Every finding on record at Shakopee Friendship Manor

Based on observation, interview and document review, the facility failed to track and monitor dishwasher temperatures and take timely action to correct the temperature, for 1 of 1 dishwasher reviewed for kitchen. This deficient practice had the potential to affect all 51 residents residing in the facility.Findings include:On 8/17/26 at 9:12 a.m., dietary aide (DA)-A was observed using the dishwasher. DA-A was unaware if the dishwasher used chemicals or heat to sanitize the dishes. During the wash cycle on the dishwasher, observed the water temperature reached only 146 degrees Fahrenheit (F) and not the required temperature of at least 150 degrees F.On 8/17/26 at 9:13 a.m., dietary manager (DM)-A stated the dishwasher used heat sanitization. DM-A stated she would expect staff to monitor dishwasher temperatures during cycles, but stated that information was not recorded and had never been recorded. On 8/17/26 at 9:14 a.m., observed second load of dishes through the dishwasher. Observed wash temperature reached only 147 degrees F.On 8/17/26 at 5:03 p.m., DA-B stated he had no idea if the dishwasher sanitized dishes with heat or chemicals. DA-B stated he thought dishwasher temperature was to be 160 degrees F for both wash and rinse cycles. DA-B stated he wasn't told very specifically. DA-B stated he would check the temperature at the start of his shift and periodically during his shift. On request, DA-B ran an empty rack through the wash. Observed wash temperature ranging from 149-160 degrees F.On 8/18/26 at 9:12 a.m., observed DA-A using the dishwasher. Observed wash cycle reach only 142 degrees F.On 8/18/26 at 9:15 a.m., cook (C)-A was not able to explain the required temperatures for the wash or the rinse cycle of the dishwasher, adding if the temperature was low, it typically came up with the next cycle. Observed a load of dishes through the dishwasher. C-A verified the temperature was 143 degrees F during the wash cycle. C-A verified this was the fifth consecutive rack of dishes to have been washed. C-A confirmed wash and rinse temperatures for the dishwasher were not documented or monitored.On 8/18/26 at 12:17 p.m., administrator was notified of low dishwasher wash cycle temperatures and lack of recording and monitoring of dishwasher temperatures. Administrator had been unaware of this concern.On 8/18/26 at 12:44 p.m., DM-A was notified of low dishwasher wash cycle temperatures. DM-A stated the previous dishwasher had a booster heater, however, when the dishwasher was replaced a few years ago the company reported it had an internal booster already installed. DM-A stated she monitored the temperatures in the morning when she arrived but confirmed she did not document them. DM-A identified it would be important to track and monitor the temperatures in the event of a foodborne illness.On 8/18/26 at 2:54 p.m., DM-A stated the low wash temperatures observed by surveyors since 8/17/26, was a new problem. Prior to surveyors bringing it to her attention on 8/17/26, she had not been aware of wash temperatures below 150 degrees F. DA-A acknowledged wash and rinse temperatures were not documented so the wash temperature could have been below 150 degrees F and she wouldn't have known. DA-A stated new dietary staff who washed dishes were trained by current dietary staff and worked alongside them but nothing was documented to ensure new staff were specifically informed and understood how to read temperatures, what the required wash and rinse temperatures should be, and what to do if out of range.Champion brand dishwasher manufacturer specifications dated 8/26, indicated the required wash temperature of 150 degrees F.Facility Infection Control Food Handling Policy last revised 3/21/19, indicated High Temperature Dishwasher (heat sanitation) - Wash 150-165 degrees F for 45 seconds.Facility Infection Control for Kitchen policy dated 03/13/25, indicated staff were to take temperature of dishwater and record results on water temperature log sheet after each meal.

Based on interview and document review, the facility failed to ensure resident mail was delivered on Saturdays for 7 of 8 residents (R4, R14, R22, R26, R45, R46, R52) reviewed during resident council.Findings include:On 8/18/26 at 10:00 a.m., during resident council meeting, the following residents were in attendance:R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, clear speech, could usually understand and be understood. R4 was dependent upon staff for mobility in a wheelchair.R14's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment, clear speech, could understand and be understood. R14 required substantial assistance for mobility with a wheelchair.R22's annual MDS assessment dated [DATE], indicated severed cognitive impairment, unclear speech, was sometimes understood and could usually understand. R22 was dependent upon staff for mobility in a wheelchair.R26's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, clear speech, could usually understand and be understood. R26 was independent for mobility with a wheelchair and required supervision with a walker.R45's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R45 required substantial assistance for mobility with a walker and a wheelchair.R52's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R52 was independent for mobility with a wheelchair and would walk short distances with a walker with supervision.R54's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R54 was independent with a walker for mobility.When asked during resident council meeting, all residents indicated they did not receive their mail on Saturdays.On 8/18/26 at 10:40 a.m., activity director (AD)-A stated on weekdays the receptionist (R)-D or business office manager obtained the mail from the mailbox located outside near the street and placed it on her desk. AD-A stated she was responsible for sorting the mail and delivering it to the residents. AD-A was unaware of the facility process to get mail to residents on Saturdays.On 8/18/26 at 11:36 a.m., R-D stated she often found Saturdays mail on her desk when she arrived to work Monday morning and was not aware of the process for delivering resident mail on Saturdays.On 8/18/26 at 11:40 a.m., maintenance director (MD)-A stated if he worked on a weekend, he picked up the mail and placed it in the locked office near the administrator's office. MD-A stated if he didn't work over the weekend, he would have picked up the mail on Monday morning and placed it on the R-D's desk.On 8/18/26 at 12:17 p.m., administrator confirmed there was not a process for resident mail to be delivered to residents on Saturdays and that residents had the right to receive their mail on Saturdays.A policy on resident mail deliver was requested and not received.

Based on observation, interview and document review, the facility failed to ensure residents had accessible access to previous State survey results for 8 of 8 residents (R4, R14, R22, R26, R45, R46, R52, R54) reviewed for resident council.Findings include:On 8/18/26 at 10:00 a.m., during resident council meeting, the following residents were in attendance:R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, clear speech, could usually understand and be understood. R4 was dependent upon staff for mobility in a wheelchair.R14's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment, clear speech, could understand and be understood. R14 required substantial assistance for mobility with a wheelchair.R22's annual MDS assessment dated [DATE], indicated severed cognitive impairment, unclear speech, was sometimes understood and could usually understand. R22 was dependent upon staff for mobility in a wheelchair.R26's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, clear speech, could usually understand and be understood. R26 was independent for mobility with a wheelchair and required supervision with a walker.R45's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R45 required substantial assistance for mobility with a walker and a wheelchair.R52's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R52 was independent for mobility with a wheelchair and would walk short distances with a walker with supervision.R54's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R54 was independent with a walker for mobility.When asked during resident council meeting, no residents were able to identify where to locate previous state survey results.On 8/18/26 at 10:55 a.m., activity director (AD)-A accompanied surveyor on tour to locate previous survey results. Binder was located in the 100 wing lounge. Observed binder in the corner of the room on the bottom shelf of an end table. A chain attached the binder to the table. Observed the binder had been titled General Resident Data Manual includes Minnesota Department of Health Survey Results. AD-A agreed the binder had been heavy and would not be easily accessible to a resident in a wheelchair on the bottom shelf of the end table.On 8/18/26 at 10:59 a.m., observed glass enclosed bulletin board in the main entrance vestibule. Indicated the resident data booklet (aka State survey binder) could be located in the 100 wing lounge.On 8/18/26 from 10 a.m. to 3 p.m., observed two covered laundry carts positioned in front of the end table holding the survey binder. At 4:15 p.m., the laundry carts had been moved and a mechanical lift had been placed in the 100 wing lounge blocking access to the survey binder.On 8/18/26 at 12:17 p.m., administrator stated the survey results had been located in the wing one lounge on the end table. Administrator confirmed the binder had been chained to the end table. Administrator stated the binder had always been located in that space and she hadn't thought about accessibility to residents. Administrator agreed the 100 wing was primarily administration offices but stated residents often came to the 100 wing to access their funds and attend activities. Administrator agreed the binder had been heavy and confirmed it would not be accessible to a resident in a wheelchair on the lower shelf.A policy on location of state survey results was requested and not received.

Based on observation, interview and document review, the facility failed to ensure residents had accessible access to grievance forms for 8 of 8 residents (R4, R14, R22, R26, R45, R46, R52, R54) reviewed for resident council.Findings include:During an observation on 8/17/26 at 9:40 a.m., of common resident areas, grievance forms were not observed to be readily accessible to residents.On 8/18/26 at 10:00 a.m., during resident council meeting, the following residents were in attendance:R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, clear speech, could usually understand and be understood. R4 was dependent upon staff for mobility in a wheelchair.R14's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment, clear speech, could understand and be understood. R14 required substantial assistance for mobility with a wheelchair.R22's annual MDS assessment dated [DATE], indicated severed cognitive impairment, unclear speech, was sometimes understood and could usually understand. R22 was dependent upon staff for mobility in a wheelchair.R26's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, clear speech, could usually understand and be understood. R26 was independent for mobility with a wheelchair and required supervision with a walker.R45's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R45 required substantial assistance for mobility with a walker and a wheelchair.R52's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R52 was independent for mobility with a wheelchair and would walk short distances with a walker with supervision.R54's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R54 was independent with a walker for mobility.When asked during resident council meeting, no residents were able to identify where to find a form to file a grievance. Each resident attending indicated they would speak to a staff member if they had a concern.Grievance reports were requested for the past six months only one was received dated 5/2/26.On 8/18/26 at 10:40 a.m., activity director (AD)-A stated residents would bring concerns to nursing staff. Nursing staff would be expected to complete a form and provide to her. AD-A would then provide the form to the appropriate department leader. AD-A acknowledged residents and family members should be able to fill out their own grievance form and do so anonymously if they wished. AD-A was unaware if grievance forms were available to residents without needing to ask a staff member for it.On 8/18/26 at 10:59 a.m., observed a glass enclosed bulletin board in the main entrance vestibule. Bulletin board included information for filing of grievances which indicated a grievance (complaint) may be voiced to a staff member or in a written complaint. A Grievance Report Form will be completed by the appropriate department and turned into social services for review and follow up.On 8/18/26 at 12:17 p.m., administrator stated grievance reports would go through a staff member. Administrator stated the facility does not have a strong population of independent residents who could complete a form independently. Administrator confirmed a resident's family member would also be able to file a complaint on their behalf. Administrator confirmed grievance forms were not available for residents or family members to initiate, nor were there boxes in which to submit them, and acknowledged there was not a process for a resident or family member to submit a grievance anonymously.Facility Grievance Policy, undated, provided to residents in the admission folder included a grievance (complaint) may be voiced to a staff member or in a written complaint. A Grievance Report Form will be completed by the appropriate department and turned into the Social Services for review and follow up.

Based on observation, interview and document review, the facility failed to ensure residents had accessible access to contact information for the ombudsman for 8 of 8 residents (R4, R14, R22, R26, R45, R46, R52, R54) reviewed for resident council.Findings include:During a resident council meeting on 8/18/26 at 10:00 a.m., the following residents were in attendance:R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderately impaired cognition, clear speech, could usually understand and be understood. R4 was dependent upon staff for mobility in a wheelchair.R14's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment, clear speech, could understand and be understood. R14 required substantial assistance for mobility with a wheelchair.R22's annual MDS assessment dated [DATE], indicated severe cognitive impairment, unclear speech, was sometimes understood and could usually understand. R22 was dependent upon staff for mobility in a wheelchair.R26's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, clear speech, could usually understand and be understood. R26 was independent for mobility with a wheelchair and required supervision with a walker.R45's quarterly MDS assessment dated [DATE], indicated moderately impaired cognition, clear speech, could understand and be understood. R45 required substantial assistance for mobility with a walker and a wheelchair.R52's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R52 was independent for mobility with a wheelchair and would walk short distances with a walker with supervision.R54's quarterly MDS assessment dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R54 was independent with a walker for mobility.When asked during resident council, no residents were able to identify where the ombudsman's contact information was located or how to contact the ombudsman.On 8/18/26 at 10:40 a.m., activity director (AD)-A stated the contact information for the ombudsman had been posted in the vestibule at the main entrance.On 8/18/26 at 10:55 a.m., AD-A accompanied surveyor to locate ombudsman information. In the main entrance vestibule, which required a resident to open a door to access, observed glass enclosed bulletin board with ombudsman contact information. Observed the information was posted above eye level for a resident in a wheelchair and there had also been glare from outside light on the glass making reading the information difficult or impossible.On 8/18/26 at 12:19 a.m., the administrator confirmed the ombudsman information had been posted in the glass enclosed bulletin board located in the vestibule and stated the information was accessible to residents as they could open the door to the vestibule using the handicap button. Administrator confirmed the information was above eye level for a resident in a wheelchair and there could be a glare on the glass making reading the information difficult. Administrator stated ombudsman information had been discussed with each resident at the time of their admission to the facility. Administrator acknowledged most residents do not review all the documents in their admission folder due to the amount of information received and admission folders get placed in a drawer or the family will take them home making the information inaccessible to the resident.

