residents, contrary to manufacturers' recommendations and had purchased slings that were not approved brands. He stated it was a common marketing approach to void a warranty if end-users did not purchase accessories and associated products of the same brand, but the facility viewed this as a recommendation and not a requirement. The RNC confirmed the facility did not have systems in place prior to the fall incident to monitor the condition of the slings, ensure residents were appropriately measured and weighed to identify the correct sling size, or provide the information for direct care staff. The RNC stated the facility had conducted annual skills fairs in the past during which nursing staff were required to demonstrate competency in clinical procedures such as use of mechanical lifts. He stated the facility had not held a skills fair for the past one to two years. On [DATE] at 10:58 AM, in a telephone interview, the Medical Director confirmed the facility's administrative team informed him of the circumstances of resident #1's fall. However, he acknowledged he was never told the CNAs lifted the resident off the floor and placed her in bed without notifying the nurse or waiting for the resident to be assessed for injury. Review of the Facility Assessment Tool dated [DATE] revealed the facility would provide general care and services such as mobility, fall prevention and assistance with transfers. A list of competencies to be completed annually noted transfers with a gait belt and mechanical lift were required. The document indicated the facility had a Preventative Maintenance program for equipment including mechanical lifts and lift slings to ensure proper function. The job description for Director of Nursing effective [DATE] revealed he/she would conduct regular rounds to monitor delivery of nursing and supervise staff education activities. The job description for Administrator effective [DATE] revealed he/she would direct overall operation of the facility to maintain excellent resident care. Essential duties and responsibilities included working with management staff to plan all aspects of the facility's operations and ensuring equipment is safe and hazardous conditions are addressed.

Based on observation, record review, and interview, the facility failed to maintain resident equipment in safe operating condition; failed to follow manufacturers' directions for use; failed to ensure full body mechanical lifts were paired with the correct slings, and failed to ensure staff were using the correct sling size for 14 of 15 residents reviewed for accidents, of a total sample of 42 residents, (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15). On 1/31/22 at approximately 1:15 PM, resident #1 fell during a transfer from a recliner chair to her bed with a full body mechanical lift. The Certified Nursing Assistants (CNAs) who performed the task failed to inspect the sling prior to use. They did not notice one of the loops had frayed edges, and resident #1 fell headfirst from the sling while she was suspended above the floor when the frayed loop that secured one corner of the sling detached from the lift. The CNAs did not immediately notify the assigned nurse of the fall with possible head injury. Instead, they lifted resident #1 by her arms and legs and transferred her from the floor to her bed without any interventions to prevent further injury. The resident quickly exhibited signs and symptoms of respiratory distress, and decreased blood pressure, heart rate and respiratory rate. Emergency Medical Services was alerted and resident #1 was transferred to an ambulance at approximately 1:38 PM. The resident's heart stopped while she was in the vehicle in the facility's parking lot. She received cardiopulmonary resuscitation for approximately 60 minutes and there was a reasonable likelihood she could have experienced severe pain and/or further injuries including organ damage and fractures before she was pronounced dead at the hospital. The facility's failure to conduct mechanical lift evaluations, ensure staff were competent in performing transfers, and provide safe and appropriate equipment placed all residents who required a mechanical lift for transfers at risk and resulted in Immediate Jeopardy. The Immediate Jeopardy was ongoing as of the survey exit on 02/05/22. Finding: Cross reference F600, F689, F726, and F835 In telephone interviews on 2/02/22 at 4:55 PM and 6:15 PM and on 2/04/22 at 2:16 PM, CNA B stated CNA A assisted her to transfer resident #1 from the bed to the chair with the full body mechanical lift on Monday, 1/31/22. She noted they agreed to use the green attachment loop on the sling for a flatter position to place her in bed. CNA B did not recall if the top green attachment loop was frayed. She recalled as CNA A moved the mechanical lift towards the bed, the resident suddenly screamed, and she heard her hit the floor. I heard the resident cry out. It happened so fast. I didn't really see how it happened. Too fast to do anything. She wasn't close enough to hit any furniture or the bed. She hit the ground. Her shoulder and head were on the ground and her legs were still in the sling. The left shoulder loop had pulled off. CNA B said she told CNA A they had to get the resident up off the floor. She explained while resident #1 cried out they picked her up by her arms and legs and lifted her from the floor to the bed. CNA B explained she knew they should not pick resident #1 up, but she was crying, and