Every finding on record at The Good Samaritan Society-Kissimmee Village

Based on observation, record review and interview the facility failed to ensure potentially hazardous food was at the correct holding temperature, staff followed practices to prevent physical contamination of food and make sure cookware & equipment are clean and sanitary. Finding: On 12/8/25 at 11:22 AM, the initial kitchen inspection was conducted. In the dishwashing room there was a dietary aide with a beard putting away Dome Pellet Covers. The aide was not wearing a beard guard. He indicated his beard guard had fallen off, time unknown, but failed to explain why he had not donned a new guard. Several minutes later the Kitchen General Manger and Registered Dietitian (RD) arrived, and they said they both round in the kitchen and oversight of the staff. In the three-compartment sink, dishes were observed floating in the sanitizer water. The RD confirmed that the dishes need to be completely submerged in the sanitizer. On a clean storage rack there was an 8-inch frying pan with a significant amount or carbon buildup. The buildup was so pronounced; it was difficult to determine if this was a stainless-steel frying pan or frying pan with a non-stick coating that was disintegrating. As the RD said the pan would be replaced, the General Manger threw the pan away in the garbage can. The facility used a bag-in-the box juice and beverage dispenser. Observations of the dispensing gun and nozzle revealed it was not clean & sanitary. The nozzle was removed and a beige and pink like sludge was on the inside of the nozzle and dispensing gun. The staff, including the General Manager and RD could not explain when the dispensing gun and nozzle had been cleaned & sanitized. Review of the facility menu revealed Homemade Meatloaf was the lunch main entree on 12/11/25. The lunch tray line was observed on 12/11/25 at 11:15 PM. There was dietary aide taking the hot holding temperature of the food on the steam table. The hot holding temperature of potentially hazardous foods needed to be at 135 degrees Fahrenheit or above. The aide was using a digital stem bayonet style instant read thermometer. She plunged the thermometer through several pieces of meatloaf and indicated the temperature was above 135 degrees Fahrenheit. The aid was instructed to take the internal temperature of only one slice of meatloaf; the temperature was 127.9 degrees Fahrenheit. The aide stated the holding temperature was too low.

Based on observation, record review and interview, the facility failed to follow the menu for mashed potato portion size. The facility's non-compliance had the likeliness to potentially affect residents who prefer mashed potatoes. Findings:Review of the facility's menu revealed garlic mashed potatoes would be severed for lunch on 12/11/25. The Diet Spreadsheet noted a number 8 scoop was to be used to portion the garlic mashed potatoes, which means residents would receive a 4-ounce portionOn 12/11/25 at 11:15 AM, the lunch tray line was observed. After the staff completed taking the hot holding temperatures on the steam table, serving utensils were placed near each food item and the staff started plating the meals. The staff had used a number 10 scoop for the garlic mashed potatoes instead of a number 8 scoop. A number 10 scoop is a 3.2-ounce portion which was contrary to the facility's menu. The staff present could not explain why the wrong size scoop was used even though there was oversight provided by the kitchen manager and registered dietitian.

Based on interview, and record review, the facility failed to appropriately record and investigate grievances to ensure resolution in a timely manner for 1 of 2 residents reviewed for grievances, of a total sample of 49 residents, (#145).Findings: Resident #145 was admitted to the facility on [DATE] with diagnoses including fracture of unspecified part of right clavicle, unspecified fracture of the lower end of right radius, and presence of right artificial ankle joint. Review of the Minimum Data Set quarterly assessment with assessment reference date of 11/22/23 revealed resident #145 had a Brief Interview for Mental Status score of 15/15, which indicated she was cognitively intact. Review of the facility's Grievance Log revealed grievances were filed by the resident or on her behalf on 8/24/25 and 9/02/25. Review of the grievance filed 8/24/25 revealed the issue was addressed with solutions offered to the resident and resident representative. The grievance filed 9/02/25 concerned customer service provided by two staff members, a Certified Nursing Assistant (CNA) and a licensed nurse. The investigation contained a statement from the CNA but did not contain a statement from the identified nurse. On 12/11/2025 at 10:32 AM, the Director of Nursing (DON) reviewed the grievance for 9/02/25. She verified she was responsible for investigating the grievance and providing a resolution. The DON reviewed the investigation and confirmed no statement was taken or documented regarding the licensed nurse. She stated she thought the CNA's actions were the real issue and did not think to interview the nurse. The DON acknowledged the facility did not conduct a thorough investigation as all parties involved were not given the opportunity to tell their side of the story. In a phone interview on 12/09/2025 at 11:35 AM, resident #145's son verified he filed grievances on behalf of his mother while at the facility. He explained although the facility responded to those grievances, they had not responded to his complaint of a bill he received after his mother left the facility. He explained the facility sent a statement which he questioned but it had not been resolved. On 12/11/25 at 10:35 AM, the Business Office Manager (BOM) reviewed resident #145's financial record. He reported she admitted to the facility on [DATE] under a managed care program, transitioned to private pay on 9/14/25 and discharged on 9/26/25. He acknowledged resident #145's son had contacted him regarding the bill. The BOM explained he contacted the managed care program who provided information resident #145 was not covered after 9/13/25. The BOM reviewed the Social Services progress notes in the electronic medical record which indicated she was covered until discharge. He stated Social Services had not provided the business office with that information and that he had not collaborated with the Social Services department when resident #145's son expressed his concern over the bill. On 12/11/25 at 11:49 AM, the Administrator reported she had spoken to resident #145's son regarding the bill. She explained she sent it to the corporate office along with information for their review and resolution. She stated resident #145 should not be getting any further bills until the matter was resolved. She confirmed it would be an issue if a resident or resident representative was billed for an amount not owed. The Administrator acknowledged she did not initiate a grievance form for the complaint expressed by resident #145's son. She stated one should have been filled out. Review of the facility's policy and procedure for Grievances, Suggestions or Concerns dated 12/02/24, revealed that grievances, suggestions and concerns were to be deemed as high priority customer satisfaction issues. The facility staff were instructed to make prompt efforts to resolve a grievance and keep the resident/resident representative apprised of progress toward resolution. The document clarified that an investigation must be completed for all grievances. The policy noted the investigation could be informal but must be thorough and allow all interested parties an opportunity to submit evidence relevant to the complaint.

Based on observation, interview, and record review, the facility failed to ensure each resident received an accurate assessment that was reflective of their status, needs, and areas of decline for 2 of 2 residents reviewed for resident assessments, of a total sample of 49 residents (#10 and #119).1.Resident #10 was admitted to the facility on [DATE] with diagnoses that included dementia, Alzheimer's disease, mild cognitive impairment, anxiety, adjustment disorder, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed resident #10 received treatment and services for hospice care, dialysis, tracheostomy care, mechanical ventilator, radiation, and oxygen therapy. Review of resident #10's medical record revealed no physician orders or care plans related to the need for dialysis, hospice, radiation, oxygen therapy, or tracheostomy care. There was no documentation in the medical record other than in the MDS Quarterly assessment that resident #10 received dialysis, hospice, radiation, oxygen therapy or tracheostomy care. 2. Resident #119 was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis including type 2 diabetes, anemia, hyperlipidemia and chronic kidney disease stage 3. Review of the MDS Significant Change assessment dated [DATE] revealed resident #119 had renal insufficiency and received dialysis while a resident in the facility. Review of resident #119's medical record revealed no physician orders related to the need for dialysis and no care plan for dialysis services or treatment. There was no documentation in the medical record pertaining to resident #119 receiving dialysis services or treatment while at the facility. On 12/11/25 at 12:59 PM, the MDS Coordinator reviewed Section O – Special Treatments, Procedures and Programs for resident #10's MDS quarterly assessment dated [DATE] and resident #119's MDS significant change assessment dated [DATE]. She verified the coding for each was incorrect and did not accurately reflect each resident's status. She was unable to recall what happened that day or why the assessments were miscoded. The MDS Coordinator acknowledged the assessments were inaccurate and needed to be modified. Review of the facility's policy and procedure for MDS 3.0 Resident Assessment Instrument dated 10/27/25 revealed during the observation period, each team member would review the electronic medical record to determine if there was accurate documentation to support coding for the MDS.

Based on observation, interview, and record review, the facility failed to complete a new Preadmission Screening and Resident Review (PASARR) level I screening to ensure other mental health services were not required for 2 of 2 residents reviewed for PASARR, of a total sample of 49 residents, (#11 and #107).Findings: 1.Resident #107 was initially admitted to the facility on [DATE] with diagnoses that included anxiety, epilepsy, and migraine. From 2015 to 2025 other diagnoses were added to include Alzheimer's disease, dementia, mood disorder, schizoaffective disorder, major depression, altered mental status, cognitive communication deficit, and psychotic disorder. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed resident #107 was severely, cognitively impaired. Resident #107's Order Summary Report dated 12/11/25 revealed she was on Depakote sprinkles twice per day for mood disorder, Remeron at bedtime for depression, and Trazodone twice a day for depression. Review of the Comprehensive Care Plan for resident #107 revealed a care plan for behaviors initiated on 1/04/23 and revised 4/01/25 which indicated the resident had behavior symptoms related to dementia. The care plan described the resident could be argumentative at times, had history of making threats to others, grabbed, yelled, talked loud to others at times, had physical outbursts, and imitated other's behaviors. Review of the PASARR level I form for resident #107 dated 1/03/23 revealed there had been no Mental Illness (MI) diagnosis provided; therefore, the screening was incomplete and did not accurately assess whether the resident received the appropriate services based on her diagnoses. Resident #107's medical record revealed a psychiatric note dated 11/14/25 that detailed she was being seen for anxiety, reported low energy and poor concentration. She also reported feeling anxious and excessively worried, with symptoms occurring several times. A previous psychiatric note dated 11/06/25 revealed the resident was being treated for depression, dementia, mood disorder, and schizoaffective disorder. During that visit it was noted that staff had reported the resident was yelling, screaming, and crying all day. 2. Resident #11 was admitted to the facility on [DATE]. Facility staff completed the Preadmission Screening and Resident Review (PASARR) on 6/17/25 and noted the resident had depressive disorder, a form mental illness. On or about 8/27/25 the bipolar disorder, another form of mental illness, was added to the resident #11's list of diagnoses. Further record review revealed that the resident's PASARR was not updated. On 12/11/25 at 5:20 PM, RN (X) indicated she was responsible for the residents' PASARRs. She said PASARRs both residents #107 and #11, needed to be updated to reflect the diagnoses of anxiety and bipolar disorder, respectively.

Based on observation, interview and record review, the facility failed to provide an ongoing activity program for 3 of 3 residents reviewed for activities, of a total sample of 30 residents, (#5, #8, #135) Findings: 1. Resident #135 was admitted to the facility 11/09/23 and placed under Hospice Care 10/25/24. admission diagnoses included unspecified dementia, depression and hypothyroidism. The Minimum Data Set Quarterly assessment dated [DATE] references resident #135 had a staff assessment for Mental Status due to resident #135 rarely/never understood. The staff assessment for Mental Status rated resident #135 as having severe cognitive impairment, being fully dependent on staff for all activities of daily living and transport. Activity preferences in the assessment included music, activities with groups of people, and outside visits. The activities care plan initiated 9/02/24 and revised 10/23/25 indicated resident #135 had a potential for activity deficit and unable to self-pursue activity interest, initiating stimulation, socialization, and dependent on staff for activity. The goal for her is to maintain involvement in cognitive and sensory stimulation, and social activities. The care plan, initiated 1/08/25, indicates resident #135 prefers listening to 60's, 70's and 80's music. Documented interventions include music therapy, stress ball, aroma therapy, manicure, sensory blankets, dolls, and outdoor strolls. Additional intervention includes assisting to and from locations as needed to attend scheduled activities, birthday celebrations, special events, music entertainment, and encourage to take part in activities to maintain current level of cognitive functioning and to slow decline. Review of Resident #135's medical record revealed an 'Intervention/Task' Activities log for the month of December 2025. Resident #135's Activity log from December 1st through December 11th, 2025, revealed days of a single activity per day focusing on Sensory Stimulation. The Sensory Stimulation entailed 5 out of 11 days of television, 2 out of 11 days of radio/iPod, and 1 day out of 11 sitting outside. Two days were without activities. On 12/8/25 at 10:59 AM, resident #135 was sitting at the #3 Nursing Station with her eyes open but did not respond to questions. There were 4 other residents in the hallway at the # 3 Nurse's Station, doing no activity other than listening to Christmas music playing from hallway. No other interaction from the staff or activity observed. At 2:00 PM, resident #135 was still sitting in#3 Nursing Station with 3 other residents, her position was unchanged. No staff interaction or other activity was observed. On 12/9/25 at 11:15 AM, resident #135 was in dining area at table alone. She was slightly reclined in Geri-chair. CNA's were standing in hallway of dining area conversing with each other while 11 other residents were sitting in the dining area. No staff interaction or activity observed. At 2:45 PM, resident #135 was again in #3 Nursing Station with two other residents. sitting in the same position in her Geri-chair. There was no staff interaction or activities taking place except Christmas music playing from the nearby Christmas tree. On 12/9/25 at 2:50 PM, Certified Nursing Assistant (CNA) L stated she was not familiar with the activities of resident #135 and said she usually checked the iPad to see activities and assistance needed for residents. On 12/10/25 at 9:45 AM, resident #135 in #3 Nursing Station with three other residents. There was no staff interaction or activity observed besides some Christmas music playing from nearby Christmas tree. After lunch at 2:20 PM, resident in #3 Nursing Station with three other residents. Christmas music playing and no staff interaction or activity observed. On 12/11/25 at 9:30 AM, resident #135 observed in #3 Nursing Station with three other residents. Position unchanged, Christmas music playing and no staff interaction or activity observed. On 12/11/25 at 2:15 PM, Nurse L stated she cared for resident #135 multiple times and said sometimes she got her days and nights confused. The nurse stated 'Activities' staff take resident #135 to activities that are scheduled during day. The nurse stated the facility had a lot of activities. The nurse did not say why resident #135 was observed over the past four days only sitting in #3 Nursing Station and not participating in activities. On 12/11/25 at 3:30 PM, resident #135 in room eyes closed, lying on right side towards wall. Room is quiet with no TV or music. On 12/11/25 at 3:53 PM, the Activities Director explained sensory stimulation activity included, aroma therapy, hand massage, foam puzzles, music therapy, sensory blanket, butterfly garden, and sitting outside. She stated activities are documented daily in the plan of care. She stated #3 Nursing Station if primarily hospice patients and were usually included in activities in the morning and afternoon because the residents were more awake. She stated her staff was responsible for bringing residents to activities. Resident activity log reviewed for past two weeks and reflected resident #135 was not present on the attendance log for attending any activities. 2. Resident #5 was admitted to the facility on [DATE] and her diagnoses included Sequelae of Cerebral Infarction, Hemiplegia, Hemiparesis, Adjustment Disorder, Anxiety and was Hospice. On 2/9/25 at 12:55 PM the resident was in a high back wheelchair sitting in front of Nurse's Station 3. The resident's head hung down with her face in her right hand. There was Christmas music coming from a Christmas tree and she sat there with other residents. There were not any staff to engage the residents, and the residents did not interact amongst themselves. Review of the resident's admission Minimum Data Set (MDS) dated [DATE] noted she scored a '0 on the Brief Interview for Mental Status (BIMS), which means the resident's cognition was severely impaired. The MDS noted resident #5's customary routine & activities in Section F. This section noted music, doing favorite activity(s) and going outside for fresh air were very important to the resident #5. The resident's care plan noted the resident had left eye visual impairment, communication and mobility problems. The care plan noted the resident alteration in activity involvement as she participates in one-to-one conversation and prefers time in room. The activity care plan goal read, .will express satisfaction with Bingo and maintain involvement. The activity care plan approaches indicated the resident #5's preference for classic/Christian music, outdoor strolls, play bingo and watching TV channels 62 and 18. On 8/15/25 the resident's music preference was updated to merengue, bachata and R&B music. On 12/10/25 at 2:03 PM, resident #5 was in her wheelchair, sitting across from Nurse's station 3. Christmas music was playing and there were several other residents in the area. Again, there were not any staff to engage the residents, and the residents did not interact amongst themselves. The residents in this area appeared to be of poor cognition. Resident #8 was admitted to the facility on [DATE] and his diagnoses included Alzheimer's disease, Chronic Obstructive Pulmonary disease, Schizoaffective disorder, Dementia and was currently on Hospice. On 12/9/25 at 1:06 PM, resident #8 was in his [NAME]-chair, which was parked against the wall, across from Nurse's station 3. There were 5 other residents in the area, and they were not conversing with each other and there were no staff to engage the residents in an activity. Christmas music was coming from the Christmas tree. Review of resident #8's annual MDS dated [DATE] noted the resident cognition was severely impaired. Section F, Customary Routine/Activities, noted it was very important for the resident #8 to do things with groups of people and do his favorite activity. The resident's care plan noted he had a communication problem related to his disease state and he is unable to express his wants/needs. However contrary to his communication problem, his activity care plan goal read, Resident will attend/participate in activities of choice 3- 5 times weekly. The approaches on the resident's activity care plan were revised on 5/1/25 and his preferred activities were upbeat Spanish music, singing, watching horse videos, garden stroll, rummaging through sensory box, sensory items. On 12/10/25 at 12:35 PM, resident #8 was in his Geri-chair and it was slightly reclined. His chair was parked across from Nurse station 3, with the back of the chair up near the wall, next tot the water cooler. Christmas music was coming from the Christmas tree and there were 8 other residents in the area. The residents did not engage each other; they sat in their chairs as the Christmas music played on a continuous loop. On 12/11/25 at 3:45 PM residents #5 and #8 were sitting in their chairs across from Nurse's station 3. Christmas music was playing from the Christmas tree and there were several residents in the area, just sitting in their chairs. A few minutes later, at 3:53 PM, the Activities Director gave an explanation/overview of the facility's Activity Program. She stated she could not determine if he likes Christmas music, but he would get agitated if he does not like something. When asked why resident's #5 & #8 were not provided Spanish style music based on each of their activity care plans, the Activity Director stated that she needed more activity staff. When resident #5's care plan goal for bingo was discussed, the Activity Coordinator said, Bingo is on the weekends. However, she could provide documented evidence when resident #5's most recent bingo participation. She stated the music box that comes with the Christmas tree on a continuous loop, and the same Christmas music is played. When asked why the residents, which included #5, #8 and # 135, were situated near Nurse's station 3, she said station 3 is primarily Hospice residents. She could not explain why each Department Manager could not take a few minutes out of their day, on a rotating schedule, to engage the low cognitive aware residents and ensure all residents have meaningful activities.

Based on observation, interview, and record review, the facility failed to prevent medication administration error rate of 5% or greater for 1 of 13 residents sampled for medication administration, (#87). There were 2 medication errors in 25 opportunities for a medication error rate of 8%. Findings:Resident #87 was admitted to the facility on [DATE] with diagnoses that included dementia, insomnia, anxiety, depression, restlessness and agitation, moderate protein-calorie malnutrition, and generalized muscle weakness. On 12/10/25 at 10:48 AM, Registered Nurse (RN) A was observed during medication administration for resident #87. She pulled up Morphine Sulfate 0.25 milliliters (ml) liquid solution into a medication cup and Lorazepam 0.5 ml liquid solution into another cup. RN A proceeded to resident #87's room to administer the medication. He was lying in bed with his eyes closed in a semi-reclined position with the hospice nurse sitting at the bedside. RN A brought the medication cups to the resident's lips and poured the contents of both cups into his mouth. It was unable to ascertain whether the resident swallowed the medication or if he was holding it in his mouth. Review of resident #87's active physician orders for 12/10/25 revealed he had been receiving hospice services since 8/22/25. He had orders for Morphine Sulphate (concentrate) oral solution 0.25 ml sublingually (under the tongue) every 2, 4, and 6 hours for shortness of breath and Lorazepam oral concentrate 0.5 ml under the tongue every 2 and 4 hours for shortness of breath. On 12/10/25 at 12:05 PM, the hospice nurse was at the bedside with resident #87 and confirmed he was on crisis care, which meant a hospice nurse would be at the bedside 24 hours per day during the resident's decline or active dying process. She said she observed when RN A administered the medications to resident #87 and noted they had not been properly administered under the tongue as ordered. She said it was important to administer these medications under the tongue to ensure they were absorbed into the body and not left sitting in the resident's mouth due to difficulty with swallowing. She said she did not educate the nurse because she was aware that the facility did not have the supplies needed to administer the medication in the correct way. On 12/10/25 at 12:12 PM, RN A said she was aware the medications had been administered incorrectly and that they were supposed to be administered sublingually. She explained the pharmacy provided an insulin syringe with the medication, but the syringe had the measurements scratched out from multiple uses and she had not requested a new syringe from the pharmacy. She said the correct way to pull up the medications was to pull them up into two syringes and administer them under the tongue instead of using the medication cups which would not allow for them to be placed under the tongue of the resident. The nurse stated she had not let her supervisor or Director of Nursing (DON) know she did not have the needed supplies to appropriately administer the medications per the physician order. She agreed that she should have held the medication until she was able to administer it appropriately and notified the physician. On 12/10/25 at 2:28 PM, the DON said RN A was new to the facility and was not aware there were extra syringes available for her to administer the medications. The DON indicated the nurse should have asked a supervisor. She explained her expectation was for medications to be administered per physician's order.

Based on interview, and record review, the facility failed to ensure a thorough investigation was conducted and completed for missing narcotics for 1 of 1 resident of a total sample of 44 residents, (#76). Findings: Clinical record review revealed resident #76, a [AGE] year-old-male was admitted to the facility on [DATE]. His diagnoses included cellulitis to the right lower limb, peripheral vascular disease, chronic pain syndrome, and dorsalgia. Review of the resident's physician orders revealed an order dated [DATE] for Percocet ,d+[DATE] milligram (mg) one tablet every six hours as needed for moderate pain. The order was discontinued on [DATE], and a new order was noted for Percocet ,d+[DATE] mg one tablet every six hours Review of the facility's Reportable log revealed an entry on [DATE] for misappropriation of property, and documentation revealed twenty-four (24) tablets of Percocet ,d+[DATE] mg for resident #76 was unaccounted for. On [DATE] 4:23 PM, the incident was reviewed with the Administrator, the Director of Nursing (DON) and the Social Services Director (SSD). The SSD explained she was responsible to complete the Agency For Health Care Administration (AHCA) Nursing Homes Federal Reporting Immediate and 5-day reports, notify the Ombudsman, and law enforcement of the incident, and submit the Department of Children and Family (DCF) report. She stated the investigations for reportable incidents were done by the Interdisciplinary Team (IDT). The AHCA Report #189603 Immediate, and 5-day was submitted by the facility on [DATE], and [DATE] respectively. The DON recalled that on [DATE] at 6:45 PM, she was notified by the Clinical Care Leader of a discrepancy in narcotic count where 24 tablets of Percocet for resident #76 were unaccounted for. Actions taken by the facility included a search of the medication cart, and medication room was conducted on Station 2. The resident's Medication Administration Record (MAR) was reviewed, a pharmacy inquiry was made regarding delivery of the medication, staff present were interviewed, the Physician Assistant was notified of the missing medication, and a prescription was obtained for pain medications for the resident, which was replaced at the facility's expense. On [DATE], and on [DATE], a drug test was performed for three nurses. Four remaining medication carts were searched for a total of five of five carts. In-service was conducted with nursing staff regarding the Process of completion of the Controlled Drug Record, and medication delivery process. Clinical leaders were to check the Controlled Drug Record daily for completion. The DON stated the Pharmacy verified they delivered 30 Percocet tablets to the facility on [DATE], and 120 tablets on [DATE]. She stated that initially the resident was on the medication every 6 hours as needed, but with the frequency of use, the medication was changed to one tablet every 6 hours around the clock on [DATE]. The DON recalled the facility reviewed copies of drug receipts, and some signatures were not readable. She said the investigation revealed narcotics were not being entered properly on the Controlled Drug Record. She verbalized the facility could not identify when the resident's Percocet tablets went missing, and they could not identify who was involved. She shared the Root Cause was due to varied staff, facility nurses and Agency nurses, and a lack of oversight. An Investigation Statement dated [DATE] and documented by the SSD, revealed the resident stated he had not received his Percocet, and the SSD explained the facility had to report, and investigate the incident. No other statements could be identified, and when asked about statements from the staff, the DON said she did not see any other statements in her binder. When asked if an Ad Hoc Quality Assurance Performance Improvement (QAPI) was completed, the DON replied no, and said the Medical Director was made aware since he was the resident's physician. She stated the incident was discussed in QAPI on [DATE]. They spoke about what was identified and spoke about the education and process in place. Review of the AHCA 5-day Report, revealed documentation to indicate the facility would conduct audits weekly for four weeks, then monthly for two months. Review of the Controlled Medication Audit revealed audits were completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The completion instructions on the Audit form read, The DNS (Director of Nursing Service) or designee, to audit narcotic procurement and counting daily x 1 week then 2 times weekly x 2 weeks then weekly x 4. Questions/probes on the form were: Are controlled medications properly stored with double lock? Are appropriate medications counted with change of shift each day with signatures to indicate no concerns? Are all medications reviewed and signed in by the floor nurse with pharmacy courier when delivered? Narcotics that are discontinued, or expired of a discharged resident are immediately destroyed and/or returned as appropriate? A check mark should be in the yes or no column, and there was a column for any additional comments. The DON stated the audits were completed for two weeks, then the Regional Clinical Nurse directed the facility to discontinue the audits and change to probing questions. The audits did not address the accurate completion of the Controlled Drug Record. On [DATE] at 9:40 AM, the DON stated the facility could not prove the resident's medication was missing, and the facility did not have copies of invoices for medications delivered. Review of the Work with Order File provided by the facility, that was faxed from the Pharmacy on [DATE] at 5:04 PM, revealed the following: Oxycodone-Acetaminophen (Percocet): ,d+[DATE] Tab on [DATE], 30 tablets were ordered and shipped to the facility. On [DATE] 12 tablets were ordered and shipped, on [DATE] 12 tablets were ordered, and was shipped on [DATE]. On [DATE], 12 tablets were ordered and shipped, and on [DATE], 120 tablets were ordered and shipped to the facility. This revealed a total of 186 tablets of Percocet ,d+[DATE] mg was delivered to the facility between [DATE] to [DATE]. Review of the resident's MAR for the period [DATE] to [DATE] revealed a total of 82 tablets were administered to the resident, and from [DATE] until [DATE], 77 tablets were administered, a total of 159 tablets out of 186 tablets, leaving a balance of 27 tablets that were unaccounted for. The Work with Order File from the pharmacy was requested by the facility after interviews with the surveyor. The facility could not verify, and ensure an accurate inventory, and accounting of the Percocet received and administered for resident #76 prior to [DATE]. On [DATE] at 4:05 PM, the investigation was discussed with the DON, regarding missing statements from staff, and follow-up with the pharmacy. The DON said there was a lack all around and confirmed that a thorough investigation was not done. The facility's policy Abuse And Neglect-Rehab/Skilled, Therapy & Rehab reviewed and revised on [DATE], read, The investigation may include interviewing employees . Interview all involved (employee, resident and family) .Consider having each person write his or her memory of the event. If possible, get signed and dated statements from any witnesses.

Based on interview, and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was completed to evaluate the need for additional mental health resources and appropriate placement of a resident prior to admission for 1 of 1 residents reviewed for PASRRs of a total sample of 44 residents, (#29). Findings: Resident #29 was admitted to the facility on [DATE] from an Assisted Living Facility with diagnoses that included unspecified dementia, Bipolar disorder, and Major Depressive Disorder. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] section A1500 (PASRR) coded O which incorrectly indicated resident #29 did not have a serious mental illness and/or an intellectual disability according to the stated level II PASRR. Review of the MDS Section I, Active Diagnosis revealed resident #29 was diagnosed with Non-Alzheimer's dementia and Manic depression/Bipolar disease. A Psychology Evaluation Note dated 3/07/23 revealed resident #29 reported recurrent, mild depressive symptoms which included trouble concentrating, fatigue, decreased self-esteem, a lack of pleasure and a loss of interest in activities she normally found pleasurable. The psychologist described resident #29 as having mild cognitive impairment with a psychiatric history of depression, anxiety and episodic mood difficulties. Review of resident #29's medical record revealed no documentation of a level I PASRR, nor a level II PASRR in her record. On 2/01/24 at 10:48 AM, the Social Service Director described a level I PASRR was used during pre-admission to assess a possible resident's mental, physical and psychological abilities to determine if a resident with psychiatric history was appropriate for the long-term care or skilled nursing setting. She explained the screening also determined if a resident needed further screening for additional specialized services for their serious mental illness or intellectual disability. The Social Service Director stated the PASRR screenings were important to help meet the residents' needs, properly develop their plan of care and ensure the resident would be the right fit for the facility. She further explained the level I PASRR was supposed to be completed before admission to the facility, and if a resident was found without screening completed, she would be tasked to complete it. On 1/31/24 at 2:36 PM, the station 1 Unit Manager (UM) stated she was not able to find a level I nor a level II PASRR in resident #29's medical records. She confirmed resident #29 had a psychiatric history and should have had a level I PASRR on admission. She was unsure if resident #2 required a level II PASRR. About an hour later at 3:28 PM, the station 1 UM confirmed the facility could not provide documentation of a level I nor a level II PASRR for resident #29. She explained that because the level I screening had not been done, the Social Service Director had just completed one which indicated resident #28 had a serious mental illness and required a level II PASRR which was to be scheduled. On 2/01/24 at 9:51 AM, the Social Service Director stated the level I PASRR was usually included in the paperwork that came from the hospital but if a resident was admitted from home or from an Assisted Living facility like resident #29, they usually would not have one performed prior to admission. She explained the previous Health Information Management (HIM) supervisor had done audits on all new admissions to check the needed paperwork, but she was not sure who, if anyone was currently responsible for that task. On 2/01/24 at 10:26 AM, the current HIM supervisor stated she was unaware of any audits of new admission documents by the previous supervisor nor of any problem with missing PASRR screenings. She explained she assumed nurses were responsible to ensure the correct paperwork was included in the admission documents and that they should notify the Social Service Director if the screening was needed. The HIM supervisor stated a facility wide audit was needed to ensure all applicable residents had a PASRR completed. On 2/01/24 at 3:18 PM, the Social Service Director stated they had not started an audit to determine how many residents were missing the PASRR, but she could see from her notebook at least five other residents who came from home were missing them. The Social Service Director stated this was a problem. Review of the job description, Health Information Management Technician, Long Term Care dated 11/13/23 revealed the employee would understand regulatory standards for accurate medical records. They would also complete admission-related functions including retrieval of previous medical records. The Pre-Admission Screening and Resident Review policy dated 12/11/23 described the purpose to determine admission criteria for residents with mental illness and ensure those individuals would receive the care and services needed in the most appropriate setting. The policy defined serious mental illness to include mood, or severe anxiety disorders and others. The document indicated, All prospective residents will be screened for possible serious mental disorders or intellectual disabilities and related conditions. The policy further detailed a positive level I screen necessitated an, in-depth evaluation of the individual, known as a PASRR level II conducted by a state- designated authority prior to admission.