Based on interview and document review, the facility failed to evaluate hazards, implement interventions to reduce hazards and risks, monitor for effectiveness, and modify or add interventions when necessary for 2 of 2 residents (R7 and R50) reviewed for falls.Findings include:R7's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated moderate cognitive impairment, use of wheelchair, substantial assistance for personal hygiene, dependent on staff for lower body dressing, dependent for going from sitting to standing and transfers, no falls since the prior assessment, and diagnoses of high blood pressure, renal (kidney) in sufficiency, and diabetes.R7's care plan revised on 2/24/26, indicated at risk for falls related to confusion, weakness, stroke. Interventions dated 10/28/25, included anti-slip fabric between mattress and bedframe and in wheelchair, call light attached to bed unless resident specifies another location and knows where to locate call light, change position- turn/reposition per tissue tolerance, fall risk tool per protocol and as needed, follow toileting program, follow facility fall protocol, for falls with no injury, notify provider during business hours of fall, next business day if fall occurs after hours, contacting on call provider after business hours in unnecessary, glasses clean and fitting properly, hearing aides in and working, grippy socks, PT/OT evaluate and treat as ordered or as needed, toilet at regular intervals, wear proper foot wear, quarterly review of transfer safety at scheduled are conference. Additional interventions dated 11/3/25, indicated small red square on door frame-risk for falls, small yellow square with check mark on door frame-must do frequent visual checks.Review of R7's incident report document printed 8/18/26, indicated falls on 11/2/25, 11/3/25, 11/21/25, and 6/19/26. R50's quarterly MDS assessment dated [DATE], indicated severe cognitive impairment, use of walker, partial assistance for dressing and hygiene, supervision for going from sitting to standing and transfers, two or more falls without injury since prior assessment, two or more falls with injury since prior assessment, and diagnoses of high blood pressure, renal (kidney) insufficiency, and dementia.R50's care plan dated 8/5/25, indicated at risk for falls related to gait/balance problems, incontinence, vision and hearing problems, wandering, Interventions dated 8/5/25, included anticipate and meet the resident's needs, call light attached to bed unless resident specifies another location and knows where to locate call light, change position- turn/reposition per tissue tolerance, correct ambulatory equipment and in good working condition, fall risk tool per protocol and as needed, follow toileting program, follow facility fall protocol, for falls with no injury, notify provider during business hours of fall, next business day if fall occurs after hours, contacting on call provider after business hours is unnecessary, glasses clean and fitting properly, hearing aides in and working, pain management, PT/OT evaluate and treat as ordered or as needed, toilet at regular intervals, wear proper foot wear, weekly observation of safety with transfers completed by nurse, quarterly review of transfer safety at scheduled care conference. Intervention dated 12/8/25, indicated anti-slip fabric between mattress and bedframe. Intervention dated 12/29/25, indicated low bed. Intervention dated 3/1/26, indicated grippy socks. Intervention dated 6/8/26, indicated swim noodles.Review of R50's incident report document printed 8/18/26, indicated falls on 11/15/25, 11/19/25, 12/27/25, 12/29/25, 1/20/26, 1/24/26, 1/29/26, 3/10/26, 3/25/26, 5/1/26, 5/7/26, 5/8/26, 5/12/26, and 6/16/26. During interview on 8/18/26 at 12:25 p.m., nursing assistant (NA)-A stated he worked with R7. NA-A stated he was not aware of any fall interventions for R7, except that R7 required two staff for transfers sometimes. NA-A stated he thought the red and yellow squares on R7's door indicated R7 had some dietary restrictions. NA-A was not aware the red square meant R7 was at risk for falls and the yellow square meant R7 needed more frequent checks due to falls. NA-A stated he did not know fall interventions for each resident and the nurse would let him know if he needed to do something different for R7.During interview on 8/18/26 at 12:47 p.m., NA-C stated he could find fall information on the kardex (tool used by the NA to indicate resident needs and preferences), but was not aware of any recent interventions for R7 or R50.During interview on 8/18/26 at 1:41 p.m., NA-B stated the red and yellow squares on the doors were used by dietary to know resident food restrictions. NA-B was not aware the squares indicated fall risk and need for more frequent checks due to falls.During interview on 8/18/26 at 12:27 p.m., licensed practical nurse (LPN)-A stated she completed a fall report after each fall, documented the fall, and gave the form to the assistant director of nursing (ADON) or director of nursing (DON). LPN-A stated she thought they did the full fall investigation and decided if different or new interventions to prevent further falls needed to be put in place. LPN-A stated she did not always review interventions and whether they were in place and further stated sometimes people fall a lot and there is just nothing more you can do, you couldn't possibly do something new every time.During interview on 8/18/26 at 8:43 a.m., LPN-B stated the ADON and DON had conversations about the falls after receiving the fall report from the nurse. LPN-B stated finding the cause of the fall and reviewing interventions or adding a new intervention would be important to prevent future falls.During joint interview on 8/18/26 at 11:32 a.m., ADON and DON were present. DON stated the expectation for falls was that the nurse working at the time completed a fall investigation report which included a summary of the fall and whether there were injuries. The fall investigation report was then reviewed by the ADON and DON during a verbal discussion but a fall huddle or reenactment, full fall investigation and root cause analysis were not completed. ADON stated any nurse could add interventions to the care plan but she was the one who usually updated the care plan. She did not review all current interventions after each fall. ADON stated there were only so many interventions they could try. ADON further stated there were red and yellow squares on resident doors to indicate who was a fall risk and who needed more frequent monitoring. ADON and DON stated they were not aware some staff had confirmed they did not know what the red and yellow squares indicated, and they would need to do education on that. ADON stated it would be important to fully investigate each fall, monitor and evaluate interventions, adjust, and add interventions to prevent future falls. ADON stated she thought they needed to work on improving their fall process.During interview on 8/18/26 at 12:15 p.m., medical director (MD) stated he thought it would be important to discuss and review every fall with the interdisciplinary team, complete a root cause analysis, and determine if current interventions were working or if some could be taken away and other interventions added. MD stated interventions should be reviewed after every fall to try to prevent resident injury.Facility Falls Prevention Policy and Procedure dated 3/16/16, indicated the following:Purpose of the falls prevention is to: initiate preventative approaches, high risk residents for falls will be identified on the resident's room door frame for all staff to be aware of residents being at risk for falls. Monitor and evaluate resident outcome. Post fall management: investigate the possible contributing factors associated with the fall, initiate interventions when necessary. Post fall evaluation: DON/Designee will review/investigate fall and ensure interventions have been initiated as needed and if further interventions are needed.

Based on observation, interview, and document review, the facility failed to ensure a mechanical lift was used in accordance with manufacturer's guidelines and Federal law to complete a safe transfer for 1 of 3 residents (R1) reviewed who used mechanical lifts. Two nursing assistant (NA) staff members, one of which was not [AGE] years of age, attempted to transfer R1 using the lift, but did not properly secure the sling to the device prior to lifting R1 up. This resulted in R1 falling onto the floor and sustaining multiple injuries including a fractured shoulder and head laceration. These findings constituted an immediate jeopardy (IJ) situation for R1. The IJ began on 5/3/26 when the two NA staff members failed to fully connect the lift sling to the device, nor did they double check the sling attachment prior to initiating the transfer of R1. R1 was raised from the bed with only three of the four attachment points placed which caused R1 to fall from the sling onto the floor and sustain serious physical injuries. The administrator and director of nursing (DON) were notified of the IJ on 5/8/26 at 9:46 a.m. The facility took appropriate corrective actions prior to the onsite survey so the IJ was removed on 5/4/26, and these findings are issued at past non-compliance.Findings include: The EZ Way Classic Lift Operator's Instructions, revised 3/2026, identified directions for the lift devices used by the care center. This included a section labeled, Safety Notes, which directed multiple items including, For safe operation . operators should watch the training video, read through this manual, complete the competency checklist, and practice on fellow staff members before using with patients. The section also listed, As always, patient lifts should only be operated by trained personnel, and a full patient assessment should be conducted to determine the appropriate accessory [sling] size and type prior to use. The manual listed step-by-step instructions for how to transfer a patient from their bed to a chair/wheelchair. This included attaching the sling loops nearest the patient's shoulders to the hanger bar hooks of the lift nearest each shoulder, crossing the sling leg straps and attaching to the opposite side of the hanger using the loops and, Make a final check of all four loop attachment points to ensure each loop is sufficiently attached to the respective hook of the hanger bars.A submitted Facility Reported Incident (FRI), dated 5/3/26, identified R1 was being transferred using a mechanical lift shortly before 7:00 a.m. from her bed to wheelchair by two NA staff members. One of the NA staff came into the hallway and retrieved the nurse who entered the room to find R1 with her head and shoulders were out of the sling and being held by the second aide. R1 was lowered completely to the floor and found to have a skin tear which was three centimeters (cm) long. R1 had pain in her right arm when moved and a portable x-ray order was obtained. On 5/7/26 at 10:03 a.m., a tour was completed of the campus which identified three mechanical EZ-Way lifts (Model L500PN) in the hallways for use. There were no slings present with the machines and each of them demonstrated no obvious defects when pushed, pulled, or inspected. At 10:18 a.m., NA-A was interviewed and stated they used the mechanical lifts regularly during their shift to help transfer residents. NA-A explained use of the device while demonstrating it with the machine. This included each resident having their own personal sling, placing the sling underneath them and crossing the leg straps, securing it to the metallic hanger bar using the colored loops adding once the loops are attached, the users needed to double-check them to ensure they were secured. NA-A stated only someone 18 or older was able to use the device and someone less than [AGE] years old could only assist with a transfer such as adjusting the person's position or helping move the wheelchair underneath the patient during a transfer. NA-A stated the schedule sheets identified who was and was not [AGE] years old and felt staff knew to check that if questions. NA-A stated they had received education on use of the mechanical lifts when they started at the care center along with additional education in the past few days as someone had fallen from the lift. NA-A stated they only knew minimal details of the incident but had been told R1 fell onto the floor due to one of the sling loops not being hooked right. On 5/7/26 11:22 a.m., R1's family member (FM)-A and FM-B were interviewed. FM-A explained they received a telephone call on 5/3/26 in the early morning saying R1 had fallen and sustained a head laceration and possible broken arm. FM-A and FM-B then arrived at the care center a short while later and R1 did not want to go to the hospital for further care which they honored. FM-A stated a portable x-ray was ordered after the fall as R1 was very much complaining of significant pain in her arm after the fall. FM-A stated they had installed a camera in R1's room prior to the fall and had the entire event of the fall on recorded clips. They had presented these to the care center leadership on 5/4/26, when they saw on the clips the fall was human error with use of the lift device. FM-A stated the care center leadership was shocked when they saw the footage on 5/4/26. FM-A stated the two NA helping R1 on the clips didn't secure the sling straps or double check them at any point prior to lifting R1 up from the bed. FM-A stated the fall directly resulted in R1 having a fractured shoulder and head laceration along with some worsened bruises on her arms which had not been there prior. After the fall, R1 then had a very rapid change of status and actively declined until she passed away on 5/5/26. FM-A and FM-B both reiterated they knew the facility had acted on this incident and were re-training the staff members on using the mechanical lifts since it happened. R1's quarterly Minimum Data Set (MDS), dated [DATE], identified R1 had severe cognitive impairment and several medical conditions Alzheimer's Disease and age-related physical debility. R1 was recorded as being dependent on staff for chair/bed-to-chair transfers. R1's care plan, dated 5/5/26, identified all R1's identified actual or potential problems and interventions to address them. The care plan identified R1 was at risk for falls and injury due to her cognitive impairment and incontinence and listed a goal which read, [R1] will be free of falls through the review date. The plan listed interventions to help R1 meet that goal including camera placement in her room and, Weekly observation of safety with transfers completed by Nurse/TMA [trained medication aide]. The plan continued and identified R1 had an activities of daily living (ADL) self-care deficit and needed extensive assistance with bed mobility, bathing and transfers. The plan outlined, TRANSFERS: Total assist of 2 staff with the use of Hoyer Lift. This had a start date of 8/6/24 and last revision on 11/4/25.R1's Treatment Administration Record (TAR), dated 4/2026, identified R1's nursing and medical treatments along with spaces to record their administration. This included a treatment labeled, Observe Transfer on Bathday [sic] . every day shift every 2 weeks on Sun for monitoring. This was last completed on 4/26/26 and no issues were identified. R1's progress note, dated 5/3/26 at 7:38 a.m., identified R1 had fallen out of the mechanical lift and two NA were present at the time of fall. The nurse assessed R1 and identified a head laceration on the right side of her head and pain in the right arm and elbow. R1 was recorded as grimacing and stating ouch ouch with arm movement. R1 was assisted back into bed and family updated. R1 refused to go to the hospital. R1's progress note, dated 5/3/26, identified R1's shirt was removed after the fall, and she was found to have bruises on her right elbow which were light blue in color and tender to touch. R1 had another bruise on her upper arm which was tender to touch, swollen and was firm when palpated. An ordered x-ray was pending at this time. R1's Radiology Report, dated 5/4/26, identified right shoulder and right elbow x-ray were completed. The report identified, [Shoulder] Results: Fracture of the surgical neck. No dislocation of the head . Conclusion: Acute appearing fracture of the surgical neck as noted. On 5/7/26 at 12:21 p.m., the video clips provided to the care center by FM-A and FM-B were watched with the director of nursing (DON) and assistant director of nursing (ADON) present. A total of six clips were attached, and each was dated 5/3/26 with a corresponding timestamp. The camera was pointed down from R1's head-of-bed and NA-D was on the left side with NA-E on the right side. A tan-colored sling was positioned underneath R1 and NA-E attached both the upper and lower points on the right side. NA-D attached the upper loop to the hanger on the left side, however, did not attach the lower (leg) point. The clips continue and the following were observed: 6:46:56 - NA-E walked around the bed to the side with the lift controls present. NA-D stood in the middle of the room moving a commode and NA-E then moved R1's wheelchair into the middle of the room. NA-D and NA-E are heard conversing aloud while R1 waited in the attached sling with her hands crossed. 6:47:19 - NA-E stood at the controls of the mechanical lift and used it to raise R1 up from the bed. Neither NA-D nor NA-E were seen to double-check the attachment points to ensure the sling was correctly attached as the left lower hanger attachment point did not have a sling loop secured on it as the device was raised up with R1 inside. NA-E turned away from watching R1 as R1 was raised and conversed with NA-D who was back in the middle of the room doing other tasks. Neither of them had a physical hand on R1 as she was raised from the bed. The metallic hanger on the mechanical lift was seen to immediately turn from parallel to perpendicular to the bed as R1 was lifted. 6:47:41 - R1 was raised up from the bed and NA-E pulled R1 off the bed surface by pulling the mechanical lift away from the bed and into the middle of the room. NA-D came to the bedside at 6:47:48 and physically grabbed R1's feet as R1 was being lifted away from the bed. R1 was then seen in the air and immediately fell out of the sling onto the floor on her right side and an audible gasp was heard. The final clip ended at 6:47:53. DON and ADON verified the footage as observed and was provided by FM-A and FM-B to them on 5/4/26. The DON and ADON both acknowledged the loop was not secured to the lift hanger prior to transferring R1, and that staff did not at any observed point double-check the loops prior to lifting R1 in the device. DON stated the two staff members involved were immediately removed from the schedule when they learned of these clips. Further, DON stated NA-E was not [AGE] years old yet and should not have been operating the lift in the manner they were at the time of the incident. When interviewed on 5/7/26 at 12:35 p.m., NA-D verified they were present and helping with the transfer of R1 on 5/3/26 when she fell from the lift. NA-D stated they had been educated on using the mechanical lifts prior to the incident involving R1 but had missed securing the loop to the hanger when R1 was transferred. NA-D stated they had noticed the wheelchair needed to be moved to complete the transfer and just got distracted and forgot to attach it. NA-D then assumed NA-E had noticed it and attached it prior to lifting R1 up in the machine. NA-D verified they never re-checked the loops to ensure they were secured prior to the transfer and expressed, I should have. NA-D reiterated they believed NA-E would have caught and attached the last loop to the hanger adding, I assumed she [R1] was good to go. NA-D stated there was poor communication between them and NA-E which they attributed to causing the fall for R1. NA-D explained they should have also been the one operating the lift machine as they were over [AGE] years old and NA-E was not, however, at the time that was just something I really wasn't thinking about. After the fall, the nurse responded to the situation and took over the care. The DON then arrived onsite and directed NA-D and NA-E to not work with the lifts for the remainder of the shift. The following day (5/4/26), the management then started to re-train staff, including them, on the machines and how to use them safely. NA-D stated the DON made them watch the footage of the fall provided by family and reiterated miscommunication had caused the incident in their opinion. NA-D stated they had not worked again since 5/3/26 but felt confident and safe to use the mechanical lifts moving forward. When interviewed on 5/7/26 at 12:57 p.m., NA-E verified they were present and helping with the transfer on 5/3/26 when R1 fell onto the floor. NA-E stated NA-D had called them into the room to help transfer R1 and the attached their side of the sling loops to the metallic hanger. NA-E then raised R1 up from the bed and next thing I knew R1 fell onto the floor. NA-E stated they had seen the video footage of the incident and verified the one loop on the left side was not attached, nor did they double-check the loops prior to lifting R1 up from the bed surface. NA-E stated that from the video footage, it also seemed like themself and NA-D were talking and not really paying attention to the transfer which was something they should not have been doing. NA-E then stated they sometimes forget to double-check the loops as being secure before lifting patients and then abruptly stopped and said aloud, I [actually] never double check 'em. NA-E stated they would usually not double-check them as they had just attached them, so they knew they'd be attached. NA-E verified they were under [AGE] years of age and use of the machine like they were doing on 5/3/26 was not something we're supposed to do. When asked why they were using the machine and not the other NA present, NA-E responded, I really have no reason why. NA-E stated someone should have double-checked the loops and had physical contact with R1 the entire time she was being raised up in hindsight. The following day (5/4/26), NA-E stated they were re-educated on slings and the lifts but had not worked again since this incident happened. NA-E stated they had no formal education in the lift machines prior to the incident but rather just a quick discussion about them from another staff member on the floor. NA-E stated they felt the fall happened as we weren't paying enough attention. On 5/7/26 at 1:39 p.m., DON and ADON were interviewed. They explained the NA staff were trained on mechanical lifts through the new employee orientation (NEO) process and staff were not allowed to physically use or run the machines until they turned 18-years-old. They provided the education for NA-D that showed training had been completed prior to the incident on 5/3/26, however, did not have any documentation to provide for NA-E as they weren't supposed to be using the machine like that at all. ADON stated they use the TAR intervention with the nurse or TMA watching a transfer as their audit system to ensure safe transfers and staff should be aware of who is and isn't 18 by the blue dot on the schedules. DON verified the fall on 5/3/26 is what caused the shoulder fracture, head laceration, and the bruising as recorded in the record. DON stated the cause of the fall was solely due to human error. When the fall happened, the DON came onsite to start investigating it. They reported it to the State agency (SA) and directed NA-D and NA-E to no longer use the lifts for the remainder of the shift. The following day (5/4/26), the family then presented the video clips of the incident and the footage was unsettling. DON added, I watched it multiple times to make sure I saw what I saw. They both acknowledged the loop not being secured or double-checked, and NA-D and NA-E seemingly not paying attention to R1 as she was being raised. DON said the situation was frustrating. DON explained they had nurses' meetings scheduled for 5/4/26 prior to the incident happening, so they just shifted the agenda to the lifts and started re-education then. The re-education included repeating the checklist of use to ensure competency and reiterating to staff members that persons less than 18 cannot use the devices other than minimal assistance. They were also going to include this incident as part of their ongoing QAPI (Quality Assurance) review. The facility Mechanical Lift Policy (HOYER), dated 4/2025, identified two staff were always required when using the machine and sling size was determined by the weight of the resident. A procedure was listed which included informing the resident of the transfer, checking for a clear pathway from start to finish, checking slings for wear-and-tear, positioning the sling and . lift Resident just enough off the bed/wheelchair and double check positioning of sling straps before moving Resident off the bed/wheelchair to new surface. However, the policy did not provide any language or direction on age-of-use with the device or what a 16- or [AGE] year-old person could assist with and still comply with Federal law. A United States (US) Department of Labor Field Assistance Bulletin No. 2011-3, dated 7/2011, identified the Department's position on use of power-driven patient lifts/hoists under the Child Labor Provisions of the Fair Labor Standards Act. The bulletin identified the position that use of the devices was not allowed, however, the Department . will not charge a child labor violation when a 16- or [AGE] year-old employee assists [underlined] a trained adult employee . The bulletin listed several items which the below age user may assist with including attaching the slings and operating the controls with directions reading, You may only assist [underline] in the 'hands on' activities discussed above and may not engage in them by yourself, adding further, Remember, until you are 18-years-old, you may not operate any floor-based vertical powered patient/resident lift devices . by yourself. The IJ began on 5/3/26 and was removed on 5/4/26 when the facility took corrective actions. These actions included reporting the incident to the SA, starting immediate re-education to the staff members on use of the mechanical lifts to ensure competency and safety, and evaluating other residents for potential safety concerns with transfers. These actions were verified as being implemented on 5/4/26, and observations and interviews made during the abbreviated survey (exited 5/8/26) supported the immediacy was removed prior to survey so these findings are past non-compliance.