we panicked. The Emergency Department Clinical Summary Final Report dated 1/31/22 indicated the resident arrived at the Emergency Department on 1/31/22 at 2:07 PM with cardiopulmonary resuscitation in progress. The resident's time of death was called by the physician on 1/31/22 at 2:36 PM. On 2/02/22 at 6:27 PM, the Maintenance Director stated the facility had seven standing mechanical lifts and only one full body mechanical lift. He was informed there were currently two full body mechanical lifts located on the 300 Wing. The Maintenance Director explained he was not sure of the difference between a standing lift and a full body lift. On 2/03/22 at 11:21 AM, the facility's Regional Nurse Consultant (RNC) provided a list of all the facility's mechanical lifts and the manufacturers' operating instructions. On 2/03/22 at 11:30 AM, the Maintenance Director explained the lift involved in resident #1's fall was not recorded on the list because it was rented from an outside provider and was now kept in the maintenance shed. On 2/03/22 at 11:40 AM, during a tour of the maintenance shed, the Maintenance Director and RNC showed Brand A model HPL 700 full body mechanical lift with a Brand B sling model R111, which were the equipment that was used during resident #1's fall. The Maintenance Director stated he removed the lift from the facility on 1/31/22, after resident #1 fell . He stated he inspected the lift and found nothing wrong with it. The Maintenance Director and the RNC confirmed the sling attached to the mechanical lift was the one from which the resident fell . The sling had multiple, colored attachment loops at each of the four corners which were used to adjust residents' positions while in the sling from seated upright to recumbent. One of four green attachment loops on the size large sling attached to the lift was frayed. Inspection of the sling revealed there were fibers separated from the main section of the green attachment loop. Photographic evidence obtained. The Maintenance Director and RNC were asked to describe the facility's procedures related to inspection of mechanical lift slings to ensure the equipment was in good working condition. They did not respond to that request, but instead stated staff should have thrown out the damaged sling rather than use it to transfer resident #1. Review of page 3 of the Brand A HPL 700 instruction manual revealed a list of slings that were compatible with that mechanical lift. The manual did not list any Brand B slings as compatible. On 2/04/22 at 12:43 PM, in a telephone interview with the Health Care Product Support Team member for Brand A mechanical lift used for resident #1 during her fall, he explained the Brand A HPL 700 lift came with a bariatric spreader bar and a standard spreader bar was also available. He stated the bar had six loop connections, but the slings used with this lift could have either four or six attachment loop connectors. The Support Team member referred to page 3 of the instruction manual and stated the only manufacturer-recommended slings were noted in the manual. He explained the Brand A HPL 700 mechanical lift was safety-tested with only the slings noted in the manual. When asked if a third-party sling such as Brand B sling should be used with the Brand A HPL 700 lift, he stated safety would not be guaranteed. He said, Using a non-recommended sling could lead to an accident such as a sling tearing away from the lift hooks. On 2/04/22 at 2:53 PM, in a telephone interview, Brand B sling Customer Service Representative validated Brand B slings were not recommended for use with another manufacturer's mechanical lift such as the Brand A HPL 700 model. She stated the Brand B sling, model R111, was designed and safety-tested to be used with Brand B mechanical lifts only. She confirmed use of an Brand B sling with a third-party lift would result in the end-user assuming liability for resulting injuries to residents. She explained selection of the appropriate size sling was important, and the resident had to be measured and weighed to ensure safety. Review of the Brand B sling sizing chart revealed the R111 model was a large sling that Best Fits: 150-300 lb. The sizing chart noted, Use a combination of the client's weight and body measurements to determine the most appropriate sling size. Review of resident #1's medical record revealed no documentation that her body measurements in conjunction with her weight were obtained or utilized to determine the appropriate sling size. Review of the Brand B Patient Slings Owner's, Operator and Maintenance Manual revealed a list of mechanical lifts that could be used with the Brand B R111 sling model. The Brand A HPL 700 was not listed as an authorized brand of mechanical lift. The manual noted, Brand B slings are designed specifically for use with Brand B Patient Lifts and made to support the patient during lift and transfer procedures. A warning in the manual read, After each laundering (in accordance with instructions on the sling), inspect sling(s) for wear, tears and loose stitching. Bleached, torn, cut, frayed or broken slings are unsafe and could result injury. Discard immediately. On 2/03/22 at approximately 12:00 PM, resident #4 was observed in the facility's [CONDITION(S)] room with a mechanical lift sling underneath her in a chair. Inspection of the sling revealed one of the green loop attachments was frayed. Photographic evidence obtained. Facility staff were notified of the safety concern. The