Based on interview, and record review, the facility failed to ensure accurate record for receipt and disposition of controlled medications was completed to enable accurate reconciliation, and to account for missing Percocet tablets for 1 of 1 resident of a total sample of 44 residents, (#76). Findings: Clinical record review revealed resident # 76 a [AGE] year-old-male was admitted to the facility on [DATE]. His diagnoses included cellulitis to the right lower limb, peripheral vascular disease, chronic pain syndrome, and dorsalgia Review of the resident's physician orders revealed an order dated 3/09/23 for Percocet 5-325 milligram (mg) one tablet every six hours as needed for moderate pain. The order was discontinued on 9/26/23, and a new order was noted for Percocet 5-325 mg one tablet every six hours. Review of the facility's Reportable log revealed an entry on 10/20/23 for misappropriation of property, and documentation revealed twenty-four (24) tablets of Percocet 5-325 mg for resident #76 was unaccounted for. On 1/30/24 at 4:23 PM, the incident was discussed with the Administrator, the Director of Nursing (DON, and the Social Services Director (SSD). The SSD explained she was responsible to complete the Agency For Health Care Administration (AHCA) Nursing Homes Federal Reporting Immediate and 5-day reports, notify the ombudsman, and law enforcement of the incident, and submit the Department of Children and Family (DCF) report. She stated the investigations for reportable incidents was done by the Interdisciplinary Team (IDT). The DON recalled on 10/20/23 at 6:45 PM, she was notified by the Clinical Care Leader of a discrepancy in narcotic count, and that 24 Percocet tablets were missing for resident #76. The DON stated a search of the medication cart, the medication room on Station 2, and the remaining four medication carts in the facility was conducted. The resident's Medication Administration Record (MAR) was reviewed, staff on duty at the time were interviewed, and an inquiry was made to the Pharmacy regarding delivery of the medication. She stated the Physician Assistant was made aware, and a prescription was obtained for pain medication for the resident, to be replaced at the facility's expense. The DON stated the Pharmacy confirmed delivery of Percocet for the resident on 9/22/23 of 30 tablets, and on 9/26/23, of 120 tablets. She stated that initially, the resident was on Percocet every 6 hours as needed, but with the frequency of use, the medication was then changed on 9/26/23, and scheduled for every 6 hours around the clock. The DON recalled the resident's MAR reviewed for the period 9/17/23 to 9/25/23, and 9/26/23 to 10/20/23, revealed the resident received Percocet 5-325 mg every 6 hours, and the facility verified that 24 tablets of Percocet were missing. She stated no medication was available for the resident on investigation, and to address the resident's pain, the facility called the physician, and the pharmacy, and the facility assumed payment for the medication sent by pharmacy, and an authorization code was received from the pharmacy to retrieve the medication from their onsite emergency medication dispenser for immediate administration. The DON stated drug test was performed on 10/21/23, and on 10/23/23, on three nurses who worked the 7 AM to 7 PM, and 7 PM to 7 AM shifts and results were all negative. She said statements were obtained from the nurses; however, the facility could not provide documentation of the statements. The DON recalled the facility reviewed copies of drug receipt, and some signatures were not readable. She said the investigation revealed narcotics were not being entered properly on the Controlled Drug Record. The DON verbalized the facility could not identify when the resident's Percocet tablets went missing, and they could not identify who was involved. She shared the Root Cause was due to varied staff, facility nurses and Agency nurses, and a lack of oversight. She stated in-service education to address the delivery of narcotics was initiated, and staff were educated that two nurses must receive and sign the receipt for the drug and obtain a copy of the receipt. The DON said audits were started on 10/25/23 to 10/30/23, however, no documentation could be identified to indicate the Controlled Drug Record, the Controlled Medication Utilization Record were checked, and reconciled with the medication packets. She stated the Pharmacy Consultant did not review the resident's Controlled Medication Utilization Record, but she was informed by the Consultant Pharmacist, that the incident was discussed at the Pharmacy Corporate level. On 1/30/24 at 5:16 PM, Licensed Practical Nurse (LPN) A confirmed that he cared for resident #76 on 10/20/23. He recalled the resident was scheduled to receive Percocet 5-325 mg but when he checked the medication cart, there was no Percocet for the resident. LPN A stated he called the pharmacy and was told three packets of Percocet for resident #76 had been delivered to the facility. He recalled he informed the pharmacy there was no Percocet and was told the Pharmacy could not dispense any more. The LPN said the supervisor followed up with the pharmacy and was told the pharmacy could not send any more Percocet. LPN A stated the supervisor reviewed the resident's narcotic sheet, and at first thought the Percocet was missing, but it was a miscalculation of the medication, and no medication card was missing. On 1/31/24 at 9:40 AM, the DON stated that initially, the facility thought 24 tablets of Percocet were missing. She said the pharmacy had sent 120 tablets on 9/26/23. She stated the facility could not prove the medication was missing. The Controlled Medication Utilization Record for the resident was reviewed with the DON. On 9/15/23, and on 9/22/23, 12 tablets of Percocet 5-325 mg was received and administered leaving a balance of 0 on the respective Records. On 9/26/23, 120 tablets of Percocet 5-325 mg was received. Between 9/28/23 to 10/05/23, 30 tablets were administered. A Controlled Medication Utilization Record for resident #76 could not be identified for the period 9/23/23 to 9/25/23, and for the period 10/06/23 to 11/05/23. The DON stated the records could not be found, verbalizing there was an issue with missing records in the Health Information Management (HIM). Based on information reviewed on the resident's Controlled Medication Utilization Records, a total of 144 tablets of Percocet 5-325 mg was received by the facility between 9/15/23 to 9/26/23. Review of the resident's Medication Administration Record (MAR) revealed documentation to indicate the resident received Percocet 5-325 mg on 9/23/23 at 12:34 AM, at 12:45 PM, and at 6:45 PM. On 9/24/23 at 7:14 PM, and on 9/25/23 at 11:00 AM, and 11:15 PM. The resident's Controlled Medication Utilization Record for this period could not be found. As per the DON, doses were obtained from their onsite emergency medication dispenser with authorization. Review of the resident's MARs from 10/05/23 to 10/20/23 revealed 41 tablets of Percocet 5-325 mg was administered to the resident. The total amount of Percocet tablets administered to the resident based on review of Controlled Medication Utilization Records, and his MAR for the period 9/01/23 to 10/20/23 was 125. From 9/15/23, to 9/26/23, 144 tablets of Percocet was delivered to the facility, which indicated nineteen (19) tablets were unaccounted for. This was confirmed by the DON. She said the facility did not know if the medication was sent by the pharmacy, since the facility did not have any paperwork to prove the delivery. She stated the facility did not have copies of the invoices for the medications delivered. The DON stated the Controlled Drug Record was not completed accurately by the nurses when narcotics were received, so the facility could not account for medications received, or the name of the resident the medication was for. She stated the incident was discussed in the facility's Quality Assurance Performance Improvement (QAPI) meeting on 11/25/23. They spoke about what was identified, and the education and process in place. The DON stated the allegation was not substantiated, because the facility did not have any proof that the resident's Percocet tablets were missing, as there was a lack of documentation. She said they were unable to prove what was on hand, and what was missing, and said there must be paperwork somewhere, but the facility did not have it. On 1/31/24 at 10:32 AM, the Administrator stated that review of the report of medications retrieved from the onsite emergency medication dispenser revealed no medication was retrieved for the period 9/20/23 to 9/24/23. The facility was unable to explain where the medication documented on the MAR as administered to the resident on the dates mentioned was obtained. On 01/31/24 12:16 PM, Registered Nurse (RN) D, recalled it was on a Friday night in October 2023, the Administrator called her and said she had to come to the facility within twenty-four to forty-eight hours for a drug test as some narcotics were missing. RN D stated she came to facility and had the test done, and it was negative. She said she was not told which resident's narcotic was missing, only that some Percocet were missing for a resident she was assigned to. On 01/31/24 at 2:15 PM, resident #76 stated he recalled when he could not get his medication, because it was not in the medication cart, and the nurse did not know the code for the emergency dispenser. When asked if he was told why the medication was not available, the resident said it was because the nurse did not have a code. Review of the Work with Order File provided by facility, that was faxed from the Pharmacy on 1/31/24 at 5:04 PM revealed the following: Oxycodone-Acetaminophen (Percocet): 5-325 Tab that on 9/05/23 30 tablets were ordered and shipped to the facility. On 9/15/23 12 tablets were ordered and shipped, on 9/17/23 12 tablets were ordered, and was shipped on 9/18/23. On 9/22/23, 12 tablets were ordered and shipped, and on 9/26/2023, 120 tablets were ordered and shipped to the facility. This revealed a total of 186 tablets of Percocet 5-325 mg was delivered to the facility between 9/05/23 to 9/26/23. Review of the resident's MAR for the period 9/01/23 to 9/30/23 revealed a total of 82 tablets were administered to the resident, and from 10/01/23 up until 10/20/23, 77 tablets were administered, a total of 159 tablets out of 186 tablets, leaving a balance of 27 tablets that were unaccounted for. The Work with Order File from the pharmacy was requested by the facility after interviews with the surveyor, hence the facility could not verify, and ensure an accurate inventory, and accounting of the Percocet received and administered for resident #76 prior to 1/31/24. The facility's policy Medications: Controlled reviewed and revised on 6/13/2023 documented purpose was, To provide verification and reconciliation of all controlled medications Reconciliation: refers to a system of recordkeeping that ensures as accurate inventory of medications by accounting for controlled medications that have been received, dispensed, administered and/or including the process of disposition. The policy Medication: Missing/Diversion of Medications reviewed/revised on 9/18/2023 outlined the steps to be taken by the facility in the event of missing/diverted medications, and directs that an investigation should be performed, and the facility should work closely with the pharmacy staff to prove when and what amount of the medication was sent to the location.

Based on observation, interview, and record review, the facility failed to act on PRN (as needed) psychotropic medication duration limits for 2 of 5 residents reviewed for Unnecessary Medications from a total sample of 44 residents, (#91, #98). Findings: 1. Review of the medical record revealed resident #98, a [AGE] year old male was admitted to the facility on [DATE] and readmitted from an acute care hospital on 10/09/23 with diagnoses that included cerebral vascular accident (stroke), aphasia (inability to formulate speech), dementia, lack of coordination, type 2 diabetes mellitus, and unsteadiness on feet. The Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date (ARD) 8/03/23 identified the resident was unable to complete a Brief Interview for Mental Status (BIMS), was rarely or never understood, noted by staff to have short-term and long-term memory problems, severely impaired cognitive decision making abilities, disorganized thinking that fluctuated and changed in severity, and he had no behaviors or rejections of care. The assessment showed the resident required assistance from staff to complete Activities of Daily Living (ADLs), mobility functions in and out of bed, and to walk; he fell two or more times, and he received high risk antipsychotic and antianxiety medications five out of seven days, and antidepressant medication for seven out of seven days during the look-back period. The Comprehensive Care Plan Focus included communication problems related to expression of thoughts, behavior symptoms, grief, risk for acute pain, ADL self-care deficits, history of falls, and risk for injuries from falls. On 1/29/24 at 11:20 AM, resident #98 was observed on the nursing unit sitting at a group table of four. He was not able to verbally communicate. On 1/30/24 at 3:01 PM, the resident was observed walking in the hallway using a walker, assisted and supervised by two facility staff. Review of the Electronic Health Record (EHR) showed from 7/11/23 to 8/15/23, PRN medication orders were implemented for Lorazepam (anti-anxiety), Benadryl (antihistamine), and Haldol (anti-psychotic) 1 Milliliter (ml) combined in a transdermal (absorbed through the skin) gel for anxiety, every four hours. The Medication Administration Record (MAR) documented nurses administered the medication 27 times, over 36 days. From 8/15/23 to 9/05/23, PRN orders were implemented for Ativan (anti-anxiety) 1 milligram (MG) transdermal gel for anxiety, every four hours. The MAR documented nurses administered the medication 9 times, over 21 days. From 9/12/23 to 10/10/23, orders were implemented for Ativan (anti-anxiety) 0.5 MG transdermal gel for anxiety, every six hours. The MAR documented nurses administered the medication 8 times, over 28 days. The August 2023 Pharmacy Consultant Report read, resident has a PRN order for an anxiolytic, without a stop date: Ativan gel . Rationale for Recommendation: CMS (Centers for Medicare and Medicaid Services) requires that PRN orders for non-antipsychotic psychotropic drugs be limited to 14 days. On 2/01/24 at 3:26 PM, the Director of Nursing (DON) explained the facility's process for ensuring PRN psychotropic medications had a 14-day duration limit included reconciliation reviews upon resident admissions, psychiatric provider assessments, nursing management tracking, and monthly Medication Regimen Review (MRR) reports. She checked resident #98's medical record, and acknowledged there were three PRN psychotropic medication orders in place from 7/11/23 to 10/10/23 that were not reviewed by nursing management while they had extended well beyond the 14-day limit. She said she had only been working at the facility for three months and stated, there should have been a 14 day stop date. In a joint telephone interview with the DON and the facility's Pharmacy Consultant on 2/1/24 at 3:47 PM, the Pharmacy Consultant stated reports were submitted to the facility every month with recommendations that included orders that showed PRN psychotropic medication orders that were missing a stop date. He explained, the use of PRN anti-anxiety and anxiolytics were high-risk, especially in the elderly and they required special monitoring for over-use because they could mask other underlying root causes. 48878 2. Resident #91, [AGE] year-old female, was admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease, anxiety disorder, major depressive disorder, and persistent mood disorder. Review of the resident's Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 11/10/23 revealed resident #91 had severely impaired cognitive skills for daily decision making. She had indicators of behavior symptoms and rejection of care with no indicators of psychosis. She was dependent on staff for her Activities of Daily Living (ADLs) and received antianxiety and antidepressant medications. Review of resident #91's discontinued/completed physician orders dated 5/2/23 noted Ativan Transdermal Gel 1 milligram (mg) every four hours as needed (PRN) for anxiety with a discontinue date of 8/15/23. Further review of the medical record revealed the physician did not provide a rationale for the extended time frame for Ativan beyond the 14-day use. Review of the Medication Administration Record (MAR) reflected the resident received 10 doses of Ativan Gel PRN beyond the 14 days. Review of the Pharmacy Consultation Report dated 5/15/23 noted resident # 91 had a PRN order for Lorazepam (Ativan) 1 milligram (mg) without a stop date. It was recommended to document the intended duration of therapy, and the rationale for the extended time frame. The rationale for the recommendation indicated CMS requires that PRN orders for non-antipsychotic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order. Review of the resident's active physician orders revealed resident #91 had an active order since 10/26/23 for Ativan Transdermal Gel 0.5 milligram (mg) every twelve hours as needed (PRN) for anxiety. Further review of the medical record revealed the physician did not provide a rationale for the extended time frame for Ativan beyond the 14-day use and did not indicate a specific duration or stop date. The resident's MAR showed he received 17 doses of Ativan Gel PRN beyond the 14 days. On 02/01/24 at 3:26 PM the DON stated that anxiolytics prescribed as needed (PRN) should receive a 14 day stop date. She stated resident # 91 had Ativan Gel prescribed as needed (PRN) on 5/2/23 with a stop date of 8/15/23. She stated it should have had a 14 day stop date and the resident should not have received the medications past the 14 days. The DON also acknowledged the resident had an active order for Ativan Gel as needed (PRN) since 10/26/23. She stated there should have been a 14 day stop date and the resident should not have received the Ativan Gel PRN past 14 days unless the provider noted a rationale and duration for the extended time frame. On 02/01/24 at 3:47 PM, the Pharmacist stated that Anxiolytics prescribed as needed (PRN) need a stop date of 14 days or a rationale with the duration of the extended time period noted. He stated the Ativan given to the resident on an as needed basis ought to have been limited to a 14-day duration. The facility's standards and guidelines dated 2/10/23 and titled, Medication: Drug Regimen Review read, PURPOSE To prevent medication errors that could cause harm to a resident or result in resident hospitalization . To identify the potential for adverse events. pharmacists and nurses play a vital role in improving health care .

Based on interview and record review, the facility failed to maintain effective communication between nursing staff and medical providers, and failed to collaborate with a dialysis center to promote adequate treatment, monitoring, and continuity of care for 2 of 2 residents reviewed for dialysis care and services, out of a total sample of 5 residents, (#1 and #3). The facility's failure to respond appropriately to ongoing communication from the dialysis center and failure to coordinate care to ensure necessary services were arranged in a timely manner placed residents #1 and #3 at risk for potential complications and caused actual harm for resident #1, that was inconsistent with the goals of the resident and his representative. Findings: 1. Review of the medical record revealed resident #1, a [AGE] year-old male, was originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included end-stage renal disease with dependence on dialysis, coronary artery bypass graft or open heart surgery, type 2 diabetes, amputation of both legs above the knees, and hypertensive heart disease. According to the National Kidney Foundation, Dialysis is a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to. By performing some of the kidney's usual duties, dialysis helps to maintain safe levels of minerals in your blood, such as potassium, sodium, calcium, and bicarbonate. The organization's website indicated it was important to complete dialysis treatments according to the prescribed schedule and inform the dialysis provider about medications and supplements taken (retrieved on [DATE] from https://www.kidney.org/atoz/content/dialysisinfo). Hyperkalemia is a medical problem in which there is too much potassium in the blood. Potassium is necessary for the proper function of nerves and muscles, including the heart, but too much potassium can be dangerous as it can cause serious heart problems. According to the National Kidney Foundation, the normal level of potassium in the blood should be between 3.5 and 5.0 milli-equivalents per liter (mEq/L). Very high potassium needs immediate medical care as people will have few or no symptoms (retrieved on [DATE] from https://www.kidney.org/atoz/content/what-hyperkalemia). Review of the Minimum Data Set (MDS) Quarterly assessment with assessment reference date of [DATE] revealed resident #1 was cognitively intact. The document showed the resident had no behavioral symptoms and did not reject evaluation or care that was necessary to achieve his goals for health and well-being. The MDS assessment revealed resident #1 required dialysis. Review of the medical record revealed resident #1 had a care plan for dialysis related to end-stage kidney disease, initiated on [DATE]. The goal was the resident would not have any signs and symptoms of complications from dialysis. The care plan interventions instructed nurses to encourage resident #1 to go for scheduled dialysis appointments on Mondays, Wednesdays, and Fridays. On [DATE] at 11:28 AM, in a telephone interview, the dialysis center's Social Worker (SW) explained resident #1 received dialysis at the center three times weekly, on Mondays, Wednesdays, and Fridays. She recalled someone from the skilled nursing facility called the dialysis center on the morning of Wednesday, [DATE], shortly before the resident's scheduled treatment time. The SW stated the facility informed them resident #1 tested positive for COVID-19 and was on the way for his dialysis treatment. The SW explained she informed the facility staff member that the dialysis center was not able to accommodate patients with COVID-19 at that time, but she would reach out to other centers that might be able to treat resident #1. The SW stated she called the facility on Thursday [DATE] in the morning to inform them she still had not found a dialysis center that could offer services for resident #1 due to his communicable disease. She stated she informed them the resident should be transferred to the hospital for dialysis. The SW recalled she contacted the facility again on Thursday afternoon to inquire about resident #1's status and whether he had been transferred to the hospital yet. The SW stated she was told the resident was still in the facility and she asked if the nurse could contact his attending physician to obtain an order for hospitalization for dialysis. The SW said, I was told that the physician would not send him to the hospital, and would continue to monitor him in the facility. I expressed my concerns and strongly advised hospitalization as he was a cardiac patient and they said they would let the physician know. The SW recalled on the morning of Friday [DATE] at about 10:00 AM, she asked the dialysis center's Clinical Coordinator to call the facility to explain the importance of sending the resident to the hospital as he had not been dialyzed since Monday. The SW emphasized the facility had been told multiple times that resident #1 needed to be treated in a hospital setting if a dialysis center was unavailable. She stated after the Clinical Coordinator spoke with the facility's Regional Director of Nursing (DON) there was no further communication that day. She stated when she arrived at work on the following Monday morning, she found out resident #1 died . The SW said, He was young and very compliant with his treatment. He would never have chosen to miss treatments. On [DATE] at 11:52 AM, in a telephone interview, the dialysis center's Clinical Coordinator recalled a telephone conversation with the facility's DON on Friday [DATE]. the Clinical Coordinator confirmed the telephone call was initiated by the dialysis center as the staff were concerned that resident #1 would miss yet another scheduled treatment. The Clinical Coordinator stated the DON began to read results from a lab report to her, but when she heard the resident's potassium level of 6.9, she interrupted immediately and warned that the level was too high. The Clinical Coordinator explained she recommended an immediate transfer to the hospital as she knew the resident had not been dialyzed for a long time and his potassium was too high. She stated in the three years resident #1 received dialysis at the center, she had never known him to have a high potassium level. The Clinical Coordinator explained dialysis removed excess potassium from the blood which was especially important for patients with cardiac diagnoses. She recalled the Regional DON stated the facility's physician did not want to send him out to the hospital as he was being monitored in-house. The Clinical Coordinator stated she told the Regional DON that if the facility physician was not a nephrologist, a doctor who specialized in treating diseases that affected the kidneys, resident #1 needed to be treated at a hospital. The Clinical Coordinator stated she was saddened but not shocked at the news of the resident's death as she was aware that was a potential outcome of missing dialysis. On [DATE] at 12:16 PM, in a telephone interview, resident #1's ex-wife explained she was his healthcare surrogate. She recalled the resident called her to let her know he tested positive for COVID-19, but he never told her he missed dialysis treatments. The ex-wife stated she would have expected the facility to notify her of the missed treatments. She said, If I had known, maybe I could have pushed more to get him to the hospital. The ex-wife stated she was informed the facility tried to give medication in place of dialysis, but the resident was ultimately transferred to the hospital on Friday, [DATE]. She recalled the following morning she received a call from the Emergency Department (ED) physician who explained the resident was put on dialysis to try and lower his potassium level. The ex-wife stated the ED physician explained at some point after dialysis, the resident had a cardiac event, his heart stopped, and he died . She stated she felt like the facility did not value her ex-husband as a human being and his death was devastating for the entire family. She confirmed he would never have wanted to miss dialysis treatments. On [DATE] at 12:35 PM, the facility's DON stated resident #1 tested positive for COVID-19 on a Tuesday and the facility notified the dialysis center. She explained the dialysis center could not accept the resident for treatment so the facility notified the attending physician and obtained an order for immediate labs on Thursday. The DON stated based on the lab results, the resident received an order for a drug to decrease the resident's potassium level. She emphasized the resident only missed one dialysis treatment prior to being transferred to the hospital. When asked if it was possible for one missed treatment to have a negative impact on the resident's health, the DON did not respond. On [DATE] at approximately 12:40 PM, the Regional DON stated the facility's administrative and clinical leadership team met after they were informed resident #1 died in the hospital. She said, I asked what the current process was for missed treatments. They did not appear to have a process in place to address missed dialysis treatments. The Regional DON explained nursing staff thought that calling the physician and getting orders was adequate and they did not escalate the issue to nursing administration. She acknowledged she was called out of clinical meeting on Friday morning to speak with the dialysis center's SW and Clinical Coordinator. The Regional DON verified they expressed concerns about resident #1's labs and recommended sending him to the hospital. She confirmed the Clinical Coordinator informed her the dialysis center had called the facility prior to Friday regarding transferring the resident to the hospital. On [DATE] at approximately 12:45 PM, the DON stated after she was made aware of the situation on Friday morning, she called resident #1's attending physician who directed her to absolutely send the resident to the hospital. The DON confirmed the facility did not utilize 911 for Emergency Medical Services (EMS); instead staff contacted a non-emergency ambulance service at about 11:00 AM and they provided an estimated time of arrival of two hours later. On [DATE] at 1:07 PM, the Station 1 Registered Nurse (RN) Unit manager (UM) recalled resident #1 tested positive for COVID-19 during facility-wide testing on Tuesday, [DATE]. She explained she notified the dialysis center on Wednesday, [DATE] at about 8:45 AM, just before the resident was to leave for his dialysis treatment, and was informed he could not receive his treatment at that location. She said, I expected them to take him that day. She did not provide a response when asked why the facility did not notify the dialysis center on Tuesday morning when the resident tested positive. The RN UM described multiple conversations with the dialysis center SW on Wednesday and Thursday, with no positive feedback on a dialysis location that could meet the needs of a patient with COVID-19. She stated at about 12:35 PM on Thursday, [DATE], she called the Physician Assistant (PA) who worked under the supervision of resident #1's attending physician. The RN UM stated the PA ordered immediate labs and instructed her to monitor the resident for changes in status. She recalled she asked the PA if the resident would be transferred out, and he wanted the labs done first. She said, I spoke to resident and evaluated him. No negative findings at that time. I explained the issues with dialysis center. He was not happy about that. I told him that if they don't find a way to dialyze him, he would have to go to the hospital. The RN UM stated the lab results showed a high potassium level and the PA ordered a daily oral medication to treat the condition, Sodium Polystyrene Sulfonate for three days, with follow up labs on Monday [DATE]. She stated the PA also discontinued resident #1's daily potassium supplement. On [DATE] at 3:39 PM and [DATE] at 9:39 AM, in telephone interviews, the dialysis center's Advance Practice Registered Nurse (APRN) recalled the SW informed her resident #1 tested positive for COVID-19 and the nursing facility did not want to send him to the hospital for dialysis. She stated she told the SW the resident must be sent to the hospital if the facility was not able to provide in-house dialysis. The APRN stated she was not surprised resident #1 had a high potassium level on Thursday afternoon as his last dialysis treatment was on Monday. When asked about the effect of a potassium supplement in that situation, she expressed surprise and stated that drug was not on the resident's medication list at the dialysis center. The APRN emphasized if she had seen it, she would have discontinued the potassium supplement. She explained the dialysis center expected the facility to provide current medication lists so dialysis providers would be aware of clinical conditions that might affect the individual's treatment plan. She confirmed that lack of communication affected effective collaboration on the plan of care. She said, I would expect collaboration with medication changes at the very least. She explained daily potassium supplements were discouraged for dialysis patients. She stated she usually did not replace this electrolyte unless the level was below 3.0, and then only with a one-time dose. The APRN explained low potassium levels were usually treated by adjusting the potassium level in the cleansing fluid used during dialysis treatments. She said, I would expect them to communicate and call before or after they add something like potassium. The APRN stated her expectation was the facility would have used EMS, not non-emergency transport, to transfer resident #1 to the hospital when his lab result showed a potassium level of 6.9. She stated treatment with Sodium Polystyrene Sulfonate was appropriate in situations where a dialysis machine was not immediately available, but dialysis should be started as soon as possible. She explained the drug would lower potassium levels temporarily, but within a few hours the levels would increase. The APRN explained resident #1 was at high risk for an acute cardiac event. On [DATE] at 12:20 PM, in a telephone interview, the dialysis center's nephrologist confirmed he completed resident #1's monthly assessment on Monday, [DATE], his last day of dialysis. The nephrologist explained it was standard for dialysis to be scheduled three times weekly as it is an intermittent treatment for patients with little or no residual kidney function. He verified resident #1 needed dialysis three times weekly. The nephrologist explained there was the potential for multiple complications if dialysis was not done, including electrolyte issues. He validated a potassium level of 6.9 was very concerning and when informed the resident was treated in the facility with Sodium Polystyrene Sulfonate, the nephrologist said, That is not appropriate to manage hyperkalemia for a dialysis patient. He would need to be dialyzed. He was not aware resident #1 received a potassium supplement and explained he should not have been receiving it; however, he acknowledged the facility and community physicians had autonomy to treat their patients. The nephrologist stated on Friday, [DATE], the day the resident was transferred to the hospital, he was on call for the hospital Emergency Department (ED) and they called me because he was there. The nephrologist explained it took time to set up a dialysis, but resident #1 was put on the machine as soon as possible, and he died later that night after the treatment was complete. The nephrologist stated it was a very unfortunate situation. On [DATE] at 2:19 PM, in a telephone interview, the PA recalled when he was informed resident #1 missed dialysis, he asked how the resident felt and was told he had no complaints. The PA stated he understood the resident would probably have his dialysis treatment on the following day, Friday [DATE]. The PA denied any conversations between him and facility staff regarding the possibility the resident would not receive dialysis the next day, and he stated he never received messages from the dialysis center regarding sending the resident to the hospital. The PA verified he ordered Sodium Polystyrene Sulfonate on the evening of Thursday [DATE], to treat resident #1's high potassium level. He explained the drug could work quickly, possibly in one day, or after one to two doses. He said, Nobody told me at any time that [dialysis] was not definitely arranged. If I would have known, I may have made a different decision on Thursday. On [DATE] at 2:54 PM, the Station 1 RN UM stated when she spoke with the PA on Thursday afternoon, she was hopeful resident #1 would be able to get his dialysis treatment on Friday morning as the dialysis center was still actively searching for a location. The RN UM did not recall telling the PA that resident #1's dialysis treatment was confirmed for Friday, [DATE]. She said, Even during the last conversation on Thursday, [the dialysis center] did not sound very sure. Review of Progress Notes revealed the Station 1 RN UM contacted the dialysis center on Thursday, [DATE] at 12:35 PM. The note indicated the dialysis center was unable to treat residents who were positive for COVID-19. A progress note dated [DATE] at 1:35 PM revealed the RN UM spoke with the dialysis center's SW and was informed they still had not found a dialysis site for resident #1. On [DATE] at 9:56 AM, the DON stated the facility was aware resident #1 needed his dialysis treatments and they proceeded step by step towards that end after he tested positive for COVID-19 with a rapid antigen test on Tuesday, [DATE]. The DON acknowledged the resident's medical record did not show any documentation of the facility's attempts to secure dialysis treatment for resident #1 in the hospital until dialysis center staff contacted the facility's Regional DON on Friday, [DATE]. She explained after a positive antigen test, the facility's process was to collect another specimen and obtain a follow up polymerase chain reaction (PCR) test from the lab for confirmation of the COVID-19 diagnosis. The DON stated the facility sent the PCR test to the lab and a negative result was reported on [DATE], after resident #1's death. On [DATE] at 10:31 AM, the facility's Staff Educator stated the facility did not provide detailed education to nurse on the care of residents who required dialysis. However, she explained each resident who went out to dialysis treatments had a binder with a communication form to guide the nursing assessment and ensure necessary monitoring was completed. The Staff Educator stated she expected nurses to check the binder prior to each dialysis appointment to verify there was a face sheet with demographic information and an updated medication list when if there was a change in physician orders. She stated on return from dialysis, the facility nurse should review the resident's form for pertinent information and/or recommendations from the dialysis center in case there are new orders. On [DATE] at 11:55 AM, the Station 1 RN UM verified the assigned nurse was to complete a communication form before a resident left for dialysis, and if the form was not returned with the resident, the nurse had to call the dialysis center to obtain the required information. She validated she would have expected nurses to provide the dialysis center with resident #1's new medication order for a potassium supplement and also a copy of the lab result that triggered the order when the change was made in September. The DON acknowledged it was important for the facility and dialysis providers to communicate regarding medications administered at both sites. She stated a current medication list should always accompany residents to dialysis treatments. Review of the Dialysis Communication/Referral (For Visits to Dialysis) form, dated [DATE], revealed the document was to be completed by the facility's licensed nurses and dialysis staff. The form included a section for staff to check if additional information such as lab results, physician orders, and medication and/or treatment administration records were attached. On [DATE] at 11:59 AM, the Health Information Management Coordinator stated she reviewed resident #1's medical record and did not find any dialysis communication forms in the facility's document storage system. On [DATE] at 4:18 PM, the dialysis center's Assistant Administrator stated to her knowledge, resident #1 had not brought communication forms to his dialysis treatments for a while. She stated the dialysis center faxed a weekly update to some skilled nursing facilities at their request. However, the Assistant Administrator said, [Name of the facility] never asked for weekly updates, and we never sent them. Review of resident #1's medical record revealed a physician order dated [DATE] for a Comprehensive Metabolic Panel (CMP) lab test. The result report dated [DATE] showed the resident's potassium level was L or low at 3.10 mEq/L. A physician order for Potassium Chloride Extended Release tablet 10 mEq once daily was obtained on [DATE]. Review of the Treatment Administration Record (TAR) showed resident #1 had a CMP ordered for chronic kidney disease on [DATE]. The lab report showed the sample was collected on [DATE] at 4:30 PM and the result indicated the resident's potassium level was CH or critically high at 6.9 mEq/L. The Order Summary Report showed physician orders dated [DATE] to discontinue the Potassium Chloride supplement and give Sodium Polystyrene Sulfonate 120 milliliters (ml) daily until [DATE], to treat resident #1's hyperkalemia. The TAR showed the facility obtained a physician order on [DATE] at 10:30 AM to transfer resident #1 to the hospital via non-emergency transportation to be dialyzed. The document indicated the resident left the facility for the hospital over five hours later, at 3:44 PM. Review of the hospital record revealed resident #1 was seen in the ED on [DATE] at 4:08 PM. Lab tests done a few minutes later at 4:21 PM revealed his potassium level remained critically high and by then had increased to 7.2 mEq/L. An electrocardiogram (EKG) was done and it showed changes associated with high potassium levels. The ED physician noted the resident was critically ill and treatments included a cardiac monitor, labs, EKG, hyperkalemia protocol, and nephrology consult for immediate dialysis. The ED physician wrote, The high probability of sudden, clinically significant deterioration in the patent's condition required the highest level of my preparedness to intervene urgently. Review of resident #1's medical record revealed a Change in Condition Evaluation dated [DATE] at 10:28 AM that showed he tested positive for COVID-19. There was no documentation of notification of the dialysis center until [DATE] at 8:44 AM when the Station 1 RN UM called to inform the dialysis center just before the resident was scheduled to leave for his scheduled treatment. The TAR indicated the PCR lab test to confirm COVID-19 status was scheduled for Wednesday, [DATE], but the specimen was not collected. A progress note dated [DATE] at 5:58 AM read, PCR testing supplies not available. Notified lab and was advised that supplies will be delivered in the morning. Specimen to be collected tomorrow. The TAR revealed the PCR lab test was rescheduled for Thursday, [DATE], but was again not collected. A progress note written by the RN UM on [DATE] at 7:55 AM read, Rescheduled due to lab not bringing specimen packet. The medical record did not show that the physician was notified the PCR test was not done, and there was no evidence the rapid antigen test was repeated to determine if resident #1 actually had COVID-19. A lab result form revealed the PCR specimen was collected on Friday, [DATE] at 4:27 AM. The result was reported to the facility on [DATE], after resident #1 died , and showed that the specimen was negative for COVID-19. Review of the facility's policy and procedure for Dialysis Services, revised on [DATE], revealed the purpose was to provide dialysis services to residents when necessary. 13252 2. Resident #3 admitted to the facility on [DATE] and his diagnoses included atherosclerotic heart disease, congestive heart failure, lack of coordination, abnormal gait and end-stage renal disease. Review of the physicians orders noted the resident was to receive dialysis, three times a week, on Mondays, Wednesdays and Fridays. The resident was to be transported to a dialysis facility/provider approximately 5 miles from the nursing home. Review of the residents dialysis care plan, initiated [DATE], indicated that the nursing home staff was not to draw blood or take blood pressure in his upper left arm due to the location of his arterial-vascular, dialysis access. However the care plan did not specify how the resident's renal care needs would be coordinated with the dialysis center, especially the communication between the nursing home and the dialysis center in regards to medication, labs, nutrition, etc, so that the resident obtain and maintains highest practicable level of function as it pertains to the resident's chronic kidney disease. On [DATE] at 11:10 AM, resident #3's direct care nurse was near his room at a medication cart. She said the resident left for dialysis at 10 AM and would return to the facility around 4 PM. The nurse did not provide any insight how resident #3's renal care needs are coordinated between the nursing home and the dialysis center. She added, the clinical nurse might communicate with the dialysis center, but she was not sure. The direct care nurse stated that no communication forms are sent with the resident, when he goes to the dialysis center and no communication forms come back with the resident upon return to the nursing home. The direct care nurse was re-interviewed at 1:50 PM, on [DATE] and she admitted that there used to be a form in which the nursing home fills out the top section when residents leave for dialysis. The dialysis center is to fill out the middle section and the nursing home is to fill out the bottom section of the form when the resident returns to the nursing home. The nurse stated that the facility had stopped using/sending out the communication form for some time but could not explain why. On [DATE] at 2:12 PM, the care plan coordinator indicated the direct care nurses were to perform pre/post dialysis documentation but was not sure if it was being done. The care plan coordinator could not describe the process how the nursing home communicates with the dialysis center so that resident #3's renal care needs could be met.

