Every finding on record at Savannah Post Acute LLC

Based on observations and staff interviews, the facility failed to ensure dietary staff followed standardized recipes and accurately measured ingredients when preparing pureed foods. This failure compromised the nutritional value and flavor of meals provided to five of five sampled residents [R] who required a pureed consistency diet. This deficient practice created the potential for decreased nutritional intake and possible weight loss for residents receiving a pureed diet.Findings include:During an observation on 07/28/2026 at 4:12 PM of puree preparation, [NAME] EE stated that no recipes were used when preparing the pureed meal. Observation of the pureed sweet potatoes revealed the potatoes initially could not be blended to a smooth consistency, and water was added. Observation of the puree of the Smithville ham revealed that an unmeasured amount of water was added as the liquid component.During an observation on 07/28/2026 at 4:20 PM of puree preparation with [NAME] EE, [NAME] EE was observed preparing pureed sweet potatoes and pureed cut {named} ham. [NAME] EE stated that three slices equaled one serving. She reported that recipes have not historically been used when preparing pureed items.During an interview on 07/28/2026 at 4:37 PM, Dietary Account Manager FF and Dietary District Manager GG stated that ideally dietary staff should follow a recipe, but there was no strict protocol requiring adherence to recipes.During an interview on 07/28/2026 at 4:40 PM, the Corporate Nurse stated she understood the concern and would ensure the Dietary Manager received education.

Based on staff interviews, record review, and a review of the facility policy titled MDS Completion and Submission Timeframes, the facility failed to transmit an assessment within the required timeframe for one of 25 sampled residents (R) (R83). The discharge MDS record for R83 was more than 120 days old, which triggered the Resident Assessment Facility Task.Findings include:Review of the policy titled MDS Completion and Submission Timeframes, revised October 2023, documented Policy Statement: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Policy Interpretation and Implementation:1. The assessment coordinator or designee is responsible for ensuring resident assessments are submitted to CMS' Internet Quality Improvement Evaluation System (iQIES) in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. 3. Submission of MDS records to the iQIES is electronic. A hard copy of each record submitted is maintained in the resident's clinical record for a period of fifteen (15) months from the date submitted.During an interview on 07/28/2026 at 3:45 PM, the Minimum Data Set (MDS) Coordinator BB stated that the facility had 14 days to complete an assessment upon admission, based on the Assessment Reference Date (ARD), and that assessments were required to be completed quarterly and annually. She stated that a Significant Change in Status Assessment was required when there was a change in a resident's condition. MDS Coordinator BB confirmed that assessments must be transmitted within 14 days of completion. She reviewed R83's MDS list and confirmed that both the 5 Day and Discharge MDS assessments had not been transmitted. She reported that someone had mistakenly checked the Do Not Submit to CMS box on the Discharge MDS, which caused the transmission error.During an interview on 07/28/2026 at 5:57 PM, the Administrator stated that he expected the Minimum Data Set (MDS) assessments to be complete and accurate. He also stated that he expected all assessments to be transmitted in a timely manner.

Based on observations, staff and resident interviews, and a review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to obtain orders, a care plan, and a self-administration assessment for one of 25 sampled residents (R) (R46) before leaving medications at the bedside. This deficient practice had the potential to place R46 at risk of overmedication and medical complications.Review of the facility's policy titled, Self-Administration of Medications by Patients/Residents, effective February 01, 2024, documented Policy Statement: Each resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse/Registered Nurse and physician have determined that the practice would be safe for the resident and other residents of the healthcare center. Procedure: 1. The opportunity to self-administer medications is reviewed during the routine assessment by the healthcare center's interdisciplinary team utilizing the Electronic Health Record Observation tool, Medication Self- Administration assessment. 2. If the resident or family member desires to self-administer medications, an assessment is conducted by the Licensed Nurse to assess the individual's cognitive, physical, and visual ability to carry out this responsibility. 3. If the Licensed Nurse determines the resident or family member to be capable of self-administration of medications, the attending physician must write an order to that effect that includes the specific medications based off the Self-Administration Medication assessment. 4. If the resident or family member demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted.Review of the facility's electronic medical records (EMR) revealed R46 was admitted to the facility on [DATE] with pertinent diagnoses including lumbago with sciatica, generalized muscle weakness, essential hypertension, chronic congestive heart failure, and age-related physical debility.Review of the Annual Minimum Data Set (MDS) dated [DATE] documented Section C Cognitive Patterns, Brief Interview for Mental Status (BIMS), as 09 - Moderate cognitive Impairment.Review of the comprehensive care plan for R46, dated 05/19/2027, revealed interventions to give medications as ordered, with no care plan or focus area in place for self-administration of medication.Review of the clinical record for R46 revealed no assessment for self-administration of medication.Review of the Physician's Orders for R46 revealed medications scheduled for every morning (9:00 AM), including high-risk medications such as Bumex {Bumetanide 2 mg(milligrams)} for Congestive Heart Failure (CHF), Entresto (49-51 mg) and Spironolactone (25 mg) for hypertension, Carvedilol (6.25 mg), Gabapentin (800 mg), and Hydrocodone-Acetaminophen (5-325 mg) for chronic pain. Further review revealed no order for self-administration of these medications.Observation and interview on 07/27/2026 at 9:45 AM at R46's bedside revealed two medication cups with medications present. R46 stated that he takes his daily medications at his convenience.During an interview on 07/27/2026 at 9:50 AM, R46's Certified Medication Aide (CMA) AA revealed that she leaves the medications at the bedside because he self-medicates.During an interview on 07/27/2026 at 3:45 PM, the Corporate Nurse stated there are no residents in the facility who are assessed to safely self-administer medications.During an interview on 07/27/2026 at 4:00 pm, the Regional Nurse, Director of Nursing (DON), and Assistant Director of Nursing (ADON) confirmed that the CMA should have stayed with the resident to administer medications.During an interview on 07/29/2026 at 11:15 AM, the Administrator revealed it is his expectation that medications are administered by authorized personnel when they are not assessed to self-administer their own medications, stating negative outcomes could occur if medications were not taken as ordered.

Based on resident interviews, staff interviews, and a review of facility records, the facility failed to provide written notification to the resident explaining the reason for the required room change for one of 25 sampled residents(R) (R130). This deficient practice had the potential to limit the resident's understanding of the reason for the move and reduce the resident's ability to participate in decisions regarding their care and living arrangements.Findings include:Review of the electronic medical record (EMR) revealed that R130 had been admitted to the facility with diagnoses including, but not limited to, insomnia, depression, shortness of breath, anxiety disorder, and hypertension.Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.During an interview on 07/26/2026 at 1:32 PM, R130 stated her concerns regarding her recent move from 100 Hall to 200 Hall on 07/24/2026. She stated that she and her former roommate had been unable to get along and reported that she had not been notified prior to the room change. The resident expressed dissatisfaction with the relocation, noting that she had been moved from a two person room to a three person room and would have preferred to remain on 100 Hall.During an interview on 07/28/2026 at 3:50 PM, the Social Services Director (SSD) stated that the resident had not been included on the room change list. The SSD advised that residents were required to receive two days' notice prior to an anticipated room change. She stated that she had not been involved in the decision to relocate the resident and that the decision had been made by the Interdisciplinary Team (IDT). She reported that she had been unsure of the reason for the room change and confirmed that the resident should have been provided with a room change form.During an interview on 07/28/2026 at 4:20 PM, the Minimum Data Set (MDS) Coordinator stated that she had been on leave and, upon returning on Monday, learned that the resident had been moved to 100 Hall. She stated that, based on information provided to her, R130 and her roommate had been experiencing difficulties. She advised that the resident who initiated or filed the complaint was typically the individual who was moved. She further stated that the resident and the resident's family were required to be notified two days prior to a room change.During an interview on 07/29/2026, the SSD confirmed that no room change request had been completed for the resident.During an interview on 07/29/2026 at 12:19 PM, the Director of Nursing (DON) stated that when a roommate conflict occurred, the resident identified as the complainant was typically the resident asked to move. She stated that if the resident refused to move, alternative solutions would be explored to help the residents coexist and attempt to resolve the situation. The DON confirmed that a room change form had not been completed for the resident's relocation. She stated that the resident had agreed to move when asked; however, she acknowledged that the resident may not have wanted to relocate.During an interview on 07/29/2026 at 3:07 PM, R130 confirmed that she did not want to move from her room and stated that she had never consented to the room change. She reported that, on the day of the move, the Unit Manager (UM) had come to her room and informed her that she needed to relocate. R130 stated that she told the UM she did not want to move and was not willing to do so. She reported that the UM responded, Yes, you are moving, as the DON and I have made a determination that you had to move.

Based on staff and resident interviews, record review, and review of the facility policy titled Clinical Change in Condition Management, the facility failed to notify the resident representative (RP) of a change in condition for one resident (R) (R125) of eight residents sampled for closed records.This failure resulted in the RP not being informed of the resident's condition change.Findings include:Review of the policy titled Clinical Change in Condition Management, effective February 1, 2024, documented the following: Policy Statement: The interdisciplinary team strives to identify and manage all residents that are experiencing a change in condition.Procedure 7. Verify that family/responsible party has been notified.Review of the electronic medical record (EMR) revealed R125 was admitted to the facility on [DATE]. Pertinent diagnoses include, but are not limited to, type 2 diabetes mellitus with diabetic neuropathy, unspecified, which places the resident at increased risk for impaired sensation, altered circulation, and potential foot complications.Review of R125's discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a Staff Assessment for Mental Status indicating the resident's short term memory was intact, cognitive skills for daily decision making were severely impaired, and no behaviors were noted during the assessment period.Review of R125's care plan revealed a problem of cellulitis related to a skin infection, initiated on 04/08/2026. Goals included, but were not limited to, R125 demonstrating decreased redness, swelling, and pain, and completion of the prescribed antibiotic therapy without complications. Interventions included, but were not limited to, administering antibiotics as ordered through 04/17/2026, monitoring the affected area for redness, warmth, and swelling, and observing for any adverse reactions associated with treatment.Review of the Physician's Orders for R125 revealed the following:Order dated 04/08/2026: Bactrim DS Oral Tablet 800 160 mg (sulfamethoxazole trimethoprim) - Give 1 tablet orally two times a day for cellulitis for 10 days. Order discontinued 04/14/2026.Order dated 04/14/2026: Clindamycin HCl Oral Capsule 300 mg (clindamycin HCl). Give 1 capsule orally every 6 hours for cellulitis for 10 days.Review of progress notes dated 04/08/2026 documented the resident complained of right foot pain. No scratches or cuts were noted. The right foot was described as red in color. The right foot was assessed, and a new order was obtained for Bactrim DS for cellulitis. Pain medication was administered as ordered. Staff documented they would monitor for any change to the right foot.Review of progress notes dated 04/09/2026 documented antibiotic therapy in progress for right foot cellulitis. Bactrim was administered without adverse reaction. The right foot remained red and painful. The resident was in bed that day. Staff documented they would monitor for any changes.During an interview on 07/28/2026 at 1:24 PM, the complainant confirmed not being notified of R125's change in condition or the ordered antibiotics for a new diagnosis of cellulitis.During an interview on 07/28/2026 at 5:22 PM, Admissions (HH) revealed that she had been working the day R125 was transferred to the hospital. She confirmed that the family member was given the wrong hospital during the notification process.During an interview on 07/28/2026 at 5:27 PM, the Director of Nursing (DON) stated that R125 was sent out because she had been experiencing issues with her foot and was sick that day, including nausea and vomiting. The DON confirmed that the family should have been notified when the resident's foot condition was first assessed. During an interview on 07/29/2026 at 3:30 PM, Certified Nursing Assistant (CNA) LL revealed that anytime she identified anything out of the normal or unusual with one of her residents (such as swelling or bruising), she notified her charge nurse.During an interview on 07/29/2026 at 3:35 PM, Licensed Practical Nurse (LPN) MM revealed that anytime a CNA reported a change, or she identified a change during her assessments, she initiated a change in condition SBAR (situation, background, assessment, recommendation) form and followed up with a progress note, a notification to the provider, and a notification to the family/RP.During an interview on 07/29/2026 at 3:40 PM with the Assistant Director of Nursing (ADON), she revealed she was aware of a situation involving a resident who had developed cellulitis in the foot and that nursing staff had failed to notify the RP. She confirmed that someone should have notified the RP.

