Every finding on record at Southview Acres Healthcare Center

Based on interview and record review, the facility failed to treat a wound when first discovered for one of one resident (R1) when the facility staff identified a wound on 3/16/26, applied a dressing, and then notified the provider and initiated treatment on 3/23/26. Findings include:R1's provider encounter note dated 3/4/26 did not include a skin assessment of R1. R1's minimum data set (MDS) dated [DATE] indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia with other behavioral disturbances. R1's additional diagnoses included vascular dementia without behavioral disturbance, acquired absence of left leg above knee, acquired absence of right leg above knee, vascular disease, and reduced mobility. R1 had no ulcers, wounds, or skin problems. R1's weekly bath audit dated 3/17/26 indicated under the title Skin Status i.e., bruises, skin tears, rashes, redness, blisters, or any other open areas. R1 had non-tender lymph nodes observed on right upper hip. R1's progress note dated 3/23/26 indicated R1 had a new skin issue located right above his knee on his amputation site. This wound was staged at a stage four pressure ulcer/injury with full thickness skin and tissue loss. The progress note indicated R1's bone was exposed and had erythema/edema. The wound was measured 1.56 centimeters (cm) in length and 1.64 cm wide. The wound had 29% granulation and 80% slough. There was moderate amount of serosanguineous exudate. The progress note indicated the dressing was intake and there was 26%-75% dressing saturation. R1's provider order dated 3/23/26 indicated registered nurse (RN)-B called NP indicating R1 had an ulcer on his right stump and there was slough at wound bed and exposed bone. NP ordered doxycycline monohydrate 100 milligrams (mg) by mouth twice a day for seven days for an infection of the skin and/or soft tissue. R1's skin issues assessment dated [DATE] indicated R1 had a new would to his above the knee amputation stump. The wound measured 1.56 by 1.64, and the wound bed is 20% granulation and 80% slough with a small area of exposed bone. There was erythema to the peri wound with no order or pain. The assessment indicated R1's wound was a stage four pressure ulcer/injury with full-thickness skin and tissue loss. R1's dressing appeared intact, and the dressing had moderate amount of saturation. R1's progress note dated 3/23/26 indicated R1 had a new would to his above the knee amputation stump. The wound measured 1.56 by 1.64, and the wound bed is 20% granulation and 80% slough with a small area of exposed bone. There was erythema to the peri wound with no order or pain. The nurse practitioner (NP) was updated and reviewed the picture, and determined the wound was a diabetic ulcer with R1's peripheral vascular disease and severe protein-calorie malnutrition as contributing factors. NP ordered doxycycline for possible cellulitis due to the erythema. Wound order treatment consisted of UrgoTul Ag, calcium alginate, and a bordered foam dressing. R1's guardian was updated. R1's medication admission record (MAR) dated 3/23/26 indicated R1 would receive Doxycycline Monohydrate 100 mg by mouth twice a day for infection of the skin and/or soft tissue for seven days. This order was marked completed on 3/23/26 at 8:00 p.m., 3/24/26 at 9:00 a.m. and 8:00 p.m., 3/25/26 at 9:00 a.m. and 8:00 p.m., and 3/26/26 at 9:00 a.m. R1's MAR dated 3/24/26 indicated the nurse would provide wound treatment to right stump daily and as needed by cleansing with Vashe and let moistened gauze remain on would bed for 3 minutes, apply skin prep to peri wound, place UrgoTul on wound bed followed by calcium alginate and cover with a bordered form dressing. This order was marked and completed on 3/24/26 and 3/25/26. R1's weekly bath audit dated 3/24/26 under the title Skin Status R1 had no new skin alterations i.e., bruises, skin tears, rashes, redness, blisters, or any other open areas. During an interview on 3/26/26 at 8:30 a.m., guardian-A indicated he was notified about the wound during a care conference on 3/23/26. Guardian-A indicated there was a progress note in R1's medical records between 3/21/26 and 3/22/26 about R1's wound. During an interview on 3/26/26 at 9:34 a.m., licensed practical nurse (LPN)-A stated if she saw a resident had a wound, she would let the provider know right away and get treatment orders. During an interview on 3/26/26 at 11:24 a.m., RN-B stated she received a note on 3/22/26 that R1 had a wound on his right stump and RN-B had assessed it on 3/23/26. After RN-B assessed the wound, RN-B had a care conference with guardian-A. During an interview on 3/26/26 at 1:10 p.m., LPN-B stated she had discovered the wound on 3/23/26. LPN-B was providing cares for R1 when she saw the wound dressing on his stump, the dressing was dated 3/16/26, but there were no initials to indicate who applied the dressing. LPN-B asked other nurses working if they had noticed the wound on R1's stump and none of the other nurses knew about the wound. During an interview on 3/26/26 at 1:12 p.m., RN-C stated she worked the overnight shift on 3/16/26, 3/17/26, 3/18/26, and 3/19/26. RN-C stated she did not notice a wound on R1's stump during any of her shifts. If she found a resident had a wound, she would contact the provider and then use the house standing orders for treatment while she waited for treatment from the provider. During an interview on 3/26/26 at 1:33 p.m., LPN-C stated she worked the evening shift on 3/16/26, 3/17/26, 3/18/26, and 3/20/26 and she did not notice a wound on R1's stump during any of her shifts. If she discovered a wound on a resident, she would assess the wound, then contact the provider for treatment and update the family. During an interview on 3/26/26 at 1:40 p.m., LPN-E stated she worked with R1 on the evening of 3/16/26. LPN-E stated she did not see any dressing applied to R1's stump. During an interview on 3/26/26 at 1:46 p.m., LPN-D stated she worked with R1 on 3/16/26 during the day shift and she did not see R1's wound on 3/16/26. LPN-D stated she did recall seeing a band-aid with a date on his stump during her shift but could not recall the date noted. During an interview on 3/26/26 at 2:00 p.m., LPN-A stated she did not see R1's wound when she worked on 3/16/26 because she was not looking for a wound. LPN-A stated she did not know how or who applied R1's dressing on 3/16/26. During an interview on 3/26/26 at 2:15 p.m., RN-B stated when she assessed R1's wound on 3/23/26, there had already been a dressing on the wound. RN-B did not recall where the dressing came from or who applied dressing on the wound. RN-B stated the dressing had a date of 3/16/26 but did not have initials of the staff member who applied the dressing. During an interview on 3/26/26 at 4:22 p.m., RN-D stated it is the expectation that when a nurse discovers a wound, the nurse would notify the provider the day the wound was found and then treat the wound based on what the provider orders. RN-D stated the wound should be assessed at the duration the provider orders. The facility's Standing Orders for Skilled Nursing Facility revised in 2025 indicated if the facility wound management process was not available staff should assess all wounds and dressings daily and change dressings every three days and as needed. The Standing Orders indicated the nurse could treat the wound with normal saline or non-cytotoxic wound cleaner and cover with a non-adherent dressing and secure appropriate cover dressing while avoiding tape to the skin. Staff should notify the provider the next business day of a new wound or injury.

Based on interview and record review, the facility failed to maintain medical records that are accurately documented for five of six residents (R1, R2, R3, R5, and R6) when their weekly bath audits did not indicate wounds that they were being treated for.Findings include: R1's minimum data set (MDS) dated [DATE] indicated R1 was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia with other behavioral disturbances. R1's additional diagnoses included vascular dementia without behavioral disturbance, acquired absence of left leg above knee, acquired absence of right leg above knee, vascular disease, and reduced mobility. R1 had no ulcers, wounds, or skin problems. R1's weekly bath audit dated 3/17/26 indicated under the title Skin Status i.e., bruises, skin tears, rashes, redness, blisters, or any other open areas. R1 had non-tender lymph nodes observed on right upper hip. R1's weekly bath audit dated 3/24/26 indicated under the title Skin Status i.e., bruises, skin tears, rashes, redness, blisters, or any other open areas. R1 did not have any new or old skin alterations. R1's wound documentation indicated R1 was receiving treatment on his stage four pressure ulcer/injury on his right above the knee amputation from 3/23/26 through 3/25/26. R2's MDS dated [DATE] indicated R2 was admitted to the facility on [DATE] with a primary diagnosis of paraplegia. R2's additional diagnoses included pressure-induced deep tissue damage of left hip, pressure ulcer of other site, pressure ulcer of other site stage three, pressure ulcer of right ankle stage three, pressure ulcer of left hip stage four, pressure ulcer of right heel stage four, and pressure ulcer of left heel stage three. R2's weekly bath audits dated 1/7/26, 1/14/26, 1/21/26, 1/28/26, 2/4/26, 2/18/26, 2/25/26, 3/4/26, 3/11/26, and 3/18/26 indicated R2 did not have any new or old skin alterations. R2's wound documentation indicated R2 was receiving treatment for his open lesion on his right Achillies on 1/5/26, 1/12/26, 2/2/26, 2/9/26, 2/16/26, 2/23/26, 3/7/26, 3/9/26, 3/16/26, and 3/23/26. R2 was receiving treatment for stage three pressure ulcers on his right heel on 1/5/26, 1/12/26, 1/19/26, 1/26/26, 2/2/26, 2/9/26, 2/16/26, 2/23/26, 3/7/26, 3/9/26, 3/16/26, and 3/23/26. R2 was receiving treatment for his left shin wound on 3/9/26 and 3/23/26. R2 was receiving treatment for his stage three right medial calf wound on 1/5/26, 1/12/26, 1/19/26, 1/26/26, 2/2/26, 2/9/26, 2/16/26, 2/23/26, 3/7/26, 3/9/26, and 3/23/26. R2 was receiving treatment for his unstageable right medial malleolus wound on 1/5/26, 1/12/26, 1/19/26, 1/26/26, 2/2/26, 2/9/26, 2/16/26, 2/23/26, 3/7/26, 3/9/26, 3/16/26, and 3/23/26. R2 was receiving treatment for his stage three left heel pressure ulcer/injury on 1/5/26, 1/12/26, 1/19/26, 1/26/26, 2/2/26, 2/9/26, 2/16/26, 2/23/26, 3/7/26, 3/9/26, 3/16/26, 3/21/26, and 3/23/26. R3's MDS dated [DATE] indicated R3 was admitted to the facility on [DATE] with a primary diagnosis of malignant neoplasm of prostate. R3's additional diagnoses included pressure ulcer of left heel stage three, pressure ulcer of other site stage three, pressure ulcer of other site unspecified stage, and pressure ulcer of sacral region stage four. R3's weekly bath audit dated 3/25/26 indicated R3 did not have any new or old skin alterations. R3's wound document indicated R3 received treatment to his right heel pressure ulcer/injury on 3/23/26. R5's MDS dated [DATE] indicated R5 was admitted to the facility on [DATE] with a primary diagnosis of type two diabetes mellitus with other skin ulcers. R5's additional diagnoses included pressure-induced deep tissue damage of left ankle, pressure ulcer of left heel stage four, and non-pressure chronic ulcer of other part of left foot with other specified severity. R5's weekly bath audits dated 2/10/26, 2/17/26, 3/3/26, 3/17/26, and 3/24/26 indicated R5 did not have any new or old skin alterations. R5's wound documentation indicated R5 received treatment for his diabetic ulcer on left heel on 2/9/26, 2/23/26, 3/2/26, 3/16/26, 3/23/26, and 3/25/26. R5 received treatment for his diabetic ulcer on left medial calf on 2/23/26, 3/2/26, 3/9/26, 3/16/29, 3/23/26, and 3/25/26. R6's MDS dated [DATE] indicated R6 was admitted to the facility on [DATE] with a primary diagnosis of end stage renal disease. R6's additional diagnosis included peripheral vascular disease. R6's weekly bath audits dated 1/8/26, 1/15/26, 1/22/26, 2/5/26, 2/12/26, 2/19/26, and 3/12/26 indicated R6 did not have any new or old skin alterations. R6's wound documentation indicated R6 received treatment for his unstageable pressure ulcer/injury to his left dorsum second digit on 1/26/26, 2/2/26, 2/16/26, 2/23/26, 3/2/26, 3/9/26, 3/16/26, and 3/23/26. R6 received treatment for an abscess on his coccyx on 1/5/26, 1/12/26, 1/26/26, 2/2/26, 2/9/26, 2/16/26, 2/23/26, 3/2/26, 3/9/26, 3/16/26, and 3/23/26. During an interview on 3/26/26 at 11:24 a.m., registered nurse (RN)-A stated she was unsure why R1's skin alterations were not documented on the weekly bath audit on 3/24/26. RN-A stated that education would be provided to the nurse who completed the bath audit. During an interview on 3/26/26 at 1:10 p.m., licensed practical nurse (LPN)-B stated when a resident takes a bath, the nursing aid will alert the nurse who will complete the skin audit. The nurse will check for redness, swelling, and open wounds. If there are any new skin alterations, she would note that on the weekly bath audit. If there are no new skin alterations, LPN-B stated she would chart nothing new. During an interview on 3/26/26 at 1:12 p.m., RN-C stated when a resident is taking a bath, they would complete the weekly skin audit. If RN-C found a new wound or skin alteration, she would make a report in risk management. During an interview on 3/26/26 at 1:33 p.m., LPN-C stated when she is completing a skin audit on a resident, she is looking for any marks under the breasts, under the arms, groin, buttocks, and feet. If there is a new wound, she would document that in the weekly bath audit. During an interview on 3/26/26 at 1:40 p.m., LPN-E stated when a resident is taking a bath, they would complete the resident's weekly bath audit. LPN-E stated she would document what she found on the resident's skin on the weekly bath audit. During an interview on 3/26/26 at 1:46 p.m., LPN-D stated the nurse will check a resident's skin when the resident is taking a nap. If the resident has a new or old wound, LPN-D would document that on the weekly bath audit. During an interview on 3/26/26 at 4:22 p.m., RN-D stated any new or existing wound should be noted on the weekly bath audit. RN-D stated before three months ago staff was instructed not to put the existing wounds on the weekly bath audits, but nurses are now expected to note both new and existing wounds on the weekly bath audit. A policy on weekly bath audits was requested and none was received.

Based on interview and document review the facility failed to electronically submit direct care staffing information (including agency and contract staff) per day, based on payroll and other verifiable and auditable data to Centers for Medicare and Medicaid Services (CMS). The had the ability to impact all 171 residents residing at the care facility. Findings include:The care facilities Payroll Based Journal (PBJ) Staffing Data Report for fiscal year quarter 1 2026 (October 1 - December 31), dated 3/4/26, indicated the facility failed to submit data for the quarter. During an interview on 03/0926 at 12:24 p.m., the administrator stated the PBJ information was submitted through their corporate team, and he would look into how this was missed. During a follow up interview on 12:10 p.m., the administrator stated he spoke with his corporate team, and it was discovered the wrong facility's information was uploaded in place of their facility's staffing information and it didn't stick in the system. A facility policy titled Payroll Based Journal, dated 3/2/25, indicated it was the policy of the facility to adhere to the mandatory submission of staffing information based on payroll data with a deadline of February 14th for fiscal quarter 1 submissions. The policy further indicated, Section 6106 of the Affordable Care Act (ACA) requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data.

Based on interview and document review, the facility failed to notify the attending physician of a change in condition for 1 of 1 resident (R181) reviewed for discharge process.Findings include:R181 was admitted to the facility on [DATE] with an admission diagnosis of lumbar stenosis without neurogenic claudication, and other specified postprocedural state. R181 left the faciity on 1/10/26.R181's medical record was reviewed and lacked documentation about reporting R181's leaving the facility against medical advice (AMA) to his primary physician.R181's progress note dated 1/10/26 at 5:58 a.m., indicated R181's wife arrived at the facility at 4:50 a.m. and requested to get R181's medications ready because she was taking R181 home with her. The progress note indicated the nurse in charge educated R181 and his wife about AMA. The nurse in charge advised them the facility would not be able to release the medications. R181's progress note dated 1/13/26 at 3:09 p.m., documented a phone call from a spine center requesting an update about R181. The spine center wanted to verify R181 left the facility AMA, and without medications. During interview on 3/12/26 at 10:29 a.m., the assistant director of nursing/infection control preventionist (IP) reviewed R181's medical record and verified R181's primary physician was not updated about R181 leaving AMA.During interview on 3/12/26 at 10:42 a.m., the director of nursing (DON) stated the provider needed to be notified when a resident left AMA. DON stated she would look into R181's situation and provide further details. No additional information was received. Facility's policy titled Resident Leave Against Medical Advice dated 4/19/19, indicated the resident's assigned nurse will contact the primary physician to inform of the resident's decision to leave against medical advice.

Based on interview and document review, the facility failed to ensure a resident was reassessed and failed to implement new interventions to prevent skin breakdown after developing a stage III pressure injury while a resident at the facility for 1 of 2 residents (R123) reviewed for pressure injuries. Findings include:R123's quarterly Minimum Data Set (MDS) dated [DATE], indicated R123 required substantial staff assistance with personal hygiene, dressing and bathing and was dependent on staff for toileting. The MDS indicated R123 was at risk but did not have any pressure ulcers.R123's care plan included a focus of potential for skin impairment related to immobility and incontinence last revised 12/19/23. Interventions included use of pressure reducing wheelchair cushion and pressure reducing mattress.R123's care plan, dated 1/16/26, indicated R123 had a coccyx wound requiring wound care and to keep resident skin clean and well lubricated. The care plan lacked any new, specific pressure reducing interventions to prevent R123 from developing new (or re-opening) pressure injuries. R123's wound note, dated 1/19/26, indicated R123 had a stage III pressure injury to her coccyx that had re-opened last week and the plan of care in place remained effective.R123's significant change MDS, dated [DATE], indicated R123 received hospice services and required substantial staff assistance with personal hygiene, dressing and bathing and was dependent on staff for toileting. The MDS further indicated R123 was at risk for pressure ulcers and had one stage III pressure injury not present on admission. R123's wound note, dated 2/23/26, indicated R123's coccyx wound had resolved. During an interview on 3/11/26 at 12:37 p.m., registered nurse (RN)-F stated staff used barrier cream and a silicone dressing for R123's bottom even without a pressure injury. RN-F stated R123 was not on any specific turning and reposition schedule. During an interview on 3/11/26 at 1:03 p.m., clinical manager and licensed practical nurse (LPN)-C stated R123's interventions depended on who the aide was that was working, stating R123 would often refuse cares but a few aides were able to get her up and out of bed. LPN-C stated the aides who worked with the residents rotated to different units but work well together. LPN-C confirmed the care plan needed to be updated to remove wound care and confirmed there had been no updates to the potential for skin impairment care plan since R123 developed a pressure injury in January. LPN-C stated she believed the current interventions were effective because R123. had the one issue and hasn't had anymore.During a follow up interview on 3/12/26 at 11:02 a.m., clinical manager and LPN-C stated R123 should not be getting a silicone dressing on her coccyx as the wound resolved and there were no new orders after the wound healed for continued dressing, only barrier cream. LPN-C also confirmed R123 was not on a specific turning and repositioning schedule. During an interview on 3/12/26 at 12:10 p.m., the director of nursing (DON) stated that even though R123 was on hospice care she would expect to see new care planned interventions for pressure injury prevention and skin protection after the development of a pressure injury, stating, we still don't want to see pressure injuries in hospice.A facility policy titled Prevention of Pressure Injuries, dated 3/6/25, instructed staff to reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team and to review the interventions and strategies for effectiveness on an ongoing basis.

Based on interview and document review, the facility failed to notify the State Long-Term Care (LTC) Ombudsman of facility-initiated transfers to an acute care facility on an emergent basis, and failed to ensure a written notice of bed hold was provided and documented in the electronic medical record (EMR) for 2 of 2 residents (R10, R17) reviewed for hospitalizations. Findings include:R10 R10's significant change in status (SCSA) Minimum Data Set, dated [DATE], identified R10 with severe cognitive impairment, and diagnoses of liver cancer, kidney disease, dementia, and psychosis (disconnection with reality, including hallucinations and delusions).R10's progress note (PN) dated 12/15/25, identified R10 had an unwitnessed fall with injury and was sent to the emergency department (ED). PN lacked indication a bed-hold or transfer form was offered and signed.R10's PN dated 1/24/26, identified a fall with major injury and was sent to the ED.PN lacked indication a bed-hold or transfer form was offered and signed.R17 R17's quarterly MDS dated [DATE], identified R17 with severe cognitive impairment and diagnoses of Alzheimer's, arthritis, dementia, anxiety, depression and fibromyalgia (chronic disorder involving pain, fatigue, sleep disturbances and cognitive issues).R17's emergency room (ER) After Visit Summary dated 2/19/26, identified R17 was sent to eh hospital on (date) and returned on (date) for a medication-related concern. PN failed to indicate if a bed-hold or transfer form was offered to her emergency contact.During interview with registered nurse (RN)-D on 3/11/26 at 12:48 p.m., RN-D stated when a resident was transferred to the hospital, the facility was expected to obtain a signed bed-hold and transfer policy from the resident or a verbal agreement prior to resident leaving the facility. RN-D stated she was expected to obtain a copy of the signed form and give it to the Health Unit Coordinator (HUC) who was then expected to download or scan it into the residents EMR. In addition, RN-D stated she would send the resident to the hospital with a face sheet, medication list, and a copy of a current Provider Order for Life Sustaining Treatment (POLST) form. RN-D stated she would call the guardian and emergency contact to obtain verbal consent if a resident was unable to provide it and then document this in a progress note in the EMR.During interview with licensed practical nurse (LPN)-D on 3/11/26 at 12:59 p.m., LPN-D stated whenever a resident was transferred to the hospital, the facility was expected to ask family or the resident's guardian for verbal permission to approve a bed-hold and transfer notice. LPN-D stated, I fill out form saying I have verbal permission, uploaded it into the residents EMR, wrote it in the progress note.During interview with RN-B on 3/11/26 at 1:26 p.m., RN-B stated whenever a resident was transported to the hospital that a signed bed-hold and transfer policy must be obtained each time they leave. RN-B stated a copy of the signed form is uploaded into the residents EMR and expectation was to document the bed hold in the progress note.During interview with HUC-A on 3/11/26 at 1:31 p.m., HUC-A stated bed-holds went with the resident to the emergency room and HUC-A scanned a copy of the signed form and put it in the EMR.During interview with LPN-H on 3/12/26 at 8:30 a.m., LPN-H stated when she sent a resident to the hospital she would fill out the written form to get consent, leave a copy at the facility to be scanned into the chart, and send a copy with the resident along with other paperwork to the hospital. LPN-H stated she was nurse on duty when R10 fell and broke his hip on 12/15/25 and was sent to the hospital. LPN-H stated she did not recall if she got the bed-hold and transfer form, but if she had, she would have entered it into R10's progress notes. LPN-H looked at R10's progress notes and verified there was no mention of providing or offering a bed-hold notice and transfer form to R10.During interview with health unit coordinator (HUC)-B on 3/12/26 at 8:43 a.m., HUC-B stated that when a resident was transferred to the hospital, the facility was expected to print out a resident face sheet, POLST, medication list and have the resident sign a copy of the bed-hold and transfer policy prior to leaving the facility. In instances where the resident was unable to acknowledge the bed-hold form then the guardian or emergency contact was informed, and the nurse was required to document the discussion in the progress note of the EMR. In addition, the HUC was responsible for uploading a copy of the signed bed-hold and transfer form into the EMR.During interview with LPN-I on 3/12/26 at 10:03 a.m., LPN-I stated he was the nurse on duty when R17 fell and fractured his arm on 1/24/26 and was sent to the hospital. LPN-I stated he did not recall filling out bed-hold or transfer form prior to sending R17 to the hospital. LPN-I stated, it should be signed and scanned into the chart, but I do not recall it being done. LPN-I stated expectation of staff to print a face sheet, medication list, and POLST to accompany the resident to the hospital.During interview with registered nurse (RN)-A on 3/12/26 at 11:26 a.m., RN-A stated expectation of nursing staff to immediately provide a copy of the bed-hold policy and notice of transfer to the patient or guardian prior to transfer to hospital. In addition, the resident face sheet, medication list and current POLST to all accompany resident to the hospital. RN-A stated expectation of facility staff to upload a signed copy of the notice of transfer to the resident's electronic medical record (EMR). RN-A verified both R10 and R17's EMR lacked documentation of a bed-hold/transfer notice, and a progress note to indicate it was done.During interview with director of nursing (DON) on 3/12/26 at 11:04 a.m., DON stated expectation of staff to provide copy of bed-hold policy and notice of transfer when residents were leaving the building for hospitalizations. DON stated a signed copy should be scanned into the EMR. As for notifying the Office of the State Long-Term Care Ombudsman of discharges and transfers, DON stated the director of social services (SS)-D is responsible for that task.During interview with SS-D on 3/12/26 at 11:17 a.m., SS-D stated she was responsible for sending discharge notifications to the State Ombudsman monthly. However, SS-D stated she was unaware of needing to send notices of transfers and hospitalizations to the Office of the State Long-Term Care Ombudsman too., and stated, I did not know that I had to.Attempts to call/contact R10 and R17's guardian and primary emergency contacts and the Ombudsman were made but no answer or call back was obtained.Undated facility policy titled Transfer or Discharge Notice identified expectation of facility to provide transfer or discharge notice to resident where, An immediate transfer or discharge is required by the resident's urgent medical needs. In addition, The resident and/or representative will be notified in writing of the following information which included the facility bed-hold policy and, A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman.