Based on record review, and interview, the facility failed to protect the resident's right to be free from neglect by not ensuring the correct procedure was followed when using a full body mechanical lift to transfer residents, failed to provide nursing care and services to ensure proper post-fall nursing evaluation was conducted and failed to complete a thorough investigation for possible neglect for a fall with major injury for 1 of 7 residents sampled for falls, (#1). This failure resulted in resident #1' transfer to the hospital for treatment of a fractured clavicle and laceration to the head requiring staples. Clavicle fracture (collarbone), is diagnosed through physical examination and x-rays. Resident #1 likely experienced severe pain and swelling at the site of the collarbone fracture and possible visible deformity in some cases. On 7/10/23 at approximately 9:30 AM, the facility failed to prevent an avoidable fall for a physically and cognitively impaired resident. The fall occurred during a transfer from a bed to a wheelchair with a full body mechanical lift. Resident #1 fell feet first from the sling while she was suspended above the floor when one of six loops that secured the sling was not attached to the lift. The staff failed to follow the policy to have two trained staff for mechanical lift transfers, failed to ensure a time out safety stop and did not ensure that all straps were secure before moving the resident away from the surface. The Certified Nursing Assistant (CNA) moved the resident before she was assessed by a nurse and did not inform the facility that the resident fell from the sling to the floor. The nurse was not notified until after the resident was lifted back into the sling and transferred back into the bed. The facility failed to ensure policies and procedures were implemented to ensure the safety of all residents who required mechanical lifts for transfers. The facility used one brand of mechanical lift. The facility's failure to conduct surveillance for the safe use of a mechanical lift to ensure staff were competent in performing transfers placed all 45 residents who required a mechanical lift for transfers at risk and resulted in Immediate Jeopardy starting on 7/10/23. The Immediate Jeopardy was removed on 8/10/23. Findings: Cross reference F689, F609, and F835 Resident #1, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included diabetes mellitus, dementia, Alzheimer's disease, anxiety disorder, and abnormal posture. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 4/22/23 revealed the Brief Interview for Mental status (BIMS) score was 3 out of 15 indicating the resident's cognition was severely impaired. Resident #1 required extensive assistance of one person for bed mobility and extensive assist of two persons for transfers. Review of the resident's annual MDS assessment with ARD of 7/21/23 showed the BIMS was not completed as the resident was rarely or never understood. The resident now required extensive assist of two persons for bed mobility and total assistance of two persons for transfers. Review of resident #1's medical record revealed a care plan dated 7/12/23 for acute pain/discomfort related to a fracture of the left clavicle. A care plan initiated 11/12/18 and revised on 7/11/23 for activities of daily living (ADL) noted the resident required physical assistance of two staff for transfers with total lift with high back medium sling. Review of the Task List Report instructed physical assist of two staff for transfers with total lift with high back medium sling. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 7/11/23 revealed resident #1 was hospitalized for a primary diagnosis of hit by (mechanical) lift. The form indicated she was not ambulatory and required two assistants for transfers. The skin care assessment indicated the resident had a bruise to her left clavicle, bruise to left foot and a laceration to posterior scalp. A Progress Note dated 7/10/23 at 1:32 PM read, resident sent out to ED [emergency department] to get CT [computed tomography] scan for injury on back of head. CNA stated the resident hit her head on one of the bars of the mechanical lift while in the lift. Resident not able to explain what happened. Resident has an open and bleeding laceration to the back of her head, alert and oriented to person, sent to ED for further assessment. On 8/08/23 at 9:50 AM, the Risk Manager stated on 7/10/23 at 10:58 AM, she was notified that resident #1 was being transferred to the hospital because she was hit on the back of the head. She stated CNA A told her the resident was lying in bed and as she moved the lift bar over to the resident to hook her up to the mechanical lift, the resident moved her head and hit one of the bars on the lift. The Risk Manager said the two CNAs who were present at the time of the injury were asked for statements of how the injury occurred. She said the next day, she reviewed the statements from the CNAs regarding the resident hitting her head and said this did not make sense as the resident had a fractured clavicle. She said leadership wanted to interview both CNAs. She noted CNA A gave the same account of the injury but CNA B's demeanor changed when she attempted to provide the same account of the incident. She explained CNA B came back not long after that interview at 11:30 AM, crying. She recanted her statement and said she observed the resident was lifted out of bed with a mechanical lift by CNA A. She said as the CNA moved the lift, the resident was suspended in midair and fell out of the lift onto the floor. The Risk Manager stated CNA B did a reenactment of the incident using a mannequin and the mannequin fell feet first out of the sling with the head on the lift and her legs were over the lift. CNA B stated at that time, she asked CNA A if they should call the nurse and CNA A told her not to notify the nurse because she wanted to transfer the resident back in bed. The Risk Manager stated CNA B said she helped CNA A get resident #1 back into the sling from the floor and transferred the resident back to bed with the mechanical lift. She stated CNA A told her they had to agree to give the same account of the incident than what actually occurred or they would both get fired. The Risk Manager stated CNA B said that CNA A cleaned up the blood from the floor first and then proceeded to notify the nurse. The Risk Manager explained CNA B did not assist CNA A to get the resident out of bed with the lift but she did assist in helping CNA A get the resident back into bed after the fall. The Risk Manager indicated CNA B should not have assisted with the resident's transfer back into bed as she was not their employee, she was from a contracted hospice agency and they could not ensure if she had mechanical lift training. On 8/08/23 at 1:30 PM, the Risk Manager stated the root cause of the incident was CNA A did not follow the process to have two staff to transfer a resident with a mechanical lift and the sling was not secured properly. On 8/07/23 at 1:09 PM, during a telephone interview, CNA A asserted resident #1 did not fall. She said she was going to transfer the resident with the mechanical lift but when she pushed the lift toward the bed, the resident turned and hit her head on the lift. It was an accident, I did not mean to hit her. I did not hook the sling to the lift because the lady moved her head when I was bringing the lift to the bed and hit her head. She did not fall, only got hit in the head with the lift. CNA A stated, you need two people when you use the lift. There was another CNA in the hall and I asked her to help me. I did not know if she was a staff of the facility. She reiterated the resident did not fall and that she did not even get the resident out of bed. She insisted the resident remained in bed before and after being hit in the head by the lift. She did not explain how the resident sustained a fractured collar bone but stated she may have applied too much pressure when she tried to stop the bleeding from the head laceration. On 8/07/23 at 4:00 PM, during a telephone interview with CNA B, she stated she worked for a contracted Hospice service and was in the hall when CNA A asked her to help transfer resident #1. She explained she was not aware if she could assist another CNA with mechanical lift transfers. She stated CNA A lifted the resident out of bed with the mechanical lift, and the resident fell out of the sling, and hit her head. She said the resident's head was bleeding and CNA A asked her to assist to get the resident back to bed. She conveyed CNA A did not want to tell the staff the resident fell but wanted to give a different account of the incident. She said CNA A told her to write that resident #1 accidentally hit the pole of the lift and if their explanations did not match, they would both lose their jobs. CNA B said when she first spoke to Administration, she told them the same explanation as CNA A. She said, my conscience was bothering me so bad that I couldn't stand it. I went and talked to the Hospice nurse and told her what really happened. She asked me what I was going to do, and I told her I want to tell them [the facility] the truth. The Hospice nurse went with me when I talked to them. I went to them and told them the truth. CNA B stated she told the administration team that resident #1 fell out of the lift. She said she saw one of the hooks was not fastened to the lift and she fell out. She said, the resident was moaning when she fell . There was blood on the floor and the other CNA cleaned it up before she called the nurse. On 8/07/23 at 3:20 PM, CNA C stated 2 staff were needed to transfer a resident with a mechanical lift. She said they cannot allow contracted hospice staff to help with that mechanical lift transfers because they would not know if staff were trained. She noted the facility educator trained their staff on the use of mechanical lifts and informed the staff they were not allowed to have non-staff members, such as contracted staff to help with mechanical lift transfers. CNA C stated this was not new information, it has always been the standard. On 8/08/23 at 2:57 PM, the Regional Director of Clinical Operations stated the incident was discussed and decided that it was not neglect because CNA A was in the act of providing care to the resident to stop the bleeding. It did not seem like a willful act and she did not leave the resident unattended. He said, She tried to provide care even if she did it in the wrong way. When asked if they considered neglect after identifying the resident was moved post fall with an obvious head injury before being assessed by a nurse and the blood cleaned from the floor, the Director of Clinical Operations did not provide an answer. On 8/09/23 at 11 :50 AM, during an interview with the Administrator and Director of Nursing (DON), the DON explained, neglect is when you have orders and do not fulfill the orders, if you know that something is going on with a resident, like a change in condition and you don't report it, or if the resident is asking for something and you refuse to help. That is highest level of neglect. The Administrator said, When you fail to give care to the resident or the right kind of care. The Administrator stated their mechanical lift policy instructs there must be two employees to operate the lift. A hospice contracted staff is not an employee of the facility. He said he didn't think to report the incident when they discovered one of the employees involved in the lift transfer incident was not their employee, but was contracted staff, because it was imperative to fully investigate what happened and fix it to ensure it did not happen again. The Administrator stated CNA A was terminated and was reported to the state certification board. He added the Hospice contractor was notified that CNA B could not return to the facility. He explained the incident was discussed with their Corporate office and the decision was made to report it as a State reportable incident rather than neglect which required federal reporting. On 8/09/23 at approximately 12:15 PM, the Administrator, Risk Manager and Assistant Director of Nursing (ADON) demonstrated a reenactment of CNA B's demonstration of the lift incident that involved resident #1. The ADON placed a sling on the bed under the mannequin. When she moved the lift to the bed, the hanger bar was located over the midsection of the mannequin, not close to the head. The ADON and Risk Manager attached the upper 4 loops from the sling to the hooks on the hanger bar. Then they hooked the left leg loop to the right-side hook on the hanger bar in a crisscross fashion, leaving the right leg strap lying on the mannequin. When they lifted the sling above the mattress the mannequin remained in the sling. When they moved the mechanical lift away from the bed, the mannequin began sliding feet first out of the sling but was held in the sling by the left leg strap of the sling. The upper half of the mannequin remained in the sling. It was discussed at that time that the leg straps could not possibly have been attached properly. The mannequin was placed back in the bed, the leg straps were attached by the loops to the hanger bar not being crisscrossed and as the mechanical lift was moved away from the bed the mannequin slid feetfirst out of the sling to the floor. The reenactment identified that not only was a loop left off the hook of the hanger bar, but the leg straps were not placed on the resident properly. The administrative team acknowledged they had not assessed this incident thoroughly. Review of the Mobility Support and Positioning Policy reviewed 3/29/23 read: TIME OUT is done prior to lifting the resident off the bed or the transfer surface. TIME OUT is done as follows: Raise the lift arm until the strap loops are taut but the resident has not left the surface. Stop, check, and verbalize all loops are secure. Continue to observe all loops remain secure and attached to the hooks on the hanger bar. Two or more employees will use the total lift to transfer resident from surface to surface. Check the Kardex, kiosk, service plan, or care plan for the type and amount of assistance needed for repositioning. Place the total lift at bedside with the hanger bar over resident's midsection. Crisscross leg straps through each other and attach straps to the lift. Review of the CNA job description included, assists the resident in transferring, repositioning, and walking using correct, appropriate transfer techniques and equipment. The resident sample was expanded to include three additional residents who were identified as at risk for falls/actual falls. The facility submitted an acceptable Immediate Jeopardy removal plan and the implementation actions were validated by the survey team: * On 7/10/23 at 9:30 AM it was reported a resident was hit in the head with a bar from a mechanical lift. She was sent to the hospital for treatment/evaluation. * On 7/11/23 at 2:00 PM, the facility made aware that resident #1 sustained a left clavicle fracture. * On 7/12/23 CNA A was suspended. After investigation identified that employee was involved with the lift and subsequent fall of the resident, employee was terminated and License was reported to Florida Department of Health (Florida state agency that regulates health care practitioners). CNA B removed from building with Do Not Return status sent to Hospice provider. * On 7/12/23 education on Mechanical Lifts Policy and Procedure with competencies for all staff began and on 07/14/2023 100% of the staff were trained. * On 7/24/23 State Adverse Incident Report filed with the Florida Agency for Health Care Administration (Florida state survey agency). * On 8/10/23, Federal Immediate report completed, reported to Florida Department of Children and Families (DCF) (Florida state abuse investigation agency) Hotline and Law Enforcement, voicemail message left for Long Term Care Ombudsman, Food and Drug Administration (FDA) (the federal agency that regulates medical devices) was notified about mechanical lift incident. * Re-Education of staff was completed for Abuse Neglect Policy and Procedure on reporting and notification with posttest completed. All staff were completed on 8/ 10/2023 and any staff on leave will be completed prior to working their next shift. * Facility Administrative team which included Senior Director were educated on 08/10/2023 by Regional Clinical Services Director on reporting to include abuse and neglect policy and procedures. Review of the in-service attendance sheets validated mechanical lift education accompanied by return demonstrations were completed using the facility's policy and procedure for Mobility Support and Positioning and Safe Resident Handling for facility and Agency staff, with 100% completion as of 7/14/23. New hires/agency will receive education during orientation, and messages were left for two staff on leave to have training prior to return to work. Abuse, neglect, and exploitation education began on 8/10/23 and all staff will be educated prior to working their next shift, including agency staff. Interviews conducted on 8/10/23 from 11:00 AM to 4:45 PM, with 11 facility staff including Licensed nurses, Activity Associate and CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan or Kardex to identify number of persons, and who could assist with the mechanical lift for resident transfers. They verified a return demonstration was completed after the education. They confirmed they received Abuse/Neglect education followed by a post test.

Based on interview, and record review, the facility failed to thoroughly investigate an incident involving neglect and failed to report the results of the investigation to the State Survey Agency related to an avoidable fall with major injury for 1 of 7 residents sampled for falls, (#1). On 7/10/23 at approximately 9:30 AM, the facility failed to prevent an avoidable fall for a physically and cognitively impaired resident. The fall occurred during a transfer from a bed to a wheelchair with a full body mechanical lift. Resident #1 fell feet first from the sling while she was suspended above the floor when one of six loops that secured the sling was not attached to the lift. The staff failed to follow the policy to have two trained staff for mechanical lift transfers, failed to ensure a time out safety stop and did not ensure that all straps were secure before moving the resident away from the surface. The Certified Nursing Assistant (CNA) moved the resident before she was assessed by a nurse and did not inform the facility that the resident fell from the sling to the floor. The nurse was not notified until after the resident was lifted back into the sling and transferred back into bed. The facility failed to ensure policies and procedures were implemented to ensure the safety of all 45 residents who required mechanical lifts for transfers. The facility used one brand of mechanical lift. The facility's failure to complete a thorough investigation resulted in Immediate Jeopardy starting on 7/10/23. The Immediate Jeopardy was removed on 8/10/23. Findings: Cross reference F689, F600, and F835 Resident #1, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included diabetes mellitus, dementia, Alzheimer's disease, anxiety disorder, and abnormal posture. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 4/22/23 revealed the Brief Interview for Mental status (BIMS) score was 3 out of 15 indicating the resident's cognition was severely impaired. Resident #1 required extensive assistance of one person for bed mobility and extensive assist of two persons for transfers. On 8/08/23 at 9:50 AM, the Risk Manager stated on 7/10/23 at 10:58 AM, she was notified that resident #1 was being transferred to the hospital because she was hit on the back of the head. She stated Certified Nursing Assistant (CNA) A told her the resident was lying in bed and as she moved the lift bar over to the resident to hook her up to the mechanical lift, the resident moved her head and hit one of the bars on the lift. The Risk Manager said the two CNAs who were present at the time of the injury were asked for statements of how the injury occurred. She said the next day, she reviewed the statements from the CNAs regarding the resident hitting her head and said this did not make sense as the resident had a fractured clavicle. She said leadership wanted to interview both CNAs. She noted CNA A gave the same account of the injury but CNA B's demeanor changed when she attempted to provide the same account of the incident. She explained CNA B came back not long after that interview at 11:30 AM, crying. She recanted her statement and said the resident was already in the lift, off the bed and fell out of the lift onto the floor. The Risk Manager stated CNA B did a reenactment of the incident using a mannequin and the mannequin fell feet first out of the sling with the head on the lift and her legs were over the lift. CNA B stated at that time, she asked CNA A if they should call the nurse and CNA A told her not to notify the nurse because she wanted to transfer the resident back in bed. The Risk Manager stated CNA B said she helped CNA A get resident #1 back into the sling from the floor and transferred the resident back to bed with the mechanical lift. She stated CNA A told her they had to agree to give a different account of the incident than what actually occurred or they would both get fired. The Risk Manager stated CNA B then said that CNA A cleaned up the blood from the floor first and then proceeded to notify the nurse. The Risk Manager indicated after CNA B provided a more factual account of the incident, she knew the facility had a different type of situation that she originally thought. On 8/08/23 at 1:30 PM, the Risk Manager stated the root cause of the incident was the CNA did not follow the process of having two staff when using a mechanical lift for transfers and the sling was not secured properly. On 8/08/23 at 2:57 PM, the Regional Director of Clinical Operations stated the incident was discussed with the management team and decided that it was not neglect because CNA A was in the act of providing care to the resident to stop the bleeding. He explained it did not seem like a willful act and she did not leave the resident unattended. He said, She tried to provide care even if she did it in the wrong way. The Regional Director was questioned whether they considered neglect after they identified, CNA A gave false account of the fall, moved the resident who had head injury before she was assessed by the nurse and then tried to cover up the fall by cleaning the blood off the floor, the Director of Clinical Operations did not provide an answer. On 8/09/23 at approximately 12:15 PM, the Administrator, Risk Manager and Assistant Director of Nursing (ADON) demonstrated a reenactment of CNA B's demonstration of the lift incident that involved resident #1. The ADON placed a sling on the bed under the mannequin. When she moved the lift to the bed, the hanger bar was located over the midsection of the mannequin, not close to the head. The ADON and Risk Manager attached the upper 4 loops from the sling to the hooks on the hanger bar. Then they hooked the left leg loop to the right-side hook on the hanger bar in a crisscross fashion, leaving the right leg strap lying on the mannequin. When they lifted the sling above the mattress the mannequin remained in the sling. When they moved the mechanical lift away from the bed, the mannequin began sliding feetfirst out of the sling but was held in the sling by the left leg strap of the sling. The upper half of the mannequin remained in the sling. It was discussed at that time that the leg straps could not possibly have been attached properly. The mannequin was placed back in the bed, the leg straps were attached by the loops to the hanger bar not crisscrossed and as the mechanical lift was moved away from the bed, the mannequin slid feet first out of the sling to the floor. The Administrator acknowledged that not only was a loop left off the hook of the hanger bar, but the leg straps were not placed on the resident properly. On 8/09/23 at 11 :50 AM, the Director of Nursing (DON) and the Administrator spoke about investigating . The DON explained, neglect is when you have orders and do not fulfill the orders, if you know that something is going on with a resident, like a change in condition and you don't report it, or if the resident is asking for something and you refuse to help. That is highest level of neglect. The Administrator noted neglect was When you fail to give care to the resident or the right kind of care. The Administrator indicated their policy was to always have 2 staff present when transferring a resident with a mechanical lift. He said he didn't think to report the incident when they found out that one of the employees involved in the lift transfer was not their employee because the first thought was to investigate what happened and fix it to ensure it doesn't happen again. The Administrator stated CNA A was terminated and reported to the State Nurse Aide Registry when we found out the truthful account of resident #1's fall. He stated the incident was discussed with their Corporate office and they did not feel it was neglect and the incident was not reported to the State Agency. The facility submitted an acceptable Immediate Jeopardy removal plan and the implementation actions were validated by the survey team: * On 7/10/23 at 9:30 AM it was reported a resident was hit in the head with a bar from a mechanical lift. She was sent to the hospital for treatment/evaluation. * On 7/11/23 at 2:00 PM, the facility made aware that resident #1 sustained a left clavicle fracture. * On 7/12/23 CNA A was suspended. After investigation identified that employee was involved with the lift and subsequent fall of the resident, employee was terminated and License was reported to Florida Department of Health (Florida state agency that regulates health care practitioners). CNA B removed from building with Do Not Return status sent to Hospice provider. * On 7/12/23 education on Mechanical Lifts Policy and Procedure with competencies for all staff began and on 07/14/2023 100% of the staff were trained. * On 7/24/23 State Adverse Incident Report filed with the Florida Agency for Health Care Administration (Florida state survey agency). * On 8/10/23, Federal Immediate report completed, reported to Florida Department of Children and Families (DCF) (Florida state abuse investigation agency) Hotline and Law Enforcement, voicemail message left for Long Term Care Ombudsman, Food and Drug Administration (FDA) (the federal agency that regulates medical devices) was notified about mechanical lift incident. * Re-Education of staff was completed for Abuse Neglect Policy and Procedure on reporting and notification with posttest completed. All staff were completed on 8/ 10/2023 and any staff on leave will be completed prior to working their next shift. * Facility Administrative team which included Senior Director were educated on 08/10/2023 by Regional Clinical Services Director on reporting to include abuse and neglect policy and procedures. Review of the in-service attendance sheets validated mechanical lift education accompanied by return demonstrations were completed using the facility's policy and procedure for Mobility Support and Positioning and Safe Resident Handling for facility and Agency staff, with 100% completion as of 7/14/23. New hires/agency will receive education during orientation, and messages were left for two staff on leave to have training prior to return to work. Abuse, neglect, and exploitation education began on 8/10/23 and all staff will be educated prior to working their next shift, including agency staff. Interviews conducted on 8/10/23 from 11:00 AM to 4:45 PM, with 11 facility staff including Licensed nurses, Activity Associate and CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan or Kardex to identify number of persons, and who could assist with the mechanical lift for resident transfers. They verified a return demonstration was completed after the education. They confirmed they received Abuse/Neglect education followed by a post test.