Based on interview and document review, the facility failed to ensure signs of a potential gastrointestinal (GI) bleed were acted upon or evaluated timely and, if needed, referred for care or treatment to reduce the risk of complication for 1 of 1 residents (R1) reviewed who was hospitalized with GI complications. Findings include: R1's Entry Minimum Data Set (MDS), dated [DATE], identified R1 admitted to the care center on 9/15/25 from the acute care hospital. R1's initial Medicare/5-Day MDS remained, In Progress, at the time of survey.R1's Interagency Transfer Form, dated 9/10/25, was completed by the admitting hospital and outlined R1 as having a past medical history significant for colon cancer and chronic kidney disease (CKD). The report outlined R1 admitted to the hospital on [DATE] after a mechanical fall with a resulted odontoid fracture (i.e., a form of cervical fracture). R1's medical history was detailed which included a history of right hemicolectomy (a surgical procedure that involves removing the right side of the colon) in June 2025; however, the completed report lacked any evidence R1 had a current or active GI bleed which was being treated or monitored while he had been hospitalized . R1's progress note, dated 9/15/25, identified R1 admitted to the care center via a transport service. R1's vital signs were listed as being within normal limits and he rated his pain at three (out of ten). R1 had no skin issues present aside from a scab on his head. The note concluded with, . no other area of concern noted at this time. R1's corresponding Admission/re-admission Summary - V6, dated 9/15/25, identified an evaluation completed by the care center' staff which detailed a brief review of systems. The evaluation included a section labeled, A4. Elimination, which outlined R1 as having urinary and bowel incontinence, having a last bowel movement on 9/15/25, and having hypoactive bowel sounds in all four quadrants. The completed summary lacked any concern or indication of R1 having an active or monitored GI bleed. R1's POC (Point of Care) Response History, dated 9/22/25, outlined a task labeled, B&B - Bowel and Bladder Elimination, and recorded responses from the staff members for the previous 14 day period. This recorded R1 as having a large bowel movement (BM) on 9/16/25 at 4:30 p.m., and another large bowel movement on 9/17/25 at 12:00 p.m. The report continued and identified both of these BM(s) were, Formed/Normal, in consistency. However, R1's progress note, dated 9/17/25 at 12:19 p.m., identified R1 was being transferred to the hospital [due to prior complaints of head pain after a fall]. The note outlined, EMTS [sic] just came in to pick up resident . staff stood resident up to move to gurney [and] a large amount of very bloody black stool come [sic] down his leg . [EMT] stated it smells like a GI bleed . placed on the gurney and left the building to ED . The note was authored by licensed practical nurse (LPN)-A. When interviewed on 9/22/25 at 10:06 a.m., nursing assistant (NA)-A explained they had worked with R1 during his few days at the care center and recalled him as often saying he feels dizzy with ambulation. NA-A stated R1 needed help with dressing and most cares. NA-A explained they were assisting R1 with ambulation on 9/17/25 when he, again, reported being dizzy and was lowered to the floor. NA-A stated they did not recall ever helping R1 after a BM, however, then expressed everyone was complaining about the smell in the room. NA-A explained they had noticed a foul odor in R1's wash room the morning of 9/17/25 before the breakfast meal (i.e., approx. 7:30 a.m.) which NA-A described as the same smell as happened when R1 evacuated his bowels with the EMT present later in the day. NA-A stated they had not always noticed that odor but felt it was because R1 had just used the bathroom. NA-A stated they did not report this odor to the nurse as someone from a previous overnight shift had told them R1's room sometimes smells, so they assumed it had been addressed. NA-A stated they didn't recall ever seeing any active bleeding from R1, however, verified the odor they noticed in the early morning hours on 9/17/25 was the same one they smelled later in the afternoon when R1 was transferred to the hospital adding, It's not a normal smell. NA-A expressed further the odor was, Not a [typical] poop smell.When interviewed on 9/22/25 at 11:04 a.m., LPN-A verified they were assigned care for R1 on 9/17/25 and helped transfer him to the hospital. LPN-A explained R1 had been lowered to the ground earlier on 9/17/25, and he had complained of severe head or neck pain afterward which was the reason for the hospital transfer. LPN-A recalled that day and expressed R1 had gotten up for the day per usual and had said he was fine. Then while being prepared for the hospital transfer, the NA staff called her back into the room as they had noticed a large amount of blood in R1's incontinence product. LPN-A stated this happened between the time EMS was contacted and when they arrived. LPN-A stated R1 was visibly uncomfortable at this time. The EMS then arrived and R1 was assisted to stand to transfer to their stretcher and, at that time, R1 became incontinent of bowel and it had just flooded down his pants leg. LPN-A stated the stool was loose and had lots of blood in it with an evident odor. The EMT present then responded aloud, [He] has a GI bleed, I can smell it. R1 was then transferred to the hospital. LPN-A acknowledged the odor of a GI bleed as being a mixture of rotten egg and metallic smell adding aloud, I think you [surveyor] did a really good job [describing it]. LPN-A verified nobody had reported any concerns about the same odor being present in his room earlier that day adding, Nobody reported nothing. LPN-A stated if it had been reported, they would have started monitoring R1's vital signs and updated the physician immediately with that information adding, I would call right away just because I don't know what it is. R1's medical record was reviewed and lacked evidence the odor identified by the direct care staff had been evaluated timely to determine what, if any, potential causative factors existed. Further, the record lacked evidence staff had reviewed R1 on 9/17/25 prior to the EMT arrival for what, if any, other symptoms of a potential GI bleed were present or needed to be addressed, including potentially emergently, despite the direct care staff smelling the potential distinctive odor of a GI bleed several hours prior. On 9/22/25 at 1:26 p.m., the assistant director of nursing (ADON) and director of nursing (DON) were interviewed, and both verified they had an opportunity to review R1's medical record. ADON explained R1 had previously been at the care center a few months prior after having bowel surgery. He re-admitted to the center on 9/15/25 after having a fall and was in a cervical collar for his fracture. ADON stated the medical record showed R1 having a formed stool the day prior and R1 consuming some bowel-related medications; however, both the ADON and DON expressed nobody had reported any concerns about R1 having a potential GI bleed smell in their room on the morning of 9/17/25. ADON stated R1 consumed an iron supplement with their medications, however, acknowledged that would not cause the same, distinct odor a GI bleed causes. ADON stated if the NA staff had smelled such an odor, then it should be reported to the nurse right away to be addressed adding a GI bleed needs to be handled pretty quick to help improve the outcome to the patient. Further, ADON stated they typically complete a hospitalization review for each hospitalized resident as part of their overall quality assurance (QA) process, which may have helped them to identify the potential delay in care; however, they had not completed it yet as R1 remained hospitalized . The facility' Change of Condition policy, dated 3/2025, identified the facility would consult with the resident and notify their physician if a significant change in status was identified. A procedure was outlined which included evaluation of the changes through observations, obtaining a set of vital signs at the onset of the change, and obtain other relevant data, as needed, for a complete evaluation. Then, if needed, notify the physician and ensure the events are recorded in the medical record. Further, the policy outlined examples of situations which required immediate physician notification or situations which could be notified to them within 8 hours. The examples of an eight (8) hour notification included abdominal pain with emesis, seizure activity, med errors (non life-threatening), increased behaviors, and respiratory changes (i.e., cough, congestion). However, the policy lacked an example of a potential GI bleed (i.e., odor with stool, black stools) under either example base.

