Every finding on record at Shell Rock Senior Living

Based on observation, staff interviews, and policy review the facility failed to clean the kitchen convection oven and handwashing sink. In addition, the facility failed to ensure staff wore hairnets and didn't touch food with their contaminated gloved hands. The facility reported a census of 34 residents. Findings include: During an initial kitchen walk through on 9/2/25 at 9:18 AM observed the white hand washing sink had a dark brown discoloration around the drain measuring approximately 6 inches by 6 inches. In addition, the convection oven had a brown-like sticky discoloration on the inside and the outside of the doors, throughout the inside of the oven and on the metal racks. An observation of the Dietary Manager wearing a baseball cap without a hair net, and the hair appeared over one inch in length protruding out below the baseball cap. During a follow-up walk through observation on 9/3/25 at 11:56 AM the hand washing sink continued to have a dark brown discoloration around the drain measuring approximately 6 inches by 6 inches. The convection oven also continued to have a brown sticky-like discoloration on the inside and outside of the doors and throughout the inside of the oven and on the metal racks. During an observation on 9/3/25 at 11:59 AM the Dietary Manager held a cool whip container with a gloved hand and a spatula with another gloved hand. As she scooped out the cool whip onto the dessert to serve, she took the gloved hand holding the cool whip container and used her index finger to scrape off the spatula to get the whip cream to cover dessert. During the observation, she continued to wear a baseball cap without a hairnet. During an observation of the noon meal service on 9/3/25 from 11:55 AM to 12:55 AM while wearing gloves, Staff D, Cook, touched the diet name cards, serving utensils, plates, and transportation carts. Staff D proceeded to grab the garlic bread and place one on each residents' plate with the same gloved hands. Staff D served approximately 32 servings of garlic bread with contaminated gloves During an interview on 9/3/25 at 12:55 PM Staff D revealed he didn't use tongs during meal service and instead grabbed each piece of garlic bread and set them on the plates with his gloved hands. He explained as long as he had gloves on, he didn't need to use a tongs to touch the bread. During an interview on 9/3/25 at 2:45 PM the Infection Preventionist said she hadn't completed audits on the kitchen practices.During an interview on 9/4/25 at 10:47 AM the Director of Nursing (DON) reported she didn't know why Staff D wore gloves during 9/3/25 noon meal service, as that isn't their normal routine. She expected them to use tongs to place the bread on the plates. During an interview on 9/4/25 at 10:37 AM the Administrator revealed she would expect the Dietary Manager to wear a hairnet and not just a baseball cap. She also informed Staff D during the 9/3/25 noon meal service does not normally wear gloves as that is not their normal routine and practice and believe it was due to being nervous, and food should not be touched with contaminated gloves. The facility's undated General Food Preparation and Handling policy directed the following: a. Clean and sanitize the kitchen surfaces and equipment as appropriate. b. Disposable gloves are single use item and should be discarded after each use. Employees should wash hands prior to putting gloves on and after removing gloves. c. Food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas or other suitable implements to avoid manual contact with prepared foods. d. Use tongs or other servings utensils to serve breads or other items to avoid bare hand contact with food

Based on clinical record review, observation, policy review, and staff interviews, the facility failed to have a separate entrance and exit for clean and dirty laundry into the laundry room. In addition, the facility failed to use proper infection control practices when staff touched resident medication with their bare hand prior to medication administration. The facility reported a census of 34 residents. Findings include:1. On 9/3/25 at 1:48 PM observed the laundry room, the staff used the same entrance and exit for clean and dirty laundry items. The room entrance/exit measured approximately 5 feet in width and couldn't keep workflow from cross-contamination. During an interview on 9/3/25 at 1:52 PM the Laundry Manager reported they used the same exit and entrance for clean and dirty laundry items. During an interview on 9/3/25 at 2:45 PM the Infection Preventionist explained she hadn't completed audits on laundry. During an interview on 9/4/25 at 10:47 AM the Director of Nursing (DON) said having clean and dirty laundry going in and out the same door wouldn't prevent cross-contamination. 2. During an observation on 9/3/25 at 3:19 PM Staff A, Certified Medication Aide (CMA), failed to perform hand hygiene after leaving the medication cart to go to the medication room. She returned carrying a cold tub of pudding and supplement drinks. Staff A pulled the medication cart keys from her pocket, unlocked the medication cart, touched the laptop mouse, and laptop keypad. Staff A reviewed Resident #31 Electronic Medication Administration Record (EMAR) for acetaminophen (Tylenol) 650 milligrams (MG) scheduled at 4:00 PM. Staff A pulled a stock bottle of acetaminophen from the medication cart, shook out two 325 MG tablets from the bottle into the lid with one of the pills falling to the left outside of the medication cup. Staff A picked up the acetaminophen tablet with her bare left hand and placed the pill back in the cup. Staff A then administered the medication to Resident #31. Resident #31's September 2025 EMAR showed Staff A signed to indicate administration of the acetaminophen 650 MG at 4:00 PM. Interview on 9/4/25 at 8:34 AM Staff B, CMA, reported staff shouldn't touch medications with their bare hands. She used a spoon or a glove to handle medications. Interview on 9/4/25 at 8:35 AM Staff C, Licensed Practical Nurse (LPN), voiced staff should never touch pills with bare hands. She would put on a glove to handle a pill. In addition, she explained someone should complete hand hygiene before starting and ending a medication pass. During an interview on 9/4/25 at 9:17 AM the Director of Nursing (DON) explained staff should complete hand hygiene before and after a medication pass. She expected the nurses and/or CMAs to do hand hygiene after logging onto the computer and before setting up the medications. The nurses/CMAs should sanitize their hands or put on a glove if they need to touch a resident's medication. The Medication Management-Medication Administration Policy updated 4/16/24 directed to clean hands before handling medication and before having contact with the resident. The Policy failed to address how staff responsible for medication pass should touch medications during medication set up.

Based on observation and staff interviews the facility failed to post daily staffing in a visible place for all visitors and residents to see. The facility reported a census of 34 residents.Findings include: During an observation on 9/2/25 at 10:42 AM the facility posted the Daily Staffing on a bulletin board behind the nurses' station out of view of residents, families, and visitors.During an observation on 9/3/25 at 1:55 PM the Daily Staffing remained at the same place out of site from residents, families, and visitors behind the nurses' station. During an interview on 9/4/25 at 10:37 AM the Administrator reported they kept the Daily Staffing behind the nurses' station. During an interview on 9/4/25 at 10:47 AM the Director of Nursing (DON) explained they used to keep the staff in the hallway in front of the nurses' station until the tack board broke. Now it's positioned behind the nurses' station.

Based on record review, observation, staff interview, and policy review the facility failed to provide the correct portion size of 8 ounce (oz.) of chicken and pasta alfredo for 32 of 34 residents during a meal observation on 9/3/25 at the noon meal service. The facility reported a census of 34 residents. Findings include:The facility's menu for the noon meal on 9/3/25 titled, Week 2 Wednesday, dated 5/14/25 instructed to provide 8 oz. of chicken and pasta alfredo. During an observation of the noon meal service on 9/3/25 from 11:55 AM to 12:55 AM, Staff D, Cook, used a 6 oz. scoop instead of an 8 oz. scoop as the menu directed for serving 32 servings of chicken and pasta alfredo. During an interview on 9/3/25 at 12:53 PM the Dietary Manager reported they provided a heaping 6 oz. scoop of the chicken and pasta alfredo to all residents instead of using an 8 oz. scoop as they didn't have 8 oz scoops in the facility and needed to order more. She explained she told Staff D he should use 2, four (4) oz. scoops, but he didn't. During an interview on 9/3/25 at 12:55 PM Staff D said he used a 6 oz. scoop of chicken and pasta alfredo instead of the 8 oz. scoop as the facility didn't have any 8 oz. scoops. During an interview on 9/4/25 at 10:47 AM the Director of Nursing (DON) stated she expected all residents get the intended scoop size of the chicken and pasta alfredo. She added if the facility didn't have an 8 oz. scoop, they should have placed an order to get new ones. During an interview on 9/4/25 at 10:37 AM the Administrator reported she expected the staff to follow the menu and use the scoop size as directed. The facility's undated Select Menu policy lacked direction to use the proper scoop sizes.

Based on observation, staff interviews, and policy review the facility failed to keep flies off the food prior to serving. The facility reported a census of 34 residents. Findings include: During an observation on 9/3/25 at 12:08 PM a fly landed on two (2) bowls of crushed pineapple, then flew over, and landed on pureed peas. The kitchen had (4) flies present during the observation in the kitchen and one (1) dead fly noted on a cupboard door from 11:55 AM to 12:55 AM. During an interview on 9/3/25 at 2:45 PM the Infection Preventionist reported she hadn't completed audits on practices in the kitchen.During an interview on 9/4/25 at 10:37 AM with the Administrator explained the facility had bug traps but didn't know when pest control last came to the facility. She reported flies shouldn't land on the food during food service. Review of the facility's undated General Food Preparation and Handling policy instructed to prepare food items to conserve maximum nutritive value, develop, enhance flavor, and keep free of harmful organisms and substances. Review of the facility's undated policy Pest Control Program directed the facility to use a variety of methods to control certain seasonal pests, i.e. (example) flies. The program would involve indoor and outdoor methods deemed appropriate by the outside pest service, state and Federal regulations.

Based on clinical record review, staff interview and policy review the facility failed to identify a weight loss and notify the primary care provider (PCP), dietitian, and/or family for 1 or 2 residents (Resident #3) reviewed for weight loss. The facility identified a census of 34 residents. Findings include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 8/14/25. The MDS indicated Resident #3 weighed 191 pounds (#) at admission.The Order Summary Report (physician orders) included an order dated 8/18/25 to complete daily weights. In addition, call the PCP if Resident #3 had a difference in weight as 3# or more in a day, or 5# or more in a week. The Weights and Vitals Summary viewed 9/3/25 listed only the following weights. The dates not listed, lacked a weight:a. 8/14/25 191.4# b. 8/20/25 197.5# (difference of 6.1#). c. 8/23/25 191.4 (difference of 6.1#)d. 8/24/25 191.4#e. 8/25/25 188# (difference of 3.4#)f. 8/26/25 191.2# (difference of 3.2#)g. 8/28/25 186# (difference of 5.2#)h. 8/29/25 186#i. 8/30/25 186#j. 8/31/25 185#k. 9/1/25 180.5# (difference of 5.5#)l. 9/2/25 179#m. 9/3/25 180# The Progress Note written by Staff E, Licensed Practical Nurse (LPN), on 8/14/25 at 3:07 PM documetned the resident weighed 191.4# and was on a regular diabetic diet with unknown likes and dislikes. The clinical record lacked any further documentation of nutritional status or weights. The Nutritional Assessment Note written by Staff F, Dietitian, on 8/17/25 at 5:07 PM acknowledged the resident's weight as 191.4# on 8/14/25.The clinical record lacked any additional documentation by the Dietitian. The clinical record lacked documentation the facility notified the PCP or family. During an interview on 9/3/25 at 5:00 PM the Director of Nursing (DON) explained the Dietitian didn't know about Resident #3's weight loss and didn't address the loss. She added the facility didn't notify the PCP of any of the weight increases and decreases as ordered. During an interview on 9/4/25 at 11:47 AM, the administrator explained the facility didn't have a weight loss policy, that they followed the current standard of practice. She deferred to the Nurse Consultant when asked which standards of practice the facility followed. The Nurse Consultant explained the facility didn't have a weight loss policy, but she expected the facility to follow physician's orders. During an interview on 9/4/25 at 11:51 AM, the DON explained she didn't do any weekly notification to the Dietitian about weight loss.