Based on observation, interview, and document review, the facility failed to revise the care plan to include a comprehensive pain management plan for 2 of 3 residents (R6, R42) reviewed with a history of pain. Findings include: R6's quarterly minimum data set (MDS) dated [DATE], indicated R6 had moderately impaired cognition and a diagnosis of heart failure, kidney failure, and dementia. The MDS indicated R6 received scheduled pain medications, did not receive as-needed pain medications, and did not receive non-medication interventions for pain during the look-back period (LBP). R6's care plan dated 10/29/25, included a pain care plan that indicated R6 had acute pain/ chronic pain but did not further describe R6's pain. The care plan had a goal that the resident would report satisfactory pain control. The pain care plan included one intervention, which was as follows: evaluate for non-verbal indicators of pain. The pain care plan did not indicate what non-pharmacological interventions should be utilized for managing R6's pain. R6's order summary dated 3/10/26, indicated R6 had an order for 650 milligrams (mg) of acetaminophen (an over-the-counter pain medication) three times a day for chronic pain, with a start date of 7/14/25, a discontinued date of 3/9/26, and then reordered on 3/9/26. The summary included an order for a lidocaine pain relief patch to the mid-upper back every 12 hours, started on 8/26/25, discontinued on 3/9/25, and restarted on 3/9/26. The summary indicated R6 also had an order for 500 mg of methocarbamol (a muscle relaxant) every four hours as needed for pain, with a start date of 10/17/25. During an interview on 3/11/26 at 10:11 a.m., registered nurse (RN)-D confirmed she was R6's nurse for the day. RN-D stated that R6 had a history of chronic pain and had previously been seeing a pain medicine team for this pain. RN-D stated R6's pain was sporadic and varied in location but was sometimes in his back. RN-D stated that the non-pharmacological interventions she had used to assist R6 with his pain were music, redirection, snacks, and reminiscing, and she had found these effective. During an interview on 3/12/26 at 8:04 a.m., licensed practical nurse (LPN)-B confirmed she was R6's nurse for the day and stated that when R6 had pain, it was generally in his upper back and that non-pharmacological pain interventions such as heat or ice were implemented to assist with his pain. LPN-B stated she would look at the care plan to see what pain interventions were effective for R6 but was unsure if this was on the care plan or not. During an interview on 3/12/26 at 8:47 a.m., LPN-G, the unit nurse manager, stated that R6 had a history of upper back pain and utilized pain medications. When asked what nonpharmacological pain interventions had been found helpful with R6's pain, LPN-G stated that things such as fresh air, one-on-one time, and reassurance were helpful nonpharmacological interventions to assist R6 with his symptoms. LPN-G stated she and social services worked together to update resident care plans, but when asked if these nonpharmacological pain interventions were part of his care plan, LPN-G stated she was unsure. During an interview on 3/12/26 at 9:14 a.m., the director of nursing (DON) stated that she would expect nursing staff to assess and observe for signs and symptoms of resident pain, and as they see these signs or symptoms, they should attempt non-pharmacological pain interventions. The DON stated she would expect non-pharmacological pain interventions to be outlined in the care plan but acknowledged this might take some time to develop as they get to know the residents. R42's annual Minimum Data Set (MDS), dated [DATE], indicated R42 was admitted to the care facility on 12/26/23, had severe cognitive impairment, and was dependent on staff for all activities of daily living (ADLs). The MDS further indicated R42 received scheduled and as needed pain medication but did not receive and non-pharmacological pain interventions. R42's Orders indicated an order, dated 3/2/26, for Oxycodone (a narcotic pain medication) 5 milligrams (mg) once a day and every 6 hours as needed, not to exceed 3 doses. R42's orders, dated 5/7/25, indicated orders for methocarbamol (a muscle relaxant) 500mg three times a day for pain, diclofenac gel to right wrist three times a day for pain and Tylenol 650 mg three times a day for pain. R42's March medication administration record (MAR), indicated R42 had received as needed oxycodone seven times in the past ten days. R42's care plan, dated 11/2/24, indicated R42 had chronic pain related to upper extremity contracture and a history of shoulder injuries. The care plan indicated an intervention to medicate R42 with as needed medications if non-medication interventions were ineffective. The pain care plan did not indicate what non-pharmacological (non-medication) interventions should be utilized for managing R42's pain. R42's electronic medical record (EMR), to include progress notes, lacked evidence of documented or care planned non-pharmacological pain interventions that should be attempted prior to administering as needed pain medication. During observation on 3/9/26 at 5:58 p.m., R42 was out in the main living area in a broda chair. R42 appeared to be leaning to the right and in distress moaning and restless. Staff approached R42 to help reposition him in his broda chair. During an interview on 3/11/26 at 7:20 a.m., nursing assistant (NA)-D stated R42 would stay in bed until near lunch time, and she believed the nurses would give him something for pain prior to transferring him out of bed to help with his pain. NA-D stated if a resident appeared in pain, including R42, there were no non-medication interventions would try, she would tell the nurse. During an interview on 3/11/26 at 10:04 a.m., registered nurse (RN)-F stated R42 was unable to verbally communicate but could at times nod yes or no to simple questions such as are you in pain. RN-F stated staff often had to read his non-verbal signs of pain such as facial grimaces or groans. RN-F stated for non-pharmacological interventions staff would get him out of bed into his broda chair. During an interview on 3/11/26 at 1:03 p.m., nurse manager and licensed practical nurse (LPN)-C stated it was the expectation that non-pharmacological pain interventions be care planned and attempted and documented prior to as needed pain medication being administered. During a follow up interview on 3/11/26 at 2:35 p.m., nurse manager and LPN-C stated when staff notice R42 to be in pain they hold his hands, reposition him in his broda chair and if he still shows signs of pain they offer him pain medication. LPN-C confirmed that none of the non-pharmacological pain interventions were care planned or documented as attempted. The facility's Comprehensive Person-Centered Care Plans policy dated 11/30/21, indicated that a person-centered care plan would be developed for each resident. The policy indicated care plan interventions would be derived through analysis of the information gathered as part of the comprehensive assessment. The policy indicated the care plan would include services that would be furnished to attain or maintain the resident's highest practicable well-being.

Based on interview, observation and document review, the facility failed to ensure a comprehensive care plan was developed and implemented for 1 of 1 resident (R13) reviewed for pain management.Findings include:R13's admission Minimum Assessment Data (MDS) dated [DATE], indicated R13 was cognitively intact, had no behaviors, and didn't refuse cares. MDS indicated R13 needed substantial assistance with toileting hygiene, bathing, dressing, personal hygiene, and transfers. The MDS assessment also indicated R13 received scheduled and as needed (PRN) pain medications, as well as opioid and antipsychotic medications.R13's Clinical Diagnosis Report dated 3/12/26, indicated diagnoses of chronic obstructive pulmonary disease, chronic pain, post-traumatic stress disorder, repeated falls, failure to thrive, and heart failure.R13's orders dated 3/12/25 included the following medications:Hydromorphone HCL 2 milligrams (mg) tablets. Give 0.5 tablet by mouth three times a day.Hydromorphone HCL 2 mg tablets. Give 0.5 tablet by mouth every 6 hours as needed (PRN)Acetaminophen oral tablet 500 mg. Give one tablet every 8 hours PRNLidocaine external cream 4%. Apply small amount to left chest wall twice a day.Gabapentin oral capsule 100 mg by mouth three times a day.R13's care plan dated 3/12/26, did not include a care plan for pain.During interview on 3/10/26 at 11:46 a.m., R13 stated he had chest surgery last year and since then he has experienced pain. During the interview R13 rated his pain as 7. R13 said the pain comes and goes.During interview on 3/10/26 at 3:21 p.m., nurse manager/licensed practical nurse (LPN)-C stated R13 had problems with pain. LPN-C stated R13 scheduled an appointment to see a doctor due to severe foot pain.During interview on 3/11/26 at 10:44 a.m., LPN-C verified his pain management had not been care-planned.During interview on 3/11/26 at 10:49 a.m., the director of nursing (DON) stated R13 should have had a care plan for pain and she expected the staff would assess resident's pain and monitor for side effects and pain therapy effectiveness.A facility policy titled Comprehensive Person-Centered Care Plans dated 11/30/21, indicated the comprehensive, person-centered care plan will include measurable objectives and timeframes, and describe the services that are furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being.

Based on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded with the potential for inaccurate federal reimbursement and resident care planning for 3 of 5 residents (R5, R8, and R25) reviewed for MDS accuracy. Findings include: R5's Annual Minimum Data Set (MDS), dated [DATE] indicated R5 was admitted to the care facility on 1/13/25. Section GG Functional Abilities and Goals section of the MDS was dashed not assessed. R8's quarterly MDS, dated [DATE], indicated R8 was admitted to the care facility 11/22/24. Section GG Functional Abilities and Goals section of the MDS was dashed not assessed. R25's quarterly MDS dated [DATE], indicated R25 was not receiving hospice care and was admitted to the facility on [DATE]. R25's Order Summary Report dated 9/23/25 included an active order that indicated R25 had signed on to receive hospice care on 9/4/25 with a diagnosis of Parkinson's disease. During an interview on 3/12/26 at 8:01 a.m., licensed practical nurse (LPN)-E stated that R25 was receiving hospice care and had been since his admission to the facility. During an interview on 3/12/26 at 9:20 a.m., the MDS Coordinator (MDSC)-A stated the GG section of the MDS was discussed daily at their morning team meeting and was also assessed by utilizing the resident's electronic medical record (EMR) to determine how well a resident functions and how much support they need with activities of daily living (ADLs). The MDSC-A stated they attempt to coordinate baths for each resident to fall within the 3-day lookback period but that it can be challenging with the large size of their facility. The MDSC-A confirmed R5's and R8's GG section of their most current MDS was dashed as not assessed. The MDSC-A also stated it was their responsibility to indicated on the MDS if a resident was receiving hospice services which was determine based on a list the chaplain send out with all residents receiving hospice services listed. The MDSC-A confirmed R25's most current MDS did not indicated R25 was receiving hospice services, and it should. A facility policy titled Resident Assessments, dated 11/30/2021, indicated the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews.

Based on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn to prevent the spread of infection for 1 of 1 residents (R9) observed for enhanced barrier precautions (EBP), (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities). Facility also failed to ensure hand hygiene was performed for 1 of 2 residents (R73) reviewed for transmission-based precautions (TBP).Findings Include: Review of Centers for Disease Control (CDC) guidance dated 4/1/24, Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated Examples of high-contact resident care activities requiring gown and glove use for EBP included: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care: any skin opening requiring a dressing. R9's significant change MDS dated [DATE] indicated R9 was cognitively impaired, had physical behaviors toward others with no impact to the resident, and did not refuse cares. R9's MDS indicated he had a pressure ulcer and had an indwelling catheter. MDS indicated diagnoses of atrial fibrillation, hypertension, non-Alzheimer's dementia, depression, post-traumatic stress disorder, neurogenic bladder and obstructive and reflux uropathy. R9's Profile report indicated EBPs. R9's Clinical Orders included orders for a urinary catheter and sacrum/coccyx wound care. R9's care plan titled Risk for Urinary infection indicated R9 was on EBP. R9's functional care plan revised on 12/23/25, indicated R9 required extensive assistance of 2 person for transfers, dressing and toileting hygiene. R9's functional care plan also indicated he needed total assistance of 2 for transfers with mechanical lift. During observation on 3/10/26 at 12:50 p.m., an EBP sign was observed on R9's on the wall, next to his room's door. The sign directed staff to use a gown and gloves while providing personal cares and transfers. During observation and interview on 3/10/26 at 11:54 p.m., R9 was observed being transferred by two nursing assistants (NA) from his bed to his wheelchair after personal cares. With the sling under R9, one NA hooked the straps onto the lift, they elevated him off the bed and placed him in the wheelchair with the sling under his body. Once sitting on his wheelchair, they unhooked the sling. Neither of the NAs were wearing a gown. During interview on 3/10/26 at 12:58 p.m., NA-C stated she provided catheter care and peri care after an episode of bowel incontinence. NA-C stated after she provided personal cares, she removed her gown and then placed the sling under R9 to prepare to transfer him from his bed to the wheelchair. NA-C stated, I am supposed to wear a gown during transfers, and I did not use one. During interview on 3/11/26 at 10:21 a.m., NA-B stated she helped NA-C to transfer resident from his bed to his wheelchair the previous day. NA-B stated she didn't touch R9, she only touched the Hoyer and added As long as I don't touch him, I don't need to wear a gown. During interview on 3/11/26 at 12:28 a.m., the director of nursing (DON) stated the staff should follow the sign instructions. DON stated the staff needed to use a gown during transfers to avoid transmitting infections. The facility's policy titled Isolation-Categories of Transmission-Based and Enhanced Precautions dated 10/2021, directed staff to wear gloves and gowns during high-contact resident care activities: Dressing Bathing/showering Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Wound care: any skin opening requires a dressing. According to the Centers for Disease Control (CDC), Extended Spectrum Beta Lactamase (ESBL) is a group of bacteria that cause infections in healthcare settings and is resistant to many common antibiotics making infections hard to treat. Good hand hygiene and infection prevention practices can help reduce infection risk. R73 R73's quarterly Minimum Data Set (MDS) dated [DATE], identified R73 with intact cognition and was independent in personal cares. R73's diagnoses included anxiety and ulcerative colitis (inflammation of the inner lining of the colon). In addition, R73 had an ostomy (surgical opening in the abdominal wall that re-routes stool outside the body into a bag). R73's physician orders (PO) dated 9/12/23, indicated Resident may be placed in isolation precautions [sic] per facility infection control policy. R73's electronic medical record (EMR) banner identified R73 with Extended Spectrum Beta Lactamase (ESBL) with onset date of 9/7/25, with PPE Requirements Gloves, Gown. During medication observation and interview on 3/10/26 at 8:32 a.m., licensed practical nurse (LPN)-A stated R73 was placed on contact precautions due to colostomy and not ESBL despite R73s EMR banner. R73's door frame had a Contact Precautions sign posted on it stating, EVERYONE MUST: Clean their hands, including before entering and when leaving the room. LPN-A obtained medications from medication cart in the hallway and crushed them per PO. During the observation LPN-A opened and closed medication cart drawers and used the laptop to identify each medication that he was preparing. After placing each medication in the pill crusher and putting them into a medication cup LPN-A then locked the medication cart and closed down his laptop screen. During this time, LPN-A did not wash or sanitize hands. Then LPN-A knocked and entered R73's room without hand hygiene, gloves, or any other PPE. LPN-A offered R73 her crushed medications to take with applesauce. Then LPN-A exited room and sanitized hands. LPN-A verified he did not wash hands or apply gloves or PPE prior to entering R73's room to administer her medications. During interview with LPN-C on 3/10/26 at 8:43 a.m., LPN-C stated she was nursing manager of unit where R73 resided. LPN-C stated expectation of staff to wear [sic] PPE when entering the room to give meds for residents who were identified as being on Contact Precautions. LPN-C stated, hand hygiene is important to protect both the resident and staff. During interview with infection control preventionist (IP) on 3/10/26 at 8:49 a.m., IP stated expectations that if a resident was identified as being on contact precautions, and if [staff] was administrating medications, then there would be no need to wear any PPE but should use hand hygiene before entering the room. Facility policy titled Administering Medications, reviewed 12/13/2021 state, Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications.

Based on observation, interview, and document review the facility failed to provide assessments and routine dental services to 2 of 2 residents (R87, R152) reviewed for dental care. Findings include: R152's significant change Minimum Data Set (MDS) dated [DATE], indicated intact cognition, diagnoses of traumatic subdural hemorrhage (brain bleed) with loss of consciousness, weakness, dysphagia, and required substantial assistance with oral hygiene. During observation and interview on 3/12/26 at 8:48 a.m., R152 was sitting on the edge of his bed in his room. He stated his mouth was sore and he opened his mouth where there were several missing teeth. He further stated he hadn't seen a dentist since he was admitted (9/16/24) and would like to. He told several staff members about his mouth pain but was unable to recall which staff members he told. R152's MDS dental assessment (completed by Apple Tree Dental) dated 9/2/25, indicated R152 had broken natural teeth, requires staff supervision with oral care, recommended a routine dental referral, and non-urgent dental care needs. R152's care plan dated 2/20/26, indicated R152 required the physical assistance of one staff for personal hygiene but did not address oral care specifically. R152's medical record lacked documentation of routine dental care (i.e. dental appointment). During interview on 8:55 a.m., the Health Unit Coordinator (HUC)-C stated orders for ancillary services (dental, podiatry, vision, etc.) were put in upon admission. Then MDS does an assessment to see what services are needed and the clinical manager can prescribe orders for a referral. When there are enough residents, they (dentist) will come to the facility. HUC-C further stated the residents should be seen within 6 months of the referral. Apple Tree Dental was scheduled to come on 3/17/26 but R152 was not scheduled to be seen. HUC-C stated there was not an official list of residents for this month's visit. The surveyor asked when R152's last dental visit was and HUC-C was unable to find that information. R87 R87's quarterly Minimum Data Set (MDS) dated [DATE], identified R87 with severe cognitive impairment and dependent on staff for all cares including oral hygiene. In addition, R87 had diagnoses of dementia and dysphagia (difficulty swallowing). R87's care plan dated 3/3/25 identified R87 with Impaired Dentition-edentulous, no dentures. R87's physician orders (PO) and electronic medical record (EMR) failed to indicate an order for dental services. During interview with licensed practical nurse (LPN)-H on 3/12/26 at 8:30 a.m., LPN-H stated expectations for orders to be obtained from provider and the Health Unit Coordinator (HUC) would then make the appointment and arrange transportation. During interview with HUC-B on 3/12/26 at 8:43 a.m., HUC-B stated expectation of facility to obtain a referral from a provider and HUC would then facsimile order and resident face sheet to the contracted dental provider for the facility who comes a couple times a year to facility to provide routine dental services. During interview with Registered Nurse (RN)-A on 3/12/26 at 10:26 a.m., RN-A stated expectation of all residents to be seen by a dentist usually yearly or every 6 months. RN-A looked in R87's electronic medical record and verified no dental assessments were done. RN-A stated, we should still ensure everyone has a dental visit or least offered yearly. During interview with director of nursing (DON) on 3/12/26 at 11:09 a.m., DON stated expectation of all residents, Should be seen annually at least and documented in the chart that it was done. DON verified R87 EMR failed to indicate any dental services were offered or provided. Attempts at contacting R87's responsible party were made but no answer or call back was obtained. The facility policy regarding dental services dated 2/8/22, indicated all dental services provided are recorded in the resident's medical record.

Based on interviews and document review the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (R1) reviewed for abuse. In addition, the facility failed to protect 1 of 3 residents (R1) while the investigation was conducted. Findings include: On 6/17/25 at 5:47 p.m., a Brief Interview for Mental Status (BIMS) was conducted. Summary score was 12 and indicated moderate impaired cognition. R1's care plan dated 6/24/25, identified at risk for falls related to restless leg syndrome (RLS), CVA, altered mental status, and lace of safety awareness. Noted to have uncontrolled movement of legs that pulled him out of bed. Staff were instructed to assist him with ambulation, transfers, utilizing therapy recommendations and encourage him to spend time in central location for increased supervision. He made statements and accusations which were unsubstantiated, unfounded and untrue. Family and friend reported this was not new behavior. Staff were directed to provide refused care at an alternative time per his preference, listen to his accusations/complaints and validate feelings behind them, investigate and evaluate resident statements, ensure safety of resident and others, refer to psychiatric evaluation, and establish boundaries and limits with two-person entry for cares. He had an identified behavior problem (placed self on floor) despite analysis of the five whys, and his perception of time was not real. Staff were directed to observe behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved, situations, and document behavior and potential causes. His safety was at risk and there was a potential for abuse due to current use of medications and need for assistance with cares and mobility. Staff were directed to keep him safe and free from abuse by being removed from potentially dangerous situations. Review of Nursing assistant (NA) behavior monitoring and interventions from 6/6/25 through 6/19/25 identified: -6/6/25, 6/7/25, and 6/8/25, no behaviors observed for all shifts. -6/9/25 no behaviors noted on day or evening shift. During night shift at 4:43 a.m. he was noted to be physically aggressive (PA) towards others, repetitive motions (RM), and verbalized persistent beliefs (VP). Interventions: provided calm environment(CE), behaviors worsened (W), and reapproached (RA), unchanged response. -6/10/25 no behaviors noted on day or night shift. During evening shift at 8:10 p.m. he was noted to be agitated (A), accusing of others (AO), PA, redirected (RD), RA, behaviors better (B). -6/11/25, no behaviors observed for all shifts. -6/12/25 no behaviors noted on day and night shift. During the evening shift at 10:59 p.m. behaviors identified were AO, and cursing at others (CO). Interventions identified RD and behaviors B. -6/13/25, 6/14/25, and 6/15/25, no behaviors noted on day or evening shift. 6/13/25 at 9:42 p.m., 6/14/25 at 7:44 p.m., and 6/15/25 at 6:59 p.m. he expressed frustration/anger at others (FR), and PA. Interventions provided: RD, RA, and behaviors B. -6/16/25, 6/17/25, 6/18/25, and 6/19/25, no behaviors observed for all shifts. R1's progress notes from 6/6/25, 6/7/25, 6/11/25, and 6/18/25, identified: -On 6/6/25 at 3:06 p.m., resident was very rude to writer, licensed practical nurse (LPN)-A. He requested a cigarette to go outside for a smoke, writer informed him that he would need to wait until his friend arrived before the cigarette could be provided. Resident became upset and told the writer to stay quiet . he would call the police and report writer to the social worker . clinical manager and social worker were contacted to speak with resident . Later approached resident to check blood glucose level. Resident responded he did not want her to touch him and refused . at 6:20 p.m. resident approached LPN-A and apologized . -Late entry on 6/7/25 at 3:50 p.m., resident yelled and screamed at nurse . resident verbalized he was being abused by then nurses because they were not allowing him access to his cigarettes and lighter . reminded of facility smoking policy and safety precautions . not effective, agitated with social worker and called friend to assist him off grounds to smoke. -Late entry on 6/7/25 at 12:35 a.m., to clarify nurse (LPN-A) was kneeling behind resident by bedside. He elbowed nurse twice and then rolled onto the floor . call light used to ask two NAs to help resident off floor . -On 6/7/25 at 5:39 a.m., writer (LPN-A) found resident intentionally had rolled out of bed at 12:35 a.m., rushed to his room to prevent him from rolling out of bed and asked what are you doing? Resident pushed writer and stated leave me alone, do not touch me . place call light on and called two NAs to help transfer him back to bed. no injury. -No documentation in progress notes by nursing staff on 6/11/25. Seen by NP for follow up visit at 8:34 a.m. no concerns. -On 6/18/25 at 8:24 a.m. resident seen at bedside by nurse practitioner; staff notified her of accusations from him. He reported nurse knee [sic] on neck and then slapped face. Discussed incident with resident and he would not provide details but did respond saying he was safe. Denied injuries or pain, no sign of trauma, no bruising, erythema and seated in wheelchair. Police officer (PO) incident report dated 6/18/25 at 1:02 p.m., identified dispatch advised a male caller claimed elder abuse and wanted to speak to a police officer. Upon arrival, PO contacted R1 and he informed him around midnight he had fallen out of bed activated call light for assistance, staff walked by his room, ignored him on the ground asking for help. He was assisted up into his wheelchair where he was left for around three hours. Sometime on 6/11/25, between 3:30 a.m. and 4:00 a.m. he had fallen out of bed and an unknown head nurse came (described her) into his room, placed her knee down next to his head, struck him in the head once, and slapped him with her hand. he was upset staff were not responding to assist him in a timely manner and did not want to get anybody into trouble. PO was flagged down by a staff member, facility administrator, and informed him R1 had frequently filed false accusations against staff members and frequently upset when his care plan was changed. Administrator indicated he was aware of the alleged incident last week of a nurse in the transitional care unit (TCU) struck him in the head with her shin, placed her knee on his head, tapped him on his head, and told him to settle down. PO was informed by administrator that this incident was handled internally, due to a second staff member being present denying these accusations. With new information on a different date, the separate claims of a staff member kneeling next to him and slapped him (while by themselves) administrator informed PO he would request a further investigation into his claims. Email sent to PO by facility administrator on 6/18/25 at 4:08 p.m., identified the complaint received today has been investigated by our team and is nearly identical to an earlier episode that R1 shared while on our TCU (downstairs). When interviewed R1 stated that the head nurse kneed him with her shin, placed her knee on his head, tapped him on his head, and was told to settle down. The earlier instance referenced was very similar in that a head nurse was mentioned and said they placed their knee on his neck. Because we had an eyewitness able to clearly state that what he described did not happen we did not submit a Vulnerable Adult (VA) report to the state. Resident care plan was updated to include that type of behavior. However, with today's allegation and not having an eyewitness available and additional abuse alleged, we submitted a VA to Minnesota Department of Health (MDH) and the staff member in question was suspended as protocol. Facility investigation report dated 6/20/25 at 5:15 p.m., identified R1 reported whoever was in charge that night placed her shins on the side of my head, tapped me on the forehead and told me to settle down. He pushed perpetrator away and stated that was abuse. He also stated he thought they were all pissed off for the many times he had fallen. This was a mirrored event of what happened on 6/6/25 . After interviewing staff on Oakdale Avenue (2nd floor) they indicated they had not seen physical confrontation between staff and resident. He had a history of making false allegation, being untruthful, and threatening to call the police. He called police frequently (5 to 6 times since admission) to this facility . his sister reported he had same behavior at the Veterans Affairs (VA) . allegation was not verified. Interview on 6/24/25 at 11:55 a.m., R1 stated he was admitted to facility at the end of April 2025 and lived on the 1st floor TCU. He had moved him up to 2nd floor about one week ago. While he lived on TCU, was assaulted by a female staff charge nurse, and told by facility staff he lied about the incident. He had restless leg syndrome, once it started, he rolled from side to side and fell out of bed. It was later in the night, the charge nurse walked by his room while he laid on the floor and did not stop at first. When the nurse entered his room, she was angry with him, placed her shin bones against his head, he told her to stop that hurts and she tapped him on his head. He grabbed her calf muscle, pushed her away and said, that hurts, she yelled at him to stop rolling. He told her to get out of his room, she was the only one in there at the time. Interview on 6/25/25 at 9:18 a.m., LPN-A stated on the evening of 6/6/25 she randomly checked on R1 and saw he rolled out of bed. She rushed into the room alone, his legs were on the floor and upper body remained on the bed. Per her reflex, she tried to support him with her thigh against his back, called for help, and he elbowed her with his left hand. She placed call light on and he told her to leave the room. By the time staff arrived to his room he had fallen to the floor. She did not use force, he swore at her, and she stayed out of his room after that. Two NAs assisted him back to bed. She was taken off work for one shift on 6/18/25, returned on 6/19/25, and had not taken care of him since. Interview on 6/25/25 at 11:00 a.m., licensed social worker (LSW) stated three staff nurses working on TCU were interviewed and asked two questions: -are there any known behaviors regarding R1 and, - did they noticed anything strange with the resident. LSW stated nursing staff were not asked about abuse, witnessed or alleged. The allegation made by R1 indicated LPN-A placed her shins on the side of his head, her thigh on the side of his body to help prevent the fall, could have been different but seemed similar. R1 was able to describe what the head/charge nurse looked like. LPN-A was suspended on 6/18/25, and the interview was completed. LPN-A was allowed to return to work on 6/19/25, night shift prior to completion of the investigation which was on 6/20/25. Our policy identified she should have been placed on leave without resident contact until the investigation was completed. It would have been important to be off work because there was an allegation of abuse, the residents are vulnerable, would want to be confident that abuse did not continue to happen, and all residents were safe. She stated would have been important to have completed interviews with those residents on TCU at minimum where he lived when it was identified the alleged incident may have taken place, and had only an explanation of what the staff nurse looked like. The facility policy was not followed. Interview on 6/25/25 at 11:30 a.m., designee social worker (DSW) stated he had completed the interviews with the residents on 2nd floor, where R1 currently lived. No residents and very few staff were interviewed on TCU where the allegation happened. He added it would have been important to follow the facility policy/protocol investigation process and interviews should have been completed with residents that lived in the TCU and staff that worked there to hear from everyone. Interview on 6/25/25 at 1:29 p.m., registered nurse (RN)-A stated R1 rolled out of bed frequently due to RLS and was able to make his needs known. There were days we were unable to predict when he would roll off his bed, had fragile skin, had some bruising, and skins tears. He heard how R1 had arguments with staff but had not heard or witnessed any physical abuse. He was not interviewed regarding any concerns/incidents with staff. Interview on 6/25/26 at 1:52 p.m., nursing assistant (NA)-B stated she had worked at facility for six months usually upstairs but had floated down to TCU occasionally. She was familiar with R1 and provided cares for him. She had not been interviewed by anyone regarding concerns. Interview on 6/25/25 at 2:09 p.m., NA-C stated she had worked at facility for approximately 3 years, usually the day shift on TCU. She was familiar with R1 and provided cares for him. She had not been interviewed by anyone regarding concerns or incidents related to abuse. During an interview on 6/25/25 at 3:04 p.m., clinical coordinator (RN)-C stated there were no residents and only a few nurses interviewed on TCU. Residents were interviewed on 2nd floor where he currently lived. It would have been important to interview residents and staff on TCU, he was unable to provide staff name but described what she looked like. The allegation was abuse and we would have wanted the residents kept safe. He described her as the hit nurse at night. The social worker would have been the one to identify who should be interviewed. She interviewed LPN-A with the SW but that was the only staff she had interviewed. The resident interviews could have possibly provided information to confirm if they had experienced anything similar as what R1 reported. During an interview on 6/26/25 at 10:01 a.m., director of nursing (DON) stated R1's perception of time was not accurate and his cognition was intact. Interviews where not completed with staff NAs or residents on the TCU unit. Interviews with residents and staff are useful to help determine the outcome in the allegation of abuse, in addition to R1's interview. She stated LPN-A worked on 6/17/25, placed on suspension on 6/18/25, and then allowed to come back to work the night shift of 6/19/25 (11:00 p.m.-7:00 a.m.). R1 was moved from TCU on 6/16/25, and LPN-A had not worked with him since the allegation. DON stated a witness was identified during the previous allegation, unsure of which staff it was, and unable to locate the interview. During the investigation, in hindsight, the residents' on TCU should have technically been interviewed prior to the completion of the investigation and prior to LPN-A's return to work. It would have been important to separate residents from a potential perpetrator. During an interview on 6/26/25 at 1:20 p.m., administrator stated when there was an allegation of physical abuse the alleged perpetrator (AP) would be suspended from work until the investigation had been completed and determined whether it occurred or not. Staff and residents were interviewed after an allegation of abuse to help identify if there was a pattern. Our goal was to make sure the residents are safe and protect the staff if residents were physical with them. Facility policy Abuse, Neglect, Exploitation, or Misappropriation - Reporting and Investigating dated 2023, identified all reports of resident abuse (including injuries of unknown origin), neglect, exploitation or theft/misappropriation of resident property are reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of all investigation are documented and reported. The administrator ensures that the resident and person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. The individuals conducting the investigation as a minimum interviews any witness to the incident, interviews staff members on all shifts who have had contact with the resident during the period of the alleged incident, interviews other residents to whom the accused employee provides cares or services to and documents the investigation completely and thoroughly.