Based on interview, and record review, the facility failed to prevent an avoidable fall with major injury for a vulnerable, physically, and cognitively impaired resident, and failed to ensure the correct procedure was followed when using a full body mechanical lift to transfer residents for 1 of 7 residents sampled for accidents, of a total of 45 residents requiring mechanical lifts for transfers, (#1). This failure resulted in the resident sustaining a fractured left clavicle and laceration to the head requiring staples. Clavicle fracture (collarbone), is diagnosed through physical examination and x-rays. Resident #1 likely experienced severe pain and swelling at the collarbone fracture and with possible visible deformity. On 7/10/23 at approximately 9:30 AM, resident #1 fell during a transfer from bed to a wheelchair with a full body mechanical lift. Resident #1 fell feet first from the sling while she was suspended above the floor when one of six loops that secured the sling was not attached to the lift. The staff neglected to follow the policy to have two trained staff for mechanical lift transfers, failed to do a safety stop, and did not ensure that all straps were secure before moving the resident away from the surface. After the resident fell , the Certified Nursing Assistant (CNA) moved the resident prior to having her assessed by a nurse and did not inform the facility that the resident fell from the sling to the floor. The nurse was not notified until after the resident was lifted back into the sling and transferred back to bed. The facility's failure to conduct mechanical lift monitoring to ensure staff were competent in performing transfers, placed all 45 residents who required a mechanical lift for transfers at risk and resulted in Immediate Jeopardy starting on 7/10/23. The Immediate Jeopardy was removed on 8/10/23. Findings: Cross reference F600, F609, and F835 Resident #1, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included diabetes mellitus, dementia, Alzheimer's disease, anxiety disorder, and abnormal posture. Review of the resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 4/22/23 revealed the Brief Interview for Mental status (BIMS) score was 3 out of 15 indicating the resident's cognition was severely impaired. Resident #1 required extensive assistance of one person for bed mobility and extensive assist of two persons for transfers. Review of the resident's annual MDS assessment with ARD of 7/21/23 revealed the BIMS score was not completed as the resident was rarely or never understood. The assessment showed the resident required extensive assist of two staff persons for bed mobility and total assistance of two persons for transfers. Review of resident #1's medical record revealed a care plan dated 7/12/23 for acute pain/discomfort related to a fracture of the left clavicle. A care plan initiated 11/12/18 and revised on 7/11/23 for activities of daily living (ADL) noted the resident required physical assistance of two staff for transfers with total lift with high back medium sling. Review of the Task List Report instructed physical assist of two staff for transfers with total lift with high back medium sling. A Progress Note dated 7/10/23 at 1:32 PM read, resident sent out to ED [emergency department] to get CT [computed tomography] scan for injury on back of head. CNA stated the resident hit her head on one of the bars of the mechanical lift while in the lift. Resident not able to explain what happened. Resident has an open and bleeding laceration to the back of her head, alert and oriented to person, sent to ED for further assessment. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 7/11/23 revealed resident #1 was hospitalized for a primary diagnosis of hit by (mechanical) lift. The form indicated she was not ambulatory and required two assistants for transfers. The skin care assessment indicated the resident had a bruise to her left clavicle, bruise to left foot and a laceration to posterior scalp. On 8/08/23 at 9:50 AM, the Risk Manager stated on 7/10/23 at 10:58 AM, she was notified that resident #1 was being transferred to the hospital because she was hit on the back of the head. She stated CNA A told her the resident was lying in bed and as she moved the lift bar over to the resident to hook her up to the mechanical lift, the resident moved her head and hit one of the bars on the lift. The Risk Manager said the two CNAs who were present at the time of the injury were asked for statements of how the injury occurred. Review of CNA A's statement noted, 7/10/23 at 9:30 AM, I was preparing the resident for the (mechanical) lift and at a moment she moved her head to the wall and when the machine moved and it hit hard to her head when I look, she was bleeding and I told the nurse. Review of CNA B's statement read, 7/10/23, while I was passing by after giving care to my patient around 9:30 the CNA stopped me to watch her transfer the pt (patient) with lift. While she was putting the adjustment pt made fast movement with her head a get head hit. Accident in the machine. The Risk Manager explained she reviewed the information from the hospital that showed the resident had a fractured left clavicle. She said the statements from the CNAs that the resident's head was hit by the lift and the hospital's findings of fractured clavicle did not make sense. She indicated she notified the management team and they interviewed the two CNAs again. She said CNA A told the same story but CNA B's demeanor had changed while trying to tell the details of the incident. The Risk Manager recalled CNA B came back shortly after the interview, crying and recanted her statement. She explained the resident was in the lift away from the bed and fell out of the lift onto the floor. The Risk Manager stated CNA B did a reenactment of the incident using a mannequin that showed the resident fell feet first out of the sling with her head on the lift and her legs over the lift. She said after the fall, CNA B asked CNA A if they should call the nurse and CNA A told her not to notify the nurse because she wanted to transfer the resident back in bed. The Risk Manager stated CNA B said she helped CNA A get resident #1 back into the sling from the floor and transferred the resident back to bed with the mechanical lift. She stated CNA A told her they had to agree to give a different account of the incident than what actually occurred so they would not lose their jobs. She said CNA A cleaned up the blood from the floor first and then proceeded to notify the nurse. The Risk Manager indicated after CNA B provided a more factual account of the incident, she knew the facility had a more serious issue to deal with. The Risk Manager explained CNA B did not assist CNA A to get the resident out of bed with the lift but she did assist in helping CNA A get the resident back into bed after the fall. The Risk Manager indicated CNA B should not have assisted with the resident's transfer back into bed as she was not their employee, she was from a contracted hospice agency and they could not ensure if she had mechanical lift training. On 8/08/23 at 1:30 PM, the Risk Manager stated the root cause of the incident was CNA A did not follow the process to have two staff to transfer a resident with a mechanical lift and the sling was not secured properly. On 8/07/23 at 1:09 PM, during a telephone interview, CNA A asserted resident #1 did not fall. She said she was going to transfer the resident with the mechanical lift but when she pushed the lift toward the bed, the resident turned and hit her head on the lift. It was an accident, I did not mean to hit her. I did not hook the sling to the lift because the lady moved her head when I was bringing the lift to the bed and hit her head. She did not fall, only got hit in the head with the lift. CNA A stated, you need two people when you use the lift. There was another CNA in the hall and I asked her to help me. I did not know if she was a staff of the facility. She reiterated the resident did not fall and that she did not even get the resident out of bed. She insisted the resident remained in bed before and after being hit in the head by the lift. She did not explain how the resident sustained a fractured collar bone but stated she may have applied too much pressure when she tried to stop the bleeding from the head laceration. On 8/07/23 at 4:00 PM, during a telephone interview with CNA B, she stated she worked for a contracted Hospice service and was in the hall when CNA A asked her to help transfer resident #1. She explained the resident fell , hit her head and it was bleeding and CNA A wanted to put the resident back to bed because she did not want to tell the staff the resident fell . She indicated CNA A told her to write that resident #1 accidentally hit the pole of the lift and if their explanation did not match, they would both lose their jobs. CNA B said when she first spoke to administration, she told them the same explanation as CNA A. She said, my consciousness was bothering me so bad that I couldn't stand it. I went and talked to the hospice nurse and told her what really happened. She asked me what I was going to do, and I told her I want to tell them [the facility] the truth. The nurse went with me when I talked to them. I went to them and told them the truth. CNA B stated she told the administration team that resident #1 fell out of the lift. She said one of the hooks was not fastened to the lift and she fell out. She said, the resident was moaning when she fell . There was blood on the floor and the other CNA cleaned it up before she called the nurse. On 8/09/23 at approximately 12:15 PM, the Administrator, Risk Manager and Assistant Director of Nursing (ADON) demonstrated a reenactment of CNA B's demonstration of the lift incident with resident #1. The ADON placed a sling on the bed under the mannequin. When she moved the lift to the bed, the hanger bar was located over the midsection of the mannequin, not anywhere near the head. The ADON and Risk Manager attached the upper 4 loops to the hooks on the hanger bar. They hooked the left leg loop to the right-side hook on the hanger bar (crisscrossed), leaving the right leg strap lying on the mannequin. When they lifted the sling above the mattress, the mannequin remained in the sling. When they moved the mechanical lift away from the bed the mannequin began sliding feet first out of the sling but was held in the sling by the sling's left leg strap. The upper half of the mannequin remained in the sling. The reenactment identified that not only was a time out not done but a loop was left off the hook of the hanger bar and the leg straps were not placed properly on the resident. The Administrator stated their mechanical lift policy instructs there must be two employees to operate the lift. A hospice contracted staff is not an employee of the facility. He said they identified CNA B was not their employee, but was contracted Hospice staff. He explained it was imperative to fully investigate what happened and fix it to ensure it did not happen again. The Administrator stated CNA A was terminated and was reported to the state certification board. He added the Hospice contractor was notified that CNA B could not return to the facility. He explained the incident was discussed with their Corporate office and decided the incident did not qualify as neglect. Review of the Mobility Support and Positioning Policy reviewed 3/29/23 read: TIME OUT is done prior to lifting the resident off the bed or the transfer surface. TIME OUT is done as follows: Raise the lift arm until the strap loops are taut but the resident has not left the surface. Stop, check, and verbalize all loops are secure. Continue to observe all loops remain secure and attached to the hooks on the hanger bar. Two or more employees will use the total lift to transfer resident from surface to surface. Check the Kardex, kiosk, service plan, or care plan for the type and amount of assistance needed for repositioning. Place the total lift at bedside with the hanger bar over resident's midsection. Crisscross leg straps through each other and attach straps to the lift. Review of the CNA job description included, assists the resident in transferring, repositioning, and walking using corrects appropriate transfer techniques and equipment. The resident sample was expanded to include three additional residents who were identified as requiring a mechanical lift for transfer, and three residents at risk for falls/actual falls. The facility submitted an acceptable Immediate Jeopardy removal plan and the implementation actions were validated by the survey team: * On 7/10/23 at 9:30 AM it was reported a resident was hit in the head with a bar from a mechanical lift. She was sent to the hospital for treatment/evaluation. * On 7/11/23 at 2:00 PM, the facility made aware that resident #1 sustained a left clavicle fracture. * On 7/12/23 CNA A was suspended. After investigation identified that employee was involved with the lift and subsequent fall of the resident, employee was terminated and License was reported to Florida Department of Health (Florida state agency that regulates health care practitioners). CNA B removed from building with Do Not Return status sent to Hospice provider. * On 7/12/23 education on Mechanical Lifts Policy and Procedure with competencies for all staff began and on 07/14/2023 100% of the staff were trained. * On 7/24/23 State Adverse Incident Report filed with the Florida Agency for Health Care Administration (Florida state survey agency). * On 8/10/23, Federal Immediate report completed, reported to Florida Department of Children and Families (DCF) (Florida state abuse investigation agency) Hotline and Law Enforcement, voicemail message left for Long Term Care Ombudsman, Food and Drug Administration (FDA) (the federal agency that regulates medical devices) was notified about mechanical lift incident. * Re-Education of staff was completed for Abuse Neglect Policy and Procedure on reporting and notification with posttest completed. All staff were completed on 8/ 10/2023 and any staff on leave will be completed prior to working their next shift. * Facility Administrative team which included Senior Director were educated on 08/10/2023 by Regional Clinical Services Director on reporting to include abuse and neglect policy and procedures. Review of the in-service attendance sheets validated mechanical lift education accompanied by return demonstrations were completed using the facility's policy and procedure for Mobility Support and Positioning and Safe Resident Handling for facility and Agency staff, with 100% completion as of 7/14/23. New hires/agency will receive education during orientation, and messages were left for two staff on leave to have training prior to return to work. Abuse, neglect, and exploitation education began on 8/10/23 and all staff will be educated prior to working their next shift, including agency staff. Interviews conducted on 8/10/23 from 11:00 AM to 4:45 PM, with 11 facility staff including Licensed nurses, Activity Associate and CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan or Kardex to identify number of persons, and who could assist with the mechanical lift for resident transfers. They verified a return demonstration was completed after the education. They confirmed they received Abuse/Neglect education followed by a post test.

Based on interview, and record review, the facility failed to effectively use its resources to identify safety concerns related to the use of mechanical lifts and slings; and failed to ensure staff were knowledgeable of mechanical lift transfer techniques, for 1 of 7 residents reviewed for accidents and mechanical lift use, (#1). On 7/10/23 at approximately 9:30 AM, the facility failed to prevent an avoidable fall for a physically and cognitively impaired resident. The fall occurred during a transfer from bed to a wheelchair with a full body mechanical lift. Resident #1 fell feet first from the sling of the lift while she was suspended above the floor when one of six loops that secured the sling was not attached to the lift. The staff failed to follow the policy to have two trained staff to transfer using mechanical lift and failed to do a time out safety stop to ensure all straps were secure before moving the resident away from the surface. The Certified Nursing Assistant (CNAs) did not immediately notify the assigned nurse of the fall with possible head injury. Instead, they placed resident #1 back in the sling, attached it to the mechanical lift and transferred her from the floor to her bed without any interventions to prevent further injury. The facility used one brand of mechanical lift. The facility's failure to conduct mechanical lift spot monitoring to ensure staff were competent in performing transfers placed all 45 residents who required a mechanical lift for transfers at risk and resulted in Immediate Jeopardy starting on 7/10/23. The Immediate Jeopardy was removed on 8/10/23. Findings: Cross reference F600, F609, and F689 On 8/08/23 at 9:50 AM, the Risk Manager stated on 7/10/23 at 10:58 AM, she was notified that resident #1 was being transferred to the hospital because she was hit on the back of the head with the mechanical lift. She said CNA A told her the resident was lying in bed and as she moved the mechanical lift closer to the resident to attach her to the sling, the resident moved her head and hit one of the bars on the lift. The Risk Manager noted they obtained statements from both CNAs A and B that were involved in the incident. She explained the next day she reviewed the information from the hospital that documented resident #1 had a fracture of the left clavicle. She indicated the statements from the CNA did not make sense as they reported the resident hit her head and not the shoulder. She said she informed the management team and the CNAs were interviewed again. She recalled CNA A told the same story but CNA B's demeanor was different when she conveyed details of the incident. The Risk Manager explained CNA B came back shortly after, crying and recanted her statement. She said CNA B reported the resident was in the lift, and when the lift was moved away from the bed, the resident fell out of the lift and hit her head. The Risk Manager stated they asked CNA B to do a reenactment of the incident using a mannequin. She said during the reenactment, the mannequin fell feet first out of the sling and hit head against the lift. She said CNA B asked CNA A if they should call the nurse and CNA A said she wanted to get the resident back in the bed first. The Risk Manager stated CNA B then helped CNA A get resident #1 back in the sling from the floor and hooked the sling to the mechanical lift. She stated CNA A told her CNA B that their stories had to be the same or they would both get fired. The Risk Manager explained CNA A cleaned up the blood from the floor and then notified the nurse. The Risk Manager acknowledged the CNAs did not do a time out safety check before moving the resident in the mechanical lift and gave false statements about the facts of the incident. On 8/07/23 at 1:09 PM, during a telephone interview, CNA A asserted resident #1 did not fall. She said she was going to transfer the resident with the mechanical lift but when she pushed the lift toward the bed, the resident turned and hit her head on the lift. It was an accident, I did not mean to hit her. I did not hook the sling to the lift because the lady moved her head when I was bringing the lift to the bed and hit her head. She did not fall, only got hit in the head with the lift. CNA A stated, you need two people when you use the lift. There was another CNA in the hall and I asked her to help me. I did not know if she was a staff of the facility. She reiterated the resident did not fall and that she did not even get the resident out of bed. She insisted the resident remained in bed before and after being hit in the head by the lift. She did not explain how the resident sustained a fractured shoulder bone but stated she may have applied too much pressure when she tried to stop the bleeding from the head laceration. CNA stated she had received mechanical lift training when she was hired and in February of 2023. On 8/07/23 at 4:00 PM, during a telephone interview with CNA B, she stated she worked for a contracted Hospice service and was in the hall when CNA A asked her to help transfer resident #1. She explained she was not aware if she could assist another CNA with mechanical lift transfers. She stated CNA A lifted the resident out of bed with the mechanical lift, and the resident fell out of the sling, and hit her head. She said the resident's head was bleeding and CNA A asked her to assist to get the resident back to bed. She conveyed CNA A did not want to tell the staff the resident fell but wanted to give a different account of the incident. She said CNA A told her to write that resident #1 accidentally hit the pole of the lift and if their explanations did not match, they would both lose their jobs. CNA B said when she first spoke to Administration, she told them the same explanation as CNA A. She said, my conscience was bothering me so bad that I couldn't stand it. I went and talked to the Hospice nurse and told her what really happened. She asked me what I was going to do, and I told her I want to tell them [the facility] the truth. The Hospice nurse went with me when I talked to them. I went to them and told them the truth. CNA B stated she told the administration team that resident #1 fell out of the lift. She said she saw one of the hooks was not fastened to the lift and she fell out. She said, the resident was moaning when she fell . There was blood on the floor and the other CNA cleaned it up before she called the nurse. On 8/08/23 at 2:57 PM, The Regional Director Clinical Operations stated the incident was discussed among the group and the group decided that it was not neglect because the CNA was in the act of providing care to the resident by trying to stop the bleeding. It did not seem like a willful act and it was not like she left the resident unattended. He said, She tried to provide care even if she did it in the wrong way. When asked if moving a resident who fell before being assessed by a nurse, and cleaning up blood off the floor before giving care to the resident and notifying the nurse was providing care or was it neglect, the Director of Clinical Operations gave no response. On 8/08/23 at 1:30 PM, the Risk Manager stated the root cause of the incident was that the CNA did not follow the process for two people when using a mechanical lift and the sling was not secured properly. The Administrator stated their mechanical lift policy instructs there must be two employees to operate the lift. A hospice contracted staff is not an employee of the facility. He said he didn't think to report the incident when they discovered one of the employees involved in the lift transfer incident was not their employee, but was contracted staff, because it was imperative to fully investigate what happened and fix it to ensure it did not happen again. The Administrator stated CNA A was terminated and was reported to the state certification board. He added the Hospice contractor was notified that CNA B could not return to the facility. Review of CNA A's completed training included Safe Resident Handling was completed on 2/07/23. The return demonstration included the time out session for the operator and partner to ensure sling hooks and loops were secure prior to moving the resident. On 8/09/23 at 12:45 PM the Administrative team explained they had not done any spot monitoring of staff's competency with mechanical lifts. They stated staff were educated when they were hired then annually. They stated the equipment was used improperly which caused resident #1 to fall from the sling to the floor. They asserted CNA A did not follow the mechanical lift transfer procedure despite having been trained several times. Review of the Director of Nursing job description read, Monitors the operations of the nursing staff and ensures compliance with regulations on organizational and governmental standards of practice. Responsible for the overall quality of care provided by the organization's nursing personnel. The facility submitted an acceptable Immediate Jeopardy removal plan and the implementation actions were validated by the survey team: * On 7/10/23 at 9:30 AM it was reported a resident was hit in the head with a bar from a mechanical lift. She was sent to the hospital for treatment/evaluation. * On 7/11/23 at 2:00 PM, the facility made aware that resident #1 sustained a left clavicle fracture. * On 7/12/23 CNA A was suspended. After investigation identified that employee was involved with the lift and subsequent fall of the resident, employee was terminated and License was reported to Florida Department of Health (Florida state agency that regulates health care practitioners). CNA B removed from building with Do Not Return status sent to Hospice provider. * On 7/12/23 education on Mechanical Lifts Policy and Procedure with competencies for all staff began and on 07/14/2023 100% of the staff were trained. * On 7/24/23 State Adverse Incident Report filed with the Florida Agency for Health Care Administration (Florida state survey agency). * On 8/10/23, Federal Immediate report completed, reported to Florida Department of Children and Families (DCF) (Florida state abuse investigation agency) Hotline and Law Enforcement, voicemail message left for Long Term Care Ombudsman, Food and Drug Administration (FDA) (the federal agency that regulates medical devices) was notified about mechanical lift incident. * Re-Education of staff was completed for Abuse Neglect Policy and Procedure on reporting and notification with posttest completed. All staff were completed on 8/ 10/2023 and any staff on leave will be completed prior to working their next shift. * Facility Administrative team which included Senior Director were educated on 08/10/2023 by Regional Clinical Services Director on reporting to include abuse and neglect policy and procedures. Review of the in-service attendance sheets validated mechanical lift education accompanied by return demonstrations were completed using the facility's policy and procedure for Mobility Support and Positioning and Safe Resident Handling for facility and Agency staff, with 100% completion as of 7/14/23. New hires/agency will receive education during orientation, and messages were left for two staff on leave to have training prior to return to work. Abuse, neglect, and exploitation education began on 8/10/23 and all staff will be educated prior to working their next shift, including agency staff. Interviews conducted on 8/10/23 from 11:00 AM to 4:45 PM, with 11 facility staff including Licensed nurses, Activity Associate and CNAs revealed they were knowledgeable about the facility's transfer policy, and the need to review the care plan or Kardex to identify number of persons, and who could assist with the mechanical lift for resident transfers. They verified a return demonstration was completed after the education. They confirmed they received Abuse/Neglect education followed by a post test.

Based on interview and record review, the facility failed to review and/or revise comprehensive care plans for activities of daily living (ADLs) related to transfers, to reflect the appropriate device and sling size for 7 of 11 residents reviewed for mechanical lift use, out of a total sample of 11 residents, (#13, #14, #15, #16, #17, #20, and #21). Findings: Review of the facility's policy and procedures for Care Plans, revised on 9/22/22, revealed the Interdisciplinary Team (IDT) would review residents' care plans at least quarterly to ensure provision of appropriate care and services. The facility's policy and procedure for Comprehensive Care Plan and Care Conferences, revised on 10/21/22, revealed purposes to develop a person-centered care plan for each resident and to provide an ongoing method of assessing, evaluating, and updating the care plan. The document indicated a designated member of the IDT would implement a process for developing and updating care plans, which would be reviewed by each member of the IDT before the care conference. The policy revealed each resident's care plan would be driven by identified issues or concerns and his/her needs, and would be .a powerful, practical tool representing the best approach to providing quality of care and quality of life. The document indicated care plans were to be reviewed with each completed Minimum Data Set (MDS) assessment and in addition to updates during a care plan review, care plans must be revised as the resident's needs/status changes. 1. Review of the medical record revealed resident #13 was admitted to the facility on [DATE] with diagnoses including complete lesion at C2 level of the cervical spine, metabolic encephalopathy, generalized muscle weakness, and Parkinson's Disease. The MDS Quarterly assessment with assessment reference date (ARD) of 6/30/23 revealed resident #13 required assistance from two or more staff for transfers between surfaces including to or from the bed and wheelchair. The resident's balance was unsteady during surface-to-surface transfers and he was only able to stabilize with staff assistance. Resident #13's nursing care plan for ADL self-care performance deficit related to dementia was initiated on 3/25/23. The care plan intervention for transfers was revised on 3/27/23 to reflect the instruction to transfer the resident between surfaces with the assistance of two staff, and a total mechanical lift with a large full body sling. Resident #13's Certified Nursing Assistant (CNA) care plan or Kardex revealed care directives for Mobility and Transfers included use of a mechanical lift and a size large sling. Review of resident #13's medical record revealed his weight was 133 pounds on 6/05/23, 133 pounds on 7/10/23, and 135 pounds on 8/02/23. The sling manufacturer's guide revealed a medium sling was suitable for residents who weighed between 125 and 175 pounds. On 10/04/23 at 11:31 AM, the MDS Coordinator stated resident #13's most recent care plan meeting was on 6/05/23. She acknowledged she was not aware the resident required a medium sling based on his weight, instead of the large sling noted on the nursing care plan and Kardex. 2. Review of the medical record revealed resident #14 was admitted to the facility on [DATE] with diagnoses of generalized muscle weakness, unsteadiness on her feet, lack of coordination, dementia, and a history of falling. The MDS Admission assessment with ARD of 9/03/23 revealed resident #14 was totally dependent on two or more staff for transfers between surfaces. The resident's balance was unsteady during surface-to-surface transfers, and she was only able to stabilize with staff assistance. Review of resident #14's care plan for ADL self-care performance deficit, initiated on 8/29/23, revealed the resident required assistance from two staff with a full body mechanical lift and a medium sling for transfers. The intervention had a revision date of 9/06/23. Resident #14's Kardex directed CNAs to transfer her with a medium sling. The sling manufacturer's guide indicated the recommended size sling for the resident's weight of 210 pounds on 8/29/23 and 227.5 pounds on 10/04/23 was large, which was suitable for weights of 174 pounds to 250 pounds. 3. Review of the medical record revealed resident #15 was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included right-side weakness and paralysis due to a stroke, generalized muscle weakness, abnormal posture, unsteadiness on his feet, lack of coordination, and osteoarthritis. The MDS Quarterly assessment with ARD of 9/15/23 revealed resident #15 was totally dependent on two or more staff for surface-to-surface transfers. The resident had functional limitation in range of motion and impairment of one arm and both legs. Review of resident #15's care plan for ADL self-care performance deficit, initiated on 6/23/23 revealed an intervention for transfers that read, Transfer Between Surfaces: 2 staff assist, assistive support/device, lift type, high back, medium sling. The care plan had a revision date of 6/23/23 and the care directive was transcribed to the resident's Kardex to include a medium sling. Review of resident #15's weight revealed between June 2022 and October 2023, his weight ranged from 189 pounds to 214 pounds, which according to the sling manufacturer's guide, required a large sling. 4. Review of the medical record revealed resident #16 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included stroke, altered mental status, weakness, arthritis, and fibromyalgia or chronic, widespread pain. The MDS Quarterly assessment with ARD of 7/07/23 revealed resident #16 was totally dependent on two or more staff for surface-to surface transfers. The resident had functional limitation in range of motion and impairment of one arm and both legs. Review of the care plan for ADL self-care performance deficit, revised on 8/11/23, revealed an intervention for transfers with the assistance of two staff and a large sling, but it did not indicate the type of mechanical lift to be used. The resident's Kardex did not include the type of lift either and included the instruction for CNAs to use a large sling for transfers. Review of the medical record revealed on 7/10/23, resident #16 weighed 161.5 pounds, on 8/11/23 she weighed 164.5 pounds, and on 10/04/23 the resident weighed 156.5 pounds. The weights indicated the appropriate size sling for resident #16 was medium. 5. Review of the medical record revealed resident #17 was admitted to the facility on [DATE] with diagnoses including stroke with left-side weakness and paralysis, contractures of the foot and knee, a history of falling, osteoarthritis, and lack of coordination. The MDS Quarterly assessment with ARD of 8/07/23 revealed resident #17 was totally dependent on staff for transfers. She had unsteady balance during surface-to-surface transfers and was only able to stabilize with staff assistance. The resident had functional limitation in range of motion and impairment of one arm and both legs. Review of resident #17's care plan for ADL self-care performance deficit, initiated on 5/25/13, revealed an intervention for transfers by two staff with a total lift and a large sling. The intervention had a revision date of 2/22/19. Review of resident #17's Kardex revealed Mobility and Transfer instructions for CNAs that included use of a large sling with the mechanical lift. The sling manufacturer's guide indicated the resident's weight of 157 pounds on 2/27/19 indicated she needed a medium sling on the date the intervention was initiated. Her weight ranged from 154 pounds on 1/11/22 to 139.5 pounds on 10/04/23, appropriate for a medium sling only at the time of all MDS assessments and care plan reviews during that period . 6. Review of the medical record revealed resident #20 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, adult failure to thrive, muscle spasm, left leg fracture, and osteoporosis. The MDS Annual assessment with assessment reference date of 8/25/23 revealed resident #20 was totally dependent on two or more staff members for transfers between surfaces including to or from the bed and wheelchair. The document indicated the resident had unsteady balance during surface-to-surface transfers and was only able to stabilize with staff assistance. Review of resident #20's care plan for ADL self-care performance deficit, initiated on 11/23/21 and revised on 9/14/23, revealed no active instructions or information related to transfers. Review of canceled and resolved care plan interventions showed the resident's last intervention related to transfers was initiated on 9/16/20 and resolved on 10/04/20. The intervention indicated the resident required assistance of two staff with a gait belt and walker to transfer between surfaces at that time. On 10/05/23 at 3:04 PM, the facility's Risk Manager (RM) explained after she was made aware of concerns related to inaccurate and/or incomplete care plans regarding to mechanical lifts and slings, she conducted an audit of the care plans for all residents who used mechanical lifts for transfers. The RM acknowledged during review of resident #20's care plans, she discovered there were no interventions regarding the type of equipment or level of assistance the resident needed during transfers. The RM stated nursing staff informed her they had been using a mechanical lift to transfer the resident but no staff had reported the care plan was missing instructions for transfers. 7. Review of the medical record revealed resident #21 was admitted to the facility on [DATE] with diagnoses including Guillain-Barre Syndrome, cervical spinal stenosis, lack of coordination, unsteadiness on his feet, polyneuropathy, and generalized muscle weakness. The MDS Quarterly assessment with ARD of 8/04/23 revealed resident #21 required extensive assistance from two or more staff for transfers. The resident's balance was unsteady, and he was only able to stabilize with staff assistance. The resident used a wheelchair for mobility. Review of resident #21's care plan for ADL self-care performance deficit, initiated on 4/29/23, noted he required assistance from two staff for transfers. The intervention was initiated on 5/01/23 and revised on 8/09/23. The care plan did not show the type of mechanical lift the resident required and indicated he required a large sling. Review of the medical record revealed on 8/02/2, resident #21 weighed 169.5 pounds and 9/04/23 he weighed 168 pounds, which indicated a medium sling was the appropriate size for him. On 10/04/23 at 11:31 AM and 3:08 PM, the MDS Coordinator stated she was the facility's care plan coordinator. She confirmed her duties included quarterly reviews of all care plans and more frequently if any change in status required the revision of a care plan. The MDS Coordinator explained although each section of a resident's care plan was reviewed by the appropriate member of the IDT, she was ultimately responsible for the accuracy of all care plans. The MDS Coordinator reviewed the ADL self-care performance deficit care plans for residents #13, #14, #15, #16, #17, #20, and #21 and validated the documents were not accurate and/or complete related to mechanical lift type and/or sling size for each resident. She stated residents' weights were available in the medical record and she was usually informed of any residents who lost or gained weight. The MDS Coordinator acknowledged quarterly care plan reviews were the opportune time to verify the type of mechanical lift, weight, and the appropriate size sling for each resident who used a device for transfers. Review of the job description for Long Term Care MDS Nurse, dated 8/23/23, revealed she evaluates care provided to each resident and keeps care plans current. The MDS Nurse was expected to collaborate with other members of the IDT to ensure the best quality of life possible for each resident. On 10/05/23 at 10:48 AM, the Director of Nursing (DON) stated her expectation was the MDS Coordinator would regularly review residents' care plans in their entirety and revise them if necessary, to ensure they were accurate and met residents' needs. On 10/05/23 at 12:05 PM, the RM explained the quarterly care plan review for every resident was the opportunity to examine all interventions and crosscheck that goals and interventions were still appropriate. The RM acknowledged it was important for each care plan to reflect the unique needs of each resident.

