Every finding on record at Sunnyside Care Center

Based on observation, interview and document review, the facility failed to implement standards of practice to ensure a safe transfer for 1 of 3 residents (R1) reviewed for accidents. This resulted in actual harm when R1 fell from the lift during a staff assisted transfer, sustained a small subarachnoid hemorrhage, hematoma and open wound at back of head, prominent soft tissue swelling and bruising of the right elbow, was sent to the emergency department (ED), admitted to the hospital, required overnight neurological monitoring, wound care and pain control. The facility implemented corrective action, so the deficient practice was issued at past non-compliance.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified he was admitted to facility on 9/3/25, from a skilled nursing facility. R1 had difficulty communicating some words or finishing thoughts but was able if prompted or given time and had unclear speech. R1 had severely impaired cognition, never/rarely made decisions, and no behaviors. R1 was dependent upon staff for oral/toileting/personal hygiene, dressing, all transfers, used a wheelchair for mobility, and had impaired /functional limitations in range of motion of both upper and lower extremities bilaterally. Diagnoses included: cerebrovascular accident (CVA) (stroke), anemia (low red blood cells), and aphasia (a disorder that affects your ability to speak and understand what others say to you). R1 had no falls or skin conditions since admission. R1's care plan dated 4/13/26, identified:Activities of daily living (ADL) self-care deficit related to hemiplegia (one sided paralysis or weakness) of the right side due to CVA. R1 was dependent upon staff for all cares and transfers. Staff were directed to transfer R1 with assist of two, Hoyer lift (brand of full body mechanical lift), using a medium sling/beige in color.R1 was at moderate risk for falls related to poor communication/comprehension, unaware of safety needs, and impaired mobility. Staff were directed to anticipate needs, use safe transfer techniques, mobility aids, and monitor for changes in condition, reassess fall risk on a regular basis, address contracture thorough positioning and range of motion exercises. R1 had actual fall from lift. Staff were directed to check range of motion daily and monitor/document/report as needed (PRN) to medical doctor (MD) signs/symptoms (s/sx): pain, bruises, change in mental status, new onset of confusion, sleepiness, inability to maintain posture, and agitation.R1 had an alteration in musculoskeletal status related to (r/t) contracture of the left forearm, left hand, and right lower leg. Staff were directed to anticipate needs, place call within reach, respond quickly, and encourage the use of supportive devices: hand and leg braces, and wedge in wheelchair as recommended.R1 received antiplatelet medication, Aspirin (ASA). Staff were directed to monitor skin for bruising, sudden severe headaches, and sudden change in mental status.R1 was started on Narcotic/Tramadol on 4/10/26 related to acute pain due to dressing changes on injuries from fall. Staff were directed to administer medication as ordered by provider, monitor/document for side effects and effectiveness every shift.Chronic pain r/t contractures. Staff were directed to administer Tylenol as ordered and administer half-hour before treatments of care and evaluate effectiveness.R1 had potential impairment to skin. Staff were directed to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces.R1's Fall Risk assessment dated [DATE] at 10:34 a.m., identified no history of falls, unable to ambulate, bedrest/wheelchair, and aware of limits. R1's fall risk score was 35 (moderate risk 25-44). R1's physician orders identified:Order date 9/5/25, Aspirin 81 milligrams (mg) oral tablet chewable one tablet via g-tube one time a day for cerebral infarction (stroke). May give orally or via g-tube.Order date 4/10/26, Tramadol Hydrochloride (HCL) oral tablet 50 mg by mouth two times a day for pain.Order date 4/10/26, Tramadol Hydrochloride (HCL) oral tablet 50 mg by mouth every four hours as needed (PRN) for pain, must be least four hours from scheduled dose.Order date 4/10/26, Scalp Wound: clean with wound cleaner or soap and water. Apply Adaptec or petroleum dressing, gauze and kerlix. Elbow Wound: only change every 14 days unless increased drainage, peeling of dressing or dressing loses integrity, then ok as needed (PRN). Clean with wound cleaner or soap and water. Apply versatile one (silicone contact layer), gauze, kerlix and ACE wrap PRN. May rewrap as needed. Remove dressing to shower and change dressing PRN to keep clean, dry and intact.Order date 4/16/26, Right elbow: clean with Vashe (would cleanser) soak two minutes between each dressing change. Dress with Mepilex, change every three days and PRN for drainage. You may remove the Mepilex to check the wound in between the three days and/or clean the wound. Reapply the same bandage if not too soiled after doing this. Place Tubi grip (an elastic tubular bandage), on the right arm over the Mepilex every day shift every three days for wound cares.Order date 4/16/26, Scalp: wash with Vashe soaked gauze for two to five minutes daily. After soaking, try to remove scab gently if it lifts away easily otherwise leave alone. Once cleaned and debrided if able, place Adaptec gauze over the wound, then 4 x 4's, and secure around the head with a roll of soft roll gauze. Change dressing daily for wound care.ED provider notes dated 4/8/26 at 9:15 a.m., identified R1 presented to ED following a witnessed fall from a Hoyer lift. It was reported he fell backwards out of the back of it hitting back of head causing laceration on back of head and abrasion on right elbow with no loss of consciousness. R1 winced in pain when back of head was cleaned. Medical Decision Making: CT scan of spine and abdomen negative, CT of head revealed tiny amount of subarachnoid blood products about the left frontal lobe, and x-ray of right elbow negative for fracture but showed soft tissue swelling. Neurosurgery recommended holding aspirin and outpatient follow-up. No neurosurgery interventions needed. Given R1 was non-verbal status, and large hematoma will be admitted overnight to hospital for neuro status monitor and repeat head CT. admitted to hospital observation on 4/8/26 at 2:23 p.m., and discharged back to facility on 4/9/26 at 2:52 p.m.R1's CT of head without contrast dated 4/8/26 at 9:23 a.m., impression: tiny amount of subarachnoid blood products about the left frontal lobe. No significant mass effect or midline shift. Contusion/laceration overlying the right parietal and occipital bones without underlying fracture.R1's CT scan of right elbow without contrast dated 4/8/26 at 12:16 p.m., impression: prominent soft tissue swelling about the lateral epicondyle (the bony prominence on the outer side of the humerus at the elbow) without displaced elbow fracture accounting for limitations. Medial and lateral epicondylar enthesophytes (bony spurs (calcifications) at the elbow where tendons attach). Surgical consult dated 4/9/26 at 11:55 a.m., identified he was seen for a surgical evaluation regarding wound care to the scalp and right elbow. R1 fell out of the sling during a transfer yesterday, hit his head, and sustained a small subarachnoid hemorrhage (bleeding in the space between the brain and the tissues that cover the brain). There was quite a bit of bleeding. Wounds were not bleeding. Examination identified hematoma (trauma to the blood vessels causing a collection of blood under the skin) to the right posterior scalp with a small opening at the base and right elbow skin tear well adhered to the skin underneath with granulation tissue at the base of the wound. No drainage or bleeding noted. Dressed the scalp with Adaptec, gauze, kerlix, and elbow with versatile one (silicone contact layer), gauze, kerlix, and ACE wrap loosely. Plan: change dressings daily and clean wounds with wound cleaner or soap and water. R1's Weekly Wound Round Documentation dated 4/10/26, at 9:11 a.m., identified a new wound was acquired on 4/8/26, small subarachnoid hemorrhage after fall, hematoma developed with open wound and drainage at back of head on right side. Wound measured 3 cm length, 1.5 cm with, 1 cm depth, and stage: none with minimal serosanguineous (thin, watery, pale, red/pink) drainage. Current treatment plan: clean with wound cleaner or soap and water. Apply Adaptec, gauze, and kerlix. Pain level 3/10.R1's Weekly Wound Round Documentation dated 4/10/26 at 9:17 a.m., identified a new wound was acquired on 4/8/26, bruising and swelling to right elbow with skin tear. Wound measured 2 cm in length, 1.5 cm width, 0 depth, and stage: none with no drainage. No active bleeding noted, clear versatile dressing remained intact, dried dark blood noted under clean dressing. No s/s of infection. Current treatment plan: see right elbow order. Pain level 3/10. Positioning plan: elevate elbow and apply ice.R1's progress noted dated from 4/8/26 through 4/10/26, identified:On 4/8/26 at 8:25 a.m., R1 was being transferred from bed to wheelchair following bath and ADL assistance with two nursing assistants (NA's). Sling was placed under resident and attached to Hoyer lift. While resident was being transferred, fell out of the sling and landed on his right side hitting his head and sustained a laceration to back of right head and right elbow. Pressure applied to laceration and emergency medical services (EMS) was called, arrived and transferred R1 to emergency department (ED) for evaluation. Family and primary care provider updated on incident.On 4/8/26 at 2: 33 p.m., R1 evaluated in ED following incident of fall out of Hoyer lift. Computed tomography (CT) scan (combination of x-rays and computer to see inside the body) of head showed tiny amount of subarachnoid blood products about [sic] the left frontal lobe. No significant mass effect or midline shift. Contusion/laceration overlying the right parietal and occipital bones without underlying fractures. R1 was admitted . Medical doctor (MD) stated given nonverbal status and large hematoma will admit overnight to hospital for Nereo status monitoring and repeat head CT.On 4/9/26 at 2:24 p.m., readmission after one night stay at local hospital. Diagnoses: small subarachnoid hemorrhage with scalp hematoma and skin tear to right elbow after fall from Hoyer lift. Nurse to nurse report received from hospital nurse. Attempted magnetic resonance imaging (MRI) (magnetic waves used to create detailed 3D images of soft tissues, organs, and bones) and did not tolerate and CT scan of right elbow was competed with no displaced fracture resulted. No changes in neurological status since admission and denied pain.On 4/9/26 at 10:25 p.m., New skin issue #1: right elbow, open lesion, acquired in-house. Length 4.5 cm x depth 3 cm, dressing appearance: leaking, dressing saturated 25%. New skin issue #2: rear scalp laterally, laceration, partial or complete separation of the outer layers of the joined incision, closure method other: 4 x 4's wrapped head with gauze. Painful: yes, leaned forward in wheelchair. Length 4.5 cm x with 3.0 cm. Daily treatments. New skin issue #3: right elbow bruising acquired in house. Length 4 cm x width 3.5 cm. Dressing changed to head, lots of dried blood, lots of dried blood, writer attempted to clean, redressed wound after lightly cleansed. Bruising and hematoma present. Dressing change: area cleansed, and dressing applied.On 4/10/26 at 1:45 p.m., telehealth zoom visit completed with R1 and primary provider regarding follow-up after fall from Hoyer lift. R1 had a head and right elbow injuries. Discussed pain management especially during heavy care times. Sent order for Tramadol.On 4/10/26 at 5: 36 p.m., applied ice pack to right elbow two times today for 20 minutes each time d/t pain, swelling and bruising at right elbow. Tolerated well Facility five-day report submitted on 4/10/26 at 1:14 p.m., identified two nursing assistants (NAs) assisted R1 with ADLs following a bath. The lift sling was placed under R1 and attached to the lift. [NA]-A started to raise R1 off the bed when both NAs heard the sling adjust. The NAs rechecked all loops of the sling were on the hooks of the lift and reported they were. [NA-A] continued to raise R1 off bed to transfers to wheelchair. [NA-B] started to guide R1's feet off the bed when he suddenly dropped to the floor. R1's head and shoulder fell to the ground with feet stayed in the sling. NAs quickly removed his feet from the sling and assisted him to the ground. Help was called and licensed practical nurse [LPN]-A arrived immediately. Pressure was applied to laceration on back of head on right side and right elbow. [LPN-A] instructed [NA-B] to get director of nursing (DON). DON arrived at room and called 911. R1 laid on floor alert and shock head yes/no when asked questions. No clutter or debris around R1, floor was dry, no concerns for the environment being a factor in incident. Vital signs and assessment completed until EMS arrived. R1 was admitted to the hospital for observation following incident. R1 injuries included: tiny amount of subarachnoid blood products about the left frontal lobe, prominent soft tissue swelling about the lateral elbow without discrete displaced underlying fracture, and no nor changes noted. Facility investigation was inconclusive and unable to determine the cause of the fall from the full body lift. Care plan was followed, two staff assisted with transfer, proper lift sling (medium) was used, free from rips, tears and in good condition, lift was inspected by maintenance department after incident and found to be in full working order.R1's general surgery consult dated 4/16/26, identified R1 presented for follow-up for wound care after a fall a little over a week ago, sustained an elbow laceration as well as a scalp hematoma and hospitalized . R1's head hematoma was located to the right posterior scalp, scab was noted to be over the wound, no bleeding or pain on palpation, and no signs of infection during exam. R1's right elbow skin tear had granulation tissue at the base of the wound, no drainage, small amount of bleeding with manipulation, no signs of infection, swelling of the right arm and resolving ecchymosis (bruising). The wounds were cleaned and mechanically debrided. Hair trimmed around scalp wound to aid in wound healing and keep hair out of wound. Wound care orders and instructions were provided (see orders above). Return visit in about one week around 4/23/26.R1's electronic medication administration record (EMAR) April 2026, identified:Acetaminophen extra strength oral tablet 500 mg give two tablets via g-tube three times a day for pain. From 4/1/26 through 4/8/26, R1 was administered Acetaminophen 1000 mg three times a day for a total of 21 times with pain rated at 0/10 (20 times) and 2/10 (one time). From 4/9/26 through 4/26/26, R1 was administered 1000 mg three times a day for a total of 21 times with pain rated at 0/10 thirteen times, 1/10 two times, 2/10 one time, 3/10 four times, 4/10 one time.Tramadol HCL 50 tablet give by mouth two times a day for pain, administered as scheduled a.m. and p.m. shifts, 12 times from 4/10/26 through 4/16/26.Tramadol HCL 50 mg tablet give by mouth every four hours PRN for pain and must be at least four hours from scheduled dose. Administered one time on 4/13/26 at 4:23 p.m. pain level rated at 3/10.During an interview/observation on 4/16/26 at 9:25 a.m., primary provider nurse practitioner (NP) stated R1 had vascular dementia, expressive aphasia, no decision making compacity and his wife was his guarantee. Since R1's severe complex stroke he was severely contracted, very ridged with no mobility, dyskinesia identified by slow or involuntary movements with possible involuntary spasms, and placed him at high risk for falls. R1 had a history of