Based on observations, staff interviews, and a review of the facility policy titled, Storage Medication, the facility failed to ensure that all medications were stored and labeled properly in one of two medication rooms in Magnolia Hall, located behind the nurses' station. This deficient practice had the potential to result in residents receiving medications that were no longer potent or effective in treating the conditions for which they were prescribed. Findings include:Review of the policy titled Storage Medication, dated January 2024, documented POLICY Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure. 14. Outdated, contaminated, discontinued, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal (Refer to Section 5 - Disposal of Medications, Syringes and Needles), and reordered from the pharmacy (Refer to Section 3.2 - Ordering and Receiving Non Controlled Medications), if a current order exists.During an observation and medication storage inspection of the medication room on Magnolia Hall, located behind the nurses' station, on 07/28/2026 at 11:50 AM with Licensed Practical Nurse (LPN) DD, two bottles of Bisacodyl 5 mg were observed with expiration dates of 02/2026 and 03/2026. Observation also revealed an opened vial of (named) Protein Derivative in the medication refrigerator that did not have an opening date on the vial or on the box containing the vial.During an interview on 07/28/2026 at 11:58 AM, Licensed Practical Nurse (LPN) DD confirmed that the Bisacodyl bottles were expired. She also confirmed that the opened Tuberculin Protein Derivative vial did not have an open date on either the vial or the box. She stated that all opened medication vials should have an open date and that nursing staff were responsible for labeling open vials because they were the personnel accessing them. During an interview on 07/28/2026 at 12:17 PM, Unit Manager CC stated that expired medications and medications without an open date must be discarded. During an interview on 07/28/2026 at 5:08 PM, the Director of Nursing (DON) stated that central supply was responsible for rotating stock when they restocked medications, which occurred once or twice a week. She stated that staff were expected to place open dates on any multi use medications.During an interview on 07/28/2026 at 5:57 PM, the Administrator stated that staff were expected to follow manufacturer recommendations for medication storage. He stated that medications must be within their expiration date and that multi dose medications must be dated when opened.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled Minimum Data Set (MDS)/Care Plans, the facility failed to ensure care plans accurately reflected residents' assessed needs for two of 25 sampled residents(R) (R3 and R25). R3 had an active order for depression medication that was not included on the care plan, and R25 was care planned for a fall mat that was not in place. These failures had the potential to result in psychosocial harm for R3 and physical harm for R25. Findings included: 1. A review of the electronic medical record (EMR) revealed that R25 had diagnoses including, but not limited to, generalized muscle weakness, repeated falls, difficulty walking (not elsewhere classified), unspecified lack of coordination, conversion disorder with seizures or convulsions, generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus. Review of the most recent Quarterly Minimum Data Set (MDS) assessment for R25, dated 07/01/2026, revealed that Section GG (Physical Abilities and Goals) documented that the resident required substantial/maximal assistance. Review of the care plan for R25 revealed a Focus, last revised 06/01/2026, indicating that the resident had a history of falls and exhibited behaviors related to seizure activity. Interventions included an intervention, revised 06/01/2026, directing staff to continue to keep fall mats at the bedside to lessen the chance of injury. Observations revealed that R25's fall mat was consistently not in place as care planned. On 07/26/2026 at 1:15 PM, R25 was observed lying in bed asleep with no fall mat in place. On 07/27/2026 at 12:50 PM, observation of the resident's bedroom again revealed that no fall mat was present. A subsequent observation on 07/27/2026 at 1:05 PM, after LPN JJ escorted the resident to her room, confirmed that the fall mat was still not in place. During an interview on 07/28/2026 at 12:50 PM, CNA II stated that the resident was at risk for falls and had experienced several falls within the past year, including recent incidents. CNA II stated that the resident attempted to get out of bed independently but required staff assistance for safety. During an interview on 07/28/2026 at 1:15 PM, LPN JJ stated that the resident continued to believe she could ambulate independently and frequently attempted to get out of bed without assistance. LPN JJ reported that the resident was often found sitting on the side of the bed attempting to stand but lacked the strength to do so safely. She stated that the resident had fallen out of bed and was at high risk for falls due to her history of numerous falls. During an interview on 07/28/2026 at 1:42 PM, the Director of Nursing (DON) stated that, while observing R25's room, the resident's care plan was reviewed and confirmed to include the use of a fall mat. The DON further confirmed that, at the time of the observation, no fall mat was positioned beside the resident's bed. 2. Review of the policy titled Minimum Data Set (MDS)/Care Plans, dated February 01, 2024, documented Policy Statement: Each resident will have an individualized interdisciplinary plan of care in place. The baseline care plan will be completed within 48 hours of admission. The Interdisciplinary Team will continue to develop the care plan in conjunction with the RAI (MDS 3.0) and CAAS, completing and conducting CCP meetings by Day 21 post admission. The Comprehensive Care Plan will be reviewed and revised on a quarterly basis, with a significant change in condition, on re admission from inpatient hospital stay, and as requested by the Resident/Representative. The Comprehensive Care Plan will be resident centered, having the individual resident as the locus of control. The Comprehensive Care Plan will be ongoing, focusing on each individual resident as a unitary being. Residents and their representatives will play an active role in the development of goals and implementation of the residents' Comprehensive Care Plan. The section titled Procedure: . documented 6. The Care Plan Summary will include: Resident/Resident Representative Goals; all medications and treatments; all diagnoses and medical orders; restorative therapies; resident specific information; recent blood tests and diagnostic tests; ambulation and transfer status. Review of the EMR revealed that R3 was admitted on [DATE] with diagnoses including, but not limited to, polyneuropathy (unspecified), generalized anxiety disorder, depression (unspecified), and unspecified atrial fibrillation. Review of R3's 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Section GG revealed that the resident required assistance with activities of daily living (ADLs). Review of the care plan for R3 revealed that the care plan did not indicate that the resident was receiving antidepressant medication for depression. Review of R3's physician orders revealed an order dated 06/23/2026 for Cymbalta Oral Capsule Delayed Release Particles 30 mg (Duloxetine HCl): Give 3 capsules by mouth one time a day for depression. During an interview on 07/28/2026 at 4:54 PM, the MDS Coordinator BB stated that the MDS Coordinators were responsible for updating the care plan. She accessed R3's orders in EMR and confirmed that the resident had been prescribed Cymbalta since 06/24/2026 for depression. She then accessed R3's care plan and confirmed that the care plan did not address depression or any behavior monitoring. During an interview on 07/28/2026 at 5:08 PM, the DON stated that she expected the care plan to reflect the current status of residents and any identified problems. The DON confirmed that if a resident was receiving antipsychotics, antibiotics, or depression medication, this classification should be addressed on the care plan.

Based on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure that phenytoin (a medication used to prevent and control seizures) was not administered at the same time as a high-protein supplement for one of five residents (R) (R9) observed during medication pass observation. This deficient practice had the potential to place R9 at risk of medical complications related to potential reduced medication absorption. Findings include: A review of the facility policy titled Medication Administration revealed that medications are administered as prescribed by the provider. Under procedures, medications are reviewed for any special precautions, and the needed evaluations are performed prior to administering medication to the resident. A review of the Minimum Data Set (MDS) for R9, dated 9/13/2025, revealed that Section GG (Functional Abilities and Goals) revealed that R9 required substantial assistance for activities of daily living (ADLs). Review of the care plan for R9, dated 8/20/2025, revealed that R9 was at risk for seizure activity. The goal was for R9 not to experience seizure activity through the next review date.Review of laboratory results for R9, dated 10/14/2025, revealed phenytoin levels were 9.5 micrograms per milliliter (ug/ml). The normal range was 10 to 20 ug/ml. Review of the Medication Administration Record (MAR) for R9 revealed the following medication schedules:Dilantin Infatabs oral tablet chewable 50 milligram (mg) (phenytoin) (a medication used to prevent and control seizures), three tablets by mouth three times a day, scheduled for 9:00 am, 2:00 pm, and 9:00 pm. The medication was documented as administered as ordered from 10/1/2025 through 10/22/2025. House supplement 120 milliliters (ml) two times a day, scheduled for 10:00 am and 2:00 pm. The supplement was documented as administered as ordered from 10/1/2025 through 10/22/2025, with 50 to 100 percent consumption documented. An observation and concurrent interview with Licensed Practical Nurse (LPN) AA on 10/22/2025 at 2:17 pm revealed that she administered Dilantin and the house supplement to R9 at the same time. An interview with the Pharmacy Consultant on 10/22/2025 at 3:08 pm revealed that the pharmacy label should provide instructions if the medication had food or drug interactions. She stated that the house supplement had high protein levels, and Dilantin should be administered one hour before or two hours after receiving the high-protein supplement. She confirmed that the current medication schedule for R9 was for Dilantin to be administered at 9:00 am, 2:00 pm, and 9:00 pm, and the house supplement to be administered at 10:00 am and 2:00 pm. An interview with the Director of Nursing (DON) on 10/23/2025 at 9:53 am revealed that the pharmacy made recommendations for medication schedules. She stated there were no safety alerts in place for contraindications. An interview with the Administrator on 10/23/2025 at 3:46 pm revealed that medication schedules were entered by the nurse or nurse practitioner, and the pharmacy made recommendations for medications.