Based on observation, interview, and document review, the facility failed to ensure recorded complaints of pain or discomfort were comprehensively assessed and, if needed, interventions developed to ensure adequate comfort for 1 of 2 residents (R12) reviewed for pain management. Findings include: R12's quarterly Minimum Data Set (MDS), dated [DATE], identified R12 had moderate cognitive impairment but demonstrated no delusional thinking. The MDS recorded R12 as consuming scheduled pain medication, but having no as-needed (i.e., PRN) medications or non-pharmacological interventions done for pain. Further, the MDS recorded R12 as, Frequently, having pain with a moderate intensity recorded. On 7/21/25 at 1:57 p.m., R12 was observed seated in her wheelchair while in her room. R12 demonstrated no obvious physical symptoms of pain at this time (i.e., grimacing, moaning), however, when interviewed she expressed having pain in her legs and knees due to a fall which happened awhile ago. R12 explained she was currently working with physical therapy (PT) but it was not doing good to help the pain and she continued to have troubles with walking. R12 described the pain as a sore and expressed aloud, It's terrible. R12 stated the staff were aware of her pain as they just add another pain pill, and another, and another, however, it remained ineffective to adequately control her pain. R12 was asked if she'd ever had ice or heat applied to her knees and abruptly responded, That don't help. R12 stated she had been using some knee patches while working with therapy and those did help some, however, she only used them when working with therapy and expressed maybe wearing those more often would help her pain.R12's care plan, dated 2/18/25, identified R12 was on pain medication and listed a goal which read, [R12] will be free of any discomfort or adverse side effects from pain medication through the review date, along with several interventions to help R12 meet this goal. The interventions included providing pain medication as ordered, allowing her to rest to facilitate relief, completing a pain flow sheet per protocol, using non-medication techniques to help relieve pain and, Review pain medication efficacy. [A]ssess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen[,] no treatment regimen or change in regimen required but continue to monitor closely . Therapeutic regimen followed, but pain control ot adequate, changes required. R12's Pain Assessment, dated 2/13/25, identified R12 was evaluated for pain using the MDS questions (i.e., Have you had pain or hurting at any time in the last 5 days?) with R12 being recorded as having no pain or hurting during the last five days.R12's most recent Pain Assessment, dated 5/11/25, identified R12 was again evaluated using the MDS questions but now R12 endorsed having pain or hurting with a recorded frequency of, Frequently. The pain was listed as not having much, if any, effect on R12's sleep but did have interference with her day-to-day activities recorded as, Occasionally. The intensity of the pain was recorded as, 2. Moderate. However, the evaluation lacked any comprehensive assessment of the pain including the pain' characteristics, history of the pain, items which worsened or improved it, or R12's goals for pain management; nor did the evaluation outlined what, if any, changes to R12's pain control regimen (i.e., medication adjustment, non-pharmacological interventions) would be considered or implemented to help reduce the pain. R12's progress note(s), dated 5/21/25 and 6/27/25, respectively, identified R12 had a care conference held where R12's pain medications were reviewed. However, on 6/27/25, a note recorded R12 as sitting on the bedside in the morning and, . complaining of knee pain and noted to be short tempered. R12 was provided her scheduled pain medications and had no further complaints recorded. R12's POC (Point of Care) Response History, dated 7/22/25, identified a look-back period of 21 days with recorded nursing assistant (NA) data asking, Resident complained of pain? This recorded the staff marking R12 as having complained of pain on 7/13/25, 7/15/25, 7/18/25, and 7/19/25.R12's Medication Administration Record (MAR), dated 7/2025, identified R12's current medications along with spacing to record their respective administration. The MAR outlined R12 had orders including:- Muscle Rub Cream 10-15% applied once daily which was ; - Tramadol (a narcotic) 25 milligrams (mg) twice a day with a, Pain Level, recorded for each administration. These levels ranged from 0 to 3 (i.e., mild) on the scale; - Tylenol 1000 mg three times daily with a, Pain Level, recorded for each administration. These levels ranged from 0 to 3 on the scale. R12's Treatment Administration Record (TAR), dated 7/2025, identified R12's current treatments along with spacing to record their respective administration. The TAR outlined ta treatment for non-pharmacological pain interventions (i.e., massage, warm pack, cold pack) along with a number to represent which intervention was done and spacing to record which was used and if it improved the pain. This identified only a single non-pharmacological intervention of, Cold Pack, as being done on 7/8/25 with the pain being recorded as improved. The TAR lacked any other recorded non-pharmacological interventions being done despite R12 having documented pain on 7/13/25, 7/15/25, 7/18/25, and 7/19/25, per the POC Response charting.When interviewed on 7/22/25 at 8:52 a.m., NA-A stated they had worked with R12 in helping with her with transfers, and expressed needed extensive assistance for many activities of daily living (ADLs). NA-A stated R12 used to complain of knee pain but they had not heard her voice complaints for awhile. NA-A stated the nurses did a muscle rub on R12 and reiterated they had not heard complaints of pain from R12 for awhile adding, Me, personally [hadn't heard any]. R12's medical record was reviewed and lacked evidence R12's pain had been comprehensively evaluated to determine what, if any, additional interventions were needed to ensure comfort for R12 despite a potential change in her reported pain (i.e., Pain Assessments) and direct care staff charting R12 as having pain. The record lacked a comprehensive assessment of the pain including the pain' characteristics, history of the pain, items which worsened or improved it, or R12's goals for pain management. When interviewed on 7/22/25 at 10:26 a.m., licensed practical nurse (LPN)-A stated they had not worked closely with R12 but were aware of her care needs. LPN-A stated they had not heard R12 complain of pain themselves but explained the Pain Assessment(s) were the only documented evaluation of pain the nurses' completed to their knowledge. LPN-A stated if a resident started complaining of pain, the staff could repeat the evaluation or place a progress note with their evaluation and implement condition monitoring on the resident. LPN-A verified the POC Response History documentation was charted by the NA staff and verified R12 had recorded pain on several dates in July 2025. LPN-A stated there was no documented comprehensive assessment in the medical record per se but expressed complaints of pain should be evaluated adding it was more a verbal process than documented process. On 7/22/25 at 12:25 p.m., the assistant director of nursing (ADON) and director of nursing (DON) were interviewed. ADON verified they had been able to review R12's medical record, and explained the 'Pain Assessment(s)' were done on admission and with the MDS' cycle thereafter. ADON stated pain was tracked and monitored using the 'Pain Level' on the MAR and TAR, too, explaining R12 had dementia and was occasionally confused or forgetful so staff could also use the Pain AD scale then (uses physical signs to equate pain levels). ADON stated the charted pain for R12 was mild in nature but expressed the assessments needed more detail and evaluation recorded adding, I would agree with your [surveyor] point. ADON added, There is room for improvement. ADON verified the only comprehensive evaluation documented within the medical record for pain was via the annual MDS if a Care Area Assessment (CAA) triggered for the person. ADON stated it was important to ensure complaints of pain were evaluated to provide good quality of life. A facility' provided Pain Management Policy and Procedure, dated 4/2025, identified a pain level of 1 to 3 was considered, Mild Pain, and listed a procedure which included each resident having an initial pain interview completed and having that reassessed on readmission, annually, quarterly and with a significant change in condition. The policy outlined, Resident experiencing pain should be treated with non-pharmacological and pharmacological methods to help relieve pain and re-evaluate for effectiveness of interventions used. The policy outlined a section on how to evaluate and record pain for severely cognitively impaired residents, which included a progress note and review of interventions, however, the policy did not outline how or what would be included in an assessment for non-severely impaired residents.

Based on observation, intervention, and document review, the facility failed to develop a comprehensive care plan to ensure safety with wandering behaviors for 1 of 1 residents (R9) reviewed who had a history of wandering. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R47 had severe cognitive impairment and was dependent on staff during the lookback period (LBP) to use her manual wheelchair. The MDS indicated R9 had not wandered during the LBP. R9's progress note dated:-3/24/25 at 10:14 p.m., indicated R9 had been wandering trying to find the doctor's office. -4/1/25 at 9:36 p.m., indicated R9 was often wandering down halls and 1:1 and redirection had been effective interventions. -4/2/25 at 3:25 p.m., indicated R9 was wheeling herself into other residents' rooms and attempting to push a wheelchair that was in the hallway. -4/7/25 at 3:01 p.m., indicated R9 was wheeling herself in her wheelchair around the unit and yelling at the laundry lady to come back here. The note indicated staff would continue to redirect the resident. -4/11/25 at 2:48 p.m., indicated R9 was restless and wandering that shift.-4/17/25 at 1:51 p.m., indicated R9 was very anxious and wheeling herself around the unit, asking for help leaving. -5/28/25 at 2:58 p.m., indicated R9 continued to wander up and down both the long and short hall, and staff were able to redirect the resident. -5/28/25 at 3:18 p.m., indicated R9 had been wandering and getting into other residents' rooms. R9's Wandering Risk assessment dated [DATE], indicated R9 was disoriented, forgetful/short attention span, independent with mobility with a mobility aide, had Alzheimer's disease, and was taking antipsychotics and antidepressants. The assessment indicated R9 had a known history of wandering and indicated R9 had a high risk for wandering.R9's Wandering Risk Scale dated 4/17/25, indicated R9 was able to follow instructions, could move without assistance while in the wheelchair, and had no history of wandering. The assessment indicated R9 was a low risk for wandering. R9's Wandering Risk assessment dated [DATE], indicated R9 was disoriented, did not understand surroundings or what was being said, and exhibited fear and anxiety. The assessment indicated R9 had Alzheimer's disease and was taking antipsychotics and antidepressants. The assessment indicated R9 had a known history of wandering and indicated R9 had a high risk for wandering.R9's Order Summary Report dated 7/17/25, indicated R9 was a wander risk as well as a fall risk, so red and yellow squares were placed on the outside of the door, and staff were to complete frequent checks on the resident. R9's Follow Up Question Report dated 6/23/25 to 7/22/25, indicated R9 wandered in the hallway on 7/5/25 and 7/21/25 and into other rooms/unsafe areas on 7/6/25, 7/11/25, and 7/21/25.R9's care plan was reviewed and did not include any behavioral interventions for R9 when wandering behaviors were observed. During an observation on 7/21/25 at 1:52 p.m., R9 was observed sitting in a recliner in her room with her eyes open. R9 did not respond or make eye contact to questions. During an interview on 7/22/25 at 1:20 p.m. with licensed practical nurse (LPN)-B and trained medication assistant (TMA)-A, LPN-B stated R9 was able to wheel herself around independently in her wheelchair and did have a history of wandering down the halls and into other resident rooms. LPN-B and TMA-A agreed that they had both attempted redirecting R9 and giving her an activity to do, and that had been a helpful intervention when R9 was wandering. During an interview on 7/23/25 at 9:21 a.m. with the director of nursing (DON) and assistant director of nursing (ADON), a registered nurse (RN), the ADON stated she would expect staff to redirect R9 if she were found wandering. The ADON stated she would expect R9's wandering behaviors to be care planned as soon as the behaviors started, including personalized interventions, so staff could be aware, as they did utilize agency staff. The ADON stated wandering was not a new behavior for R9, and it was kind of her baseline, so she was unsure why this had not made it on the care plan. The facility's Care Planning Policy dated 4/9/25, indicated the facility would develop a comprehensive care plan to reflect each resident's objective goals and include services that would be given to maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and document review, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) were completed, retained in the medical record, and readily available to ensure continuity of care with mental health needs for 1 of 1 resident (R30) reviewed for PASARR. Findings include:R30's significant change Minimum Data Set (MDS) dated [DATE], indicated R30 had moderate cognitive impairment, did not have delusions, hallucinations or behaviors.R30's Clinical Diagnosis Report printed 7/23/25, indicated R30 was admitted on [DATE] and indicated diagnoses of paranoid schizophrenia (a chronic mental health disorder characterized by significant disturbances in thought, perception, and behavior, primarily marked by paranoid, delusions and hallucinations), cerebral infarction (area of damaged tissue on the brain), muscle weakness, drug induced dyskinesia (uncontrolled, involuntary muscle movement), diabetes, and hypertension.An attached Fax from Senior LinkAge Line, dated 4/5/23, included R30's Preadmission Screening (PAS) which stated Based on the information provided for this nursing home admission, it appears this consumer MEETS Level of Care for purposes of MA payment. The Fax from senior LinkAge Line also included a letter which indicated the Senior LinkAge Line forwarded the PAS to the county/manage care organization for processing. The PAS is not final until the lead agency sends documentation to the nursing facility. R30's entire medical record was reviewed and lacked evidence the facility followed up with the Senior LinkAge Line to find out if further assessment was needed.During interview on 7/22/25 at 11:03 a.m., the administrator stated when a new resident was admitted from a hospital the hospital' social workers sent the PAS screening. The facility usually received the PAS screening upon new residents' admission. In the event a new resident was admitted from home, the facility completed PAS screening. Administrator stated once a PAS screening was received, it was immediately filed on residents' medical record. The administrator reviewed R30's record and verified the medical record lacked documentation of any further assessment done by the Senior LinkAge Line or a letter to confirm R30 did not meet the requirements to be evaluated for a level II screening. Administrator stated she was not aware the facility needed to follow up and obtain a document stating whether a resident needed an OBRA Level II referral.On 7/23/25 at 1:54 p.m., the facility provided a document via e-mail. The document was titled OBRA Level I Criteria Screening for Developmental Disabilities or Mental Illness and was dated 1/11/23. This document indicated R30 had cognitive or behavioral signs that would lead someone to suspect the presence of developmental disabilities or related conditions. This document also indicated R30 had a diagnosis or symptoms of mental illness that significantly interfered with functioning in life activities or caused significant distress the past six months. In addition, the document indicated R30 needed supportive services or interventions due to mental illness to maintain functioning within the past two years, and indicated an OBRA Level II referral was needed.During interview on 7/23/25 at 8:50 a.m., administrator stated she oversaw the PAS screenings and before the interview on 7/22/25 she was not aware a follow up was necessary. Administrator stated the purpose to complete a PASSAR screening was to know the residents' level of care and services needed. A PASARR policy was requested but was not provided.

Based on observation, interview, and document review, the facility failed to ensure a change with hearing ability was acted upon, fully evaluated and, if needed, treated or referred to the audiologist for 1 of 1 residents (R1) reviewed who complained about worsening hearing. Findings include: R1's annual Minimum Data Set (MDS), dated [DATE], identified R1 had severe cognitive impairment but demonstrated no delusional thinking. Further, the MDS recorded R1 as having, Adequate, hearing with no hearing aid use.On 7/21/25 at 1:43 p.m., R1 was observed seated in a recliner chair while in her room. R1 did not have any hearing aids or audio devices present on her at this time. R1 was interviewed and stated her hearing in the left ear had been getting worse which concerned her. R1 was asked if they'd been seen by the audiologist for this and abruptly laughed stating, I can't afford it. R1 was hard-of-hearing during the interview and would often times turn her head to the left side and respond, Say again[?], to the surveyor's questions. R1 stated she did not wear hearing aids and, again, responded, I can't afford it. R1 stated she thought staff were aware of her hearing concerns but was unsure what, if anything, was being done about it. Further, R1 stated she had her ears checked and flushed (i.e., wax removal) before, however, it was in a clinic setting prior to her admitting to the care center. R1's Nursing Summary(s), dated 10/2024 to 4/2025, were reviewed. These each contained a section labeled, A. Hearing and Hearing Aids, which had two questions to be answered by the evaluator. These identified: On 10/24/24, R1's hearing was recorded as, Adequate, and no hearing devices were used. On 1/13/25, R1's hearing was recorded as, Moderate difficulty, and no hearing devices were used. On 4/14/25, R1's hearing was recorded as, Adequate, and no hearing devices were used.On 7/15/25, R1's hearing was recorded as, Minimal difficulty, and no hearing devices were used. When interviewed on 7/22/25 at 8:56 a.m., nursing assistant (NA)-A stated they had helped R1 multiple times with various cares. NA-A stated R1 was hard-of-hearing and one ear seemed to be worse than the other adding, I'm not sure which ear it is but she is [hard-of-hearing]. NA-A stated R1 had been hard-of-hearing for awhile now and staff would, at times, have to repeat words to her for her to hear them. NA-A stated the believed the nurses were aware of R1's hearing difficulties adding, They take care of it.However, R1's medical record was reviewed and lacked evidence the potential changes in hearing ability (i.e., adequate to moderate/minimal difficulty) had been comprehensively evaluated to determine what, if any, interventions or potential treatment was needed such as irrigation, flushing, or referral to the audiologist, despite the documented changes on the completed nursing summary(s) and direct care staff being aware of R1's hearing difficulty. When interviewed on 7/22/25 at 10:28 a.m., licensed practical nurse (LPN)-A stated they had worked with R1 only a handful of times. LPN-A stated they didn't feel R1 had too much difficult with hearing but added, I tend to raise my voice a little louder [when conversing with elderly]. LPN-A stated nobody had reported concerns with R1's hearing to their recall, however, expressed any changes with hearing should be evaluated using a visual inspection to check for wax build-up and then doing treatment, if needed. LPN-A stated if an audiologist referral was needed, then family could be asked and that could be arranged. LPN-A stated this process, including evaluation and treatment, should be recorded in the progress notes.On 7/22/25 at 12:37 p.m., the assistant director of nursing (ADON) was interviewed, and verified they had an opportunity to review R1's medical record. ADON explained all residents were asked upon admission what, if any, ancillary services they wished for which included audiology and R1's family had only consented to podiatry back then. ADON stated the medical records personnel had since visited with R1's family about other services, however, it was not documented. ADON stated they were going to have the nurse working that day (7/22) go check in R1's ears and see if there was any wax build-up which could be addressed. ADON acknowledged the completed 'Nursing Summary(s)' which documented R1's potential hearing difficulties on some of them and expressed if a change was noticed, then staff should let the nurse or management know so it could be acted upon. ADON stated they were unaware the direct care staff had noticed R1 to be hard-of-hearing, too, and explained audiology was currently not one of the 'prompted' questions being asked at care conferences, either, so it could potentially be added to that and evaluated more often with residents adding, That's another opportunity to improve. ADON verified any changes with hearing should be evaluated and acted upon adding it was important for a resident's quality of life.A facility' policy on hearing evaluations and/or treatment was requested, however, none was received.