Based on observation, interview, and record review the facility failed to ensure proper enhanced barrier precautions (EBP), glove use, and hand hygiene was performed during incontinence care for 1 of 3 (R1) residents reviewed for incontinence care. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 needed extensive assistance with personal hygiene and had a suprapubic catheter (tube inserted into the bladder through an incision in the lower abdomen). R1's EBP signage undated, indicated staff needed to wear gloves and gown when providing high-contact resident care activities such as changing linens, providing hygiene, or changing brief. During an observation on 3/26/25 at 10:43 a.m., nursing assistant (NA)-A and NA-B were observed sanitizing hands and placing on gloves prior to going into R1's room. R1 had a sign indicating he was on EBPs and a bin of personal protective equipment (PPE) was outside the entrance of his door. NA-A and NA-B entered R1's room to assist him with personal hygiene without gowns on. NA-A open R1's soiled incontinent brief and cleansed R1's peri-area, then placed the bowel filled wipes in-between R1's thighs. NA-A grabbed clean towel and wash clothes with her soiled gloves on and went to R1's shared bathroom and got the wash clothes wet. R1 was assisted to his left side, NA-A cleansed R1's buttocks with wash clothes which had bowel on them and rolled the bowel filled wash clothes and brief under R1's body. NA-A removed her gloves, did not perform hand hygiene and removed R1's linen for the right side of his bed pushing the linen under R1. NA-A adjusted R1's pillow under his head, applied a clean fitted sheet to the right side of the bed, and placed a clean brief under R1's buttocks. NA-A assisted R1 to his right side. NA-B cleansed R1's left side near his buttock as there was bowel present, then removed the soiled brief and soiled linen from under R1. NA-B did not remove her soiled gloves and applied the clean fitted sheet to the left side of R1's bed. R1 was then placed on his back. NA-A removed soiled wipes with bowel from R1's groin area without gloves on stating, I shouldn't be doing this, and placed the bowel soiled wipes in the trash. NA-A grabbed a clean towel and started wiping the remaining bowel off of R1's genital area with no gloves on. NA-A and NA-B strapped R1's clean brief together and adjusted his gown. NA-B removed her gloves and did not sanitize her hands. NA-A raised R1's head and leg with the bed remote, adjusted R1's pillow under his head, applied his blanket. NA-B applied new gloves without sanitizing hands and NA-A turned R1 to his right side as NA-B placed a pillow behind R1's back. NA-A left R1's room without sanitizing her hands. During an interview on 3/26/25 at 11:35 a.m., NA-B stated she did not notice R1's EBP sign on his door and that is why she did not wear a gown into his room. Further, NA-B stated she did not remove her gloves after providing personal hygiene to R1 or sanitize her hands after removing her gloves. On 3/26/25 at 12:20 p.m., NA-A stated it slipped her mind that R1 was on EBPs and that is why she did not wear a gown when assisting R1 with personal hygiene. NA-A stated she forgot to remove her gloves after providing personal hygiene to R1. NA-A stated she did not sanitize her hands after removing her soiled gloves. NA-A stated she grabbed soiled wipes from between R1's legs without gloves on because she felt rushed and she did not sanitize her hands before leaving the room. On 3/27/25 at 9:52 a.m., infection preventionist (IP)-A stated if when a resident was on EBPs and staff provided personal care they needed to wear a gown and gloves and follow what the signage and policy stated. IP-A stated staff were expected to remove gloves after cleaning the soiled areas, sanitize their hands, apply new gloves, and not touch soiled products without gloves on. Staff should remove all PPE prior to leaving the residents room and sanitize their hands. On 3/27/25 at 10:09 a.m., the director of nursing (DON) stated when staff entered a room with a resident on EBP they were expected to do hand hygiene, apply gown, and gloves before providing personal cares. They were expected to follow the policy on hand hygiene. Handwashing/ Hand hygiene policy reviewed 8/25/21, indicated staff would complete hand hygiene before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with bodily fluids, and after removing gloves. Enhanced Barrier precautions (EBPs) policy reviewed 10/18/22, indicated gown and gloves would be used during high contact resident care activities such as providing hygiene, changing linens, and changing briefs.

Based on observation, interview, and document review, the facility failed to assess and, if able, implement interventions to ensure privacy was maintained during provision of wound care for 1 of 1 resident (R108) reviewed who expressed being claustrophobic and not wanting their doorway closed to public view. In addition, the facility failed to ensure resident' identifiable personal care information was kept secured and out of public view when stored on 1 of 1 mobile medication carts. This had potential to affect 1 of 1 residents and 14 residents (R53, R21, R74, F85, R82, R65, R7, R38, R103, R147, R154, R116, R102 and R128) of the second floor whose information was listed on an exposed care sheet. Findings include: PRIVACY WITH CARE: R108's quarterly Minimum Data Set (MDS), dated [DATE], identified a section to record R108's cognitive screening (i.e., BIMS). However, this was dashed as, Not Assessed [See F638]. On 1/6/25 at 2:04 p.m., R108's room was observed from the public hallway with her room door being left wide open. R108 was lying in bed with a mobile cart placed adjacent to the room doorway in the hallway at a ninety-degree angle, and two staff members were inside the room dressed in disposable gowns and tending to R108's leg. The two staff members were completing a dressing change to R108's leg and each time the one staff member moved to the side, red-colored tissue and associated bodily drainage was exposed on R108's leg. After a few minutes of observation, R108 noticed the surveyor standing in the hallway watching the wound care and asked aloud, What's he doing out there? The two staff members turned and looked at the surveyor in the hallway when one staff responded, Maybe looking for someone, I don't know. However, no attempt to close the doorway was offered or made at this time and R108 continued to make several looks at the surveyor who remained in the public hallway. At 2:08 p.m., the director of nursing (DON) approached the surveyor and R108's room from down the hall. DON observed R108's open doorway along with the care inside, and was questioned if they knew why the door would be left open for such. DON responded, No, I don't, and identified the one staff member in the room as registered nurse manager (RN)-D. DON stated R108 could be super particular and she would follow-up. DON then approached R108's room and asked if the door could be closed when RN-D aloud responded, She wants it open. R108 then voiced aloud, I have nothing showing. DON returned to the surveyor and expressed she would review the care plan to ensure the door being open was outlined. R108's care plan, revised 11/27/24, identified a section labeled, Personalized Care ., which outlined an intervention reading, Going outside for fresh air: Very important 12/4/24: Fresh air is very important. Keep door open at all times, unless changing brief. In addition, a subsequent section outlined, ADL self care needs, included an intervention reading, PERSONAL HYGIENE/ORAL CARE . -Patient feels Claustrophobic. Door to room to remain open at all times, unless commode, or Brief change. This intervention was listed as being revised, 01/06/2025. The care plan lacked information on what, if any, other options had been attempted or offered to R108 to ensure personal privacy was maintained for her and others. On 1/6/25 at 2:53 p.m., R108 was interviewed in her room. R108's room had two ceiling-mounted tracks installed for privacy curtain(s), however, no physical curtains were installed on these tracks. R108 verified she wanted the doorway left open due to being very claustrophobic, and voiced if anyone saw inside while care was happening, such as the observed wound care, then such was their problem and not mine. R108 stated they resided in a medical care center and people should expect to see things which may be unsightly adding, That's reality. However, R108 stated nobody from the care center had asked or offered other options to her prior (i.e., turning mobile cart to cover door entrance, portable curtains) but, again, reiterated aloud it wasn't her concern adding, No, because I don't think it's an issue. R108's medical record was reviewed and lacked evidence what, if any, additional options had been offered or attempted to provide as much privacy as able for R108 and others (i.e., passerby's) during the provision of care with exposed wound tissue and potential bodily fluid (i.e., blood). On 1/7/25 at 12:23 p.m., social services designee (SSD)-B and RN-D were interviewed. RN-D verified they were providing care which was visible from the hallway and felt nothing was flowing [i.e., blood] but acknowledged the wound tissue would be visible adding, [The] red tissue would have been very visible. SSD-B stated R108's room was somewhat isolated down towards the end of the hallway, however, acknowledged they had not addressed what, if any, options were available to ensure R108's privacy and others' was maintained adding, We have not thought of that. SSD-B stated if R108's room had been located in a more heavy traffic area, then it would have been addressed they felt. RN-D verified the care center had, at least at one time, some portable privacy screens which would allow the door to be kept open. RN-D explained the interdisciplinary team (IDT) had discussed using one of them prior, however, then questioned how it would be stored or cleaned. RN-D stated turning the mobile cart (used for wound supplies) to cover the door would be good adding aloud, I think that would be a very easy option. RN-D verified R108 did, at times, allow her doorway to be closed partially, too, with cares prior. RN-D and SSD-B both verified evidence of what, if any, options had been offered or presented to R108 for privacy with wound care should have been documented in the medical record. Further, RN-D stated it was important to ensure privacy was maintained adding aloud, It's a dignity issue for all involved. A provided Confidentiality of Information and Personal Privacy policy, dated 12/2021, identified the care center would safeguard personal privacy. The policy outlined, The facility will strive to protect the resident's privacy regarding . b. medical treatment . d. personal care. 44656 EXPOSED RESIDENT INFORMATION: During observation on 1/8/25 at 1:44 p.m., a medication cart for second floor residents was left unattended with a patient care sheet which contained personal information including name, room number, personal preferences, physical and food assistance needs. The facility was under construction with six contracted flooring employees installing laminate flooring in the second floor hallway where the unattended medication cart was located. During interview on 1/8/25 at 1:46 p.m., with facility administrator who walked by the unattended cart, the administrator stated, this [pointing to patient care sheet] should not be visible. This is private information. The administrator placed the care sheet face down under some papers on the medication cart. During interview with facility assistant director of nursing (IPCP) on 1/8/25 at 2:29 p.m., the IPCP stated resident personal information contained in the Care sheet should not be left unattended for Privacy matter. During interview with registered nurse (RN-A) on 1/9/25 at 10:46 a.m., RN-A stated, care sheets with patient information should not be left unattended. Someone could look at the patient information which they have no business doing. During interview with nurse manager of second floor (RN-C) on 1/9/25 at 1:37 p.m., RN-C stated, Care sheets should never be left unattended on the cart. For HIPPA (health information portability privacy act). RN-C stated the medication cart in question would be assigned the nurse passing medications for two wings of the facility where the laminate flooring was being installed and the care sheet included 25 residents and their information. Facility policy titled Confidentiality of Information and Personal Privacy dated reviewed 12/08/2021, The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. In addition, The facility will strive to protect the resident's privacy regarding his or her: a. accommodations; b. medical treatment; c. written and telephone communications; d. personal care; e. visits; and f. family and resident group meetings.

Based on interview, observation and document review, the facility failed to ensure comprehensive care plans were developed and maintained to facilitate person-centered care for 2 of 2 (R142, R139) residents reviewed for care planning. R142 R142's quarterly Minimum Data Set (MDS) dated [DATE], indicated R142 was cognitively intact, had no behaviors, did not refuse cares, needed set-up for oral hygiene and eating, and required maximal assistance with mobility and all activities of daily living (ADL). The MDS also indicated R142 had no pressure ulcers. R142's Clinical Diagnosis report printed on 1/8/24, indicated R142 had diagnoses of encounter for orthopedic aftercare following surgical amputation, type II diabetes (a condition in which the pancreas doesn't make enough insulin causing the body to have trouble controlling blood sugar and using it for energy), local infection of the skin and subcutaneous tissue, atherosclerotic heart disease (damage or disease in the heart's major blood vessels), essential hypertension (abnormally high blood pressure that's not the result of a medical condition) , chronic kidney disease, induced constipation, occlusion and stenosis of right carotid artery (narrowing of the right carotid artery), right buttock pressure ulcer, anxiety disorder, irritable bowel syndrome (a digestive condition that causes pain, gas, diarrhea, and constipation), benign prostatic hyperplasia(enlargement of the prostate gland that causes problems with urination), retention of urine, hemorrhoids, and lower back pain. R142's Clinical Orders report, printed on 1/8/25, did not include any orders related to R142's right prosthetic leg. R142's care plan printed on 1/8/25, included a Functional Restorative Plan, Activities of Daily Living (ADLs), and Risk for falls. The Functional Restorative Plan indicated limited mobility, weakness. The goal indicated resident will improve in ambulation. The interventions indicated walking activity: ambulate with assistance of 1 using walker in hallway. The ADL care plan's goal indicate the resident will maintain the current level of function on ADL's. The intervention dated 10/16/24 for ambulation indicated the resident requires extensive assistance by 1 staff to walk with walker in room and between surfaces with a revision date of 12/28/24. The fall risk's care plan indicated R142 was at risk for falls r/t being BKA(R) [below the knee amputation-right leg]. The goal indicated R142 will be free of falls. Interventions indicated anticipation of needs and placement of call light within reach. All these care plans failed to indicate R142 had a prosthetic leg. During observation and interview on 1/7/25 at 1:51 p.m., R142 was sitting on his recliner watching television. R142 stated the staff doesn't know how to put on my prosthetic leg. Nobody knows what they are doing, only two nursing assistants (NA) know what to do. They [NA] have not been trained. I need to tell them what to do. R142 stated he was supposed to ambulate in the hallway twice a day with a NA, but it was not done, unless one of the two NA (mentioned before) were working. During interview on 1/7/25 at 2:38 p.m., NA-D stated R142's Kardex didn't mention his prosthetic leg, but he was trained by the therapist. NA-D stated he believed all staff members were trained how to put the prosthetic leg on and off. During interview on 01/07/25 at 3:17 p.m., nursing assistant (NA)-E stated she didn't know how to put on R142's prosthetic leg. NA-E stated R142's Kardex did not have any information about his prosthetic leg. During interview on 1/8/25 at 9:00 a.m., nurse manager/registered nurse (RN)-C verified there was no mention of R142's prosthetic leg in his physician orders, care plan or Kardex. RN-C stated NA-D, registered nurse (RN)-E, licensed practical nurse (LPN)-D and herself were trained by the physical therapist. RN-C stated all the staff was trained. RN-C stated the therapist trained all the nursing assistants. During interview on 1/9/25 at 11:25 a.m., physical therapist (PT)-A stated she demonstrated to RN-C and NA-D how to put on the prosthetic leg. PT-A stated she only trained those two people, and stated nobody else was trained. PT-A stated the nurse managers were supposed to train all the staff that works with R142. PT-A stated R142 received his leg when he was in the facility's transitional care unit. R142 needed to follow a progressive schedule to wear his orthopedic leg, but R142 offered various reasons why he didn't follow the progressive schedule. PT-A stated R142 should had been able to wear his prosthetic leg the whole day before he was discharged from therapies and moved to the long-term care unit. During interview on 1/8/25 at 1:04 p.m., director of nursing (DON) verified R142's physician orders, care plan, Kardex, and medication/treatment administration record failed to mention R142's prosthetic leg. DON stated, she expected the care plan was updated because it was important for the staff to know how to care for the resident and how to put on and care for his prosthetic leg. 49339 R139 R139's quarterly Minimum Data Set (MDS), dated [DATE], identified R139 was cognitively intact with no hallucinations or delusions. Diagnoses included: cerebral infarction (also known as an ischemic stroke; occurs when blood flow to the brain is blocked, causing the brain tissues to die), hypertension (high blood pressure), diabetes (a disease that occurs when you blood glucose is too high), arthritis, multiple sclerosis (disease that causes breakdown of the protective covering of the nerves that can result in numbness, weakness, trouble walking, vision changes and other symptoms), anxiety, depression, dysphagia (swallowing disorder), hemiplegia (paralysis that affects one side of the body) and fibromyalgia (condition that involves widespread body pain and tiredness). In addition, R139 was dependent on staff for transfers and mobility, and required maximal assistance from staff for dressing, personal hygiene and eating. During interview on 1/06/25 at 1:12 p.m., R139 stated she can sense when she has to urinate and stated she would like to be able to use the toilet instead of going in her incontinence pad. R139 stated staff do not offer to bring her to the bathroom to use the toilet and this would be her preference. During a follow up interview on 1/09/25 at 9:41 a.m., R139 was observed lying in bed. R139 once again, expressed a desire to be able to use the toilet. R139 stated, I don't like to go in my underwear. R139 stated most of the time she can feel when she has to urinate. R139 stated staff do not offer to bring her to the bathroom or to use a bedpan [a device used as a receptacle for the urine and/or feces of a person who is confined to a bed] and added they just change my pad. R139 stated she feels confident that she can sit on the toilet with support as she has been working with physical therapy for a long time. R139 stated, they offered me a bedpan a long time ago, which wasn't the best, but they don't even offer that let alone the toilet. R139 indicated that staff transfer her with a Hoyer lift [mechanical lift/device that lifts patients from one place to another who cannot bear weight on their lower extremities] and physical therapy use a EZ stand [manual standing aid to allow patients to assist themselves in preparation for transferring] to transfer her. R139's care plan, printed 1/9/25, identified the following: - TRANSFER: Resident requires assist x2 Standing Lift. - TOILET USE: Resident requires extensive assist x 1 staff. - The resident is incontinent of bladder Impaired Mobility - BRIEF USE: The resident uses disposable briefs. Change per schedule and prn. - INCONTINENT: Check (with cares every AM, PM, Before or after meals and on first and third rounds at night and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. R139's care plan lacked evidence of coordination between providers (facility and therapy). Additionally, R139's care plan lacked evidence of R139's preference to use the toilet. Additionally, R139's care plan lacked evidence of R139's fluctuating ability in transfers. R139's Kardex, printed 1/8/25, indicated the following: -TOILET USE: Resident requires extensive assist x1 staff. -TRANSFER: Resident requires assist x2 Standing lift. On 1/07/25 at 3:50 p.m., nursing assistant (NA)-B stated they are familiar with R139. NA-B indicated R139 needs assist of 2 staff and a mechanical lift for all transfers. Furthermore, R139 was incontinent of bowel and bladder. NA-B stated they know of R139 using the bedpan once previously, about 2-3 months ago but not since. NA-B stated they do not offer to put R139 on the toilet and just provide incontinent cares for R139. NA-B indicated that R139 was able to identify when she needs incontinent cares completed. On 1/08/25 at 12:34 p.m., NA-A verified they are familiar with R139 and indicated R139 was on incontinence checks. NA-A indicated they have not offered R139 to use the toilet or the bedpan. NA-A verified they refer to the Kardex for resident needs. NA-A stated they are unsure how R139 transfers. After reviewing the Kardex, NA-A indicated the Kardex indicated R139 transfers with assist of 2 staff and an EZ Stand (standing mechanical lift)/standing lift. NA-A indicated they are trained to follow the Kardex on resident needs. On 1/08/25 at 12:59 p.m., licensed practical nurse (LPN)-E indicated R139 required total staff assistance. After reviewing R139's care plan, LPN-E indicated R139 transfers with assist of 2 staff and EZ Stand/standing lift. On 1/08/25 at 1:11 p.m., registered nurse (RN)-C verified they are familiar with R139. RN-C indicated R139 transfers with an EZ stand/standing lift and assist of 2 staff. RN-C indicated R139 was incontinent of bowel and bladder. RN-C indicated they attempted to transfer R139 to use the toilet but unable to recall when. RN-C indicated they offered R139 the use of the bed and indicated that was more than 6 months ago. RN-C indicated they would look for documentation regarding this. During a follow up interview on 1/08/2025 at 2:40 p.m., RN-C indicated they could not find any documentation around offering the use of the toilet or bedpan. RN-C indicated, most cognitively intact people want to use the toilet. On 1/08/25 at 1:30 p.m., physical therapist (PT)-A verified R139 currently receiving physical therapy services and was discharged from occupational therapy services on 12/20/24. PT-A stated, Generally speaking, if someone is able to sue an EZ-Stand [manual standing aid to allow patients to assist themselves in preparation for transferring], they can use a toilet, maybe not be left alone. PT-A verified during R139's last PT session, R139 transferred with an EZ stand/standing lift with moderate assistance. On 1/09/25 at 9:52 a.m., licensed practical nurse (LPN)-C indicated R139 transfers with a mechanical lift. LPN-C indicated they were unsure if R139 was offered the bedpan or toilet. LPN-C indicated R139 was on scheduled to have her incontinent pad check and changed. On 1/09/25 at 10:05 a.m., NA-C indicated R139 transfers with a Hoyer lift and assist of 2 staff and R139 does not use a bedpan or the toilet. NA-C indicated R139 will ask to be changed when needed as R139 was able to identify when they need to be changed. NA-C verified they have not offered R139 the bedpan or the use of the toilet. On 1/09/25 at 10:56 a.m., PT-B verified R139's last physical therapy was 1/6/24 and used the EZ stand. PT-B indicated, I don't know why that would be a problem if they can sit safely on the toilet, when asked about a resident using a toilet when transferring with a mechanical lift. PT-B indicated part of the physical therapy goal is using the EZ stand with staff. On 1/09/25 at 1:34 p.m., physical therapy assistant (PTA)-A verified they are familiar with R139. PTA-A verified R139 transfers with an EZ stand and indicated there have been no updates sent to nursing in 6-12 months, on recommendations changing how R139 transfers. On 1/09/25 at 1:55 p.m., director of nursing (DON) verified nursing staff would look at the care plan/Kardex for resident needs (how they transfer, preferences, etc.). DON verified R139's care plan indicated R139 transfers with assist of 2 staff and EZ stand/standing lift. A facility policy titles Care Plans, Comprehensive Person-Centered, reviewed 11/30/21, indicated comprehensive, person -centered care plans will: - reflect the resident's expressed wishes regarding care and treatment goals - aid in preventing or reducing decline in the resident's functional status and/or functional levels Facility policy titled Care Plans, Comprehensive Person-Centered reviewed 11/30/21, also indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Based on interview, and document review, the facility failed to comprehensively reassess and, if needed or able, develop interventions to ensure activities-of-interest were advertised, offered and/or provided for 1 of 2 residents (R222) reviewed for activities and whom resided on the short-term unit (i.e., TCU). Findings include: R222's admission Minimum Data Set (MDS), dated [DATE], identified R222 had intact cognition and demonstrated no delusional thinking. The MDS outlined several questions with a response of importance to R222, including having reading materials, keeping up with the news, and doing her favorite activities. These were all coded with a response of, Somewhat important, or, Very important. R222's Therapeutic Recreation/Activity Evaluation, dated 11/27/24, identified R222's background information along with a section labeled, Recreation Interest/Needs, which contained checkmarks placed next to applicable items. These outlined R222 liked activities in groups, independently, in her room or day room, and marked her participation as, Independent/individual. The evaluation outlined R222's current interests as, television, music (rock), getting rest, card making, making Victorian ornaments, beading, family phone calls, and also outlined R222 needed assistance to get to/from activities areas. The evaluation concluded with a section labeled, Summary, which outlined, . plans on short stay and to return home. At this time she states she is not in the 'mood' to do anything, discouraged with health status. When she starts feeling better, she stated she may enjoy engaging in activities offered . Proceed to plan of care. The completed evaluation lacked what, if any, in room options for doing her identified interests were offered or provided (i.e., craft material, beads). On 1/6/25 at 12:54 p.m., R222 was interviewed while in her room on the TCU. R222 explained she had admitted in November 2024 and, upon admission, was non-weight bearing due to a boot placed on her leg adding, [it was] very difficult for me to get around, period. R222 stated she had not been attending much, if any, activities and explained it was due to multiple reasons including her immobility and feeling, at times, it was more depressing to be around elderly, confused people. R222 stated she knew there were some activities offered but didn't know what they were as there was no calendar posted in her room. R222 stated, I think there is one somewhere [posted] but not in here. R222 explained she was now no longer non-weight bearing and would be more open to activities, if offered, however, she stated nobody ever came and offered any activities to her, either, which she voiced, I would be receptive to that. R222 stated she recalled going to a music program once since admitting which was around Christmas adding, That was nice. R222's care plan, dated 12/12/24, identified R222 was able to verbalize her preferences and was independent in meeting her emotional, intellectual, social and physical needs. The care plan outlined a single intervention for this which read, Resident enjoys participating in their favorite activities - getting rest, watching television, card making, making Victorian ornaments, beading . The intervention was initiated and last revised both on 11/27/24. When interviewed on 1/7/25 at 11:56 a.m., nursing assistant (NA)-G stated they worked with R222 over the past weekend along with stray lights here and there. NA-G stated R222 rarely left her room or attended activities adding, Not really. NA-G stated they felt the lack of attendance with activities was her choice adding, I think she keeps herself busy. NA-G stated the TCU did have a posted activities calendar outside the main elevators adding sometimes each resident' room will have them but they hadn't ever seen one in R222's room to their recall. NA-G stated nobody had directed them to ever offer activities or go through the calendar with her adding, Not specifically to her, no. R222's progress note, dated 12/11/24, identified R222 was advanced to weight-bearing as tolerated (WBAT) with use of the PRAFO boot; and on 12/20 could be WBAT without it applied. R222's activity attendance was requested. A provided Follow Up Question Report, printed 1/7/25, identified R222's recorded activities, level of participation and the corresponding date of each. This record identified R222 attended or had provided only four activities since admission to the care center in November 2024. These included: On 12/4/24, a chaplain visit was recorded with R222 having active participation. On 12/22/24, a music group was recorded with R222 having active participation. On 12/24/24, a party or special event along with friend/family visits were recorded with R222 having active participation. R222's medical record was reviewed and lacked any evidence R222 had been comprehensively reassessed to determine what, if any, activities needs were needed to promote quality of life despite R222 rarely attending services and having healed with no longer being non-weight bearing. There was no evidence what, if any, in-room activities were offered or provided despite R222 expressing interest in such when assessed upon admission. On 1/8/25 at 12:32 p.m., the therapeutic recreation coordinator (TRC) and chaplain (CH) were interviewed. TRC explained they don't typically program activities on the TCU as, from past experience, had not ever seen enough attendance to justify it. As a result, upon admission they meet with TCU residents' and explain they are welcome to attend the activities on the other floors for the LTC residents. TRC stated if someone expressed wanting to be involved, then they'd likely be given an in-room calendar. CH explained they round on the unit and do a scheduled program every other week, however, both CH and TRC verified they don't round on the units daily to invite residents on the TCU to activities. TRC stated any in-room activities would be offered on the initial evaluation adding if offered and declined, then such would also be indicated on the evaluation. When questioned on what, if any, re-evaluation process existed as people on the TCU are likely to have evolving health needs (i.e., get better, more energy), TRC explained the re-admission was not an automatic and they wouldn't typically re-visit it until the MDS cycle (i.e., quarterly) came due. A facility' activities programming policy was requested, however, none was received.