Based on observations, interviews, record review, and review of the facility's policy titled Minimum Data Set (MDS)/Care Plans, the facility failed to implement a care plan to monitor for adverse effects from anticoagulant medication for one of three sampled residents (R) (R8). This deficient practice had the potential to place R8 at increased risk of medical complications. Findings include:Review of the facility's policy titled Minimum Data Set (MDS)/Care Plans, dated 2/1/2024, revealed that the Procedure section included 3. Each discipline will be responsible for the initiation and ongoing follow-up for care plans as related to their area of expertise.Review of the Quarterly MDS for R8, dated 9/28/2025, revealed Section I (Active Diagnoses) documented diagnoses including but not limited to, bilateral pulmonary embolism (a blood clot in the lung), deep vein thrombosis (a blood clot in the leg), stroke, and hypertension. Review of the care plan for R8 revealed a Focus area, initiated 9/23/2025, of diagnoses of bilateral pulmonary embolism and deep vein thrombosis. Interventions included administering medications as ordered and documenting side effects and effectiveness. Review of the Medication Administration Record (MAR) for R8, dated 10/1/2025 to 10/31/2025, revealed an order for Eliquis (a blood-thinning medication used to prevent and treat blood clots) 5 milligrams (mg) two tablets twice a day for 7 days, then 5 mg one tablet twice a day for 100 days. Further review of the MAR for R8 revealed no documented monitoring for side effects from Eliquis. Review of the clinical record revealed no documented monitoring for side effects from Eliquis. An interview with the Nurse Practitioner (NP) on 10/22/2025 at 1:33 pm revealed that when a resident received an anticoagulant, the resident would need to be monitored for medication side effects. An interview with the Director of Nursing (DON) on 10/23/2025 at 9:53 am stated that nurses were expected to follow the care plan. She confirmed there was no documentation of monitoring for side effects from the anticoagulant for R8.

Based on observation, staff interviews, and review of the facility's document titled Enhanced Barrier Precautions in Nursing Homes Algorithm, the facility failed to ensure respiratory staff followed infection control practices during tracheostomy care for one of two residents (R) (R13) with a tracheostomy. The deficient practice had the potential to place R13 at risk of respiratory illness and infection due to cross-contamination. Findings included: Review of the facility's document titled Enhanced Barrier Precautions in Nursing Homes Algorithm, dated 2022, revealed, The purpose of this algorithm is to outline when to use and how to implement enhanced barrier precautions (EBP). 1. EBP are indicated for the following residents who are: At increased risk of MDRO (multidrug-resistant organism) acquisition (e.g., resident has a wound or indwelling medical device) .In addition to following Standard Precautions, gowns and gloves should be worn during the following high-contact resident care activities: Device care or use. With implementation, it is critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use . To accomplish this: Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required personal protective equipment (PPE) (e.g., gown and gloves) . Definitions. Indwelling medical device: An indwelling medical device provided a direct pathway for pathogens in the environment to enter the body and cause infection. Examples include, but are not limited to . tracheostomy tubes . Review of R13's Quarterly Minimum Data Set (MDS) assessment, dated 4/14/2025, revealed Section GG (Functional Abilities and Goals) documented R13 was dependent for activities of daily living (ADLs). Section I (Active Diagnoses) documented diagnoses including debility, cardiorespiratory conditions, aphasia, cerebrovascular accident (CVA), hemiplegia or hemiparesis, and respiratory failure. Section O (Special Treatments, Procedures, and Programs) documented that R13 received oxygen (O2), suctioning, and tracheostomy care. Observation of R13's room door revealed EBP signage on the door indicating the type of precautions, the required PPE that all healthcare personnel must wear, and the high-contact resident care activities that required the use of a gown and gloves, which included tracheostomy care. Observation on 5/14/2025 at 10:15 am of Respiratory Nurse Technician LL providing tracheostomy care for R13 revealed Respiratory Nurse Technician LL donned a mask and gloves. Respiratory Nurse Technician LL suctioned R13's tracheostomy, donned sterile gloves, connected the tube, placed a small amount of normal saline, and suctioned two passes. Respiratory Nurse Technician LL removed the tracheostomy collar and discarded it, removed the split gauze, cleaned around the tracheostomy stoma, assessed the stoma, placed new split gauze, placed a new collar, and secured the tracheostomy. The Respiratory Nurse Technician stated he changed the inner cannula twice a day, and the tracheostomy tube was changed once a month. In an interview on 5/14/2025 at 11:10 am, Respiratory Nurse Technician LL confirmed R13 was on EBP. He stated he did wear a mask and gloves during R13's tracheostomy care and did not wear a gown. Respiratory Nurse Technician LL stated he wore gloves and a mask while providing care to residents on EBP and a gown for residents on contact isolation-precautions. In an interview on 5/15/2025 at 9:39 am, Respiratory Nurse Technician KK stated staff should wear gloves, a gown, and a mask when providing tracheostomy care. In an interview on 5/15/2025 at 10:55 am, the Director of Nursing (DON) stated she expected staff to wear gloves and a gown while providing care to a resident on EBP, and to wear gloves, a gown, and a mask while providing tracheostomy care.

Based on observation, resident and staff interviews, and review of the facility policy titled Menus, the facility failed to ensure four of 49 sampled residents (R) (R90, R106, R103, and R72) were offered meal choices. In addition, the facility failed to ensure meal menus were followed for one of 49 sampled R (R72). Findings include: Review of the facility policy titled Menus, revised 10/2022, revealed the Procedures section included, . 6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. 8. Menus will be posted in the Dining Services department, dining rooms, and resident/patient care areas. 1. Review of R90's Quarterly Minimum Data Set (MDS) assessment, dated 3/18/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). In an interview on 5/13/2025 at 12:25 pm, R90 stated he was not given a choice of meals, and the only alternative food offered was a peanut butter and jelly sandwich. He stated he gets what the facility gives him for meals. 2. Review of R106's Quarterly Minimum Data Set (MDS) assessment, dated 3/14/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). In an interview on 5/14/25 3:04 pm, R106 stated that she eats in the dining area because she has a choice of food. R106 explained that she only eats in the dining room because when she eats in her room, she does not get to choose what she wants to eat. She stated that the only alternative offered was a peanut butter and jelly sandwich. 3. Review of R103's Quarterly Minimum Data Set (MDS) assessment, dated 3/7/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). In an interview on 5/14/2025 at 3:12 pm, R103 stated she never got to choose what meal she wanted since she ate in her room, and further stated that if she ate in the dining room, she would be able to make a meal choice. 49675 4. Review of R72's Annual Minimum Data Set (MDS) assessment, dated 3/7/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). In an interview on 5/12/2025 at 1:26 pm, R72 stated he never knew what he would be served at mealtimes. He stated residents who ate in their rooms were not provided a menu choice, and the menu was inaccurate. He stated he got what the facility gave him at meals. Observation on 5/13/2025 at 1:02 pm revealed R72 sitting in his room, eating lunch. He was served ribs, mashed potatoes, and broccoli. His meal tray ticket indicated he was to receive a turkey burger on a bun, chips, tomato salad, fruit salad, and tea. The menu for the day stated the lunch meal would be a tuna salad hoagie or turkey burger, country tomato salad, creamy cucumber and onion salad, potato chips, macaroni salad, and deluxe fruit salad. R72 stated he was not asked what his choice for the meal was. Observation on 5/14/2025 at 12:45 pm revealed R72 sitting in his wheelchair, eating lunch. His meal tray had a hamburger patty with gravy, mashed potatoes with gravy, and carrots. The meal tray ticket indicated he was to receive a garlic-baked pork chop, buttered rice, seasoned okra, dinner roll, and brownie. The menu for the day stated the lunch meal would be sausage jambalaya, Salisbury steak, seasoned okra, sliced parsley carrots, mashed potatoes, cornbread, and a double chocolate brownie. R72 stated he was not asked what his choice for the meal was. In an interview on 5/14/2025 at 4:45 pm, the Dietary Manager (DM) confirmed that residents who receive lunch in their rooms do not know what meal they will receive, as substitutions are not written on the menus. She had no explanation for the discrepancies between what meal was posted to be served, what meal was on the tray tickets, and what was served. The DM confirmed that all residents should have the opportunity to have preferences of foods, and the posted meals should be served. In an interview on 5/14/2025 at 4:55 pm, the Administrator stated residents should be informed of the menu and offered an alternative. The Administrator further stated that all residents should be given a menu and allowed to choose what foods they wanted for their meals.