Based on interview and record review, the facility failed to review and/or revise comprehensive care plans for activities of daily living (ADLs) related to transfers, to reflect the appropriate device and sling size for 7 of 11 residents reviewed for mechanical lift use, out of a total sample of 11 residents, (#13, #14, #15, #16, #17, #20, and #21). Findings: Review of the facility's policy and procedures for Care Plans, revised on 9/22/22, revealed the Interdisciplinary Team (IDT) would review residents' care plans at least quarterly to ensure provision of appropriate care and services. The facility's policy and procedure for Comprehensive Care Plan and Care Conferences, revised on 10/21/22, revealed purposes to develop a person-centered care plan for each resident and to provide an ongoing method of assessing, evaluating, and updating the care plan. The document indicated a designated member of the IDT would implement a process for developing and updating care plans, which would be reviewed by each member of the IDT before the care conference. The policy revealed each resident's care plan would be driven by identified issues or concerns and his/her needs, and would be .a powerful, practical tool representing the best approach to providing quality of care and quality of life. The document indicated care plans were to be reviewed with each completed Minimum Data Set (MDS) assessment and in addition to updates during a care plan review, care plans must be revised as the resident's needs/status changes. 1. Review of the medical record revealed resident #13 was admitted to the facility on [DATE] with diagnoses including complete lesion at C2 level of the cervical spine, metabolic encephalopathy, generalized muscle weakness, and Parkinson's Disease. The MDS Quarterly assessment with assessment reference date (ARD) of 6/30/23 revealed resident #13 required assistance from two or more staff for transfers between surfaces including to or from the bed and wheelchair. The resident's balance was unsteady during surface-to-surface transfers and he was only able to stabilize with staff assistance. Resident #13's nursing care plan for ADL self-care performance deficit related to dementia was initiated on 3/25/23. The care plan intervention for transfers was revised on 3/27/23 to reflect the instruction to transfer the resident between surfaces with the assistance of two staff, and a total mechanical lift with a large full body sling. Resident #13's Certified Nursing Assistant (CNA) care plan or Kardex revealed care directives for Mobility and Transfers included use of a mechanical lift and a size large sling. Review of resident #13's medical record revealed his weight was 133 pounds on 6/05/23, 133 pounds on 7/10/23, and 135 pounds on 8/02/23. The sling manufacturer's guide revealed a medium sling was suitable for residents who weighed between 125 and 175 pounds. On 10/04/23 at 11:31 AM, the MDS Coordinator stated resident #13's most recent care plan meeting was on 6/05/23. She acknowledged she was not aware the resident required a medium sling based on his weight, instead of the large sling noted on the nursing care plan and Kardex. 2. Review of the medical record revealed resident #14 was admitted to the facility on [DATE] with diagnoses of generalized muscle weakness, unsteadiness on her feet, lack of coordination, dementia, and a history of falling. The MDS admission assessment with ARD of 9/03/23 revealed resident #14 was totally dependent on two or more staff for transfers between surfaces. The resident's balance was unsteady during surface-to-surface transfers, and she was only able to stabilize with staff assistance. Review of resident #14's care plan for ADL self-care performance deficit, initiated on 8/29/23, revealed the resident required assistance from two staff with a full body mechanical lift and a medium sling for transfers. The intervention had a revision date of 9/06/23. Resident #14's Kardex directed CNAs to transfer her with a medium sling. The sling manufacturer's guide indicated the recommended size sling for the resident's weight of 210 pounds on 8/29/23 and 227.5 pounds on 10/04/23 was large, which was suitable for weights of 174 pounds to 250 pounds. 3. Review of the medical record revealed resident #15 was admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included right-side weakness and paralysis due to a stroke, generalized muscle weakness, abnormal posture, unsteadiness on his feet, lack of coordination, and osteoarthritis. The MDS Quarterly assessment with ARD of 9/15/23 revealed resident #15 was totally dependent on two or more staff for surface-to-surface transfers. The resident had functional limitation in range of motion and impairment of one arm and both legs. Review of resident #15's care plan for ADL self-care performance deficit, initiated on 6/23/23 revealed an intervention for transfers that read, Transfer Between Surfaces: 2 staff assist, assistive support/device, lift type, high back, medium sling. The care plan had a revision date of 6/23/23 and the care directive was transcribed to the resident's Kardex to include a medium sling. Review of resident #15's weight revealed between June 2022 and October 2023, his weight ranged from 189 pounds to 214 pounds, which according to the sling manufacturer's guide, required a large sling. 4. Review of the medical record revealed resident #16 was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included stroke, altered mental status, weakness, arthritis, and fibromyalgia or chronic, widespread pain. The MDS Quarterly assessment with ARD of 7/07/23 revealed resident #16 was totally dependent on two or more staff for surface-to surface transfers. The resident had functional limitation in range of motion and impairment of one arm and both legs. Review of the care plan for ADL self-care performance deficit, revised on 8/11/23, revealed an intervention for transfers with the assistance of two staff and a large sling, but it did not indicate the type of mechanical lift to be used. The resident's Kardex did not include the type of lift either and included the instruction for CNAs to use a large sling for transfers. Review of the medical record revealed on 7/10/23, resident #16 weighed 161.5 pounds, on 8/11/23 she weighed 164.5 pounds, and on 10/04/23 the resident weighed 156.5 pounds. The weights indicated the appropriate size sling for resident #16 was medium. 5. Review of the medical record revealed resident #17 was admitted to the facility on [DATE] with diagnoses including stroke with left-side weakness and paralysis, contractures of the foot and knee, a history of falling, osteoarthritis, and lack of coordination. The MDS Quarterly assessment with ARD of 8/07/23 revealed resident #17 was totally dependent on staff for transfers. She had unsteady balance during surface-to-surface transfers and was only able to stabilize with staff assistance. The resident had functional limitation in range of motion and impairment of one arm and both legs. Review of resident #17's care plan for ADL self-care performance deficit, initiated on 5/25/13, revealed an intervention for transfers by two staff with a total lift and a large sling. The intervention had a revision date of 2/22/19. Review of resident #17's Kardex revealed Mobility and Transfer instructions for CNAs that included use of a large sling with the mechanical lift. The sling manufacturer's guide indicated the resident's weight of 157 pounds on 2/27/19 indicated she needed a medium sling on the date the intervention was initiated. Her weight ranged from 154 pounds on 1/11/22 to 139.5 pounds on 10/04/23, appropriate for a medium sling only at the time of all MDS assessments and care plan reviews during that period . 6. Review of the medical record revealed resident #20 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, adult failure to thrive, muscle spasm, left leg fracture, and osteoporosis. The MDS Annual assessment with assessment reference date of 8/25/23 revealed resident #20 was totally dependent on two or more staff members for transfers between surfaces including to or from the bed and wheelchair. The document indicated the resident had unsteady balance during surface-to-surface transfers and was only able to stabilize with staff assistance. Review of resident #20's care plan for ADL self-care performance deficit, initiated on 11/23/21 and revised on 9/14/23, revealed no active instructions or information related to transfers. Review of canceled and resolved care plan interventions showed the resident's last intervention related to transfers was initiated on 9/16/20 and resolved on 10/04/20. The intervention indicated the resident required assistance of two staff with a gait belt and walker to transfer between surfaces at that time. On 10/05/23 at 3:04 PM, the facility's Risk Manager (RM) explained after she was made aware of concerns related to inaccurate and/or incomplete care plans regarding to mechanical lifts and slings, she conducted an audit of the care plans for all residents who used mechanical lifts for transfers. The RM acknowledged during review of resident #20's care plans, she discovered there were no interventions regarding the type of equipment or level of assistance the resident needed during transfers. The RM stated nursing staff informed her they had been using a mechanical lift to transfer the resident but no staff had reported the care plan was missing instructions for transfers. 7. Review of the medical record revealed resident #21 was admitted to the facility on [DATE] with diagnoses including Guillain-Barre Syndrome, cervical spinal stenosis, lack of coordination, unsteadiness on his feet, polyneuropathy, and generalized muscle weakness. The MDS Quarterly assessment with ARD of 8/04/23 revealed resident #21 required extensive assistance from two or more staff for transfers. The resident's balance was unsteady, and he was only able to stabilize with staff assistance. The resident used a wheelchair for mobility. Review of resident #21's care plan for ADL self-care performance deficit, initiated on 4/29/23, noted he required assistance from two staff for transfers. The intervention was initiated on 5/01/23 and revised on 8/09/23. The care plan did not show the type of mechanical lift the resident required and indicated he required a large sling. Review of the medical record revealed on 8/02/2, resident #21 weighed 169.5 pounds and 9/04/23 he weighed 168 pounds, which indicated a medium sling was the appropriate size for him. On 10/04/23 at 11:31 AM and 3:08 PM, the MDS Coordinator stated she was the facility's care plan coordinator. She confirmed her duties included quarterly reviews of all care plans and more frequently if any change in status required the revision of a care plan. The MDS Coordinator explained although each section of a resident's care plan was reviewed by the appropriate member of the IDT, she was ultimately responsible for the accuracy of all care plans. The MDS Coordinator reviewed the ADL self-care performance deficit care plans for residents #13, #14, #15, #16, #17, #20, and #21 and validated the documents were not accurate and/or complete related to mechanical lift type and/or sling size for each resident. She stated residents' weights were available in the medical record and she was usually informed of any residents who lost or gained weight. The MDS Coordinator acknowledged quarterly care plan reviews were the opportune time to verify the type of mechanical lift, weight, and the appropriate size sling for each resident who used a device for transfers. Review of the job description for Long Term Care MDS Nurse, dated 8/23/23, revealed she evaluates care provided to each resident and keeps care plans current. The MDS Nurse was expected to collaborate with other members of the IDT to ensure the best quality of life possible for each resident. On 10/05/23 at 10:48 AM, the Director of Nursing (DON) stated her expectation was the MDS Coordinator would regularly review residents' care plans in their entirety and revise them if necessary, to ensure they were accurate and met residents' needs. On 10/05/23 at 12:05 PM, the RM explained the quarterly care plan review for every resident was the opportunity to examine all interventions and crosscheck that goals and interventions were still appropriate. The RM acknowledged it was important for each care plan to reflect the unique needs of each resident.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services related to administration of tube feedings via gastrostomy tube and monitoring weights according to physician orders and professional standards of practice; and failed to implement a recommendation by the dietitian to discontinue tube feeding that was no longer clinically indicated, for 1 of 1 resident reviewed for tube feeding, out of a total of 3 residents in the facility who received tube feedings, (#13). Findings: Review of the medical record revealed resident #13 was admitted to the facility on [DATE] with diagnoses including gastrostomy status, metabolic encephalopathy, generalized muscle weakness, Parkinson's Disease, and dementia. A gastrostomy is a surgical procedure in which a tube is inserted directly into the stomach through an incision in the abdomen wall. The tube is used to provide feeding or medications (retrieved on 10/09/23 from www. medical-dictionary.thefreedictionary.com/gastrostomy) The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 6/30/23 revealed resident #13 required supervision of one staff member for eating and drinking. The MDS assessment indicated the resident was 68 inches tall and weighed 140 pounds. The document revealed during the 7-day look back period, the resident's nutritional approaches included a feeding tube, a mechanically altered diet, and a therapeutic diet. Resident #13 received 51% or more of his total calories by tube feeding and his average fluid intake was 501 cubic centimeters per day by tube feeding. Review of resident #13's medical record revealed a care plan for activities of daily living self-care performance deficit related to dementia was initiated on 3/25/23. The interventions included assistance of one staff member for tube feeding. A care plan for tube feeding related to inadequate oral intake, initiated on 3/25/23, instructed staff to elevate the head of the resident's bed during tube feedings and monitor for complications. Resident #13 had a care plan for a nutritional problem related to dysphagia or difficulty swallowing initiated on 3/28/23. The goal was for the resident to maintain stable weight. The care plan was revised on 6/27/23 to reflect new interventions of a therapeutic diet and food with modified texture. Review of the Order Summary Report dated 10/04/23 revealed a physician order dated 3/25/23 to document the resident's 24-hour intake one time daily. An order dated 4/20/23 indicated the resident was placed on a Consistent Carbohydrate diet with level 2 mechanical texture, and thin consistency liquids. An order dated 5/10/23 directed nurses to provide 150 milliliters (ml) water flushes four times daily every four hours. An order dated 8/24/23 revealed resident #13 was to receive Diabetisource tube feeding at the rate of 55 ml per hour for 12 hours daily, on at 8:00 PM and off at 8:00 AM. On 10/04/23 at 10:40 AM, a bag of Diabetisource tube feeding dated 10/02 and a full bag of water hung from a pole at resident #13's bedside. The tube feeding pump was off and the tubing was not connected to the resident. On 10/04/23 at 11:31 AM, the MDS Coordinator reviewed resident #13's medical record and discovered a progress note written by the dietitian on 9/24/23 that indicated the resident no longer required tube feeding. The MDS Coordinator stated the facility's contracted dietitian was in the building once weekly on Sunday and she usually emailed the management team weekly with information about the residents she assessed. The MDS Coordinator did not recall any email communication or physician order regarding discontinuing the resident's tube feeding. She was informed there were bags of water and tube feeding on the pole at the resident's bedside. The MDS Coordinator confirmed the medical record showed resident #13 still had an active physician order for Diabetisource at 55 ml per hour from 8:00 PM to 8:00 AM every night. She explained the dietitian was able to enter orders and all new orders were reviewed in the daily clinical management meeting. The MDS Coordinator acknowledged it did not benefit the resident if the dietitian did not enter orders and communicate with the Interdisciplinary Team (IDT) to ensure implementation of her recommendations. On 10/04/23 at 11:44 AM, the Station 2 Unit Manager (UM) validated the bag of tube feeding at resident #13's bedside had been accessed and was dated 10/02. The UM confirmed the 1000 ml bag appeared full and since there was no time noted on the bag, it was impossible to know when the feeding should be discarded. Review of the label revealed the instruction to use for a maximum of 48 hours. Review of resident #13's medical record revealed a Nutritional Status Quarterly Nutrition Note dated 9/24/23 at 2:57 PM, signed by the dietitian. The document indicated the resident's weight was stable and listed his weights as 126 pounds on 4/03/23, 133 pounds on 6/05/23, 133 pounds on 7/10/23, and 135 pounds on 8/02/23. The note revealed the dietitian observed the resident in the dining room and he tolerated his diet well. She wrote, No longer reliant on enteral nutrition, meeting needs via [oral] intake. Pending September [weight]. The note indicated resident #13 would continue to receive 150 ml water flushes every four hours and the dietitian would continue to monitor his weight and oral intake and alter dietary approaches as needed. Review of the medical record revealed as of 10/04/23, resident #13's last recorded weight was obtained on 8/02/23. Review of the medical record on 10/05/23, revealed additional weights were included in the medial record, 136 pounds in September 2023 and 134 pounds for October 2023. On 10/04/23 at 1:17 PM and 5:16 PM, in telephone interviews, the dietitian explained she was previously the facility's full-time dietitian but recently accepted another job, and since the beginning of September she only worked one day on the weekends. She explained she was usually in the building on Sundays and occasionally switched to a Saturday if necessary. The dietitian validated she discontinued resident #13's tube feeding on 9/24/23 as he was eating his meals adequately. She stated the goal was for residents to eat by mouth if at all possible and this resident's daughter preferred him not to be on tube feedings The dietitian explained the advantages of eating by mouth included more probiotics, a better quality of life, and decreased risk of aspiration. She stated she wanted to continue water flushes to ensure adequate hydration and maintain patency of the gastrostomy tube as it was still used for medication administration. When asked how she communicated her recommendations to the facility, the dietitian stated she had access to the electronic medical record and could enter and discontinue orders as indicated. She was informed the order for Diabetisource at 55 ml per hour remained active. The dietitian said, I believe it was an oversight on my part. The tube feeding is no longer necessary. She acknowledged her decision to discontinue resident #13's tube feeding was made without review of his weight in September as it was not available on 9/24/23. The dietitian was informed the facility's policy and procedure indicated residents on tube feedings were to be weighed weekly. She stated she had been informed she could discontinue weekly weights if she determined them to be unnecessary. Review of the facility's policy and procedures for Responsibilities of the Dietitian, revised on 5/12/23, revealed the dietitian was accountable and responsible for her practice and would communicate with and review recommendations with a designated facility staff member. The policy indicated the dietitian would be involved in the nutrition risk committee and the interdisciplinary care plan team. The document indicated the dietitian would document in the medical record, and the facility would ensure she had access to paper and electronic documents that were necessary for resident reviews. On 10/05/23 at 10:48 AM, the Director of Nursing (DON) stated once informed about the concerns regarding administration of resident #13's tube feeding, she initiated an investigation. The DON stated her preliminary findings were that the night nurse on 10/02/23 spiked or accessed the tube feeding but did not infuse it as ordered from 8:00 PM to 8:00 AM, and the night nurse on 10/03/23 did not administer the feeding either. The DON was informed of the conflict noted in water flush order that was written as 150 ml four times daily and every four hour which would be every six hours. The DON stated her expectation was nurses would follow physician orders as written, and if confused about any order, they should reach out to the physician for clarification or ask the UM for advice. She confirmed the IDT was responsible for ensuring orders and recommendations were entered into the medical record and implemented. The DON explained the dietitian usually communicated with the IDT via emails, but she did not recall any email regarding discontinuation of the resident's tube feeding. Review of the Enteral Feed Record for October 2023 revealed no initials to indicate the night nurse infused resident #13's tube feeding on 10/02/23. Review of the facility's policy and procedure for Enteral Nutrition (Tube Feeding), revised 6/07/23, revealed a purpose of providing guidance when the inability to eat indicated the use of tube feeding was unavoidable. The policy indicated residents on tube feeding would receive appropriate treatment and services to restore oral eating skills if possible. The procedure revealed physician orders would include the amount and frequency of fluid boluses. The document read, Residents on enteral feedings will be weighed at least weekly. On 10/05/23 at 12:05 PM and 3:16 PM, the facility's Risk Manager (RM) confirmed the facility did not currently have a dietitian on site. She stated residents on tube feedings and those being monitored for weight loss were usually reviewed during the weekly Nutritional at Risk meeting. The RM explained the meetings were usually led by the dietitian; however, the last meeting was held a few weeks ago as the facility's full-time dietitian left. When asked who decided to terminate the Nutritional at Risk meetings, the RM said, I don't think it was a decision. We just didn't have them. She stated when a dietitian worked in the facility, they were expected to attend the daily clinical meeting and report or discuss any concerns with the IDT, but recently the facility had to rely on email communication from the contracted dietitian. The RM validated the dietitian was expected to adhere to the facility's policies and procedure regarding weekly weights for residents who received tube feedings. She acknowledged the DON had oversight of clinical issues and the dietitian should have communicated with the DON regarding discontinuing tube feeding.

Based on observation, interview, and record review, the facility failed to provide appropriate care and services related to administration of tube feedings via gastrostomy tube and monitoring weights according to physician orders and professional standards of practice; and failed to implement a recommendation by the dietitian to discontinue tube feeding that was no longer clinically indicated, for 1 of 1 resident reviewed for tube feeding, out of a total of 3 residents in the facility who received tube feedings, (#13). Findings: Review of the medical record revealed resident #13 was admitted to the facility on [DATE] with diagnoses including gastrostomy status, metabolic encephalopathy, generalized muscle weakness, Parkinson's Disease, and dementia. A gastrostomy is a surgical procedure in which a tube is inserted directly into the stomach through an incision in the abdomen wall. The tube is used to provide feeding or medications (retrieved on 10/09/23 from www. medical-dictionary.thefreedictionary.com/gastrostomy) The Minimum Data Set (MDS) Quarterly assessment with assessment reference date of 6/30/23 revealed resident #13 required supervision of one staff member for eating and drinking. The MDS assessment indicated the resident was 68 inches tall and weighed 140 pounds. The document revealed during the 7-day look back period, the resident's nutritional approaches included a feeding tube, a mechanically altered diet, and a therapeutic diet. Resident #13 received 51% or more of his total calories by tube feeding and his average fluid intake was 501 cubic centimeters per day by tube feeding. Review of resident #13's medical record revealed a care plan for activities of daily living self-care performance deficit related to dementia was initiated on 3/25/23. The interventions included assistance of one staff member for tube feeding. A care plan for tube feeding related to inadequate oral intake, initiated on 3/25/23, instructed staff to elevate the head of the resident's bed during tube feedings and monitor for complications. Resident #13 had a care plan for a nutritional problem related to dysphagia or difficulty swallowing initiated on 3/28/23. The goal was for the resident to maintain stable weight. The care plan was revised on 6/27/23 to reflect new interventions of a therapeutic diet and food with modified texture. Review of the Order Summary Report dated 10/04/23 revealed a physician order dated 3/25/23 to document the resident's 24-hour intake one time daily. An order dated 4/20/23 indicated the resident was placed on a Consistent Carbohydrate diet with level 2 mechanical texture, and thin consistency liquids. An order dated 5/10/23 directed nurses to provide 150 milliliters (ml) water flushes four times daily every four hours. An order dated 8/24/23 revealed resident #13 was to receive Diabetisource tube feeding at the rate of 55 ml per hour for 12 hours daily, on at 8:00 PM and off at 8:00 AM. On 10/04/23 at 10:40 AM, a bag of Diabetisource tube feeding dated 10/02 and a full bag of water hung from a pole at resident #13's bedside. The tube feeding pump was off and the tubing was not connected to the resident. On 10/04/23 at 11:31 AM, the MDS Coordinator reviewed resident #13's medical record and discovered a progress note written by the dietitian on 9/24/23 that indicated the resident no longer required tube feeding. The MDS Coordinator stated the facility's contracted dietitian was in the building once weekly on Sunday and she usually emailed the management team weekly with information about the residents she assessed. The MDS Coordinator did not recall any email communication or physician order regarding discontinuing the resident's tube feeding. She was informed there were bags of water and tube feeding on the pole at the resident's bedside. The MDS Coordinator confirmed the medical record showed resident #13 still had an active physician order for Diabetisource at 55 ml per hour from 8:00 PM to 8:00 AM every night. She explained the dietitian was able to enter orders and all new orders were reviewed in the daily clinical management meeting. The MDS Coordinator acknowledged it did not benefit the resident if the dietitian did not enter orders and communicate with the Interdisciplinary Team (IDT) to ensure implementation of her recommendations. On 10/04/23 at 11:44 AM, the Station 2 Unit Manager (UM) validated the bag of tube feeding at resident #13's bedside had been accessed and was dated 10/02. The UM confirmed the 1000 ml bag appeared full and since there was no time noted on the bag, it was impossible to know when the feeding should be discarded. Review of the label revealed the instruction to use for a maximum of 48 hours. Review of resident #13's medical record revealed a Nutritional Status Quarterly Nutrition Note dated 9/24/23 at 2:57 PM, signed by the dietitian. The document indicated the resident's weight was stable and listed his weights as 126 pounds on 4/03/23, 133 pounds on 6/05/23, 133 pounds on 7/10/23, and 135 pounds on 8/02/23. The note revealed the dietitian observed the resident in the dining room and he tolerated his diet well. She wrote, No longer reliant on enteral nutrition, meeting needs via [oral] intake. Pending September [weight]. The note indicated resident #13 would continue to receive 150 ml water flushes every four hours and the dietitian would continue to monitor his weight and oral intake and alter dietary approaches as needed. Review of the medical record revealed as of 10/04/23, resident #13's last recorded weight was obtained on 8/02/23. Review of the medical record on 10/05/23, revealed additional weights were included in the medial record, 136 pounds in September 2023 and 134 pounds for October 2023. On 10/04/23 at 1:17 PM and 5:16 PM, in telephone interviews, the dietitian explained she was previously the facility's full-time dietitian but recently accepted another job, and since the beginning of September she only worked one day on the weekends. She explained she was usually in the building on Sundays and occasionally switched to a Saturday if necessary. The dietitian validated she discontinued resident #13's tube feeding on 9/24/23 as he was eating his meals adequately. She stated the goal was for residents to eat by mouth if at all possible and this resident's daughter preferred him not to be on tube feedings The dietitian explained the advantages of eating by mouth included more probiotics, a better quality of life, and decreased risk of aspiration. She stated she wanted to continue water flushes to ensure adequate hydration and maintain patency of the gastrostomy tube as it was still used for medication administration. When asked how she communicated her recommendations to the facility, the dietitian stated she had access to the electronic medical record and could enter and discontinue orders as indicated. She was informed the order for Diabetisource at 55 ml per hour remained active. The dietitian said, I believe it was an oversight on my part. The tube feeding is no longer necessary. She acknowledged her decision to discontinue resident #13's tube feeding was made without review of his weight in September as it was not available on 9/24/23. The dietitian was informed the facility's policy and procedure indicated residents on tube feedings were to be weighed weekly. She stated she had been informed she could discontinue weekly weights if she determined them to be unnecessary. Review of the facility's policy and procedures for Responsibilities of the Dietitian, revised on 5/12/23, revealed the dietitian was accountable and responsible for her practice and would communicate with and review recommendations with a designated facility staff member. The policy indicated the dietitian would be involved in the nutrition risk committee and the interdisciplinary care plan team. The document indicated the dietitian would document in the medical record, and the facility would ensure she had access to paper and electronic documents that were necessary for resident reviews. On 10/05/23 at 10:48 AM, the Director of Nursing (DON) stated once informed about the concerns regarding administration of resident #13's tube feeding, she initiated an investigation. The DON stated her preliminary findings were that the night nurse on 10/02/23 spiked or accessed the tube feeding but did not infuse it as ordered from 8:00 PM to 8:00 AM, and the night nurse on 10/03/23 did not administer the feeding either. The DON was informed of the conflict noted in water flush order that was written as 150 ml four times daily and every four hour which would be every six hours. The DON stated her expectation was nurses would follow physician orders as written, and if confused about any order, they should reach out to the physician for clarification or ask the UM for advice. She confirmed the IDT was responsible for ensuring orders and recommendations were entered into the medical record and implemented. The DON explained the dietitian usually communicated with the IDT via emails, but she did not recall any email regarding discontinuation of the resident's tube feeding. Review of the Enteral Feed Record for October 2023 revealed no initials to indicate the night nurse infused resident #13's tube feeding on 10/02/23. Review of the facility's policy and procedure for Enteral Nutrition (Tube Feeding), revised 6/07/23, revealed a purpose of providing guidance when the inability to eat indicated the use of tube feeding was unavoidable. The policy indicated residents on tube feeding would receive appropriate treatment and services to restore oral eating skills if possible. The procedure revealed physician orders would include the amount and frequency of fluid boluses. The document read, Residents on enteral feedings will be weighed at least weekly. On 10/05/23 at 12:05 PM and 3:16 PM, the facility's Risk Manager (RM) confirmed the facility did not currently have a dietitian on site. She stated residents on tube feedings and those being monitored for weight loss were usually reviewed during the weekly Nutritional at Risk meeting. The RM explained the meetings were usually led by the dietitian; however, the last meeting was held a few weeks ago as the facility's full-time dietitian left. When asked who decided to terminate the Nutritional at Risk meetings, the RM said, I don't think it was a decision. We just didn't have them. She stated when a dietitian worked in the facility, they were expected to attend the daily clinical meeting and report or discuss any concerns with the IDT, but recently the facility had to rely on email communication from the contracted dietitian. The RM validated the dietitian was expected to adhere to the facility's policies and procedure regarding weekly weights for residents who received tube feedings. She acknowledged the DON had oversight of clinical issues and the dietitian should have communicated with the DON regarding discontinuing tube feeding.