Based on observation, interview, and document review the facility failed to comprehensively assess, care plan, and implement interventions to prevent recurrent pressure ulcers for 2 of 2 resident (R39 and R142) who had a history of pressure ulcers. Findings include: R142 The Centers for Medicare (CMS) State Operations Manual (SOM) Appendix PP, dated 8/8/2024, identified definitions for pressure ulcer care and treatment. This included, Avoidable, being outlined as, . the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define and implement interventions that are consistent with resident needs . monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. In addition, the guidance provided several stages of injury definition which included, Stage II Pressure Ulcer: Partial-thickness skin loss with exposed dermis . presenting as a shallow open ulcer. Adipose (fat) is not visible and deeper tissues are not visible. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis . During interview on 1/7/25 at 1:51 p.m., R142 was observed seated on his recliner, watching television. R142 stated he had a bed sore on his bottom. R142 stated the bed sore was going to get worse because the area was not covered with a dressing, and the staff only applied a cream. R142 stated the staff is supposed to get me up or turn me every two hours, but they don't. R142 stated he was also concerned about having to wait too long for staff to help him when he is incontinent of bowel. R142 stated yesterday, 1/6/25, he returned from a doctor's appointment and informed the nurse on duty he had a bowel movement and needed to be changed. R142 stated he waited one hour and 15 minutes before he was cleaned. R142's quarterly Minimum Data Set (MDS) dated [DATE], indicated R142 was cognitively intact, had no behaviors, did not refuse cares, needed set-up for oral hygiene and eating, and required maximal assistance with mobility and all activities of daily living (ADL). The MDS also indicated R142 had no pressure ulcers. R142's Clinical Diagnosis report printed on 1/8/24, indicated F142 had diagnoses of encounter for orthopedic aftercare following surgical amputation, type II diabetes (a condition in which the pancreas doesn't make enough insulin causing the body to have trouble controlling blood sugar and using it for energy), local infection of the skin and subcutaneous tissue, atherosclerotic heart disease (damage or disease in the heart's major blood vessels), essential hypertension (abnormally high blood pressure that's not the result of a medical condition) , chronic kidney disease, induced constipation, occlusion and stenosis of right carotid artery (narrowing of the right carotid artery), right buttock pressure ulcer, anxiety disorder, irritable bowel syndrome (a digestive condition that causes pain, gas, diarrhea, and constipation), benign prostatic hyperplasia (enlargement of the prostate gland that causes problems with urination), retention of urine, hemorrhoids, and lower back pain. R142's Clinical Orders report, printed on 1/8/25 indicated orders for weekly bath audits, Pro-source liquid 30 milliliters (ml) every day, nurse to monitor APM mattress pump (pressure relieving speciality mattress) is well functioning every shift. R142's report did not include skin care orders. R142's Braden scale (a tool used to assess a patient's risk of developing pressure ulcers, or pressure injuries) dated 11/12/24, indicated a score of 15, which indicated R142 was at risk to develop a pressure area. R142's care plan initiated on 8/6/24, indicated R142 had impairment to skin integrity. R142's care plan goal indicated the resident will develop clean and intact skin by the review date. The goal also indicated Pressure ulcer stage 2 right intergluteal cleft, healed 12/7/24. Care plan interventions indicated: - Intervention dated: 8/26/24: Apply barrier cream after each incontinent episode with a revision date of 8/6/24. - Intervention dated: 8/26/24: Keep skin clean and dry. Use lotion on dry skin with a revision date of 8/6/24. - Intervention dated: 8/26/24: The resident needs pressure reducing cushion to protect the skin while in wheelchair. Revision date 8/6/24. - Intervention dated: 8/26/24: The resident needs a pressure relieving mattress, APM, pillows to protect the skin while in bed. Revision date 11/21/24. - Intervention dated: 12/9/24: Encourage good nutrition and hydration to promote healthier skin. No revision dates. - Intervention dated: 12/9/24: Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, s/sx [sign and symptoms] of infection, maceration, etc., to MD. No revision dates. - Intervention dated: 12/9/24: Treatment per order. Revision date 1/8/24. R142's care plan listed no further updates following 12/9/24. On 12/24/24 R142's transferred to the hospital emergency department for evaluation due to blood in the stool. The emergency department's Summary report dated 12/24/24, indicated lower gastric bleed was ruled out and included the following laboratory reports: Hepatic Function Panel: Albumin 3.8 low (normal 4.0-4.9) Complete blood count (CBC): red blood count 4.11 low (normal 4.30-5.90), hemoglobin 11 low (normal 13.5-17.5). R142's progress note authored by R142's primary physician dated 1/9/25, indicated the following laboratory tests results dated 7/29/24: red blood count 3.7 low, and hemoglobin 9.8 low. R142's weekly bath audits completed between 12/7/24 and 1/1/25 indicated no skin impairments. R142's progress note dated 1/4/25 at 3:04 p.m. indicated R142 had a shower, his skin was checked and appears intact with no signs of concerns or abnormalities. R142's progress note dated 1/5/24 at 8:25 p.m. stated patient is breaking down on the coccyx area due to refusing to be repositioned while sitting in his chair. During observation and interview on 1/7/25 at 2:38 p.m., R142 stated he had a bowel movement and requested to be changed. Nursing assistant (NA)-D applied R142's prosthetic leg and assisted him to stand up. NA-D cleaned R142 perineal (rectal area) area and R142 moaned in pain and said, it hurts! RN-C came into the room and verified the two pressure areas but said she didn't feel comfortable staging affected area, RN-C observed a pressure area, on each buttock; she measure the pressure area on the left buttock measured about two centimeters (cm) in length and one cm in width, and the pressure area on his right buttock measured one by one cm. During observation and interview on 1/7/25 at 3:06 p.m., registered nurse (RN)-E verified R142 skin breakdown. RN-E stated his bottom had healed but stated every time R142 takes antibiotics, he gets diarrhea, and his bottom opens. RN-E proceeded to cleanse the area and applied alginate powder and Vitamin A and D cream. Duirng interview on 1/7/25 at 3:17 p.m., NA-E stated all nursing assistants received training about how to care for him. We use a barrier cream for this bottom. Everytime we go to his room he is on the phone. He is busy and asks us to come back. We use the Kardex. During interview on 1/7/25 at 3:20 p.m., nurse manager RN-C stated she was not aware of any documentation on R142's progress notes about the skin breakdown on his coccyx (bottom) area. RN-C stated she would look at R142's skin later in the afternoon. During interview on 1/7/25 at 3:42 p.m., NA-D stated since yesterday, R142 complained of buttocks' pain during toileting cares. NA-D stated they always apply barrier cream after they clean him up. NA-D stated R142 often refuses to reposition and likes to sit down on his recliner chair for most of the day. NA-D stated his Kardex indicated repositioning every two hours and walking once a day. NA-D stated R142 used his call light to request help. NA-D stated the nursing assistants would inform the nurses of R142 refusal of cares. During interview on 1/7/25 at 3:55 p.m., licensed practical nurse (LPN)-D stated he worked on January 5th and when he cleaned R142's coccyx and buttocks, R142 complained of pain. LPN-D stated he observed R142 had a new pressure area on his right buttock and the skin in both buttocks was red. LPN-D documented in the progress notes, R142's skin had started to breakdown. LPN-D stated when he moved from the 1st floor TCU unit to the current unit, he had a pressure area on his right buttock which healed a few weeks ago. LPN-D stated on 1/5/24, he performed the same treatment used for his previous pressure area. LPN-D left a voice mail for the nurse manager, RN-C because he knew the next day [Monday] the facility's wound team would make rounds. During interview on 1/8/25 at 8:47 a.m., RN-C stated R142 had a pressure area on his right buttock that healed. RN-C stated when a resident developed a new pressure area, the nurse needed to complete a Braden Scale, a wound evaluation, and determine what happened and how to prevent future occurrences. RN-C verified R142's skin care plan did not include any turning and reposition schedule, RN-C said I missed it. RN-C veirifed there was no consistent documentation of resident's refusal to turn and reposition, and added that should have been considered when R142 was re-assessed after his previous pressure ulcer healed. RN-C stated on 1/7/24 she visualized R142's skin and obtained an order to apply collagen powder over affected area and Vitamin A and D cream over affected area. RN-C stated he had not measured the affected areas and was going to request the assistance of their lead wound nurse to classify R142's coccyx skin breakdown. During observation and interview on 1/8/25 at 12:17 p.m., R142 was sitting on recliner and NA-D assisted him to lay down in bed. The director of nursing (DON), RN-C and lead wound nurse/RN-D were present in the room to observe affected areas. RN-C and DON verified R142 had a stage II pressure area on each buttock. RN-C used a digital program to measure the pressure areas. The pressure area on his left buttock measured 2.3 cm in length by 1.9 cm in width, and the pressure area on his right buttock measured one by one cm. During interview on 1/8/25 at 12:43 p.m., the director of nursing (DON) stated when a pressure area heals, the facility continues to monitor the wound for two more weeks. The monitoring is done by the Integrated Wound practitioner. The facility then implements measures to prevent re-occurrence which includes the use of a barrier cream, repositioning resident, the use of a specialty mattress, and a cushion for his chair. DON added, changes to the existing care plan are made if indicated. The DON stated when a new skin impairment area was identified, she expected the nurses to do a skin assessment, educate the resident to lay down and reposition, call the physician to obtain orders to start a treatment, complete a Braden scale and an Incident Report on the resident's electronic record which would alert the nurse manager and her (DON) about any new skin impairment. During interview on 1/0/25 at 10:34 a.m., physician assistant (PA)-A stated when a resident develops a pressure area he needs to be notified as soon as possible, so a resident can be re-assessed by the wound care team. PA-A stated when a pressure area is not addressed right away the ulcers can increase in size, cause pain, also pressure areas are an avenue for infections. PA-A stated he was not notified about the new pressure areas. During interview on 1/9/25 at 11:58 a.m., registered dietician (RD)-A stated on Monday morning during their interdisciplinary team meeting (IDT), the nurse manager, RN-C reported R142 had a new area of skin impairment associated with moisture. RD-A stated on 1/8/25 she re-assessed R142 and kept him on Pro-source nutritional supplement. RD-A stated she had not been informed about R142's new pressure wounds areas and even with this R142's Pro-Sources orders would not need adjustment. RD-A stated R142's intake was adequate and his weight was stable, and she felt R142 had what he needed to heal his pressure area. RD-A stated she had not reviewed R142's most recent albumin level because the level could be affected by inflammation and other medical conditions. RD-A stated she trusted the hemoglobin and oxygenation levels more. R142's Nutrition Assessments dated 8/7/24, 11/12/24, and 12/2024 lacked documentation of hemoglobin and/or albumin levels. During interview on 1/9/25 at 12:19 p.m., lead wound nurse, RN-D stated R142 risked further skin breakdown if action is delayed after a new skin impairment area is identified. RN-D stated if a pressure area goes unchecked, it will get worse. RN-D stated the development of a new pressure area represents a change in condition and the physician needed to be notified right away. 44656 R39 R39's quarterly Minimum Data Set (MDS) dated [DATE], identified R39 with severe cognitive impairment, did exhibit rejection of cares, had an indwelling catheter (tube and bag to drain urine from the bladder), diagnoses of kidney disease, neurogenic bladder (nerve damage to bladder), obstructive uropathy (blockage of urine flow) , dementia, Parkinson's disease, malnutrition, and chronic obstructive pulmonary disease (damaged lungs that limit airflow in and out of lungs). In addition, R39 was indentified as at risk for pressure ulcers, had one stage 2 pressure ulcer acquired at the facility, had two stage 3 pressure ulcers that were present upon admission/entry or reentry to facility, utilized pressure reducing device for chair and bed, and received pressure ulcer/injury care. R39's physician orders (PO) with a start date of 11/15/2024, documented the following order for R39 Pillow between knees when in bed for comfort and another order with a start date of 5/20/24, R39 is to have blue wedge abductor [device to prevent tissue breakdown] with strap in place when in w/c [wheelchair] on days/evening to help separate knees and to between position feet. R39's nursing assistant care sheet (Kardex) dated 1/8/25, identified R39 required the following: The resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested; Encourage Resident to frequently shift weight; Extensive assist/one-person physical assist One Person assist with turning and repositioning when in bedTwo [sic] persona assist to boost up in bed; Application of pillow between knees when in bed; Lower blue knee abductor wedge with strap to be used when up in w/c to help separate knees and to better position feet. During observation on 1/6/25 at 5:38 p.m., R39 was observed seated in a Broda chair (specialized positioning wheelchair) in dining room watching television without the ordered protection between his knees. During observation on 1/7/25 at 8:05 a.m., R39 was observed in bed without padding between the knees. During observation on 1/7/25 at 3:41 p.m., R39 was observed seated in a Broda chair in the dining room watching television without the ordered blue wedge abductor in place. During observation on 1/8/25 at 8:43 a.m., R39 was observed lying in bed, positioned on his right side with no pillow or padding between knees. During interview with NA-A on 1/8/25 at 12:58 p.m., NA-A stated, I get report from the previous shift verbally and look at kardex to tell me what they [residents] need. NA-A stated every resident has a kardex and [it tells us] what we need to do. We also look in the computer care plan to tell what needs to be done. During observation and interview with nurse manager registered nurse (RN-A) on 1/9/25 at 10:46 a.m., RN-A identified R39 was lying in bed with no pillow between his knees. RN-A stated, [R39's] care plan says to have pillow between knees when in bed. His legs are contracted enough to be touching and we want to eliminate or reduce pressure injuries to the area. During observation and interview with LPN-A on 1/9/25 at 10:54 a.m., LPN-A verified there was no pillow or padding between R39's knees while he was lying in bed. LPN-A stated, yeah, [R39] is on a turning schedule. [R39] can't move himself unless we help him. He is a high skin breakdown risk. And Padding or something should be between [R39] knees. It says so in the care plan and should be done. His knees bed inwards to touch so there needs to be something between them when he is in bed and in the wheelchair. During observation and interview with NA-A on 1/9/25 at 10:55 a.m., NA-A stated, [R39] is a skin breakdown risk, a pillow should be between the knees when in bed and it is not. During interview with assistant director of nursing (IPCP) on 1/8/25 at 2:29 p.m., IPCP stated the expectation of facility direct care staff is to follow the kardex and care plan for positioning and applying the blue wedge pillow between R39's knees when up in wheelchair and pillow between knees when in bed. IPCP stated R39 was identified as high risk for pressure ulcers with interventions in place. Facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 7/12/22 indicated the nursing staff and practitioner will assess and document an individual's significant risk factor for developing pressure ulcers, for example, immobility, recent weight loss, and a history of pressure ulcers. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, with and depth, presence of exudates or necrotic tissue. b. Pain assessment. c. Patient's mobility status. d. Current treatments, including support surfaces; and e. All active diagnoses.

Based on interview and document review, the facility failed to ensure a quarterly Minimum Data Set (MDS) was completed in a timely and/or comprehensive manner to facilitate accurate evaluation of resident' conditions for 2 of 3 residents (R50, R108) reviewed for MDS accuracy. Findings include: R50 The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, identified the RAI process (i.e., MDS) was completed to help evaluate resident' strengths and areas for care-planning. The manual listed all types of assessments to be completed along with corresponding timeframe's for them via a graph labeled, RAI OBRA-required Assessment Summary. This directed a quarterly MDS should be completed (i.e., signed) within, ARD + 14 calendar days. R50's significant change MDS, dated [DATE], identified R50 had severe cognitive impairment, demonstrated hallucinations, and was on hospice. R50's electronic medical record listed a section labeled, MDS, which listed every completed MDS to date for R50. A subsequent quarterly MDS, with an assessment reference date (ARD) 12/24/24, was listed but categorized as, In Progress. The MDS was not completed with multiple sections being red-colored and having little or no data entered and being labeled, In Progress. The uncompleted sections included, Hearing, Speech and Vision, and, Behavior, and, Bladder and Bowel, among several others. R50's medical record was reviewed and lacked evidence why the MDS had not been completed timely per the RAI manual (due 1/7/25). When interviewed on 1/8/25 at 1:07 p.m., registered nurse (RN)-F verified they help complete the MDS for the campus. RN-F verified R50's quarterly MDS was not finished and should have been within 14 days of the ARD adding, We haven't gotten to it yet. RN-F stated the corresponding assessments for the sections (i.e., pain assessments, bladder assessments) didn't seem to be finished in the record, either, which would likely cause many sections on the MDS to be dashed as 'not assessed' adding aloud, It will unfortunately. R108 The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, identified the RAI process (i.e., MDS) was completed to help evaluate resident' strengths and areas for care-planning. The manual outlined all sections of the MDS to be completed and listed, C: Cognitive Patterns, as used, Determine the resident's attention, orientation, and ability to registered and recall information, and whether the resident has signs and symptoms of delirium. Further, it listed, D: Mood, as used, Identify signs and symptoms of mood distress and social isolation. R108's quarterly MDS, dated [DATE], identified the MDS was signed as completed. However, the sections labeled, Section C - Cognitive Patterns, and, Section D - Mood, had all their respective answers (sections used to evaluate the resident) dashed as, - Not assessed, or, - Not assessed/no information. R108's medical record was reviewed and lacked evidence why the MDS had not been completed in a comprehensive manner to accurately evaluate R108's cognition or mood symptoms. When interviewed on 1/7/25 at 1:29 p.m., RN-F verified the MDS was coded correctly, however, it was coded as 'not assessed' due to the corresponding assessments (i.e., BIMS, PHQ-9) not being completed. RN-F stated the social services department was responsible to complete those and then the captured data gets transferred to the MDS. RN-F stated they felt the assessments, and subsequently the sections of the MDS, not being completed thoroughly was kind of an outlier. However, RN-F stated it was important to ensure the MDS was thoroughly completed as it helped showed the most accurate picture of the resident. A provided MDS Completion and Submission Timeframes policy, dated 4/2023, identified the care center would complete and submit assessments in accordance with federal and state timeframe's. The policy outlined, Timeframes for completion and submission is based on the current requirements published in the [RAI] manual.