Based on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure that three of 11 sampled residents (R) (R24, R45, and R49) were administered oxygen (O2) therapy in accordance with the physician's orders. This failure had the potential to place R24, R45, and R49 at risk of respiratory complications and unmet needs. Findings include: Review of the facility policy titled Oxygen Administration, dated 2/1/2024, revealed the Preparation section included, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 1. Review of R24's Annual Minimum Data Set (MDS) assessment, dated 2/17/2025, revealed Section O (Special Treatments, Procedures, and Programs) documented that R24 received O2. Review of R24's Electronic Medical Record (EMR) revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia. Review of R24 's Clinical Physician Orders revealed an order dated 6/17/2024 for O2 at 2 liters per minute (LPM) via a nasal cannula (NC) continuously. Observations on 5/12/2025 at 12:35 pm and 2:05 pm revealed R24 receiving O2 by an O2 concentrator via a NC at a flow rate of 3.5 LPM. 2. Review of R45's Quarterly MDS assessment, dated 3/17/2025, revealed Section O (Special Treatments, Procedures, and Programs) documented that R45 received O2. Review of R45's EMR revealed diagnoses including, but not limited to, COPD. Review of R45's Clinical Physician Orders revealed an order dated 5/14/2024 for O2 at 2 LPM via NC O2: 90 percent or above. Every shift for shortness of breath. Observations on 5/12/2024 at 10:01 am and 6:00 pm revealed R45 receiving O2 by an O2 concentrator via a NC with the flow rate set at 4.5 LPM. In an interview on 5/12/2024 at 1:20 pm, the Respiratory Therapist (RT) confirmed that R45 was receiving O2 at 4.5 LPM. The RT verified increasing the flow rate due to having concerns with the resident's O2 saturation reading of 88 percent. He verified that the physician's order was 2 LPM and adjusted the flow rate to 2 LPM. In an interview on 5/15/2025 at 10:00 am, the Director of Nursing (DON) confirmed that R24 and R45 were receiving O2 at the wrong flow rate and not per physician orders. She stated that the RT should not be changing the flow rate without a physician's order. She reported being uncertain of which staff could have changed R24 's O2 flow rate. 50171 3. Review of R49's Admission MDS assessment, dated 4/18/2025, revealed Section C (Cognitive Patterns) documented a BIMS score of 13 (indicating little to no cognitive impairment). Section O (Special Treatments, Procedures, and Programs) documented that R49 received O2. Review of R45's EMR revealed diagnoses including, but not limited to, COPD and chronic respiratory failure with hypoxia. Review of R49's Clinical Physician Orders revealed an order dated 4/18/2025 for O2 at 2 LPM via NC continuously for shortness of breath. O2 saturation to maintain saturation 90 percent or above every shift. In a concurrent observation and interview on 5/12/2025 at 12:24 pm, R49 was observed receiving O2 at 3.5 LPM via a NC. R49 stated her O2 should be set at 2 LPM, and it had been set at 3.5 LPM since she was admitted . Observation on 5/12/2025 at 6:10 pm revealed R49 receiving O2 at 3.5 LPM via a NC. In a concurrent observation and interview on 5/13/2025 at 11:00 am, Licensed Practical Nurse (LPN) DD confirmed that R49's oxygen was set on 3.5 LPM. LPN DD further confirmed the physician's order was for O2 at 2 LPM. LPN DD stated the nurses were responsible for ensuring the O2 flow rate was set correctly. In an interview on 5/13/2024 at 3:06 pm, the DON stated that she expected nursing staff to ensure each resident's O2 was administered according to the physician's orders.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure one of 49 sampled residents (R) (R12) received services to maintain or improve their functional abilities. Specifically, the facility failed to ensure a supportive footrest/leg rest was secured to R12's wheelchair. This deficient practice had the potential to place R12 at risk of unmet needs and a diminished quality of life. Findings include: Review of R12's Annual Minimum Data Set (MDS) assessment, dated 4/2/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview Mental Status Score (BIMS) of 14 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident had lower extremity impairment on both sides, required maximal assistance for lower body dressing, and was dependent for putting on and taking off footwear. Section M (Skin Conditions) documented that the resident was at risk for developing pressure ulcers and had one stage four pressure ulcer. Review of R12's Care Plan Report revealed a Focus area, dated 5/20/2024, that the resident has peripheral vascular disease. Interventions included elevating legs when sitting or sleeping, monitoring/documenting for excessive edema, and encouraging the resident to elevate legs. Review of R12 's clinical record revealed diagnoses including, but not limited to, varicose veins of right lower extremity with ulcer of ankle, non-pressure chronic ulcer of right heel and midfoot with unspecified severity, contracture right knee, hemiplegia and hemipareses following unspecified cerebrovascular disease affecting the right dominant side, long term use of anticoagulants, acquired absence of left leg above knee, hypertension, and peripheral vascular disease. Observation on 5/12/2025 at 12:08 pm revealed R12 in a wheelchair, propelling himself in the hallway towards the activity room with his right lower extremity (RLE) highly elevated in the air and extended outward in an upward position without the support of a leg rest/footrest attachment. Observation on 5/12/2025 at 1:00 pm revealed R12 sitting in a wheelchair in the activity area and holding his RLE in the air without the support of a leg rest or other supportive device. In a concurrent observation and interview on 5/12/2025 at 3:00 pm, R12 was observed sitting in a wheelchair in the hallway and holding his RLE in the air without the support of a leg rest or other supportive device. R12 stated he had a leg rest with an attached footrest for the wheelchair and was unable to put it on the wheelchair unassisted, and that staff did not assist him. Observations on 5/13/2025 at 12:01 pm and 3:00 pm, 5/14/2025 at 2:15 pm, and 5/15/2025 at 3:00 pm revealed R12 sitting in a wheelchair, propelling himself in the hallway with his RLE highly elevated in the air, extended outward and dangling in the air without the support of a leg rest or other supportive device. In a concurrent observation of R12 and interview on 5/15/2025 at 12:55 pm with the Physical Therapy (PT) Director and the Director of Nursing (DON), both confirmed R12 should not be positioned in his wheelchair without the attachment of a supportive device such as a leg rest/footrest due to R12's right ankle ulcer, contracture, and immobility. The PT Director stated that the therapy department had assessed R12 for a leg rest/footrest, obtained the device from R12's room, and attached it to the wheelchair. The DON stated the resident would be at risk of injury, pain, edema, added pressure, and discomfort by holding his RLE in an elevated position without the supportive device. The DON further stated she was unaware that R12's wheelchair did not have the leg rest/footrest attached. The DON stated that her expectation was for staff to ensure the resident's leg rest/footrest is attached to the wheelchair daily. She stated that nursing staff were responsible for ensuring that the resident's leg rest/footrest was applied as part of resident care services.

Based on observations, staff interviews, record review, and review of the facility policy titled Person Centered Care Plans, the facility failed to develop a person-centered care plan for one of 11 residents (R) (R24) who received oxygen (O2). In addition, the facility failed to implement the care plan for two of 11 R (R45 and R49) who received O2. These deficient practices had the potential to place R24, R45, and R49 at risk of respiratory complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility policy titled Person Centered Care Plans, dated 2/1/2024, revealed the Policy Statement section included, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The Procedure section included, . 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Review of R24's Annual Minimum Data Set (MDS) assessment, dated 2/17/2025, revealed Section O (Special Treatments, Procedures, and Programs) documented that R24 received O2. Review of R24's Electronic Medical Record (EMR) revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia. Review of R24 's Clinical Physician Orders revealed an order dated 6/17/2024 for O2 at 2 liters per minute (LPM) via a nasal cannula (NC) continuously. Review of R24's Care Plan Report revealed a Focus area, revised 1/31/2025, for being at risk for ineffective peripheral tissue perfusion, and was on continuous O2. There were no interventions for the use of O2 in the care plan. Observations on 5/12/2025 at 12:35 pm and 2:05 pm revealed R24 receiving O2 by an O2 concentrator via a NC at a flow rate of 3.5 LPM. 2. Review of R45's Quarterly MDS assessment, dated 3/17/2025, revealed Section O (Special Treatments, Procedures, and Programs) documented that R45 received O2. Review of R45's EMR revealed diagnoses including, but not limited to, COPD. Review of R45's Clinical Physician Orders revealed an order dated 5/14/2024 for O2 at 2 LPM via NC O2: 90 percent or above. Every shift for shortness of breath. Review of R45's Care Plan Report revealed a Focus area, revised 1/2/2025, for has a diagnosis of COPD and respiratory failure, is on O2. Interventions included O2 via nasal prongs at 2 LPM. Observations on 5/12/2025 at 10:01 am, 1:20 pm, and 6:00 pm revealed R45 was receiving O2 at 3.5 LPM via a NC. 50171 3. Review of R49's Admission MDS assessment, dated 4/18/2025, revealed Section O (Special Treatments, Procedures, and Programs) documented that R49 received O2. Review of R45's EMR revealed diagnoses including, but not limited to, COPD and chronic respiratory failure with hypoxia. Review of R49's Clinical Physician Orders revealed an order dated 4/18/2025 for O2 at 2 LPM via NC continuously for shortness of breath. O2 saturation to maintain saturation 90 percent or above every shift. Review of R49's Care Plan Report revealed a Focus area, dated 4/23/2025, for has a history of chronic respiratory failure with hypoxia and a diagnosis of COPD. Interventions included O2 via nasal as ordered by the physician. Observations on 5/12/2025 at 12:24 pm, 6:10 pm, and 5/13/2025 at 11:06 am revealed R49 receiving O2 via a NC at 3.5 LPM. During an interview on 5/15/2025 at 12:28 pm, the MDS Coordinator confirmed O2 interventions were not addressed on R24's care plan. She stated the care plan interventions should be followed for R45 and R49, including the O2 flow rate. She further stated that the care plan served as a blueprint for nurses to provide resident care. Cross-Reference F695

Based on staff interview and record review, the facility failed to ensure one of three residents (R) (R10) reviewed for Pre-Admission Screening and Resident Review (PASRR) Level II assessment was referred to the appropriate state-designated authority for review. This deficient practice had the potential to place R10 at risk of not receiving services or care according to their needs. Findings include: Review of R10's Annual Minimum Data Set (MDS) assessment, dated 12/30/2024, revealed Section A (Identification Information) documented R10 had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. Section I (Active Diagnoses) documented diagnoses including anxiety disorder and manic depression (bipolar disease). Review of R10 's electronic medical record (EMR) revealed an admitted [DATE] with diagnoses including, but not limited to, bipolar disorder mixed severe with psychotic features, dated 11/23/2022 and created 3/8/2024. Review of R10's EMR revealed no PASRR Level II. Review of a facility-provided list of residents with PASRR Level II revealed that R10 was not included on the list. In an interview on 5/13/2025 at 12:00 pm, the Administrator verified that R10 did not have a PASRR Level II and should have had a submission for one.

Based on staff interview and record review, the facility failed to ensure that the Minimum Data Set (MDS) assessment was accurately coded for one of five sampled residents (R) (R24) with a Pre-Admission Screening and Resident Review (PASRR) Level II. Findings include: Review of R24's Annual MDS, dated [DATE], revealed Section A (Identification Information) documented the resident had not been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. Section I (Active Diagnoses) documented diagnoses including anxiety disorder, depression, and manic depression (bipolar). Review of R24 's electronic medical record (EMR) revealed an admitted [DATE]. Review of R24's PASRR Level II revealed an approval date of 3/7/2022. During an interview on 5/15/2025 at 12:08 pm, the MDS Coordinator stated she was unaware that R24 had received approval for a PASRR Level II. She stated she planned to submit a modification of R24's MDS to accurately code the PASRR Level II.

Based on resident and staff interviews, record reviews, and review of the facility policy titled Bed Hold and Returns Policy, the facility failed to ensure one of 49 residents (R) (R72) was provided with a written bed hold notice. This failure had the potential to place the resident or resident representative at risk of being uninformed about their rights related to their return to the facility. Findings include: Review of the facility policy titled Bed Hold and Returns Policy, dated 2/1/2024, revealed the Procedure section included, . 3. Prior to a transfer, written information will be given to the residents and the residents' representatives that explains in detail: a. The rights and limitations of the resident regarding bed holds. b. the reserve bed payment policy as indicated by the state plan c. the facility per diem rate required to hold a bed or to hold a bed beyond the stated bed hold period. Review of R72's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Review of R72's Clinical Resident Profile revealed the resident was his own responsible party. Review of R72's Clinical Census revealed R72 was transferred to the hospital from the facility on 2/27/2025 and 4/29/2025. Review of R72's clinical record revealed no evidence of the provision of a notice of bed hold provided to R72 on 2/27/2025 or 4/29/2025. In an interview on 5/24/2025 at 1:00 pm, R72 stated the facility did not provide a written bed hold notice on 2/27/2025 or on 4/29/2025. In an interview on 5/15/2025 at 11:17 am, Licensed Practical Nurse (LPN) BB stated that when a resident is transferred from the facility to a hospital, she prints the resident's orders, face sheet, and notifies the physician and family. She stated she will put a blank bed hold policy into the packet that goes with transport, but does not give anything in writing to the resident. In an interview on 5/15/2025 at 11:26 am, the Director of Nursing (DON) stated that residents were to be given a bed hold policy when they transferred from the facility. She confirmed there was no record of R72 being given a bed hold policy on 2/27/2025 or 4/29/2025. She revealed that the resident should have been notified in writing of the bed hold policy at the time of each transfer.