Administrator confirmed the loop attachment was frayed and the sling had to be replaced prior to any attempts to transfer resident #4 with a mechanical lift. On 2/03/22 at 12:34 PM, resident #4's direct caregiver, CNA F stated she was aware the sling she used to transfer the resident was damaged. She said, I knew this loop was a little frayed, but I was not going to use that loop. CNA F could not explain why the sling was not discarded immediately as per manufacturer's recommendations. On 2/03/22 at 2:15 PM, during a discussion of resident #1's fall from the full body mechanical lift with the Administrator, Director of Nursing (DON), and RNC, they stated they found out about the condition of the damaged, frayed sling on 2/01/22, the day after resident #1 fell . They stated after the incident, the administrative team checked on all residents who required full body mechanical lifts for transfers to ensure their slings were in good condition. They confirmed the team did not find any additional slings that were frayed. They could not explain how or why a frayed sling was found underneath resident #4 after the facility's audit of all slings was completed. On 2/04/22 at 11:52 PM, the Director of Housekeeping and Laundry stated her staff was responsible for washing mechanical lift slings and if they noted obvious damage she would remove the sling from use and ask for a replacement. She confirmed neither she nor her staff were ever instructed to thoroughly inspect the slings after laundering according to the manufacturer's recommendations. Resident #8 was admitted to the facility on [DATE] with diagnoses including paralysis of one side of the body and seizures. Review of the resident's medical record revealed a physician's order dated 2/03/22 for use of a full mechanical lift for transfers by two staff persons. The order directed staff to use a medium-sized sling for transfers. On 2/04/22 at 3:47 PM, resident #8's direct care CNA M described how she transferred the resident. She explained the size of the sling used with the full body mechanical lift depended on the resident's weight. CNA M stated if a resident weighed between 175 and 200 pounds she would use a large sized sling. She added that if a resident weighed over 200 pounds she would use the blue sling, but she acknowledged she did not know the actual size of the blue sling. When asked what size sling resident #8 required, she said, I don't remember. Review of resident #9's medical record revealed a diagnosis of dementia. The resident had a physician's order dated 2/03/22 for full body mechanical lift transfer with a medium sized sling. On 2/04/22 at 3:30 PM, resident #9's direct care CNA P said, I don't know who chooses the size of the slings for the residents. She stated if she had to determine a sling size for a resident, she would look at the resident's weight. She acknowledged she used the large sized sling to transfer resident #9 although the resident was not a big person. CNA P explained she used a blue sling with resident #9, but after further inquiry, it was discovered CNA P referred to the color of the blue loop attachment of the sling not the actual size of the sling. Resident #10 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)], Spinal Stenosis, and a history of falls. The resident's medical record included a physician's order dated 2/04/22 for transfers with a full body mechanical lift and a medium sized sling. The order directed staff to utilize three persons for transfers and the resident needed to wear a helmet during transfers. On 2/04/22 at 4:02 PM, contrary to the physician's order, resident #10's direct care CNA K stated the resident was transferred with a full body mechanical lift by two staff person transfer with a small sized sling. CNA K stated she thought the sling size was in the residents' plan of care in the computer but explained sometimes it was not. Medical record reviews for residents #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15 revealed they required a full body mechanical lift for transfers The medical records did not include any documentation that the residents' body measurements were used in conjunction with their weights to determine appropriate sling sizes per manufacturers directions for use. Review of the facility's incident investigation of resident #1's fall from the mechanical lift, dated 1/31/22, revealed the facility's root cause analysis concluded the resident's preexisting medical condition was the cause of the fall, and did not note the damaged condition of the sling. On 2/04/22 at 5:12 PM, a meeting was held with the Administrator, DON, and RNC. There was no indication the facility had recognized the frayed attachment loop on the sling as factor to resident #1's fall. The administrative team was not aware of compatibility issues related to the mechanical lifts and the slings used to by the facility. There were no processes in place to that included sling inspection after laundering and resident sling size determination as per manufacturers' directions. Review of the facility's policy and procedures for mechanical lifts titled, Lifting Machine, Using Portable dated November 2016 read, The purpose of this procedure are to help lift residents and to promote comfort and to maintain good alignment while the resident is being moved. The document did not address equipment compatibility, identification and use of the appropriate sling size for each resident or incorporate sling measuring guidelines.