Based on clinical record review, Center for Medicare and Medicaid (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User Manual, and staff interview the facility failed to complete a significant change in condition assessment for 1 of 1 residents admitted to hospice care services (Resident #23). The facility identified a census of 34 residents.Findings include:/Resident #23's Minimum Data Set (MDS) assessment dated 6 /18/25 identified a Brief Interview for Mental Status (BIMS) score of 9, indicating a moderate cognitive loss. The MDS included diagnoses of stroke, atrial fibrillation (irregular heart rate), high blood pressure, diabetes mellitus, and pain unspecified.Resident #23's Clinical Census reviewed 9/3/25 identified Resident #23 admitted to hospice care on 6/19/25. The Hospice Visit Noted dated 6/19/25 at 6:41 PM reflected Resident #23's legal representative signed paperwork for her to start hospice care services with a primary diagnosis of stroke and a secondary diagnosis of failure to thrive with congestive heart failure. The Progress Note reflected hospice left copies of her hospice admission paperwork for the Director of Nursing (DON) and the Business Office/Executive Director. A Hospice Election Form signed by Resident #23's legal representative documented a date of 6/19/25. A Hospice Comprehensive Assessment and Plan of Care Update Report documented a Start of Care (SOC) date of 6/19/25 and documented the last hospice visit date as 6/25/25. The reason listed for the meeting as Resident #23's a new admission to hospice care. The Care Plan Focus initiated 7/3/25 documented Resident #23 had a terminal diagnosis that required hospice care and directed the staff to observe for signs and symptoms of discomfort and to report to the nurse. An Order Summary Report signed by the Provider on 8/5/25 lacked documentation of a hospice order. An CMS 802 Matrix form provided by the facility on 9/2/25 lacked documentation Resident #23 received hospice care services. A 9/2/25 review of Resident #23's MDS Summary Page lacked completion of a documented SCSA MDS when Resident #23 admitted to hospice care. During an interview on 9/3/25 at 12:38 PM the Assistant Director of Nursing (ADON) explained she completed a SCSA MDS when someone admitted or discharged from hospice care or if they have a change in condition from their baseline. The ADON reviewed Resident #23's MDS Summary Page and reported she did a quarterly MDS on 6/18/25, but missed the SCSA MDS for admission to hospice care.On 9/3/25 at 12:57 PM the Regional Nurse Consultant verbalized the facility didn't have an MDS Policy but, they followed the RAI Guidelines. The CMS LTC RAI 3.0 User's Manual, Version 1.19.1 October 2024, Chapter 2, page 2-24 and 2-25 under Significant Change in Status Assessment (SCSA) directed the SCSA is a comprehensive assessment that must be completed when the interdisciplinary team (IDT) determined that a resident met the significant change guidelines for either a major improvement or decline. A Significant Change is defined as a major decline in a resident's status that: will not normally resolve itself without interventions by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting. Impacts more than one area of the residents' health status; and requires interdisciplinary review and/or revision of the care plan. An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing.

Based on record review and staff interviews the facility failed to have a full time (40 hours a week) Director of Nursing (DON) at the facility. In addition, the facility failed to have eight (8) hours of consecutive Registered Nurse (RN) coverage a day for 4 of 30 days reviewed. The facility reported a census of 34 residents. Findings include: Record review of nursing schedules from 8/12/24 to 9/12/24 lacked RN coverage for 4 days: 8/16/24, 8/19/24, 8/28/24, and 9/2/24. During an interview on 9/13/24 at 11:16 AM the Administrator confirmed the facility didn't have 8 consecutive hours of RN coverage from 8/12/24 to 9/12/24. The days that the facility didn't have RN coverage: 8/16/24, 8/19/24, 8/28/24, and 9/2/24. During an interview on 9/15/24 at 11:46 AM the DON reported being the current DON as of 9/12/24. She informed she came to the facility for a routine rounding visit, as she is Regional Clinical Quality Specialist for the facilities corporation. She let she let the DON at the time know the state entered the building for the annual recertification survey and the DON said she no longer wanted to be the DON and gave notice effective immediately. She also reported she expected to have a full-time DON employed at the facility and have 8 hours of RN coverage a day. The Administrator informed on 9/15/24 at 12:29 PM the prior DON last worked in the facility on 8/12/24. They said the prior DON hadn't been to the facility since. They wanted her license removed and she would no longer be the DON of the building effective 9/12/24.

Based on observation, record review, resident and staff interviews the facility failed to provide routine repositioning for 1 of 3 residents (Resident #19). The facility reported a census of 34 residents. Findings include: Resident #19's Minimum Data Set (MDS) assessment date 8/14/24 identified a Brief Interview of Mental Status (BIMS) score of 8, indicating severely impaired cognition. Resident #19 required total assistance from staff for transfers and bed mobility. The MDS reflected he didn't walk. The MDS included diagnoses of hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), hip fracture, and a need for assistance with personal care. On 9/14/24 at 1:15 PM Staff A, Certified Nurse Aide (CNA), reported Resident #19 will get up in the morning and staff didn't assist him to lay down or reposition him until after lunch on most days of the week. She added the staff never reposition him when in bed. The Care Plan Focus dated 6/18/21 reflected Resident #19 had limited physical mobility with a high fall risk related to a stroke. The Intervention instructed Resident #19 required assistance of 2 staff to reposition and turn in bed. On 9/14/24 at 2:12 PM Resident # 19 revealed he laid in bed and didn't get get repositioned while in his bed. During an interview on 9/15/24 at 11:56 AM the Director of Nursing (DON) reported they expected all dependent residents to receive routine repositioning.

Based on observation, policy review, staff, and resident interview, the facility failed to find or replace 1 of 1 resident (Resident #25) hearing aides when they identified them missing. The facility reported a census of 34 residents. Findings include: Resident #25's Minimum Data Set (MDS) assessment dated [DATE] reflected he wore a hearing aid. The MDS identified a Brief Interview of Mental Status (BIMS) of 9, indicating moderately impaired cognition. The MDS included diagnoses of dementia, depression, and need for assistance with personal care. The Progress Note dated 6/13/24 at 9:36 AM reflected he saw his Doctor at the facility. The facilities Social Worker (SW) must review with him regarding lost hearing aids. On 9/13/24 at 11:21 AM Resident #25 reported he lost his hearing aids a few months ago and is hard of hearing. He explained it bothered him and he didn't want to talk because he couldn't hear. On 9/15/24 at 11:52 AM the Director of Nursing (DON) reported she believed the SW had the responsibility of looking into the situation but went on leave and it possibly got overlooked. She explained she expected the staff find or replace Resident #25 hearing aids as soon as possible so he could effectively communicate. During an interview on 9/15/24 at 12:21 PM the Administrator explained he learned the SW last worked on 6/13/24 at the facility and currently taking leave. The Grievance Process policy, reviewed January 2023 instructed residents have the right to file grievances, and the facility will make prompt efforts to resolve grievances.

Based on record review and staff interview the facility failed to code the Minimum Data Set (MDS) to reflect 1 of 2 residents (Resident #1) reviewed for hospice was receiving hospice services. The facility reported a census of 34 residents. Findings include: Resident #1's Census documented she started hospice services on 9/28/23. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] lacked documentation that she received hospice services. On 9/15/24 at 11:53 AM the Director of Nursing expected the facility to code the MDS correctly if a resident received hospice services. The facility used the Resident Assessment Instrument (RAI) for guidance on accurate coding.