Based on resident and staff interviews, record review, and review of the facility policy titled Abuse, Neglect, and Misappropriations, the facility failed to report an allegation of abuse in a timely manner for one of seven residents (R) (R20) reviewed for abuse. Findings include: Review of the facility policy titled Abuse, Neglect, and Misappropriations, reviewed 1/1/2025, revealed the Policy Components section included, . G. Reporting/Response 1 . Reporting Guidelines: . Any allegation of neglect, exploitation, mistreatment, or misappropriation of resident property must be reported to the State Regulatory Agency within 24 hours. Review of R20's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 99 (indicating the resident was unable to complete the interview). Review of R20 diagnoses included, but were not limited to, schizophrenia, unspecified, type 2 diabetes mellitus with hyperglycemia, and muscle weakness. Review of R20's clinical record revealed there was no documentation of a report of abuse allegation to other staff or the Administrator. Review of the Facility Incident Report Form, dated 2/25/2025, documented that the date of the incident was 2/12/2025. The Details of Incident documented Resident came to the nurse's station reporting 'There was a man in my room. I needed to go home. He was trying to stick his penis in me.' In an interview on 5/14/2025 at 10:25 am, the Assistant Director of Nursing (ADON) revealed that the allegation of abuse was reported to the State Agency late because the nurse to whom the resident reported the allegation only entered a note in the progress notes and did not report the incident to anyone. The ADON stated that the nurse no longer worked at the facility. In an interview on 5/14/2025 at 10:36 am, the Administrator confirmed that the allegation of abuse involving R20 was not reported to the State Agency within the required time frame. She stated her expectation was for staff to report abuse allegations immediately, so it can be reported to the State Agency as required.

Based on resident and staff interviews and record review, the facility failed to promote care in a manner that maintained or enhanced dignity and respect for one of 49 sampled residents (R) (R72). Specifically, the facility failed to ensure the correct size brief was available to prevent incontinence leakage. This deficient practice had the potential to place R72 at risk of a diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: Review of R72's clinical record revealed diagnoses including, but not limited to, morbid obesity due to excess calories, muscle weakness, and need for assistance with personal care. Review of R72's Annual Minimum Data Set (MDS) assessment, dated 3/7/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented R72 required maximal assistance with toileting hygiene. Section H (Bladder and Bowel) documented that R72 was always incontinent of bladder and bowel. Review of R72's care plan revealed a Focus of bowel and bladder incontinence. Interventions included checking every two to three hours and as needed, and providing incontinent care. In an interview on 5/12/2025 at 1:26 pm, R72 stated that the facility often ran out of the correct size of brief he needed, resulting in him having to wear a smaller size, which caused leakage. He revealed this caused him to feel embarrassed, and he felt that he must request a bath each time this happened. In an interview on 5/14/2025 at 11:42 am, Certified Nurse Assistant (CNA) CC stated that residents were measured to determine the size of the brief a resident needed. She stated residents had briefs in their rooms, and further stated there were times, if a resident was out of briefs, a brief from another resident's supply would be used, and it may not always be the correct size. In an interview on 5/14/2025 at 8:56 am, the Central Supplies Clerk stated residents were measured to ensure they received the correct brief size. She stated she entered measurements into a conversion program that the supplier offered on their ordering site. She confirmed that the facility was running out of 3x-size briefs. She stated her expectation was for residents to receive the correct size brief. In an interview on 5/14/2025 at 10:36 am, the Administrator stated the facility ordered briefs weekly. She stated residents were measured to determine the size of the brief the resident required. She stated her expectation was for staff to ensure residents receive the correct size brief. She further stated she was aware that R72 was receiving a smaller brief than needed.

Based on staff interviews, record review, and review of the facility policy titled, Person Centered Care Plans, the facility failed to develop a care plan for one of four sampled residents (R) (R1) with a history of wandering and exit-seeking behaviors. This failure increased the potential for R1 to not receive treatment and/or care according to their needs. Findings include: A review of the facility policy titled Person Centered Care Plans, dated 2/1/2024, revealed the Policy Statement was A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Procedure section included . 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. g. Incorporate identified problem areas. H. Incorporate risk factors associated with identified problems. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. A review of R1's clinical record revealed diagnoses including, but not limited to, dementia, psychotic disturbance, mood disturbance, anxiety, depression, lack of coordination, and unsteadiness on feet. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section E (Behaviors) documented wandering behavior occurred one to three days, section GG (Functional Abilities and Goals) documented R1 was independent with mobility, and section P (Restraints) documented a wander/elopement alarm was not used. A review of R1's care plan revealed no focus area, goals, or interventions for wandering or elopement prior to 9/15/2024. A review of the clinical record revealed on 8/18/2024 at 11:29 pm, Licensed Practical Nurse (LPN) GGG documented R1 continued to ambulate, entering residents' rooms and occasionally getting out of the wheelchair and attempting to hit the writer. Continued to exit seek and will not cooperate with staff. A review of the clinical record revealed on 9/15/2024 at 6:20 pm, LPN NN documented that a visitor approached her and reported he had to push R1 back into the facility when he saw R1 near the school located near the facility. R1 stated she went outside to make a call to her mother. A review of the clinical record revealed on 9/15/2024 at 6:35 pm, Registered Nurse (RN) FF documented R1 was found outside of the facility with no injuries. During an interview with the DON on 9/18/2024 at 2:20 pm, the DON verified there were no care plan interventions for wandering or elopement on R1's care plan before 9/15/2024. The DON further confirmed there was a delay in assessing R1 for elopement. During an interview on 9/18/2024 at 2:30 pm, the Administrator stated behaviors of wandering and exit-seeking should be care planned. During an interview on 9/23/2024 at 10:44 am, LPN PP stated that staff used the care plan as guidance for interventions to properly address residents' concerns. During an interview on 9/23/2024 at 11:36 am, the MDS Coordinator stated all residents should be assessed for elopement upon admission and quarterly thereafter. The MDS Coordinator stated R1 was cognitively impaired and had insisted on leaving the facility on numerous occasions. The MDS Coordinator further stated if a resident exhibited exit-seeking behaviors, the behaviors should be included in their care plan. During further interview, the MDS Coordinator verified that R1's care plan did not include a focus area or interventions for elopement until after the resident had eloped on 9/15/2024. Cross-Reference F689

Based on record review, resident and staff interviews, and review of facility policy titled, Resident Lift the facility failed to ensure that one of three residents (R A) was transferred appropriately using a Hoyer lift with two-person assist. Actual harm was identified on 11/25/18 when CNA EE transferred R A by herself without the assistance of any other staff or mechanical lift, as care planed, and the resident fell and suffered a fractured tibia and fibula which required open reduction internal fixation surgery. Findings include: Review of the facility policy titled, Resident Lift dated 6/1/15 with revision date of 5/30/18 documented the following: #2 - At least two trained staff are needed to transfer a resident when using a lift. Record review revealed that RA was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in Section C: Cognitive Pattern, that RA was assessed as 13 on her Brief Interview for Mental Status (BIMS) score, which means that she was cognitively intact. Also, review of Section E: Behaviors, revealed no behaviors during the look back period. Further review of Section G: Functional Status, revealed that RA was totally dependent and required two plus person physical assist. Section G0400, of this same assessment, documents that R A had impairment to her bilateral upper and lower extremities. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in Section C: Cognitive Pattern, that RA was assessed as 15 on her Brief Interview for Mental Status (BIMS), which means that she was cognitively intact. Also, review of Section E: Behaviors, revealed no behaviors during the look back period. Further review of Section G: Functional Status, revealed that RA was totally dependent with two-person assist. Review of the care plan for R A revised 12/27/18, revealed that resident required assistance with transfers, bed mobility, bathing, grooming related to her left AKA and [MEDICAL CONDITIONS] with interventions of using a mechanical lift (5/13/16) and two-person lift required during transfers (5/13/16). Review of the Fall Risk Evaluation dated 11/25/18 revealed that the resident was assessed for falls and the assessment revealed that the resident scored 16 indicating that the resident was at risk for falls (A resident who scores a 10 or higher is at risk). Review of a Situation, Background, Assessment, and Recommendation (SBAR) dated 11/25/18 revealed the following documentation: Situation: The change in condition, symptoms, or signs observed and evaluated are fracture of tibia and fibula, this started on 11/25/19. The Functional Status Evaluation revealed: An X-ray obtained yielding results of fractured tibia and fibula. Further review of the SBAR revealed the following documented under Appearance: Resident appears to be in excoriating pain related to fall acquiring (sic) a fracture, transferred to an acute care hospital. Record review of a Physician order dated 11/25/18 revealed an order to send RA to hospital ER (emergency room ) for TX (treatment) and evaluation of Fx (fracture) of tibia and fibula. Review of the Radiology Report dated 11/25/18 revealed an acute tibia/fibula fracture. Review of a radiology report from an acute care hospital dated 11/26/18 for the right tibia revealed diffuse osteopenia and fracture, proximal tibia and fibula. Review of an acute care hospital X-Ray Report dated 11/26/18 for the right femur revealed severe osteopenia. Review of an acute care hospital report (page 2 of 2) dated 11/26/18 revealed that RA had a right intra-articular proximal tibia fracture, and options were discussed including operative and non-operative options. Further review revealed that the physician recommended open reduction internal fixation surgery and RA elected to have this surgery. Review of a typed statement documented the following: Statement from RA of event on 11/25/18 dated 12/3/18: Certified Nursing Assistant (CNA) EE tried to transfer her (the resident) from the wheelchair to the bed by herself. She usually don't have me and this was her first time putting me to bed. She (CNA EE) went to put me in bed but I felt like she didn't have a good grip on me. When she transferred me, I got to the tip (edge of the bed), then my leg went to buckle and gave away. I heard my knee cracked and I yelled out and clear my lungs. I know that this was an accident. (sic) The typed statement was witnessed by the CEO (Chief Executive Officer) and Unit Manager but was not signed by the resident. Review of a handwritten statement from CNA EE dated 11/26/18 documented the following: I lowered the bed, pulled the covers back. I put the locks on the chair. I secured her (RA) by grabbing around the waist, and lifting her out the wheelchair. She (RA) held onto the chair and her and the chair was going up at the same time. I tried to put her back in the chair, but she got heavy, so I lowered her to the floor. When I seen that her foot was under her, I slowly moved her foot out from under her. I called for help and two co-workers came to help me get her in bed. I am very sorry this happened. The statement was signed by CNA EE. Review of a typed statement dated 12/3/18 documented the following, in pertinent part: CNA EE and the Administrator visited with RA in the hospital on [DATE] . RA said, when the CNA (CNA EE) placed me on the bed, my knee buckled or gave way, I slid off the bed with the CNA helping me down to the floor. That is when my knee started hurting. This statement was signed by the CEO and CNA EE. Review of a typed statement dated 12/4/18 documented the following, in pertinent part: that the Unit Manager and the Administrator visited with the resident and discussed the incident and RA explained, she wanted to be put in bed, the CNA pulled the chair next to the bed, placed me on the bed and then my knee gave way or buckled. That's when me and the CNA went to the floor, and somewhere in that situation my knee was hurt. This statement is signed by the CEO and the Unit Manager. Interview with RA on 8/7/19 at 2:20 p.m., revealed that she felt that staff did not do their job because she was a two person assist for a Hoyer lift, and a Hoyer lift wasn't used on the day that she fell . RA said that the Certified Nursing Assistant (CNA) did the transfer by herself even after she mentioned to her that she was a two person assist. RA stated that the CNA said she could do it by herself. The resident stated that the fall resulted in a fracture of her right knee, which she had to be hospitalized for [REDACTED].>Interview with CNA CC, on 8/8/19 at 10:30 a.m., revealed that the resident was a two person assist at the time of the fall, as well as now. Interview with CNA EE on 8/8/19 at 1:53 p.m., revealed that she has not worked with the resident since the incident. She stated that, at the time of the incident, she was trying to transfer RA from her wheelchair to the bed when the resident's leg got stuck in the wheelchair, which CNA EE stated that she was unaware of at the time, so she (CNA EE) lowered RA to the floor. CNA EE stated that she had worked with the resident four to five times prior to this incident. CNA EE confirmed that she knew that the resident was a two-person assist.