seizures without seizure activity and on high-risk medications. R1 had a fall from the lift, some type of mechanism where he did not remain in the lift. R1's mobility did not contribute to the fall. NP was notified immediately and R1 was sent to emergency room (ER). R1 did not lose consciousness and diagnosed with a subarachnoid hemorrhage, occipital and skin abrasions, hematoma, and required dressing changes. R1's right arm/elbow area was very tender, and he displayed non-verbal cues of discomfortable/pain. R1 was started on pain management for the dressing changes. At 9:37 a.m., observation identified NP visited R1 in his room and completed an examination. R1 sat in wheelchair fully dressed in pressure relieving boots on both feet. NP pulled down the dressing located on R1's right elbow and examined the hematoma approximate size of a quarter, dark purple with moderate amount of red/bloody drainage on dressing. At 9:45 a.m. unidentified staff entered the room and stated R1 had an appointment at the clinic now for right elbow injury and removed him from the room in his wheelchair.During an observation on 4/16/26 at 2:00 p.m., NA-A brought lift machine and medium sling into room [ROOM NUMBER] and demonstrated how she transferred R1 on 4/8/26, with the same lift. NA-A stated a medium sized tan sling with dark gold trim was used for the lift transfer per R1's care plan. R1 had received a bath, laid in bed, bath sling was removed and R1 was dressed for the day. NA-B assisted with transfer and stood on the left side of the bed by the window. R1's wheelchair was in the corner of the room over by the window. The medium lift sling was placed underneath R1 with the top of the sling positioned about five inches below his shoulders so that the bottom of the sling covered his bottom, (demonstrated on surveyor the placement of the sling), and crisscrossed sling between his legs. NA-A pushed the hoyer lift over the bed, legs closed, and brakes on bed. NA-A hooked up the sling loops to the lift bar on R1's right side: placed short black loop on top and the longer dark tan loop on top of the black loop (doubled looped). Then, NA-A hooked up the right lower long dark tan colored loop to the lift bar. NA-B hooked up the left side sling loops the same. NA-A stated she used the lift controls and lifted R1 up, then heard a noise, like the black loop on the upper side and the sling were adjusting to his [R1's] body weight. We heard the loop pop down, I [NA-A] stopped raising him [R1] up, I checked the loops, and all were connected to the metal bar of the lift. NA-A lifted R1 off the bed except for his feet with the hoyer lift, and pulled back the lift until R1 was off the bed. NA-A waited for NA-B to come around the end of the bed. NA-B swung R1's feet off the bed, and faced away from the lift. NA-A stated He [R1] hit the ground hard. He had blood coming from the back of his head and right elbow. R1 was able to respond and shook his head yes when she asked if he was okay. Once R1 hit the floor his legs hung in the sling attached to the hoyer lift. NA-A did not remove the upper short black loops, only the long loops of the sling from the machine and lowered his legs down to the floor and yelled for a nurse. A staff nurse and DON came to R1's room, stayed with him while he laid on the floor, NA-A exited the room. R1 was transferred to ER via ambulance. During an interview on 4/16/26 at 2:30 p.m. NA-A stated she had placed the short black loop on the upper part of the lift bar and the longer dark tan loop on top of the black loop (doubled looped). She had doubled looped the sling loops for security in case the shorter back loop let go. She was informed after the fall that was not the correct way to attach the sling loops to the lift. NA-A stated she had no idea what happened, was unsure if R1 tilted backwards, or how R1 landed on the ground but thought the upper right black short sling loop let loose from the lift. NA-A stated, NA-B may have lifted R1's legs too high when she swung them off the bed and could have possibly caused the fall. She was unsure if R1 slid out or fell from the sling, and how far he fell prior to when he hit the ground. NA-A stated she was taught, unsure where she learned this technique, the lower part of the lift sling was to be placed so that it covered the resident's bottom and top part of the sling was positioned about five inches below the shoulders. This technique was how she placed the sling on R1 prior to when he fell on 4/8/26. The top of the sling was placed down too low. NA-A stated R1's sling was not inspected prior to the fall, inspected after the fall, and no concerns were identified. During an interview on 4/16/26 at 4:08 p.m., family member (FM) stated she was contacted right away after R1 had fallen from the lift and was concerned about the fall. FM stated she had observed staff many times transfer R1 with the lift. FM stated staff always used two assist for transfers, and seemed knowledgeable. A staff member had informed her what they thought had caused the fall from the lift during a visit, one of the loops on the sling was not pulled down and hooked up properly. FM stated staff needed to take the time to double check the sling loops were hooked up properly before they actually pulled R1 up with the lift.During an interview/observation on 4/17/26 at 9:47 a.m., R1's sling was inspected by surveyor with DON present. DON verified it was the same sling used during R1's transfer and fell on 4/8/26. The sling was cream colored with dark tan trim, size medium. The sling appeared intact without tears or rips. DON stated EZ Way sling sizing chart indicated the resident was measured from the neck to the tailbone and the correct sling was identified. R1's sling should have been placed so that the top trim was positioned just above his shoulder and the bottom part of the sling two inches below the tail bone where his bottom met the chair so that R1 did not sit on the sling. DON stated the resident's body should be supported during the lift and transfer. When a sling was placed too high, the resident could have fallen through the sling and if it was placed too low, they could have flipped out the top of the sling. During a follow-up interview on 4/17/26 at 3:00 p.m., DON stated staff were expected to have attached only one loop from the sling to the lift machine on each side (upper and lower) to ensure there was not an error with an incorrect loop being on there. There would be a possibly staff would have not been able to see if the loop underneath remained on lift bar, resulting in both sides looking the same, if not, that may have affected the balance of the sling on the lift. DON stated if the top of the sling was placed on a resident lower than shoulder height, this could potentially cause a fall with a shift in weight of the resident. DON stated the sling and lift machine were inspected after R1's fall on 4/8/26, and everything looked ok. The investigation was completed, and facility was unable to identify what caused R1's fall from the lift but could have resulted from human error. R1's injuries from the fall included a subarachnoid hemorrhage, a tiny amount of bleeding of the frontal lobe and lacerations to the elbow and back of the head. R1 was sent to ER for evaluation, admitted to hospital, monitored/neuro checks, dressings applied to hematoma/lacerations, and administered pain medications. R1 experienced increase in pain due to the fall from the lift with dressing changes. Tramadol was ordered and pain was well controlled. During an interview/observation on 4/17/26 at 10:15 a.m., NA-B brought lift machine and medium sling into room [ROOM NUMBER] and demonstrated how she transferred R1 on 4/8/26, with the same lift. NA-B stated she was notified via walkie assistance was needed with R1. NA-B entered R1's room to assist NA-A with R1's transfer from shower chair to bed, without incident. Once R1 was placed on the bed, they removed the shower sling, got him dressed, placed a medium lift sling him, lined up the top of sling to the top of his shoulders. The sling loops were crisscrossed between his legs. NA-A moved the lift over the bed. NA-B was unsure if legs of machine were opened or closed. NA-B stood on R1's left side by window, R1's wheelchair was placed to the right side of the window, kiddy corner from the bed. NA-B connected the lower long dark tan loops of the sling on both sides and the upper left side short black loop to the lift. NA-A connected the right top shoulder black short loop to the lift. NA-A lifted R1 up, but not off the bed yet, We heard a pop sound, most likely a crease in the sling underneath R1 moved or adjusted. NA-B double checked the loops, and all looked ok. NA-A raised R1 up and off bed except for his feet remained on the bed. NA-B walked around to the end of the bed on the left corner, grabbing R1's feet while NA-A pulled the machine backwards away from the bed. R1's feet slid on the mattress until they reached the edge of the bed and supported his feet as they came off the bed. As NA-A pulled lift away from bed the sling rotated so that R1's back faced the machine and his front faced the window. NA-B looked up to see how R1 was doing, made eye contact, then saw him fall out of the top, right side of the sling. NA-B unsure if the right upper short black loop remained hooked onto the lift at time of fall. R1's upper shoulder and head were on the floor and his legs remained in the sling. R1 had Prevalon (puffy boots placed to relieve pressure from heels) boots on both feet, these may have got caught in the sling. NA-B stated NA-A came around the machine and removed the right long sling from the lift and removed the left long sling from the lift. NA-B stated she was unable to remember where the short top black loops were located after the fall, the right upper black loop may have not been on all the way and let go or the sling may not have been wrapped around R1 properly, his weight could have shifted once she had taken his feet off the bed. NA-B saw R1's weight shift, but was unsure if R1 leaned forward, feet sank a bit lower than she had expected, prior to the fall. During the fall, NA-B saw R1 hit his head, saw blood as he laid on the floor, he reached back with his left hand to his head and stated ouch. R1 made a face, and his face turned red. Staff nurse arrived in room immediately, applied pressure to the back of his head. During this interview, NA-B stood in front of the lift with the sling attached to lift. NA-B positioned the lift at the height from which R1 fell and stated R1 fell approximately 5 feet 6 inches (from top of his head) to the floor on 4/8/26. NA-B pulled herself off the floor for the rest of the shift following the incident.During an interview on 4/17/26 at 12:40 p.m., EZ Way Lift representative (R) stated staff would be expected to position the lift sling on the resident with top part of sling along the shoulders and the bottom part down to the tailbone, not over the hips. Resident should not be sitting on the sling. If the sling was positioned too low on the upper back there could have been a possibility resident fell out of the sling, leaned back and flipped out, or fell out of the right side of the sling. R stated if a sling loop was not attached properly to the lift machine and became unhooked and the sling was not placed up high enough on the body, the resident could have fallen out of the right side of the sling. R stated she was unable to verify if this incident was human error since she was not at the facility. She planned on going to the facility on 6/2/26, to provide education to the staff on EZ lifts.During an interview on 4/17/26 at 1:38 p.m., registered nurse (RN)-C stated staff were expected to place the top of the lift sling over the shoulder bone at the top of the shoulders and the bottom of the sling just below where the tailbone is located. This would be important so that the resident was transported safely via lift. R1 had increased pain after the fall from the lift on 4/8/26, with dressing changes to the elbow and head. Prior to the fall R1 was receiving only Tylenol for pain management. R1 continued to receive Tylenol following the incident, but had tramadol added for pain management.EZ Way Smart Lift Operator's Instructions dated 9/10/26, identified the lift was designed primarily to lift patients from bed, chair, toilet, and floor. Transferring patient from bed to chair, wheelchair, or toilet:Log roll onto side, position sling so that handles on the back of the sling face the mattress. Center the sling under the patient's spine using the center handle as a guide with the base of the sling approximately two inches below the tailbone. At a minimum, top of sling to top of horseshoe portion of the sling should run from patient's neckline to at least 2 inches below tailboneLog roll opposite direction and pull rest of sling out the other side.Lay on back and make sure the sling is centered beneath the patient.Lift left thigh, pull the left sling leg of the sling under the patient's thigh and place excess sling over the top of the left thigh, repeat the same steps for the right thigh.Make sure there are no cords or other objects near the path of the lift or near the bed that could obstruct the wheels of the lift.Do no lock wheels of EZ Smart Lift when lifting or transferring patients.Turn hanger bar spreader so the two sling hanger bars are parallel to the patient's body and the sides of the bed.Using the down button lower the boom, so it is positioned a few inches over the body of the patient. The goal is to provide for ease of the sling.Attach the loops nearest the patient's shoulders to the hanger bar hooks of the lift nearest each shoulder using the same length and color of loop strap on each side.Take the sling leg lying over the right leg, cross it over and attach it on the hook of the hanger bar located on the left side of the patient using the same length and color of loop strap on each sling.Make a final check of all four loop attachment points to ensure each loop is sufficiently attached to the respective hook of the hanger bars. Patient is now ready to be lifted.Push up button on the hand control to initiate the upward motion of the lift boom.Continue the upward motion until there is tension on the sling legs, making sure all loops on the sling are securely hooked on hanger bars.Lift the patient's knee and smooth out the sling under each of the thighs, if necessary.Continuing lifting the patient so he/she is just high enough to clear the bed.Ensure there are no obstructions on the path of travel.Maneuver the lift away from the bed.During the transfer, do not roll lift over obstructions or into objects that could create imbalance of the lift. Only use the lift operator's handles attached to the mast to maneuver the lift at all times. Do not attempt to move the lift using the boom.Using the spreader bar, adjust the legs of the lift to go around a wheelchair. Position the wheelchair under the patient and lock wheelchair wheels. Using the handles located on the back of the sling, position the patient so that he/she is properly aligned to be lowered onto the wheelchair.Facility policy Safe Resident Handling/Transfers dated 4/2/26, identified it is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, and as the need arises or changes in equipment occur. Staff will perform mechanical lifts/transfers according to the manufacturer's instruction for use of the device.Mechanical lift staff training started on 4/8/26 and was provided to the majority of nursing staff prior to the start of their next shift by 4/9/26. Documents reviewed: EZ Way smart lift operator's instructions and Safe Handling policy. A copy of the owner's manual for both lifts and safe handling policy were placed at the nurse's station. EZ Way Lift representative was notified of incident and in person education for staff was scheduled for June 2, 2026.