Based on observation, record review, resident interview, staff interview, facility kitchen photos, and facility policy review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure the kitchen had working equipment to clean the dishes, such as a dishwasher and garbage disposal. The dishwasher failed to release the required chemicals used to clean the dishes. The sink used for the garbage disposal had standing debris filled water. The tour of the kitchen revealed multiple items covered in dirt, dust, and debris. The kitchen had undated and open items. The meal planned for that evening's dinner had flies landing on the food. In addition, the kitchen had spiderwebs and mold in the kitchen. Due to the lack of working equipment used to disinfect and clean the dishes, the standing debris filled water, insects in the kitchen touching the food, the undated and opened food, this resulted in an immediate jeopardy situation that began on 6/27/24. The Department notified the facility on 7/18/24 at 4:05 PM. The facility removed the immediacy on 7/18/24 by completing the following: a. The facility disposed of the prepped evening meal around 3:00 PM and procured the evening meal from an outside source. b. The facility switched to paper products for all dinnerware until the repair of the dishwasher. c. The facility contacted their food and equipment provider around 3:00 PM to schedule the repair of the chemical dispensers on the dishwasher and the 3-compartment sink. The facility put these out of service until the completion of the appropriate repairs. d. The facility disposed of all undated/unlabeled food items. e. The facility initialized cleaning of the food debris in the refrigerators, counters, and other areas. The facility will have the cleaning of the areas completed prior to beginning any food prep in those areas. f. The facility added additional fly traps in the kitchen area. g. The facility contacted the regional maintenance person regarding the garbage disposal in the dish washing area. h. The facility-initiated staff education on the following: i. Food Storage ii. Employee Sanitary Practices iii. Dry Storage Areas iv. Cleaning and Sanitation of Food Service Areas v. Dish Machine vi. Pest Control The facility planned to procure food from alternative sources until they could address all areas of concern appropriately and the necessary utilities worked. The scope lowered from a L to F at the time of the survey after ensuring the facility implemented education with their policy and procedures. The facility identified a census of 33 residents. Findings include: During the tour of the kitchen on 7/18/24, the surveyor photographed the following at: a. 12 PM - A fly on the cake served to the residents at the same time. A dead fly on the counter top in the food prep area located by a bag of coffee. A buildup of grease, dust, dirt, and debris on an automatic shut off valve located between the stove and oven in the same area. b. 12:02 PM - Dust, dirt and debris on the fan located on the ceiling in the food prep area. c. 12:03 PM - Food, dirt and debris on the walls in the food prep area d. 12:04 PM - Dirt and debris built up on silverware located in a drawer in the food prep area. A buildup of dust, dirt, and debris along the lip of the inside of the same drawer. e. 12:05 PM - A buildup of dust, dirt and debris along the baseboard and floor around and under the oven and on the same oven. A buildup of a black substance on the surface area of the stove. A dark dried substance and debris in a wash basin located on the clean storage rack beside the stove. f. 12:06 PM - Food and debris splattered on a coffee dispenser located on the clean storage rack beside a three (3) compartment sink, a buildup of dust, dirt and debris on a ceiling vent located above the 3 compartments sink and clean storage rack beside the sink, food and debris on the lid of a crock pot stored on the same rack and a buildup of dust, dirt and debris on the floor and rack that stored the above stated items. g. 12:06 PM - An undated opened jar of minced garlic and a squeeze bottle of ranch dressing in the kitchen refrigerator. h. 12:07 PM - An opened can of diced pears covered loosely with aluminum foil a pitcher that contained applesauce, an undated open bag of parmesan cheese, and a buildup of a brown substance along the inside base of the refrigerator. i. 12:08 PM - A bag of unlabeled, undated, opened lunch meat. j. 12:09 PM - A small container of pink ice cream/sorbet position on its side, opened, spilled, and dripped down on a bag of tortilla shells in the freezer located beside the refrigerator. A buildup of dried food and food particles in the oven. k. 12:14 PM - The dishwasher's base/holding area contained tan colored water with food particles, a disposal sink full of tan, thick water with food items, a buildup of food particles along the parameter of the clean side of the dishwasher counter area located on the clean side of the machine, a buildup of dust, dirt and debris on top of the dishwasher. l. 12:18 PM - A wash basin which contained , steel wool devices and a soiled towel located on the bottom shelf of a 4 wheeled cart in the food prep area beside a [NAME]/oven cooking appliance. m. 12:24 PM - An open bag of spaghetti noodles located in an open box with food debris not dated in the dry storage area. n. 12:28 PM - Food and debris on clean dishes located on a storage rack positioned beside the serving table in the kitchen prep area. o. 12:31 PM - A garbage can positioned right beside the clean dishes used to serve the lunch meal. b. 12:33 PM - flies remained on various pieces of unserved cake. p. 12:38 PM - Dish cleaning racks used to run dishes through the dishwasher appeared gray in color, soiled with a black substance throughout the entire racks. q. 1:19 PM - observed an unknown staff member rinse the dishes in the disposal sink water, as described above, then position the dishes in the gray/black racks and run them through the dishwasher with the same water located in the base/holding area. r. 1:24 PM - witnessed an unknown staff member remove the dishes from the clean side of the dishwasher area and proceed to store them on the storage shelves. s. 2:04 PM - Spider webs and debris located on the racks that contained various food items and a plastic storage bin containing popcorn dated 5.1.23 located on the same rack in the dry storage area. t. 2:16 PM - A large, metal cooking pan with a debris filled lid, an undated and unlabeled dried food and a large bowl of strawberries and bananas in the refrigerator in the dining room. u. 2:17 PM - A pitcher containing applesauce with dried applesauce along the upper inside, spout and lid of the pitcher. v. 2:38 PM - A buildup of spiderwebs, dust, dirt and debris on the pipes beside the 3 compartment sink and storage rack which contained cleaned dishes, pans, and a buildup of mold on the floor in the same area located under the pipes as described above. On 7/18/24 at 12:50 PM observed the Dietary Manager (DM) tested the sanitization element of the cleansing red bucket Staff C, Environmental Aide, utilized to clean the dining room tables. The DM indicated the sanitizing agent tested at 25, she confirmed the test should have been 50. On 7/18/24 at 12:54 PM witnessed Staff C return to the kitchen area, empty the sanitizing bucket, and refill the bucket with the facility's sanitizing agent. The DM tested the sanitizing agent in the bucket which registered 0. The DM confirmed the observation. On 7/18/24 at 12:56 PM witnessed the DM test the sanitizing agent in the bucket Staff D, Cook, used to clean the dining room tables receive a 0 result. During an interview at the same time the DM confirmed the observation. Staff C proceeded to the dining area and wiped down more dining room tables. On 7/18/24 at 1:10 PM the DM checked the dishwasher sanitizing agent reveal a test result of 0, however the temperature reached 124 degrees F during the rinse cycle which registered within normal limits (WNL). On 7/18/24 at 1:19 PM observed Staff D rinse the dishes in the dirty, disposal water which contained disposed food and a variety of liquids. Staff D placed the dishes in the dishwasher, that didn't have a sanitizing agent, while Staff E, Dietary Aide, removed the items and stacked them on the storage racks in the kitchen. During an interview on 7/18/24 at 1:58 PM Staff D described the kitchen as dirty, but felt it is a work in progress. Staff D verified he observed a few flies in the kitchen area, the facility's dishwasher broke down 2 weeks prior to the disposal, and he knew food should have a label once opened and placed in the refrigerator or freezer. During an interview on 7/18/24 at 2:06 PM Staff F, Cook, confirmed the facility had a dirty kitchen. The disposal sink broke a couple weeks before, so it took longer to wash the dishes. The staff member verified the flies in the kitchen, he failed to test sanitizing agents, he knew food should have dates and labels when opened and stored in the freezer and refrigerator. During an interview on 7/18/24 at 2:12 PM Staff E confirmed she observed flies in the kitchen but felt they weren't too bad. During an interview on 7/18/24 at 4:30 PM the DM confirmed they cooked and served the fried potatoes without a label or date in the refrigerator in the dining area assessable to the residents on 7/5/24. In addition, they served the unlabeled and undated strawberries stored in the same refrigerator, on 7/16/24. A Dry Storage Areas policy and procedure dated 2021 directed the facility staff to maintain the dry storage areas to keep food safe and free of infestation or contamination. The procedures instructed to keep the floors, walls, shelves and other storage areas clean. The procedure directed canned and dry foods should have a label and a date of receipt so they use it within six (6) months of delivery. A Food Storage policy and procedure form dated 2021 defined the Policy as the facility provided sufficient storage facilities as a means to keep foods safe, wholesome, and appetizing. Store the food in an area clean, dry and free from contaminants. The Procedure instructed the following: a. Storage areas would have been free from rodent and insect infestation. b. Store the leftover food in covered containers or wrapped carefully and securely with a clear label and date before refrigerated. c. Cover, label, and date all food, then routinely monitor the facility consumed food, including leftovers, by their safe use by dates, frozen, or discarded. d. Keep all freezer units clean and in good working condition at all times. e. Cover, label, and date all frozen foods, to ensure the facility consumed or discarded the food by their safe use by dates. The facilities Cleaning and Sanitation of the Dining and Food Service Areas dated 2021 defined the policy as the food and nutrition services staff maintain the cleanliness and sanitation of the dining and food services areas through compliance with a written, comprehensive cleaning schedule. Review of June 2024 and July 2024 Facility Cleaning Schedule forms directed the facility staff to wash and sanitize the kitchen's can opener, food processor, toaster, mixer, steam table, prep tables, countertops, beverage table coffee urns, top of the dishwasher, stovetop/brill, kitchen floor, hand washing sink, food carts, the pot and pan sink in the mornings and nights. The facility staff failed to clean and sanitize the areas on the following dates: June 27th and 28th as well as July 1st thru the 13th. A Resource: Sanitation of Dishes/Dish Machine policy and procedure directed the facility staff the low temperature of the dishwasher spray type dish machines as 120 degrees Fahrenheit, used chemicals for sanitation.

Based on observation, record review, staff, and resident interview the facility failed to maintain and promote resident's dignity while serving meals for 3 of 3 residents reviewed (Residents #1, #2 and #3). The facility identified a census of 33 residents. Findings include: During an interview on 7/18/24 at 1:07 PM the Dietary Manager (DM) confirmed the facility had their garbage disposal broken for 2 weeks with the parts on back order. Prior to that their dishwasher had broken down but now functional. The DM also confirmed the dietary staff served all meals with paper products because of the dishwasher not functioning and then the disposal broken, but the residents didn't like it. On 7/18/24 at 12:03 PM observed the dietary staff serve the meal on ceramic plates. During an interview on 7/18/24 at 4:30 PM the DM confirmed the staff only served the noon meal on ceramic plates because of the presence of a Surveyor. On 7/18/24 at 5:30 PM saw the resident's meal served on paper plates with Styrofoam glasses and plastic silverware. On 7/19/24 at 12:10 PM observed the resident's meal served on paper plates with Styrofoam glasses and plastic silverware. During an interview on 7/18/24 at 2:43 PM Resident #1 indicated a month prior to the present the dietary staff served their meals on paper plates and plastic silverware because of a broken disposable and sink. At first the reason started with a broken dishwasher and now the waste disposal. Resident #1 reported if she or the surveyor had the issue, they would have immediately solved the problem. When she questioned the staff members about the repair process, they replied they required corporate approval. Resident #1 felt they used her money she paid every month to reside at the facility but failed to fix the problems. She paid a premium price out of her own pocket while she has resided at the facility. During an interview on 7/19/24 at 11:40 AM Resident #2 indicated the dietary staff served their meals on paper plates, Styrofoam glasses, and plastic silverware for quite a few weeks because of their broken dishwasher. Resident #1 declared she didn't like it. During an interview on 7/19/24 at 11:43 AM Resident #3 indicated the dietary staff served their meals on paper plates, Styrofoam glasses, and plastic silverware for several weeks. She didn't feel this was handy especially with the silverware. During an interview on 7/19/24 at 10:50 AM Staff A, Licensed Practical Nurse (LPN), explained the dietary staff served meals on paper plates with Styrofoam glasses and sporks as silverware which the residents hated. During an interview on 7/19/24 at 10:54 AM Staff B, Certified Medication Aide/Certified Nursing Assistant (CMA/CNA), explained the dietary staff served meals on paper plates with Styrofoam glasses and sporks as silverware. Staff B said the residents didn't like using those items, especially the sporks.