Based on observation, interview, and document review, the facility failed to implement and maintain enhanced barrier precautions (EBP) for 1 of 1 residents (R22) reviewed for transmission based precautions. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], indicated R22 was admitted to the facility on [DATE], had intact cognition and diagnoses of hemiplegia (paralysis) affecting right dominant side and rhabdomyolysis (condition where damaged muscle fibers leak into the blood, causing kidney and heart problems). R22's progress note (PN) dated 5/22/24, indicated R22 was sent to emergency room for urinary retention and returned to facility with a foley catheter in place. R22's physician note dated 5/30/24, documented R22 was transferred to theER on [DATE], with symptoms of urinary retention and a catheter was placed and, Will be discharged home with a leg bag. R22's care plan (CP), physician orders (PO) and Kardex (nursing assistant care sheet) downloaded on 6/4/24, lacked mention of a foley catheter in place and EBP precautions. During observation and interview on 6/3/24 at 2:50 p.m., R22's room was observed with EBP signage posted outside door in the hallway. Nursing assistant (NA)-A was observed to be in R22 bathroom with water running rinsing out a graduated cylinder used for foley catheter drainage. NA-A not wearing personal protective equipment (PPE) gown. NA-A left the room and R22 stated, [I] have catheter or whatever its called. R22 stated, [NA-A] did not wear a gown. During interview with NA-A at 3:01 p.m., NA-A stated there was EBP signage posted outside R22's doorway, and that R22, has catheter, and staff, supposed to wear gloves and should have had a gown on. R22 stated she, Spaced it right off just now helping him and verified she did not wear a PPE gown when emptying R22's catheter contents (urine) into graduated cylinder from bedside to the bathroom. NA-A stated, [I] totally spaced the gown and should have had one on. During interview with NA-B on 6/4/24 at 10:45 a.m., NA-B stated, anyone with an open wound, catheter and bags, we wear PPE gown and gloves. During interview with NA-C on 6/5/24 at 12:49 p.m., NA-C stated for residents with EBP signage posted on the outside of the room, we put on gown and gloves in case of spills or liquid gets on us. I put it on every time for hands on care. During interview with NA-D on 6/5/24 at 12:58 p.m., NA-D stated the expectation of EBP care is, we have gowns and gloves. We wear them when entering room and doing hands on care only like catheter cares, wounds. It is posted outside the door. Everyone with a catheter we should always wear gown and gloves when caring for them hands on. During interview with licensed practical nurse (LPN)-A on 6/4/24 at 10:30 a.m., LPN-A stated resident rooms with EBP signage posted on the outside of the room, if we go in for emptying catheter, we wear gloves and gown. During interview registered nurse (RN)-A on 6/5/24 at 12:56 p.m., RN-A stated the nursing assistants are to, ask if they have questions about any type of care they are to provide, including EBP. During interview with infection control preventionist (IP) on 6/4/24 at 1:32 p.m., IP stated she had placed R22 in EBP when he returned from theER on [DATE], with a foley catheter. IP stated the expectation for EBP care is for staff who are providing hands on care, including catheter care, should be hand sanitizing [before entering resident room], put on gown and gloves. During interview with both IP and the assistant director of nursing (ADON) on 6/4/24 at 2:06 p.m., IP and ADON looked at R22's EMR and stated the EMR lacked mention of EBP on the orders, care plan, and Kardex, which is where it should be. Facility policy titled Friendship Manor Health Care Center Enhanced Barrier Precautions dated 3/10/2023 direct, it is with the recommendation of the CDC (Centers for Disease Control) that any resident who meets the following requirements will have EBPs initiated: -Any resident with an indwelling medical device such as a urinary catheter, port, ostomy, G tube, PICC or central line. Furthermore policy stated, At the minimum, the nurse or nursing assistant performing cares will be wearing a contact gown and gloves.

Based on interview and document review, the facility failed to ensure a comprehensive care plan was developed, and maintained to ensure appropriate care was provided for 1 of 1 residents (R29) reviewed for dignity. Findings include: R29's significant change in status Minimum Data Set (MDS), dated [DATE], indicated R29 was admitted in 2/26/24, had intact cognition and required maximum assistance for toileting, dressing lower part of body, footwear. R7 required moderate assistance from staff for personal hygiene, dressing upper part of body, shower/bathing. MDS further identified, R7 was dependent on staff for sitting to standing and transfers. Noted for toilet transfer, resident refused. R29's MDS indicated no behaviors were present, and no rejection of care exhibited. Section V: Care Area Assessment (CAA) summary, the following care areas were triggered and marked as addressed in care plan: communication; ADL function/rehabilitation potential; urinary incontinence and indwelling catheter; psychosocial well-being; activities; nutritional status; dental care; pressure ulcer; and pain. Section 0: Special Treatments and Programs identified R29 had occupational therapy from 2/27/24 to 3/27/24 and physical therapy from 2/27/24 to 3/27/24. R29's diagnosis report, printed 6/5/24, included the following diagnoses: atrial fibrillation (irregular heart beat), mild cognitive impairment (condition in which people have more memory or thinking problems than other people their age), muscle weakness, repeated falls, weakness, cardiomyopathy (disease of heart muscle), chronic kidney disease (kidneys not filtering waste properly), hypertension (high blood pressure), pain in left leg, congestive heart failure. R29's care plan, printed on 6/5/24, had the following focus areas: - [R29] past meaningful activities to help identify her likes and experiences to better identify her likes and experiences to better care for her with a date initiated of 2/28/24 - The resident is independent for meeting emotional, intellectual, physical, and social needs with a date initiated of 3/1/24 - the resident has potential nutritional problem r/t CHF [congestive heart failure], HTN [hypertension], CKD [chronic kidney disease], elevated BMI [body mass index] with a date initiated of 3/2/24. The care plan lacked evidence of assistance needed for activities of daily (ADLs), cognitive concerns, behavioral symptoms, falls, pressure ulcers, communication, bowel and bladder, dental care, skin integrity, medication needs/monitoring, and pain, which were identified in the CAA. The care plan lacked evidence of preference and potential for future discharge. The care plan lacked evidence of rehab potential as care plan identified working with PT [physical therapy] and lacked identification of discharging from PT and occupational therapy (OT) services. During interview on 6/03/24 at 1:51 p.m., R29 stated I am here because I can't care for myself anymore. I can't change my own depends, I can't walk anymore, and I must have staff help me with all that. R29 stated, they even have to help me sit up in bed. R29 indicated throughout the interview that she prefers only female staff. On 6/04/24 at 9:52 a.m., nursing assistant (NA)-H stated if they are working with a resident that they don't currently with, they would look at the care plan and Kardex for information needed to help care for the resident. NA-H stated they would also get information from the previous nursing assistant working, nurse working and the nursing assignment sheets. On 6/05/24 at 8:27 a.m., NA-C verified that they are familiar with R29. NA-C stated that R29 is an assist of one with transfers, uses a wheelchair for mobility, is able to pivot transfer and doesn't ambulate for more than a couple of steps. NA-C stated R29 has has made some accusations, so there need to be two in the room at all times. NA-C verified nursing assistants have access to the Kardex which is a shorter version of the full care plan. NA-C verified R29's Kardex did not indicate how R29 transfers, care needs, the preference for female only caregivers and the need for two staff being present. NA-C stated they would refer to the nurse and nursing assistant assignment sheet for any questions. On 6/05/24 at 8:32 a.m., NA-B verified they have worked with R29 previously but did work with her often. NA-B stated that if they are assigned to work with a resident they are not familiar with, they will refer to the Kardex, care sheet and ask the nurse any questions. On 6/05/24 at 8:39 a.m., registered nurse (RN)-A verified they are familiar with and currently work with R29. RN-A stated R29 is particular about needs and knowing her routine is the best intervention to reduce behaviors. RN-A verified R29 does have behaviors at times. RN-A verified R29 prefers only female staff and requests a check and change at night. RN-A stated the staff on the floor do not add to the care plan as the MDS coordinator does this. RN-A stated when an intervention is put in place, the MDS coordinator is notified, and it is then added to the care plan. On 6/05/24 at 8:47 a.m., MDS coordinator (MDS)-C verified they complete the MDS assessment and initiate/update the care plan for the facility. After reviewing R29's care plan, MDS-C stated, it's incomplete. MDS-C verified the only sections in the care plan are nutrition and activities. MDS-C verified a comprehensive care plan should be completed and include ADLs (activities of daily living), bowel and bladder, behaviors, medication, diagnosis, everything. MDS-C verified a care plan identified how she is taken care of, assistance she needs, care to be provided in a consistent manner, and can reduce behaviors. On 6/05/24 at 10:35 a.m., assistant director of nursing (ADON) stated a comprehensive care plan is important so that we can provide the best quality care for each individual resident. ADON verified R29's care plan was incomplete. On 6/05/24 at 1:33 p.m., administrator stated a comprehensive care plan is important so we know how to best care for our residents, know their limitations and what they need. A facility policy titled Care Planning Policy, revision date 2/16/24, was provided. The policy indicated the facility will develop an individualized plan of care that is designed to address the resident's specific problems, risk factors, and complications. Care plans are developed upon admission to the facility, and then reviewed quarterly, annually, and upon significant change in status.

Based on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all 48 residents who resided at the facility. Findings include: Review of the Payroll Based Jouranal (PBJ) Staffing Data Report, submitted for the first quarter of 2024 (October 1-December 31), identified no RN hours for the following dates: 10/21/23, 10/22/23, 12/3/23, 12/26/23 and 12/31/23. Review of the facility staffing schedules with the dates identified above, 2/24, 3/24, 4/24, 5/24 weekends and holiday staffing schedules. These schedules identified the following dates with no RN hours on 3/24/24 and 5/27/24. During interview on 6/05/24 at 9:46 a.m., staffing coordinator (SC)-E verified she does the nursing schedules for the facility. SC-E verified there the expectation was to have a RN in the facility every day for at least 8 consecutive hours. SC-E verified there was no RN working the following days: 10/21/23 10/22/23 12/3/23 12/16/23 3/24/24 5/27/24 SC-E stated the RN coverage has gotten better as another RN was hired in March. SC-E stated, it is a work in progress. SC-E stated when there is an open shift for RN coverage, it is posted to the medical staffing agency site to obtain coverage, if current staff do not pick up the shift. SC-E stated that nursing leadership has worked the floor to help ensure there is 8 hours of RN coverage daily when needed. SC-E stated since hiring another RN in March, there is now RN coverage every weekend but it gets difficult if there is a call in. During interview on 6/05/24 at 10:52 a.m., nursing assistant (NA)-F stated, a nurse is always in the facility, but I don't look to see if it is a RN or LPN [licensed practical nurse]. They further indicated there was always a nurse for support for them to go to. During interview on 6/05/24 at 10:55 a.m., NA-G stated there is typically a RN here, sometimes the ADON will work on the weekends to help. They always try to get a RN to work on the weekends. NA-G stated there is always a RN during the week because the office people are here, and they are RN's. During interview on 6/05/24 at 10:38 a.m., assistant director of nursing (ADON) verified the expectation is to have an RN on for eight consecutive hours each day. ADON verified she has worked on the floor to help ensure that has been met, with one of them being 12/31/23. ADON verified the dates listed above did not have RN coverage for at least 8 hours. During interview on 6/05/24 at 1:23 p.m., administrator stated the facility tried to have an RN on for eight hours each day as that is the expectation. The administrator reviewed dates above and verified no RN worked those days. The administrator verified she submited the PBJ information and will follow up on the data for 12/31/23 as the administrator stated there was RN coverage that day. A facility policy on staffing was requested and not provided.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement interventions for 1 of 1 resident (R1) who was at risk for pressure ulcers (PU) and currently had a pressure ulcer. Findings include: R1 was admitted to the facility on [DATE], with diagnoses identified on the active physician order sheet, dated 5/17/23, including; fracture of the vertebrae (dislocation/fracture of the backbone), muscle weakness (decreased strength in the muscles), osteoarthritis (tissue at the ends of the bone wears down) and pain in the thoracic spine. R1's admission minimum data set (MDS) dated [DATE], identified R1 as having a baseline interview for mental status (BIMS) of 12 (moderately impaired cognition). R1 required extensive assistance with activities of daily living (ADL's) that included bed mobility. The MDS identified R1 as being at risk for PU's and identified a unhealed stage 2 pressure ulcer. Review of the admission data collection form dated 4/19/23, identified R1 as having a pressure ulcer (PU) on the coccyx (tail bone). There was no documentation related to the description of the PU or interventions. Review of the current Braden scale dated 5/11/23, indicated a score of 16 meaning at risk for PU. Review of the nursing progress notes dated 4/26/23 at 2:45 a.m. and 6:23 a.m., identified R1 with a open sore on the coccyx that measures 1.2 cemtimers (cm) The note indicated there was redness on the testes and around rectum with an intervention of buttpaste (barrier cream) applied. Review of the current physicians orders dated 5/17/23, included orders for a pressure reduction cushion in wheelchair and on bed, butt paste to buttocks/coccyx every 4 hours and check skin weekly on bath days. Review of the care plan, reviewed on 5/4/23, identified R1 as having a ADL self-care deficit and potential impairment to skin integrity related to a fracture, vertebrae pain, incontinence weakness and limited physical mobility. Interventions included; reposition every 2 hours, daily skin check with cares over bony areas, follow facility protocols related to treatment of injury, document causal factors to eliminate and resolve, pressure reducing mattress and to wheelchair, weekly skin audit on bath day, weekly treatment documentation to include measurements of each skin breakdown and check and change every 2 hours for incontinence. During observation and interview with the resident on 5/16/23 at 12:30 p.m., R1 was laying in bed on his back. Nursing assistant (NA)-A turned the resident on his side, when the surveyor asked to see the residents skin condition on the coccyx. R1 was noted with a 7 inch unblanchable area of redness on the coccyx. There were no open areas noted. During interview with NA-A during this time, NA-A stated the resident did have an open area on the coccyx, but had healed about a couple of weeks ago. NA-A indicated R1's coccyx is always red and butt past is applied. NA-A further indicated R1 will reposition himself, and staff will remind him at times when he forgets. During interview on 5/16/23 at 1:30 p.m., licensed practical nurse (LPN)-B, indicated she had not been aware of R1's skin condition on the coccyx and confirmed weekly skin assessments had not been implemented. During observation on 5/17/23 at 8:15 a.m., the R1 was assisted into bed for a nap and positioned on his back. R1 was not repositioned until he was gotten up at 11:00 a.m. (2 hours 45 min). R1 remained on his back during this time. During interview with R1 at this time, R1 confirmed he had not been repositioned while in bed. R1 stated he attempts to lift his buttocks up while in bed independently, but that he is unable to do for very long. R1 further stated he prefers to lay on his back, because he has a lot of pain when moving. During interview on 5/17/23 at 9:00 a.m., the assistant director of nursing (ADON) indicated she had not been aware of the PU on the residents coccyx on admission, but stated when the PU was identified it should have been assessed and monitored weekly to prevent further breakdown. Review of the facility policy titled Pressure Injury Prevention and Managing Skin Integrity reviewed on 5/1/23, indicated the purpose of the policy is for nursing to assess and manage skin integrity for all residents and to heal pressure injuries. The procedure included; skin audit on admission and re-admission, daily skin checks during ADL's daily by the NA and weekly by a nurse, residents who are at risk for skin breakdown per risk assessment results will have pressure reduction interventions, preventive skin care treatments, education and prevention of skin breakdown for resident and medical records and MDS nurse will review and complete audits to ensure prevention and promote healing of PU's.