Based on observation, interview, and document review the facility failed to ensure personal protective equipment (PPE) practices and hand hygiene were performed during a high contact care activity for 1 of 3 residents (R1) in enhanced barrier precautions (EBP) with indwelling devices and open wound.Findings include:R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 was admitted to facility on 9/3/25, from a skilled nursing facility. R1 had difficulty communicating some words or finishing thoughts but was able if prompted or given time, and unclear speech. R1 had severely impaired cognition, never/rarely made decisions, and no behaviors. R1 was dependent upon staff for oral/toileting/personal hygiene, dressing, all transfers, used a wheelchair for mobility, and had impaired /functional limitations in range of motion of both upper and lower extremities bilaterally. Diagnoses included: cerebrovascular accident (CVA) (stroke), anemia (low red blood cells), neurogenic bladder, multidrug-resistant organism (MDRO) (a germ such as bacteria, fungi, viruses, and parasites that are resistant to many antibiotics), aphasia (a disorder that affects your ability to speak and understand what others say to you). R1 had feeding tube and indwelling urinary catheter.R1's care plan dated 4/13/26, identified:Enhanced Barrier Precautions (EBP) (infection control interventions designed to reduce transmission of MDROs) and instructed staff to use proper gowning and gloving with high contact care to prevent risk of MDRO transmission.Activities of daily living (ADL) self-care deficit related to hemiplegia (one sided paralysis or weakness) of the right side due to CVA. R1 was dependent upon staff for all cares and transfers. R1 had an inability to drink fluids on his own and had a gastrostomy tube (G-Tube) (a flexible tube placed into the stomach surgically through the abdomen used for administration of fluids and medications). Staff were directed to use EBP with dressing/bathing/showering/transferring/changing linens/providing hygiene, changing brief or assisting with toileting, device care or use of the feeding tube.R1 had a suprapubic catheter (a thin flexible tube that carries urine straight out of bladder through an opening in the lower abdomen and into a collection bag). Staff were instructed to use EBP with high contact resident care. Staff MUST WEAR GLOVES AND GOWN. During an observation on 4/16/26 at 12:57 p.m., physical therapy assistant (PTA) pushed R1 in wheelchair into his room. Nursing assistant (NA)-C followed R1 and PTA into R1's room. There was an EBP sign located on the outside of R1's door and a personal protective equipment (PPE) cart. NA-C and PTA did not apply gown or gloves prior to working with R1. NA-C and PTA transferred R1 from his wheelchair to the bed with use of the full body lift.During an observations on 4/16/26 at 1:05 p.m., NA-D entered R1's room without a gown on. NA-C and NA-D applied gloves, NA-D stood on right side, NA-C stood on left side of R1's bed, rolled him to his left side, pulled down his pants, verified brief was clean, and pulled up brief/pants. R1 was rolled onto his right side and lift sling was removed. Both NAs grabbed ahold of each side of the bed protector located underneath R1 and lifted/boosted him up in the bed, placed pressure relieving boots on both feet, a wedge cushion underneath his left side, pillows between his legs, underneath his lower leg, and under each arm. NA-C and NA-D left the bedside, removed gloves and sanitized their hands before leaving R1's room.During an observation on 4/16/26 at 1:30 p.m., registered nurse (RN)-A entered R1's without gown or gloves on and held a small pill cup. RN-A informed R1 she planned on administering his medications via g-tube. RN-A collected supplies and applied gloves. R1's shirt was raised up to access the g-tube and end of large syringe was attached. RN-A proceeded to administer R1's medicaitons.During an observation on 4/16/26 at 4:45 p.m., RN-B entered R1's room without a gown or gloves on, placed a blue chux on the bedside table, opened Kerlix gauze wrap and a 4 x 4 gauze dressing. She removed the dressing from the back of his head without gloves on and described the wound as 2.5 centimeters (cm) x 3 cm, scant amount of bloody drainage on old dressing, and minimal swelling. The wound site had a dark red scab on it. RN-B did not wash or sanitize her hands, applied clean gloves, applied a folded 4 x 4 gauze dressing, wrapped the Kerlix gauze around his head to secure the dressing, then placed a strip of paper tape to secure the Kerlix gauze, and removed gloves. RN-B cleaned up the garbage and exited room without washing or sanitizing her hands.During an interview on 4/16/26 at 3:00 p.m., NA-D stated staff were expected to wear a gown when a resident was placed in EBP if they planned on changing the brief and/or doing anything below the waistline to prevent the spread of infection to staff, residents and visitors. According to the E-B-P sign on his [R1's] door, we should have placed a gown on and did not prior to transferring him from the wheelchair to the bed earlier. NA-D stated the only time staff were not required to wear a gown was when answering a call light or administration of a oral medication. R1 had a suprapubic catheter and a feeding tube so required EBP use with close contact cares. During an interview on 4/16/26 at 3:25 p.m., NA-C stated residents in EBP had a sign on their door. Staff would be expected to wear a gown and gloves when cares were completed and when working with bodily fluids. NA-C states it was important to follow EBP requirements to prevent possible spread of infection from one person to another. NA-C stated earlier when she assisted with R1's transfer/cares and should have worn a gown but forgot. During an interview on 4/16/26 at 5:00 p.m., RN-B stated when a resident was placed in EBP staff were expected to wear a gown only while dealing with peri area and/or stoma (a surgical opening in the abdomen used for medical purposes). RN-B read the EBP sign on R1's door and stated the sign was misleading but going forward, yes, technically staff would be expected to wear a gown when working closely with R1 to avoid transmission of germs to be passed onto ourselves and the residents.During an interview on 4/17/26 at 10:57 a.m., RN-A stated when a resident was placed in EBP, staff were expected to use PPE anytime they came in contact with the resident and touched them. RN-A stated she had just figured that out yesterday and realized when R1's medications were administered via g-tube she did not wear PPE. RN-A stated she wore gloves but should have had a gown on to protect R1 and other residents from getting infections and prevent the transfer of germs from one person to another.During an interview on 4/17/26 at 1:38 p.m., RN-C stated staff were expected to wear PPE when a resident was placed in EBP anytime they touched the resident to prevent infection from spreading from one person to another.During an interview on 4/17/26 at 3:00 p.m., director of nursing (DON) stated R1 was admitted to the facility with a previous diagnosis of ESBL, a urinary catheter, g-tube, and placed in EBP. Staff would be expected to wear PPE, a gown and gloves, for tasks that require it (listed on EBP sign posted on door) and during contact with the resident. The use of PPE helped prevent the spread of germs and infection with others.Facility policy EBP dated 4/2/26, identified EBP referred to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employ targeted gown and gloves use during high contact resident care activities. It was the policy of this facility to implement EBP for the prevention of transmission of MDROs. High contact resident care activities include dressing, bathing, transferring, providing hygiene, change linens, change briefs or assisting with toileting, device care: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC (peripherally inserted central catheter) line, midline catheters, and wound care: any skin opening requiring a dressing. EBP sign, undated, Centers for Disease Control and Prevention (CDC) posted on R1's room door identified an orange sign with two red stop signs and written information: EVERYONE MUST: -Clean their hands, including before entering and when leaving the room. -PROVIDERS AND STAFF MUST ALSO: Wear gloves and gown for the following: High Contact Resident Care Activates- Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device (urinary catheter, feeding tube) care or use, wound care: any skin opening requires a dressing.