Based on observation, clinical record review, interviews, facility policy, and investigation review, the facility failed to ensure staff provided a safe transfer with a mechanical lift for 1 of 4 residents reviewed that required transfer assistance (Resident #1). Resident #1 sustained a fall on 2/19/24 from a mechanical lift transfer when the mechanical lift sling strap came undone resulting in Resident #1 falling to the floor feet first, striking their head, and receiving a left subtrochanteric femoral fracture (hip fracture). The facility reported a census of 34 residents. Finding include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired decision-making abilities. Resident #1 required substantial to maximal assistance with transfers and bed mobility. The MDS included diagnoses of cerebrovascular accident (stroke), non-Alzheimer's dementia, hemiplegia/hemiparesis (weakness/paralysis to one side of the body), and generalized weakness. Resident #1 had no falls since entry. The Care Plan Focus dated 6/8/21, identified Resident #1 as a high fall risk due to their history a stroke. The Goal listed Resident #1 wouldn't have a major injury related to a fall. The Interventions indicated Resident #1 required the assistance of two staff for transfers with a full mechanical lift with the large divided leg sling. The Care Plan Focus dated 2/19/24, identified Resident #1 had a left femur fracture related to a fall. The Goal reflected Resident #1 wouldn't have signs or symptoms of pain, would return to their previous routine, and have diminished pain. The Interventions directed the following: a. Resident #1 required a full-body mechanical lift to transfer and reposition with two staff members. b. Up in wheelchair for all meals. c. Stabilize left leg during bed mobility - no twisting or turning leg inward or outwards, limit hip bending as much as possible. An undated Self-Report reflected on 2/19/24, at approximately 11:00 AM, the Director of Nursing (DON) notified the Executive Director, Resident #1 fell from the full-body mechanical lift and sustained a laceration to his scalp. The facility sent him to the hospital by ambulance. The Hospital faxed documentation to confirm pelvic fracture on 2/21/24, around 9:00 AM. On 2/19/24, at approximately 10:20 AM, Staff A, Certified Nursing Assistant (CNA), and Staff B, CNA, provided perineal (peri-) care to Resident #1 in his room. Staff B heard the call light of another room go off over the walkie and left Resident #1's room to check on the other resident. Staff A continued working alone with Resident #1. Staff A connected Resident #1's sling to the full-body mechanical lift and began to transfer him from the bed to the wheelchair. Resident #1 began to vigorously cough, causing the sling to come undone from the hook on the lift. Resident #1 slid out of the sling, fell to the floor, and started to bleed from the top of his scalp. The DON's head to toe assessment on 2/19/24 revealed a bleeding head wound and decreased responsiveness. At 11:00 AM, on 2/19/24, emergency medical services (EMS) arrived and left with Resident #1 at approximately 11:20 AM. The inspection of the full-body mechanical lift sling used to transfer Resident #1 revealed the sling intact with no rips or tears. The Maintenance staff inspected the mechanical lift following the incident. The lift had a missing spring in the black loop clip on the full-body mechanical lift. Maintenance replaced the spring on 2/19/24, and tested the full-body mechanical lift to ensure proper functioning. Staff A and Staff B stated the full-body mechanical lift and clips worked properly prior to initiating the transfer. Resident #1's Care Plan at the time of the incident directed he required two staff for the full-body mechanical lift transfer. Two staff were not present as stated in the Care Plan at the time of the incident. The community will continue to follow the current Care Plan and add therapy's recommendations for transfers and repositioning. The maintenance staff inspected all of the mechanical lifts and slings in the facility on 2/19/24, to ensure they worked properly. On 2/19/24, the DON educated Staff A and Staff B on the facility's safe resident handling policy and observed them complete a full-body mechanical lift transfer in accordance with the facility full-body mechanical lift competency. The DON would educate all nursing staff regarding the facility safe resident handling policy and transfer competency. A Facility Fall Report and corresponding progress note documented by the DON, on 2/19/24 at 10:45 AM, revealed a CNA called from Resident #1's room requesting help and stated a resident fell . Upon entering the room, witnessed Resident #1 lying on his left side on floor, with a large amount of bloody drainage surrounding his head. The CNA reported she transferred Resident #1 with full-body mechanical lift, when he started vigorously coughing and the strap to lift came undone. At that time Resident #1 fell to the floor, hitting his head. Staff applied pressure to his observed laceration on his right occipital (back part of the brain). The nurse initiated a neurological (neuro) that revealed Resident #1 had a decreased response and labored breathing. The staff continued talking with Resident #1 and he became more alert, responding to questions with appropriate answers. The facility called the ambulance to transport him to the emergency room (ER). The Adverse Event Note dated 2/19/24 at 11:16 AM, reflected a CNA requested help in a resident's room because a resident fell . Resident #1 laid on his left side on the floor with a large amount of bloody drainage surrounding his head. The CNA reported as she transferred Resident #1 with the full-body mechanical lift, he began vigorously coughing and the strap came off the lift dropping Resident #1 to the floor, hitting his head. The staff applied pressure to the laceration on his right occipital. The completed neuro checks and head to toe assessment revealed decreased responsiveness and labored breathing. The nurse talked with Resident #1, as he became more alert, responding to questions with appropriate answers. The nurse contacted an ambulance for transport to the ER. The facility notified his wife who planned to meet him at the ER. At 11:00 AM, emergency medical services (EMS) arrived and left with Resident #1 at approximately 11:20 AM. Interview on 5/9/24 at 11:15 AM, Staff A confirmed on 2/19/24 at approximately 10:20 AM, Staff B and her placed the full-body mechanical lift sling underneath Resident #1 while he laid in bed, and then attached the sling to the full-body mechanical lift. Staff B heard on the walkie another resident had a call light sounding, so Staff B left his room. Staff A continued to transfer Resident #1 without Staff B assistance. While Staff A swung Resident #1 around to position him in the wheelchair with his back to the wheelchair, Resident #1 started to cough and on the third cough the front right side on the sling popped off the lift. Resident #1 started to fall out of the sling. Staff A stated that she attempted to stop him from falling but couldn't get around the full-body mechanical lift before Resident #1 landed on the floor. She hollered for a nurse to come to the room to assist Resident #1. Staff A recalled the sling and full-body mechanical lift in good working condition. Staff A, confirmed the facility policy instructed to always transfer a resident with two staff at all times. Staff A confirmed the facility educated her on using two staff with mechanical lift transfers at all times, double check sling placement, and the sling is connected correctly. Interview on 5/8/24 at 3:45 PM, Staff B confirmed on 2/19/24 at approximately 10:20 AM, Staff A and her placed the full-body mechanical lift sling underneath Resident #1 while he laid in bed, and then attached the sling to the full-body mechanical lift. Staff B heard a call light going off in another resident's room on the walking and then left Resident #1's room. When Staff B returned, she saw Resident #1 on the floor with blood coming from their head. Staff B stayed with Resident #1 and Staff A went into the hallway to summon a nurse. Staff B couldn't recall the position of the full-body mechanical lift or if the lift had the sling attached. Staff B verified it is the expectation to always use two staff with a full-body mechanical lift transfer. Staff B reported they received education on using 2 staff at all times with the mechanical lift transfers, double check sling placement, and check the sling connection. Interview on 5/9/24 at 11:45 AM, the DON, stated that on 2/19/24 approximately 10:20 AM, Staff A, came out of Resident #1 room screaming that she needed a nurse immediately. The DON went right away and found Resident #1 on the floor perpendicular (similar to a T) to Resident #1's bed. His wheelchair sat at the end of the bed and the full-body mechanical lift in the northwest corner with the bar about 60 inches (5 foot) off the floor, with the sling still attached to the full-body mechanical lift, and the right front strap of the sling was off the bar of the full-body mechanical lift. The DON confirmed they expected the staff to always use 2 assists with all full-body mechanical lift transfers. They verified educating Staff A and Staff B on the required use of 2 staff with mechanical lift transfers, double check the sling placement, and check correction connection of the sling to the lift. Interview on 5/8/24 at 2:15 PM, the Executive Director explained their investigation of the incident on 2/19/24, determined incompatibility of the brand of full-body mechanical lift and the slings used by the facility. The facility threw all the incompatible slings away and ordered new slings for the specific full-body mechanical lift. The facility inspected the full-body mechanical lift after the incident and found a sprung black clip on the right upper side of the bar, that wouldn't spring back. They put that lift out of commission until fixed. The Executive Director confirmed they expected the staff use 2 staff for full-body mechanical lift transfers. Interview on 5/8/24 at 2:30 PM, the Maintenance Director, explained after the incident on 2/19/24, the facility inspected the full-body mechanical lift and found the left back spring, sprung not letting the black clip spring back into place. They took that full-body mechanical lift out of commission until they replaced the spring. The Maintenance Director they inspected the full-body mechanical lift every Monday morning. That full-body mechanical lift didn't get inspected until after the incident. Review of Resident Lifts: Inspect mobile lifts signed by the Maintenance Director on 2/19/24 indicated they replaced the clip spring on full-body mechanical lift after fall. They inspected all of the full-body mechanical lifts slings without concerns. The Full-Body Mechanical Lift competency checklist updated 5/11/21, signed on 2/19/24 by Staff A and Staff B, reflected they received education, in addition to verbal and hands-on demonstration of facility procedure for use of the full-body mechanical lift. Procedures include: *Prior to conducting the transfer task, the two caregivers agree on who will take the lead and who will be the helper. *The sling and lift are visually inspected to assure both are in good condition prior to use. The sling is checked to make sure it is the correct size. *The two caregivers agree on the loops to be hooked up to the lift. *Both caregivers agree the clips and loops are secure to the lift and in proper position prior to moving the resident and positioned safely in the sling. *The lead pulls the lift from the bed. The helper may assist with moving the lift away from the bed if required but should primarily assist with turning the lift. *The helper should always maintain contact with the resident during the transfer. *Immediately stop transfer if resident moves, ensure resident safety and proper positioning then resume transfer. If unable to ensure safe positioning stop transfer and lower resident to safest positioning available, such as bed or chair On 5/8/24 at 3:15 PM, observed Staff C, CNA, and Staff D, CNA, transfer Resident #1 with the full-body mechanical lift and a full body sling. Staff C and Staff D demonstrated proper transfer technique. They checked the engagement of the black safety clips and the sling didn't have frayed edges on the loops. The Safe Resident Handling Policy revised January 2016 directed to minimize or eliminate the manual lifting of a resident whenever possible. This is to ensure the safety of the resident and caregiver during transfer and repositioning task. Objective Criteria: Each resident will be assessed initially upon admission. Any changes in transfer status will be reassessed on an as needed basis or thorough quarterly reassessments. Nursing or therapy will determine the resident's transfer status based on the following criteria, but nursing has the final decision on the mode of transfer: Total Body Lift: (requires 2 caregivers) 1. Resident is unable to bear weight. 2. Resident is unable to participate in transfer process. 3. Any other transfer type is excluded due to a medical condition or co morbidity. Inspection: All lifts, slings, friction reducing devices, and lateral transfer devices will be visually inspected prior to use. If slings, friction reducing devices, or lateral transfer devices are noted to be ripped, torn, fraying, or have separating seams, they will not be used. Remove the damaged item from service and tag it as DO NOT USE. Any mechanical lift noted not in proper working condition or has potentially dangerous changes in assembly (i.e. nut/bolt loose on boom or wheel loose) should immediately be marked and tagged as DO NOT USE. Needs Repair. Tags are available at the nursing station or the DON's office. The staff will notify the charge nurse and maintenance as soon as possible. Staff must use a different mechanical lift for transfers. Complete the monthly maintenance on the lifts per manufacturer guidelines to ensure they are in good working order. If maintenance determines the lift is not safe to use, the maintenance department will mark and tag lift as DO NOT USE. Needs Repair and will either repair lift, or will contact vendor for them to repair lift. Tags are available at the nursing station or the DON's office.

Based on record review, observations, staff interviews, and policy review the facility failed to keep kitchen equipment clean and sanitary for 32 of 32 residents that receive meals from the kitchen. The facility reported a census of 32 residents. Findings include: During an interview on 10/3/23 at 12:47 PM the Dietary Manager revealed she had cleaning schedules in place and there are no issues with them getting completed. During an observation of meal service on 10/4/23 from 11:53 AM to 12:25 PM revealed the following: a. Convection oven with brown substance baked on the wire racks, crumbs and debris throughout the bottom and unable to see through the window due to brown discoloration. b. Top of the convection oven with visible debris, dust, and a sticky substance. c. Four (4) slice toaster with black, brown, and yellow discoloration throughout the top. d. Steam table with brown and yellow spill marks by all knobs, the bottom with dust, debris, and yellow spills. e. Oven griddle with brown discoloration throughout the top and sides and brown substance down the front. f. Oven burners with black residue and brown splatters/spills down the front. g. Inside the oven a black substance and brown substance throughout. h. Microwave with a yellow substance on the bottom and brown splatters on the door. i. Air conditioning unit with black/gray dust covering the vent. j. Fan above the clean dishes with dust hanging from it. k. Floors with visible debris and collections of black buildup by kitchen equipment. During an observation on 10/4/23 at 11:45 AM revealed a large plastic bag of hot dogs on the counter. Staff C, Cook, grabbed the hot dogs with a gloved hand and divided the hot dogs into four (4) separate plastic bags and sealed the bags, the bags she put the hot dogs into had visible liquid dripping from them that came from the large hotdog bag. Staff C then continued to grab a container with her hands that still had gloves on, place the bags in the container, open a refrigerator, and place them in the refrigerator. She then removed her gloves. During an observation on 10/4/23 at 12:00 PM Staff D put on gloves and grabbed 3 slices of bread from a bread bag and placed them on a plate, she opened multiple single serving butter packets and buttered the breading without removing her gloves she then tore the slices in half and brought to Staff C. During an observation on 10/4/23 at 12:11 PM the Dietary Manager informed the staff she would get the bread and butter for the meal. She applied gloves, then for multiple observations she would grab bread from the bread bag, touching the outside of the bread bag, open individual single serve butter containers to butter the bread, then pick them up and take over to the cook on a plate. During an interview on 10/4/23 at 10:47 AM the facility Dietician revealed she would expect the staff to do regular cleaning with cleaning schedules. She then informed she would expect the fan and air conditioner to be clean because they blow on clean dishes. Record review of the facilities Weekly Cleaning Schedules for 8/23, 9/23, and 10/23 revealed the facility does not have a plan in place to clean the following: a. Toaster b. Steam table d. Microwave f. Air Conditioner g. Floors The facilities policy titled General Sanitation of Kitchen from 2021 documented the following: 1. Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule.