Based on interview and record review, the facility failed to provide intravenous (IV) antibiotics as ordered by the Infectious Disease Physician for a resident's infected unstageable right heel pressure wound that resulted in rehospitalization for 1 of 4 sampled residents reviewed for IV medications, (#1). Findings: Resident #1 was admitted to the facility on [DATE] for skilled nursing, and wound care services. Her diagnoses included an infected unstageable pressure ulcer on her right heel, chronic bilateral leg edema, diabetes, breast cancer, vascular dementia, and history of strokes. Resident #1's Admission Nursing Data Collection dated 4/25/23 at 10:51 PM, noted she was admitted with a right antecubital forearm IV midline. Her admission orders included IV antibiotic, Cefepime 1 gram (gm) every 8 hours for right heel infected pressure wound to be given until 4/28/23. Review of the April 2023 Medication Administration Record (MAR) showed the resident received Cefepime as ordered from 4/25/23 to 4/28/23. A midline catheter is a small tube used to give treatments and to take blood samples. The catheter is inserted into a vein in your arm. The end of a midline, inside your body, does not go past the top of your armpit. A midline catheter can stay in place for up to 30 days. Retrieved 6/26/23 at 10:49 AM www.drugs.com/cg/midline-catheter.html Review of the Infectious Disease consultant physician notes dated 5/4/23 noted the resident went for a follow-up visit for the right heel pressure wound. The physician ordered IV Cefepime 1 gram to be continued every 8 hours for two more weeks from 5/4/23 to 5/18/23. Review of the resident's medical record revealed no physician orders documented to continue Cefepime IV for two more weeks. Review of progress notes and the MAR for May 2023 noted no transcription of IV Cefepime or any indication the IV antibiotic was given. There was no documented evidence the resident received IV Cefepime from 5/4/23 through 5/18/23 as ordered by the Infectious Disease physician for the infected right heel pressure wound. On 5/30/23 at 2:36 PM, a voicemail was left for Certified Nursing Assistant (CNA) C who accompanied resident #1 for the follow up visit with the Infectious Disease physician on 5/4/23. On 5/31/23 2:41 PM, CNA C returned the call and confirmed she accompanied resident #1 on 5/4/23 to the follow up appointment. CNA C recalled she was with the resident during her appointment when the physician assessed the wound. She explained the Infectious Disease physician wrote some documents and gave her a large envelope to take back to the facility. She said they returned to the facility between 5 PM and 6 PM. She stated she handed the visit paperwork to the resident's nurse, Licensed Practical Nurse (LPN) A. CNA C reiterated she gave the paperwork directly to the nurse, then left. Review of the medical record showed the resident went to another follow up appointment with the Infectious disease physician on 5/18/23. On 5/30/23 at 1:05 PM, CNA D recalled going with resident #1 to the hospital on 5/18/23 to see the doctor about her right heel pressure wound. She said it was another follow up visit with the Infectious Disease doctor. She explained she stayed with the resident during the assessment. She recalled she was in the room with the resident during the assessments. CNA D stated the doctor jumped back when she took the dressing off the resident's foot and made a face like it smelled really bad. She indicated the doctor told the resident the wound was more infected and she was sending the resident to the hospital to be admitted and said, you are not going back to the facility. CNA D explained the doctor was very upset with the nursing home and told the resident, I'm sorry because I was the one who sent you to that place and you aren't going back, The CNA said the doctor was asked her if there really was a wound physician at our facility and she replied, yes and he visited every week. CNA D said her sense of smell was not good but she smelled the odor from the resident's right heel when the dressing was removed which meant that it must have smelled really bad. An Infectious Disease physician's visit note dated 5/18/23 noted resident #1 went for a second follow-up visit. During this visit, the resident was transferred to the hospital from the physician's office. In emails dated 5/18/23 to the facility, the hospital's nurse and Licensed Certified Social Worker indicated the resident was readmitted to the hospital due to malodorous and worsening right foot pressure ulcer. On 5/30/23 at 9:56 AM, the facility's Social Worker, Risk Manager, Administrator and acting Director of Nursing (DON) acknowledged the facility nurse failed to review the orders the Infectious Disease physician sent from the 5/4/23 follow up visit. They acknowledged the orders to continue the IV antibiotic were not transcribed to the MAR and the resident did not receive the IV Cefepime for the additional two weeks as ordered. The Social Worker stated she had received emails and calls from the hospital's nurse and Social Worker on 5/18/23 informing them of the Infectious Disease physician's concerns about the resident's worsening right heel pressure ulcer. The Social Worker stated they were informed the right heel ulcer had a very odorous smell and looked worse. She said she was informed the resident was readmitted to the hospital for testing and IV antibiotics. She stated she immediately informed the DON at that time and an investigation was started. On 5/30/23 at 2:20 PM, telephone calls were made to the hospital's Social Worker (SW) and voicemails were left inquiring about resident #1. The hospital's SW called back on 6/2/23 at 9:47 AM and reported she had received permission from the resident to speak about her condition. She explained the resident had received more intensive IV antibiotic therapy, had multiple other tests done including Magnetic Resonance Imaging (MRI) and wound cultures. She reported the right heel wound cultures done on 5/18/23 revealed infection with two different bacteria. She noted the resident was admitted to the hospital on 5/18/23 and remained there as of 6/2/23. A facility policy and procedure (P/P) titled, Physician/Practitioner Orders - Rehab/Skilled was reviewed. It included the following: Purpose - To provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders. To provide a procedure that facilitates the timely and accurate processing of physician/practitioner orders. Transcribing/Processing Orders - Orders are processed and transcribed into PCC [Point Click Care electronic medical record system] - clinical - Orders immediately upon receipt of an order. All orders must be noted by the licensed nurse who has processed the order. Orders may include but not be limited to: admission orders, orders received throughout resident's stay, consultant orders . A facility policy titled, Pressure Ulcers included: A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing, prevent infection and prevent new pressure ulcers from developing.

Based on interview, and record review, the facility failed to implement procedures to ensure a resident's wishes related to health care treatments and procedures at the end of life were accurately recorded and available to nursing staff, and failed to honor an advance directive that reflected the decision to withhold Cardiopulmonary resuscitation (CPR) for 1 of 8 sampled residents, (#1). These failures contributed to resident #1 receiving CPR in violation of an explicit wish for a natural, dignified death. There was likelihood resident #1 experienced severe pain, and could have suffered broken bones, organ damage and a prolonged dying process. On [DATE], resident #1's husband, her Power of Attorney (POA), provided the facility's Admissions Coordinator with her advance directive, a Do Not Resuscitate Order (DNRO) form. The husband signed the document in the designated area and facility staff were responsible for obtaining the physician's signature on the form and implementing the DNRO. The Admissions Coordinator handed the incomplete DNRO form to an unknown nurse, but facility staff neither obtained the physician's signature nor updated resident #1's medical record to reflect her wish not to be resuscitated. On [DATE] at 2:23 PM, resident #1's condition declined, and she became unresponsive. Nursing staff checked the resident's electronic medical record (EMR) for a physician's order and searched the unit's advance directive binder where DNRO forms were kept. There was no DNRO in the EMR and no paper DNRO form in the binder. Nursing staff therefore determined resident #1 had Full Code or full resuscitation status and they initiated CPR. Facility staff called 911 and when Emergency Medical Services (EMS) personnel arrived at the resident's bedside, they continued CPR during transport from the resident's room to the ambulance via stretcher. Resident #1 suffered aggressive resuscitation measures on the way to the hospital and in the Emergency Department (ED) until she was pronounced dead on [DATE]. The facility's failure to honor the right to choose withholding of lifesaving interventions placed all residents with a DNRO advance directive at risk for serious psychosocial harm, physical trauma, and a prolonged, undignified death from unwanted resuscitation efforts. This failure resulted in Immediate Jeopardy starting on [DATE]. The Immediate Jeopardy was removed on [DATE]. The scope and severity of the deficiency was decreased to D, no actual harm, with potential for more than minimal harm, that is not Immediate Jeopardy after verification of the facility's immediate corrective actions. Findings: Resident #1, a [AGE] year-old female, was admitted to the facility from the hospital on [DATE]. Her diagnoses included dementia, chronic atrial fibrillation, seizures, major depressive disorder, and heart failure. The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1 required a surrogate to make healthcare decisions. The Minimum Data Set (MDS) Admission assessment dated [DATE] noted the resident had a Brief Interview for Mental Status score of 7 out of 15 which indicated severely impaired cognition. Review of an Admission note dated [DATE] revealed resident #1's husband came to the facility and signed the admission contract. The note indicated he was his wife's power of attorney (POA). The document read, .All policies and procedures explained. DNR. On [DATE] at 3:25 PM, the Admissions Coordinator reviewed the above note and confirmed she met with resident #1's husband on [DATE], the day after admission. She recalled the husband signed all required admission paperwork and a DNRO form. The Admission Coordinator stated she went to Station 2 where resident #1's room was located and handed the DNRO form to a nurse, but could not recall the name of the nurse. She explained the nurse was responsible for obtaining the physician's signature on the DNRO form and entering the physician's order in the EMR. Review of resident #1's State of Florida NOT RESUSCITATE ORDER form revealed the document was signed by the resident's husband on [DATE], but it was never signed by the physician. On [DATE] at 11:18 AM, in a telephone interview, resident #1's husband stated his wife was admitted to the facility for rehabilitation services and his plan was for her to remain in the facility and transition to long-term care. He explained his wife had been diagnosed with dementia approximately two years ago and the disease was progressively worsening. He stated his wife now did not even recognize him at times. He stated she had been through a lot recently with episodes during which she zoned out and had several seizures that led to repeated hospitalization s. Resident #1's husband explained as his wife's POA, he selected a DNR status to ensure she would not have to endure any more aggressive or intrusive healthcare treatments and procedures. The husband stated on [DATE], he missed a telephone call from the facility and later retrieved a message on his voicemail that his wife had been transferred to the hospital ED. He recalled he received a telephone call from the hospital regarding his wife's critical status, but he was unable to get to the hospital before she died . When asked if anyone at the hospital or the facility informed him that his wife received CPR prior to her death, he said, That's the first I've heard of it. He confirmed he signed the DNRO form on the day after his wife was admitted to the facility when he met with the Admissions Coordinator. The husband stated after he signed the DNRO form, no one from the facility updated him on his wife's code status, nor did he think it was necessary to ask about it. He said, I assumed they would have followed through on their process to ensure the DNR was in place. On [DATE] at 1:45 PM, in a telephone interview, the former Station 2 Unit Manager (UM) stated she did not recall receiving resident #1's DNRO form from the Admissions Coordinator. She explained if a DNRO form was not signed by the physician, the nurse should contact the physician to obtain a verbal order for DNR status. She stated another nurse would act as a witness to the verbal order and the resident's code status would be changed to DNR in the EMR. The UM stated the nurse would then place the DNRO form in the physician's designated folder so it could be signed at his/her next visit to the facility. The Unit Manager said after the physician signed the DNRO form, it would be placed into the unit's Advance Directives binder with the resident's face sheet. Review of resident #1's EMR and the Station 2 Advanced Directives binder revealed the process described by the former Station 2 UM was not followed by nurses. On [DATE] at 2:12 PM, Licensed Practical Nurse (LPN) C described the sequence of events on [DATE], the day resident #1 received CPR. She recalled she was assisting the Assistant Director of Nursing (ADON) when resident #1's assigned nurse, LPN H, informed them resident #1 looked fine earlier that morning but now looked different. LPN C stated it was possibly between 1:30 PM and 2:00 PM, when she arrived in resident #1's room and she noticed the resident was very pale and she had an abnormal breathing pattern. LPN C said, Her eyes were kind of rolled back and dilated. LPN C stated she informed LPN H that resident #1 does not look good and needed to go to the hospital. LPN C stated she left the resident's room and went to the Station 2 nurses' station to check the Advance Directives binder and resident #1's EMR for her code status. LPN C stated there was no DNRO form in the binder and no DNRO in the EMR. LPN C recalled as she was about to return to resident #1's room, she saw LPN H move the cart with emergency medical equipment with resuscitation equipment to the room. LPN C stated she used the overhead paging system to alert staff there was a Code 99 emergency on Station 2. LPN C stated she then returned to resident #1's room with the Advance Directives binder and a laptop computer to validate the resident's code status. She recalled upon entering the room, she observed two other nurses with LPN H at the bedside and CPR was in progress. LPN C stated the ADON arrived within a few minutes and immediately asked about the resident's code status. LPN C stated she responded, Full Code. She is not in the Advance Directive book. LPN C stated she checked the EMR again and verified the resident was to receive CPR. LPN C stated when EMS personnel arrived at the facility, they took over performing CPR from the nurses, and transported resident #1 to the hospital. LPN C explained the following day, the facility's Risk Manger informed her resident #1 had a DNRO form but it was not signed by the physician. On [DATE] at 4:35 PM, the Risk Manager recalled she was near the facility's front lobby when EMS personnel left the building with resident #1 on the afternoon of [DATE]. The Risk Manager stated at that moment, the Admissions Coordinator informed her resident #1's husband had signed a DNRO form. The Risk Manager explained she informed the facility's Administrator and initiated an incident investigation. She stated she discovered resident #1's DNRO form had been scanned into the facility's electronic document storage system on [DATE], but the physician had not signed it. The Risk Manager could not account for what happened to resident #1's DNRO form between [DATE] when it was signed by the husband and [DATE] when she found the scanned, unsigned document. On [DATE] at 11:37 PM, the Health Information Management (HIM) / Medical Records technician, explained each Nursing Station had a box for documents that needed to be scanned into the facility's electronic document storage system. She explained nurses and physicians would place documents and forms in the box and she would either file or scan them as indicated. The HIM / Medical Records technician could not recall if she ever saw resident #1's DNRO form. She explained prior to this incident, she never checked DNRO forms for completeness including physician's signature, prior to scanning them. She could not explain why resident #1's DNRO form would have been placed in the box of completed documents to be filed or scanned if the physician had not yet signed the form. On [DATE] at 12:54 PM, the facility's Social Worker (SW) stated she never discussed advance directives with resident #1 or her husband. She explained this information was normally discussed during comprehensive care plan meetings but this meeting was never held during the resident's stay in the facility. The SW stated audits of residents' advance directives were to be conducted each month, but the last time this process occurred was on [DATE], prior to resident #1's admission. She did not respond when asked why the monthly advance directives audits were not conducted in September, October or [DATE]. On [DATE] at 4:57 PM, during review of resident #1's care plans with the Care Plan Coordinator, she stated resident #1's baseline care plans were initiated on [DATE]. She acknowledged the resident's advance directive related to DNR status was not included in her care plans. The Care Plan Coordinator explained the resident's Admission MDS assessment was completed on [DATE], and the comprehensive care plan meeting with the resident and/or her representative should have been completed within 14 days after that assessment, or approximately 21 days after admission. She validated advance directives were to be reviewed and updated if necessary at comprehensive care plan meetings, but resident #1's meeting never took place. The Care Plan Coordinator verified if the facility's comprehensive care plan process had been properly implemented, staff would have identified the resident's selection of DNR status prior to the incident on [DATE]. Review of the immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team: *On [DATE] and [DATE], the attending physician, Medical Director, Administrator, Director of Nursing (DON), family and the facility's administrative team were notified of the incident and an investigation was initiated. *On [DATE], an Ad Hoc Quality Assurance and Performance Improvement (QAPI) committee meeting was held. A Performance Improvement Plan on advance directives was started. *On [DATE], the HIM technician was re-educated about advanced directive scanning and procedures. *From [DATE] to [DATE], the facility educated Administration and Licensed Nurses on the topic of Advance Directives to include a post-test. On [DATE], 67.5 percent were trained and as of [DATE], a total of 95 percent of eligible staff were trained. *From [DATE] to [DATE], the facility took actions taken to reduce the risk of future occurrences. Staff were educated on the Policy and Procedure related to: Honoring Advance Directives with a focus on Code Status & Following the Physician's orders with post-test ([DATE]); New Hire staff orientation to include education on the Policy & Procedure related to Honoring Advance Directives with a focus on Code Status & Following the Physician's orders (ongoing); Adjust admission check list to be reflected on bright pink sheet ([DATE]); Laminated card on the emergency carts that read, STOP!! CHECK CODE STATUS!! ([DATE]) Advance directives will be validated during review of admission at the morning meeting for status, documentation, order, and care plan; Medical Director will review advance directives for any missing physician signatures during QAPI meeting; Weekly Audits to include (a) Advance directives identified on admission sheet (b) Order in place (c) Care plan reflects order (d) Scanned into electronic documents storage (e) Placed in binders if needed. * Review of the facility's in-service education titled, GSS Kissimmee Advance Directive/DNR Procedure dated [DATE] revealed the following: 1. Process starts with Admissions - Admissions will bring up the question to case the manager in hospital about Advance Directives. Admission team will verify CODE STATUS, DOCUMENT and SIGNATURES. Follow up will be conducted with case manager regarding physician signatures and uploading. Admissions will get a BRIGHT PINK sheet to check off. 2. Once resident is admitted , the transfer and DNRO forms will be given to both Social Services and Nursing departments to double/triple check code status and signatures. If both signatures present, verify order and identification in chart is in place, COPY given to HIM for scanning and ORIGINAL to Advance Directives binders on Nursing Stations. 3. IF SIGNED ONLY by FAMILY, FAX to the physician and OBTAIN VERBAL CONSENT. SOCIAL SERVICE (or any department may witness) and Nursing can obtain signatures from FAMILIES and PHYSICIANS. 4. INCLUDE/PASS ON INFORMATION in end-of-shift report for follow up. 5. ADVANCE DIRECTIVES will be validated during REVIEW of ADMISSIONS at the morning meeting for STATUS, DOCUMENTATION, ORDER, and CARE PLAN. 6. ADVANCE DIRECTIVES to be REVIEWED at all care plan meetings. *On [DATE], the facility reviewed residents who had Code 99 events over the previous 30 days to ensure policies, procedures and residents advance directive wishes were followed. The facility audited current residents' medical records to ensure code status orders and care plans were accurate, with documentation to support the orders. Advance Directive binders were audited to ensure all DNROs were in place. *On [DATE], an Adverse Incident Report was filed with the Agency for Health Care Administration. On [DATE], interviews were conducted with three Registered Nurses and three LPNs regarding the facility's IJ removal plans and in-service education for Advance Directives / DNR. Four of six licensed nurses verbalized understanding of the education provided. The resident sample was expanded to include seven additional residents, three who elected DNR status and four who elected Full Code status. Interviews and record reviews revealed no concerns for residents #2, #3, #4, #5, #6, #7, and #8 related to advance directives.