Based on interview and document review, the facility failed to obtain informed consent and provide education to the resident or resident representative on the risks and benefits regarding the use of opioid medication for 1 of 5 residents (R22) reviewed for unnecessary medications. Findings include: Review of R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had intact cognition and had diagnosis which included anemia (A condition in which the body does not have enough red blood cells), hemiparesis (a medical condition characterized by weakness on one side of the body, often affecting the arm, leg, and potentially the face), and multiple sclerosis (MS) (A chronic autoimmune disease that affects the central nervous system brain and spinal cord). Identified R22 had pain and was on a pain regimen. R22's significant change Care Area Assessment (CAA) dated 3/26/25, identified R22 reported pain as always present. Identified R22's pain made it difficult for R22 to sleep and that pain medication was available. R22's care plan revised 4/5/25, identified R22 had pain related to MS and received pain medication. Care plan directed staff to administer medications as ordered and monitor and document side effects. R22's Order Summary Report dated 5/19/25, identified orders for the opioid medication Oxycodone 5 milligrams (mg) every four hours as needed for pain with a start date of 5/16/25. R22's medication administration record (MAR) identified R22 received Oxycodone 5 mg two times on 5/16/25, and two times on 5/17/25. R22's medical record lacked evidence of education to R22 or R22's representative regarding the risks and benefits of the opioid medication. During an interview on 6/9/25 at 1:30 p.m., R22 stated she has used oxycodone a few times in the past month. R22 stated she did not recall anyone talking with her regarding the risks and the benefits of oxycodone use. During an interview on 6/10/25 at 10:33 a.m., registered nurse (RN)-A verified R22 had a new order for oxycodone since 5/16/25, and R22 had received four dosed of the opioid medication in the past month. RN-A confirmed education regarding risk and benefits regarding the opioid medication had not been done with R22 or her representative. RN-A stated the current process is to only provide education regarding risk versus benefits with psychotropic medication use. During an interview on 6/10/25 at 10:43 a.m., acting director of nursing (DON) stated she did not think anyone had completed education with R22 regarding the benefits and risk of the opioid medication. DON stated her expectation was that education regarding the risks and benefits of the opioid medication should have been completed with R22 prior to starting the opioid medication. During an interview on 6/10/25 at 11:39 a.m., pharmacist consultant (PC) stated it was important to educate residents regarding the risks and benefits of using an opioid medication. CP stated her expectation was the facility would have provided R22 with education regarding the risks and benefits of the opioid prior to starting the opioid medication. Review of a facility policy titled High Risk Medication revised 2/19/25, identified the facility recognized some medications were associated with greater risk of adverse consequences than other medications. Identified high risk medications could include: antidiabetic's, psychotropics, cardiac medications, opioids, diuretics and antibiotics. Identified residents and/ or representatives would have been educated on the use and risks/benefits of high risk medications including, adverse effects.

Based on observation, interview and document review, the facility failed to comprehensively assess the use of a restrictive device as a potential restraint for 1 of 1 resident (R22) reviewed for restraints. Findings include: Review of R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 had intact cognition and had diagnosis which included anemia (A condition in which the body does not have enough red blood cells), hemiparesis (a medical condition characterized by weakness on one side of the body, often affecting the arm, leg, and potentially the face), and multiple sclerosis (MS) (A chronic autoimmune disease that affects the central nervous system (brain and spinal cord). Indicated R22 required extensive assistance for activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified R22 had not had any falls since the last assessment and required a wheelchair for mobility. Indicated R22 did not use any restraints. Review of R22's significant change Care Area Assessment (CAA) dated 11/15/24, identified R22 had intact cognition, was a high risk for falls related to medication use. CAA identified R22 did not use any restraints. Review of R22's quarterly fall assessment dated [DATE], identified R22 was at high risk for falls related to history of falls and current diagnosis. Review of R22's current physician orders signed 5/19/25, did not identify an order for a restraint. R22's medical record lacked any evidence a restraint assessment had been completed. Review of R22's care plan revised 6/1/25, identified R22 had a self care deficit related to hemiparesis of the left side. Identified R22 required staff assistance and a non mechanical lift for transfers. Identified R22 required a wheelchair for mobility. Care plan lacked any evidence of a seat belt being used in R22's wheelchair. During an observation on 6/9/25 at 11:35 a.m., R22 was seated in a motorized wheelchair in her room with a seatbelt fastened around her waist. During an interview on 6/9/25 at 11:40 a.m., R22 stated she was not able to remove the seatbelt from her waist. R22 stated she was only able to use her right hand to operate her motorized wheelchair but was not strong enough to remove the seatbelt. R22 stated the seatbelt did make it difficult to move while in the wheelchair. R22 further stated staff told her the seatbelt was for her safety so she did not fall out of the wheelchair. During an observation on 6/9/25 at 5:30 p.m., R22 was seated in a motorized wheelchair in the dining room with a seatbelt fastened around her waist. During an observation on 6/10/25 at 8:05 a.m., R22 was seated in a motorized wheelchair in her room with a seatbelt fastened around her waist. During an interview on 6/10/25 at 8:10 a.m., nursing assistant (NA)-B stated R22 had the seatbelt in her motorized wheelchair fastened around her waist for a while. NA-B stated staff removed the seatbelt from R22's waist for her since R22 was not able to remove it herself. NA-B further stated she was told R22 needed the seatbelt around her waist to keep R22 from sliding out of the motorized wheelchair. During an interview on 6/10/25 at 8:15 a.m., licensed practical nurse (LPN)-B verified R22 was seated in her room in a motorized wheelchair with a seatbelt fastened around her waist. LPN-B stated the seatbelt was to prevent R22 from falling out of the wheelchair. LPN-B confirmed R22 was unable to remove the seatbelt. During an observation on 6/10/25 at 8:20 a.m., licensed practical nurse (LPN)-B asked R22 to remove the seatbelt from her waist. R22 used her right hand and attempted to remove the seatbelt and stated she was not able to remove the seatbelt. During an interview on 6/10/25 at 10:49 a.m., registered nurse (RN)-A stated she was aware that R22 used a seatbelt around her waist while in her motorized wheelchair to prevent R22 from sliding out of the wheelchair. RN-A stated she was aware R22 was not able to remove the seatbelt but did not consider the seatbelt a potential restraint since R22 was able to ask staff to remove the seatbelt. During an interview on 6/10/25 at 10:57 a.m., acting director of nursing (DON) stated she just noticed the seatbelt fastened around R22 waist in her wheelchair yesterday and prior to that she was not aware that R22 used a seatbelt around her waist while in the motorized wheelchair. DON stated the seatbelt would be considered a potential restraint since R22 was not able to remove the seatbelt and it restricted her movement. DON stated her expectation was that staff would have assessed the seatbelt to determine if it was being used as a restraint. Review of a facility policy titled Restraint Free Environment revised 2/19/25, identified a physical restraint referred to any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. Physical restraints may include, but were not limited to: using devices in conjunction with a chair, such as trays, tables, cushions, or belts that the resident could not remove and prevented the resident from rising.

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) correctly for 1 of 1 residents (R12) reviewed for resident assessment. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2023, identified Section J 1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent (cont.) Code 1, yes: if the resident has fallen since the last assessment. Continue to Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS) item (J1900), whichever is more recent. J1900: Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent code the number of falls since last assessment and if there were any injuries. R12's quarterly Minimum Data Set (MDS) dated [DATE], Section J1800 identified R12 had a fall since last assessment. Section J1900 identified R12 had one fall without an injury since last assessment. Review of R12's falls progress notes from 12/30/24 to 2/18/25, revealed the following: -on 12/30/24 at 4:20 p.m., R12 had an unwitnessed fall with no injuries. -on 2/18/25 at 8:30 p.m., R12 had an unwitnessed fall with no injuries. During an interview on 6/10/25 at 9:45 a.m., acting director of nursing (DON) verified R12 had two falls between 12/30/24 and 2/18/25. DON stated her expectation was that the MDS should have been coded accurately. Review of a facility policy titled MDS 3.0 Completion revised 2/19/25, identified residents were assessed, used a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Indicated persons completing part of the assessment must attest to the accuracy of the section they completed by signature.

R3 R3's significant change of status MDS dated [DATE], identified R3 was cognitively intact and had diagnoses which included: heart failure, arthritis and chronic obstructive pulmonary disease (lung condition that restricts breathing). Identified R3 used a walker for mobility and required supervision or touching assistance for dressing, transfers and walking. R3's activity of daily living (ADL) Function/Rehabilitation Potential CAA dated 5/22/25, identified R3 required assistance in ADLs, had impaired balance and transition during transfers and functional impairment in activity. R3's contributing factors included generalized weakness and decreased safety awareness. R3's Skilled Nursing Facility (SNF) Morse Fall Scale assessment dated [DATE], identified R3 had a history of falling, and had a score of 65, which indicated R3 was at high risk for falls. R3's comprehensive care plan revised 5/15/25, identified R3 had an ADL self-care performance deficit related to muscle weakness, and required maximum assistance with bathing, and supervision touching assistance with tub/shower transfer. R3's care plan also identified R3 was at risk for falls related to past history of falls. During an observation on 6/10/25 at 2:17 p.m., NA-A and R3 left the tub room. R3 was seated on her four wheeled walker dressed in a gown and housecoat. NA-A pushed R3 down the hall backward while R3 sat on the four wheeled walker seat, then they entered R3's room. During an interview on 6/10/25 at 2:33 p.m., NA-A stated she had given R3 a shower then transported R3 to her room. NA-A indicated R3 sometimes got overheated after her shower and needed help getting back to her room. NA-A stated she had R3 sit on the walker seat, then pushed her backwards down the hall to her room. NA-A stated this was her usual practice, and had done this for years. At 2:37 p.m. NA-A and surveyor knocked then entered R3's room and looked at R3's walker. On the rear left leg of the walker was a warning sticker that indicated this is a walking aide only. Do not use as transportation device. NA-A indicated she was unaware that walkers were not to be used to transport residents. During an interview on 6/10/25 at 10:00am., acting (DON) stated R12 had falls in the facility and was at high risk for further falls. DON stated one of R12's fall interventions was to have the wheelchair within reach of R12. DON stated her expectation was staff would have followed care planned interventions to prevent falls. During a follow-up interview on 6/10/25 at 2:53 p.m., DON stated the four wheeled walkers were not to be used to transport residents because of a tipping hazard. DON indicated she would expect staff to obtain a wheelchair to transport a resident if they were unable to walk with their walker. DON also indicated in the past R3 had transported herself while sitting on the seat of the walker, and had been educated on proper use of the walker. Review of a facility policy titled Fall Prevention Program revised 2/19/25 identified, each resident would be assessed for fall risk and receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Identified the nurse would initiate interventions on the resident's care plan in accordance to the resident's level of risk. The facility policy titled Safe Resident Handling/Transfers revised 2/19/25, identified the facility ensured that residents were handled and transferred safety to prevent or minimize risks for injury and provide and promote a safe and secure and comfortable experience. The policy identified the interdisciplinary team or designee would evaluate and assess each resident's individual needs, on admission and reviewed quarterly, after a significant change in condition or based on direct care staff observations or recommendations. Based on observation, interview and document review, the facility failed to implement interventions for 1 of 1 residents (R12) who had several falls in the facility and remained at high risk for falls. Further, the facility failed to ensure safe transportation of a resident (R3) who was at risk for falls. Findings include: R12's significant change Minimum Data Set (MDS) dated [DATE], identified R12 had severe cognitive impairment and diagnosis which included cancer, hypertension (elevated blood pressure) and dementia. Identified R12 required extensive assistance with activities of daily living (ADLs), which included: bed mobility, transfers, and toileting. R12's significant change Care Area Assessment (CAA) dated 3/26/25, identified R12 was at risk for falls related to previous falls, cognitive and visual impairment. R12's care plan revised 12/30/24, identified R12 was high risk for falls related to confusion, gait/balance problems and lack of safety awareness. Identified R1 required maximum assistance of 1 to 2 staff to move between surfaces. Identified various interventions for falls which included: ensure wearing non skid socks at night, call light within reach and walker within reach at all times. Review of R12's fall assessment dated [DATE], identified R12 had an impaired gait, weakness, and required a walker. Identified R12 was at high risk for falls. Review of R12's falls progress notes from 12/30/24 to 5/31/25, revealed the following: -on 12/30/24 at 4:20 p.m., R12 had an unwitnessed fall and was found in his room lying on the floor in front of the recliner. No injuries noted, R12 was unable to say what happened. Root cause: R12 was attempting to self transfer. Intervention added to the care plan: ensure walker was within reach. -on 2/18/25 at 8:30 p.m., R12 had an unwitnessed fall and was found lying on the floor in his room with regular socks on his feet with soft touch call light on. No injuries noted, R12 was unable to say what happened. Root cause -self transferring. Intervention: wear non skid socks at night. -on 4/23/25 at 5:00 p.m., staff heard R12's wife yell for help and found R12 on the floor in his room next to the bed, no injuries noted. Root cause wife was attempting to transfer R12 out of his recliner when R12 lost his balance. Intervention: wife to not transfer R12. -on 5/31/25 at 5:13 p.m., staff was walking with R12 when wife started walking with R12 and R12 fell landing on his wife, no injuries to R12 or wife. Root cause: R12 lost balance as wife began walking with R12. Intervention: Remind wife to not walk with R12. During an observation on 6/9/25 at 1:48 p.m., R12 was seated in his recliner in his room, walker was turned around and pushed up against the wall approximately five feet from R12. During an observation on 6/9/25 at 2:58 pm., R12 was seated in his recliner in his room, walker continued to be turned around and pushed up against the wall approximately five feet from R12. During an observation on 6/10/25 at 9:34 a.m., R12 was seated in his recliner in his room, walker was turned around and pushed up against the bed approximately six feet from R12. Nursing assistant (NA)-B and registered nurse (RN) acting director of nursing (DON) verified R12's wheelchair was pushed up against the bed approximately six feet from R12. During an interview on 6/10/25 at 9:38 NA-B stated R12 required staff assistance for transfers. NA-B stated R12 had previous falls and was at risk for further falls. NA-B stated R12's walker should have been within reach of R12.