Based on record review and staff interviews the facility failed to accurately code Minimum Data Set (MDS) Assessments when they inaccurately coded 1 of 1 residents Preadmission Screening and Resident Review (PASRR) (Resident #1), 1 of 1 residents use of anti-coagulant (blood thinner) medication (Resident #20), and 1 of 2 residents Hospice status on two different MDS assessments (Resident #8). The facility reported a census of 32 residents. Findings include: 1. Record review of Resident #1 PASRR dated 6/27/2023 documented she was a Level II PASRR and needed specialized services. Record Review of Resident #1 MDS dated [DATE] documented her as a Level I PASRR. During an interview on 10/4/23 at 3:12 PM with the facilities MDS Nurse revealed Resident #1 is a PASRR Level II and her 9/28/23 MDS assessment was coded incorrectly. 2. Record review of Resident #20 MDS dated [DATE] documented he received anti-coagulation medication for the 7 days of the look-back period. Record review of Resident #20 Medication Administration Record for September revealed he had not receive anti-coagulation medication during the 7 day look back period. During an interview on 10/4/23 at 1:49 PM with the facilities Director of Nursing (DON) revealed it was an error in coding and the facility was going to make a modification to the MDS and fix it. During an interview on 10/5/23 at 11:17 AM the facilities DON stated she would expect for the MDS to be coded accurately. 42134 3. The admission MDS for Resident # 8 dated 2/8/23 documented an admitted [DATE]. The MDS coded the resident as not receiving hospice services prior to admission or since admission. The resident's payor source beginning on 2/1/23 and not changing through 10/5/23 listed Hospice as the only payor. During an interview on 10/2/23 at 1:41 PM, the resident's son explained the resident was receiving hospice services prior to admission and since admission. 4. The quarterly MDS for Resident #8 dated 8/9/23 did not code the resident as receiving hospice services. During an interview on 10/4/23 at 3:31 PM, Staff E, Registered Nurse(RN), MDS nurse, confirmed the MDS's for Resident #8 were coded incorrectly. During an interview on 10/4/23 at 4:56 PM, the Director of Nursing (DON) explained they do not have an MDS policy, they follow the Resident Assessment Instrument (RAI) manual.

Based on observation, record review, and staff interviews the facility failed to provide 3 of 37 medications as ordered by the provider. The facility reported a census of 32 residents. Findings include: During an observation on 10/3/23 at 11:57 AM Staff A, Certified Medication Aid (CMA), set up Resident #10's medications revealed she took out the following medications and put them into a medication cup. a. Iron b. Thiamine (Vitamin) c. Creon Delayed Release (enzyme for digestion) Staff A then proceeded to take the Iron and Thiamine and crush them together. She then opened the Creon capsule and mixed all three (3) medications together with applesauce. Staff A then on 10/3/23 at 12:01 PM gave the crushed medications in applesauce to Resident #10 and he swallowed them. Record review of Resident #10 Orders dated 10/4/23 lacked an order for him to have crushed medications. In an e-mail correspondence 10/4/23 at 11:36 AM the Director of Nursing (DON) revealed Resident #10 should receive his medications whole (in applesauce per his preference). He does not have an order to crush his medications, unfortunately that was in error. During an interview on 10/4/23 at 4:55 PM the DON revealed they do not have a medication administration policy they follow best practices and pharmacy recommendations. During an interview on 10/5/23 at 11:14 AM the DON stated she plans to contact the Doctor and discuss if he can have an order to crush his medications as needed. She went by a cheat sheet that was not correct.

Based on record review, staff interviews, and policy review the facility failed to complete assessments for 1 of 1 residents before and after dialysis treatments received at a certified dialysis facility (Resident #34). The facility reported a census of 32 Residents. Findings include: Record review of Resident #34 Dialysis Assessment log revealed assessments were completed, in progress, or incomplete on the following dates: 10/2/2023 Dialysis Pre and Post Assessment In Progress 9/29/2023 Dialysis Pre and Post Assessment In Progress 9/25/2023 Dialysis Pre and Post Assessment Complete 9/20/2023 Dialysis Pre and Post Assessment In Progress 9/11/2023 Dialysis Pre and Post Assessment Complete 9/1/2023 Dialysis Pre and Post Assessment Complete 8/30/2023 Dialysis Pre and Post Assessment Complete 8/25/2023 Dialysis Pre and Post Assessment Incomplete 8/21/2023 Dialysis Pre and Post Assessment Complete 8/18/2023 Dialysis Pre and Post Assessment Complete 8/16/2023 Dialysis Pre and Post Assessment Complete 8/14/2023 Dialysis Pre and Post Assessment Complete 8/9/2023 Dialysis Pre and Post Assessment Complete 8/7/2023 Dialysis Pre and Post Assessment Complete 8/4/2023 Dialysis Pre and Post Assessment Complete Review of Resident #34 Dialysis Pre and Post Assessments revealed multiple assessments where the facility failed to get current vital signs and instead used ones not taken on the days of the assessments. Record review of Resident #34 Care Plan, created on 7/30/23 and revised on 10/4/2023, instructed she received dialysis at a local dialysis center on Monday, Wednesday, and Friday. Record review of Resident #34 Census revealed she was in the hospital from 9/2/23 to 9/8/23. Record review of Resident #34 Progress Notes from 8/1/23 to 10/3/23 revealed no documentation of dialysis appointments missed or rescheduled. Through review off the Resident #34 Census, Care Plan dialysis dates, and Progress Notes the facility failed to complete assessments on: a. 8/2/23 b. 8/11/23 c. 8/23/23 d. 8/28/23 e. 9/13/23 f. 9/15/23 g. 9/18/23 h. 9/22/23 i. 9/27/23 Record review of a policy provided by the facility, Dialysis Care Plan and Treatment Sheet dated February 2019, lacked instruction to nursing staff on if pre and post dialysis assessments are needed and how to complete them. During and interview on 10/5/23 at 11:19 AM the Director of Nursing (DON) revealed she would expect a pre and post dialysis assessment be completed on dialysis days.

Based on clinical record review and staff interview the facility failed to provide an assessment and implement interventions based on that assessment for 1 of 1 resident reviewed for falls (Resident #13). The facility reported a census of 32 residents. Findings include: The Progress Note for Resident #13 written by Staff B, Licensed Practical Nurse (LPN), on 9/5/23 at 10:49 AM documented she heard a noise in the hall and found the resident had fallen to the floor to his left side. Staff assisted the resident into a wheelchair so the ambulance could get through with another resident. Upon assessment the resident was able to move his left leg a small amount independently and voiced discomfort in his hip area. The resident was unable to rate his pain on a 0/10 scale but reported his left leg felt twisted. The Progress Note written by Staff B, LPN, on 9/5/23 at 1:42 PM documented the fall occurred at 8:00 AM. The Progress Note written by Staff B, LPN, on 9/5/23 at 11:02 AM documented the resident had a left femoral neck fracture. The Progress Note written by Staff B, LPN, on 9/5/23 at 12:29 PM documented the resident would be having surgery to repair the fracture. During an interview on 10/4/23 at 12:28 PM Staff B, LPN, explained she was in the next room when she heard a noise in the hall. She entered the hall, to see the end of the fall. The resident landed on his left side across the hall. The ambulance crew was needing to get past the resident with another resident. Staff B stated she asked the resident if he could move his extremities. She noted he could only move the left leg a little bit. The resident did not complain of pain. Staff B explained that her and another staff member lifted the resident off the floor and placed him in a wheelchair. Upon further assessment Staff B noted the resident was grimacing and complained of a little bit of pain. Staff B, LPN, explained she knew putting him in the wheelchair might be a problem. During an interview on 10/4/23 at 5:11 PM the Director of Nursing (DON) explained she would not have expected the resident to be put in a wheelchair.

Based on staff interviews and policy review the facility failed to have a qualified professional serve as the Dietary Manager. The facility reported a census of 32 residents. Findings include: During an interview on 10/2/23 at 3:32 PM the facility Administrator revealed their Dietary Manager is not a Certified Dietary Manager. During an interview on 10/3/23 at 12:47 PM the facility Dietary Manager revealed she started in August of this year (2023) and got enrolled in a Certified Dietary Manager course a couple of weeks ago but has not started it. Record review of the facilities policy, Director of Food and Nutrition Services from 2021, revealed the facilities current Dietary Manager does not meet the criteria of the facilities policy to serve as the Dietary Manager. During an interview on 10/4/23 at 10:49 AM the facility Dietician revealed the Dietary Manager should be certified in the future.