Based on observation, interview and document review, the facility failed to comprehensively assess and monitor bruises for 1 of 1 resident (R22) reviewed for non-pressure related skin conditions. Findings include: R22 was admitted to the facility on [DATE]. Diagnosis listed on the Physician Order sheet dated 5/16/23, located in the medical record included; osteoporosis (bones become week and brittle), Alzheimer's disease (a progressive disease that destroys memory and other mental functions), macular degeneration (eye disease that causes vision loss), and mood and anxiety disturbance (mental health disorder characterized by feelings of worry, and fear that interfere in ones daily activities). During observation and interview on 5/15/23 at 1:59 p.m., R22 was noted to have a large dark bluish bruise on the top of the right hand. The bruise covered the entire top of the hand. R22 indicated she was not sure how she got the bruise, and unsure if they were improving or worsening. R22's quarterly Minimum Data Set (MDS) assessment, dated 4/6/23, identified R22 as having a brief interview for mental status (BIMS) score of 8 indicating impairment in cognition. The MDS indicated R22 required extensive staff assistance with activities of daily living (ADL's). Review of the current physicians orders included a weekly skin check on bath day. Review of the current skin assessment dated [DATE], indicated the resident is at risk for skin breakdown that included bruises. No other documentation was found in the medical record, addressing R22's weekly skin checks or condition of skin since 4/16/23. R22's current care plan dated 8/20/20, identified the resident as having potential for impairment to skin integrity, related to cognitive impairment and being at risk for bruising and skin tears due to fragile skin. Interventions included; daily skin check with cares, follow facility protocols for treatment of injury, skin check weekly on bath day and document and cover arms with long sleeved shirts. Review of the progress notes, did not include any bruising over the past 2 months. During interview on 5/16/23 at 10:30 a.m., licensed practical nurse (LPN)-B indicated she had not been aware of R22's bruise on the right hand. LPN-B stated R22 is at risk for bruising and should be monitored daily. LPN-B further indicated R22 does wheel herself in the hallway and could possibly bump herself on something, but was unsure how she got the bruise or for how long she had it. During interview on 5/16/23 at 11:00 a.m., nursing assistant (NA)-A indicated he had been aware of R22's bruise on the top of the right hand for at least a week. NA-A stated R22 usually always has a bruise on her hands, but was unsure how she gets them. NA-A further indicated R22 wheels herself around in her wheelchair and could possible bump her hands, but had not witnessed. During interview on 5/17/23 at 9:15 a.m., the assistant director of nursing (ADON) indicated she had not been aware of R22's bruise on the top of the right hand. The ADON stated staff should be reporting skin concerns to the charge nurse when identified, and then monitored as well as completing a incident report. The ADON confirmed this had not been done. A policy related to non-pressure related skin concerns was requested, but not provided.

Based on observation, interview and document review, the facility failed to ensure a gradual dose reduction (GDR) was attempted or an adequate medical justification for the use of psychoactive medications for 1 of 5 residents (R19) who was reviewed for unnecessary medications. Findings include: R19 was admitted on [DATE]. R19's diagnosis (identified on the physician order sheet in the medical record) dated 5/16/23, included; delusional disorders (mental health condition in which a person can't tell what's real from what is imagined), anxiety disorder (a mental heath disorder characterized by feelings of worry or fear in ones daily activities), cerebral infarction (disrupted blood flow to the brain), major depressive disorder ( mood disorder that causes persistent feeling of sadness or loss in daily life), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and psychotic disturbance (mental disorder that cause abnormal thinking and perceptions from reality). R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 as having a brief interview for mental status (BIMS) score of 3 (severe cognition impairment). The assessment indicated R19 received seven days of antipsychotic medications, seven days of antianxiety medications and seven days of antidepressant medications. R19 did not exhibit any mood or behaviors during the assessment period. The MDS indicated a gradual dose reduction (GDR) had not been done, but a clinical contraindication had been documented for continued use. Review of the current physicians orders dated 5/16/23, included Ativan (used for anxiety) 0.5 milligrams (mg) bid (twice a day)order date 12/4/19, Celexa (used for depression) 10 mg daily, order date 4/29/21 and Zyprexa (used to treat mental disorders) 5 mg tid (three times a day), order date 4/14/12/21. Review of a consultant pharmacist medication review note dated 8/1/22, included a recommendation to the provider to evaluate continued use of the Celexa, and if a dose change is not indicated at the time to provide a clinical rationale for continued use. A comment from the provider included a rejection to the recommendation and indicated R19 exhibits persistent depressive symptoms, and continue same plan and re-evaluate in 90 days. No further recommendations had been done after the 90 days and the medication did not get evaluated by the provider for the Celexa. The pharmacy consultant did not include a recommendation for Ativan. Review of a provider progress note dated 3/5/23, included a review and justification for continued use of the Zyprexa without a GDR. The progress note did not address the Ativan or the Celexa. Review of the mood and behavior tracking form for the past 3 months, did not include any exhibited target behaviors. R19's care plan reviewed on 3/1/22, identified R19 as having physical and verbal aggression that included vulgar language, hitting out at staff with cares and inappropriate sexual comments towards staff. Interventions included; administer medications and document effectiveness, allow time to express self, monitor behaviors/interventions and document when occur, engage in calm conversation, anticipate needs and intervene before agitation occurs During observation and interview on 5/17/23 from 8:30 a.m. to 10:00 a.m., R19 was sitting in the lounge calmly. R19 yelled out a swear word during this time, but was not directed towards anyone. No other behaviors were observed. During observation on 5/17/23 from 12:30 p.m. to 1:30 p.m., R19 was observed being assisted with activities of daily living (ADL's) and was cooperative and calm during this time. No other behaviors were observed. The resident was calm and cooperative throughout random observations during the survey. R19 was not able to be interviewed due to decline in cognition. During interview on 5/16/23 at 2:30 p.m., nursing assistant (NA)-A indicated R19 exhibits behaviors of physical abuse towards staff when providing cares. NA-A indicated this happens several times during the week, and the resident does not always respond to re-direction. During interview on 5/17/23 at 9:00 a.m., licensed practical nurse (LPN)-B indicated R19 exhibits behaviors of physical aggression and will hit out at staff with cares, LPN-B further indicated not all behaviors get documented like they should. During interview on 5/17/23 at 1:30 p.m., the assistant director of nursing (ADON) confirmed minimal documentation of R19's target behaviors. The ADON also verified R19's Celexa and Ativan had not been addressed for continued use in the past year. A policy was requested, but not provided

Based on observation, interview and document review, the facility consulting pharmacist failed to address the continued use of psychoactive medications for 1 of 5 residents (R19) reviewed for unnecessary medications. Findings include: R19 was admitted on [DATE]. R19's diagnoses (identified on the physician order sheet in the medical record) dated 5/16/23, included delusional disorders (mental health condition in which a person can't tell what's real from what is imagined), anxiety disorder (a mental heath disorder characterized by feelings of worry or fear in ones daily activities), cerebral infarction (disrupted blood flow to the brain) major depressive disorder ( mood disorder that causes persistent feeling of sadness or loss in daily life), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and psychotic disturbance (mental disorder that cause abnormal thinking and perceptions from reality). R19's quarterly Minimum Data Set (MDS) dated [DATE], identified R19 as having a brief interview for mental status (BIMS) score of 3 (severe cognition impairment). The assessment indicated R19 received seven days of antipsychotic medications, seven days of antianxiety medications and seven days of antidepressant medications. R19 did not exhibit any mood or behaviors during the assessment period. The MDS indicated a gradual dose reduction (GDR) had not been done but a clinical contraindication had been documented for continued use. Review of the current physicians orders dated 5/16/23, included Ativan (used for anxiety) 0.5 milligrams (mg) bid (twice a day)order date 12/4/19, Celexa (used for depression) 10 mg daily, order date 4/29/21 and Zyprexa (used to treat mental disorders) 5 mg tid (three times a day), order date 4/14/12/21. Review of a consultant pharmacist medication review note dated 8/1/22, included a recommendation to the provider to evaluate continued use of the Celexa and if a dose change is not indicated at th the time to provide a clinical rationale for continued use. A comment from the provider included a rejection to the recommendation and indicated R19 exhibits persistent depressive symptoms and continue same plan and re-evaluate in 90 days. No further recommendations had been done after the 90 days and the medication did not get evaluated by the provider for the Celexa. Review of a provider progress note dated 3/5/23, included a review and justification for continued use of the Zyprexa without a GDR. The progress note did not address the Ativan or the Celexa. Review of the mood and behavior monitoring for the past 3 months did not include any exhibited behaviors on the tracking form. During interview on 5/17/23 at 1:30 p.m., the assistant director of nursing (ADON) confirmed minimal documentation of R19's target behaviors. The ADON also verified R19's Celexa and Ativan had not been addressed for continued use in the past year. During interview on 5/18/23 at 11:20 a.m., the facility contracted pharmacist confirmed he had not addressed R19's Ativan in the past year and did not follow up with the recommendation for continue use of the Celexa when the provider addressed continued use for 90 days and then evaluate. The consulting pharmacist did confirm R19 had been on Celexa and Ativan for over a year without a GDR. The consulting pharmacist also confirmed he would expect a justification from the physician annually for continued use of the medication, but he does not follow up unless it has been a year. A policy was requested, but not provided.

Based on observation, interview, and document review, the facility failed to comprehensively assess and develop interventions to proactively provide comfort and ensure adequate pain-relief measures were in place for 1 of 1 resident (R29) reviewed who was non-verbal and demonstrated potential physical signs of pain (i.e., teeth grinding, grimacing). Findings include: R29's significant change Minimum Data Set (MDS), dated [DATE], identified R29 had severely impaired decision-making but demonstrated no rejection of care behaviors. In addition, the MDS outlined R29 was totally dependent on staff for their activities of daily living (ADLs), consumed scheduled pain medication only, and demonstrated no indicators of pain or possible pain in the last five (5) days. Further, the Care Area Assessment (CAA) for pain did not trigger to be completed. R29's most recent Pain Interview (3.0) - V3, dated 4/21/23, identified instructions to complete the evaluation if the resident was able to communicate properly. If they were not, then the evaluation directed to, . skip to Section E. The first question on the evaluation outlined, Should Pain Assessment Interview be Conducted? This was answered by staff as, 0. No, and the remainder of the pain evaluation was left blank and not completed. R29's care plan, dated 5/15/23, identified R29 was non-verbal and consumed pain medication and listed a goal for R29 to be free of any discomfort or adverse side effects from the pain medication. The care plan listed several interventions to help R29 meet this goal, including one-to-one visits using distraction, providing analgesic medications as ordered, and completion of the Pain flow sheet per protocol. On 5/15/23 at 2:37 p.m., R29 was observed laying in bed while in their room with their jaw line visibly moving in a slight side-to-side manner. R29's eyes were closed and they did not respond to verbal interaction by the surveyor; however, R29's mouth made an audible grinding-like noise which could be heard from the doorway to the room. Later, on 5/15/23 at 3:24 p.m., R29 remained in bed but now had their eyes open but still did not respond to the surveyor' interactions. R29 continued to have audible, grinding-like noises coming from their mouth with no visible mouth guards or protectors in place. A telephone call was placed to R29's family member (FM) on 5/15/23, with a request to be called back to discuss R29's care while at the nursing home; however, a return call was never received. During subsequent observation, on 5/16/23 at 11:23 a.m., R29 was seated in a high-back wheelchair in the main dining room at the table. R29's eyes were open and, again, they had audible grinding-like noise coming from their mouth which stopped as R29 yawned, and then resumed when their mouth closed. R29 had no other physical signs of pain (i.e., grimacing), however, remained non-verbal with interaction. R29's progress note(s), dated 4/21/23 to 5/17/23, were reviewed and identified: On 5/5/23, R29 had range of motion performed and the staff recorded, . showed signs of discomfort with facial wincing . cream [muscle] was applied and wrist brace was placed back one, no signs of discomfort noted . continue to monitor. On 5/11/23, R29 had . occ[asional] teeth grinding this morning . Pain meds given as ordered, no s/s [signs or symptoms] of pain. R29's Medication Administration Record (MAR), dated 4/2023, identified R29's current physician-order medications and treatments along with their respective administration dates and/or times. This identified R29 had orders for tramadol (a non-narcotic pain medication) 25 milligrams (mg) twice a day for pain with a corresponding, Pain Level, being recorded. This identified ratings of two (2) recorded on 4/13/23 and 4/26/23. In addition, the MAR included orders for, Muscle Rub Cream 10-15%, to be applied twice a day, and Tylenol 650 mg three times daily with another corresponding, Pain Level, being recorded. This identified a rating of three (3) on 4/1/23. R29's current MAR, dated 5/2023, identified these same orders remained in place and were being administered to R29; with recorded pain levels of two (2) on 5/12/23, four (4) on 5/5/23, five (5) on 5/8/23, and two (2) on 5/12/23. Further, neither MAR outlined specific start or stop dates for these medications. When interviewed on 5/16/23 at 1:16 p.m., nursing assistant (NA)-B explained they had worked with R29 and described them as needing total help for cares. NA-B stated R29 was almost always non-verbal and would very rarely speak and, when they did, it was typically just an isolated curse word. NA-B stated they had noticed R29 to be grinding their teeth which had been happening for at least six months, and expressed it had been reviewed with R29's family and the medical provider to their knowledge. NA-B stated R29 did occasionally have physical symptoms of pain, like a grimace with care, but felt it was observed not very often but added it happened with no mobility and with R29 just kind of sitting there. NA-B stated they did not feel R29 was in significant pain, overall, and expressed they would report such concerns to the nurse if they noticed them. R29's medical record was reviewed and lacked evidence R29 had been comprehensively assessed for pain and comfort needs, or subsequent interventions and efficacy of the current medication regimen, despite having several recorded episodes of pain since 4/21/23 (the most recent pain interview) in the progress notes and MAR, and direct care staff observing signs of potential physical pain during periods of rest. On 5/17/23 at 9:03 a.m., licensed practical nurse (LPN)-C was interviewed and explained R29 consumed Tylenol and tramadol for pain, and they had a topical application of muscle rub applied to the wrist twice a day. LPN-C stated they monitored R29 for pain using the PainAD scale which is used for non-verbal persons and to record the pain levels in the MAR using the same tool. LPN-C expressed there was not a comprehensive pain evaluation in the EMR to their knowledge, rather they would start short term condition charting if they observed or witnessed an issue, including pain, with a non-verbal person. LPN-C verified R29 was not currently on such charting for pain, and they explained there had been some days they noticed R29 to grimace with range-of-motion or the application of their wrist splint; however, the pain seemed to kind of resolve after the application of the device. LPN-C reiterated there was no formal comprehensive pain assessment or evaluation, to their knowledge, in the medical record and reiterated just day-to-day charting and the condition monitoring would be used for such. On 5/17/23 at 1:08 p.m., the assistant director of nursing (ADON) was interviewed. ADON explained non-verbal residents should be evaluated for pain using the PainAD scale along with a review of progress notes, and vital signs, and this was done in a day to day manner. However, there was no formal comprehensive assessment process to review pain and the subsequent interventions; rather the MDS was the evaluation process the facility used. ADON stated if staff were seeing signs of potential pain, then pain monitoring in the MAR could be implemented and the medical provider updated to readdress the situation. ADON reviewed R29's medical record and stated there had been no adjustments to R29's consumed pain medication orders since October 2022 (seven months prior), and reiterated there was no comprehensive assessment process documented in the medical record aside from the completed MDS adding, Not to my knowledge. A provided Pain Management Policy and Procedure, dated 2/2023, identified each resident would have an initial pain interview completed upon admission and then be reassessed on readmission, annually, quarterly, and with a significant change in condition. The policy outlined pain monitoring would be completed quarterly on every shift, and such monitoring could be stated . when resident is verbally or physically showing signs and symptoms of increase [sic] pain, and the medical provider updated. Further, the policy outlined the PAINAD would be completed for residents with cognitive impairment or whom were unable to answer if having pain; however, lacked direction on what, if any, other indicators or assessment process would be completed to ensure a comprehensive evaluation of a non-verbal resident' pain symptoms and interventions.