Based on record review, hospital History and Physical form review, Facility Incident Report Form review, facility Summary of Incident and Findings report review, and staff interview, the facility failed to ensure safety during transfer in accordance with the Care Plan of one (1) resident ("X") who required transfer via mechanical lift, of five (5) sampled residents who required transfer via mechanical lift, of eleven (11) residents on the survey sample. This failure resulted in actual harm for Resident "X", who required a Bariatric sling during mechanical lift transfers, but was instead transferred with a large sling, rather than the required Bariatric sling. During this lift transfer, the lift sling broke, Resident "X" fell to the floor, and was later diagnosed with [REDACTED]. Findings include: The August 2014 Quarterly Minimum Data Set assessment of Resident "X" documented diagnoses, in Section I - Active Diagnosis, including, but not limited to, Diabetes Mellitus, [MEDICAL CONDITION]/[MEDICAL CONDITION], and [MEDICAL CONDITION]. Section G -Functional Status documented Resident "X" to have impairment in Range of Motion in one upper extremity and both lower extremities, and that the resident was dependent for transfer. Section K - Swallowing/Nutritional Status documented a weight of 430 pounds. Review of the Care Plan of Resident "X" revealed a Focus area, originally dated 03/21/2014, which identified the resident to be at a moderate risk for falls related to [MEDICAL CONDITION] and Mobility Dependence, with an identified Goal of the resident being free of injury. An additional Focus area, also dated 03/21/2014, referenced on the Care Plan of Resident "X" identified the resident's Activities of Daily Living performance deficit related to Obesity, a history of [MEDICAL CONDITION], and [MEDICAL CONDITION]. Interventions to address the Activities of Daily Living deficit of Resident "X" included for staff to utilize a Hoyer Lift with all transfers. An 11/10/2014, 6:45 p.m. Nurse's Notes entry documented that Licensed Practical Nurse (LPN) "BB" observed Resident "X" sitting in front of a wheelchair, with part of a Hoyer lift sling hanging from the lift and part underneath the resident. LPN "BB" assessed Resident "X" and noted a dark brown area of one (1) inch on the left mid-calf. LPN "BB" documented that Emergency Medical Services was called to transport Resident "X" to the hospital. The hospital History and Physical (H&P) of 11/11/2014 for Resident "X" documented the fall from a Hoyer lift in the nursing facility, and that the resident complained of pain in the left hip, mid-thigh, and knee. This H&P documented an X-ray revealed Resident "X" to have a distal left femur fracture. An 11/10/2014 Facility Incident Report Form documented that on that date, Certified Nursing Assistants (CNAs) "AA" and "CC" were transferring Resident "X" from the wheelchair to bed via mechanical lift, and the resident fell when the lift sling broke. An 11/14/2014 Summary of Incident and Findings report documented facility investigation had determined that during this mechanical lift transfer, CNA staff used a mechanical lift sling requested by Resident "X" which was not the correct sling, per the resident's size and weight. This lift sling tore and Resident "X" fell to the floor. During a 12/02/2014, 4:00 p.m. interview, the Administrator acknowledged that on 11/10/2014, CNA staff used the wrong lift sling to lift Resident "X", stating that a Bariatric sling should have been used instead of the Blue sling which was used and broke during the transfer. Based on the above, Resident "X" had [DIAGNOSES REDACTED]. The Care Plan of Resident "X" identified a fall risk related to Obesity and Mobility Dependence, and identified an Activities of Daily Living deficit related to Obesity, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Care Plan Interventions included the use of a Hoyer Lift with all transfers, and a Care Plan Goal indicated that Resident "X" would be free of injury, as related to the risk for falls. However, despite the Care Plan of Resident "X" identifying a fall risk and an Activities of Daily Living deficient in part related to Obesity and specifying Hoyer Lift transfer, and despite the resident requiring a Bariatric mechanical lift sling during lift transfer, on 11/10/2014, direct-care staff used an incorrect lift sling instead of the required Bariatric sling during lift transfer of Resident "X". This incorrect lift sling broke, Resident "X" fell from the lift to the floor, and the resident was subsequently diagnosed with [REDACTED]. Cross refer to F323 for more information regarding Resident "X".