Based on observations, record reviews, policy review and staff interviews, the facility failed to ensure that residents were free of significant medication errors, specifically the facility failed to accurately transcribe a PT/INR (coagulation) laboratory order for 1 of 3 residents reviewed (Resident #1) on anticoagulation therapy. As a result Resident #1's INR was not monitored as ordered, resulting in Resident #1 having increased confusion, fatigue, slurred speech, and required an ambulance transfer to the local emergency room . Resident #1 required treatment at the local emergency room with an INR at critical levels (>15). Additionally, the facility failed to accurately transcribe an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1 after her discharge from the hospital. Due to inaccurate transcription of warfain, Resident #1 received more [MEDICATION(S)] than was ordered on 2/22, 2/24, and 2/27/22, resulting in a significant medication error. [MEDICATION(S)] is a high risk medication that is administered to prevent blood clots. The medication is titrated based on a blood test PT/INR to keep in therapeutic range, typically 2-3. Too high of a PT/INR can result in bleeding/hemorrhaging, too low can result in clot formation which can result in a [CONDITION(S)] or stroke. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The facility reported a census of 41 residents. Findings Include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 required extensive assistance of two or more people for transfers and bed mobility. Resident #1 scored a 7 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The Care Plan Focused area revised 1/11/22 documented that Resident #1 had an alteration in hematological status related to anticoagulant use and history of [CONDITION(S)]. The goal revised on 1/24/22 indicated Resident #1 would remain free of complications related to altered hemotolgical status through the review date. The interventions were as follows. 1. Administer medications as ordered 2. Obtain lab work as ordered. Report the results to the medical provider and follow-up as indicated. A laboratory report dated 1/27/22 reported a [MEDICATION(S)] (PT) result of 4.14. The report documented an order from the provider dated 1/27/22 at 8:11 a.m. to hold [MEDICATION(S)] that day. On 1/28/22 change [MEDICATION(S)] to 3 milligrams (mg) Monday, Wednesday, Friday, and Saturday, 4 mg on all other days. Recheck an INR in two weeks. The order was signed and dated as noted by Staff A, Registered Nurse (RN) on 1/27/22 at 11:42 a.m. The Consultation Note dated 2/17/22 documented that Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was on [MEDICATION(S)] for [CONDITION(S)]. When Resident #1 presented to the emergency room her INR was found to be elevated at 17. During an interview on 3/2/22 at 2:11 p.m. Staff A confirmed that she received and noted the order on 1/27/22 to recheck the INR in 2 weeks (2/10/22). Staff A remarked that she must have put the lab on the calendar for the wrong date because it was not written on 2/10/22. During an interview on 3/3/22 at 3:30 p.m. Staff B, RN, stated she had worked on 2/22/22, and found that the old [MEDICATION(S)] cards were still in the medication cart. Staff B clarified that the [MEDICATION(S)] was an alternating dose cards from before Resident #1's hospital admission. Staff B responded that old cards should be pulled from the medication cart if there was a new order. Staff B reported that she checked the order folder and found the 2/21/22 Hospital Discharge Orders. Staff B determined that the Hospital Discharge Orders indicated to return to the same dose of [MEDICATION(S)] as before the hospital admission. Staff B entered the orders into the electronic chart and gave Resident #1 the [MEDICATION(S)] from the old medication cards. Staff B stated that she always pulled the old medication cards if there was a change in the order, then Staff B would get the new dose of [MEDICATION(S)] from the emergency medication kit (E-kit). Staff B clarified that she didn't need to take [MEDICATION(S)] from the E-kit and gave the [MEDICATION(S)] to Resident #1 from the cards that continued to be in the medication cart. Provider Interview During an interview on 3/1/21 at 1:00 p.m. the Facility Provider A, Advanced Registered Nurse Practitioner (ARNP), confirmed that no INR lab was completed on 2/10/22 as ordered on 1/27/22 to be completed in 2 weeks. The provider stated they would have expected the lab to be completed as ordered. The provider further stated that it was her professional opinion that had the lab been completed as ordered, Resident #1's raising INR could have been noticed sooner. Facility Provider A explained she would have changed the [MEDICATION(S)] order in response. Facility Provider A stated that [MEDICATION(S)] was titrated based on lab results, she was unable to prescribe [MEDICATION(S)] accurately without a lab being completed as ordered. Further record review The Hospital Discharge Summary dated 2/21/22 revealed Resident #1 presented to the emergency department on 2/15/22 from the nursing home with a decreased level of consciousness and confusion. Resident #1 was found to be septic (infected with microorganisms, especially harmful bacteria) secondary to a urinary tract infection and dehydration. Resident #1's INR was found to be over 15, and she was in an apparent grave situation. The Discharge orders included [MEDICATION(S)] 3 mg daily. The Discharge Medication Reconciliation Order Report dated 2/21/22 documented a discharge order for [MEDICATION(S)] 3 mg orally (by mouth) daily. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. [MEDICATION(S)] sodium tablet 3 mg started on 1/28/22 put on hold 2/17/22 until 2/20/22 then held from 2/20/22 until 2/20/22 until 2/21/22, then discontinued on 2/21/22. 2. [MEDICATION(S)] sodium tablet 3 mg by mouth once a day for [CONDITION(S)] (Afib) starting on 2/21/22 at 4:00 p.m. 3. [MEDICATION(S)] sodium tablet 4 mg give one tablet by mouth in the evening on Tuesday, Thursday, and Sunday starting on 2/22/22 at 4:00 p.m. The order was discontinued on 2/28/22 at 3:15 PM. a. The dosage was given on 2/22/22, 2/24/22, and 2/27/22. 4. [MEDICATION(S)] sodium tablet 3 mg give 3 mg by mouth once a day every Monday, Wednesday, Friday, and Saturday for Afib starting on 2/23/22 at 4:00 PM. The order was discontinued on 2/28/22. a. The dosage was given on 2/23/22, 2/25/22, and 2/26/22. 5. [MEDICATION(S)] tablet 500 mg (antibiotic), give twice a day for a urinary tract infection for seven days starting on 2/1/22. Resident #1 received the medication as order for the next seven days ending on 2/7/22. According to the Mayo Clinic website related to the use of [MEDICATION(S)] updated 2/1/22 using [MEDICATION(S)] and [MEDICATION(S)] is usually not recommended, but may be required in some cases. If both medicines are prescribed together, the doctor may change the dose or how often to use one or both of the medicines. It is very important that the doctor check the patient's progress at regular visits to make sure the medicine is working properly. Blood tests, such as an INR, are needed to check for proper dosage and unwanted side effects. Be sure to keep all appointments. According to a Facility Medication Error Report dated as completed on 2/28/22 by the Director of Nurisng (DON) documented Resident #1 received 4 mg of [MEDICATION(S)] on 2/22/22, 2/24/22, and 2/27/22 not as ordered. Medication ordered upon hospital discharge directed 3 mg daily. The medication error report described: medication was entered into electronic chart on 2/21/22 at the correct dose of 3 mg daily. On 2/22/22 the order was changed to 3 mg Monday, Wednesday, Friday, and Saturday alternating with 4 mg on Tuesday, Thursday, and Sunday as dose had been before hospitalization by Staff B. The transcription error was clarified that the hospital medication discharge orders state modify and discontinue, continue or prescribe on the right hand side of the document next to the medication. Order directed to be modified to 3 mg daily upon hospital discharge. Facility Provider A was notified of the medication error. A PT/INR lab was ordered with no adverse effects noted. The DON provided education to Staff B. The Laboratory Report dated 2/24/22 obtained at 6:41 a.m. revealed an INR of 2.47. The notes indicated that Facility Provider A noted to continue the current dose of [MEDICATION(S)] and recheck an INR in one week. The Laboratory Report dated 3/1/22 documented an INR result of 3.86. The form indicated notification to Facility Provider A requested clarification of what doses Resident #1 received of [MEDICATION(S)] over the past seven days. The facility clarified the amount of [MEDICATION(S)] had received over the last 7 days, which included the days the resident received additional [MEDICATION(S)] in error. On 3/1/222 at 1:28 p.m. Facility Provider A indicated that Resident #1 received a total dose of 23 mg in the past 7 days. Facility Provide A ordered to start [MEDICATION(S)] at 3 mg daily and recheck an INR in one week. DON interviews During an interview on 3/1/22 at 2:00 p.m. the DON reported there wasn't a written facility policy for transcription of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON responded that the third shift (night shift) was responsible to recheck new orders for accuracy. The DON further stated she was unable to determine what nurse failed to catch that the INR was on the wrong date on the calendar which resulted in the lab not being completed as ordered on 2/10/22. The DON responded that this resulted in an error, as [MEDICATION(S)] titrated was based on lab results. The DON stated that she had transcribed the hospital discharge orders for Resident #1 on 2/21/22 which directed 3 mg of [MEDICATION(S)] daily. The nurse on duty, an agency nurse, should have removed the old medication cards from the medication cart to prevent an error, but the DON didn't think she did. The DON further stated the agency nurse gave the first dose of [MEDICATION(S)] upon return from the hospital from the old card, and should have gotten the dose from the emergency kit (E-kit). The DON reported no [MEDICATION(S)] was removed from the E-kit for Resident #1 upon return from the hospital. The DON stated she thought Staff B changed the order the next day (2/22/22) because the old cards were still in the medication cart. The State Agency informed the facility of the Immediate Jeopardy (IJ) on March 3, 2022 at 4:50 p.m. The facility staff removed the Immediate Jeopardy on March 3, 2022 through the following actions: 1. Two current residents at facility on [MEDICATION(S)] daily. The residents' orders were reviewed on 3/3/22 at 6:00 p.m. with their physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The lab orders were reviewed and confirmed to be correct on 3/3/22 at 6:05 p.m. Resident #1 found to be due to have a redraw on 3/7/22. Resident #5 due to have a redraw on 3/17/22. 2. Staff A received education on the process of documenting INR lab draws, through the triple check process. 3. Staff B received education on transcribing orders, medication administration, and the triple check process. 4. All nurses would be educated on 3/3/22 by 10:00 p.m. All nurses not working will be educated prior to the start of their next shift. 5. All INR lab draws would be audited Monday-Friday on residents receiving [MEDICATION(S)] by the DON and/or her designee. 6. Medication audits would take place Monday-Friday on all residents receiving [MEDICATION(S)] by the DON and/ or her designee. The IJ was lowered to a D level.