Based on observation, interview and record review, the facility failed to prevent a physically and cognitively impaired resident from exiting the facility; failed to conduct accurate elopement assessments and implement appropriate interventions to address elopement risk; failed to ensure an alarm system functioned effectively to maintain a secure environment; and failed to ensure staff were knowledgeable of elopement protocols to promote safety for 29 of a total sample of 33 residents reviewed for elopement, (#1, #4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #30, #31, #32 and #33). Approximately 48 hours after admission, on 8/28/21 at 5:23 PM, the facility failed to prevent resident #1, a physically and cognitively impaired resident from exiting the facility unsupervised through the exterior exit door on Station 1 right hallway. Resident #1 was outside on the hot, sunny day for over 15 minutes, and traveled approximately 30 feet away from the exit door. The facility was unaware of resident #1's whereabouts until a staff member inside the facility happened to look through a window and saw her standing in the grass. By the time staff arrived outside to retrieve resident #1, she had fallen to the ground. While resident #1 was out of the facility unsupervised, there was reasonable likelihood she could have been injured when she fell , become lost or been hit by a car. These failures contributed to the elopement of resident #1 and placed all residents who were ambulatory or mobile, with or without an assistive device, at risk for serious injury/impairment/death, and resulted in Immediate Jeopardy starting on 8/28/21. Findings: Cross reference F600 and F835 Resident #1, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included altered mental status, hypertension, diabetes, urinary tract infection (UTI) and pneumonia. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 8/20/21 revealed resident #1 was hospitalized for a primary diagnosis of altered mental status, was not capable of making healthcare decisions and required a surrogate. She was alert, disoriented, but could follow simple instructions. The form indicated resident #1 ambulated and transferred with assistance but did not use an assistive device. Review of resident #1's medical record revealed a Nursing Admit Re-Admit Data Collection form dated 8/26/21. The document indicated resident #1 was admitted to the facility from the hospital to continue intravenous and oral antibiotic therapy for pneumonia and a UTI. The form indicated she was alert and oriented to person and place, had weakness in all extremities, ambulated independently and was not potentially at risk for elopement. The admission data collection forms included a detailed Elopement assessment dated [DATE]. Review of the form revealed a purpose To collect information to determine risk factors of elopement. In response to questions regarding resident #1's history, the admission nurse noted no risk factors. According to the paperwork received from the hospital, the nurse should have selected at least the following five risk factors: admission within the last month, as she was admitted that day; caregiver or staff change, as she was recently cared for by assisted living facility (ALF) staff and then hospital staff; change in normal behavior, as evidenced by her diagnosis of altered mental status; changes in medication, as she was in the facility to receive antibiotic therapy for acute illnesses; and a recent room change due to transfers from the ALF to the hospital and then to the facility. Due to her level of consciousness and mental status, resident #1 would not have been able to reliably respond to other significant questions regarding a history of wandering or leaving a building. The document indicated resident #1 had no mood or behavioral risk factors for elopement. Based on her primary diagnosis of altered mental status and her need for a healthcare surrogate, she was not able to provide information that included the following: recent changes due to losses of a loved one or a medical or physical condition, past elopement attempts, failure to return from outings, verbalizing wanting to leave and wandering. The Elopement Assessment form indicated resident #1 had no diagnoses that put her at risk for elopement, although her diagnosis of altered mental status would be appropriately classified as either organic brain disease or other diagnosis, as listed on the document. Since the assessment identified no history, mood, behaviors, or diagnoses that suggested she was at risk for elopement, a care plan for elopement did not trigger. Instructions on the form directed nurses to update the attached care plan for elopement as indicated. Care plan interventions included to check resident per an individualized frequency, 1:1 supervision, application of an electronic monitoring device, offer to walk with resident outside and ensure exit door alarms were in working order. None of these preventative interventions were initiated, and resident #1 was not offered the appropriate care, supervision and services required to ensure her safety. An incident report dated 8/28/21 at 6:00 PM revealed resident #1 was observed . out side the building sitting in the grass. between 5:30 PM and 5:45 PM. The report indicated resident #1 was resistant and extremely combative during multiple attempts to return her to the facility and calmed down only when facility staff contacted her daughter to intervene by telephone. The document noted the resident was ambulatory without assistance, exhibited poor judgement and decision making and had predisposing factors including admission within the last 72 hours. The report read, Door alarm present, however may not be as loud at the nursing station. Review of the Incident List log for Station 1 right hallway exit door revealed the door was breached on 8/28/21 at 5:23 PM and alarmed for 14 minutes and 41 seconds until it was silenced by an unknown staff member at 5:38 PM. The Station 1 right hallway exit door was next opened at 5:41 PM, at the approximate time staff observed resident #1 outside the facility and went to retrieve her. On 9/04/21 at 5:17 PM, resident #1 was interviewed in the facility's secure Memory Care Unit. She was alert but disoriented to time, place, and situation. She did not recall her recent stay in the hospital nor why she was currently in the facility. Resident stated her current location was St. [NAME], Missouri rather than Kissimmee, Florida and thought she had been in the facility for a couple months, instead of ten days. Resident #1's long term memory was not intact as she said, I don't know what type of work I did. When asked about the day she got outside the facility she said, I was very upset about something. I don't remember what. I pushed the door, and I went outside. I fell but didn't hurt myself. On 9/04/21 at 6:01 PM, the elopement incident was discussed with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The ADON stated Licensed Practical Nurse (LPN) A, the Station 1 nurse, did not assume care of resident #1 during that day shift as she did not realize the resident was on her assignment. The ADON explained resident #1 was initially assigned to Station 4 on admission, but she was temporarily placed in a private room on Station 1, pending the result of a Corona Virus Disease 2019 (COVID-19) test. She stated resident #1 was the only resident on Station 1 right hallway, and she was assigned to the Station 1 nurse and a Station 4 Certified Nursing Assistant (CNA) on the day she eloped. The ADON confirmed there were alarms on exterior exit doors. When asked how resident #1 was able to exit the facility without knowledge of the staff, she said, The alarms used to be louder in the past and now the call light and door alarm both sound the same. The DON stated the split assignment of a Station 1 nurse and a Station 4 CNA caring for resident #1 probably contributed to confusing circumstances. She said, I'm not sure who made the assignment or who switched her room. I asked the question of the nurses and they explained it was for her to wait there until we got the [COVID-19 test] result. It was not a logical assignment. On 9/04/21 at 6:27 PM, in a telephone interview with the weekend nursing supervisor, Registered Nurse (RN) C, she recalled staff informed her a resident was outside the facility and when she arrived at the area she observed resident #1 sitting in the grass. RN C said, She came out the door and went outside on her own. Nobody saw her leave. She walked to the place she was found. RN C stated resident #1 was the only resident on the Station 1 right hallway that day, and one side of the double doors at the entrance to the hallway was closed which decreased visibility of the hallway. She recalled interacting with the resident earlier that morning and noted she was forgetful and confused. RN C said, I believe the alarm is a very low sound. It used to be very loud, but it was changed about a year ago to a softer sound. I don't know why the volume was changed. I believe it was possible that it alarmed but staff did not hear it. RN C explained it was also possible that no staff realized the exit door was opened because the alarm sounded like a call light at the nurses' station. RN C stated she did not make the staffing assignments and when she was informed staff on two separate units were caring for resident #1 she thought it was strange. She said, I was told that's what they were doing. RN C acknowledged that although she was the weekend supervisor, she did not make any changes in the assignments. On 9/05/21 at 8:06 AM, in a telephone interview, resident #1's daughter stated her mother had a recent, sudden decline in status. The daughter said, We are all in shock of her recent behavior. She is a very different person now. She stated within the last six weeks, her mother fell and hit her head on a table, was taken to the hospital emergency room three times for increased confusion and was eventually diagnosed with a severe UTI. Resident #1's daughter explained in addition to her mother's recent changes in mental status and personality, she was also very unsteady and at high risk for falls. During a review of resident #1's elopement assessment with the daughter, she confirmed her mother was too confused to provide accurate responses to the questions and she was not sure how the facility completed the form. She said, No one called to ask me anything. She stated she was not aware her mother was placed on a hallway by herself or that she fell when she was outside. Resident #1's daughter said, When I found out they allowed her to get outside, I was shocked and scared. She could not be watched properly if she was on a hallway by herself. Mom would never be safe outside the facility. On 9/05/21 at 11:02 AM, the interim DON confirmed resident #1 was the only resident on the Station 1 right hallway. She said, I gave the ok to put the patient there. The interim DON stated resident #1 required a private room, but she could not explain why she placed a newly admitted resident on a hallway by herself or why she did not adjust the assignments to designate Station 1 CNAs and nurses to provide care. She suggested staff did not realize the degree of the resident's confusion, and said, On admission she looked ok. She acknowledged resident #1 was not known to the staff and had not been ideally monitored by Station 4 staff during her 2-day stay on Station 1. The interim DON added, She was not safe outside on her own, in the courtyard maybe, but we would not have let her go out on their own. On 9/05/21 at 11:28 AM, CNA B stated she was usually assigned to residents on Station 4 for the 7:00 AM to 3:00 PM shift. CNA B recalled her Unit Manager (UM) told her resident #1 on Station 1 would be on her assignment. She said, I've never had to take care of residents on two units before. I was questioning it, but I was told by the Unit Manger that I had to do it. On the day resident #1 got outside, CNA B described her assignment as a total of eight residents located on three hallways, Station 4 left hallway, Station 4 right hallway and resident #1 on Station 1 right hallway. She said, Honestly, I was exhausted that day. I saw her maybe three times for the day. I ran over there to check, but I was worried about my other residents on Station 4. CNA B recalled resident #1 was confused and a little off when answering questions. CNA B said, This assignment did not sound like right planning to me. If [the resident] put on her call light I would not know unless one of the Station 1 CNAs called me. I wished she was closer. On 9/05/21 at 4:17 PM, CNA D stated she worked on Station 4 for the 3:00 PM to 11:00 PM shift and on 8/28/21 she was assigned to care for resident #1 who was on Station 1. She said, In report, I was told I had a resident on Station 1. That is not normal. I asked the Unit Manager how I was supposed to know what was happening when I turned my back to her. There was no way I could give her the attention I needed to because she was too far away. CNA D explained the exit door alarms were not loud and she sometimes did not hear them on Station 4. She said, And I definitely couldn't hear it on Station 1 on the other side of the building. On 9/05/21 at 4:39 PM, in a telephone interview, CNA I recalled she was seated at the bedside of a resident on the Station 1 left hallway and happened to look through the window above the bed. CNA I stated she saw resident #1 standing in the grass. She stated she reported her observation to the Station 1 nurse and then went outside to retrieve the resident. CNA I said, When I went outside she was sitting in the grass, not standing anymore. She explained when resident #1 was brought back into the facility, she overheard that a CNA from Station 4 was supposed to come across to take care of her. Review of the facility's floor plan revealed Station 1 was located on the opposite side of the building from Station 4. The CNAs assigned to care for resident #1 had to leave their regular assignments and travel approximately 175 feet from the Station 4 nurses' station, past administrative offices and the front lobby to get to resident #1's room on Station 1. On 9/04/21 at 8:20 PM, the facility's Maintenance Director stated the exterior exit doors were fire doors and opened without delay by pushing on the panic bar. He explained an alarm would sound immediately and it could only be silenced by a staff member entering a code on the keypad next to the door. The Maintenance Director stated the alarm was also integrated with the call light annunciator. He said, It has the same alarm sound as the call lights. That's what they would have heard from the middle of the station. On 9/04/21 at 8:40 PM, during a tour of the Station 1 right hallway, the Maintenance Director demonstrated the function of the door alarms. He pointed to an additional mini screamer alarm on the door but explained it was off since he only used it as a back-up if the system was not functioning. He pushed on the panic bar, the door opened immediately, and a soft alarm sounded. The Maintenance Director closed the door and entered a code on the keypad to silence the alarm. He was asked to test the system again, and from the nurses' station in the middle of Station 1, the faint door alarm was not audible, but a call light sound was noted. Resident #1's elopement route was retraced on 9/05/21 at 1:30 PM. She walked from her room towards the end of the Station 1 right hallway, passing empty rooms on both sides of the hallway. Resident #1 traveled approximately 100 feet without an assistive device and pushed on a panic bar to open the exterior exit door. Once outside, she turned left, stepped off the paved path and walked onto a grassy area. She was observed approximately 30 feet away from the exit door, near a garden bed. If resident #1 had turned right, she would have crossed the entrance to the facility's main circular driveway and approached a large retention pond with a low fence and steeply sloping sides. The pond was approximately 30 feet to the right of Station 4 left hallway exit door. If resident #1 had stayed on the paved path she would have reached the parking lot that was approximately 50 feet away. Resident #1 was found in a grassy area bordered by a drainage ditch, and adjacent to a moderately trafficked 2-lane private road. Across from the facility there was a frequently used gated access road to a busy shopping center. Review of historical weather data revealed on 8/28/21 at 4:56 PM, it was 90 degrees Fahrenheit (F) and sunny with a 67% humidity level (retrieved on 9/05/21 from www.timeanddate.com). The heat index or feels like temperature in the shade that day was 104 degrees F. Heat indices of 103 degrees F. or above are classified as dangerous and can lead to heat exhaustion and heat stroke (retrieved on 9/10/21 from www.weather.gov). On 9/06/21 at 12:57 PM, in a telephone interview with the UM, she stated on admission it was decided that Station 4 nurses and CNAs would care for resident #1 even though she was on Station 1. She said, I asked [the interim DON] why resident was put on Station 1. It did not make sense to me. It did not make sense to a lot of us. The Station 4 CNAs brought it to my attention that it wasn't safe to take care of a resident on Station 1. I told them I was aware, but I had to follow protocol. The UM explained it was difficult for CNAs to leave their assigned residents on Station 4 to care for resident #1 on Station 1. She explained CNAs could not see the call light if resident #1 needed something, and they could not monitor her closely. The UM said, If resident was on Station 4, she would have been cared for more appropriately. She stated resident #1 was confused and the normal process would be to call a family member to obtain accurate information during admission data collection. The UM acknowledged it was not safe for the call light and exit door alarms to sound the same as staff were not able to distinguish when an immediate response was necessary. On 9/05/21 at 12:40 PM, the DON reviewed resident #1's elopement assessment and validated the inaccuracies identified on the form. She stated nurses should have contacted a family member or staff at the ALF to obtain the required information. The DON acknowledged if the assessment had been completed accurately, the facility would have discovered resident #1's true elopement risk level and implemented an appropriate care plan to provide the level of supervision she needed. The DON stated the facility did not have a process in place to ensure accuracy of assessments. She stated the split assignment was a contributing factor to resident #1's elopement. In interviews on 9/05/21 at 12:16 PM and 2:09 PM, the Clinical Learning Development Specialist stated all staff received education on elopement in new-hire orientation. During review of the Rehab/Skilled Required Annual Training 2021 Calendar approved on 1/21/21, she acknowledged the scheduled monthly mandatory topics did not include elopement. She stated in the last five years she recalled organizing only three elopement drills. When asked what the facility did in the last week to prevent an elopement from reoccurring, the Clinical Learning Development Specialist said, For these first seven days, department heads spoke about it. She explained frontline staff were not involved in the discussion. Interviews with staff representing all shifts revealed they were unfamiliar with the facility's elopement policy and procedures and did not recall recent education on resident safety related to door alarms or elopement and wandering. Frontline staff verbalized concerns regarding the volume and tone of exit door alarms. On 9/04/21 at 4:42 PM, LPN J stated he worked for a staffing agency and did not work in the facility often. He denied receiving education on the facility's elopement prevention protocols. On 9/04/21 at 4:54 PM, LPN K stated the exterior exit door alarms sounded, but were soft. She explained the alarms used to be louder, but the volume was changed. On 9/04/21 at 5:04 PM, CNA L stated she had never participated in an elopement drill nor in-services on elopement prevention. On 9/04/21 at 9:06 PM, CNA M stated she regularly worked on Station 1. She could not recall receiving education on elopement for many years. She stated she was aware resident #1 got out of the facility without staff knowledge and said, Maybe the alarm is not loud enough for us to know the door opened. On 9/04/21 at 9:11 PM, CNA H said, We cannot hear the alarms. In the hallways it sounds the same as call light. We can't always tell which one it is. CNA H did not recall receiving education on elopement policies and procedures. She was not able to describe specific actions to be taken after a resident went missing. On 9/05/21 at 11:43 AM, in a telephone interview with RN E, she recalled receiving education on elopement in new hire orientation, but no in-services since then. She stated she had never participated in an elopement drill. On 9/06/21 at 10:57 AM, during a meeting with the facility's administrative team, the Administrator stated she was aware of a technology shift in 2020 that resulted in a lowered volume of exterior door alarms. She confirmed the facility never provided in-services to staff on the change in alarm volume or implemented new procedures to respond to or monitor exit doors. The DON confirmed the Maintenance Director provided a report that showed the Station 1 right hallway exit door was opened on 8/28/21 at 5:23 PM, and the associated alarm and call light tone sounded for over 14 minutes. She acknowledged when an unknown staff member eventually responded, he/she silenced the door alarm without looking outside or initiating elopement protocols. The DON acknowledged that all residents who could get to the exit doors were still at risk for elopement since the alarm system was unchanged and staff had not yet been re-educated. She provided a list of 28 additional residents who were mobile, with or without a device, and therefore potentially able to access exterior doors and exit the facility unsupervised. The DON validated residents #4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #30, #31, #32 and #33 were at risk. The QAPI Coordinator stated she led the facility's monthly Safety Committee meetings and she had no record of concerns regarding door security, alarms or lack of elopement drills in the Safety Committee meeting minutes. She said, The issues with the doors and alarms should have been discussed in the safety meetings. The administrator stated she was not able to provide documentation of elopement drills as the facility had not conducted these exercises since she had assumed her position one year ago, in August 2020. She explained elopement drills were not required by the facility's corporate office. The administrator was informed the Clinical Learning Development Specialist was not able to show evidence of regular staff training on elopement policies and procedures. She did not respond when asked how the facility trained staff and ensured competency in prevention of elopement. Review of the facility's policy and procedure Elopement - Rehab/Skilled reviewed/revised on 8/02/21 revealed a purpose To assess and identify residents at risk for elopement. The document indicated the facility would outline procedures to monitor and supervise these residents to minimize elopement risk. The procedure included assessment with appropriate and individualized care plan interventions. The document read, Elopement drills are recommended to be completed on a routine basis. It included the expectation that all employees would participate in drills and reports would be filled with Safety Committee Minutes. Review of the attached Preventing Elopement Focus Audit checklist revealed a requirement to monitor newly admitted residents in first 24 to 48 hours in the facility to monitor their location and identify behavior patterns and routines. The audit form included verification of elopement drills and education regarding response to elopement.

Based on observation, interview and record review, the facility failed to effectively utilize its resources to provide oversight of assessments and staff assignments to ensure appropriate levels of supervision; failed to maintain a secure environment with an effective door alarm system; and failed to ensure staff received education and demonstrated proficiency in elopement prevention procedures before and after an elopement incident, for 29 of a total sample of 33 residents reviewed for elopement, (#1, #4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #30, #31, #32 and #33). Approximately 48 hours after admission, on 8/28/21 at 5:23 PM, the facility failed to prevent resident #1, a physically and cognitively impaired resident from exiting the facility unsupervised through the exterior exit door on Station 1 right hallway. Resident #1 was outside on the hot, sunny day for over 15 minutes, and traveled approximately 30 feet away from the exit door. The facility was unaware of resident #1's whereabouts until a staff member inside the facility happened to look through a window and saw her standing in the grass. By the time staff arrived outside to retrieve resident #1, she had fallen to the ground. While resident #1 was out of the facility unsupervised, there was reasonable likelihood she could have been injured when she fell , become lost or been hit by a car. These failures contributed to the elopement of resident #1 and placed all residents who were ambulatory or mobile, with or without an assistive device, at risk for serious injury/impairment/death, and resulted in Immediate Jeopardy starting on 8/28/21. Findings: Cross reference F600 and F689 Resident #1, an [AGE] year-old female, was admitted to the facility from the hospital on 8/26/21. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #1's medical record revealed an Elopement assessment dated [DATE]. The document indicated the resident had no history, mood, behaviors, or diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, a baseline care plan for elopement was not triggered by the responses and no preventative interventions were implemented. On 9/05/21 at 12:40 PM the Director of Nursing (DON) stated the expectation was the admitting nurse should have contacted a family member or staff at the resident's assisted living facility to obtain relevant, accurate information. On 9/05/21 at 8:06 AM, in a telephone interview with resident #1's daughter, she stated her mother had a recent, sudden decline in status. She stated within the last six weeks, her mother fell and hit her head on a table, was taken to the hospital emergency room three times for increased confusion and was eventually diagnosed with a severe UTI. During a review of resident #1's elopement assessment with the daughter, she confirmed her mother was too confused to provide accurate responses to the questions and she was not sure how the facility completed the form. She said, No one called to ask me anything. An incident report dated 8/28/21 at 6:00 PM revealed resident #1 was observed . outside the building sitting in the grass. between 5:30 PM and 5:45 PM. The report indicated resident #1 was resistant and extremely combative during multiple attempts to return her to the facility and calmed down only when facility staff contacted her daughter to intervene by telephone. The document noted the resident was ambulatory without assistance, exhibited poor judgement and decision making and had predisposing factors including admission within the last 72 hours and a medication error. The report read, Door alarm present, however may not be as loud at the nursing station. On 9/04/21 at 5:43 PM, the administrator confirmed resident #1 eloped on 8/28/21. She explained during the last seven days the facility's administrative team initiated an incident investigation which showed an issue with exterior exit door alarms as they made the same sound as call bells. The administrator stated the facility had not yet installed new equipment or implemented new procedures since the incident. She explained another issue was resident #1's assigned nurse did not assume care of the resident although she received change of shift report. The administrator said, We are trying to work with the alarm provider. We will be in-servicing the staff. On 9/04/21 at 7:56 PM, the facility's Quality Assurance and Performance Improvement (QAPI) Coordinator stated she was notified of resident #1's elopement on 8/30/21, two days after it occurred. She explained she assembled a committee to review the incident and determine the root cause. The QAPI Coordinator stated she identified a concern with the faint sound of the exit door alarms which she described as not noticeable. She explained the Maintenance Director was currently considering implementing louder alarms such as breakaway screamer alarms. The QAPI Coordinator explained resident #1's nurse stated was not aware the resident was on her assignment on the day she eloped. She confirmed resident #1 was on Station 1 but the nursing assignment was split between a Station 4 Certified Nursing Assistant (CNA) and the Station 1 nurse. When asked if the split assignment was a contributing factor to the elopement, she said I'm still trying to figure out that part of it. I believe this a communication and environment problem. She stated although the investigation was incomplete, the facility had identified a root cause of the elopement as an employee error related to the assigned nurse not realizing resident #1 was assigned to her. However, the QAPI Coordinator did not offer any insight into the system failures that contributed to resident #1's elopement and the lack of appropriate care and supervision. She acknowledged although seven days had passed since the elopement incident, the facility still had not installed any new equipment or revised monitoring to address the identified concern of the door alarms. She confirmed the facility was still in process of discussing a facility-wide fix. The QAPI Coordinator acknowledged the circumstances that contributed to resident #1's elopement were unchanged, and if any resident accessed an exterior exit door, the potential for another elopement still existed. When asked what the facility needed to do to ensure immediate safety of residents, she said, To avoid this we need louder alarms and education. The QAPI Coordinator confirmed the facility had not conducted any elopement drills or educated staff since the elopement incident. On 9/04/21 at 8:20 PM, the facility's Maintenance Director stated the exterior exit doors were fire doors and opened by pushing on the panic bar. He explained an alarm would sound immediately and it could only be silenced by a staff member entering a code on the keypad next to the door. The Maintenance Director stated the exit door alarm was integrated with the call light annunciator and there was no way to differentiate between both sounds. He explained an updated electronic wandering device system was installed a few months before and since then the exit door alarm volume was lower. He said, I need to look into whether I can adjust the volume. The Maintenance Director stated he checked the function of all exterior exit doors and alarms weekly but did not recall reporting the lower alarm volume or the indistinguishable sounds of the exit door alarms and the call lights as areas of concern. He explained the facility's department heads and administrative team met a few days after resident #1's elopement incident and discussed conducting an elopement drill. He said, I do the fire drills. I haven't had an elopement drill in the one and a half years I have been here. On 9/04/21 at 8:52 PM, the Maintenance Director provided a weekly log used to record inspection and testing of all doors from May 2020 to August 2021. The document indicated the electronic wandering device system was updated in October 2020 and the Maintenance Director confirmed the volume of the alarm was much lower than previously. During review of the log with the Maintenance Director he validated there was a blank form with no documentation of door checks for January, February, March, and April 2021. When asked if exit doors were not checked for four months, he said, No, I guess not. He acknowledged the facility's leadership team had not implemented any new interventions or processes to secure the building and protect residents since resident #1's elopement. In interviews on 9/05/21 at 12:16 PM and 2:09 PM, the Clinical Learning Development Specialist stated all staff received education on elopement in new-hire orientation. During review of the Rehab/Skilled Required Annual Training 2021 Calendar approved on 1/21/21, she acknowledged the scheduled monthly mandatory topics did not include elopement. She explained elopement drills should be a joint effort between maintenance and nursing departments. The Clinical Learning Development Specialist stated she was not sure if the Maintenance Director had conducted elopement drills, but in the last five years she recalled organizing only three elopement drills. The Clinical Learning Development Specialist stated the facility planned to provide elopement education in the next all-staff meeting scheduled for the upcoming week. When asked what the facility did in the last week to prevent an elopement from reoccurring, the Clinical Learning Development Specialist said, For these first seven days, department heads spoke about it. On 9/06/21 at 10:57 AM, during a meeting with the Administrator, DON, Assistant Director of Nursing (ADON) and QAPI Coordinator, the administrative team reviewed its actions related to resident #1's elopement, before and after the incident. The Administrator stated she was aware of a technology shift in 2020 that resulted in a lowered volume of exterior door alarms. She explained the alarms still functioned and the Maintenance Director did not report any concerns regarding security of the building to her. The Administrator confirmed the facility never provided in-services to staff on the change in alarm volume or implemented new procedures to respond to or monitor exit doors. When informed weekly door check logs showed monitoring for the facility's exit doors had not been done from January to April 2021, the Administrator acknowledged she had not reviewed the logs recently. The ADON stated the clinical leadership team reviewed the charts of all newly admitted residents. She acknowledged the facility did not have a policy and procedure on conducting admission assessement including elopement assessment or an oversight process in place to ensure assessment accuracy. The DON confirmed the Maintenance Director provided a report that showed the Station 1 right hallway exit door was opened on 8/28/21 at 5:23 PM, and the associated alarm and call light tone sounded for over 14 minutes. She acknowledged when an unknown staff member eventually responded, he/she silenced the door alarm without looking outside or initiating elopement protocols. The DON acknowledged that all residents who could get to the exit doors were still at risk for elopement since the alarm system was unchanged and staff had not yet been re-educated. She provided a list of 28 additional residents who were mobile, with or without a device, and therefore potentially able to access exterior doors and exit the facility unsupervised. The DON validated residents #4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #30, #31, #32 and #33 were at risk. The DON explained the administrative team had not identified or addressed all the issues associated with resident #1's split nursing assignment between Stations 1 and 4. The Administrator said, Historically, we have made adjustments if staff concerns were brought to us about assignments. She was informed that multiple staff members including Certified Nursing Assistants, nurses and a Unit Manager had expressed concerns regarding the dangerous split assignment, but these concerns were not addressed. The QAPI Coordinator stated she led the facility's monthly Safety Committee meetings and she had no record of concerns regarding door security, alarms or lack of elopement drills in the Safety Committee meeting minutes. She said, The issues with the doors and alarms should have been discussed in the safety meetings. The administrator stated she was not able to provide documentation of elopement drills as the facility had not conducted these exercises since she had assumed her position one year ago, in August 2020. She explained elopement drills were not required by the facility's corporate office. The administrator was informed the Clinical Learning Development Specialist was not able to show evidence of regular staff training on elopement policies and procedures. She did not respond when asked how the facility trained staff and ensured competency in prevention of elopement. The policy and procedure for Elopement - Rehab/Skilled reviewed/revised on 8/02/21, revealed the facility would identify, evaluate and analyze hazards and risks, and implement or modify interventions to monitor residents and minimize their risk for elopement. The document indicated routine elopement drills should be conducted, and all staff were required to participate. A drill report should be documented and retained with Safety Committee minutes. The Administrator's job description, last changed on 8/25/21 read, This position is responsible for the overall leadership and management of the location . The document revealed the Administrator was charged with ensuring the facility had an effective safety program that included scheduled inspections to identify and correct concerns, and to ultimately ensure a safe environment. The job description noted the Administrator Ensures documentation and reports are completed as required by regulations and/or policy and procedure. The Administrator was expected to demonstrate competencies including clinical leadership, clinical performance improvement, organizational leadership, tactical and strategic planning, and provision of safe, reliable patient-centered care. The Director of Nursing's job description, last changed on 9/01/21 read, Has overall responsibility for the day-to-day operations of long term care facility. The DON was tasked with ensuring the provision of quality care by nursing staff, promoting environmental safety, and directing individual staff members and teams. The Facility Assessment modified on 7/30/21, revealed the Maintenance Director and the Safety committee would inspect and review new equipment and train staff to ensure competency. The document noted the facility had processes to ensure continuity of care such as ongoing education, 24 hour reports, staff to staff reports, morning meetings, safety meetings, [QAPI] process, care plan reviews.

Based on observation, interview and record review, the facility neglected to obtain a thorough history of risk factors for wandering and elopement to determine appropriate levels of supervision and monitoring; neglected to ensure staff assignments met care and safety needs; neglected to respond to an exterior egress door alarm; and neglected to perform neurological checks to identify signs and symptoms of injury after a fall, for 1 of 33 sampled residents, (#1). Approximately 48 hours after admission, on [DATE] at 5:23 PM, the facility failed to prevent resident #1, a physically and cognitively impaired resident from exiting the facility unsupervised through the exterior exit door on Station 1 right hallway. Resident #1 was outside on the hot, sunny day for over 15 minutes, and traveled approximately 30 feet away from the door. The facility was unaware of resident #1's whereabouts until a staff member inside the facility happened to look through a window and saw her standing in the grass. By the time staff arrived outside to retrieve resident #1, she had fallen to the ground. While resident #1 was out of the facility unsupervised, there was reasonable likelihood she could have been injured when she fell , become lost or been hit by a car. These failures contributed to the elopement of resident #1 and placed her at risk for serious injury/impairment/death and resulted in Immediate Jeopardy starting on [DATE]. Findings: Cross reference F689 and F835 Resident #1, an [AGE] year-old female, was admitted to the facility from the hospital on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Florida Agency for Health Care Administration ,d+[DATE] Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated [DATE] revealed resident #1 was hospitalized for a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was alert, disoriented, but could follow simple instructions. The form indicated resident #1 ambulated and transferred with assistance but did not use an assistive device. Review of resident #1's medical record revealed an Elopement assessment dated [DATE]. The document indicated the resident had no history, mood, behaviors, or diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . As a result, a baseline care plan for elopement was not triggered by the responses and no preventative interventions were implemented. An incident report dated [DATE] at 6:00 PM revealed resident #1 was observed . out side the building sitting in the grass. between 5:30 PM and 5:45 PM. The report indicated resident #1 was resistant and extremely combative during multiple attempts to return her to the facility and calmed down only when facility staff contacted her daughter to intervene by telephone. The document noted the resident was ambulatory without assistance, exhibited poor judgement and decision making and had predisposing factors including admission within the last 72 hours and a medication error. The report read, Door alarm present, however may not be as loud at the nursing station. Review of the Incident List log for Station 1 right hallway exit door revealed the door was breached on [DATE] at 5:23 PM and alarmed for 14 minutes and 41 seconds until it was silenced by an unknown staff member at 5:38 PM. The Station 1 right hallway exit door was next opened at 5:41 PM, at the approximate time staff observed resident #1 outside the facility and went to retrieve her. A progress note dated [DATE] at 6:00 PM, written by the weekend nursing supervisor Registered Nurse (RN) C, revealed on return to the facility, resident #1's blood pressure was elevated at ,d+[DATE]. The progress note indicated RN C discovered resident #1 did not receive any of her multiple scheduled blood pressure medications nor her diabetes medication and antibiotics that day. According to the American Heart Association, a normal blood pressure is less than ,d+[DATE]. A reading of ,d+[DATE] or greater would be considered a hypertensive crisis which requires immediate evaluation of symptoms to identify possible organ damage (retrieved on [DATE] from www.heart.org). Review of resident #1's Order Listing Report revealed physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Her medications included [MEDICATION(S)] 500 milligrams (mg) three times daily with meals for diabetes, and two antibiotics to treat pneumonia, Azythromycin 500 mg once daily for 3 days and [MEDICATION(S)] 1 gram once daily for 5 days. Additionally, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Record for [DATE] revealed on [DATE] resident #1's scheduled 8:00 AM, 9:00 AM and 12:00 PM medications were not administered. The document was initialed by RN G, the Station 4 nurse, who included a code to reflect resident #1 was Away from location with meds. Scheduled 2:00 PM, 5:00 PM medications and day shift pain monitoring were not administered within the required timeframe. They were administered and documented by RN C, the weekend nursing supervisor after 6:00 PM On [DATE] at 5:17 PM, resident #1 was interviewed in the facility's secure Memory Care Unit. She was alert but disoriented to time, place, and situation. She did not recall her recent stay in the hospital nor why she was currently in the facility. Resident #1 stated her current location was St. [NAME], Missouri rather than Kissimmee, Florida and thought she had been in the facility for a couple months, instead of ten days. Resident #1's long term memory was not intact as she said, I don't know what type of work I did. When asked about the day she got outside the facility she recalled, I was very upset about something. I don't remember what. I pushed the door and I went outside. I fell but didn't hurt myself. On [DATE] at 6:01 PM, the elopement incident was discussed with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The ADON stated Licensed Practical Nurse (LPN) A, did not administer resident #1's scheduled medication during the day shift as she did not realize the resident was on her assignment. The ADON explained resident #1 was initially assigned to Station 4 on admission, but she was temporarily placed in a private room on Station 1, pending the result of a Corona Virus Disease 2019 (COVID-19) test. She stated resident #1 was the only resident on Station 1 right hallway, and she was assigned to the Station 1 nurse and a Station 4 Certified Nursing Assistant (CNA) on the day she eloped. The ADON confirmed there were alarms on exterior exit doors. When asked how resident #1 was able to exit the facility without knowledge of the staff, she said, The alarms used to be louder in the past and now the call light and door alarm both sound the same. The DON stated the split assignment of a Station 1 nurse and a Station 4 CNA caring for resident #1 probably contributed to confusing circumstances. The DON explained she was newly hired at the time if the incident and said, I'm not sure who made the assignment or who switched her room. I asked the question of the nurses and they explained it was for her to wait there until we got the [COVID-19 test] result. It was not a logical assignment. On [DATE] at 6:27 PM, in a telephone interview with the weekend nursing supervisor, RN C, she recalled staff informed her a resident was outside the facility and when she arrived at the area, she observed resident #1 sitting in the grass. RN C said, She came out the door and went outside on her own. Nobody saw her leave. She walked to the place she was found. RN C stated resident #1 was the only resident on the Station 1 right hallway that day, and one side of the double doors at the entrance to the hallway was closed which decreased visibility of the hallway. She recalled interacting with the resident earlier that morning and noted she was forgetful and confused. RN C said, I believe the alarm is a very low sound. It used to be very loud, but it was changed about a year ago to a softer sound. I don't know why the volume was changed. I believe it was possible that it alarmed but staff did not hear it. RN C explained it was also possible that no staff realized the exit door was open because the alarm sounded like a call light at the nurses' Station. RN C stated she did not create the staffing assignments and when she was informed staff on two separate units were caring for resident #1 she thought it was strange. She said, I was told that's what they were doing. RN C acknowledged that although she was the weekend supervisor, she did not make any changes in the assignments. On [DATE] at 8:06 AM, in a telephone interview with resident #1's daughter, she stated her mother had a recent, sudden decline in status. The daughter said, We are all in shock of her recent behavior. She is a very different person now. She stated within the last six weeks, her mother fell and hit her head on a table, was taken to the hospital emergency room three times for increased confusion and was eventually diagnosed with a severe UTI. Resident #1's daughter explained in addition to her mother's recent changes in mental status and personality, she was also very unsteady and at high risk for falls. During a review of resident #1's elopement assessment with the daughter, she confirmed her mother was too confused to provide accurate responses to the questions and she was not sure how the facility completed the form. She said, No one called to ask me anything. Resident #1's daughter recalled receiving a telephone call from the facility regarding her mother getting outside. She stated a nurse informed her that her mother was extremely agitated and hysterical and was too frightened to take her medication. Resident #1's daughter explained her mother had a significant history of hypertension over the last [AGE] years and needed to take several critical blood pressure medications. She stated she was not aware her mother was placed on a hallway by herself, and she was not informed she did not receive her medications that day or fell when she was outside. Resident #1's daughter said, When I found out they allowed her to get outside, I was shocked and scared. She could not be watched properly if she was on a hallway by herself. Mom would never be safe outside the facility. On [DATE] at 11:02 AM, the interim DON confirmed resident #1 was the only resident on the Station 1 right hallway. She said, I gave the okay to put the resident there. The interim DON stated resident #1 required a private room, but she could not explain why she placed a newly admitted resident on a hallway by herself or why she did not adjust the assignments to designate Station 1 CNAs and nurses to provide care. She stated she expected CNAs to think of all residents, not only those assigned to them. The interim DON suggested staff did not realize the degree of the resident's confusion, and said, On admission she looked ok. She acknowledged resident #1 was not known to staff and had not been adequately monitored by Station 4 staff during her 2-day stay on Station 1. The interim DON confirmed resident #1 did not receive care and services from neither Station 1 nor Station 4 nurses between 7:00 AM and 6:00 PM on [DATE]. She acknowledged nurses not giving medications or regularly evaluating a resident's status throughout a shift met the definition of neglect. The interim DON added, She was not safe outside on her own, in the courtyard maybe, but we would not have let her go out on their own. On [DATE] at 11:28 AM, CNA B stated she was usually assigned to residents on Station 4 on the 7:00 AM to 3:00 PM shift. CNA B recalled her Unit Manager (UM) told her resident #1 on Station 1 would be on her assignment. She said, I've never had to take care of residents on two units before. I was questioning it, but I was told by the Unit Manger that I had to do it. On the day resident #1 got outside, CNA B described her assignment as a total of eight residents located on three hallways, Station 4 left hallway, Station 4 right hallway and resident #1 on Station 1 right hallway. She said, Honestly, I was exhausted that day. I saw her maybe three times for the day. I ran over there to check, but I was worried about my other residents on Station 4. CNA B recalled resident #1 was confused and a little off when answering questions. She stated during her checks on the resident at breakfast and lunch times that day, resident #1 told her she had not yet received any medication. CNA B explained she assumed the resident was confused and did not remember getting her medication. CNA B said, This assignment did not sound like right planning to me. If [the resident] put on her call light I would not know unless one of the Station 1 CNAs called me. I wished she was closer. On [DATE] at 11:43 AM, in a telephone interview, RN E stated she was the Station 1 nurse on the 7:00 PM to 7:00 AM shift on the night before resident #1 eloped. She stated although she was resident #1's assigned nurse, the CNA who attended to her was from Station 4. RN E said, I don't ever remember seeing that. It would be better if a CNA from Station 1 gave care. They should have done the assignment differently. On [DATE] at 4:17 PM, CNA D stated she worked on Station 4 during the 3:00 PM to 11:00 PM shift and on [DATE], she was assigned to care for resident #1 who was on Station 1. She said, In report, I was told I had a resident on Station 1. That is not normal. I asked the Unit Manager how I was supposed to know what was happening when I turned my back to her. There was no way I could give her the attention I needed to because she was too far away. CNA D explained the exit door alarms were not loud and she sometimes did not hear them on Station 4. She said, And I definitely couldn't hear it on Station 1 on the other side of the building. On [DATE] at 12:57 PM, in a telephone interview with the UM, she stated on admission it was decided that Station 4 nurses and CNAs would care for resident #1 even though she was on Station 1. She said, I asked [the interim DON] why resident was put on Station 1. It did not make sense to me. It did not make sense to a lot of us. The Station 4 CNAs brought it to my attention that it wasn't safe to take care of a resident on Station 1. I told them I was aware, but I had to follow protocol. The UM explained it was difficult for CNAs to leave their assigned residents on Station 4 to care for resident #1 on Station 1. She explained CNAs could not see the call light if resident #1 needed something, and they could not monitor her closely. The UM said, If resident was on Station 4, she would have been cared for more appropriately. She stated resident #1 was confused and the normal process would be to call a family member to obtain accurate information during admission data collection. The UM acknowledged it was not safe for the call light and exit door alarms to sound the same as staff were not be able to distinguish when an immediate response was necessary. On [DATE] at 5:32 PM, LPN F stated he worked on Station 4 on the 7:00 AM to 7:00 PM shift on the day before resident #1 eloped. He recalled he was assigned to over 20 residents on the busy Station 4 rehabilitation unit and was taken aback when he discovered he would be responsible for an additional resident on another unit. LPN F explained there were 2 CNAs working with him on Station 4, one of whom was also assigned to resident #1 on Station 1. He said, I did not feel I could give good care to a patient on another unit. I felt that while I was walking back and forth something could have happened on my unit. I refused the assignment and [the interim DON] changed it so the Station 1 nurse would be assigned to her. After that no other Station 4 nurse took care of that resident. In interviews on [DATE] at 12:40 PM and [DATE] at 5:00 PM, the DON confirmed resident #1's elopement assessment was not accurate. During review of the document, the DON identified eight possible areas of concern related to resident #1's elopement risk that were not noted by the admission nurse. She stated the nurse should have contacted a family member or staff at the resident's assisted living facility to obtain relevant, accurate information. The DON confirmed if resident #1's elopement risk level had been determined correctly, then an appropriate care plan would have been triggered by the assessment and the resident would have been provided with the supervision she needed. The DON described the split assignment between Stations 1 and 4 as a big part of the problem that contributed to resident #1's elopement and missed medications. She said, My first question when I arrived in the building that evening was, 'Who was the person who made that assignment? The DON acknowledged resident #1 was first observed through the window standing in the grass, and staff found her seated when they arrived outside the facility. She confirmed this change in position was an unwitnessed fall and required neurological checks to identify any change in condition resulting from a head injury. Review of resident #1's chart with the DON revealed neurological checks were not completed per facility protocol or accepted professional standards. The DON stated nurses had not taken responsibility to complete the required assessments. Neurological checks or neuro checks are assessments to identify changes in level of consciousness that occur with a head injury. Residents should be assessed immediately after a fall, frequently throughout the shift, and then regularly for at least 72 hours (retrieved on [DATE] from www.hcpro.com). Review of resident #1's medical record revealed Neuro Check forms that directed nurses to complete an initial neuro check evaluation with vital signs, followed by four evaluations 30 minutes apart. The document indicated neuro checks should continue every 8 hours for three days. However, after resident #1's fall on [DATE] at approximately 5:45 PM, her neurological status was evaluated thoroughly on four occasions, [DATE] at 10:42 PM, [DATE] at 5:52 AM, 12:20 PM and 10:22 PM. There were no neuro checks documented on [DATE] and [DATE] to reflect required monitoring was done for three days. On [DATE] at 8:20 PM, the facility's Maintenance Director explained the exterior exit doors were fire doors and opened without delay by pushing on the panic bar. He explained an alarm would sound immediately and it could only be silenced by a staff member entering a code on the keypad next to the door. The Maintenance Director said the alarm was also integrated with the call light annunciator. He said, It has the same alarm sound as the call lights. That's what they would have heard from the middle of the station. On [DATE] at 8:40 PM, during a tour of the Station 1 right hallway, the Maintenance Director demonstrated the function of the door alarms. He pointed to an additional mini screamer alarm on the door but explained it was off since he only used it as a back-up if the system was not functioning. He pushed on the panic bar, the door opened immediately, and a soft alarm sounded. The Maintenance Director closed the door and entered a code on the keypad to silence the alarm. He was asked to test the system again, and from the nurses' station in the middle of Station 1, the faint door alarm was not audible, but a call light sound was noted. CNA H walked down the hallway towards the nurses' station and when asked about the sound she said, Oh, that's a call light. She then turned and walked away without attempting to identify the source of the sound, whether call light or exit door. Review of the policy and procedure Abuse & Neglect revised in [DATE] revealed residents had the right to be free from neglect. The document indicated the facility would ensure employees were knowledgeable of the processes to report and investigate allegations of neglect and that effective systems were in place to prevent injury to residents. The Facility Assessment modified on [DATE], revealed the facility was able to care for residents with behavioral health needs by developing individualized care plans to meet their needs. The document indicated staff assignments were evaluated daily to ensure . coordination and continuity of care for residents within and across staff assignments. In addition, the facility would provide appropriate staffing to meet residents' needs through . constant communication with clinical staff and scheduler.