Based on interview and document review, the facility failed to ensure a comprehensive care-planning process (i.e., meeting) was implemented to ensure continuity of care and promote participation in care-planning for 1 of 2 residents (R222) reviewed for participation in care-planning. Findings include: R222's admission Minimum Data Set (MDS), dated [DATE], identified R222 admitted to the care center on 11/22/24 and had intact cognition. The MDS outlined R222 had symptoms of depression along with several medical conditions including heart failure, diabetes mellitus, and arthritis. The MDS outlined R222's goal was a return to the community and an active discharge plan was in place. The MDS identified what, if any, Care Area Assessments (CAA) had been triggered due to R222's MDS responses for further evaluation. These CAA(s) included activities of daily living (ADL) function, urinary incontinence, falls, and nutritional status. Further, the MDS' care plan decisions were signed as completed on 12/3/24; and the final MDS submitted on 12/9/24. On 1/6/25 at 1:11 p.m., R222 was interviewed. R222 explained they admitted to the care center from the hospital and, when they arrived, had been non-weight bearing which had now resolved. R222 expressed multiple concerns about her care while at the center including pain interventions (i.e., Aqua-K Pad) not being handled timely and felt it was due to poor communication adding aloud, Communication is a large factor here. R222 stated she had not yet felt included in her care while at the center and expressed she could not recall ever having a care conference (meeting with all disciplines present) since she admitted . R222 explained the various disciplines (i.e., nursing, dietary, therapy) seemed to rather come in one at a time and talk about things adding, But not in a group, if that's what you mean. R222 stated she would like a meeting with everyone together and felt it would reduce the communication issues she had been seeing adding, I would love that! R222's progress notes, dated 11/22/24 to 1/6/25, identified the following: On 11/22/24, R222 admitted to the care center via ambulance. R222 was recorded as alert and oriented to person, place and time. On 11/25/24, a note labeled, IDT [interdisciplinary team] Meeting Note, was recorded which outlined, IDT discussed and assisted with coding of Section GG [MDS] using staff interviews and assessments, and therapy documentation. The note lacked evidence R222 was included in the discussion. On 11/26/24, a note was completed by social services designee (SSD)-B which outlined, Resident's discharge goal is to return to the community with services . [R222] reports she had made the decision to see [sic] her home and move into an assisted living facility . stated she would return home and move from home to an AL [assisted living]. Resident will work with therapy and SS [social services] to obtain any necessary equipment for safe discharge . SS will continue to follow and assist . However, R222's entire medical record was reviewed and lacked evidence a comprehensive care conference meeting had been offered or held with R222 since they admitted to the care center. On 1/7/25 at 12:12 p.m., SSD-B and registered nurse manager (RN)-D were interviewed. SSD-B stated they were responsible to facilitate care conferences on the short-term unit (i.e., TCU) where R222 resided and expressed the meeting was typically scheduled within 72 hours after admission and documented within the medical record. SSD-B expressed they didn't recall ever having a care conference for R222. SSD-B stated it may have come due and been completed when they were on vacation adding the other social workers or social work director would have done it then. SSD-B and RN-D reviewed R222's medical record and neither were able to locate evidence a care conference had been held but SSD-B added, I would assume she had a care conference. SSD-B stated each of the floors' social workers had a little different way of documenting them. SSD-B stated they had not scheduled, as of 1/7/25, any other care conferences for R222 as I know her plan. However, SSD-B acknowledged the importance of a care conference to ensure services for care are explained and any potential barriers to discharge were identified adding such meeting should include IDT and the resident. When interviewed on 1/7/25 at 1:05 p.m., the social services director (SSDR) reviewed R222's medical record along with their Outlook system (email and calendar system) and acknowledged it lacked evidence a care conference was held for R222. SSDR explained the care conferences were typically recorded using a user-defined assessment (UDA) within the medical record, however, they were unable to locate any being done adding, I do not see that one is in here. SSDR stated a care conference should have been held around the end of November and should have included all IDT members. SSDR stated there was a checklist used to help guide the process, however, it didn't always match up with facility policy so it could have caused confusion. SSDR verified the medical record lacked evidence a care conference was held, nor evidence or rationale why it had not been and stated aloud, I think we need to do better. SSDR stated care conferences were important so the whole team knows what's going on and all are on the same page. A provided Resident Care Conference/Care Plan Review policy, dated 3/2021, identified the purpose of the care conference was to develop a plan of care and ensure resident' goals and preferences were established. The policy outlined an initial care conference should be scheduled during or shortly after admission and the responsibility to do such was with social services. The IDT would be notified of the meeting via email and the meeting should be held within the resident's room. The policy added, After the initial care conference, social services will create a care conference progress note summarizing the items discussed.

Based on observation, interview, and document review, the facility failed to ensure routine personal hygiene cares (i.e., nail care) was completed to reduce the risk of complication (i.e., scratches, infection) for 1 of 3 residents (R47) reviewed for activities of daily living (ADL) and whom was dependent on staff for their nail care. Findings include: R47's admission Minimum Data Set (MDS), dated [DATE], identified R47 had severe cognitive impairment and demonstrated no rejection of care behaviors during the review period. Further, the MDS outlined R47 was dependent on staff for bathing, and required supervision or touching assistance with personal hygiene (i.e., shaving, combing hair). R47's most recent Weekly Bath Audit 020919 - V9, dated 1/2/25, identified R47 received a bed bath. The audit listed, Was nail care rendered? which was answered, 1. Yes. The audit also listed, Are nail beds clear of debris? which was answered, 1. Yes. Further, the audit outlined, Patient has scratches on his left side of his glute, patient states that he scratched himself recently. However, on 1/6/25 at 2:01 p.m. (four days later), R47 was observed lying in bed while in his room. R47 was dressed in a hospital-gown and was unable to recall what, if any, meal had been served for lunch nor how long he had been at the care center. R47's hands were visible and R47 had several nails on both hands, especially the thumb nails, which were multiple millimeters (mm) in length. Further, multiple nails had visible brown or black-colored debris present under them. R47 was questioned on his nails and held his hands up to look at them, however, had no verbal response on them. When asked if he'd like them clipped shorter or cleaned, R47 responded aloud, Yea. R47's care plan, dated 12/4/24, identified R47 was non-ambulatory due to an ankle fracture and outlined, Resident performance: Personal hygiene - Supervision/set-up help only. Further, the care plan outlined a section labeled, ADL self care needs ., which outlined, AM ROUTINE . - Dependent dressing. The care plan lacked any outlined nail length preference for R47 (i.e., long or short), nor evidence R47 was identified to refuse nail care. On 1/7/25 at 8:31 a.m., R47 was again observed while in his room. R47 continued to have the same long, soiled nails and nail beds as had been observed the day prior. Further, the following day on 1/8/25 at 8:23 a.m., R47 was again observed to have the same length fingernails including multiple ones with debris present underneath of them. R47's medical record was reviewed and lacked evidence R47 had nail care offered or provided despite being observed for multiple days with continued long, soiled nails and/or nail beds. On 1/8/25 at 10:04 a.m., nursing assistant (NA)-F was interviewed. NA-F verified they were assigned care for R47 and had worked with him multiple times prior. NA-F described R47 as needing staff assistance with all cares except feeding adding, We do everything for him. NA-F stated R47 was generally accepting of cares and mostly just wanted to go back home. NA-F explained baths were done weekly and the nurses will help with nail care, if needed. At 10:07 a.m., NA-F observed R47's nails and verified their length and condition adding aloud, They need to be trimmed. NA-F stated the nails were kind of longer and [he] could scratch himself. R47 was asked if he'd like them clipped and responded, Yea. NA-F stated the nails should be clipped on bath day adding they were unaware of any preference for R47 to have longer, soiled nails. When interviewed on 1/8/25 at 10:57 a.m., registered nurse (RN)-H stated nail care should be completed every bath day and, if the resident is not diabetic, then the NA can do it. RN-H stated each bath is done by the NA and the nurse then should follow-up afterward to ensure the list of things they do are done, including nail care. RN-H verified nail care could be completed in-between assigned bath days, too, if noticed it was needed. RN-H stated they were assigned care for R47 that day, however, had not noticed his nails being long adding, I will look at it later. RN-H verified R47 was not diabetic and was generally accepting of care. Further, RN-H stated any attempt to do nail care should be documented in the notes. On 1/8/25 at 11:55 a.m., the director of nursing (DON) was interviewed. DON verified nail care should be completed on assigned bath days but would also be done in-between if noticed. DON added, I do expect nurses to verify the charting is done. A provided Fingernails/Toenails, Care of policy, dated 2/2022, identified a procedure to ensure nail care was done adding, Nail care includes daily cleaning and regular trimming. The policy included, Proper nail care can aid in the prevention of skin problems around the nail bed. Further, the policy directed nail care, when done, should be documented in the medical record.