Based on observations, clinical record reviews, staff interviews, and facility policy review, the facility failed to ensure staff provided a safe transfer with a mechanical lift for 1 of 5 resident's reviewed (Resident #4) that required transfer assistance. Resident #4 sustained a fall on [DATE] during a mechanical lift transfer when the mechanical lift sling strap was not properly fastened causing the strap to slip off during the transfer which resulted in the resident falling to the floor head first, striking her head and resulting in a raised area on her head. The facility reported a census of 41 residents. Findings include: Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented she had severe impaired cognitive skills. Resident #4's diagnoses included Alzheimer's disease and [CONDITION(S)] (impaired speech). Resident #4 required total dependence of two staff for bed mobility and transfers. The resident had no falls since previous assessment. The Care Plan Focus area initiated on [DATE], identified resident at fall risk related to Alzheimer's disease with a goal of no major injury related to a fall. The connected Interventions identified the following 1. Resident #4 required assistance of two staff for transfers with a full body mechanical lift. 2. Staff were re-educated on mechanical lift usage policy for safety with transfers. The Care Plan Focus, Goal, and Interventions were canceled on [DATE] when resident expired at the facility. An undated and untitled facility investigative report documented that on [DATE] at approximately 4:00 p.m. Staff C, Certified Nursing Assistant (CNA), requested assistance with a full mechanical lift transfer of Resident #4. Staff D, CNA, entered the room and reported that Resident #4 was in the bed with a hammock sling beneath her and a full mechanical lift over her. The hammock sling was fastened to the lift hangers by Staff C, CNA. Both staff preceded with the lift transfer from the bed to the chair. Staff C, CNA, maneuvered the lift while Staff D, CNA guided Resident #4's feet and legs. As Staff C, CNA, began to move the mechanical lift away from the bed and turn the lift with Resident #4 toward the chair, the sling loop at the resident's right shoulder disconnected from the hanger on the mechanical lift. Resident #4 slid from the sling onto the floor. Staff D, CNA, alerted Staff E, Licensed Practical Nurse (LPN). Staff E completed a full assessment and noted a raised area to the right side of Resident #4's head. Resident #4's family was notified. The family declined transfer or evaluation by emergency services. Staff E notified Resident #4's primary provider who and hospice services who declined evaluation by emergency services. The hospice nurse arrived and completed a head-to-toe assessment on Resident #4. The lift was inspected with no concerns noted. The Y-beam hangers without defect and the safety clips functioned appropriately. The hammock sling was inspected without noted defects. The Plan of Action identified that staff were expected to continue to follow the current care plan and the staff were to complete a second check to ensure sling loops were in proper place with the safety clips engaged. The CNA staff were educated on the full mechanical lift use. The Incident Report documented by Staff E, LPN on [DATE] at 4:05 p.m., revealed Staff E was called to Resident #4's room where she found Resident #4 lying on the floor parallel to the raised bed. Resident #4 laid on her back with her legs extended out. The staff reported they transferred Resident #4 with a mechanical lift from the bed, when they heard a snap, or a pop, and the right upper sling attachment came off the hook. When the sling attachment came off the hook, Resident #4 fell to the floor with her head and upper torso hitting the floor first. Resident #4's left leg remained in the sling, the staff had to lower the sling to the floor. Staff E noted Resident #4 moaning occasionally while lying on the floor. Staff E assessed a large bump on the right side of Resident #4's head and applied a cold pack. After assessment, the staff assisted Resident #4 off the floor with the mechanical lift and an assistance of three staff. Resident #4's neurological assessments remained within normal limits. Staff E notified Resident #4's husband who requested to not transfer Resident #4 for evaluation and to monitor her at the facility. The Adverse Event Note dated [DATE] at 4:05 p.m. documented that the staff alerted Staff E to Resident #4's room. Upon entering the room, Staff E observed Resident #4 lying on the floor parallel to her raised bed. Resident #4 laid on her back with her legs extended out. The staff reported that they were transferring Resident #4 with the mechanical full-body lift from the bed to her chair. Just as they cleared the bed, they heard a snap, pop, and the right upper mechanical sling attachment came off the mechanical lift hook. The sling attachment disconnecting from the mechanical lift resulted in Resident #4 falling to the floor hitting the floor head and torso first with her leg up in the sling. The staff lowered the sling and mechanical lift to the floor. The staff assisted resident up off the floor with the mechanical lift and three staff into Resident #4's chair. Neurological assessments initiated and were within normal limits at the time. Resident #4's pupils were equal and reactive to light but were sluggish initially. As needed acetaminophen was given for comfort. Staff E completed an assessment on Resident #4 while the Assistant Director of Nursing (ADON) was in the room. The ADON notified the Director of Nursing (DON), Administrator, the resident's family, and hospice. Resident #4's family didn't want the resident sent to the hospital for evaluation and required the staff to monitor her in the facility. Hospice came to the facility and got comfort medications ordered in case the resident experienced any discomfort. The physician was notified and denied the need for further evaluation. The section labeled interventions explained that staff were re-educated on mechanical lift usage policy for safety with transfers. The Post Fall Data Collection note completed by the DON on [DATE] at 4:15 p.m. documented on [DATE] at 4:05 p.m., Resident #4 experienced a witnessed fall to the floor with injury to her head, Resident #4 had no recent mental status changes. Before the fall a staff member assisted Resident #4. The section labeled potential root cause of the fall was identified as other. During an interview on [DATE] at 1:23 p.m. Staff C confirmed on that on [DATE] at approximately 4:00 p.m., she hooked Resident #4 up to the mechanical lift while she laid in bed. Staff C responded that as she approached the bed from Resident #4's left side, her right side was away from Staff C. Staff D responded to Staff C's request for assistance to transfer Resident #4. Staff C recalled as they started to transfer Resident #4 from the bed, she heard a noise, and the right shoulder strap attached to the mechanical lift somehow popped off but Staff was unsure how. Staff C reported they tried to help Resident #4, but her head hit the ground. Staff C confirmed the lift was in the high position when Resident #4 fell and remained in the high position after the fall. Resident #4's left leg remained in the lift sling. Staff C explained the sling was removed by the staff, and Resident #4 was assisted to fully lay on the floor. Staff C responded that she thought the right shoulder strap wasn't completely hooked before the transfer. Staff reported that she noted a lump on the right side of Resident #4's head. Staff E was summoned to room immediately. Staff C confirmed that she got re-educated to make sure that the safety clip worked properly and closed. Staff C remarked she received instruction to double check the mechanical lift straps and safety clip, then continue to monitor the resident as they completed lift transfer to prevent further occurrence. During an interview on [DATE] at 1:50 p.m. Staff D confirmed she had responded to Staff C's request for assistance with the transfer of Resident #4 on [DATE] at approximately 4:00 p.m. Staff D recalled that Staff C already attached the lift straps and Resident #4 laid in bed when she entered the room. Staff D confirmed the lift was the current full body mechanical lift that the facility currently used. Staff D stated that she was at Resident #4's feet to guide her lower legs. Staff D declared they didn't even cleared the bed when Resident #4 began to fall, Resident #4 rolled off to the edge of the bed and then fell to the floor hitting her head first. Staff D reported that it had happened so fast. Staff D confirmed she wasn't in the room when Resident #4 was attached to the mechanical lift, and didn't check the straps. Staff D stated that the right shoulder strap came unhooked. Staff D remarked that she felt the strap wasn't completely hooked, which caused the fall. Staff D further recalled that Staff E checked the safety clips on the lift after the fall and found them to be properly working. During an interview on [DATE] at 12:12 p.m. Staff E recalled that on [DATE] shortly after 4:00 p.m., she was called to Resident #4's room. Staff E found Resident #4 lying on the floor parallel to the bed on her back. Staff E observed the mechanical lift up in the elevated position with the right shoulder strap unhooked. Staff C informed Staff E they transferred Resident #4 and the right shoulder strap came unhooked. Staff E remarked that once in a while the lifts weren't working properly, so she inspected the lift and the sling, finding no problems. Staff E confirmed Resident #4 immediately had a large bump on the right side of her head. During an interview on [DATE] at 10:40 a.m. the ADON confirmed that Staff C and Staff D transferred Resident #4 fell from the lift during transfer and struck her head on [DATE]. The ADON stated she inspected the lift and sling used during the transfer. The safety clips were found to be working properly. The sling hooks were found to be in good condition, intact, and determined to not be the cause of the mal-function. The ADON explained that she determined the staff didn't get one of the straps completely hooked. As the strap wasn't completely hooked, the black safety tab was unable to click into place thus causing the strap to come off the hook, resulting in the resident's fall. The ADON reported that she didn't remove the lift from service or fill out a work order as the lift was determined to function properly, as it was staff error that caused the fall. The ADON reported she educated all staff on that day of the expectations for proper mechanical lift usage. During an interview on [DATE] at 10:45 a.m. the DON reported all staff are educated during orientation on expectations for use of the mechanical lift. The DON added that she re-educated Staff C and Staff D on proper use of the mechanical lift with a return demonstration after the fall. During an interview on [DATE] at 10:30 a.m. the Administrator explained that the company usually provided an annual service call but weren't able to provide. The Administrator confirmed they would expect staff to 1. Inspect the lift and sling prior to transfer, as hooking up and completing the transfer 2. Listen for the click that assures the hooks are secured 3. Report any concerns immediately through the facility reporting system 4. Remove the lift from service. During an observation on [DATE] at 10:30 a.m. Resident #8 was transferred with a full body lift and sling by Staff F, CNA, and Staff G, CNA. Staff F and Staff G demonstrated proper transfer technique, including to check that the black safety clips were engaged. Staff F clarified that the staff must hear the safety clip click into place to assure it was engaged. Staff G responded that expectation was to check all safety clips were working properly. Staff F added they removed a lift from usage due to safety clips not functioning properly. The Skills Checklist titled Full Body Lift---Hammock Sling revised ,d+[DATE], signed by Staff C on [DATE] documented that she received verbal and hands-on demonstration education on the facility procedure for the use of the full body mechanical lift. The procedures included the following expectations: Fasten the four loops of the sling to the Y-Beam hangers, make sure you use the same color loop on the J hooks across from each other to keep the sling even, then carefully observe and listen for the safety clip to engage. The Skills Checklist titled Full Body Lift---Bed to Chair signed by Staff D on [DATE] recorded that she received verbal and hands-on demonstration education on the facility procedure for the use of the full body mechanical lift. The procedures included the following expectations: Fasten the four loops of the sling to the Y-Beam hangers, make sure you use the same color loop on the J hooks across from each other to keep the sling even, then carefully observe and listen for the safety clip to engage. The Skills Checklist titled: Mechanical full body lift divided leg sling last revised ,d+[DATE], signed by Staff C, CNA on [DATE] documented she received verbal education and evaluation through demonstration on the facility procedure for use of the divided leg sling. The Procedure included the following expectations: Fasten the four loops of the sling to the Y-Beam hangers, make sure you use the same color loop on the J hooks across from each other to keep the sling even, then carefully observe and listen for the safety clip to engage. Use the up button on the hand control until there is tension on the straps, then double check to make sure the sling loops were nestled into the bottom of the J hooks.

Based on observation, clinical record review, staff, resident, family and Nurse Practitioner interview and facility policy review the facility failed to ensure staff maintained a safe and secure environment for 1 of 4 residents reviewed. (Resident #1) The facility census was 32. Findings include: A Minimum Data Set (MDS) assessment form for Resident #1 dated 12/26/18 included [DIAGNOSES REDACTED]. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and required extensive assistance of 2 for transfers. The MDS documented the resident had no falls since admission. A Care Plan dated 12/21/17 included a problem of activity of daily living (ADL) self care performance deficit related to right [MEDICAL CONDITION] and limited physical mobility with a fall risk. The interventions included the following: a. Transferred with assistance of 1 staff member or with 2 staff members if used adaptive equipment as needed (PRN) (dated 12/20/18) A Home Therapy Program form dated 12/20/18 directed the facility staff to transfer the resident with 1 staff assistance and 2 staff assistance if adaptive equipment had been used PRN. A Resident Incident Report form dated 1/19/19 at 6:26 p.m. documented the following: An aide called over the walkie talkie for a nurse to room [ROOM NUMBER] at 4:55 p.m The resident had fallen during transfer from commode to the wheel chair. The resident layed prone on the floor when the nurse entered. The resident had been assessed and assisted to a seated position. The resident stated that she had not hit her head during the fall but she somewhat landed on her arms. The assessment found no apparent ecchymosis or swelling but she complained of moderate pain with movement. The resident stated as she stood from the commode and waited to get into her wheel chair she just fell . The Progress Notes revealed the following entries as dated: a. 1/19/19 at 6:45 p.m. - A Certified Nursing Assistant (CNA) called the nurse to the resident's room at 4:55 p.m The CNA and the resident attempted to transfer the resident from commode to wheel chair when the resident fell forward suddenly. The resident layed prone on the floor with extremities at her sides when the nurse entered the room. The staff assisted the resident to have rolled over and assessed the resident with the following vitals: blood pressure (B/P) 134/78, pulse (P)70, respirations (R)18, temperature (T) 98.9 degrees Fahrenheit (F), an oxygen (O2) saturation rate of 99% and a pain level of 4 out of 10 with movement of the right arm. b. 1/19/19 at 7:01 p.m. - The same documentation as stated above on the Incident Report form. c. 1/19/19 at 9:12 p.m. - The resident requested [MEDICATION NAME] during bedtime cares for general aches and pains related to the fall which had already been administered at 8:45 p.m d. 1/20/19 at 5:54 a.m. - The resident's T read 97.6 degrees F and she rested the entire shift and had not gotten up. It had been unknown if she passed any clots. No complaints thus far from the fall due to resting all night. e. 1/20/19 at 7 a.m. - Upon assessment of the resident's right shoulder/arm revealed [MEDICAL CONDITION]. The resident stated she had increased pain and discomfort to the right arm/shoulder since the fall yesterday, 1/19/19 at around 4:55 p.m. Notified the physician on call regarding the above assessment, received an order to have transferred the resident to the hospital. f. 1/20/19 at 7:49 a.m. - Transferred the resident to the hospital. g. 1/20/19 at 10:30 a.m. - Received a call from the hospital and the resident had a broken right shoulder. h. 1/20/19 at 1:40 p.m. - The resident returned from the hospital. An X-ray report dated 1/20/19 at 8:26 a.m. indicated the resident sustained [REDACTED]. A Major Injury Determination Form signed by the Physician 1/19/19 classified the fracture as a major injury. During an interview 3/6/19 at 4:07 p.m. Staff A, CNA indicated as she positioned herself to the resident's left side and transferred the resident from commode to the wheel chair without the use of a gait belt, which was required, the resident just stopped and stood there. The staff member asked the resident if she had been OK and she responded by stating yes then the resident fell face first onto the floor but did not hit her head. The staff member called for assistance on the walkie talkie as the resident said ouch, ouch, ouch my arm hurts. When the nurse responded she assessed the resident and no deformity had been noted. The staff member indicated she had not transferred other resident's without the use of a gait belt and she felt the device would not have prevented the fall. During an interview 3/7/19 at 2:52 p.m. Staff A confirmed a gait belt had been present in the resident's room and she had not known why she failed to use the device because she always used a gait belt. During an interview 3/6/19 at 2:06 p.m. Staff B, Registered Nurse (RN) confirmed the resident had been transferred without the use of a gait belt which had been required. The staff member stated anyone who required staff assistance with transfers required the use of a gait belt. The staff member stated she knew when the resident fell because she had been in the medication room and although she failed to hear the fall she heard the resident as she said ouch. She then received a call on the Walkie talkie to go to the resident's room. When she entered the resident layed on her stomach in front and at an angle from the commode. The staff member checked the resident's vital signs, performed range of motion (ROM) which had been per the resident's baseline because she had [MEDICAL CONDITION] affected her right side so she had some paralysis. The resident informed the staff member that her arm hurt and it felt like it had been bruised. The resident refused to go to the hospital at that time. Three staff members then used a Hoyer lift device and assisted the resident up and into her wheel chair. The staff member performed another set of vital signs as the resident denied hitting her head like 4-5 times. The staff member indicated Staff A said as she transferred from the commode to the wheel chair without the use of a gait belt the resident tripped forward, lost her balance and fell but had not hit her head. Staff A questioned if the resident could of had a small [MEDICAL CONDITION] at that time because her [MEDICAL CONDITION] were variable and unpredictable. The staff member then called the resident's mother to inform her of the fall and to see what she would like the facility to do and the resident's mother agreed to have the facility staff monitor the resident. The staff member indicated the next day the resident's arm was swollen so they sent her out for an x-ray which identified a broken right shoulder. During an interview 3/6/19 at 12:07 p.m., Staff C, CNA confirmed the use of a gait belt had been mandated when a resident required staff assistance with transfers. During an interview 3/6/19 at 12:17 p.m., Staff D, CNA confirmed the use of a gait belt had been mandated when a resident required staff assistance with transfers. During an interview 3/6/19 at 12:20 p.m., Staff E, CNA confirmed the use of a gait belt had been mandated when a resident required staff assistance with transfers. During an interview 3/6/19 at 12:23 p.m., Staff F, CNA confirmed the use of a gait belt had been mandated when a resident required staff assistance with transfers. During an interview 3/6/19 at 1:19 p.m., the Administrator confirmed the use of a gait belt had been mandated when a resident required staff assistance with transfers. During an interview 3/6/19 at 2:23 p.m., Staff B confirmed the use of a gait belt had been mandated when a resident required staff assistance with transfers and therapy directed the appropriate transfer techniques for the residents. During an interview 3/6/19 at 3:22 p.m., Staff G, CNA confirmed the use of a gait belt had been mandated when a resident required staff assistance with transfers. The staff member also observed Staff A as she transferred random residents without the use of a gait belt even since the resident's fall. During an interview 3/6/19 at 3:30 p.m., Staff H, Certified Medication Aide (CMA) confirmed the use of a gait belt had been mandated when a resident required staff assistance with transfers. The staff member also indicated he observed pretty much all of the CNA's as they transferred residents without the use of a gait belt but not since this resident's fall. During an interview 3/6/19 at 3:46 p.m. the resident's Nurse Practitioner stated she could not say one way or another if the use of a gait belt could have prevented the fall. During an interview 3/14/19 at 10:27 a.m., a family member indicated the resident told her the facility staff failed to have utilized a gait belt device when she had been transferred on 1/19/19 which resulted in the fall and fractured shoulder. A Safe Patient Handling Program dated 2013 included the following directives: a. All employees would have been trained upon hire, annually and as needed on the use of the safe patient handling techniques including mechanical lifting devices and other equipment/aids. b. Staff would not perform complex lifts or transfers on residents without the use of assistive devices. c. Devices included a transfer belt (gait belt) to have been applied at waist level that provided a secure grip while moving residents.