Based on document review and interview, the facility failed to re-assess a change in transfer ability for 1 of 8 residents (R1) reviewed who required a mechanical lift for transfer. R1 complained of weakness during the transfer, fell from a standing lift, sustained a [MEDICAL CONDITION] was hospitalized and subsequetly died . This resulted in actual harm for R1. Findings include: R1's quarterly Minimum Data Set ((MDS) dated [DATE], included moderate cognitive impairment with a [DIAGNOSES REDACTED]. R1's ADL (activities of daily living) Care Area Assessment (CAA) dated [DATE], included the need for extensive assistance with all ADL's and mobility. R1's most recent Fall Evaluation dated [DATE], described R1 as alert and oriented, with no falls in the past three months, chair bound and non-ambulatory. Fall interventions included staff assisting with transfers. R1's ADL care plan dated [DATE], directed staff to assist with transfers using a mechanical lift, to use an EZ Way Smart Stand (a mechanical lift which requires the resident to hang onto handles and to stand up, bearing weight while being lifted) during the day shift, and an EZ Way Smart Lift (a mechanical lift which supports the entire body in a sling to transfer, no weight bearing is required) during the evening shift. Transfer with EZ Way Smart Lift and 2 assist on evening shift per family request to prevent falls out of EZ Way Smart Stand. Staff were also directed to use a seat strap (EZ Way Smart Stand accessory that attaches to the lift, and is placed loosely under the buttocks to support if resident were to try and sit during the transfer) and calf strap (strap that attaches to the Stand and goes behind the calves for support). R1's treatment administration record (TAR) dated [DATE], included to use EZ Stand with day shift and full body EZ Lift in evenings due to fatigue and decreased safety/weakness at night. R1's Daily Assignment Sheet dated [DATE], used by the nursing assistants to know how to provide care to each resident, directed staff to use the EZ Way Smart Stand during the day with the sit strap and calf strap accessories, and at 2:00 p.m. to switch to the full body lift, and assist of two staff. R1's nurse practitioner visit note dated [DATE], described R1 as having occasional back and knee pain, and a difficult time getting comfortable. R1 reported ongoing weakness and pain in her hands. R1's incident report dated [DATE], included, Aide was assisting resident from her w/c (wheel chair) to her bed with the ez stand lift when the resident raised her arms up and she slid from the ez stand lift. She did not hit her head. Resident c/o (complained of) right hip pain. Resident would not allow nurse to check range of motion and right leg appears shorter than left. Received orders to send to the ER (emergency room ) to be evaluated. Sent out at 3pm. R1's investigative report dated [DATE], included, Resident was okay to use ezstand for transfers during the dayshift and then switch over to hoyer (full body lift) lift starting at 2pm. Aide was using the ezstand but did not use the sit strap which is an added strap to the ez stand to have if the resident would try to sit down too soon to give a bit of extra support. In talking with the aide she described that when she had the resident in the ez stand and was in the middle of the transfer, she realized when she brought resident close to the bed, the bed was up a bit too high and the resident would not be able to sit on the bed. So the aide went to lower the ht (height) of the bed but then the resident stated she was feeling weak, the aide started to move the resident (while in the ez stand lift) back towards the w/c to sit her back down. But the resident let go of the hand grips and raised her arms, so she slid under the harness and landed on the floor. The aide and the nurse stated the harness strap and the behind the calf strap was buckled. The extra sit strap was not in place to help support her if her legs would bend to try to sit. The resident had severe pain in her right hip. The nurse stated resident's right leg was shorter than the left and she was not able to do range of motion to the right leg. Nurse got an order from the doctor to send to the ER to be evaluated. She was sent to the ER at 3pm and has since been transferred from SFRMC (St. Francis Regional Medical Center) to Abbott Hospital. In questioning the aide further, it was determined that the aide felt the resident wasn't transferring very well earlier in the day when she was using the EZ stand for toileting resident. When this writer asked her if she informed the nurse at that time about the transfer she stated no she did not. When it was time to lay resident down for a nap at 1:30 pm the aide stated she asked another aide if she should use the hoyer to transfer the resident to bed. That aide said no because it isn't 2pm yet so you can use the ezstand. Again this writer told the aide that she should have told the nurse and asked for assistance if she felt unsure of the transfer being safe. The instance of the aide not using the sit strap, although it was wrong of her not to follow the care plan, it was likely that would not have prevented the fall, the ER diagnosed her with Right hip fx (fracture) and pneumonia too. Which she had no symptoms of pneumonia leading up to the fall. She had not been running a temp, O2 sats (oxygen level) were good, no cough. The pneumonia caused her weakness to not tolerate holding onto the hand grips and when she let go of the lift and raised her arms she slid down through the bottom of the harness. The report indicated the nursing assistant was re-educated on transferring with the lifts and reporting condition changes. R1's nursing progress note dated [DATE], at 2:25 p.m. included a nursing assistant used the EZ Stand to transfer R1 from the wheelchair to bed. Staff used the EZ Stand waist strap (harness used for all EZ Stand transfers that connects around the torso) and calf strap. During the transfer, R1 raised arms and legs, and fell to the floor. Upon inspection, the right leg appeared to be, slightly shorter than left leg. Family was contacted. The on-call provider gave an order to send R1 to the emergency room for evaluation. R1's progress note on [DATE], at 9:38 p.m. noted hospital staff later called to inform that R1 was admitted for a, [MEDICAL CONDITION] and uncontrolled pain level. Per R1's progress note dated [DATE], at 11:17 a.m. included, Received call from (R1's family) (R1) is in a lot of pain and also has pneumonia. This writer explained what happened during the transfer with the ez stand and that (R1) stated she was feeling weak and then let go of the hand grips and raised her arms up and slid out of harness. The pneumonia could have contributed to her weakness and unable to stand as long as she usually does. The pneumonia was (diagnosed ) at the hospital as (R1) did not have any symptoms while at this facility. R1's progress note dated [DATE], at 9:09 a.m. Spoke with (R1's family) via telephone .the cardiologist states (R1) can't have surgery as she needs heart valve replaced, they will probably not do surgery for [REDACTED].'family is working at finding a hopsice' (sic) .(R1) 'is in so much pain', the family plans to 'vigil her end of life care' When interviewed on [DATE], at 12:11 p.m. family member (FM)-B stated the full body lift is what facility staff used whenever FM-B visited and was not aware they were still using the standing lift for any transfers. FM-B stated R1 was not doing well at the hospital and felt the fall could have been prevented if they had used the full body lift all the time, or at least when R1 felt weak. When interviewed on [DATE], at 12:53 p.m. registered nurse (RN)-A stated she was working at the time of R1's fall on [DATE], and found out sometime after the fall, that the nursing assistant working with R1 that day thought R1 seemed weak during an earlier EZ Stand transfer. RN-A stated her expectation was for staff to notify her when concerns about R1's weakness with transfer arose. RN-A stated if she had known about the weakness, she would have changed the daily assignment sheet right away to stop using the EZ Stand and start using the full body EZ Lift. RN-A assessed R1 after the fall, one leg was shorter than the other and was in significant pain. RN-A stated this fall could have been prevented if she had known about the concern of weakness during the earlier EZ Stand transfer. RN-A stated R1 did not like the full body EZ Lift, so they used the EZ Stand during the day as a compromise to accommodate R1's preferences. RN-A had spoken to family, who felt the fall was preventable, and planned to take R1 home from the hospital so family could be with her until she died . When interviewed on [DATE], at 2:45 p.m. the director of nursing (DON) stated the nurse aide (NA)-A who transferred R1 was new and did not know R1's normal condition as well as other staff, did not report the weakness to the nurse and should have, should have checked with the nurse about transfer concerns and should have used the buttocks strap on the lift. R1 needed assist of one staff for the EZ Stand during the day, but always assist of 2 staff with the full body EZ Lift. Staff can switch to the full body lift if the resident is weaker and should notify the nurse with any change in condition. Family had been part of the discussion and in agreement about using the EZ stand during the day and full body lift in the afternoon as R1 did not like the full body lift, and wanted to maintain some independence. When interviewed on [DATE], at 9:20 a.m. the DON stated R1 had died in the hospital. When interviewed on [DATE], at 9:59 a.m. NA-A stated [DATE], was the first day they had worked with R1 and knew R1 needed the standing lift during the day and the full body lift after 2:00 p.m. NA-A had transferred R1 after breakfast, to the toilet, and it did not go well, her buttocks hung down and didn't actually stand up like is needed, so when R1 needed to lie down again it was before 2:00 p.m. so she asked NA-B if she should use the EZ lift instead, and was told since it was before 2:00 p.m. to go ahead and use the standing lift. NA-B had not reported the difficult earlier transfer to a nurse. NA-A attached the main harness around R1's torso, and the calf strap around R1's legs, and lifted R1 out of the wheelchair. NA-A moved R1 to the bed, and then realized the bed was too tall for R1 to sit down on. NA-A went to the bed controls to lower the bed, but then R1 stated she was getting tired. NA-A tried to get R1 back to her wheelchair, but before R1's buttocks was over the chair, R1 let go of the EZ Stand handles, and fell right through the harness that was around her torso. NA-A did not realize R1 required the use of the seat strap while using the standing lift until afterwards. When interviewed on [DATE], at 10:27 a.m. NA-B stated R1 was often difficult to transfer using the EZ Stand, R1 needed reminders to bend her knees and sometimes had difficulty standing up in the lift. Nursing was aware of this, but compromised with R1 as she did not like to use the full body lift, so used the stand during the day and switched to the lift after 2:00 p.m. On [DATE], NA-A had asked her if she should use the full body lift versus the stand and NA-B told her no, use the stand lift as it was before 1:30 p.m. NA-B was not aware R1 had difficulty with the standing lift earlier in the day. If she had known, she would have told the nurse and she would have directed NA-A to use the full body lift. A Communication With Staff training document, provided during orientation, undated, required nursing assistants to communicate with the nurse about resident care related to changes in mobility, such as the ability to sit, stand or move. The training required nursing assistants to communicate with the nurse for continuity of care. Sit/Stand Mechanical Lift Policy reviewed [DATE], described the transfer as being safe when the resident was able to bear weight on both legs and hold on to the handles with at least one hand securely, or with two hands securely. The procedure described needing to apply the harness around the chest/waist, and the strap around the lower legs, and then apply the seat strap for residents who did not stand straight or had upper arm weakness.

Based on interview and record review, the facility failed to ensure that the resident environment was free of accident hazards for 1 of 6 residents reviewed, Resident #1 (R1), when the facility had no adequate scheduled maintenance system for patient lift devices, and the wheels on the EZ Way (hoyer/mechanical) lift device were sticking. During a lift, the wheels stuck, and when staff continued to push the device, a strap of the sling came off the lift, and R1 fell from the lift. R1 was hospitalized and required stitches to her head. Findings include: Medical record review revealed R1 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. R1's care plan, dated 6/27/2016 indicated R1 was to be transferred with the maximum assistance of 2 staff and a Hoyer lift. (A Hoyer lift is a mechanical lift device that uses a sling and the device to lift a resident and move them from one surface to another such as from a bed to a chair.) Nursing notes dated 9/7/2016 and written by Licensed Practical Nurse (LPN)-D revealed R1 was on the floor on her right side after sliding out of the hoyer body sling and falling to the floor. R1 was noted to be bleeding from her head and was sent to the hospital for evaluation. Hospital records dated 9/7/2016 revealed R1 was admitted to the hospital following a fall due to mechanical reasons. R1 was diagnosed with [REDACTED]. CT scan and X-rays were negative, and R1 transferred back to the facility the next day with her pain controlled with oral medications. During an interview on 11/15/2016 at 9:30 a.m., Nursing Assistant (NA)-C stated on 9/7/2016 at about 7:00 a.m. NA-C was assisting NA-E to get R1 out of bed and ready for breakfast. NA-C stated they put the Hoyer sling under R1 and hooked the sling to the lift in the usual manner. NA-C and NA-E lifted the resident off the bed and she looked stable in the lift and sling. When they attempted to turn the Hoyer to move the resident to the wheelchair, the lift wheels caught and NA-C had to forcefully push the lift in an attempt to get it to move toward the wheelchair. R1 slid out of the sling and fell head first onto the floor. NA-C stated he thought all 4 points of the sling were attached at the time of the fall. NA-C stated the lift in use at the time this occurred was old and the wheels on the lift would lock or catch at times and the staff had to forcefully push the lift to get it to move. NA-C stated the staff had reported the issue of the lift wheels catching to maintenance on prior occasions, but the problem continued. During an interview with NA-E on 11/15/2016 at 9:55 a.m., NA-E stated she was assisting NA-C with the transfer of R1 on 9/7/2016. NA-C stated she thought the straps on the sling were hooked up as usual during the lift. When the staff attempted to turn the Hoyer, the wheels stuck and the staff had to yank on the lift to get it to move. R1 then fell head first out of the lift. After R1 fell NA-E noted that one of the four straps that had been attached to the lift was hanging loose. NA-E stated that the wheels on this lift had a history of [REDACTED]. During an interview on 11/15/2016 at 10:35 a.m., LPN-D stated on 9/7/2016 she was called into R1's room and R1 was on the floor and was bleeding from her head. The Hoyer sling was hanging from the lift with 3 of the 4 sling attachment points attached to the lift. R1's vital signs were stable, but she was crying out in pain. LPN-D stated she had staff call 911 and sent R1 to the hospital for evaluation. LPN-D stated R1 has since returned from the hospital and has returned to her baseline condition. LPN-D stated the staff had no explanation as to how the sling became detached from the lift. During an interview with Maintenance staff (MS)-F and MS-G on 11/15/2016 at 12:20 p.m., they stated the lift involved in the incident had been removed from the facility and was not available for observation because they were not able to replace the wheels in the lift so the lift was discarded. MS-F and MS-G stated in July 2016 they received a concern related to wheels sticking on a lift, but they were not able to identify which lift staff were talking about, because there was no consistent way to identify the lifts in use at the facility. In July 2016 they stated they lubricated the wheels and cleaned the wheels on the lifts. Maintenance staff stated they had no documentation of the maintenance done on the lift in question because the maintenance staff do not use the same descriptions of the lifts as the nursing assistant staff, so they just have to walk around and try to ask staff which lift they are referring to when they get a concern. Maintenance staff stated the maintenance they provide monthly includes a monthly cleaning, dusting and oiling of the lifts, but this is not documented anywhere. During an interview on 11/15/2016 at 1:10 p.m., R1 stated she fell when staff were helping get her up. R1 stated she did not know what happened, but she had severe pain after the fall and had stitches to her head. R1 stated she is feeling better, but still has pain related to the injuries sustained from the fall. The manufacturers instructions for the EZ way Smart Lift, provided by facility staff, revised 8/10/15 revealed: All EZ Way equipment must be maintained regularly by competent staff according to the maintenance checklist provided. 1) Check wear of the hanger assembly bushing by moving the hanger assembly up and down. If hanger assembly moves up and down and the thickness of 2 quarters can be inserted between the hanger assembly and the load cell the hanger assembly needs to be replaced. 2) Check all bolts to ensure they are tight. 3) Check boom hanger assembly pivot bolt, peel rubber back to assure nut is tight and cotter pin is in place. Check boom to mast pivot bolt by removing plastic cap to assure nut is tight and cotter pin is in place. If plastic cap is missing order replacement. 4) Check the point where the sling hanger and hanger spreader bar meet. If excessively worn, replace the bushings immediately. The hanger spreader and the sling hanger wear points need to be checked for wear. If hooks appear worn, call EZ Way for instructions .9) check all wheels and brakes to make sure they are functioning properly. Hair that gets picked up and wrapped between wheels should be cleaned out so that the lift will roll easily.