Based on observation, interview, and document review, the facility failed to comprehensively assess and attempt alternatives prior to use of bed rails for 2 of 2 residents (R5, R26 ) reviewed who were observed to have bed rails. Findings include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 was cognitively intact and had diagnoses which included: heart failure, arthritis, and dementia. R5's MDS identified R5 was independent with dressing, hygiene, rolling left to right, transfers and walking, and required substantial/maximal assistance with putting on/taking off footwear. R5's care plan revised 6/5/25, identified R5 had an activities of daily living (ADL) self-care performance deficit related to pain and forgetfulness. R5 had the ability to roll from lying on back to left and right side and return to lying on back on the bed independently. R5 was independent lying to sitting on side of bed and transfers. R5's care plan lacked identification of a grab bar on R5's bed. R5's Bed Rail Consent form dated 3/7/25, identified R5 had a grab bar on bed to aid in positioning. The form included potential benefits and risks of bed rail use. R5's medical record lacked a comprehensive assessment of R5's bed rail including: appropriate use of bed rail, measurements to assure safety and attempted alternatives prior to the use of the bed rail. During an observation on 6/9/25 at 12:43 p.m., R5 had a double sized standard bed with a black grab bar on the right side of bed, measuring approximately 1.5 feet tall and 1 foot wide. The grab bar sat approximately two inches from the mattress, then went under the mattress. R5 indicated her daughter had brought the rail in to be used, and was not aware if any staff member had assessed it. During an observation on 6/10/25 at 10:35 a.m., R5 was dressed in street clothes sitting at her computer in her room. R5's bed continued to have a grab bar attached to bed. During an interview on 6/11/25 at 9:26 a.m., nursing assistant (NA)-A indicated R5 was independent with most cares however, required assistance with her compression stockings. NA-A stated R5 had her own personal bed, and had witnessed R5 use the grab bar a few times, to help her swing her body up and out of bed. During an interview on 6/11/25 at 10:40 a.m., licensed practical nurse (LPN)-A stated R5 was mostly independent, however, staff assisted her to put her socks on. LPN-A confirmed R5 had a grab bar on her bed, and had witnessed R5 use it to get in and out of bed. LPN-A stated their usual practice was to obtain a consent form when bed rails were used, then review them annually. LPN-A indicated R5's family had brought the grab bar to the facility. LPN-A was not aware if R5 had tried anything prior to having the grab bar installed. During an interview on 6/11/25 at 10:44 a.m., R5 indicated she used the grab bar when getting out of bed. R5 stated she would be able to get out of the bed without it however, it was handy. R5 stated her family member attached it to her bed. R26's quarterly MDS dated [DATE], identified R26 was cognitively intact and had diagnoses which included: asthma, anxiety disorder and Guillain barre syndrome ( a rare neurological disorder where the immune system attacks the peripheral nervous system, causing muscle weakness and sometimes paralysis). Identified R26 was independent with dressing, hygiene, transfers and walking, and required substantial/maximal assistance with rolling side to side. R26's care plan revised 2/20/25, identified R26 had an activities of daily living (ADL) self-care performance deficit related to Guillain barre syndrome. R26 required partial/moderate assistance of one staff in bed to turn and reposition as necessary. At times of increased pain or weakness the resident need extensive assistance of one. R26's care plan lacked identification of a grab bar on R26's bed. R26's Bed Rail Consent form dated 2/5/25, identified R 26 had a grab bar on bed to aid in positioning. The form included potential benefits and risks of bed rail use. R26's medical record lacked a comprehensive assessment of R26's bed rail including: appropriate use of bed rail, measurements to assure safety and attempted alternatives prior to the use of the bed rail. During an observation on 6/9/25 at 1:40 p.m., R26 had a double sized standard bed with a black grab bar on the right side of bed, measuring approximately 1.5 feet tall and 1 foot wide. The grab bar sat approximately two inches from the mattress, then went under the mattress. R26 indicated her bed had the grab bar on it when she came to the facility and was not aware if any staff member had assessed it. R26 stated she used the grab bar to turn herself in bed and to transfer out of the bed. During an observation on 6/11/25 at 7:29 a.m., R26 was lying in bed and used the grab bar to stand up and transfer independently into her wheelchair. R26 stated she liked having the grab bar to use when getting out of bed. During an interview on 6/10/25 at 7:45 a.m., NA-B stated R26 was pretty independent with her mobility during the day. NA-B stated she had observed R26 use the grab bar on her bed to roll herself in bed and to transfer out of bed. During an interview on 6/11/25 at 08:10 a.m., LPN-B stated R26 was mostly independent, but staff assisted her during the night. LPN-B confirmed R26 had a grab bar on her bed, and had witnessed R26 use it to get in and out of bed. LPN-B stated their usual practice was to obtain a consent form when bed rails were used, then review them annually. LPN-B was not aware if R26 had tried anything prior to having the grab bar installed. During an interview on 6/11/25 at 10:57 a.m., acting director of nursing (DON) stated the facility's usual process was to obtain consents prior to using grab bars (bed rails) on resident's beds. DON stated some of the residents had their own beds, and had grab bars on them. DON confirmed the facility had not completed assessments of grab bars. DON confirmed they did not have the manufacturer's instructions for R5 and R26's grab bars. DON indicated it was important to do an assessment of grab bars because they could be a restraint, and to ensure resident safety. Review of the facility policy titled Proper Use Of Bed Rails, revised 2/9/25, identified the facility utilized a person-centered approach when determining the use of bed rails. Appropriate alternative approaches were attempted prior to installing or using bed rails. If bed rails were used, the facility ensured correct installation, use, and maintenance of the rails. The policy identified examples of bed rails included, but was not limited to side rails, bed side rails, safety rails, grab bars and assist bars. As part of the resident's comprehensive assessment, staff were to determine whether or not the use of bed rails met those needs. The evaluation must include an evaluation of the alternatives that were attempted prior the installation or use of bed rails and how those alternatives failed to meet the resident's assessed needs. The resident assessment should assess the resident's risk of entrapment between the mattress and the bed rail or in the bed rail itself. Informed consent from the resident or resident representative must be obtained after appropriate alternatives had been attempted prior to the installation and use of bed rails. The facility would assure correct installation and maintenance of bed rails prior to use, which included: checking with the manufacture to make sure the bed rails, mattress and bed frame were compatible, and assure a proper fit. Ongoing monitoring and supervision would be completed, including documentation in the residents records, including care plan.

Based on observation, interview, and document review, the facility failed to ensure personal laundry was transported in a manner that prevented risk of contamination for 2 of 3 hallways observed for linen transportation. In addition, the facility failed to complete hand hygiene during linen delivery and ensure safe delivery of beverages during dining observation. Findings include: Review of Centers for Disease Control (CDC ) guidance, Appendix D - Linen and Laundry Management updated 5/4/23, identified linens must be sorted, packaged, transported, and stored in a manner that prevented risk of contamination by dust, debris, soiled linens or soiled items. In addition, CDC Handwashing in Communities: Clean Hands Save Lives updated 7/18/22, identified handwashing was the most important thing to prevent food poisoning. During an observation on 3/4/24 at 2:58 p.m., in the 100 hallway nursing assistant (NA)-C pushed an uncovered cart that contained clean linen down the hallway. NA-C sanitized hands and removed a washcloth and a towel from the uncovered cart and delivered the items to R18's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart as a resident wheeled by the cart. NA-C delivered the items to R24's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart and delivered the items to R14's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart and delivered the items to R1's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart as a staff member walked by the cart. NA-C delivered items to R25's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart and delivered the items to R4's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart and delivered the items to R12's room. NA-C returned to the hallway, sanitized hands and removed a washcloth and towel from the uncovered cart and delivered the items to R15's room. During an observation on 3/5/24 at 12:08 p.m., in the resident dining room Minimum Data Set (MDS) coordinator poured two glasses of milk for R20. MDS coordinator placed her right hand around one of the glasses and placed her left hand over the top part of one glass (the area you drink from) and proceeded to carry the two glasses of milk across the dining room. MDS coordinator placed the two glasses on the table in front of R20 who proceeded to drink from the glass the MDS coordinator held in her left hand. During an interview on 3/5/24 at 1:46 p.m., MDS coordinator stated her normal practice was to place her hands around the center of the glass when carrying a glass. MDS coordinator stated it was important not to touch the area of the glass a resident drank from to prevent infections. During an observation on 3/5/24 at 2:46 p.m., NA-D placed several washcloths and towels on an uncovered cart and placed the cart in the hallway near the nurses' station as two staff members walked by the uncovered cart. At 3:11 p.m., NA-D returned to the uncovered cart and pushed the cart down the 200 hallway. In addition,NA-C brought an empty cart down the hallway. NA-C proceeded to remove a washcloth and towel from the uncovered linen cart and delivered the items to R11's room. NA-C returned to the hallway with a dirty water pitcher and placed it on the empty cart and moved the uncovered linen cart down the hallway. NA-C proceeded to remove a washcloth and towel from the uncovered linen cart and delivered the items to R2's room. NA-C returned to the hallway with a dirty water pitcher and placed it on the cart with the other water pitcher. NA-C proceeded to remove a washcloth and towel from the uncovered linen cart and delivered them to R16's room as a visitor walked by the cart. NA-C returned to the hallway with a dirty water pitcher and placed it on the cart with the other water pitchers. At no time did NA-C perform hand hygiene during the above observation. During an interview on 3/5/24 at 3:12 p.m., NA-D stated her normal practice was to pass clean linen on a clean uncovered cart. NA-D stated it was important to cover the linen cart to prevent contamination of the linens. During an interview on 3/5/24 at 3:16 p.m., NA-C stated her normal process was to sanitize her hands before passing linen from a clean uncovered cart. NA-C stated she should have sanitized her hands while passing linen and the cart should have been covered to prevent possible cross contamination. During an interview on 3/5/24 at 3:38 p.m., director of nursing (DON) stated her expectation was staff would perform hand hygiene, cover linens during transport, and staff should not be touching any areas of the glass the resident drinks from. A facility policy titled Infection Prevention and Control Manual Environmental Services/Housekeeping/Laundry dated 2020, indicated the facility was to provide clean, fresh linen to each resident and prevent contamination. Identified clean linen was transported in a clean, covered cart with a solid bottom to prevent contamination while being moved through the facility. A facility policy titled General Food Preparation and Handling dated 8/1/23, indicated food items were to be prepared to be free of injurious organisms and substances. Indicated staff were to handle utensils, cups, glasses, and dishes in such as way as to avoid touching surfaces that food or drink will come in contact with.