Based on record review, Hoyer Lifts - How To Use A Patient Lifter Positioning and Transfer Guide review, facility Monthly Patient Lift Inspection review, hospital History and Physical form review, Facility Incident Report Form review, facility Summary of Incident and Findings report review, and staff interview, the facility failed to ensure safe mechanical lift transfer related to direct-care staffs' failure to utilize the required mechanical lift sling during the lift transfer of one (1) resident ("X"), of five (5) sampled residents who required transfer via mechanical lift, of eleven (11) sampled residents. This failure resulted in actual harm for Resident "X", who required the use of a Bariatric sling during mechanical lift transfers, but for whom direct-care staff incorrectly used a large sling, rather than the required Bariatric sling, during mechanical lift transfer on 11/10/2014. During this mechanical lift transfer of Resident "X", the incorrect mechanical lift sling broke, Resident "X" fell to the floor, was transferred to the hospital for evaluation, and was diagnosed via X-ray to have sustained a distal left femur fracture. Findings include: Review of the facility's Hoyer Lift - How To Use A Patient Lifter Positioning and Transfer Guide revealed the specification, in the Basic Recommendations section, that during the transfer of a resident utilizing a mechanical lift, using the correct sling attachment was very important. The Basic Recommendations section further specified that selection of the proper sling was determined by considerations which included, but were not limited to, the resident's size and weight. The Hoyer Lift instructions again specified, in the Basic Lifters: Preparation And Operation Instructions section, that staff were to ensure the correct sling component for the resident's size and weight during transfer utilizing the mechanical lift. Record review for Resident "X" revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of August 2014 which documented, in Section I - Active Diagnosis, the resident to have [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented that Resident "X" had a Brief Interview for Mental Status Summary Score of 15, indicating she was cognitively intact. Section G - Functional Status documented that Resident "X" was totally dependent on two-plus persons for transfer, required the extensive assistance of two-plus persons for bed mobility, and had a Functional Limitation in Range of Motion in the upper extremities (with impairment on one side) and in the lower extremities (with impairment on both sides). Section K - Swallowing/Nutritional Status documented that Resident "X" had a body weight of 430 pounds at the time of assessment. A Physical Therapy Recertification and Updated Plan of treatment for [REDACTED]. of bed siderails for rolling while in bed. An Evaluation For Use of Side Rails form dated 08/08/2014 for Resident "X" noted that, in addition to the use of side rails, Resident "X" also utilized a Hoyer Lift during transfer for both entering the bed and exiting the bed more safely due to a current weight of 408 pounds at the time of evaluation. Further record review for Resident "X" revealed a Nurse's Notes (NN) entry of 11/10/2014, timed at 6:45 p.m., which documented that Licensed Practical Nurse (LPN) "BB" was notified by Certified Nursing Assistant (CNA) "AA" that Resident "X" was on the floor. LPN "BB" documented that upon entering the room of Resident "X", she observed the resident sitting in front of her wheelchair. LPN "BB" documented that a Hoyer Lift was in front of the resident and wheelchair, with part of the mechanical lift sling hanging from the lift and the other part of the lift sling positioned underneath the resident. LPN "BB" documented that she assessed Resident "X"'s neurological function, vital signs, and extremities, noting all to be within normal limits, but further noted a dark brown area measuring one (1) inch on the resident's left mid-calf. LPN "BB" documented that she questioned CNA "AA" and the other CNA (CNA "CC") involved in Resident "X"'s transfer about this fall. The CNAs reported to LPN "BB" that while transferring Resident "X" with the mechanical lift, they used the Hoyer Lift sling which was already positioned under Resident "X" from the previous shift. The CNAs stated that as they began the lift transfer, they heard a "pop" when Resident "X" was approximately one-and-one-half feet out of the wheelchair, and the resident then fell to the floor. LPN "BB" documented that the Nurse Supervisor, who was notified of the fall involving Resident "X", called Emergency Medical Services (EMS) and that EMS personnel arrived at approximately 6:55 p.m. LPN "BB" documented that EMS personnel and facility nursing staff lifted Resident "X" from the floor, Resident "X" was transported to the hospital, and the attending physician was notified. A hospital History and Physical (H&P) form for Resident "X" documented the resident's hospital transfer and subsequent hospital admission on 11/11/2014. This hospital H&P documented a Chief Complaint of pain status [REDACTED]. This section of the H&P documented that Resident "X" complained of pain in both lower extremities after the fall, experiencing some pain in the right mid-thigh area, but isolating pain more to her left hip, left mid-thigh, and left knee. This H&P section also documented that imaging was done for Resident "X" in the emergency room which revealed the resident to have a distal left femur fracture. The Laboratory Data section of this hospital H&P also documented that the X-ray for Resident "X" had shown a distal left femur fracture, and the Assessment and Plan section of this H&P documented the resident would be admitted for observation for the [DIAGNOSES REDACTED]. Further record review for Resident "X" revealed a facility Nursing Admission Information form dated 11/29/2015, timed at 6:15 p.m., which documented the resident's readmission to the nursing facility, having been transported from the hospital by EMS personnel, and documented the Admitting [DIAGNOSES REDACTED]. The Admission Nurse's Notes section of this Nursing Admission Information form also referenced Resident "X"'s distal femur fracture, and documented the resident's vital signs were stable upon her readmission to the nursing facility A Facility Incident Report Form dated 11/10/2014 for Resident "X" documented the resident's fall with injury on that date. This Facility Incident Report Form documented that on 11/10/2014, CNA "AA" and CNA "CC" were transferring Resident "X" from the wheelchair to the bed via mechanical lift, and when the resident was approximately one-and-one-half feet from the wheelchair, the lift sling broke and the resident fell . A Summary of Incident and Findings report dated 11/14/2014 for Resident "X" documented the facility's investigation into the resident's 11/10/2014 fall during mechanical lift transfer. This Summary of Incident and Findings report reiterated that Resident "X" had fallen while being transferred to the bed from the wheelchair via mechanical lift. This report documented that during the mechanical lift transfer, CNA staff were using a mechanical lift sling that was requested by Resident "X", but that as the resident was positioned approximately one-and-one-half feet up (from the wheelchair), the lift sling tore and the resident fell to the floor. The report documented the facility's investigation revealed that CNA "AA" and CNA "CC" were using the mechanical lift correctly, and that the lift was in good mechanical condition. This report further documented, however, that the mechanical lift sling used during the transfer of Resident "X" was not the correct sling, as related to the resident's size and weight, but was used during the mechanical lift transfer because Resident "X" had requested the use of that specific sling. This was despite the Hoyer Lift - How To Use A Patient Lifter Positioning and Transfer Guide referenced above which specified that staff were to ensure the use of the correct lift sling, based on the resident's size and weight, during transfer utilizing the mechanical lift. Further review of the Summary of Incident and Findings report referenced above related to the 11/10/2014 fall from the mechanical lift involving Resident "X" revealed that staff re-education was completed related to this incident. Staff re-training topics included, but were not limited to, staff instruction regarding the proper use of mechanical lifts and the proper sizing of lift slings. Staff re-education topics also included staff instruction on the importance of following residents' rights, but also on the importance of making safety first in decision-making. During an interview with the Administrator conducted on 12/03/2014 at 9:20 a.m., the Administrator was questioned regarding the facility's process of maintaining mechanical lifts. The Administrator stated that each mechanical lift was inspected on a monthly basis to ensure proper function, and provided documented evidence, via Monthly Patient Lift Inspection forms, of monthly mechanical lift inspections. The Administrator further stated that the mechanical lift used during the 11/10/2014 transfer of Resident "X", during which the resident sustained [REDACTED]. During an interview conducted on 12/02/2014 at 4:50 p.m. with LPN "BB" (the nurse who examined Resident "X" after the fall, per the 11/10/2014, 6:45 p.m. NN entry referenced above), LPN "BB" stated that on 11/10/2014, she was called to the room of Resident "X" who was being attended by CNA "AA" and CNA "CC". LPN "BB" stated she observed Resident "X" on the floor, and that upon questioning, both CNAs "AA" and "CC" reported that the mechanical lift sling had "ripped" during the transfer. During an interview conducted on 12/02/2014 at 2:00 p.m. with CNA "AA" (who was assisting with the mechanical lift transfer of Resident "X" when the lift sling broke and the resident fell , per the 11/10/14, 6:45 p.m. NN referenced above), CNA "AA" stated that during the mechanical lift transfer, she and the other CNA were transferring Resident "X" from the wheelchair to the bed using the mechanical lift with a sling. CNA "AA" acknowledged that during the transfer, the lift sling ripped across both bottom attachments and Resident "X" fell to the floor. During an interview with the Administrator conducted on 12/02/2014 at 4:00 p.m., the Administrator was questioned about Resident "X"'s 11/10/2014 fall from the mechanical lift. The Administrator acknowledged that during the 11/10/2014 mechanical lift transfer resulting in Resident "X" sustaining the fall with injury, CNA staff had utilized the wrong lift sling to lift the resident for transfer (as had also been documented in the Summary of Incident and Findings report of 11/14/2014 referenced above, which indicated that CNA staff failed to use the correct lift sling as required by the resident's size and weight). The Administrator stated that the CNAs should have used a Bariatric sling to lift Resident "X" for the mechanical lift transfer, but instead incorrectly used a Blue (large, non-Bariatric) sling during the transfer. During a subsequent interview with the Administrator conducted on 01/21/2015 at 11:30 a.m., the Administrator was questioned regarding the process by which direct-care staff were to obtain the correct mechanical lift sling for use with each resident. The Administrator stated that for each resident, such as Resident "X", who required mechanical lift transfer, the correct lift sling size to use for each resident was listed on the CNA Kardex. The Administrator also stated that for each resident requiring mechanical lift transfer, a lift sling of the correct size was placed in the resident's room closet and was to be obtained by direct- care staff for use during each mechanical lift transfer of the resident. The Administrator stated that facility investigation had revealed that on 11/10/2014, the date of Resident "X"'s fall from the mechanical lift during transfer, the correct sling was located in Resident "X"'s room closet, per facility procedure. The Administrator further acknowledged, however, that on 11/10/2014, during the mechanical lift transfer resulting in Resident "X" sustaining a fall with fracture during transfer, CNA staff had incorrectly used the wrong size lift sling (Blue sling) due to Resident "X" requesting the use of that incorrect sling. During an interview with CNA "CC" conducted on 01/21/2015 at 4:05 p.m., CNA "CC" acknowledged that she assisted in the mechanical lift transfer of Resident "X" on 11/10/2014. CNA "CC" acknowledged that the mechanical lift sling used during Resident "X"'s mechanical lift transfer was a Blue sling (rather than the required Bariatric sling) which was already in place under the resident as the resident sat in the wheelchair before transfer. Based on the above, Resident "X" had [DIAGNOSES REDACTED]. In addition, Resident "X" had limited Range of Motion in the upper extremities on one side and in the lower extremities on both sides, was totally dependent on two-plus persons for transfer, had a body weight which exceeded 400 pounds, and required mechanical lift transfer utilizing a Bariatric sling. However, on 11/10/2014, direct-care staff utilized a Blue (large) sling, rather than the required Bariatric sling, during mechanical lift transfer of Resident "X". During this mechanical lift transfer utilizing the incorrect lift sling, the sling broke, Resident "X" fell to the floor, was transferred to the hospital and was diagnosed with [REDACTED].

Based on record review, hospital History and Physical form review, facility Summary of Incident and Findings report review, facility All Staff Meeting Agenda review, facility In-Service Attendance Record Signature Sheet review, and staff interview, facility certified nursing assistant staff failed demonstrate competency during mechanical lift transfer by failing to use the required Bariatric lift sling during the mechanical lift transfer of one (1) resident ("X"), of five (5) sampled residents who required transfer via mechanical lift, of eleven (11) sampled residents. This failure resulted in actual harm for Resident "X". Resident "X" required a Bariatric sling during mechanical lift transfers, but certified nursing assistant staff failed to use a Bariatric sling during mechanical lift transfer of the resident on 11/10/2014. During this mechanical lift transfer of Resident "X", the incorrect large lift sling being used by CNA staff broke, Resident "X" fell to the floor, and the resident was subsequently diagnosed with [REDACTED]. Findings include: The August 2014 Quarterly Minimum Data Set assessment of Resident "X" documented, in Section I-Active Diagnosis, that [DIAGNOSES REDACTED]. Section G-Functional Status documented that Resident "X" was totally dependent on two-plus persons for transfer, and Section K-Swallowing/Nutritional Status documented Resident "X" to have a body weight of 430 pounds. A Physical Therapy Recertification and Updated Plan of treatment for [REDACTED]. In addition, the Care Plan of Resident "X" identified an Activities of Daily Living performance deficit related to reasons including Obesity, and an Intervention specified Hoyer Lift use for transfers. A Nurse's Notes entry of 11/10/2014 at 6:45 p.m. documented that Licensed Practical Nurse (LPN) "BB" was notified by Certified Nursing Assistant (CNA) "AA" that Resident "X" was on the floor. LPN "BB" documented she observed Resident "X" sitting in front of a wheelchair and a Hoyer Lift in front of the resident, with a portion of the lift sling hanging from the lift and the other portion of the sling underneath the resident. Assessment revealed a dark brown area of one (1) inch on the resident's left mid-calf. LPN "BB" documented she questioned CNA "AA" and CNA "CC", who stated they were transferring Resident "X" using the Hoyer Lift with the sling that was already in position under the resident from the previous shift. The CNAs informed LPN "BB" that they began the lift transfer, heard a "pop" when Resident "X" was about one-and-one-half feet out of the wheelchair, and the resident fell . LPN "BB" documented Emergency Medical Services was called and Resident "X" was transported to the hospital. A hospital History and Physical (H&P) related to the hospital transfer documented that Resident "X" fell during transfer by Hoyer lift in the nursing facility, and that the resident complained of pain primarily located in the left hip, mid-thigh, and knee. The H&P documented an X-ray revealed a distal left femur fracture, and that Resident "X" was admitted to the hospital on [DATE] for observation related to the left femur fracture. A facility Summary of Incident and Findings report of 11/14/2014 documented that, as CNAs "AA" and "CC" were transferring Resident "X" to the bed from the wheelchair by mechanical lift while using the mechanical lift sling requested by Resident "X", the lift sling tore and the resident fell to the floor. The report further documented that, while CNA "AA" and CNA "CC" had used the mechanical lift correctly, the CNAs had failed to use the correct sling related to the resident's size and weight, but had instead used a mechanical lift sling requested by Resident "X". During an interview conducted on 12/02/2014 at 4:00 p.m., the Administrator acknowledged that during the 11/10/2014 mechanical lift transfer of Resident "X" when she fell and sustained injury, CNAs "AA" and "CC" had used the wrong lift sling to transfer the resident. The Administrator stated that the CNAs should have used a Bariatric sling to lift Resident "X" for the mechanical lift transfer, but instead incorrectly used a Blue sling during the transfer. During a later interview conducted on 01/21/2015 at 11:30 a.m., the Administrator stated that the correct size Bariatric lift sling had been in located in the closet in the room of Resident "X" for direct-care staff to use. The Administrator acknowledged, however, that on 11/10/2014, CNAs "AA" and "CC" had incorrectly used the wrong size lift sling while transferring Resident "X" because the resident requested the use of the incorrect sling. During a 01/21/2015, 4:05 p.m. interview with CNA "CC", this CNA acknowledged that she had aided in the 11/10/2014 mechanical lift transfer during which Resident "X" fell and was injured. CNA "CC" also acknowledged that the lift sling used during the mechanical lift transfer was a Blue sling which had been in place under Resident "X" prior to transfer. Review of an All Staff Meeting Agenda and an In-Service Attendance Record Signature Sheet, both dated 10/30/2014, revealed that on that date (and prior to the 11/10/2014 date when Resident "X" sustained the fall when the incorrect lift sling was used for lift transfer), CNA "AA" and CNA "CC" had received staff in-service training which included instruction on the correct procedures and use of mechanical lifts, and were also trained regarding mechanical lift sling size. However, despite both CNA "AA" and CNA "CC" receiving training on 10/30/2014 regarding the facility's procedures for mechanical lift use and the use of mechanical lift slings, CNA "AA" and CNA "CC" subsequently used the incorrect mechanical lift sling (at the request of Resident "X") during mechanical lift transfer of Resident "X" on 11/10/2014. As documented above, during this mechanical lift transfer of Resident "X", this incorrect lift sling broke causing Resident "X" to fall from the mechanical lift and sustain a left distal femur fracture. During an interview with the Administrator conducted on 01/21/2015 at 11:30 a.m., the Administrator acknowledged that both CNA "AA" and CNA "CC" had received training regarding Hoyer lift transfers and the correct sling/pad usage for [MEDICAL CONDITION] residents on 10/30/2014 (prior to the 11/10/2014 incident during which these CNAs then used the incorrect mechanical lift sling pad during the mechanical lift transfer of Resident "X", resulting in the sling breaking, causing the resident to fall and sustain a left distal femur fracture). Cross refer to F323 for more information regarding Resident "X".