Based on observation, clinical record review, staff and equipment representative interviews the facility failed to ensure maintenance checks were done on mechanical lifts in a timely manner to ensure resident safety and prevent major injury for one of three residents reviewed who sustained a fracture. (Resident #1) The facility reported a census of 35. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 9/24/14, documented [DIAGNOSES REDACTED]. The MDS documented Resident #1, required extensive assistance of two staff members for bed mobility and toileting and according to the MDS Resident #1 had not transferred from the bed to a chair, wheelchair or standing position in the past seven day review period. The plan of care dated 1/8/14, documented a problem of self-care deficit related to [DIAGNOSES REDACTED]. The problem included an intervention for two staff and full lift for all transfers. The care plan identified Resident #1 as dependent on staff members for all grooming and dressing needs. The care plan identified a risk for falls related to tremors and anxiety with an intervention to utilize a mechanical lift for transfers. A work history report revealed the task description that documented resident lifts inspected as needed on 7/11/14 and 1/7/14. An incident report dated 9/14/14 at 1:35 p.m., documented the nurse had been summoned to Resident#1 ' s room. Upon entering, Resident #1 lying on floor on back. Staff reported incident occurred during a transfer of Resident #1 from wheel chair to bed. Staff reported the locking clip that holds the sling corners (on the mechanical lift) failed. One corner of the sling came loose. Staff lowered Resident #1 to the floor. Noted superficial abrasion area inner left arm (from sling) No other injuries observed at this time. The form included a fall investigation, which had a section to documented interventions to prevent future falls. An intervention documented on the form identified the mechanical lift was taken out of circulation pending maintenance. Fall Investigation form dated 9/14/14 at 1:35 p.m. identified equipment malfunction of the mechanical lift during the transfer of Resident #1. The description of the fall listed mechanical failure. The intervention to prevent future falls documented prompt maintenance of the equipment. A witness incident verification form dated 9/14/14, at 1:45 p.m. included a section for staff to make suggestions on how the incident could have been prevented. Staff B (Certified Nurse Aide, CNA) documented keeping mechanical equipment in good working condition as a suggestion in the section on the form. A witness incident verification form dated 9/14/14 at 1:45 p.m. identified Staff A (CNA) documented keeping mechanical equipment well maintained as a suggestion. A progress note dated 9/14/14 at 2:40 p.m., documented the nurse was summoned to Resident #1 ' s room. Upon entering the room observed Resident#1 lying on floor on his/her back. Staff reports while transferring Resident #1 from wheel chair to bed (using Hoyer lift) the locking clip that holds the sling corners failed, causing one corner of the sling to release from its hook. Staff was able to lower Resident #1 to the floor. Noted superficial abrasion area to the inner left arm of Resident #1. No other injuries observed at this time. Hoyer lift taken out of use at this time. Out of order sign in place. Maintenance notified of need for repair. A progress note on 9/14/14 at 2:45 p.m., documented resident assessed at that time. No injury noted from recent incident. Resident #1 smiling and laughing at staff. No signs or symptoms of pain or discomfort. A progress note on 9/15/14 at 10:48 a.m., documented Resident #1 up per usual routine. No indications of discomfort related to recent incident. Up per usual routine. Continue to monitor for changes. A progress note on 9/16/14 at 10:46 a.m., documented no injury noted from recent incident. No signs or symptoms of pain. A progress note dated 9/17/14 at 10:40 a.m., documented staff reported Resident #1 presented that day with right thigh slightly enlarged and slightly warm to touch. No redness noted upon assessment. Range of motion to hip and knee appeared within residents normal parameters, which had been limited due to contractures of bilateral legs. Resident #1 did not respond to movement of the right leg consistent with discomfort. Physician notified and fax for possibility of x-ray of area. A Radiology report dated 9/18/14, documented an oblique fracture of the supracondylar right femur, with approximately 10 millimeter posterior and medial displacement of the distal fragment and approximately 10 millimeter overlap of the proximal and distal fragments for Resident#1. During an interview with Staff A on 10/6/14 at 2:00 p.m., revealed staff demonstrated the incident using the same lift. Staff A stated she thought she had used the first (shorter) of two black loops on a mesh sling to hook Resident #1 to the mechanical lift prior to the incident. Staff A, unable to positively identify which loop was connected to the lift. Staff A stated she was pretty sure. Staff A stated Staff B was located on the back side of Resident #1 and as Staff A and Staff B raised Resident #1 up when they heard a pop. Staff A stated they hadn't even moved the Hoyer lift. Staff A stated Resident #1 tensed up and arched his/her back. Staff A stated Resident #1 had done this before but it hadn't ever been a problem during a transfer. Staff A stated they had noted the right lower extremity side clip had cracked and been displaced and allowed the sling loop over the lift hook. Resident #1 fell towards Staff A and Staff B. Staff A then lowered Resident #1 to the floor. Staff A identified the loops on the sling as intact. During interview with the facility Administrator at 2:15 p.m., stated he/she felt the incident happened because a safety clip on the lift made of plastic broke. During the interview, the facility Maintenance Director entered. The Maintenance Director stated inspections on all of the plastic clips as done once a week but only documented it every six months. The Maintenance Director stated he checked the spring load mechanism on the clip. During an interview with the SMT Health Systems representative/territory manager (company that provided the mechanical lift used by the facility) at 2:55 p.m., they stated they had gone to the facility and looked at the lift in question. Representative stated the maintenance man had only been inspecting the lifts on an as needed basis and it should be done on a weekly basis. On 10/7/14 at 2:00 p.m., Staff A and Staff B (CNA) completed a demonstration of the Volaro (Hoyer style mechanical) lift used during the incident, as this surveyor observed, with a second surveyor acting as a resident that required a transfer. Staff A demonstrated how to determine correct sling size for use on a resident, and placed it under the surveyor who sat in a chair. Staff A hooked the shorter loop of the sling on the lift hook on the right upper extremity side and right lower extremity side. Staff B hooked the shorter loop on the lift hook on the left upper extremity side, and the longer loop of the sling on the lift hook on the left lower extremity side. At that time the surveyor asked if that had been how the sling had been hooked at the time of the incident. Staff A then told Staff B they had used the short loops. Staff B then removed the long loop from the left lower extremity hook and changed it to the short loop. Staff A and Staff B then proceeded to raise the surveyor in the lift. Staff A and Staff B both stated on the day of the incident, a black safety clip on the lift hooks appeared to be O.K. prior to the transfer, and both stated the sling loops had been correctly placed on the metal lift hooks. At that time Staff A and Staff B raised the surveyor in the air. Staff A stated it had been at that time the right lower extremity side had come loose, the resident fell forward, and both CNAs caught the resident and lowered them to the floor. Staff A stated that before the lift had even been moved they heard a "pop" first. Staff A stated the resident would typically become rigid during the transfers. At that time the surveyor in the sling straightened their body in a rigid fashion, duplicating what Staff A had described. The loops did not move on the lift hooks, and were unable to be budged when the observing surveyor attempted to move the loops by pulling on them. The surveyor in the sling at that time attempted bouncing and moving around in the sling while in the air. The sling loops still did not move at all. At that time, the investigating surveyor asked Staff A and Staff B if they could think of how the sling came off of the hook even if the safety clip had been non-functional, when the demonstration showed the loop did not move as long as there had been weight in the sling. Both stated they did not know how it could have come off of the hook. At that time the facility Director of Nursing who had been present, stated they believed the sling loop had come off of the hook because the resident had been contracted and possibly weighed less than the surveyor used in the demonstration. When asked, Staff A stated the only thing they could think of that could have prevented the incident would have been for the lift to have had been inspected routinely. The DON stated the resident had been a different kind of lift transfer than any other resident because the resident had been so contracted and contorted, and had spells during transfers that caused the residents body to become very rigid. At that time the surveyor asked the DON if the resident had any therapy evaluation for safety in the lift sling because of this. The DON stated no, because there had never been a problem before. During the demonstration it had been noted that at no time there had been weight in the sling after it had been raised, could the lift be manipulated to bring the loops up and over the hooks the sling hung on, either by manually trying to tip the lift arm and pull it off, or by surveyor movement in the sling. At no time during the demonstration did the loop come into contact with the plastic safety clip or place any pressure on it, after weight had been placed in the lift sling. During interview with the facility DON at 3:00 p.m., they stated after the incident, they had noted another Hoyer being used had a cracked safety clip and you could not see that it had been cracked unless you looked very closely. The DON stated they had pulled the lift from the floor and talked to the maintenance director about the fact they had stated they had inspected the remaining mechanical lifts on the floor and had not noted any other cracked clips. At that time, the surveyor asked the DON if they had any concern with using the lifts if they felt the incident had occurred due to mechanical failure. The DON stated no, because now the facility would be doing maintenance inspections like they should be. During interview with the facility maintenance director on 10/8/14 at 2:57 p.m., they verified another clip that had a hairline crack had been brought to their attention after the incident had occurred. They stated that unless you felt it you would not have known. During interview with the facility MDS coordinator on 10/9/14 at 8:45 a.m., they stated the resident had been different to transfer than other residents. They stated the resident had a seizure disorder and spastic movements that made it different. The surveyor asked if it would have been appropriate to have a therapy evaluation to determine if a mechanical lift transfer had been safe for the resident, and they stated they had never thought about doing that. They stated it would be something to think about if it came to the point the resident could ever be transferred from bed again. Review of Resident #1 ' s Treatment Administration Record (TAR) dated October 2014 revealed the application of an immobilizer to the right lower extremity for the right leg fracture. Resident #1 had an order for [REDACTED]. Given orally at a dose of 2.5 mg for pain as needed until gone. Resident #1 received a total of 6 doses before the medication was discontinued.