Based on observation, interview and document review, the facility failed to provide a dignified dining experience for 1 of 1 residents (R16) who received assistance with eating in the dining room. Findings Include: R16's quarterly Minimum Data Set (MDS) dated [DATE], identified R16 had severe cognitive impairment and had diagnoses which included: anxiety, depression, cerebral vascular accident (CVA/stroke) hemiplegia (paralysis on one side of body), and hemiparesis (weakness on one side of body) R16's care plan revised 3/4/24, identified R16 had self-care performance deficit related to hemiplegia and hemiparesis affecting left non-dominant side. R16's interventions included assistance with hygiene, bathing and dressing. R16's care plan identified R16 had potential for altered nutritional status related to CVA and required set up and assistance at times with eating. R16's care plan identified R16 received hospice care. During an observation on 3/5/24 at 8:56 a.m., R16 sat in a high back wheelchair in the dining room at a table. Nursing assistant (NA)-B stood near R16's right side, and provided 2 spoonful of eggs while he remained standing on R16's right side. NA-B went to the other side of the table, sat on a stool next to another resident and assisted the other resident. At 9:00 a.m., NA-B stood up, walked over to R16 and stood at R16's right side and provided R16 a spoonful of eggs. NA-B placed the fork into R16's bacon, asked R16 if he wanted the bacon and placed the bacon back onto the plate. NA-B provided R16 a drink of soda in a can with a straw. NA-B remained standing with left hand resting on the back of R16's wheelchair while providing R16 with spoons full of eggs and drinks. At 9:05 a.m. NA-B asked R16 if done, removed R16's dishes from the table, removed R16's clothing protector and transported R16 out of the dining room. During an interview on 3/5/24 at 10:16 a.m., NA-B stated the usual process was to be seated while assisting residents with eating. NA-B indicated it was important not to stand while assisting residents with eating and indicated NA-B should have sat while assisting R16 in order to pay attention to R16 and be at eye level. During an interview on 3/6/24 at 12:05 p.m., registered nurse (RN)-A stated staff were expected to be seated while assisting residents with eating and have conversations with them. RN-A indicated it was important to give the residents their full attention and be at eye level. RN-A verified it was not a dignified practice to stand while assisting residents with eating. During an interview on 3/6/24 at 12:14 p.m., director of nursing (DON) indicated staff were expected to be seated by residents while assisting with eating as it was important to maintain dignity and promote safety. The facility policy titled Serving A Meal dated 8/1/23, identified when residents required assistance with consuming their meal, employees would remain at the table seated, giving their attention to the resident during the duration of the meal.

Based on observation, interview and document review, the facility failed to ensure nebulizer medications were administered safely for 2 of 2 resident (R26, R9) who were observed to self administer a nebulizer and had not been assessed as safe to self administer medications. Findings include: R26 R26's admission Minimum Data Set (MDS) dated [DATE], identified R26 was cognitively intact and had diagnoses which included: multiple sclerosis (chronic disease that affects central nervous system) hemiplegia (paralysis on one side of body), hemiparesis (weakness on one side of body) and chronic obstructive pulmonary disease (COPD/chronic lung disease that cause airflow and breathing problems). R26's MDS identified R26 was dependent for self care and mobility. R26's care plan revised 12/20/23, identified R26 had an activity of daily living (ADL) self-care performance deficit related to disease processes. R26's care plan interventions included dependence on staff for bathing, dressing, and personal hygiene. Identified R26 had a cerebral infarction (CVA/stroke) which affected R26's left, non-dominant side. R26's Order Summary Report signed 3/1/24, included orders for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligram (MG)/3 milliliter (ML) 1 vial inhale orally four times a day for while awake. R26's Order Summary Report lacked an order to self administer medication. R26's medical record lacked documentation of a self-administration of medication (SAM) assessment completed. During an observation on 3/6/24 at 7:13 a.m., licensed practical nurse (LPN)-A administered R26's oral medications and topical medication. At 7:21 a.m. LPN-A opened R26's vial of Ipratropium-Albuterol inhalation solution and poured it into the nebulizer cup. LPN-A applied R26's nebulizer mask, turned on the nebulizer machine, set a timer on her watch and informed R26 she would return. LPN-A exited R26's room and went down to the end of the hall to the medication cart. LPN-A set up another resident's insulin medication, went down a different hallway and administered the insulin. At 7:38 a.m. LPN-A was observed exiting R26's room and stated she had rinsed the nebulizer out. LPN-A stated she was unaware if R26 had an order or SAM assessment for the nebulizer medication. During an interview on 3/6/24 at 7:39 a.m., registered nurse (RN)-A and LPN-A confirmed R26 did not have an order for self administration of medication, including the nebulizer. RN-A verified no residents at the facility currently had a SAM assessment completed and RN-A indicated she expected staff would remain in the room while any resident received a nebulizer medication. 45844 R9 R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had mild cognitive impairment and had diagnoses which included hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage), and cerebral vascular accident (CVA) (Stroke). Indicated R9 required extensive assistance with bed mobility, transfers, toileting and personal hygiene. Review of R9's electronic health record (EHR) revealed a SAM assessment had not been completed and R9 did not have an order for self administration of medications. R9's Physician Telephone Orders dated 2/12/24, and signed 2/20/24, directed staff to administer Ipratropium-albuterol inhalation solution DuoNeb (medication used to relax the muscles in the airways and increase air flow to the lungs) four times daily (QID) and every four hours as needed for congestion. R9's Medication Administration Record dated 2/12/24 to 3/6/24, indicated R9 had been taking (DuoNeb) 0.5-2.5 3 milligrams (mg) per three milliliters (ml) four times per day. R9's care plan dated 2/24, indicated R9 had limited mobility and required staff assistance and supervision with activities of daily living (ADL's). During a continuous observation on 3/6/24 at 7:20 a.m., R9 was seated in his recliner in his room with a mask on his face and a nebulizer running. No staff were observed in R9's room. At 7:26 a.m., trained medication aide (TMA)-A entered R9's room and shut off the nebulizer machine and removed the mask from R9's face. During an interview on 3/6/24 at 7:27 a.m., R9 stated he had been receiving the DuoNeb treatments for a few weeks now a few times a day. R9 indicated he had not been taught how to use the nebulizer machine. R9 verified nursing staff did not remain in the room while the treatment was being administered. R9 stated nursing staff turned on the nebulizer machine and placed the mask on his face and exited the room. During an interview on 3/6/24 at 7:30 a.m., TMA-A verified she had placed the nebulizer treatment on R9 and exited the room. TMA-A stated she was unsure if a SAM assessment had been completed for R9. TMA-A stated she did not have time to sit with R9 while he received his nebulizer so she would place the nebulizer on R9, turned on the machine, left the room and returned when the nebulizer was done. In addition, TMA indicated sometimes R9 would remove the mask himself and sometimes she would have to remove the mask for R9 when the nebulizer was completed. During an interview on 3/6/24 at 7:39 a.m., registered nurse (RN)-A confirmed R9 and R26 did not have a SAM assessment for their nebulizer treatments. RN-A stated none of the current residents had a SAM assessment for nebulizer's as they were not safe to self administer the nebulizers. RN-A indication her expectation was nursing staff would have stayed in the room with R9 and R26 while they received the nebulizer treatments to ensure R9 and R26 received the nebulizer treatments appropriately. During an interview on 3/6/24 at 7:42 a.m., director of nursing (DON) verified R9 and R26 did not have SAM assessments. DON indicated if the resident did not have a SAM assessment or physician's orders, staff were expected to remain with the resident during the entire nebulizer administration. Review of a facility policy titled Resident Self-Administration of Medication dated 8/1/23,identified a resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Further indicated resident's preference would be documented on the appropriate form and placed in the medical record.

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) correctly for 1 of 1 residents (R79) reviewed for resident assessment. Findings include: The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2023, identified Section 00110C1: Oxygen Therapy Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here. R79's admission Minimum Data Set (MDS) dated [DATE], Section O:Special Treatments, Procedures, and Programs. Question 001000 C identified R79 had not received oxygen in the last 14 days. Review of R79's care plan updated 3/5/24, indicated R79 required oxygen with the use of his continuous positive airway pressure (CPAP) (a machine that used mild air pressure to keep breathing airways open while sleeping). Review of R79's signed physician orders dated 2/20/24, identified R79 was to use two liters of oxygen at night with a CPAP machine. During an interview on 3/5/24 at 9:05 a.m., R79 pointed to an oxygen concentrator in his room and stated he used oxygen every night with that machine and pointed to a CPAP machine. Review of R79's admission progress note dated 2/21/24, identified R79 slept with a CPAP with oxygen attached. During an interview on 3/5/24 at 11:06 a.m., MDS coordinator verified R79 utilized oxygen at two liters at night with a CPAP machine. MDS coordinator verified Section O of R79's MDS dated [DATE], had not been coded correctly. MDS stated her expectation would have been the MDS would have been coded correctly. During an interview on 3/5/24 at 3:41 p.m., director of nursing (DON) verified R79 had received oxygen with a CPAP machine at night. DON confirmed R79's MDS dated [DATE], had not been coded accurately. DON stated her expectation would have been for staff to complete the MDS correctly. Review of a facility policy titled MDS 3.0 Completion dated 8/1/23, identified residents were assessed, used a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Indicated persons completing part of the assessment must attest to the accuracy of the section they completed by signature.