Based on clinical record review, SBAR Communication Form review, hospital ER Report review, staff interview, and facility Fall Management Program Policy review, the facility failed to ensure adequate supervision, related to fall-prevention, for one (1) resident (#3) who had a history of [REDACTED]. This failure resulted actual harm for Residents #3, in that the resident sustained [REDACTED]. Findings include: Review of the facility's Fall Management Program Policy revealed that it was the policy of the facility to provide residents with adequate supervision to minimize the risk of accidents. This Policy further specified that the facility would identify residents at risk for falls and would implement interventions to minimize the occurrence of falls for those residents at risk. The Procedure section of the Fall Management Program Policy further specified that residents would be assessed for their fall risk, including assessment at the time of facility admission, and that interventions would be utilized for all residents identified to be at risk for falls, such as the application of a gold star on the head of the bed or on the wheelchair, to ensure that staff could easily recognize those residents at risk for falls. Record review for Resident #3 revealed an Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date of 11/29/2013 which documented, in the Entry Date section, that the resident was admitted to the facility on [DATE]. Section C- Cognitive Patterns of the MDS documented a Brief Interview for Mental Status score of 12 for Resident #3, indicating that the resident had moderate cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. Section J - Health Conditions documented that Resident #3 had experienced a fall in the month prior to facility admission, and had also experienced a fall in the two (2) to six (6) months prior to admission. The facility Admission Record form for Resident #3 documented the resident's 11/22/2013 admission to the facility from an acute care hospital. The Patient Nursing Evaluation (PNE) form for Resident #3, completed at the time of admission on 11/22/2013 at 6:45 p.m., documented a Primary [DIAGNOSES REDACTED]. This PNE documented, in the Bed Safety section, that Resident #3 moved about the bed without assistance, and also documented a history of falls. The Morse Fall Risk Scale section of this PNE also documented that Resident #3 had a history of [REDACTED]. (Per the Morse Fall Risk Scale, a Morse Score of 25-44 represented a medium fall-risk.) The Admission History and Physical (H&P) form dated 11/23/2013 for Resident #3 also documented, as did 11/22/2013 PNE form and the 11/29/2013 MDS referenced above, that the resident had a past medical history which included falls. This H&P further documented, more specifically, that Resident #3 had a history of [REDACTED].#3 had weakness, debility and "numerous medical comorbidities and chronic health conditions." The Physical Examination portion of this H&P, signed by the physician and dated 11/23/2013, documented that Resident #3 had generalized weakness and also a fall-risk. However, despite Resident #3 having a known history of falls prior to facility admission, despite the resident having been assessed on the PNE, per the Morse Fall Risk Scale, to be at risk for falls on the date of admission, and despite the facility's Fall Management Program Policy specifying that each resident assessed to be at risk for falls would receive interventions (such as a star applied to the bed or wheelchair) to alert staff of the resident's fall-risk, further record review for Resident #3 revealed no evidence of any interventions or mechanisms put into place to address Resident #3's fall-risk upon the resident's 11/22/2013 facility admission. A SBAR Communication Form for Resident #3 then documented that on 12/06/2013, the resident had attempted to get out of bed, slipped and fell . This SBAR Form documented that Resident #3 sustained a hematoma on the back of the head, and that when notified, the physician ordered that the resident be transferred to the emergency room (ER) for treatment. The ER Report of 12/06/2013 for Resident #3 documented Resident #3's hospital transfer. This ER Report documented that Resident #3 had fallen at the nursing home and sustained a skin laceration to the head and complained of mild pain, further documenting that the resident had experienced no loss of consciousness or dizziness. The ER Report documented a two (2) cm. laceration of the lower central occiput, and that local anesthesia was used to allow for stapling of the laceration. This ER Report documented that after treatment via this outpatient procedure, Resident #3 was stable and was then transferred back to the nursing facility. During an interview with the MDS Coordinator conducted on 01/11/2014 at 9:10 a.m., the MDS Coordinator acknowledged Resident #3's fall of 12/06/2013, and further acknowledged that, even though the resident had been assessed to be at risk for falls upon facility admission, interventions had not been put into place to address this fall-risk, to ensure that staff monitored the resident more closely. During a post-survey, Quality Assurance telephone interview with the Director of Nursing (DON) conducted on 01/28/14 at 9:50 a.m., the DON acknowledged that for Resident #3, none of the interventions, such as a gold star applied to the bed, which were referenced in the facility's Fall Management Program Policy had been utilized for Resident #3 to address the resident's risk for falls. Based on the above, the facility failed to address the known fall-risk of Resident #3 by putting mechanisms into place to ensure adequate staff supervision of the resident. This failure allowed Resident #3 to sustain a fall from the bed, resulting in a scalp laceration which required stapling.

Based on clinical record review, SBAR Communication Form review, hospital ER Report review, National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules review, and staff interview, it was determined that prior to the completion of the comprehensive care plan, the facility failed to utilize known information regarding a pre-admission history of falls, and also failed to utilize facility assessment information indicating a continued risk for falls, for planning care to ensure monitoring and preventative measures for fall-prevention, in accordance with professional standards of quality, for one (1) resident (#3), of six (6) sampled residents at risk for falls, on the total survey sample of fourteen (14) residents. This failure resulted actual harm for Residents #3, who sustained a fall resulting in a two (2) centimeter (cm) scalp laceration which required stapling. Findings include: Review of the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules, revealed that Chapter 2 - Standards of Nursing Practice, Section 2.2.2, Standards Related to Registered Nurse (RN) Responsibility for Nursing Practice Implementation, requires in Section 2.2.2 (i) that the nurse demonstrates attentiveness and provides client surveillance and monitoring, and Section 2.2.2(o) requires that the nurse takes preventive measures to protect the client. Record review for Resident #3 revealed an Admission Minimum Data Set (MDS) assessment of 11/29/2013 which documented an Entry Date of 11/22/2013. Section I - Active [DIAGNOSES REDACTED]. Section J - Health Conditions documented a fall in the month prior to Resident #3's facility admission, and a fall in the two (2) to six (6) months prior to admission The 11/22/2013 Patient Nursing Evaluation (PNE) for Resident #3 also documented, in the Bed Safety section, that the resident had a history of [REDACTED].#3 had a fall Risk Level score of 40, indicating a medium risk for falls. However, further clinical record review for Resident #1 revealed that, even though the resident had a known history of falling prior to facility admission and had been assessed, via the Morse Fall Risk Scale, to be at risk for falls upon facility admission on 11/22/2013, there was no evidence to indicate that the facility included the resident's fall-risk in the initial care plan, or developed interventions or approaches to address the resident's fall-risk, from the time of admission on 11/22/2013 through 12/04/2013. Then, on 12/04/2013, a Care Area Assessment (CAA) Worksheet of that date for Resident #3 referenced the resident's potential for falls, and documented that the resident had impaired balance during transitions. This CAA Worksheet documented that the problem of falls was triggered for care plan entry for Resident #3. However, even after the completion of the 12/04/2013 CAA Worksheet referenced above for Resident #3 which further documented the resident's potential for falls, record review revealed no evidence to indicate that the facility included the risk of falls in the resident's initial care plan or developed interventions or approaches to address this fall-risk. A 12/06/2013 SBAR Communication Form then documented that Resident #3 had fallen from bed, sustaining a hematoma of the head, and that the physician ordered hospital transfer. Resident #3's 12/06/2013 ER Report documented a two (2) cm. skin laceration of the lower central occiput, with no loss of consciousness or dizziness, and documented stapling of the laceration. Further review of Resident #3's clinical record revealed that it was only after the resident's 12/06/2013 return to the facility from the hospital, after the fall resulting in the scalp laceration, that a subsequent 12/10/2013 Focus area was added to the resident's Interdisciplinary Care Plan which referenced the resident's risk for falls and multiple Interventions to address this risk. During an interview with the MDS Coordinator conducted on 01/11/2014 at 9:10 a.m., the MDS Coordinator acknowledged Resident #3 having been assessed to be at risk for falls, but also acknowledged that the fall risk was not addressed on the resident's initial care plan, stating that it got missed. Based on the above, despite the facility's knowledge of Resident #3's history of falls prior to facility admission, and despite the facility's assessment that the resident continued to be at risk for falls upon facility admission, the facility failed to develop interventions as preventative measures to ensure staff monitoring of the resident, in accordance with professional standards of quality, related to the prevention of falls. Residents #3 then fell and sustained in a two (2) cm scalp laceration which required stapling. Cross refer to F323 for more information regarding Resident #3.