Based on interview and record review, the facility failed to comprehensively assess a resident, reevaluate interventions, or make changes to a care plan after a fall for one of three residents (R1) reviewed for falls when R1 had a previous fall with a history of letting go of the EZ stand lift grab bars. R1's recent fall resulted in fractures of her neck and back. Findings include: R1's admission record printed 2/5/24 stated R1 was initially admitted to the facility on [DATE] to the transitional care unit (TCU) and was transferred to long-term care (LTC) on 3/16/23 with a diagnosis of weakness and anemia. Additional diagnoses included multiple sclerosis, morbid obesity, tremors, gastric ulcers, and mild cognitive impairment. R1's care plan revised on 8/1/23 indicated R1 required assistance with activities of daily living (ADLs) due to her diagnosis of multiple sclerosis. One intervention is R1 required extensive assistance by one staff with a front wheel walker and gait belt for transfers during the day and for the evening/bedtime transfer R1 will use an EZ stand lift (An EZ stand lift is a transfer assist device and is designed primarily to transfer residents from chair, wheelchair, toilet, or bed. An EZ stand lift is used when a person can be actively involved in the standing process. There are two straps that should be used during the transferring process: the shin strap and the back harness. The shin strap is applied to the resident's legs to keep the resident's feet on the foot plate or their shins on the shin pad. The back hardness should be placed around the upper body of the resident, so the sides of the harness are between the patient's torso and arm, resting two to three inches below the underarm. This harness is to ensure resident safety) The care plan stated R1 should wear her bilateral lower extremity ankle foot orthotics (AFOs) (AFO braces are external devices utilized on lower limbs to stabilize the joints to improve gait and physical functioning of the affected lower limb) braces to be in place when transferred or up in her chair. R1's Lift Mobility Status assessment dated [DATE] indicated R1 can walk with no physical assistance, can stand, can pivot, can bear weight on at least one leg, and can grip the EZ stand lift with at least one hand with enough strength to actively participate in the EZ stand lift. The assessment indicated R1 was cooperative and non-combative. R1's Fall Risk assessment dated [DATE] indicated R1 has not had any falls in the past three months and was chair bound and to assist with elimination. The assessment does not indicate how many staff R1 was dependent upon for assistance with elimination. The assessment did not indicate any gait problems but did indicate R1 required the use of assistive devices such as a cane, wheelchair, walker, or furniture. The assessment indicated R1 scored a 12 on the assessment which indicated high risk for falls. R1's quarterly MDS dated [DATE] indicated on J1800 that R1 had no falls since her prior MDS assessment on 9/15/23. R1's brief interview for mental status (BIMS) had a score of 11 indicating her cognition was moderately impaired. R1's progress note dated 1/14/24 indicated R1 purposefully let go of the EZ stand lift and slid herself out of the back harness and landed on the toilet. The progress note did not indicate if the shin strap was used. The note indicated the intervention attempted was to re-educate R1 in order to use the EZ stand lift it required R1 to follow instructions and participate accordingly, otherwise the clinical manager will have to use the mechanical lift (a mechanical lift is a designed assist with transferring residents who can't safely walk or put weight on either leg. When transferring a resident via mechanical lift, a caregiver will use a sling that attaches to the lift. The sling wraps around the resident's high and crosses between the legs and then attaches to the lift). The note indicated the intervention was effective and that R1 stated her transfer mode of preference was with the walker. The note did not identify changes to R1's plan of care. R1's medical record did not identify an incident report for the fall on 1/14/24. R1's social services care conference dated 1/16/24 indicated R1 had a decline in cognition and memory. The care conference notes indicated R1 purposefully slid out of the back harness of the EZ stand lift on 1/14/23 during transfer to the toilet and indicated this was not the first time R1 has done this. The notes indicated staff educated R1 and family that if it happens again, they will have to downgrade to a mechanical lift. The notes indicated staff explained the risk of serious injury if R1 does not participate and follow instructions to use the EZ stand lift when transferring. R1's progress note dated 1/19/23 indicated R1 refused to use the EZ stand lift and the clinical manager offered to help R1 transfer using her walker instead of the EZ stand lift. The clinical manager and the NA attempted to assist R1 into a standing position from her wheelchair but R1 was unable to do so regardless of the amount of support provided. The note indicated the clinical manager informed R1 she will need to be transferred using the EZ stand lift and she agreed. R1's incident report dated 1/29/24 indicated R1 let go of the EZ stand lift handles while being transferred from the toilet to her wheelchair and fell on the floor. The incident report indicated R1 refused to let nursing assistant (NA)-D put on the shin strap per protocol and demanded to be transferred via EZ stand lift without the shin strap. The incident report indicated R1 hit her head and complained of serious pain from her mid back to head. The report indicated R1 was transferred off the floor to her bed via mechanical lift and three persons assist. The nurse practitioner (NP) and family was notified, and R1 was sent to the emergency department (ED) for evaluation. The report indicated no injuries observed. The report indicated predisposing physiological factors included impaired memory and incontinence. R1's incident investigation report from 1/29/24 fall indicated R1 had a fall from the EZ stand lift when transferring. The report indicated NA-D was transferring R1 from the toilet back to her bed, NA-D attempted to place the shin strap and the back harness, but R1 demanded the shin strap and the back hardness not be used when in the EZ stand lift. The report indicated while moving the EZ stand lift towards the wheelchair the stand lift wheel got caught with the wheelchair and NA-D decided it was not safe to transfer to the wheelchair and started moving R1 towards the bed. The report indicated R1 stated let me fall and let go of the EZ stand lift handles and fell backwards through the harness. The report indicated R1 was rubbing her head and stating it hurt. R1 was transferred off the ground using a mechanical lift and the assistance of three staff members to her bed. The report indicated that during that transfer, R1 complained of moderate pain to her mid to upper back. The clinical manager alerted the NP and family that R1 had fallen and received orders to send R1 to the hospital for evaluation. The investigation indicated that other residents who used EZ stand lifts were interviewed and have had no issues with staff and transferring, and the use of EZ stand lifts were observed while transferring and no issues were noted. The investigation for R1 indicated the care plan was reviewed, resident and staff interviews were reviewed, and no changes were made to the policy and procedure after this incident occurred. The investigation indicated that R1 recently started letting of the EZ stand lift within the last six months with instances occurring on 1/14/24 and 9/10/23. The investigation indicated the care plan was updated and education was provided to staff about EZ stand lift training. R1's medication administration record (MAR) from January 2024, R1 had an order stated to evaluate and treat for difficult transfer and fall every shift for difficult transfer and fall. The start date of the order was 5/5/23 and the end date of the order was 2/1/24. The MAR stated that the only times this was indicated was starting the evening of 1/29/24 through 1/31/24 and that was due to R1 being hospitalized . All other dates and shifts indicated staff was completing this task. During an interview with FM-A 2/5/24 at 1:51 p.m., FM-A stated R1 had a fall on 1/29/24 and the clinical manager called her while R1 was on the floor telling me that she had a fall and while she was on the phone with the clinical manager, R1 was yelling in the background about her back. FM-A stated the clinical manager asked if she approved of the facility sending R1 to the emergency department and FM-A approved. FM-A stated she could not recall how many times R1 had fallen but though that the incident on 1/29/24 was about the fourth or fifth fall in the last six months. FM-A stated she asked the clinical manager several times to switch R1 from a EZ stand lift for transfers to a mechanical lift. FM-A stated once R1 was evaluated at the hospital it was determined that R1 had a broken neck and a broken back from the fall on 1/29/24. During an interview with NA-B on 2/5/24 at 2:19 p.m., NA-B stated he was trained on how to use the EZ stand lift when he first came to the facility. NA-B stated he had to demonstrate how to use the EZ stand lift to the leaders. NA-B stated he knows how each resident needs to be transferred by looking at the resident's care plans. NA-B stated that if a resident is refusing to transfer safely that he would leave the resident is a safe place and call for the nurse on duty. During an interview with NA-A on 2/5/24 at 2:30 p.m., NA-A stated that on his first day at the facility the leaders gave him paper documents about how to use the EZ stand lift and then he had to demonstrate to the leaders that he knew how to use the EZ stand lift. NA-A stated he looks at the resident's care plans to see how each resident is cared for. NA-A stated if a resident refuses to be transferred safely, he would report to the nurse before transferring the resident. NA-A stated when a resident falls, he would leave the resident on the ground in a safe spot then he would report to the nurse. During an interview with trained medical assistant (TMA)-A on 2/6/24 at 11:17 a.m., TMA-A stated that he knows how each resident is transferred by looking at each resident's care plan. TMA-A stated if a resident is refusing to be transferred safely, he would leave the resident where they are and will call for back up from his manager. TMA-A stated he was trained on the EZ stand lift by the education director when he first came here, and the facility has in-service trainings. TMA-A stated that he looks at each resident's care plan each shift to look for any changes made. During an interview with licensed practical nurse (LPN)-A on 2/6/24 at 11:24 a.m., LPN-A stated he knows how to transfer each resident by looking in the resident's care plan. LPN-A stated if a resident is refusing to be transferred safely, he would leave the resident and then he will ask why the resident wants to be transferred a different way than the care plan stated. LPN-A stated he will then update the clinical manager and then the clinical manager would give him direction on how to transfer the resident. LPN-A stated he was trained on using the EZ stand lift when he first came to the facility about a year ago. During an interview with NA-C on 2/6/24 at 11:32 a.m., NA-C stated that she been here about six weeks. NA-C stated that she knows how a resident need to be transferred when she looks at the care plan. NA-C stated if a resident is refusing to be transferred safely, she would leave the resident is a safe position, look at the care plan to ensure I was transferring her according to the plan, and then tell the nurse that the resident is not wanting to be transferred safely. NA-C stated she was trained on using the EZ stand lift during orientation in class by the director of staff development. NA-C stated that she was working the same floor and unit when R1 fell on [DATE]. NA-C stated she was called to assist to help R1 off the floor. NA-C stated that R1 was wearing her AFO leg braces, and she was fully dressed including her shoes. During an interview with the director of staff development (DSD) on 2/6/24 at 12:16 p.m., the DSD stated that she does the training on the EZ stand lifts. The DSD stated she demonstrates how to use the EZ stand lift and then she requires the staff member to demonstrate how to use the EZ stand lift back to her. During an interview with the clinical manager on 2/6/24 at 1:08 p.m., the clinical manager stated it is all the leader's responsibilities to train and educate staff on using the EZ stand lift. The clinical manager stated her expectations if a resident is refusing to be transferred safely, that the staff member does not transfer the resident, keeps, or puts the resident in a safe spot, and consults with a leader. The clinical manager stated the guidelines for a resident to be able to use a EZ stand lift is that the resident needs to bare weight on at least one leg, hold on to the EZ stand lift grab bars with at least one arm, and follow instructions. The clinical manager stated a resident must be able to tolerate standing. The clinical manager stated when R1 fell on [DATE], R1 was demanding NA-D to transfer her from the toilet to her wheelchair without using the shin strap or back harness. The clinical manager stated the wheel of the EZ stand lift and the wheel of the wheelchair got stuck in between each other and the resident was demanding NA-D to let her fall and then let go of the EZ stand lift grab bars. The clinical manager stated R1 was wearing a pair of jean shorts, a short sleeve shirt, her AFO leg braces, and a pair of socks at the time of the fall. The clinical manager cannot recall if R1 was wearing shoes. The clinical manager stated after R1 fell , NA-D left the room and came to get her around the corner and the clinical manager came into R1's room. R1 was holding her head, saying her head hurt, and she was moving around a lot. The clinical manager stated she attempted to get assess R1's vital signs but could not obtain a blood pressure due to R1 moving around. The clinical manager called R1's daughter while she was still on the floor to see if it would help calm R1 down enough to get a blood pressure from her which was unsuccessful. The clinical manager stated herself and two NA's transferred R1 from the floor to her bed using a mechanical lift. The clinical manager stated during the transfer, R1 started to complain of back pain, and she assessed her back and noticed there was some discomfort to her mid-back up to her neck. The clinical manager stated after R1 was transferred back to her bed she attempted to get a blood pressure reading which was unsuccessful. The clinical manager stated she called the NP to get orders on sending R1 to the emergency department for further evaluation and updated R1's daughter. The clinical manager stated R1 was not seeing physical therapy (PT) at the time. The clinical manager stated R1 had a fall on 1/14/24 due to her letting go of the EZ stand lift grab bars. The clinical manager stated during that fall, R1 had her shin strap and back harness on. The clinical manager stated R1 continued stating she had to use the toilet, R1 let go of the grab bars on the EZ stand lift, held her arms in as she fell , slid through the back harness, and fell to the ground. The clinical manager stated R1 had a cognitive decline in the last few months. The clinical manager stated she told R1 she needed to be able to pivot transfer if she was not going to use the EZ stand lift so the next time R1 needed to use the toilet, R1 used the pivot transfer and completed the transfer successfully. The clinical manager stated R1 would then use the toilet the next time and would be too weak to do the pivot transfer and then R1 would need to use the EZ stand lift again. The clinical manager stated if R1 continued falling while using the EZ stand lift she would have to use the mechanical lift. The clinical manager stated the reason she did not change her care to use the mechanical lift after the falls on 9/10/23 and 1/14/24 is because she was trying to preserve R1's independence and her right to choose her care while still maintaining safety. The clinical manager stated her expectation if a resident is not wanting to be transferred safely, then the staff members stop the transfer or does not start the transfer. The clinical manager stated it is in her scope of practice to switch the mode of transfer if one mode of transfer is deemed unsafe for the resident. The clinical manager stated when a resident falls, the fall would be put on a building charge report and then IDT will meet to discuss the fall. The clinical manager stated it is the responsibility of the clinical managers to put in interventions into a resident's care plan after a fall. During an interview with the DON on 2/6/24 at 2:00 p.m., the DON stated the facility has a representative come in twice a year to train staff on the EZ stand lift and the last time the representative came to the facility was in fall 2023. The DON stated if a resident is refusing to be transferred safely, her expectation is the staff should stop and get a nurse. The DON stated the guidelines for determining if a resident is a good candidate for an EZ stand lift is if the resident can bare weight on one leg, hold on to the grab bar on the EZ stand lift with one arm, and follow simple instructions. The DON stated if a resident is unable to follow simple instructions the staff would cue the resident. The DON stated she knows R1 had a lot of falls but there were several instances of education with R1 that she needed to hold on to the grab bars on the EZ stand lifts during transfers. The DON stated educating R1 is the only intervention that she was aware of after R1's falls on 9/10/23 and 1/14/24. The DON stated she remembers R1's fall from 1/29/24. The DON stated she was informed R1 had a fall while R1 was still on the floor. The DON stated she went to R1's room and while the clinical manager and two additional NA's were transferring R1 from the floor to her bed, the DON educated NA-D stating he needed to use all the safety features on the EZ stand lift and if R1 didn't want to use the safety features of the lift that he needed to stop and not transfer her. The DON stated NA-D has been suspended after the fall on 1/29/24. The DON stated since R1's fall on 1/29/24, she done staff education about falls and EZ lift stands. During an interview with NA-D on 2/7/24 at 10:28 a.m., NA-D stated that he has worked in the facility for about a year. NA-D stated 1/29/24 was his second time working with R1. NA-D stated he was working between two residents, with R1 being one of those residents, during the last part of his shift. NA-D stated he had transferred R1 to the toilet and left her there to go help the other resident with their cares. R1 then used her call light and NA-D went back to R1's room and he attempted to attach the shin strap and the back harness, and she was very demanding stating she did not want the shin strap or back harness. NA-D stated he was going to try transfer her to her wheelchair using the EZ stand lift without the straps and sling. NA-D stated the wheels of the EZ stand lift and the wheels of the wheelchair were caught between each other. NA-D stated R1 stated just let me fall and he told her to hang on for a few more moments and she let go of the EZ stand lift grab bars falling to the ground. NA-D stated right after the fall he notified the clinical manager. NA-D stated at the time of the fall R1 was wearing shorts, her disposable brief, her AFO leg braces, and her shoes. NA-D stated he did not know R1 had several falls in the past, that R1 lets go of the EZ stand lift grab bars, or if R1 had safety interventions in place from her previous falls. NA-D stated he was trained on the EZ stand lift when he first came to the facility. NA-D stated he was trained on how to use the EZ stand lift and then had to demonstrate it back to the leaders. NA-D stated because this was his second time working on the third floor, he would consult with the nurses on how to care for each resident. NA-D stated he did not review the resident's care plans before consulting with the nurses. NA-D stated if a resident is refusing to be transferred safely, he would refuse to transfer the resident and report it back to the nurse. During an interview with the clinical manager on 2/7/24 at 11:51 a.m., the clinical manager stated if the resident is seeing PT, then PT will determine a resident's mode of transfer and if the resident is not seeing PT, then the clinical managers can determine the mode of transfer. The clinical manager stated the reasoning behind her decision on why she kept R1's mode of transfer an EZ stand lift was R1 had demonstrated to her multiple times she was able to use the EZ stand lift and pivot transfers safely. The clinical manager stated she was trying to preserve R1's independence by keeping R1 with the EZ stand lift. The clinical manager stated R1's fall from 1/29/24 was unavoidable because R1 purposefully let go of the grab bars on the EZ stand lift. The clinical manager stated she determined R1 purposefully let go of the EZ stand lift grab bars because she had talked to several staff and the staff had reported back to her that R1 would say just let me fall and then let go of the EZ stand lift grab bars. The clinical manager stated she does not believe this is a physical decline because R1 was not complaining of her legs, her hands were not shaking, or her legs were not shaking. The clinical manager stated she thought R1 purposefully let us go of the grab bar on the EZ stand lift because R1 is stubborn, she does not like the EZ stand lift machine, and she just wanted to sit down. The clinical manager stated R1 has never told her she is weak. The clinical manager stated after R1's fall on 1/14/24 she observed R1 with her walker, walk about five feet, pivot transfer, and then sit in her wheelchair successfully. The clinical manager stated she did not do any assessments on the EZ stand lift transfers after the fall on 1/14/24. The clinical manager stated no interventions were put into R1's care plan because R1 did not fall on the ground but she fell on the toilet and IDT determined that it was not a fall. The clinical manager stated the behavioral charting that she wrote on 1/14/24 stated the fall intervention was to re-educate the resident to use the stand lift and she monitored the effectiveness by observing R1's successful use of the walker, pivot transfer, and not letting go of the grab bar on the EZ stand lift on that day. The clinical manager stated the intervention was monitored for just one day. The clinical manager stated she thought R1's fall on 1/14/24 was unavoidable because she let go of the grab bar on the EZ stand lift, brought her arms in, and slid through the sling and fell on to the toilet. The clinical manager states she did not do any assessments on R1 after her fall on 1/14/24. The clinical manager stated the care conference after R1's fall on 1/14/24 concluded the fall was an isolated event, and the facility would continue to monitor R1. The clinical manager stated the family was included in the care planning process and R1 refused the mechanical lift. A Falls and Fall Risk, Managing policy/procedure reviewed on 10/4/21 indicates staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. The policy indicates if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. The policy states in conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on observation, interview, and document review, the facility failed to comprehensively assess fall risk and implement appropriate fall interventions to decrease the risk for 2 of 3 residents (R1, R2) with falls. This resulted in harm for R1 who sustained two serious head injuries, was transferred to the hospital, and later died as a result of his injuries. Findings include: Vulnerable adult maltreatment report submitted to the State Agency dated [DATE], identified R1 was discharged from hospital on [DATE] and admitted to transitional care unit (TCU). R1 was readmitted to hospital on [DATE] . R1 was diagnosed with subdural hematoma, subarachnoid hemorrhage, parietal skull fracture, deep tissue injury to left heel, pressure injury to the coccyx. None of these conditions were present at the time of discharge from the hospital on [DATE]. R1's Face Sheet undated, identified R1 had diagnoses that included anoxic brain damage (lack of oxygen to the brain), nuclear cataract (excessive yellowing center of eye), unspecified hearing loss in the left ear, repeated falls, syncope (dizziness) and collapse (fall or give away). R1's fall risk assessment dated [DATE] identified R1 was a high fall risk with a score of 11, and had one to two falls in the last three months. R1 was chair bound and required assistance with elimination. Evaluation of R1's gait was not performed, and R1 was on medications that caused lethargy or confusion. R1 had predisposing diseases that impacted his fall risk. R1's admission assessment [DATE], identified R1 had a fall in the last month prior to admission to the facility. R1 was transferred from home to the hospital on [DATE] for an evaluation following a fall with syncope. Further identified, R1 was a Cantonese speaker and required the use of an interpreter. R1 had moderate difficulty with ability to hear, and no hearing aids or appliances were normally used. R1's family member (FM)-A was available and helped with admission assessment and anytime they needed to interpret tasks for R1. FM-A informed facility staff resident was hard of hearing and an IPad interpretation may not help. R1's bowel and bladder program screener dated [DATE], indicated R1 required assistance of one person to get to the bathroom, was alert and oriented, and sometimes mentally aware of the need to toilet. The screener identified R1 was a candidate for a bowel and bladder training program. There was no indication a bowel and bladder program had been initiated. R1's care plan dated [DATE] identified R1 was at a high risk for falls due to a history of recent falls. The care plan directed staff to anticipate and meet needs, ensure the call light was in reach, and encourage resident to use call light as needed. R1 required prompt response to all requests for assistance. Physical therapy was to evaluate and treat as ordered or as needed, and R1 required assist of one with a front wheeled walker for transfers. The care plan did not identify a toileting schedule and/or a positioning schedule. R1's initial Minimum Data Set (MDS) dated [DATE], identified R1's preferred language of Chinese, and R1 needed or wanted an interpreter to communicate with a doctor or health care staff. Brief interview for mental status (BIMS, to assess cognition) was not completed. R1's assessment for lying to sitting on the side of the bed and ability to sit to stand were not applicable and not attempted. R1's chair to bed transfer required dependent assist and toilet transfer required substantial to maximum assist. R1 required substantial to maximum assist for toileting. R1 had not had a trial of a toileting program and R1 was frequently incontinent of bladder and always incontinent of bowel. A toileting program was not being implemented to manage continence. R1's fall Care Area Assessment (CAA) with an assessment reference date of [DATE], indicated R1 had an actual fall in the last month prior to admission. However, R1's history of falling and physical performance limitations were not complete. Medications included diuretics and internal risk factors of circulatory/heart (cardiac dysrhythmias) neuromuscular/functional (incontinence and traumatic brain injury) perceptual (hearing impairment) orthopedic (arthritis) psychiatric (cognitive impairment). The care plan was not completed or identified any goals or overall objectives as a result of the CAA. R1's fall risk dated [DATE] identified R1 was a high fall risk with a score of 13. R1 had no falls in the past three months, was ambulatory and incontinent. R1 had balance problems with standing and walking, decreased muscular coordination, and required use of an assistive device. R1's incident report dated [DATE], indicated R1 had an unwitnessed fall and was found lying on the floor at 5:30 a.m. He was on his right side at the back of his room door. R1 hit the back of his head and had a laceration approximately size of a dime. R1 was shivering with a blanket partially covering his body and was unable to explain what occurred due to not speaking English. Nursing assistant reported the last time she checked on resident, he was sleeping soundly in bed. Immediate action taken was physical assessment, and vitals signs (blood pressure ,d+[DATE], pulse 88, tempature 97.3 and respirations 18).Was unable to complete pain assessment and R1 was assisted back to bed with the use of a Hoyer lift (full body mechanical lift) by two nursing staff. Level of pain rated at a score of three with facial expressions being sad, frightened, frowned body language tensed, distressed pacing, conceivability distracted or reassured by voice or touch. There were no predisposing environmental factors, physiological factors. Predisposing situation factors included using walker, call light within reach, ambulating without assist. Corresponding note dated [DATE], indicated interdisciplinary team (IDT) review of fall; patient last observed less then 60 minutes prior to fall or roll out of bed. Care plan followed. Patient did have a history of laying very close to the side of bed. Will look at and change care plan when R1 returns from emergency room and can get input from FM-A. R1's medical record from [DATE] to [DATE] between 11:00 p.m. and 5:30 a.m., had no documentation R1 was provided with any cares and/or was toileted. During interview on [DATE] at 10:55 a.m., (FM)-A indicated R1 resided with him prior to being admitted to the TCU. R1 had three falls while at home and the first fall happened due to R1 trying to get out of bed on his own and reported needing to go to the bathroom. The second fall happened while going down stairs, and the third fall happened attempting to get to the bathroom on his own. FM-A indicated R1 had the desire to go to the bathroom frequently and would attempt to go on his own. FM-A was notified of the fall on [DATE] and asked why R1 was on the floor. When FM-A arrived at the hospital R1 informed him he was trying to go to the bathroom. During interview on [DATE] at 1:33 p.m., licensed practical nurse (LPN)-A identified she was R1's nurse the night of the fall. The last time she was in R1's room was to give intravenous therapy (IV) medications (fluids) at around 12:30 a.m. LPN-A reported R1 was COVID positive and R1's bedroom door had been closed. Around 5:30 a.m. LPN-A went to check on R1 and attempted to open the door a few times but noted resistance. LPN-A was able to gain visual entrance to the room and saw R1's head against the backside of the door causing the resistance. R1 was laying on the floor and had a blood smear and a laceration (cut) on the back of his head. R1 was breathing fast and shaking. LPN-A noted blood smears and drops of blood around the bathroom and entrance to the room. LPN-A indicated it was as if R1 was coming out of the bathroom had fallen. He was positioned between the room entrance and bathroom entrance. LPN-A left R1 unattended to go get assistance from nursing assistant (NA)-A and asked when NA-A last provided cares and timing however, timing reports were inconsistent. LPN-A explained NA-A reported to her she did not toilet R1 on the last check because he was sleeping and R1 was supposed to use his call light. Then NA-A went back to assist R1 and LPN-A called nurse practitioner (NP), 911, and the nurse manager. LPN-A reported it was an unwitnessed fall with a head strike and R1 was on anticoagulation. LPN-A went back into the room to complete vitals and assessment. During interview on [DATE] at 2:30 p.m., LPN-B indicated she helped LPN-A with R1 the night of the fall with the IV around 12:30 a.m. R1 was awake at 12:30 p.m. and was in bed the whole time during the interaction. The second time LPN-B was in the room was after R1 had fallen and was already transferred back into bed. LPN-B indicated LPN-A had not called [DATE] at that time so instructed for LPN-A to call [DATE], NP and family. During interview on [DATE] at 3:52 p.m., nursing assistant (NA)-A indicated LPN-A had left R1 to find her to notify her of the fall. NA-A entered the room alone and visualized R1's head against the door to enter R1's room. R1 had dried blood matted in his hair, dried blood on both hands, dried blood spots of blood on the floor, and dried blood on the door of the bathroom. NA-A indicated it looked as though R1 was coming out of the bathroom himself and fell hitting his head on the bathroom door. R1 had gotten a blanket somehow because it was over him. R1 was only in a hospital gown and shivering, he said he was cold. NA-A transferred R1 from the floor to a standing position with the use of a transfer belt and walked him with a walker from the entrance of the room to his bed. R1 was sitting on the edge of the bed while NA-A cleaned all the blood off of him and changed his gown to get him ready to go to the hospital. NA-A was unaware of the last time R1 was toileted but thought R1 had gotten up to go use the bathroom alone and fell . NA-A stated the director of nursing,clinical manager or administrator had not asked any questions about the event since the date of the fall. NA-A indicated even though the blood that was in R1's hair, on the floor, and on the bathroom door was dried, she did not think R1 was not on the floor too long because she had just been in the room between 4:00 a.m. to 4:30 a.m. During an interview on [DATE] at 3:59 p.m., clinical manager (CM)-A indicated R1 was expected to use his call light, but only used it very very few times because R1 did not really understand. CM-A could not confidently say if R1 knew how to use the call light. Staff were suppose to check on R1 frequently and anticipate basic needs such as food and toileting due to communication barriers. It was expected staff are anticipating needs visually and should be checking during rounds no longer than an hour to confirm resident safety and avoid accidents such as falls . If residents are up in the middle of the night it was the expectation staff would offer toileting. Staff were to be visually checking residents on walking rounds if the door was closed. R1's door was kept open until testing positive for COVID on [DATE], then R1 was on isolation and his door was kept closed. During interview on [DATE] at 3:29 p.m., the director of nursing (DON) indicated the expectation with falls with head strikes include a head to toe physical assessment, neurological examination, and pain assessment to be completed. Moving a resident following a fall with a head strike would depend on the findings of the assessment. DON indicated it would be good nursing practice for the nurse to stay with the resident upon moving a resident following a fall with a head strike. DON was aware of a fall and was notified the next day on [DATE] at 11:27 a.m. by the day shift charge nurse. The investigation involved asking if the care plan was followed at the time of the fall, the last known well time, and if there was anything suspicious regarding the fall. DON indicated R1's last known well time was approximately 4:30 a.m., an hour before the fall and the nursing assistant who was involved was nursing assistant (NA)-B, however did not have time to confirm if that was accurate. DON was unaware of the last time R1 was toileted as it was not documented. DON did not identify anything suspicious regarding the event of the fall. DON indicated the facility handled the fall and everything was completed appropriately with no concerns following proper protocol and the care plan was followed. DON indicated R1 had a history of falling very close to his bed prior to admission and the causal analysis was R1 rolled out of bed and crawled to the door. DON did not complete any interviews with nurses or nursing assistants that were present at the time of the fall. During a subsequent interview on [DATE] at 11:14 a.m., DON and administrator both indicated they had not reviewed the facility's video footage as part of the fall investigation. DON stated she did not report the fall with major injury because the care plan was being followed. DON ascertained that information through the investigation that consisted of interviewing dayshift charge nurse (RN-A) and the incident report. According to her interview and the documentation of the event, the nursing assistant had reported checking on him an hour before the fall occurred. DON stated she checked the NA charting, however the time documented of that check, was completed after R1 left the facility. DON did not interview any other staff members including the staff that had worked when the fall occurred. During review of hallway camera video footage on [DATE] at 11:45 a.m. with DON and administrator identified inconsistencies with the incident report, facility investigation, and staff interviews. The DON indicated the time on the video was within 15 to 30 minutes of the actual time. The video identified the following: -12:37 a.m. LPN-A and LPN-B were in and out of the room [ROOM NUMBER]:42 a.m. LPN-B exited room and 12:45 a.m. LPN-A exited rooms. -12:45 a.m. to 4:40 a.m. staff were noted to be in hallway, however, R1's door remained closed with no visual checks completed. -4:41 a.m. LPN-A noted to be at R1's bedroom door pushing on door and had difficulty opening it. LPN-A was able to gain entrance and had her head through the opening in the door, however, did not enter room. LPN-A walked away from room with hands down at side in an unrushed manner. -4:42 a.m., NA-A entered room and at 4:45 a.m. A plastic bag was placed outside of the doorway -4:49 a.m., NA-B gowned with personal protective equipment (PPE) and brought a full body mechanical lift to the doorway of the room. Mechanical lift never entered the room. -4:53 a.m., LPN-A entered room with vital signs machine. NA-A exited room with linen in hand and returned to room with pillow and pillowcase. At 4:56 a.m. NA-A exited room and at 5:02 a.m. LPN-A exited room. -5:05 a.m. LPN-B entered the room and exited the room at 5:08 a.m. -5:22 a.m. NA-A returned to the room, exited a couple of seconds later, went back into the room at 5:27 a.m. -5:29 a.m. paramedics arrive, at 5:31 a.m. paramedics entered R1's room, at 5:34 a.m. R1 left with paramedics. During interview on [DATE] at 1:16 p.m., following the video review, the DON indicated the camera footage to actual time may vary by ,d+[DATE] minutes. Based on the camera footage R1's first and last visual check and last known well time before the fall was at 12:45 a.m. when nurse left the room. LPN-A did not immediately enter the room after observing R1 on the floor to complete a physical assessment and left R1 alone. The full body lift was never entered into the room to get R1 off the floor. During interview on [DATE] at 4:19 p.m., NP-A indicated she was notified immediately following R1 being found on the floor. She directed facility staff to send R1 to the hospital due to being on anticoagulation medication and reported bleeding from the head. NP-A indicated a fall with a head strike for a resident who was on blood thinners was a huge risk and would require immediate medical attention, especially an unwitnessed fall. NP-A would expect nursing staff to complete physical assessments right away and would not expect facility staff to attempt to transfer or walk a resident after a fall with a head strike without instruction and was under the impression R1 remained on the floor. During interview on [DATE] at 2:05 p.m., hospital medical doctor (MD)-B indicated R1 was pronounced dead at 1:30 p.m. on [DATE]. The diagnosis of R1's demise was subdural hematoma and hemorrhage. The impact of the fall to R1's head was the cause of death. MD-B indicated there was no reason to believe R1 would have not died if a fall did not occur causing R1 to hit his head. R2's face sheet, undated identified R2 had diagnoses that included cerebral infarction, hemiplegia affecting left nondominant side and neurological neglect syndrome. R2's mobility care plan dated [DATE], identified R2 had self-care deficits and required the assist of one to two staff to transfer with the use of a stand pivot with initiated date of [DATE]. R2 required minimum assist with bed mobility and heel boots on when in bed with an initiation date of [DATE]. R2's fall care plan dated [DATE], identified R2 was high to moderate risk for falls due to right side CVA (Stroke) and staff are to anticipate and meet the residents needs. Place call light within reach and encourage the resident to use it for assistance as needed. The resident uses call don't fall sign to remind R2 to call for assistance. R2's fall risk assessment dated [DATE], [DATE] and [DATE], identified R2 had a history of falls of one to two falls in the past three months. Chair bound and requires assist for elimination and the gait evaluation was not completed. R2 takes one to two medication that may cause lethargy or confusion and had one to two predisposing diseases that could impact fall risk. R2's admission MDS dated [DATE], identified R2 did not have cognitive impairment and required substantial to maximal assistance to sit to laying on the edge of the bed, sit to stand and char to bed transfers. Dependent assist for toileting transfers. Substantial maximal assistance to put on take off footwear. MDS identified R1 had a fall in the last month prior to admission, unable to determine if the resident had a fall any time in the last two to six months, and no fracture related to a fall in six months prior to admission. R1 had one fall since admission or prior assessment. R2's incident report dated [DATE] identified R2 called for help and was found on the floor facing door. Resident description: She was trying to reach wheelchair from the beside and the wheelchair rolled and she fell . Immediate action taken: vitals done, head to toe assessment done, R2 transferred back to bed via full mechanical lift and three staff and provider updated. Injury type left shoulder (front). Level of pain 5. No injuries observed post incident. Predisposing environmental factors: other, physiological factors were confusion, gait imbalance, and other, predisposing situational factors included call light within reach. R2 tries to be independent. Notes dated [DATE], IDT review of fall: R2 interviewed post fall. Stated she was sitting on beside. Decided she needed to reach for something on the wheelchair or was reaching for the wheelchair. Wheelchair rolled on her and tray table skidded across the floor and she fell . Landing strip placed at bedside. Wheelchair moved away from bedside. Grabber made sure was within reach and call don't fall sign to be placed on wall under the TV. Patient denied injury, only concerned about when she can leave room to smoke. R2's care plan was not revised with the aforementioned interventions other than placing the sign. R2's progress noted dated [DATE], titled post incident note indicates R1 had a unwitnessed fall from previous shift and fell around 14:30 p.m. and writer got report from outgoing nurse that patient verbalized trying to reach wheelchair and fell . R2 was found on the floor on the left side body facing door. Had no injuries but notified nurse of pain on the shoulder. Skin intact, alert and oriented to situation. Encouraged R2 to always call for help and a call and do not fall sign were to be added to the door. R2's progress note dated [DATE], indicated R2 was sleeping most of the night. Woke up complaining pain ,d+[DATE] in left shoulder from yesterdays fall. Offered ice pack, requested Tylenol and gave 650 milligrams (mg). Additional note dated [DATE], identified current intervention in place appear effective for patient safety, however R2 complaining of pain in left arm with swelling. On-call provider agreed with concern and approved X-rays. R2's final report from dispatch health imaging dated [DATE] identified the reason for exam was due to pain and swelling due to a fall. Study completed 73060 (LT) Xray, humerus, minimum of 2 views. Findings included a fracture of the humeral head and neck. There was no displacement or dislocation or subluxation. Impression identified an acute fracture of the humeral head and neck. A subsequent X-ray was taken on [DATE], identified there was no evidence to suggest acute fracture or dislocation, but if there were persistent symptoms, follow-up X-ray or CT (type of imaging) may be obtained if clinically warranted. During an observation and interview on [DATE] at 8:41 a.m., R2's call light noted to be tangled on the lowest part of the bed rail near the floor intertwined with the cord of the bed controls and a heating pad. The button of the call light was sitting on the ground and the clip of the call light was clipped to bed linen. There were no call don't fall signs in the room. R2 recalled fall from [DATE]. R2 indicated she was getting dressed while sitting at the edge of the bed with a nursing assistant (NA). R2 reported the NA informed her she would be right back because she had someone on the toilet. The NA was not coming back, R2 started looking for the call light, however it was tangled up at the bottom of the side rail. When attempting to reach for the call light her feet slid forward as she was wearing socks without shoes and fell to the floor. R2 recalled hitting the floor hard bruising her hip, breaking her arm, and ongoing pain from the event. When asking R2 where call light was R2 reported probably where I can't reach it, which is an ongoing issue. R2 stated she needed the call light for help because she could not move very well following her stroke. R2 reported recalling a call don't fall sign in her old room, however did not have one in her current room. During interview on [DATE] at 11:20 a.m., nursing assistant (NA)-C indicated she was familiar with R2 and was unaware if R2 had any falls. Any resident that were high risk of falls, their bed should always be lowered, a bed matt should be put in place, never leave residents on the edge of the bed, and always provide the call light by clipping it to resident's shirts and not to bedding as the bedding can fall to the floor. NA-C was unaware of any signs in R2's room for falling. During interview on [DATE] at 11:49 a.m., LPN-C stated she was in the hallway on [DATE], heard knocking and R2 yelling help me, help me coming from R2's closed door. She found R2 laying next to the door and no call light was activated. During interview on [DATE] at 11:39 a.m. RN-C indicated R2 fell at the change of shift was found by LPN-C on the floor. RN-C reported R2 was attempting to grab something while sitting at the edge of the bed, and slid off the bed. RN-C indicated R2 crawled to the door of the main entrance to the room the door was closed and the call light was on. RN-C reported doing range of motion as R2 reported pain in the shoulder. RN-C declined doing neurological checks due to R2 declined hitting head. RN-C reported RN-B took over for her following the remaining shift. The following day RN-C cared for R2 and ongoing reports of pain in the shoulder and R2 was unable to move arm or complete range of motion. RN-C indicated calling provider and received an order to complete an Xray. During interview on [DATE] at 1: 44 p.m., RN-B described R2 as impulsive, a high risk for falls, unaware of her own abilities and tried to do tasks in which she can't do on her own, such as reaching for things. RN-B indicated to be involved in two falls for R2 and the first unwitnessed fall on [DATE], was due to R2 trying to reach her call button and get something. The second fall on [DATE], RN-B was notified by RN-C at the start of RN-B's shift. Upon arrival into R2's room RN-B recalled R2 to be right next to the entrance door. The door was open as staff had been in the room, RN-B was unsure if the call light was on. RN-B completed risk management, notified clinical team and tried to contact family. The interventions in place included keeping R2's bedroom light on, bed in lowest position, and provide education to use call light. During interview with clinical manager (CM)-B on [DATE] at 11:55 a.m., CM-B reported his role was to review care plans, root cause analysis of falls and complete the facilities risk management. CM-B reported R2 had two unwitnessed falls in the facility [DATE] and [DATE]. R2 fell on [DATE], the day after admission and the root cause of fall was R2 attempting to reposition self in bed and didn't ask for help. CM-B reported R2 had her call light at the time of the fall reporting everyone always has their call light in reach. The intervention put in place was updating the care plan to R2 required minimum assist with bed mobility. Prior to the update there was no assist level identified. CM-B did not reassess the fall risk as there was no initial fall risk completed. CM-B indicated R2 was a high fall risk at the time of admission due to physical limitations. CM-B reported the fall on [DATE], was due to R2 reaching for the wheelchair from sitting on the bed, the wheelchair rolled away, and she fell in an attempt to self transfer. The call light was on, the door was closed, and it was RN-B that located R2. R2 had no injuries, education provided to call for help and a call don't fall sign was put on the door. CM-B reported causal analysis of the fall included interviews with R2 and RN-B. R2 was complaining of pain and the determination for further assessment of injury was required . CM-B indicated R2 was not found by the bedroom door, R2 did not crawl anywhere following the fall. CM-B was unaware of what was on R2's feet at the time of the fall. Interventions in place included fall don't call sign and interventions in place appear affective for patient safety. A functional mobility assessment was completed following the fall, however the post fall risk assessment was not completed until [DATE]. During interview on [DATE] at 12:41 p.m., DON indicated the intervention put in place for R2 following [DATE] fall was to continue with therapy to improve independence. The immediate intervention was notification to the on-call provider and for R2 to be monitored for pain. Following R2's second fall on [DATE], a fall don't call sign was placed on the door and patient education provided to use call light. DON was unsure if door was open or closed, unsure what was on R2's feet at the time of the fall, and if the call light was in reach. DON would expect the sign to still be in R2's room, but due to COVID and room changes it may not. DON reported that a repeat Xray of R2's shoulder revealed that R2 did not have a fracture, however that documentation was not scanned into R2's medical record. During interview with DON and Administrator on [DATE] at 5:07 p.m., indicated all residents who have high fall risk factors should have appropriate interventions to mitigate the risk of falling. The purpose of care planning was to direct the care of the patient and care plans need to be accurate and updated to ensure the appropriate interventions are provided to residents. Policy dated [DATE] titled Falls-Clinical protocol identified for facility staff to: Assessment and Recognition The physician will help identify individuals with a history of falls and risk factors for falling, Staff will ask the resident and the caregiver or family about a history of falling; The staff and physician will document in the medical record a history of one or more recent falls (for example, within 90 days). While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause include: Precipitating factors, details on how fall occurred, current medications especially those associated with dizziness or lethargy; and all active diagnoses. Cause Identification: For an individual who has fallen staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. If the cause of a fall is unclear, or if a fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. A new fall, pain assessment and care plan updated as needed. Review medications, and combinations of medications increase the risk of falling. Staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable.

Based on observation, interview and document review, the facility failed to supervisor and implement fall interventions to reduce the risk of falls for 1 of 2 residents (R3) who had repeated falls. This resulted in actual harm for R3 who sustained a head injury and fracture during a fall. Findings include: R1's group assignment sheet, not dated, indicated she was a fall risk, needed assistance of 1 for her dressing, grooming and toileting, and was a contact guard assist (use of a gait belt and staff member with all transfers). R1's Minimum Data Set (MDS) dated [DATE], indicated a Brief Inventory of Mental Status of 13 indicating no cognitive impairment. R1 was noted to need physical assistance of 1 person for activities of daily living. The facility 5-day investigation report, dated 2/1/22, indicated R1 was reported to have a displaced intertrochanteric fracture of the left femur which required surgery after a fall at the facility on 1/26/22. The investigation indicated R1 was walking without footwear and a gait belt, from bathroom with NA-E. R1's foot got caught on walker and R1 fell . NA-E's personnel record was reviewed and contained medical information. Upon interview on 2/3/22, at 3:02 p.m. family (FA)-A reported receiving a call from the facility that R1 had fallen and was sent to the hospital. RN-D told FA-A R1 was walking with her walker without shoes and a gait belt was not used. FA-A stated, I was in shock, so I called the facility back and reminded the staff she is supposed to have someone with at all times when she is walking and the use of a belt, and I did not receive an explanation other than my mother was impulsive. Upon interview on 2/3/22, at 3:27 p.m. R1 reported the day of her fall she was taken to the bathroom by a nursing assistant. She pressed the call light and the same nursing assistant assisted her with ambulating back to bed and she became unsteady and fell along with the nursing assistant. She stated I am supposed to be wearing a belt. Do I need to be reminding staff? Upon interview on 2/4/21, at 11:48 a.m. nursing assistant, (NA)-E reported she worked on 1/26/22. She was an agency staff member and was told she was working as a trained medication administrator (TMA) but was changed to working as a nursing assistant that day. She reported she was brought to the first floor of the building and told by the nurse manager to just start answering lights, that the unit was a transitional care unit (TCU), and most residents were independent. NA-E reported answering R1's call light, but by the time she entered the room, R1 was standing up with her walker. R1 told NA-E she had to go to the bathroom bad. I did not have a gait belt, I did not know how she transferred, I could see she was unsteady, so I got behind her and put my hand on her walker to stabilize it and one hand on the back of her pants. NA-E reported she left R1 on the toilet, gave her the call light and told her to press it when she was finished in the bathroom. NA-E assisted another resident to the bathroom and then went back to assist R1. R1 stood up on her own and started walking with the walker. NA-E reported Again she was unsteady, so I again placed my hand on the walker and one hand on her pants. She only had socks on. She made a jerk with one of her legs and it caught on the walker. She started to fall, and I didn't let go, so I fell with her. NA-E stated R1 hit her shoulder on the wall next to her bed, and fell to the floor, so she was lying flat on her back. NA-E immediately got up and asked for assistance and a nurse came and assisted. R1 was taken out of the facility by ambulance. NA-E reported she had worked at the facility three times and had not received any orientation or training. She was unaware there was an orientation sheet and denied signing anything at the facility. NA-E reported after RN-D spoke with her about not having a belt on her uniform or using the belt in the room, NA-E stated she went to see where the belts was in the room and there was no belt. NA-E reported after the fall she was given a group sheet, used it the rest of the day and wore a gait belt. Upon interview on 2/4/22, at RN-D reported the fall happened and the root cause was R1 was too impulsive. The NA had to make a decision about leaving her alone or leaving to get proper footwear and a gait belt. RN-D reported that due to COVID gait belts are being kept in the room on a hook. I did tell the NA that after the incident, I don't know if there was one in the room or not. I also handed her a belt. The facility reported they are starting audits and education on the gait belts in the room following the incident on 1/30/22. RN-D verified R1 was a contact guard assist and that does mean a gait belt and hands on contact with all transfers. Upon interview on 2/4/22, at 10:17 a.m. housekeeper (HSK)-A reported being unaware of the duty of watching for or placing gait belts in rooms. I was just told that this morning, I signed an education sheet. I know we are in the process right now of putting out a bunch of belts, especially on the first floor, as this is a new unit, and many rooms don't have the belts yet. Upon interview on 2/7/22 at 11:18 a.m. NA-G stated she was not orientated to the facility and started working when she arrived and that she asks other staff or residents what she need to do. NA-G stated she did not sign any documents for training or orientation. Upon interview on 2/7/22 at 2:57 p.m. NA-F stated she did not have orientation or training, but I felt safe providing care because she asked for the plan of care and has experience. Upon interview on 2/7/22 at 3:13 p.m. the director of nursing (DON) stated the facility could not find the training for NA-G and NA-F. A facility policy Safe Lifting and Movement of Residents dated 2/4/22, indicated to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.