Based on observation, interview and document review, the facility failed to provide range of motion services to prevent potential decrease in range of motion (ROM) for 1 of 1 residents (R9) reviewed who required range of motion for restorative nursing exercises. Findings include: R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 had mild cognitive impairment and had diagnosis which included hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis on one side of the body), aphasia (loss of ability to understand or express speech, caused by brain damage), and cerebral vascular accident (CVA) (Stroke). Indicated R9 required extensive assistance with bed mobility, transfers, and toileting. R9's Significant Change Care Area Assessment (CAA) dated 3/17/23, identified R9 required extensive assistance with activities of daily living (ADL's) which included dressing, bed mobility, transfers and toileting. R9's current care plan dated 3/23, indicated passive range of motions (PROM) and active range of motion (AROM) would be provided. Review of Occupational Therapy (OT) discharge summary dated 12/20/23, identified discharge recommendations: patient to remain at same skilled nursing facility (SNF) with 24 hour supervision and cares with restorative nursing program (RNP) including PROM 10 reps to right arm daily to maintain range of motion (ROM ) and endurance. In addition, left upper extremity exercises with theraband were to be completed daily. Review of R9's progress notes lacked any indication of a RNP. During an observation on 3/4/24 at 12:35 p.m., R9 was seated in his recliner in his room and used his left arm to pick up his right arm to place it on the armrest of the recliner. During an interview on 3/4/24 at 12:39 p.m., R9 indicated he had limited ROM in his right arm and right leg. R9 stated staff had not been assisting R9 with any ROM exercises. During an interview on 3/6/24 at 8:15 a.m., nursing assistant (NA)-B indicated R9 had very limited ROM on his right side and required staff assistance with ADL's. NA-B stated he had performed RNP for residents in the past however was unaware of any ROM programs currently in place for R9. During an interview on 3/6/24 at 8:20 p.m., NA-A indicated R9 had limited ROM on his right side. NA-A stated she was not aware of any RNP programs currently in place for R9. During an interview on 3/6/24 at 8:25 a.m., registered nurse (RN)-A indicated R9 had right sided hemiplegia and required staff assistance for ADL's. RN-A confirmed R9 had an OT recommendation for an RNP program to maintain ROM. RN-A verified the recommendation had not been communicated to the staff and therefore, had not been completed. RN-A stated her expectation would have been the RNP would have been communicated to staff and started upon R9's discharge from OT to prevent further loss of ROM to his right side. During an interview on 3/6/24 at 8:59 a.m., therapy director (TD) verified R9 had been discharged from OT on 2/20/24, and was to have a RNP to his right arm to prevent further loss of ROM. TD stated it would have been important to implement the RNP for R9 to prevent a decline related to further loss of ROM. During an interview on 3/6/24 at 10:05 a.m., director of nursing DON stated she was unaware R9 had not been receiving restorative services per therapy recommendations. DON indicated her expectation was staff would have followed therapy recommendations. Review of a facility policy titled Restorative Nursing Programs dated 8/1/23, identified restorative nursing programs referred to nursing interventions that promoted the resident's ability to live as independently and safely as possible and actively focused on achieving and maintaining optimal physical, mental, and psychosocial functioning. Identified the discharging therapist would communicate to the appropriate restorative aide the provisions of the residents restorative nursing plan, and provide any necessary training to carry out the plan. .

Based on interview and document review, the facility failed to ensure the infection control program included ongoing surveillance, trending and analysis of resident infections. This deficient practice had the potential to affect all 25 residents currently residing in the facility. Findings include: Review of the facility's untitled infection control logs included the following information: resident name, room number, location of resident, infection date, type of infection, diagnosis, symptoms, medication/antibiotic, provider, outcome, date infection or signs and symptoms resolved, and bacteria type. Review of the untitled infection control logs from 6/28/2022 to 6/28/2023, revealed the following: June 2022, no infections were noted on the logs. July 2022, no infections were noted on the logs. August 2022, no infections were noted on the logs. September 2022, no infections were noted on the logs. October 2022, no infections were noted on the logs. November 2022, no infections were noted on the logs. December 2022, one resident was treated with antibiotics for a urinary tract infection (UTI) who utilized a catheter. January 2023, no infections were noted on the logs. February 2023, two residents had tested positive for COVID-19 and were being monitored. Both residents were placed on transmission based precautions. March 2023, one resident was treated with antibiotics for a UTI who utilized a catheter. April 2023, three residents were treated with antibiotics, one was treated for a UTI and two residents were treated for cellulitis. May 2023, no infections were noted on the logs. June 2023, three residents were treated with antibiotics, two were treated for UTIs and one was treated for pneumonia. The logs lacked ongoing surveillance and trending of all infections which included food-borne illness, and other illnesses caused by other viruses or infections. During an interview on 6/28/23 at 11:37 a.m., the infection control program was reviewed with the director of nursing (DON). The DON confirmed she was responsible for the facilities current infection control program and used a system called Peerlytics for antibiotic monitoring and tracking. The DON confirmed she had not been tracking and trending all infections in the facility and was only tracking and trending infections treated with antibiotics. The DON also indicated the only infections that were being tracked were listed on the infection control logs: such as UTI's, upper respiratory infection (URI), cellulitis, and did not include other infection caused by viruses or food borne illness. The DON confirmed ongoing surveillance had not been completed and the infection control program had room for improvement. Review of the facility policy titled, Infectious Disease Threat Surveillance and Detection revised on 04/2019, indicated a system was in place that identified, reported, investigated, controlled and prevented infections and communicable diseases for all residents and staff. The policy monitored public health surveillance and advisory for ongoing infectious diseases within the community. The policy identified the process for assessments and recognition, cause identification, diagnostic testing and monitoring of signs and symptoms, and worked with the provider to determine the treatment plan for residents and staff.

Based on interview and document review, the facility failed to accurately code the Minimum Data Set (MDS) correctly for 1 of 1 residents (R24) reviewed for resident assessment. The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2019, identified Section O0100: Special Treatments, Procedures, and Programs: O0100K, Hospice care: Code residents identified as being in a hospice program for terminally ill persons .is provided . R24's admission Minimum Data Set (MDS) dated [DATE], Section O: Special Treatments, Procedures, and Programs. question O0100K identified R24 had been in hospice care. R24's care plan dated 5/26/23, lacked documentation R24 had received Hospice services. A progress note dated 6/20/23, indicated R24 had been evaluated by Hospice and had not met criteria for their services. During an interview on 6/27/23 at 9:51 a.m., MDS coordinator (MDSC) verified R24 had not received hospice services. MDSC confirmed R24's MDS dated [DATE], had not been coded correctly. During an interview on 6/27/23 at 3:08 p.m., director of nursing (DON) verified R24 had not received hospice services. DON confirmed R24's MDS dated [DATE], had not been coded accurately. DON stated her expectation would have been for staff to complete the MDS correctly. An MDS completion policy was requested however was not provided. DON stated the facility referred to The Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for coding of the MDS.

Based on interview and document review, the facility failed to ensure physician ordered laboratory monitoring was completed for 1 of 5 residents (R2) reviewed for unnecessary medication use. Findings Include: R2's quarterly Minimum Data Set (MDS) dated [DATE], identified R2 was cognitively intact and had diagnoses which included: schizophrenia, hypertension, chronic kidney disease, and bilateral primary osteoarthritis of knee. Indicated R2 required limited assistance with personal hygiene and supervision with transfers and locomotion. R2's care plan last reviewed 4/18/23, identified R2 required extensive assistance with personal hygiene, set up for dressing and was independent with transfers and toilet use. Identified R2 had limited physical mobility related to osteoarthritis, history of total knee replacement and right knee not properly aligned. Review of R2's Order Summary Report signed and dated 5/17/23, identified the following: -Vitamin D tablet, give 5000 unit by mouth one time a day for supplement. Recheck Vitamin D level in 4 weeks on 8/23/22. -Oysco 500+D tablet 500-200 milligram-unit (calcium carbonate-Vitamin D) give one tablet by mouth one time a day for supplement Review of R2's physician fax communication dated 7/26/22, identified an order for dosage change and lab to be drawn. The Results Notes identified nurse practitioner (NP)-A reviewed R2's vitamin D level, which was within normal range after Vitamin D3 10,000 units orally daily was received over the past four weeks. The plan was to decrease supplement to 5,000 units and see if R2 remained stable at that dose, to recheck in four weeks. Review of R2's medical record (MR) lacked any documentation R2's labs had been drawn as ordered on 8/23/22, or since that time. During an interview on 6/27/23 at 4:14 p.m., director of nursing (DON) stated a fax communication had been received on 7/26/22, with orders to decrease R2's Vitamin D supplement and the facility was ordered to complete a Vitamin D level in four weeks. DON confirmed Vitamin D level had not been completed as ordered. DON indicated she expected lab orders to be completed as ordered. During a telephone interview on 6/27/23 at 5:13 p.m. NP-A, verified she had ordered a vitamin D level to be checked on R2 to determine if the level was stable since they had decreased the dosage. NP-A indicated it was important to recheck her level after the new dosage was decreased. NP-A indicated she expected the lab would have been completed as ordered. During a telephone interview on 6/28/23 at 8:39 a.m., pharmacy consultant (PC)-A verified she was not aware R2's vitamin D level had not been checked. PC-A indicated she would expect R2's vitamin D level to be completed as ordered and confirmed she had not identified the error. PC-A stated Vitamin D supplement was provided for various reasons including calcium absorption and to stabilize mood. During an interview on 6/28/23 at 11:31 a.m., registered nurse (RN)-A confirmed R2 did not have a Vitamin D level completed. RN-A stated the facility's usual process for ensuring labs were completed as ordered was a nurse would complete the orders and another nurse would double check the orders for accuracy. RN-A indicated lab orders were entered on a calendar at the nursing desk for staff to refer to. The facility policy titled Lab And Diagnostic Test Results-Clinical Protocol revised November 2018, identified the physician would identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. The policy indicated the staff would process test requisitions and arrange for tests.

Based on interview and document review, the facility failed to ensure 1 of 5 residents (R21) was offered or received a pneumococcal vaccination. In addition, the facility failed to document and provide the risks and the benefits of refusing the influenza vaccination for 2 of 5 residents (R21 and R22) in accordance with the Center for Disease Control (CDC) recommendations. Findings include: Review of the Recommended Adult Immunization Schedule for ages [AGE] years or older, Pneumococcal Vaccination, 2023, scheduled presented from The Center for Disease Control and Prevention (CDC) identified Adults [AGE] years of age or older who have not previously received Pneumococcal 13-valent Conjugate Vaccine (PCV13) and who have previously received one or more doses of Pneumococcal Polysaccharide Vaccine 23 (PPSV23) should receive a dose of Pneumococcal 15-valent Conjugate Vaccine (PCV15) or 1 dose of Pneumococcal 20-valent Conjugate Vaccine (PVC20). The dose of PCV15 or PCV20 should be administered at least one year after the most recent PPSV23 dose. Review of R21's Minnesota Immunization Information Connection (MIIC) form identified R21 had received the Pneumo-poly (PPSV23) vaccination on 10/22/1999. R21's medical record lacked documentation R21 had received or been offered the PCV15 or PCV20 vaccines. Review of R21's Immunization Report identified R21 had refused the influenza vaccination undated. The influenza vaccination refusal lacked documentation of when it was offered and if R21 had received education regarding the risk and the benefits of receiving the vaccine. Review of R22's Immunization Report identified R22 had refused the influenza vaccination undated. The influenza vaccination refusal lacked documentation of when it was offered and if R21 had received education regarding the risk and the benefits of receiving the vaccine. During an interview on 6/28/23 at 11:37 a.m., the director of nursing (DON) confirmed the above findings and indicated she would expect nursing staff to offer the the vaccinations to the residents, document refusals, provide education and answer any questions the residents may have. The DON stated if the resident had refused the vaccine she would expect nursing staff to update the provider as well. Review of facility policy titled, Pneumococcal Vaccine dated 2/1/18, identified all residents would be offered pneumococcal vaccines to aid in prevention of pneumococcal infections. Prior to or upon admission, residents would be assessed for eligibility to receive the pneumococcal vaccine series within 30 days of admission or if medically contraindicated or if the resident had already been vaccinated. Administration of pneumococcal vaccines or revaccination would be made in accordance to CDC recommendations at time of the vaccination.