Based on observation, interview and record review, the facility failed to provide care and services for a central line intravenous catheter (IV) catheter, for 1 of 3 residents reviewed for IV access site out of a total sample of 5 residents, (#1). These failures placed resident #1 at risk for serious injury/impairment/death. Without appropriate central line catheter care, there was high likelihood resident #1 could have developed severe infection, blood clots or bled to death. Resident#1 was admitted to the facility on [DATE] from the hospital where she received IV antibiotic therapy for osteo[DIAGNOSES REDACTED], and infection in her bone. During her 13-week stay in the facility, resident #1 did not receive any care or services for her central line IV catheter. Approximately two months after resident #1 was discharged home, her daughter noticed the central line dangling from the resident's chest. Resident #1 was admitted to the hospital for two days to have the central line removed. The facility's failure to obtain appropriate admission orders [REDACTED]. The Immediate Jeopardy was identified on 8/21/20. The Immediate Jeopardy was removed on 8/14/20. Findings: Resident #1, a [AGE] year-old, female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/12/20 at 3:12 PM, during a telephone interview with resident#1's daughter, she stated her mother was discharged from the facility with a central line. She stated the family was unaware that the resident had a central line and were not given orders on how to care for the line when the resident was discharged . The daughter stated the line was in for approximately two months after she was discharged home from the facility. She called the facility for guidance and was told to take her mother to the hospital to have it removed since her mother was no longer a resident of the facility. A central line is . a tube that doctors place in a large vein in the neck, chest, groin or arm to give fluids, blood, or medication A lumen is an access channel to the catheter. (Retrieved from Centers for Disease Control and Prevention (CDC) website at www.CDC.gov, accessed on 8/24/20). A review of the facility's Care of Central Venous Catheters .not dated read, Change central line catheter site dressing every week transparent dressing (or as ordered by physician). Change central line catheter site dressing Q (every) 48 hours with gauze dressing (or as ordered by physician). Review of the hospital transfer form, AHCA Form 5000-3008 dated 11/06/19 revealed resident #1 had IV access Type: R chest tunneled cath-double lumen. The hospital History and Physical printed 11/03/19 revealed resident #1 had a central line to her right chest. The Admission Nursing Data Collection form completed on 11/06/19 at 5:00 PM by Registered Nurse (RN) A indicated resident #1 had a central line catheter to her right upper chest. Review of resident #1's medical record revealed Registered Nurse (RN) A did not obtain physician orders [REDACTED].#1's central line on admission. Review of the Licensed Nurse Weekly Skin Observation (Weekly Skin Checks) revealed only 9 of 13 scheduled skin evaluations were done. None of the skin evaluation forms included documentation of resident #1's central line. On 8/20/20 at 12:25 PM, the Minimum Data Set (MDS)/Care Plan Coordinator stated when a resident is admitted to the facility she reviewed the orders, the hospital history and physical and the hospital transfer form. She explained she greeted the resident in person but did not do an assessment. She said, I do not take off their clothes so I would not have seen the IV. The MDS Coordinator explained she developed the basic care plan and the Unit Managers (UM)s and nurses updated them. She said, I am not sure why the IV was missed . I did the best I can. The MDS Coordinator acknowledged her review of the residents and their care needs were based on chart review only. On 8/20/20 at 12:40 PM, the UM stated every newly admitted resident's chart needed to be reviewed within 24-48 hours. She stated chart review was conducted by 3 UMs and the Director of Nursing (DON) who ensured all the safety nets or essential components for care, were in place, such as fall risk assessments, code status and diets. The UM stated the Admission Nursing Data Collection form was not reviewed as part of the safety net process. The UM explained the admitting nurse should start the baseline care plan and other nurses would add to it. The UM recalled reviewing resident #1's chart with the DON and 2 other UMs to include the hospital history and physical and transfer form which had documentation of resident #1's central line. She said, I honestly don't know how 4 of us missed it. The UM stated her expectation was that nurses should communicate information on IV's in shift report and also document on weekly skin checks. On 8/20/20 at 4:00 PM and 4:52 PM, RN A confirmed he completed resident #1's admission assessment. He recalled she had a central line located in the right upper chest near her collar bone, with 2 lumens about 3-4 inches long. RN A explained he called the physician to verify the hospital discharge orders and informed the physician there were no orders for the central line. RN A told the physician resident #1 stated her central line had not been used for a long time. He recalled the physician said, ok but gave no orders. RN A stated it was strange and unusual not to receive orders for central line care. RN A suggested that other team members including the physician, Assistant Director of Nursing (ADON) and assigned nurses who assessed and evaluated resident #1 during her stay in the facility should also have noted the presence of the central line and absence of orders and a care plan. He said, Nurses do weekly skin checks . Any nurse would have seen the line and should have documented it was there. Review of Licensed Nurse Weekly Skin Observation (Weekly Skin Check forms) revealed RN A completed skin checks on resident #1 on 12/05/19 and 12/18/19 with no documentation regarding her central line. RN A