Based on observation, interview, and document review, the facility failed to follow the Centers for Disease Control (CDC) guidelines to prevent and/or minimize the transmission of COVID-19 related to failure to appropriately quarantine residents who had been directly exposed to COVID-19 for 4 of 18 residents (R1, R4, R5, and R6). In addition, failed to implement N95 respirators for 18 of 18 residents (R1, R4, R5, R6, R7, R8, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, and R20) who were quarantined due to direct exposure to COVID-19. This resulted in an immediate jeopardy (IJ) due to the increased risk for transmission of COVID-19. The IJ began on 8/4/21 when the facility failed to ensure residents who were in quarantine status due to an exposure to COVID-19 were not out of their room involved in activities with other residents, potentailly exposing them to COVID-19. Also, failed to implement transmission-based precautions (TBP) utilizing all necessary personal protective equipment (PPE) including N95 respirators, for R1 who was quarantined on 8/5/21, after being exposed to nursing assistant (NA)-A who had tested positive for COVID on 8/4/21. The facility administrator and director of nursing (DON) were notified of the IJ on 8/17/21, at 4:15 p.m. The IJ was removed on 8/18/21, at 1:42 p.m. but noncompliance remained at the lower scope and severity level of an E, pattern, no actual harm with potential for more than minimal harm that is not IJ. Findings include: Current CDC guidance dated 2/10/21, directed health care workers who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. R1's Face Sheet printed 8/18/21, indicated R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/3/21, NA-A had COVID-19 symptoms and she was tested for COVID-19 on 8/3/21, at 12:00 p.m. NA-A's lab results confirmed she was COVID-19 positive on 8/4/21, at 8:04 a.m. NA-A's positive test results was reported to the facility on [DATE], at 9:58 p.m NA-A's schedule indicated NA-A worked shifts from 7:00 a.m. to 3:15 p.m. on 8/2/21, 8/3/21, and 8/4/21. NA-A cared for R1. In addition, NA-A also cared for residents in group five on two skilled south (R4, R5, R6, R7, R8, R8, R9, R10, R11) and group three on two skilled center (R12, R13, R14, R15, R16, R17, R18, R19 and R20). Facility staffing unit records indicated R1 had a high-risk exposure to a positive COVID-19 staff (NA-A) on 8/3/21, and was placed on quarantine. Facility conducted contact tracing which revealed the 17 additional residents with possible exposure from NA-A and were placed on quarantine. On 8/16/21, at 10:27 a.m. R1 was observed in his wheelchair with no mask on across from the nursing station next to the tv room with several other residents in the tv room and in the hallways. Staff did not intervene to encourage R1 back to his room or to don a surgical mask. Registered nurse (RN)-D was interviewed and stated R1 was on quarantine and staff were to bring him to his room when he came out. RN-D stated if R1 did come out of his room, staff were to encourage R1 to wear a mask. On 8/16/21, between 2:32 p.m. to 2:44 p.m. observations made of two north unit revealing all the transmission-based precaution bins did not have N95 respirators. On 8/16/21, at 11:09 a.m. RN-B was observed less than six feet from R4 and R5 in the resident hallway tending to R4's bleeding boil. R4 and R5 had been exposed to COVID-19 from NA-A, and should have been on quarantine. RN-B was not wearing eye protection. In a subsequent interview, RN-B confirmed she did not have her eye protection on when she was within 6 feet of R4 and R5. On 8/16/21, at 12:51 p.m. R1 was observed holding the hand of R6 in front of the nurse's station next to the tv room with a surgical mask under his chin. R6 did not have a mask on, and R1 and R6 were less than six feet apart from each other. Staff then encouraged R1 to pull up his surgical mask over his nose but did not encourage him to go back to his room. Both R1 and R6 had been exposed to COVID-19 from NA-A, and should have been on quarantine. On 8/16/21, at 2:21 p.m. NA-B was observed coming down the TCU resident hallway (two residents in quarantine on this unit) towards the main entrance check-in site with no eye protection. In a subsequent interview, NA-B confirmed she did not have her eye protection on. On 8/16/21, at 2:32 p.m. NA-C was observed within the resident hallways of the TCU with no eye protection on, and NA-C confirmed she did not have eye protection. During interview on 8/16/21, at 3:17 p.m. the DON confirmed not all staff had been fit tested for N95 respirators. The DON stated staff were not wearing N95 respirators unless they were doing aerosol generating procedures. The DON stated she was unsure if staff were to wear N95 respirators when providing close cares for residents on quarantine. The DON stated the facility did have N95 respirators available, and some staff had been fit tested . On 8/17/21, at 2:28 p.m. RN-E stated N95 respirators should be worn when providing direct cares for a resident on quarantine. On 8/17/21, at 3:00 p.m. the DON stated staff were not consistently wearing N95 respirators when doing cares for residents on quarantine. The facility policy Personal Protective Equipment - Using Face Masks last revised on 8/17/21, directed staff on when to don eye protection and N95 respirators as follows: Equipment and Supplies 1. High-efficiency disposable masks (surgical/medical grade); 2. Eyewear (e.g., goggles) (Note: When the use of a mask is indicated, appropriate eyewear must also be worn.). When to Use a Mask 4. N95 mask or higher must be worn when caring for COVID positive residents, during aerosol treatments, while residents are in quarantine and during facility outbreaks. The IJ was removed on 8/19/21, at 1:42 p.m. when it was verified through observation, staff interviews and document review the facility educated staff on quarantine and the use of N95 respirators and began fit-testing direct care staff who would be wearing N95 respirators, and the facility supplied N95 respirators for staff to use.

Based on interview, and document review, the facility failed to ensure [MEDICATION(S)] (a narcotic medication) was administered as prescribed for 1 of 3 residents (R1) reviewed for medication errors. This deficient practice resulted in an immediate jeopardy (IJ) situation for R1 who received a [MEDICATION(S)] dose 20 times greater than was was prescribed, became unresponsive and subsequently died . The IJ began on [DATE], at 11:12 a.m. when R1 was administered 100 milligrams (mg) of [MEDICATION(S)] rather than 5 mg as ordered. R1 became somnolent, had fixed/glazed eyes, and died the following morning. The administrator and director of nursing (DON) were notified of the IJ at 5:27 p.m. on [DATE]. The IJ was removed on [DATE], at 12:00 p.m., but noncompliance remained at the lower scope and severity level of a D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not IJ. Findings include: R1 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also identified R1 made himself understood and usually understood others. R1 required extensive assistance with transfers, locomotion (off unit/on unit), and supervision eating. R1 had no pain, had not received opioid medications, and received hospice services. R1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 5 mg (0.25 mL) every 1 hour as needed for pain or dyspnea (shortness of breath). The medication was only to be administered, after discussion with Hospice. R1's care plan dated [DATE], identified R1 was at risk for pain and had as needed pain medication ordered. The care plan directed staff to administer medications as ordered, per hospice. R1's Individual Narcotic Record indicated on [DATE], at 11:05 a.m. registered nurse (RN)-A signed off removing 5 mL (100 mg) of [MEDICATION(S)]. This was the first dose out of a 30 mL bottle, 25 mL of [MEDICATION(S)] remained in the bottle. R1's [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-A documented the medication was E (effective). A progress note dated [DATE], at 8:05 a.m. indicated R1 died at 7:56 a.m. During interview on [DATE], at 10:27 a.m. hospice RN, RN-K stated on [DATE], she received a call R1 had died and went to the facility. RN-K stated she was denied access to the medication and the narcotic book by a nurse. During interview on [DATE], at 10:38 a.m. family member (FM)-A stated he left R1's room per staff request on [DATE], and staff assisted R1 with morning cares. Upon return to R1's room he observed a nursing assistant and RN-A leave the room. RN-A was holding a bottle in his hand. FM-A asked RN-A what the medication was. RN-A verbalized he had just given R1 a dose of [MEDICATION(S)] as R1 had reported having stomach pain. FM-A told RN-A staff were supposed to consult with hospice and himself prior to giving the medication. Approximately 45 minutes following the administration of [MEDICATION(S)], R1 reported feeling nauseous, hot, tired, and requested to be laid down to sleep. Shortly after R1 was laid down R1 went into a deep sleep and was hard to arouse. FM-A stated he asked one of the nurses how long R1 would be in that state and he was told it would take four to six hours. During interview on [DATE], at 12:23 p.m. RN-A confirmed he administered 5 mL (100 mg) of [MEDICATION(S)] to R1 on [DATE], rather than 0.25 mL (5mg). He was not aware he had made a medication error until [DATE], when he was informed by the DON R1 had died . The error was realized when hospice and FM-A inquired about the left-over supply of [MEDICATION(S)]. RN-A stated he believed the [MEDICATION(S)] was concentrated equally between milligrams and milliliters (meaning 1 mL was the same as 1 mg). During a follow-up interview on [DATE], at 2:25 p.m. RN-A stated on [DATE], after he administered [MEDICATION(S)] to R1, FM-A brought R1 back to his room because R1 had reported feeling tired, had nausea, and wanted to be laid down. RN-A stated he took R1's vital signs at that time, however, forgot to document the results as it was a hectic shift due to a heavy medication pass and attending to several hospice patients. He remembered R1's pulse was 60, oxygen saturation was 94 percent, and respirations were 20. RN-A stated that was not an excuse as R1 was administered 20 times the amount of [MEDICATION(S)] ordered. During interview on [DATE], at 1:30 p.m. the facility consultant pharmacist (CP) stated she was made aware of the medication error involving R1 being given the wrong dose of [MEDICATION(S)] and the facility was developing policies and training processes to make sure the error did not occur again. During interview on [DATE], at 1:45 p.m. the DON acknowledged a significant medication error had occurred involving R1 and stated she expected staff to follow physicians' orders in addition to the five rights of medication administration (right does, route, drug, resident, and time). Following the medication error it was identified R1's medication order was transcribed to give in mg rather mL. The medication error was avoidable and RN-A understood the magnitude of it. After the incident, education on medication administration was implemented, however, the DON did not know if all nurses, trained medication aides (TMA's), and health unit coordinators (HUC's) who administered medications or transcribed medication orders from [DATE], through [DATE], had received training. During interview on [DATE], at 2:47 p.m. R1's primary physician, medical doctor (MD)-A stated it was reported to her R1 received 5 mL (100 mg) of [MEDICATION(S)] and was, no longer responding, was somnolent, had fixed or glazed eyes, and the next morning he was found with no pulse or respirations. She believed [MEDICATION(S)] contributed to R1's death as R1 had a change of condition right after being given the dose. MD-A stated although R1 was not healthy, R1 was still talking and interacting with FM-A leading up to the medication error. MD-A stated [MEDICATION(S)] overdose side effects were typically a rapid decrease in alertness, mental status, and slowing of breathing unit breathing stopped which would typically occur quickly, but it did not have to happen that way. During interview on [DATE], at 5:08 p.m. RN-D stated she worked afternoon shift on [DATE], after RN-A. During report, RN-A verbalized he had administered [MEDICATION(S)] to R1 for stomach pain. RN-D stated during her shift R1, did not leave his bed. When we went to the room to tell him it was supper his eyes were closed. When we called his name he would open them and drop them right back. I thought he was resting and he would have woken up at some point, but he was in a deep sleep. She did not know a medication error had occurred until [DATE], when she came to work and was informed R1 had died . RN-D stated all nurses and TMA's were supposed to follow the five rights of medication administration and review read instructions when administering medications. Review of facility staff schedules and Inservice Record sheets dated [DATE] through [DATE], revealed four RNs (RN-M, RN-N, RN-O, RN-P), TMA-B, and licensed practical nurse (LPN)-C had worked since the facility was made aware of the significant medication error, however, had not received education. The DON confirmed not all staff had received education and stated staff would receive training when they worked next. The facility Administering Medications policy reviewed [DATE], directed: 3. Medications must be administered in accordance with the orders, including any required time frame. 5. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . The IJ that began on [DATE], at 11:12 a.m. and was removed on [DATE], at 12:00 p.m. when it was verified though observation, interview, and document review the facility had developed and implemented a systemic plan which included: - The facility educated all licensed nurses, TMA's, and HUCS who were actively working on a dose conversation table, the five rights of medication administration, liquid medications come in different concentrations (mg/mL), order transcription, and staff were to follow all medication details as ordered on [DATE]. - Licensed nurses, TMA's, and HUCs were notified the above education must be completed prior to working their next scheduled shift on [DATE] - The facility reviewed all resident records to ensure liquid suspension medication orders were correct on [DATE].

Based on interview and document review, the facility failed to follow interventions per care plan to reduce the risk for falls, for 1 of 3 residents (R1) reviewed for accidents. The facility's failure resulted in actual harm to R1 as a result of a fall from his bed to the floor, sustaining multiple fractures and was hospitalized . Although noncompliance was present at the time of the event, the facility had implemented appropriate corrective action by 7/14/20, resulting in a finding of past noncompliance at G level harm for R1. Findings Include: R1's [DIAGNOSES REDACTED]. Also, the MDS indicated R1's behaviors included wandering and he required total to extensive physical staff assistance of two staff for bed mobility, transfers, toileting and personal hygiene. In addition, the MDS indicated R1 had moderately impaired cognition, was not steady when going from sitting to standing position and required staff assistance to stabilize, and had a history of [REDACTED]. R1's care plan dated 1/30/20 , identified R1 was at risk for falls related to being unaware of safety needs. The care plan directed staff to ensure the the bed was in low position when R1 was in bed and a floor matt was at bedside when R1 was in bed. R1's progress note dated 6/17/20, at 11:00 p.m. indicated, Resident was seen crawling on the floor by Aide. Resident was awake in bed a few minutes before seen on the floor. Resident was asking writer what time it was. Aide went in the room to take care of resident when she saw him crawling towards his roommate's side. Room was well lit. Resident had no shoes on. Bed was in the lowest position. Vitals are within normal limits. Following that fall a fall risk assessment was completed on 6/17/20, which identified R1 was at high risk for falls and directed staff to follow the plan of care. During a review of R1's medical record, it was revealed on 7/8/20, at 3:13 p.m. a nursing note indicated the writer heard R1 yelling Help me! ow, ow, ow! at shift change when getting report, and when she had gone into the R1's room the writer noted that resident was lying diagonally on the floor mat on his left side, facing the doorway. The writer then indicated, Resident stated he was trying to get out of bed but no call light was activated, although it was within reach. Resident stated he had pain all over but mostly complaining of pain in his right knee. He did not rate his pain just yelled, 'ow ow ow!' His Range of Motion (ROM) was within normal limit (WNL) for him with the exception of his right knee. Neuros (neurological examination) were WNL. The on call nurse practitioner (NP) was updated and orders were obtained for as needed (PRN) [MEDICATION NAME] 5 milligram (mg) every 4 hrs, ice pack every hour for 15 min, and an X-ray to his Right knee. Also the family was updated. A review of the hospital Intake Report dated 7/13/20, indicated following R1's admission to the hospital and being seen by orthopedics, the following fractures were discovered: 1. Left proximal tibia/fibula fracture 2. Right proximal tibia/fibula fracture 3. Left first metatarsal base fracture 4. Left second metatarsal head and base fractures 5. Left third metatarsal head fracture 6. Left hallux proximal phalanx fracture During a review of the investigation/re-enactment file it was revealed upon interviews with several staff who had come to R1's room immediately after the fall when he was found on the floor, the staff had indicated they had found the bed at a high position with the floor mat where R1 was lying on. In addition, nursing assistant (NA)-A who had assisted R1 prior to the fall indicated she had lowered the bed, however, did not lower the bed all the way to the floor because R1 was eating at the time and the height was approximately about my waist length. On 7/15/20, at 4:07 p.m. family member (FM) stated, I received a call from the facility after the fall and was told he had fallen from his bed. The nurse told me they had found him on the floor matt but she did not tell me the bed was not lowered to the floor because the bed was supposed to be down as he always crawled out of bed. The nurse also told me they had started him on heavy pain medication and I did not put two and two together to think and ask myself why was he started on the medication. Then later that evening they called me again and told me he had broken his knee. FM further stated the same day he had called the facility and asked the facility staff to send R1 to the hospital where they had found R1 had multiple fractures involving multiple bones. On 7/15/20, at 12:27 p.m. during an interview with the director of nursing (DON) and administrator, both acknowledged following the review and investigation, they had identified the staff had failed to follow the care plan. Surveyor then informed the DON and administrator the multiple fractures R1 had been found to have when at the hospital and at this time the DON stated she was mortified at the amount of fractures. The DON stated following the fall, they had done an X-ray at the facility and R1 had been found to have one non-displaced [MEDICAL CONDITION] fibula which prompted the facility to send R1 to the hospital for evaluation. Although the facility failed to follow the care plan on 7/8/20, the facility was able to verify corrective action had been implemented, including NA-A receiving further education and corrective action on 7/9/20, on following the plan of care. The DON stated following the fall/incident, We have done a unit training for this particular training on following the care plan and we had a NA meeting Monday and Nurses meeting yesterday at 2:30 p.m. and talked about this. We have also done other trainings with the staff like making sure the call lights are at reach. We have audited bed heights and call lights in place and we continue to do real time education if things were out of norm and all the audits have been perfect. The DON stated the training had been done on 7/9/20, 7/13/20 and 7/14/20. The facility also completed an investigation timely. Therefore, this deficient practice is being cited at Past Noncompliance.