Based on observation, interview and document review, the facility failed to maintain the kitchen ice machine in a sanitary manner to prevent potential contamination for 23 of 23 residents who currently resided in the facility, as well as staff and visitors who received ice from the ice machine. Findings include: On 8/30/21, at 1:40 p.m. during the initial tour of the facility, an ice machine located in the kitchen was observed to have hard water calcium buildup on both sides of the ice bin, covering the sides, down into the top layer of ice, with multiple green and gray steaks of lime buildup extending down the top back of the inside bin. Dietary manager (DM)-A confirmed the noted buildup on the inside bin of the ice machine and indicated maintenance staff were responsible to clean the ice machine. On 9/1/21, at 11:08 a.m. during a secondary kitchen tour, dietary cook (DC)-A observed the ice machine located in the kitchen and confirmed calcium and lime buildup were present on the inside of the ice machine bin. DC-A stated environmental supervisor (ES)-A cleaned the ice machine however she was uncertain how often it was cleaned. The ice machine continued to have gray/white hard water calcium buildup on the sides of the inside bin covering front to back, an area approximately 10-12 inches from the top. The green and gray streaks of lime buildup continued to extend down the back from the top of the bin. Review of the ice machine cleaning documentation from 3/1/21, to 9/1/21, revealed the following: -The facility Logbook Documentation form identified the Ice machine, was marked done by ES-A on 4/30/21. The steps identified on the form included the ice machine was to be cleaned and disinfected based on equipment manufacturer's instructions. The facility was asked for further logs and none were provided. On 9/1/21, at 12:31 p.m. DM-A confirmed there was water calcium and lime buildup inside the ice machine located in the kitchen. DM-A indicated ES-A cleaned the ice machine every 6 months per manufacturer's recommendations. DM-A indicated it was important to clean the ice machine to prevent contaminants to be present in the ice. On 9/2/21, at 12:19 p.m. ES-A confirmed he cleaned the ice machine every 6 months. ES-A indicated he checked the ice machine every 6 months at the time of scheduled cleaning. ES-A confirmed the ice machine had lime buildup on the back of the bin where the ice dropped out and additionally had hard water scale buildup. ES-A said it was important to remove scale buildup of the ice machine to prevent it from clogging the ice maker. ES-A indicated the facility had the water tested for hardness, and it had passed, however indicated he had not received a recommendation of what to do if the ice machine had hard water buildup in between the 6 month cleaning cycle. The Manitowoc under counter ice machine U models installation, use and care manual dated 10/14, identified for interior cleaning and sanitizing, it instructed to clean and sanitize the ice machine every six months for efficient operation. If the ice machine required more frequent cleaning and sanitizing, the facility was expected to consult a qualified service company to test the water quality and recommend appropriate water treatment. A hand written note on the page of instructions provided by the facility stated last cleaned 4/26/21. The facility policy titled Ice/Ice Dispensing, dated 3/21, identified ice would be produced and dispensed in a manner to avoid contamination. The policy and procedure identified the ice dispenser would be cleaned and sanitized monthly, and/or as needed. Inside and outside of the machine and the area around the machine would be cleansed per manufacturer's direction.

Based on interview and document review the facility failed to notify the resident's representative of the transfer or discharge and the reasons for the move in writing regarding a hospital transfer for 1 of 1 residents (R1) reviewed for hospitalization . In addition, the facility failed to document a copy of the notice had been sent to the Ombudsman for hospital transfers for 1 of 1 resident (R1) reviewed for hospitalization . Findings include R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS indicated R1 required extensive assistance with dressing, personal hygiene and was totally dependent for bathing. R1's care plan revised 7/26/21, identified R1 had activities of daily living (ADL) self-care performance deficit related to spinal stenosis with [CONDITION(S)] claudication, mylagia, and [CONDITION(S)]. R1's care plan interventions identified R1 required limited assistance to maximize independence. Review of R1's progress notes dated 6/11/21, to 9/2/21, identified the following: -6/11/21, R1 transferred to hospital emergency room as ordered by primary care physician. Family member contacted and informed of transfer to hospital and agreed to hold the bed. Bed hold document signed by writer. R1 was aware of the reason why R1 was transferred to the hospital. -6/15/21, R1 returned from acute care hospital. -6/18/21, at 9:35 a.m. R1 was in her wheelchair when she returned from the dining room independently. R1 reached her doorway and asked for assistance to get over the door jam. Registered nurse noticed R1's words were slurred, R1 had right side facial drooping and right sided weakness. R1's daughter was called and the ambulance was called. Certified nurse practitioner who was on-call for R1's primary care physician was agreeable to transfer to emergency room to be evaluated further. Documentation further identified family member indicated to hold bed for now. -6/21/21, R1 returned from hospital. R1's Ecumen Transfer/Discharge Notice dated given 6/15/21, identified R1 was transferred on 6/11/21, and was signed by resident representative. R1's medical record (MR) lacked a Ecumen Transfer/Discharge Notice completed for R1's transfer to the hospital on 6/18/21. In addition, R1's MR lacked documentation that the Ombudsman was notified of her hospital transfer on 6/11/21, and 6/18/21. On 9/1/21, at 11:42 a.m. licensed social worker (LSW)-A confirmed she was responsible to complete resident transfer forms. LSW-A confirmed R1 did not have a transfer form completed for her hospital transfer on 6/18/21. LSW-A indicated her usual practice was to complete a progress note to indicate the Ombudsman had been notified of resident's transfers. LSW-A confirmed R1's MR lacked documentation the Ombudsman was notified of her two hospital transfers in June. At 11:50 a.m. LSW-A stated she found a note in her personal notebook dated 6/26/21, regarding R1's hospital transfer notification to Ombudsman however confirmed she had not documented it in R1's progress note and therefore was not able to validate if the Ombudsman had been notified. On 9/2/21, at 9:57 a.m. during a follow up interview LSW-A confirmed she had not notified the Ombudsman of R1's hospital transfer on 6/18/21. LSW-A stated she had completed a late entry progress note yesterday for R1's notification to the Ombudsman of her transfer on 6/11/21, and she had gone by the date she had written it in her personal note book. On 9/2/21, at 10:10 a.m. director of nursing (DON) confirmed LSW-A was responsible to complete resident transfer notification forms and to notify the Ombudsman for all transfers. DON indicated she expected the notifications to be completed in a timely manner. The facility policy titled Resdient Transfer/Discharge Notice, revised 2/21, identified the notice was to be given for all transfers/discharges, which included hospital transfers. The policy indicated staff were to complete all sections of the notice and to review it with the resident or guardian. The policy instructed staff to make a copy of the document and fax it to the regional ombudsman's office. The policy further instructed staff to document faxed and date on the notice and to file it into the chart under social services. The policy identified the form was expected to be mailed to the family, and should be reflected on the notice.

Based on interview and document review the facility failed to ensure written notification of the facility's bed hold policy were provided for 1 of 1 residents (R1) at the time of transfer to the hospital. Findings Include: R1's significant change Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS indicated R1 required extensive assistance with dressing, personal hygiene and was totally dependent for bathing. R1's care plan revised 7/26/21, identified R1 had an activities of daily living (ADL) self-care performance deficit related to spinal stenosis with [CONDITION(S)] claudication, mylagia, and [CONDITION(S)]. R1's care plan interventions identified R1 required limited assistance to maximize independence. Review of R1's progress notes from 6/18/21, to 9/2/21, identified the following: -6/11/21, R1 transferred to the hospital emergency room as ordered by primary care physician. Family member was contacted and informed of the transfer to hospital and agreed to hold the bed. Bed hold document signed by writer. R1 was aware of reason going to hospital. -6/15/21, R1 returned from acute care hospital. -6/18/21, at 9:35 a.m. R1 was in her wheelchair when she returned from the dining room independently. R1 reached her doorway and asked for assistance to get over the door jam. Registered nurse noticed R1's words were slurred, and R1 had right side facial drooping and right sided weakness. R1's daughter and ambulance was called. Certified nurse practitioner on-call for R1's primary care physician was agreeable to transfer to R1 to the emergency room to be evaluated further. Documentation identified family member indicated to hold bed for now. -6/21/21, R1 returned from hospital. R1's Bed Hold/Bed Hold Policy Handout For Leave form dated 6/11/21, was signed by family member and identified family member was notified per phone call on 6/11/21, signed by nurse. R1's medical record (MR) lacked documentation a written Bed Hold/Bed Hold Policy Handout For Leave form was completed for R1's transfer to the hospital on 6/18/21. On 9/2/21, at 9:57 a.m. licensed social worker (LSW)-A confirmed she was responsible to complete written bed hold forms. LSW-A indicated the licensed nurses completed the forms at times, however LSW-A indicated she checked to assure they were completed. LSW-A confirmed R1 went to the hospital in June twice and indicated a bed hold form was completed for her hospitalization transfer on 6/11/21 however no bed hold form was completed for R1's hospital transfer completed on 6/18/21. On 9/2/21, at 10:10 a.m. director of nursing (DON) confirmed LSW-A was responsible to assure bed hold forms were completed. DON indicated nursing staff obtained a verbal consent for bed hold from resident representatives after hours and the LSW completed the form and had the family or resident representative sign the form the next day. DON stated she expected the bed hold documentation to be completed in a timely manner. A facility policy was requested however was not provided.

Based on observation, interview and document review, the facility failed to follow standards of practice related to medication administration for 1 of 1 resident (R13) observed to receive an inhalation medication. Findings include: R19's annual Minimum data set (MDS) dated [DATE], identified R19 had mildly impaired cognition and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19 current admission record dated 6/9/21, identified R19 was admitted on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R19 order summary report dated 7/8/21, identified [MEDICATION(S)] (steroid) Suspension 0.25 milligrams per 2 milliliters 1 vial inhale orally one time a day related to [CONDITION(S)] and pulmonary fibrosis. Rinse mouth after use. During an observation on 9/1/21, at 9:13 a.m. registered nurse (RN)-A entered R19 room and placed [MEDICATION(S)] inhalation solution 1 vial 2 milliliters (ml) into the nebulizer cup, attached the tubing to the machine, placed the mask over R19's nose and mouth and turned machine on. At 9:23 a.m. RN-A returned to R19 room, turned the machine off and removed the mask form R19's face. RN-A rinsed out the nebulizer medication cup and mask in the bathroom sink. RN-A handed R19 a cup with water in it. R19 took a sip of water, swallowed it, and handed the cup to RN-A. R19 did not rinse and spit with the water after the nebulizer treatment. RN-A exited the room. During an interview on 9/1/21, at 11:28 a.m. RN-A stated R19 should have rinsed out her mouth after she received the [MEDICATION(S)] nebulizer treatment. RN-A indicated normally the resident rinsed her mouth and then asked to spit it out. RN-A stated she had forgot to remind R19 to rinse and spit the water out after the nebulizer treatment had finished. RN-A stated this steroid medication had the potential to be irritating to the respiratory tract and therefore it was important for the resident to rinse and spit afterwards. During a telephone interview on 9/2/21, at 12:29 p.m. consultant pharmacist stated after a resident received a [MEDICATION(S)] nebulizer treatment the mouth should have been rinsed out with water and then spit out to prevent fungal infection of the mouth. The CP stated it was a practice to follow according to the manufacturer's guidelines. During an interview on 9/2/21, at 2:43 p.m. director of nursing (DON) stated she expected the staff to instruct the resident to rinse and spit after a nebulizer treatment and to follow the manufacturer's guidelines. DON indicated it was an important practice to follow to maintain the integrity of the mouth and the teeth. The manufacturers insert provided by facility on 9/2/21, identified [MEDICATION(S)] inhalation suspension warnings and precautions. Localized infections: [NAME] [MEDICATION(S)] ([MEDICATION(S)]) infection of the mouth and throat may occur. Monitor patients for signs of adverse effects on the oral cavity. Advised patients to rinse the mouth following inhalation.