Based on interview and record review, the facility failed to implement policies to prohibit neglect for 1 of 6 residents reviewed, Resident #1 (R1), when the facility had no adequate scheduled maintenance system for patient lift devices, and the wheels on the EZ Way (hoyer/mechanical) lift device were sticking. During a lift, the wheels stuck, and when staff attempted to move the lift, a strap of the sling came off the lift and R1 fell from the lift. R1 was hospitalized and required stitches to her head. Findings include: Medical record review revealed R1 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. R1's care plan, dated 6/27/2016 indicated R1 was to be transferred with the maximum assistance of 2 staff and a Hoyer lift. (A Hoyer lift is a mechanical lift device that uses a sling and the device to lift a resident and move them from one surface to another, such as from a bed to a chair.) Nursing notes dated 9/7/2016 and written by Licensed Practical Nurse (LPN)-D revealed R1 was on the floor on her right side after sliding out of the hoyer body sling and falling to the floor. R1 was noted to be bleeding from her head and was sent to the hospital for evaluation. Hospital records dated 9/7/2016 revealed R1 was admitted to the hospital following a fall due to mechanical reasons. R1 was diagnosed with [REDACTED]. CT scan and X-rays were negative, and R1 transferred back to the facility the next day with her pain controlled with oral medications. During an interview on 11/15/2016 at 9:30 a.m., Nursing Assistant (NA)-C stated on 9/7/2016 at about 7:00 a.m. NA-C was assisting NA-E to get R1 out of bed and ready for breakfast. NA-C stated they put the Hoyer sling under R1 and hooked the sling to the lift in the usual manner. NA-C and NA-E lifted the resident off the bed and she looked stable in the lift and sling. When they attempted to turn the Hoyer to move the resident to the wheelchair the lift wheels caught, and NA-C had to forcefully push the lift in an attempt to get it to move toward the wheelchair. R1 slid out of the sling and fell head first onto the floor. NA-C stated he thought all 4 points of the sling were attached at the time of the fall. NA-C stated the lift in use at the time this occurred was old and the wheels on the lift would lock or catch at times and the staff had to forcefully push the lift to get it to move. NA-C stated the staff had reported the issue of the lift wheels catching to maintenance on prior occasions, but the problem continued. During an interview with NA-E on 11/15/2016 at 9:55 a.m., NA-E stated she was assisting NA-C with the transfer of R1 on 9/7/2016. NA-C stated she thought the straps on the sling were hooked up as usual during the lift. When the staff attempted to turn the Hoyer, the wheels stuck and the staff had to yank on the lift to get it to move. R1 then fell head first out of the lift. After R1 fell , NA-E noted that one of the four straps that had been attached to the lift was hanging loose. NA-E stated that the wheels on this lift had a history of [REDACTED]. During an interview on 11/15/2016 at 10:35 a.m., LPN-D stated on 9/7/2016 she was called into R1's room and R1 was on the floor and was bleeding from her head. The Hoyer sling was hanging from the lift with 3 of the 4 sling attachment points attached to the lift. R1's vital signs were stable, but she was crying out in pain. LPN-D stated she had staff call 911 and sent R1 to the hospital for evaluation. LPN-D stated R1 has since returned from the hospital and has returned to her baseline condition. LPN-D stated the staff had no explanation as to how the sling became detached from the lift. During an interview with Maintenance staff (MS)-F and MS-G on 11/15/2016 at 12:20 p.m., they stated the lift involved in the incident had been removed from the facility and was not available for observation because they were not able to replace the wheels in the lift so the lift was discarded. MS-F and MS-G stated in July 2016 they received a concern related to wheels sticking on a lift, but they were not able to identify which lift staff were talking about, because there was no consistent way to identify the lifts in use at the facility. In July 2016 they stated they lubricated the wheels and cleaned the wheels on the lifts. Maintenance staff stated they had no documentation of the maintenance done on the lift in question because the maintenance staff do not use the same descriptions of the lifts as the nursing assistant staff, so they just have to walk around and try to ask staff which lift they are referring to when they get a concern. Maintenance staff stated the maintenance they provide monthly includes a monthly cleaning, dusting and oiling of the lifts, but this is not documented anywhere. During an interview on 11/15/2016 at 1:10 p.m., R1 stated she fell when staff were helping get her up. R1 stated she did not know what happened, but she had severe pain after the fall and had stitches to her head. R1 stated she is feeling better, but still has pain related to the injuries sustained from the fall. The manufacturers instructions for the EZ way Smart Lift, provided by facility staff, revised 8/10/15 revealed: All EZ Way equipment must be maintained regularly by competent staff according to the maintenance checklist provided. 1) Check wear of the hanger assembly bushing by moving the hanger assembly up and down. If hanger assembly moves up and down and the thickness of 2 quarters can be inserted between the hanger assembly and the load cell the hanger assembly needs to be replaced. 2) Check all bolts to ensure they are tight. 3) Check boom hanger assembly pivot bolt, peel rubber back to assure nut is tight and cotter pin is in place. Check boom to mast pivot bolt by removing plastic cap to assure nut is tight and cotter pin is in place. If plastic cap is missing order replacement. 4) Check the point where the sling hanger and hanger spreader bar meet. If excessively worn, replace the bushings immediately. The hanger spreader and the sling hanger wear points need to be checked for wear. If hooks appear worn, call EZ Way for instructions .9) check all wheels and brakes to make sure they are functioning properly. Hair that gets picked up and wrapped between wheels should be cleaned out so that the lift will roll easily.

Based on observation, interview and document review the facility failed to ensure 1 of 1 resident (R49) with a pressure ulcer received care and treatment in accordance with recommendations and treatment orders, resulting in harm to the resident. Findings include: R49 had a stage III pressure ulcer (defined as an observable pressure-related alteration of skin with full thickness tissue loss) on the coccyx and did not receive treatment as ordered for 4 days, resulting in an increase in size of the ulcer. The resident also failed to receive orders for protein powder supplementation to promote wound healing, as recommended by the facility's dietitian. R49 was admitted to the facility on [DATE]. The resident's admission assessment indicated R49 had intact skin with no areas of breakdown. The resident's quarterly Minimum Data Set assessment dated [DATE], indicated that R49 was at risk for pressure ulcers and currently had a stage III pressure ulcer at the time of assessment. The resident was receiving a pressure relieving mattress and wheelchair cushion, was on a repositioning program and receiving nutritional interventions. The resident was coded as occasionally incontinent of bowel and bladder and required extensive assistance in mobility and transferring. [DIAGNOSES REDACTED]. A Checklist of Skin Risk Factors and Interventions (undated) was completed for R49. The facility rated the resident ' s Braden Score (a sale that measures risk for skin breakdown) as 15, or at mild risk. The resident ' s other risk factors were listed as needs assistance with ADL ' s, low [MEDICATION NAME] (a measure of serum protein), pain, diabetic, depression and a current stage III pressure ulcer on the coccyx. A Wound Flow Sheet was initiated on 11/13/11 for R49 indicating the resident had developed a stage III pressure ulcer on the coccyx. The ulcer was measured as 1 centimeter (cm) in length by 1 cm in width. The wound was described as 100% slough (necrotic tissue that is light colored, soft and moist) with no undermining or tunneling of the wound. The Resident Wound Log dated 11/14/11 indicated that the resident ' s family, physician and the registered dietitian (RD) were notified of the pressure ulcer on 11/13/11. The log indicated that the resident had complained of butt pain on the morning of 11/13/11 and the ulcer was found during a bath. A repositioning schedule was initiated for every twp hours, but it was noted that the resident preferred to remain on her back. Wound Flow Sheets for R49 were reviewed from 11/21/11 through 2/24/11. The resident's pressure ulcer showed slow improvement from 11/14/11 through 1/31/12, decreasing in size from 0.8 cm by 1 cm on 11/21/11 to 0.2 cm by 0.2 cm on 1/31/12. On 2/8/12, a dietary note indicated that the resident ' s wound continued to improve, but [MEDICATION NAME] levels drawn on 1/10/12 were low. The dietitian wrote a recommendation for one scoop of protein powder twice daily to be added to the resident's food or fluids to increase protein levels to assist in wound healing. On 2/14/12 the wound was measured at 0.4 cm by 0.2 cm, an increase from the previous measurement, and continued to have no drainage, undermining or tunneling. A dietary note dated 2/17/12 indicated that the resident ' s wound was larger and that the resident had lost weight. Again, one scoop of protein powder twice daily was recommended to aid in wound healing. A review of physician's orders [REDACTED]. On 2/20/12 the wound size was 0.5 cm by 0.5 cm, with a moderate amount of tan drainage. There was tunneling noted at 12 o'clock through 6 o'clock with 0.8 cm depth. The resident complained of tenderness at the time of the assessment. The note indicated the nurse practitioner (NP) was notified and prescribed new treatment orders. Physician orders [REDACTED]. On 2/22/12 a nursing progress note indicated R49 complained of severe butt pain related to the open area on the coccyx. The area was described as dark pink with a fluid discharge. The resident complained of severe pain during the dressing change. The resident's certified nurse practitioner (CNP) was notified to obtain an order for [REDACTED]. Physician orders [REDACTED]. No changes were made to the treatment for [REDACTED]. On 2/24/12 a nursing progress note indicated the CNP observed R49's pressure ulcer. The CNP noted clear yellow drainage and discomfort during the treatment of [REDACTED]. Physician orders [REDACTED]. On 2/27/12 R49 was seen by a registered nurse (RN-B) from a specialized wound clinic. RN-B measured the wound opening at 0.3 cm by 0.2 cm. Undermining at 12 o'clock was measured at 1.5 cm and 2 cm at 7 o'clock. RN-B noted creamy drainage from the wound, and that the area was painful to minimal pressure with the exam. The surrounding skin was noted to have a papular rash. RN-B suspected that the wound was larger than it appeared on the surface, and recommended the area be opened by surgeon to further assess it. Orders for a plan of treatment were provided to the facility by RN-B on 2/27/12. This included applying [MEDICATION NAME] gel to inside of the wound to numb it, fully irrigate with saline, irrigate with dilute Hibicleanse, and rinse again with saline. Roll gauze lightly dampened with saline and tuck into wound to get into undermining and stretch the opening. Apply [MEDICATION NAME] to wound and cover with foam dressing and tape. Change daily. RN-B also recommended a Group 2 mattress for pressure relief, and 3-4 inch foam overlay for additional wheelchair padding. The Pressure Ulcer and Impaired Skin Integrity Care plan for R49, last updated January 2012, was reviewed. The care plan problem was listed as: at risk for impaired skin integrity due to decreased mobility, occasionally incontinent of bowel and bladder, and refuses meals at times. The goal was listed that the R49 would have no skin breakdown this quarter. Approaches included Braden assessment per protocol and as needed, reposition every two hours, skin audits on bath days, treatments as needed, diabetic foot care at bedtime, air mattress, dressing to skin breakdown per orders and in-house wound nurse to follow. A clinical manager (CM-A) was interviewed on 2/28/12 regarding the resident's current treatment plan. CM-A indicated that she was waiting for a number of supplies to be delivered and would not be completing the wound care clinic's treatment orders from 2/27/12 until supplies arrived. CM-A was interviewed on 2/29/12; the nurse indicated that she was still waiting on supplies to be delivered. CM-A was interviewed at 10:30 a.m. on 3/1/12. CM-A indicated the facility was still waiting on [MEDICATION NAME] powder to be delivered and that she had not yet initiated the wound clinic treatment orders from 2/27/12. CM-A stated that they were still following treatment orders the Nurse Practitioner made on 2/24/12. The CM indicated that they had not notified R49's physician that the treatment orders from 2/27/12 had not yet been initiated and that the physician was likely unaware the previous order was still being used. The CM indicated that the wheelchair cushion recommended by the wound care clinic was due to be delivered later that day. The facility's certified dietary manager (CDM) was interviewed at 8:15 a.m. on 3/1/12. The CDM was unaware that the dietician had recommended protein powder for R49 in 2 consecutive dietary notes. The CDM indicated that the dietary staff typically fill out a Nutritional Recommendations form and give it to the CDM following each visit. The CDM would then seek out physician orders [REDACTED]. The CDM confirmed that R49 did not currently have orders for protein powder as recommended. The CDM stated the facility did not have a policy on communication between dietary staff. The facility ' s consultant registered dietitian (RD) was interviewed at 9:15 a.m. on 3/1/12. The consultant dietician confirmed that a Nutritional Recommendations form would have been completed by the dietitian for any recommendations made for R49, which would have been given to the CDM to obtain physician orders. The RD provided a copy of a Nutritional Recommendations form dated 2/17/12 indicating the dietitian requested R49 start one scoop of protein powder daily. The resident did not allow observation of the pressure ulcer by survey staff, but the CM-A provided measurements of R49's pressure ulcer at 2:00 p.m. on 3/1/12. Measurements were 0.5 cm by 0.3 cm with tunneling at 7 o'clock a depth of 3 cm and from 12 o'clock to 6 o'clock a depth of 2 cm, indicating the pressure ulcer had increased in size and depth since the wound nurse had measured the area on 2/27/12. The facility's Skin Integrity Prevention/Management Policy and Procedure dated 2/11 was reviewed. The policy stated that residents were to be screened for any risk factors for pressure ulcer development, to determine tissue tolerance, and to develop an individualized plan of care for prevention. Evaluation and assessment using the Braden Scale, Tissue Tolerance of each resident for risk would occur on admit, quarterly and as needed with any change. For ulcers that were not improved or show now progression toward healing in two weeks, the physician would be notified for a change in the treatment plan.