stated the rehab UM and other nursing administration staff reviewed charts on the day after admission and should have caught that there were no orders or care plan for resident #1's central line. RN A explained the admitting nurse was responsible for creating the baseline care plan, which was necessary to address the immediate needs of newly admitted residents. On review of the baseline care plan with RN A he confirmed there was no documentation of the central line and stated he did not recognize the signature. RN A acknowledged he did not create the document. On 8/21/20 at 9:25 AM, the DON stated the baseline care plan should be started on admission by the admission nurse. She explained other nurses, the UMs and herself sometimes assisted with this document when the admitting nurse was busy. She confirmed although she initiated and signed resident #1's baseline care plan, she did not actually assess resident #1 or do the skin check. She stated her expectation was that the admitting nurse would continue to work on the document during that shift. The DON stated the chart review process on the day following admission was a team effort. She acknowledged there was a breakdown in the chart review process as the admission assessment and information received from the hospital on admission clearly showed a central line. The DON could not explain how the wound nurse and assigned nurses did skin evaluations and did not identify or document the central line. I would have to agree the skin sweep was not done thoroughly. There is no policy for a skin check prior to discharge so the central line was not noted at that time either. The DON stated the resident was at the facility for, Three months here, two months at home. I am thankful that nothing happened to her. She could have gone septic, developed a severe infection. A central line deposits anything straight into her heart. On 8/21/20 at 11:06 AM, the administrator recalled a telephone call to the facility from resident #1's daughter, about 6 to 8 weeks after her discharge home in February 2020. He said, Someone called about an IV line being left in. I asked if they followed up with the doctor and recommended they take the issue to a doctor. The administrator stated he did not report the daughter's concern to anyone, and the DON confirmed she was never informed of the telephone call. He stated he did not report it to anyone because the daughter did not emphasize the central line as a real concern. She was more focused on getting more medications. Review of the hospital History and Physical dated 4/27/20 revealed resident #1 was admitted for removal of the central line. The document indicated resident #1 had a right upper chest central line that was placed in October 2019 and used for IV antibiotic until November 2019. The note read, This has been in place for a total of 7 months . The line was removed under the supervision of a radiologist and resident#1 remained in the hospital overnight for observation. The facility's corporate Nurse Consultant (NC) stated she was unaware of any incidents related to central lines prior to notification by the State survey agency staff on 8/12/20. The NC explained she initiated an investigation of residents who were admitted to the facility with central lines and discovered documentation of a central line on resident #1's admission data collection sheet. The NC stated the facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) committee meeting on 8/14/20 and developed a Performance Improvement Plan (PIP). Review of the Performance Improvement Plan Worksheet for IV Management revealed the facility identified the problem as Intravenous access orders not all in place and nurses were documenting in the wrong location in the chart. The PIP indicated the contributing factor was nurses were unsure of specific orders for IVs. The facility identified the root causes of the incident as Multiple new nurses (and) Education on processes. The NC explained during her investigation she did not find any orders for or documentation of central line care and management in any section of resident #1's medical record. In addition, the NC confirmed the admission nurse was not new to the facility and was knowledgeable of order input processes. The NC acknowledged the facility's PIP for central line management was not accurate because the root cause analysis did not drill down to the exact areas of breakdown or correctly identify the contributing factors. Therefore, the current PIP did not adequately address all the actions necessary to prevent reoccurrence of the incident. Review of corrective measures implemented on 8/14/20 by the facility revealed the following: Newly admitted residents will have a head-to-toe skin assessment done by 2 nurses, the wound care nurse and a UM. Education for all nurses began on 8/13/20 and will be-ongoing until 100% compliance is achieved. The topics included IV management and entry of batch orders. Staff will not be allowed to work until training has been received. Newly hired nurses will receive the education in orientation. Interviews were conducted with 7 nurses on 8/20/20 between 12:24 PM and 4:52 PM. RN A and LPN B,C,D,E,F, and G were knowledgeable about the process for obtaining admission orders [REDACTED]. Review of staff in-service attendance sheets revealed 96% of nurses had been educated. Nurses who were educated on the phone will have in-person follow-up with the DON or Staff Development Coordinator. Additional education topics for nurses will include performance and documentation of thorough weekly skin sweeps, and initiation of the baseline care plan with a revised form. The QAA committee will review audits of the interventions and re-educate and/or correct processes as needed. The audit tool included presence of IV lines, appropriate care plan and orders in place and skin checks. The sample was expanded to include 2 additional discharged residents and all current residents with IV access sites. Record reviews conducted revealed no concerns related to residents #2, 3, 4 & 5.