Based on interview and document review, the facility failed to ensure residents were free from significant medication errors for 1 of 1 resident (R1) who received received incorrect [MEDICATION NAME] dosing. This deficient practice resulted in immediate jeopardy (IJ) situation for R1, who required hospitalization with a critical INR (internationalized normalized ratio- a laboratory measurement of how long it takes blood to form a clot), and treatment for [REDACTED]. The immediate jeopardy began on 8/6/19, when an order for [REDACTED]. However, once the facility identified the significant medication error, they implemented a corrective action to prevent recurrence by reviewing policies and procedures, re-educating the staff involved and other licensed staff to ensure they understood the proper procedure for order transcription, and documentation of both the [MEDICATION NAME] dose and INR on the orders. In addition, the facility completed audits of all residents with [MEDICATION NAME] orders. The immediate jeopardy was corrected on 9/30/19, prior to the start of the survey and was therefore Past Noncompliance. Findings include: R1's five day Prospective Payment System (PPS) Minimum Data Set ((MDS) dated [DATE], identified R1 had [DIAGNOSES REDACTED]. The MDS identified R1 had intact cognition and required extensive assistance with most activities of daily living (ADL's) which included bed mobility, transfers, ambulation and toileting. Further, The MDS revealed R1 received an anticoagulant (medication prescribed to prevent or reduce coagulation of the blood, prolonging the clotting time) daily during the look back period. Review of R1's admission Care Area Assessment (CAA) dated 4/9/19, identified R1 required extensive assistance with all ADL's with the exception of eating. The CAA indicated R1 had a urinary catheter due to chronic [MEDICAL CONDITION] and a spinal fracture. Review of R1's care plan, revised 9/23/19, indicated R1 was on anticoagulant therapy related to a [MEDICAL CONDITION]. The care plan identified anticoagulant orders were to be administered per physician order. Further, R1's care plan instructed staff to monitor for side effects and effectiveness of anticoagulant therapy every shift. Additionally, R1's care plan instructed staff to monitor/document/report adverse reactions of anticoagulant therapy which included blood tinged or red blood in urine. Review of R1's progress notes revealed the following: -8/6/19, an order had been entered to give [MEDICATION NAME] 5 mg. five days a week. A repeat INR was scheduled to be drawn on 8/27/19. -8/15/19, a new urinary catheter had been placed. Hematuria (blood in the urine) had been noted prior to the insertion of the urinary catheter. A note later that day indicated urinalysis (UA) results were reported via telephone to the on call physician and orders were received to encourage fluids. Staff noted R1 continued to have hematuria. -8/16/19, increased hematuria had been noted. Staff notified the NP(nurse practitioner) and an order for [REDACTED]. -8/18/19, urine culture results indicated R1 was on the correct antibiotic to treat the UTI. Additionally, R1 continued to have hematuria. -8/21/19, at 12:52 p.m. R1 complained of a sore throat. Staff left a message for the NP. A note later, indicated NP called back and stated to continue to monitor and report back if sore throat became worse. -8/22/19, R1's husband called and requested R1 receive a throat culture due to continued pain. Staff left a message with NP. The notes indicated NP called back with an order to obtain a culture to test for strep. Staff obtained the specimen and contacted the lab to pick it up. R1's husband was notified of the new order. A note later that day indicated R1 stated her sore throat had worsened and had requested to be transferred to the local emergency department for evaluation. Additionally, R1 complained of mouth pain. Staff contacted R1's husband and it was determined R1 would stay at the facility for treatment. Staff contacted the on call physician and obtained an order for [REDACTED].>-8/23/19, R1 complained of a sore throat since the beginning of the shift and developed difficulty swallowing and neck tenderness. R1's husband contacted the facility and requested R1 be sent to the local hospital for further treatment and evaluation. Staff explained to R1's husband R1 could have been treated at the facility, however, R1's husband was insistent. Staff notified the NP of R1's husband's request to transfer R1 to the hospital. The NP ordered to change R1's antibiotics to [MEDICATION NAME] 875 mg. three times a day for sore throat infection. R1's husband contacted 911 to transport R1 to the hospital and the paramedics arrived at the facility to transport R1 to the hospital. The paramedics explained they would follow R1's husbands recommendations and transport R1 to the hospital for evaluation and treatment. Staff contacted the NP again to notify her the transfer had occurred per R1's spouse's request. The notes indicated the facility had been contacted by the hospital to report R1 had been admitted to the ICU (intensive care unit) of the hospital with a [DIAGNOSES REDACTED]. Review of R1's INR results on 8/6/19 revealed a result of 2.79 (therapeutic range 2.0 to 3.0) No further INR results were found in R1's record prior to hospitalization . Review of R1's hospital discharge summary, dated 8/27/19, revealed the following: R1 presented to the hospital on [DATE], with concerns of difficulty swallowing over the past two days and increased throat discomfort over the past several days prior to admission. R1 stated she had mild difficulty with breathing. A CTA (computed tomography [MEDICATION NAME]- a test that combines a scan with an injection of a special dye to produce pictures of blood vessels and tissues in a part of the body) of the neck was completed on 8/23/19. The test revealed R1 had thickening of her epiglottis as well as moderate to severe narrowing of the supraglottic larynx. A flexible fiberoptic nasolaryngoscopy ( a flexible lighted camera is placed through the nose to examine the nose, the area behind the nose, the back of the tongue, throat and the voice box) was completed on 8/23/19. The epiglottis was noted to be moderately swollen and reddened and there were bilateral hemorrhages extending along the entire length of both vocal cords. Additionally, the airway was noted to be slightly narrowed. R1 was given Vitamin K and three units of fresh frozen plasma and was monitored in the ICU for potential airway obstruction. R1 was discharged back to the facility on [DATE]. Review of NP and physician progress notes [REDACTED]. -8/14/19, R1 had history of [MEDICAL CONDITION] and urinary catheter use with red urine noted. Orders were obtained to check a urinalysis and urine culture as well as change the urinary catheter. -9/5/19, note indicated R1 had been hospitalized from [DATE] - 8/27/19, after being sent via ambulance per instruction of R1's husband. R1 had complaints of sore throat and difficulty with swallowing and the hospital determined R1 had a hematoma with ecchymosis to her neck and a extremely elevated INR. The hospital performed a laryngoscopy and determined R1 had a swollen inflamed epiglottis with vocal cord hemorrhage and had been admitted to the ICU of the hospital. R1 received Vitamin K and fresh frozen plasma and after the treatments R1's INR was noted to be 2.5. R1 was noted to be moaning, not talkative during this visit, fever of 102.5 and was transferred to the local hospital for evaluation and treatment at that time. Review of R1's Medication Administration Record [REDACTED] R1 incorrectly received [MEDICATION NAME] 5 mg.( instead of [MEDICATION NAME] 2 mg.) 13 times from 8/6/19, to 8/22/19. R1 was subsequently hosptalized on [DATE], to 8/27/19. Review of R1's facility Medication Error Report, dated 9/17/19, indicated R1's husband contacted the facility on 9/17/19, to inform them he believed R1 had received too much [MEDICATION NAME]. The facility contacted the [MEDICATION NAME] clinic and the [MEDICATION NAME] clinic identified R1 should have been receiving 2 mg. of [MEDICATION NAME] instead of the 5 mg. the facility had been administering to R1. On 10/3/19, at 8:04 a.m. during a telephone interview, family member (FM)-A (who identified himself as a physician) stated R1 had been admitted to the facility back in (MONTH) 2019, as a result of compression fractures and [DIAGNOSES REDACTED] (an [MEDICAL CONDITION] disease that affects multiple organs of the body.) FM-A stated R1 was on [MEDICATION NAME] for treatment of [REDACTED]. FM-A proceeded to contact the ambulance to transfer R1 to the hospital for evaluation and treatment. FM-A stated at no point did the facility suggest or offer to send R1 to the hospital. FM-A stated R1 had difficulty breathing and R1 had bruising to her right forearm as well as her neck area. FM-A indicated R1 was treated for [REDACTED]. Further, FM-A stated the [MEDICATION NAME] dose error was discovered by him after he received a pharmacy bill and noted the dose of [MEDICATION NAME] on R1's pharmacy bill. FM-A contacted the facility after receiving the bill to alert them of the [MEDICATION NAME] dosing error. FM-A stated the facility admitted there had been an error with the [MEDICATION NAME] dosing. FM-A further stated he had worked on moving her to another facility due to safety concerns and R1 had subsequently been discharged to another facility on 9/28/19. On 10/3/19, at 10:00 a.m. licensed practical nurse (LPN)-A stated his usual process when he received orders over the telephone, included a read- back confirmation process. LPN-A stated once the read back of the order had been completed, the licensed nurse wrote the order on the order sheet and the unit clerk (HUC) would place the order in the electronic health record (EHR). The licensed staff would double check the order in the EHR to the order written on the order sheet to confirm accuracy. LPN-A explained the process was the same for [MEDICATION NAME] orders, however, the order was additionally placed on the pink [MEDICATION NAME] sheet which included the most recent INR value. LPN-A confirmed on 8/6/19, he had received a new [MEDICATION NAME] dose order for R1 from the nurse at the [MEDICATION NAME] clinic via telephone and had incorrectly transcribed the order as 5 mg. instead of 2 mg., which resulted in a significant medication order. He stated he could not remember if he had followed the usual practice of read back confirmation for the order. LPN-A stated after the error had been identified in (MONTH) 2019, he had received additional training on the [MEDICATION NAME] order transcription process. LPN-A stated the additional training involved a classroom training on the transcription process as well as review of the [MEDICATION NAME] order transcription and verification process sheet. Additionally, LPN-A indicated he had completed a return demonstration on the transcription process. On 10/3/19, at 10:15 a.m. clinical nurse manager (NM)-A stated on 8/15/19, R1 had hematuria prior to placing a new urinary catheter. NM-A stated she had contacted the NP the next day regarding the deep dark red urine and a hemoglobin was ordered. NM-A stated she had asked if an INR should have been checked and one had not been ordered. NM-A confirmed the progress notes lacked evidence of her request for checking an INR. NM-A stated licensed staff had received training which included review of the revised [MEDICATION NAME] order transcription and verification steps. On 10/3/19, at 10:32 a.m. during a telephone interview the medical director (MD)-B indicated she was familiar with R1 as she had been her primary physician in the recent past. MD-B stated some residents at the facility were followed by the [MEDICATION NAME] clinic for [MEDICATION NAME] dosing and others were followed by their primary care physician. MD-B stated R1 had been followed by the [MEDICATION NAME] clinic and stated she was aware the [MEDICATION NAME] nurse had not been updated about R1 being placed on antibiotics. MD-B stated it would be expected the [MEDICATION NAME] clinic would be notified when R1 was placed on antibiotics due to the increased potential for adverse reactions. Additionally, MD-B stated staff had incorrectly transcribed the [MEDICATION NAME] order on 8/6/19 obtained from the [MEDICATION NAME] clinic, which resulted in a significant medication error for R1. Further, MD-B stated the expectation would be an INR to be re-checked when hematuria was noted as well as when R1 had been placed on antibiotics. On 10/3/19, at 10:50 a.m. director of nursing (DON) stated her expectations included licensed staff accurately transcribe [MEDICATION NAME] orders, licensed staff accurately administer the [MEDICATION NAME] and staff to monitor for adverse effects as instructed via R1's care plan. DON confirmed R1's [MEDICATION NAME] order for 8/6/19, had been transcribed incorrectly as 5 mg. instead of 2 mg. Further, DON confirmed the facility received notification from R1's husband about the error on 9/17/19, after he had received a bill from his pharmacy. DON stated the significant medication error was confirmed once telephone communication with the [MEDICATION NAME] clinic occurred. The DON confirmed R1 had received the incorrect dose of [MEDICATION NAME] from 8/6/19, until 8/23/19, when she had been hospitalized with an elevated INR of 8.0 and a hemorrhage of her epiglottis. The DON stated LPN-A had received classroom training in [MEDICATION NAME] transcription. Further, DON stated an adjustment to their [MEDICATION NAME] order transcription process had been made with an addition of writing the order for both [MEDICATION NAME] and INR on the physician order [REDACTED]. On 10/3/19, at 11:41 a.m. during a telephone interview with registered nurse [MEDICATION NAME] clinic (RNCC) confirmed communication from the facility had occurred on 8/6/19, when the INR had been 2.79 and the order for [MEDICATION NAME] 3 mg. two days a week and 2 mg. 5 days a week was given at that time. RNCC stated it was expected to obtain an INR level on the day of starting antibiotic therapy due to the high probability of adverse reactions occurring. RNCC stated they would expect to be notified if there had been an antibiotic ordered or a change in condition had occurred. On 10/3/19, at 2:15 p.m. LPN-B stated there had been recent training regarding [MEDICATION NAME] order transcription which consisted of reviewing a flyer that outlined the transcription process. LPN-B stated she had been aware of a recent error that occurred with [MEDICATION NAME] dosing. On 10/3/19, at 2:32 p.m. registered nurse (RN)-C stated she had received training recently regarding correctly transcribing [MEDICATION NAME] orders. RN-C stated she had been aware of a recent significant medication error related to incorrect [MEDICATION NAME] dosing. On 10/3/19, at 2:35 p.m. LPN-C stated she was a new employee and had recently received training on the correct process for transcribing orders. Further, LPN-C stated she had reviewed a flyer which detailed the correct process for transcribing [MEDICATION NAME] orders. On 9/30/19, at 2:38 p.m. LPN-D stated she had received training a couple of weeks ago regarding the updated process for [MEDICATION NAME] order transcription. LPN-D stated she had been aware a transcription error had occurred recently. On 10/3/19, at 2:41 p.m. RN-A stated she had received recent training on the proper steps to take to avoid transcription errors related to [MEDICATION NAME] dosing. RN-A stated the steps were outlined in a flyer for staff to review. Further, RN-A stated she had been aware of a recent medication error related to incorrect [MEDICATION NAME] dosing. On 10/3/19, at 2:47 p.m. RN-B stated she had received recent training which consisted of reviewing a flyer that outlined the correct process for transcribing [MEDICATION NAME] orders. RN-B stated she had been aware of a recent medication error related to [MEDICATION NAME] dosing. On 10/3/19, at 2:51 p.m. LPN-E stated she had received training about a week ago which consisted of reviewing a flow sheet which described the correct process for transcribing [MEDICATION NAME] orders. LPN-E stated the new training had been provided due to a recent medication order. Review of facility policy titled 10.2 Medication -Related Error revised on 5/1/10, identified a transcription error as an entire order or part of an order incorrectly transcribed from the original order. The policy instructed staff to notify pharmacy of any possible dispensing occurrences and to notify the physician/ prescriber to obtain further instructions or orders. Further, the policy instructed staff to monitor the resident in accordance to physician instructions. A policy on anticoagulant therapy was requested and not provided. The past noncompliance immediate jeopardy began on 8/6/19. The immediate jeopardy was removed and the deficient practice corrected by 9/30/19, after the facility implemented a systemic plan which included the following actions: -re-educated the employee involved in the transcription error with a classroom training on [MEDICATION NAME] order entry, the five rights of medication administration and review of the [MEDICATION NAME] order transcription and verification steps. Additionally, the re-education included the process for obtaining the INR results, notifying the physician/NP of the results as well as the previous dose of [MEDICATION NAME], obtaining the order for [MEDICATION NAME] and when the next INR is due and writing the order for both [MEDICATION NAME] and the INR directly onto the physician order [REDACTED]. -re-educated the majority of the facility licensed staff regarding the [MEDICATION NAME] order and transcription and verification steps. The education included the process for obtaining the INR results, notifying the physician/ NP of the results as well as the previous dose of [MEDICATION NAME], obtaining the order for [MEDICATION NAME] and when the next INR is due and writing the order for both [MEDICATION NAME] and the INR directly onto the physician order [REDACTED]. -[MEDICATION NAME] audits were completed on every resident receiving [MEDICATION NAME] and the audit log contained the following information: the date, patient name, INR level, next INR due, orders, alert, po (physician order) entered, po confirmed, pink sheet, lab book, current and care plan.

Based on observation, interview and document review, the facility failed to ensure staff implemented approaches identified as necessary for safe transfer using a mechanical lift for 1 of 8 residents (R105) on the first floor who required assistance with transfer utilizing a mechanical lift. This resulted in an immediate jeopardy (IJ) situation for R105. In addition to the resident in immediate jeopardy, the facility failed to ensure staff followed the care plan to reduce the risk of falls for 1 of the other 8 residents (R406) on the first floor who also required transfer with the mechanical lift. The IJ began on 1/16/17, when staff failed to implement appropriate interventions for a safe transfer using a mechanical lift for R105. The resident fell out of a sling that had not been attached properly to the mechanical lift, causing R105 to slide through an opening, hit her head and sustain a head laceration. On 1/26/17, staff were observed to transfer R105 with the mechanical lift using a sling other than what had been identified as the appropriate intervention on R105's care plan as a result of the 1/16/17, fall. The administrator and director of nursing (DON) were notified of the IJ at 4:22 p.m. on 1/26/17. The IJ was removed on 1/27/17, but noncompliance remained at the lower scope and severity level of D-isolated, which indicated no actual harm with potential for more than minimal harm that is not an IJ. Findings include: R105 was observed on 1/26/17, at 8:31 a.m. to be a petite woman who was unable to physically participate in her care. Review of R105's medical record Face Sheet, dated 1/27/16, revealed R105 was [AGE] years old with current [DIAGNOSES REDACTED]. In addition, the care plan printed 1/26/17, indicated R105 was currently receiving hospice care related to Alzheimer's dementia with a functional medical decline. Review of a Minimum Data Set (MDS) resident assessment dated [DATE], revealed R105 was totally dependent on staff to transfer between surfaces including from bed to wheelchair, and required two people to physically assist with the transfer. The facility completed a Fall Risk assessment dated [DATE], which identified R105 as at risk for falls. Review of an Incident Details report completed 1/20/17, revealed R105 had fallen during a transfer from the bed to a Broda chair (special type of wheelchair) on 1/16/17. Details of the incident were documented in the report indicating R105 was being transferred with a mechanical lift via a sling and had slid out of the sling when it was raised in the air. The report indicated R105 had struck her head on a two-drawer night stand, and had hit her back on the feet of the lift. R105 had sustained a laceration described as 1.5-2 centimeters, on the back center of her head under the hair. Corrective action details indicated R105 had been referred to the clinical manager for further assessment of the mechanical sling appropriateness. During interview with the director of nursing (DON) and registered nurse (RN) manager-F on 1/26/17, at 12:04 p.m. the DON provided additional explanation as to what had happened during the 1/16/16 incident. The DON said staff had followed the nursing assistant (NA) care guide to use a purple sling. The DON said one NA was running the mechanical lift, and another NA was guiding R105's legs. The purple sling used was a divided leg sling, that crossed at the thighs and attached at four points above the resident on the mechanical lift device. The DON explained the two NAs noticed R105's bottom was slipping down and through an opening in the bottom of the sling, and the NA guiding R105's legs couldn't get around the resident in time to grab R105 before she fell through the opening. The DON said staff had reviewed the manufacturer's recommendations and determined they had been using an appropriately sized sling. She also stated the clinical manager determines the sling size required for use for individual residents, based on manufacturer recommendations. The DON then explained when they looked on top of the lift, the two attachment points at the top of the sling, up by the shoulders, had not been connected evenly on both sides. The DON described each attachment point as having multiple loops to choose from to attach the sling to the lift. The DON said at the time when the fall occurred, the staff had connected one attachment point to the lift using the third loop, and the other using the second loop, causing the sling to be kitty-wompus. RN-F explained the loops were also color coded, and added that the right side shoulder hook had been hooked on black, and the left side had been hooked on purple, which would have tilted one side of the sling a little higher, which was how R105 had likely slid through the opening created in the bottom where the sling crossed over. When asked whether this was equipment malfunction or human error the DON said, I interpret this as a mistake, as a human error. After the fall, the DON said the facility decided to implement a full body sling for transferring R105. RN-F added that given the fact R105 could not contribute to transfers in any way, they had decided the full body sling was the correct sling to use. Review of R105's current care plan for mobility revealed R105 had a self care deficit in mobility related to transfers. Interventions dated 1/16/17, indicated R105 required the assistance of two staff, a mechanical lift, and a purple full body sling for all transfers. The nursing assistant care guide dated 1/26/17, indicated staff were to use: PURPLE FULL BODY SLING ONLY when transferring R105 with the mechanical lift. The special instruction to use the purple full body sling was typed in bold capital letters on the care guide, and was dated as having been initiated 1/16/17, signifying it had been added to R105's care guide after the fall. During observation on 1/26/17, at 8:31 a.m. nursing assistant (NA)-B prepared to transfer R105 from the bed to wheelchair using an Invacare Reliant 450 mechanical lift. R105 laid on the bed, on top of a sling that appeared blue in color. Printed on the top of the sling, above R105's head, was another resident's name. NA-A also came into the room to assist. NA-A adjusted the sling under the resident. The sling had four straps with different loops that attached to the mechanical lift, and from both sides of the bed, the staff discussed which loops to use to attach the sling to the lift. NA-A was heard to state, this is too long, as they hooked the loops to the lift. Using the mechanical lift, NA-A raised R105 above the bed while R105 was positioned in the sling. As the sling lifted off the bed, R105 began to tilt to the right, with more weight shifting onto the resident's right hip inside the sling. NA-A paused the lift, and while R105 was still up over the bed, NA-A grabbed the right side of the sling with both hands, and quickly tugged the fabric upwards to re-center R105's hips in the sling. NA-A went back to operate the lift controls. While R105 was raised in the sling, NA-A stood at the lift controls and motioned with her hands, asking NA-B to move the wheels of the wheelchair different directions. At this time, nobody was on either side of the sling. NA-B had both hands on the wheelchair near the foot of the bed and moved it from side to side, trying to interpret and follow NA-A's instructions to position the wheelchair. NA-B was over heard asking, Oh, are we going to do this sideways? The wheelchair seat faced perpendicular to the legs of the lift as NA-A used the lift controls to lower R105 into the wheelchair sideways, while NA-B guided R105's bottom over the right armrest of the wheelchair. NA-A repeated again, This is too long, the sling after R105 was seated in the wheelchair. During interview at 8:46 a.m., following R105's transfer on 1/26/17, NA-A said the sling was too long because it went up past R105's head too much, and down too far on R105's legs. NA-A then said she thought the nurses decided which sling each resident should use, but was not sure what size sling had just been used to transfer R105. NA-A said there were different sling sizes, and picked up a purple sling from another resident's room to show the surveyor. When asked what size the purple sling was, NA-A was not sure if the size was written anywhere on the sling. When asked to look at the manufacturer label on the sling, although the size was indicated on the label, NA-A stated being unable to determine the size of the sling by looking at the label. Surveyor review of the manufacturer label identified the purple sling to be size medium. NA-A also described being present when R105 had fallen during the transfer on 1/16/17. NA-A said R105 had been using a divided leg sling at that time that crossed at the legs, and that R105 had slipped out the opening in the middle at the bottom of the sling. NA-A said now they used the long slings for full body lifts. NA-A also stated there had been staff training for appropriate use of the lifts/slings on Tuesday (1/24/17) which she had attended. During an interview on 1/26/17, at 9:06 a.m. NA-B checked the label on the blue sling they had just used to transfer R105. The label indicated it was a size extra large (XL), blue sling. NA-B said there was another sling in R105's closet that had a purple binding, and explained how the color of the binding on the sling indicated the particular size. When NA-B took the sling out of R105's closet, it was observed to be a purple divided leg sling which was the style R105 had fallen out of on 1/16/17. Although the manufacturer's size label had been torn off the purple sling available in R105's closet, NA-B confirmed the slings were color coordinated for size. NA-B said the facility usually included size instructions on the nursing assistant care guide. NA-B then looked at the guide for R105 and read out loud that R105 was supposed to use a purple full body sling only. NA-B confirmed having made an error in the size of the sling that morning. NA-B stated the care guides were updated almost every day, and said the expectation was to follow the care guide, then added, I kind of went with the sling that was already in (R105's) chair, but I shouldn't have. NA-B further stated, I did not use the purple full body sling. NA-B then said she had to look at the manufacturer's size chart to know for sure, but thought the purple full body sling would be a size medium. The purple divided leg sling available in R105's closet had been labeled with R105's name. During the interview, NA-B confirmed that the blue XL sling she and NA-A had just used to transfer R105 was labeled with another resident's name. NA-B said she had noticed the sling might be too big for R105 that morning, when putting R105 in the sling before transfer. NA-B said I just used the sling that was in the chair confirming the blue XL sling was already in R105's chair that morning prior to R105's transfer. NA-B explained that staff provide R105 with a new sling on bath day, because the sling gets wet from the bath. NA-B continued, every Thursday morning R105 got a bath from facility staff, and every Monday R105 got a bath from hospice staff, so R105 would get new slings after bathing on those days. NA-B said that today, Thursday, was bath day, but R105 had not had a bath yet. NA-B said R105 would get a new sling after the bath later that day. When asked how NAs would know about any resident specific special sling, NA-B said the color correlated to the size. When asked if there were any potential outcomes for not using the correct sling, NA-B said that a resident might sit uncomfortably, or they might not go up in the sling the right way. NA-B then stated being unaware of R105's recent fall involving the mechanical lift however, acknowledged having attended a mechanical lift training on Tuesday this week (1/24/17). When asked why there had been confusion during the transfer about the wheelchair placement in relation to the lift, NA-B explained preferring the wheelchair to be closer to the lift during transfer. During a follow-up interview on 1/26/17, at 9:53 a.m. NA-A confirmed the blue sling had already been on R105's chair, and that staff would normally use what was on the chair. NA-A also stated that sometimes a sling was hung up in the closet to use. NA-A explained that when NA-B came to ask for help with the transfer, NA-B was worried about using the right sling. NA-A was then asked whether the size of the sling was checked before the transfer, and NA-A said no, the sling was not checked because it was already on R105's chair, therefore staff just used it. The facility provided the survey staff with the Invacare Lift manufacturer guidelines. The guidelines revealed recommendations for sling sizes based on user weight. According to the guidelines, for full body sling styles: the purple (medium) sling was recommended for users between 100-175 pounds; the green (large) sling was recommended for users between 150-275 pounds; and the blue (extra large) sling was recommended for users between 200-400 pounds. Weight documentation provided by facility staff revealed R105 weighed 100.2 pounds on 1/27/17. Review of the Invacare Reliant 450 user's manual revealed a warning on page 9 under the section titled, Lifting the Patient. The warning included: Adjustments for safety and comfort should be made before moving the patient. R406's Face Sheet dated 1/27/17, revealed [DIAGNOSES REDACTED]. Review of the MDS resident assessment dated [DATE], revealed R406 was totally dependent on staff to transfer between surfaces (example: moving from bed to wheelchair), and required two people to physically assist with transfers. The comments section on the MDS form, Review of Indicators of Fall Risk, revealed a falls' risk assessment indicated R406 was at risk for falls, and required use of a mechanical lift for all transfers. Review of R406's care plan for mobility, revealed R406 had a self care deficit in mobility related to transfer. Interventions dated 12/18/16, included R406 required assistance of two staff and a mechanical lift for all transfers. The nursing assistant care guide dated 1/26/17, indicated staff were to use a green sling when transferring R406 with the mechanical lift. The intervention for use of the green sling was typed in bold on the care guide. During interview at 9:53 a.m. on 1/26/17, NA-A said R406 was waiting to be transferred from the bed to the chair. After being asked how staff know which sling to use when transferring R406, NA-A unfolded the NA care guide that was kept in a pocket. While looking at the care guide, NA-A said it does not say what kind of sling. When asked to look again at the care guide, and pointing to where the guide designated green sling, NA-A said that R406 used a blue sling now, but that it was the same style as the green sling. During observation on 1/26/17, at 10:04 a.m. NA-A asked RN-G to help transfer R406 to the wheelchair. R406 laid on the bed, on top of a purple divided leg sling. Standing on each side of the bed, NA-A and RN-G discussed which color loop to use as they attached the sling up to the lift. They began to raise R406 in the air above the bed. The purple sling did not cover R406's shoulders. At that time, surveyors asked staff to stop the lift, and check that the correct sling was used. NA-A said the purple sling had been on R406's chair, and RN-G stated he thought the sling was the one staff had used in previous transfers. When asked how nursing staff were to ensure the correct sling was used, RN-G said it was a tough task, and expected NAs to find a nurse if they worried about the size or fit of a sling. RN-G said the correct sling should be listed on the care guides. When RN-G was informed by the surveyor that the nursing assistant care guide required staff to use a green sling, RN-G responded by stating he had never even seen a green sling around. In an interview on 1/26/17, at 10:16 a.m. R406 was asked how the purple sling was working. R406 stated the sling hurts my crotch. R406 was not sure how long the purple sling had been used for transfers. During interview on 1/26/17, at 10:18 a.m., RN-G checked the label on the purple sling that had been used for R406, and confirmed it was a size medium, purple sling. According to the size chart on the manufacturer label, the green sling was a size large. When asked if both staff involved in a two person transfer should verify that the correct sling is used before starting a transfer, RN-G said, I thought (NA-A) had it all set up, and that was a bad assumption on my part. RN-G acknowledged there had been mechanical lift training earlier that week, but stated he had not been able to attend. RN-G stated he planned to re-schedule the training with the nurse educator. RN-G verified having received previous training for mechanical lifts last year. In an interview at 1/26/17, at 12:04 p.m. the DON explained that the clinical manager determined the sling sizes for residents based on manufacturer recommendations. The DON said R406 actually fit both the medium and large sling based on weight, but they chose the large green sling because R406 had cancer, and transferring could be difficult for R406. RN-F said that slings should be assessed before transfer. The DON added that if something was noticed during transfer, she would expect staff to stop the transfer, lower the patient to safety, and tell a clinical manager. The DON further stated the nursing assistant assigned to the patient was responsible for ensuring use of the appropriate equipment. RN-F updated the care guides as needed, and said the sling color was designated in the care guides. RN-F said the NA assigned to the resident should check the care guide. Review of the facility provided Invacare manufacturer guidelines revealed recommendations for sling sizes based on user weight. For divided leg sling styles: the purple medium sling was recommended for users between 100-175 pounds; the green large sling was recommended for users between 150-275 pounds; and the blue extra large sling was recommended for users between 200-400 pounds. Weight documentation provided by facility staff revealed R406 weighed 156.7 pounds on 1/14/17. Review of the Mechanical Lift Transfer Policy, last revised January 2017, revealed step four of the procedure required staff to get the appropriate sized sling, according to the care guide. A Patient Lifts Safety Guide found at the FDA (Food and Drug Administration) web page, indicated persons using mechanical devices are supposed to ensure they have the correct lift and sling prior to using the lift. The guidance indicated that Choosing the correct sling is critical for safe patient transfer. In addition, the guidance indicates that if a sling is too large there is an increased risk for a resident to slip out. The guidance further included: Using the wrong sling or attaching the sling incorrectly may cause an accident that can result in serious injury or death. Surveyors requested a list of residents currently residing in the facility who use full body mechanical lifts. On 1/26/17, the DON provided a list of 24 residents in the entire facility who needed full body mechanical lifts for transfer. The immediate jeopardy that began on 1/16/17, was removed on 1/27/17, when the facility had educated staff about the importance of appropriate mechanical lift use, the importance of following care guide sheets, audited care plans and care guides to ensure residents were assigned appropriate slings, had initiated audits for staff using mechanical lifts, and had audited residents to ensure appropriate slings were available in resident rooms. During a follow up conversation with the provider on 1/30/17, at 3:00 p.m., the administrator and DON stated their Invacare product representative had told them the size of the sling did not matter if the sling was larger than what the resident required, indicating there were no minimum weight requirements for the slings identified in any of the materials. Following that conversation, MDH staff contacted the manufacturer at 3:30 p.m. (also on 1/30/17) and were informed the size of the sling was important to ensure appropriate support and posture of the resident during transfer.