Based on observation, interview and record review, the facility failed to provide adequate supervision and treatment to prevent injury from falls for 1 of 4 sampled residents reviewed for falls (#270). The facility's failure to communicate to staff the needs of the resident regarding non-weight bearing status and the use of a left knee/leg immobilizer for an existing fracture, and failure to provide adequate supervision to prevent falls resulted in actual harm. Resident #270 sustained an additional new fracture to the left femur. Findings: Resident #270 was a [AGE] year old who sustained a fracture of his left distal femur on 10/27/17 as a result of a fall at home. He had a repair of the fractured femur in hospital and was sent to a skilled nursing facility on 10/31/17. He was admitted to the current facility on 11/02/17. He had a history of [REDACTED]. Review of the 3008 Medical Certification for Medicaid Long-Term Care Services & Patient Transfer Form, dated 11/27/17 and 11/02/17, noted that the resident was disoriented, non-ambulatory, and continent of bladder and incontinent of bowels. He required 2 person assistance with transfers, was at risk for falls, was non weight bearing on his left leg, and had a left knee immobilizer. A Nursing Admit/Readmit Data Collection, dated 11/02/17, reflected that resident had a left distal femur fracture. The resident's gait was unsteady due to no weight bearing to the left lower extremity, and he required a wheelchair for ambulation. The physician's progress note, dated 11/02/17, noted that the resident was hospitalized for [REDACTED]. A nurse's progress note, dated 11/05/17 at 6:30 PM, read, resident is alert with confusion/dementia, takes off his dressing and immobilizer to left knee, resident tries to get out of bed. Resident on no weight bearing to left leg. A nurse's progress note dated 11/06/17 at 6:45 AM read, resident was sitting on the toilet. He tried to move from the toilet to the wheelchair and he fell . Resident confused. He did not use call light for assistance. Transferred to bed with the lift. The physician's progress note dated 11/06/17 indicated the resident had a fall with injury that day. The physician documented the resident had senile dementia with supportive care and an immobilizer to the left knee. An interview with the 400 hall unit manager (UM) on 11/14/17 at 10 AM revealed that the resident had a fall on 11/06/17 at approximately 6:45 AM. The UM stated that the resident slid off the toilet but did not sustain any injuries. On 11/14/17 at 2:45 PM, the UM stated that she was mistaken and the resident in fact did sustain an injury as a result of the fall on 11/06/17. She said that the resident re-fractured his left knee post fall. She stated that she was mistaken about the injury because she had been off duty for the past 4 days. An interview with the director of nursing (DON) on 11/15/17 at 9:50 AM revealed that the resident was taken to the bathroom in the early morning of 11/06/17. She stated that the certified nursing assistant (CNA) was outside the door of the bathroom because the resident wanted privacy. She stated that the resident got up off the toilet on his own and slid to the ground. She said his knee did not hit the floor. A stat (immediate) X-ray was done and revealed a fracture to his left femur. When she was asked how she was certain the resident's knee did not hit the floor when she was not present, she stated she was told this by CNA F who was involved in the incident. When she was asked about the investigation details of the fall, she stated that the assistant director of nursing (ADON) did the investigation. An interview with the ADON on 11/15/17 at 9:45 AM noted that the CNA took the resident to the bathroom as per his request. She stated that he was transferred to the toilet. She stated that the CNA was in the room right outside the bathroom door when she heard a sound and found the resident on the floor. She said the CNA gave the resident privacy as he requested and had closed the bathroom door but was right outside of the bathroom door. She stated the call light was working at the time but the resident did not use it. The CNA heard the resident calling out and found him on the floor of the bathroom. The resident complained of pain to his left leg and a stat X-ray-ray was done revealing a new fracture to the left femur. An orthopedic consultation note, dated 11/08/1,7 noted that resident #270 had a lateral femoral condyle fracture that was 10 days post-op and after fall on 11/06/17, he has a displaced supracondylar femur fracture. The note indicated resident #270 did not remember if his braces were on or off at the time of the fall and that he has some dementia. The surgeon included that mobile X-rays were taken at the rehabilitation facility that demonstrated possible motion of the fracture. The orthopedic surgeon's note indicated the X-rays performed in his office showed a displaced supracondylar femur fracture with some shortening and valgus (twisted out) angulation above the hardware. This is a new fracture. This is likely due to the fall. The orthopedic surgeon described two treatment options for resident #270 as a result of the new fracture. One option was to have surgery reopen the incision and he would need an immobilizer and would not be able to put weight on the leg for several weeks. The other option was non-operative and involved the use of a brace. The surgeon described the second option would result in deformity of the left knee, some pain, and decreased range of motion. A telephone interview with the CNA F on 11/15/17 at 11:10 PM revealed that she was not the CNA involved in the incident contrary to the information given by the DON. She stated that the director of nursing was mistaken and it was CNA H who was caring for the resident on the night he fell . A telephone interview was held with CNA H on 11/16/17 at 11 AM. She stated that she was assigned to care for the resident on the night he fell . She said that she did not know the resident well because it was the first time she was assigned to look after him. She was told at the beginning of the shift, to keep an eye on the resident, because he was confused and had been trying to get out of bed on his own. She had given him the urinal during night but when she checked on him at approximately 6:30 AM on 11/06/17, the resident was sitting at the foot of the bed, trying to stand up on his own. She said he wanted to go to the toilet to move his bowels. She said that she and the night nurse, registered nurse (RN) I, stood the resident up and held him under his arm. Both his feet were on the ground and he was not wearing the immobilizing brace. She stated that he had taken off the leg brace and his incontinence brief. She said they transferred him to his wheelchair and wheeled him to the bathroom which was 5-10 feet away. He was able to transfer himself from the wheelchair to the toilet by holding on the safety rail. Once he was on the toilet, both his feet were on the ground. He stated, I am okay now. She said he was able to stand and transfer himself very easily, like he had no pain. He kept saying that he was okay and that he could handle it. He did not tell me to leave but he implied that he was going to be on the toilet for awhile. She said, I thought he was saying he wanted privacy. She stated that she stood outside the resident's room. She clarified that she waited for the resident outside of his room in the hallways and not the resident's bathroom door. She said that she told the resident to pull the call light when he was done. She placed the wheelchair outside the bathroom door and then left his room and waited outside his room by the door. She waited about 10 minutes and then heard the resident yelling hello from the bathroom. She said she thought he was finished but when she went to his bathroom she found the resident on the floor against the wall near the sink with feces on the floor. She stated that the resident was confused and must have tried to get up on his own and slipped in the feces. She said she then called out for RN I for help. She stated that it was about 6:45 AM, which was the change of shift, so many staff came to help. When she was questioned about non-weight bearing status, she stated that the resident's kardex on the CNA tablet, read 1-2 person assist for transfers. She said that there was no information on the kardex about not toileting the resident. She was not aware that the resident should not bear weight or transfer. She said she was not informed of this as she worked on call, about one shift per week. She said the resident did not use the call light because he was confused and probably did not remember. A telephone interview with RN I on 11/15/17 at 11:30 PM revealed that he helped CNA H transfer the resident onto the toilet. He stated that the resident had tried several times to get out of bed on his own during the early morning of 11/06/17. He said he explained to the resident not to do this, but the resident was confused and was sitting at the foot of the bed trying to get up on his own when CNA H called him. The resident said he wanted to go to the toilet. He said he assisted CNA H to transfer the resident from the bed to the wheelchair. He said his leg brace was off. The resident was able to stand and hold onto the safety rail to transfer himself to the toilet. He said once the resident was on the toilet, I gently placed his left leg on the floor and took the wheelchair out of the bathroom. The RN I stated that he left the room and CNA H stayed with the resident. He said he was not aware how long the CNA stayed with the resident but stated, I think she left the room. She should have stayed with him. When asked why she should have stayed with him, he stated that the resident was confused and was a fall risk. When he was asked why a bedside commode was not used, he said he did not think of it, and there was none in the room at the time. He stated that the resident should not have been toileted because he was non-weight bearing. It all happened so fast. He said that he did not think about the weight bearing status because the resident was trying to get out of bed and he did not want the resident to fall. An observation of the resident on 11/15/17 at 12:45 PM showed he was resting in bed. He had an immobilizing brace to his left leg. The resident's wife was visiting at this time. She stated that she visited daily and stayed with him for most of the day. She stated that she took the resident for the orthopedic appointment on 11/08/17, two days after the fall. She said the surgeon was, very upset about the new fracture. He gave us options to either have another surgery to repair the fracture or to use the immobilizer brace and reassess in two weeks. She said they chose the immobilizing option at this time because having two surgeries within 3 weeks to repair the fractured left femur would be, too much, for her husband. She said she already noted a worsening of his confusion since the fall on 11/06/17. A review of the Fall Prevention and Management policy, revised 10/2017, read that the facility will have a fall prevention and management program. The procedure included, (2) care plan the appropriate interventions, including personalizing all areas. (4) communicate fall risks and interventions to prevent a fall before it occurs per the 24 hour report, care plan and kardex An interview with the occupational therapist, (OT) on 11/15/17 at 1:45 PM revealed that the resident was receiving therapy since admission and was not to bear weight on his left leg. She stated that the resident started physical therapy on 11/03/17 but his therapy was put on hold on 11/06/17 due to the fall. She stated that he was to wear his left leg immobilizer at all times. When a resident is non-weight bearing, they are not to be taken to the toilet, they have to use bedpan. She stated that it would have been impossible for the resident to be toileted as the bathroom was too small and the resident would not be able to hold onto the rail to stand on his right leg. She said it would be impossible to keep the resident's leg straight and transfer him to the toilet. She stated it was not the resident being non-compliant. He was very compliant and wanted to do therapy to get better. He just did not remember his limitations due to his confusion. She stated, when the pain with fractures begins to subside, residents think they can move again. That is why it is more important to observe them closely especially residents with any degree of dementia. She stated that residents should be somewhere they can be observed at all times. The OT stated she was aware that resident #270 had a fall on 11/06/17, but she was not aware that he sustained another fracture until informed by the surveyor, 9 days after the fracture. She said she was not informed of the new fracture and the outcome from the orthopedic surgeon's visit. An interview with the director of rehabilitation services was held on 11/16/17 at 11:26 AM. She stated that the resident had a leg immobilizer at admission and was non-weight bearing to his left leg. She said that non-weight bearing meant that not even his toes should touch the ground. She said that non-weight bearing residents cannot be toileted, they should only be using a urinal and bedpan. She stated that the resident would not have been able to pivot or transfer on 11/06/17 because he only had a few days of therapy and would not have known the proper technique. She stated that therapy did training with the nursing staff about the limitations of non-weight bearing status. My understanding is that after we teach, the information is entered onto the care plan and is then transferred onto the kardex for the CNAs. She stated that she was horrified when she found out earlier from the OT that the resident had a second fracture after falling while unassisted in the bathroom. She stated that the therapy department did not receive a copy of the orthopedic report. She was unaware if there was a policy and procedure for non-weight bearing residents. The Physical Therapy Plan of Care, dated 11/03/17, read, Precautions: NWB (non-weight bearing) to L LE (left lower extremity. To wear L (left) knee immobilizer. High risk for falls An interview with CNA J on 11/15/17 at 2:15 PM revealed that she had been assigned to the resident's care since his admission. She stated that he was a fall risk and she checked on him frequently. She said that the resident used a urinal and bed pan and was not to use the toilet at all. When asked how she was informed that the resident was not to use the toilet, she stated that she was informed by therapy. She said that he was transferred once from bed to bedside commode with therapy and 3 people assisting as his left leg had to kept straight. She said she would never attempt this without therapy staff present. It's not a problem for the resident to use the bedpan or urinal. When I explained to the resident that he had to use the bedpan or urinal, he would use it. She stated that there was no way he could even use the toilet because he would not be able to fit in the bathroom due to keeping his leg straight. There is very little room between the toilet and the wall and he would not fit. She stated that the resident was confused and had a tendency of trying to do things for himself such as getting out of bed on his own. That is the reason why he had to be checked frequently. He does not remember that he should not get up by himself. When she was asked if the toileting information was on her kardex, she stated that it was not on the Kardex. She said she knew that the resident could only use a bedpan and urinal because therapy explained this to her. Resident #270's admission physician orders did not reveal any orders for non-weight bearing status to the left leg, and did not reveal any orders for the knee/leg immobilizer to be in place at all times. The order for the knee/leg immobilizer was entered into the medical record after the fall on 11/06/17, and the order for non-weight bearing to left extremity order was entered on 11/16/17 after it was brought to the facility's attention during the survey, 14 days after admission. The resident's care plan for ADL self-care performance deficit related to dementia and left knee fracture, dated 11/02/17, included interventions that the resident required 1-2 staff assist for toileting and required 1-2 staff assistance, supervision and verbal cueing for transfers. The resident's care plan for impaired cognitive function or impaired thought processes related to dementia was dated 11/02/17. The interventions were to monitor and report changes in decision-making ability, memory, recall, and general awareness; cue, reorient, and supervise as needed. The goal for a care plan for resident has traumatic fracture, dated 11/02/17, was was will not develop permanent loss of mobility. The resident's care plan for risk for falls related to history of falls and knee fracture, dated 11/02/17, included a goal that the resident will not sustain serious injury. It read, educate resident/family about safety reminders, remind resident not to bend over to pick up dropped items, encourage use of call light to ask for assistance, monitor resident for changes in gait, mobility and changes in cognition. There were no interventions for non-weight bearing on left side or to keep immobilizer to left leg at all times. There were no interventions listed as to how to toilet the non-weight bearing resident such as using bedside commode/bed pan/urinal or the level of supervision needed for this resident. On 11/15/17 at 4 PM, the UM could not explain why the toileting interventions and level of supervision were not included in the care plan. An interview with the admitting nurse, RN K, on 11/16/17 at 2:24 PM, revealed that she did the admission orders [REDACTED]. She said the information was on the 3008 Transfer Form but stated that the information was missed getting entered on to the admission orders [REDACTED]. On 11/16/17 at 3:35 PM, the DON stated that the resident's orders were reviewed in the morning meeting on 11/07/17 but could not answer how critical orders of non-weight bearing status and a left knee immobilizer at all times were missed. When asked why the therapy department was not aware of the resident's new fracture, she stated it was discussed at the morning meeting after the orthopedic appointment with all departments including therapy present but did not know why the therapists were unaware of the new fracture. She stated she kept notes of the morning meetings but could not provide a note regarding discussion of the new fracture. She said there was no policy regarding communicating changes in resident condition with therapy department. She said, We discuss it in morning meetings and therapy is present. When asked why this fall with fracture was not considered an avoidable incident, the DON stated that the resident got up on his own from the toilet and the CNA was right outside the door. She stated that the resident had a right to privacy and that is why the CNA had closed the door. She could not explain why the resident was transferred on the toilet inappropriately when he was non-weight bearing and required his left leg to be immobilized.

Based on observation, interview and record review, the facility failed to ensure pain medication was given in a timely manner after a fall, sustaining an acute right femoral fracture with complete displacement for 1 of 4 sampled residents (#2). The failure to provide pain medication caused actual harm after the resident presented signs and symptoms of grimacing and guarding the right side of her body after the fall. The resident was not provided pain medication for over 7 hours after the fall with signs of discomfort. The X-Ray report revealed a fracture. Findings: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The last Minimum Data Set (MDS) quarterly assessment was conducted on 2/07/15. The resident's cognition was assessed as severely impaired. On the Brief Interview For Mental Status (BIMS score), the resident was unable to respond to the questions/interview. She had a score of 99, which meant she was cognitively impaired. The resident resided on the memory care unit, a secured unit. On functional status, the resident was assessed for activities of daily living (ADLs) as requiring extensive assistance with one person assistance. A review of the care plans indicated she had limited mobility related to weakness, impaired balance, and abnormal gait. She occasionally ambulated with supervision, had assistance as needed, used a wheelchair for locomotion. Interventions on mobility included 2 staff to assist for transfers. The care plans initiated on 11/18/13 and revised on 8/25/14 identified the resident with [MEDICAL CONDITION]. The goal was for the resident to remain free from discomfort. Interventions were to monitor/document and report to health care provider as needed for complications related to [MEDICAL CONDITION]: acute fracture and pain. Review of the nurses' notes dated 3/29/15 at 2:39 a.m. indicated that at 2:25 a.m., the resident's alarm sounded and staff went to her room to respond and she was found lying on her right side. Her bed was in the lowest position. An assessment was done. She had guarding on the right side and facial grimacing. The attending physician was notified and ordered a right hip X-ray. At 4:28 a.m. on 3/29/15, the nurse described in her notes that an assessment was done and indicated no apparent pain. The resident was transferred with 2 persons physical assist and did not have any injury or redness noted. The nurse told the certified nursing assistant (CNA) to toilet the resident, so she was transferred the resident to the wheelchair and took her to the toilet. Upon return to her bed, she was grimacing upon transfer. A nurse's note written on 3/29/15 at 9:08 a.m. indicated that at 7:45 a.m., the medical imaging technician completed the X-ray, and at 8:30 a.m. The X-ray report indicated an acute femoral fracture with complete displacement compatible with a garden classification IV fracture. A call was placed to the attending physician who ordered the resident to be sent to the hospital emergency room for evaluation. The next nurse's note at 10 a.m. on 3/29/15 indicated the resident was given Tylenol, a pain reliever, 650 milligrams (mg.) for discomfort. Review of the resdient's medical record revealed Tylenol, a pain reliever, 325 mg. every 6 hours as needed for pain was first ordered on [DATE]. This order was not followed. Rather, two times the dose was given and not the 325 mg. order. an order for [REDACTED]. On 3/29/15 at 11:15 a.m., the attendants from emergency medical services (EMS) arrived and transported the resident at 11:30 a.m. to the hospital. There was no documentation of a pain assessment conducted since the last nurses' notes at 2:39 a.m. on 3/29/15, when the resident was grimacing after the fall. The nurses did not assess, document, and monitor the resident's status after the fall when she exhibited signs of discomfort in the form of grimacing. The resident was not given pain medication for 7 hours and 21 minutes after she first exhibited signs of pain and discomfort after the fall at 2:39 a.m. on 3/29/15. The resident received the first pain medication at 10 a.m. on 3/29/15. In a telephone interview on 6/10/15 at 11:39 a.m., the director of nursing (DON) stated that she interviewed the nurse who was on duty at that time, that the resident did not verbally complain, and was fed for breakfast with no complaints. However, documentation was not found in the resident's medical record to show the resident was assessed after her fall. The physician was not notified about the resident's pain, and if pain medication was required in view of the results of the X-rays that determined an acute femoral fracture with complete displacement. At the time of the survey, the facility was not aware of pain medication not given to resident #2 after she exhibited grimacing after a fall, and waited over 7 hours to receive pain medication for a complaint of pain.

Based on observation, record review, and interview, the facility failed to prevent an accident that resulted in a fractured leg for resident #1, and failed to ensure 15 of 15 sampled residents of 31 residents requiring a mechanical total lift transfer, (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 &15) were free from actual and potential serious injury during mechanical total lift transfers when using the Ultralift, a sling type person lifting piece of equipment. Resident #1 sustained a fracture to the left tibia on 1/11/14 during a mechanical total lift transfer. The resident was suspended in the air by the Ultralift 3500, and as the 2 certified nursing assistants (CNAs) were attempting to transfer the resident from the bed to wheelchair, the lift stopped working. The staff failed to follow the procedure and attempted to remove the resident from the lift sling while the resident was still suspended. The staff failed to follow the instructions in the Ultralift 2500X/3500X Electric Patient Lifter Operating Instructions Manual/Users Manual (2009) that directs them "in the event the actuator will not retract and the patient is suspended raise a bed or chair high enough to safely support the patient (resident) to allow you to detach the sling" (p.12), and this failure resulted in serious injury. The facility failed to ensure that all nursing staff, nurses and CNAs, were trained appropriately regarding the use of mechanical lifts. The facility failed to ensure nursing staff demonstrated an understanding of emergency procedures involving mechanical lifts. A total of 31 residents who reside on all 4 wings of the building, were identified to require a total mechanical lift transfer. One resident sustained [REDACTED]. These practices resulted in Immediate Jeopardy starting on 1/11/14 and it was determined to be ongoing at the exit date on 2/12/14. Findings: Cross reference to F456, F490, F498, F520. 1. Review of the medical record revealed that resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most current Minimum Data Set ((MDS) dated [DATE] Section G-Activities of Daily Living (ADLs) indicated the resident is totally dependent with all ADLs and two person physical assist with transfers. Review of the care plan initiated 6/01/13 revealed the resident requires weight bearing support total lift of 2 staff assist, sling method. Record review of the 1/11/14 7:13 AM progress note for resident #1 documented by LPN #HH, revealed that the CNAs tried to transfer the resident from the bed to the wheelchair and the resident's left leg got stuck in the mechanical lift string because the lift malfunctioned. The resident was manually removed from the malfunctioning lift and the CNAs heard a sound in the resident's left knee. The resident's left knee became swollen and the resident screamed every time the left knee was touched. The resident's physician was called and an order was obtained to send the resident to the hospital for evaluation. Review of the progress note dated 1/11/14 at 6:10 PM for resident #1 documented by Nurse Manager #JJ revealed, the hospital was called at 12 noon to check on the resident's progress. The emergency room nurse reported the X-ray results that revealed the resident had a left proximal tibia fracture and they were sending her back to the facility with a knee immobilizer on the affected leg. In an interview with CNA #Z on 2/06/14 at 11:30 AM, she said on 01/11/14 at 6:30 AM, she was in the process of mechanically lifting resident #1 from the bed to the wheelchair with CNA #K. As they attempted to mechanically lower the resident down to the wheelchair, the lift stopped with the resident suspended in the lift sling above the wheelchair seat. CNA #K had her hands underneath the resident and was trying to support the resident in the lift sling as it was suspended above the wheelchair. CNA #Z stated that she tried "pushing" the button on the lift several times, but the lift would not go down. CNA #Z took the bottom right attachment loop off the lift spreader bar and then took the bottom left attachment loop off the lift spreader bar so they could slide the resident from the suspended sling into the wheelchair. Suddenly they heard a noise "like when you snap your knuckle." The CNAs then slid the resident down into the wheelchair. CNA #Z immediately notified the 7:00 PM -7:00 AM nurse, LPN #HH, of what had just happened. LPN #HH filled out a report, took CNA #Z statement and the resident was sent to the hospital. CNA #Z stated she received in-service training on the lifts when she first started working at the facility and has attended a mechanical lift training every year. "I was just in-serviced 2 weeks ago." On 02/06/14 at 12:45 PM, CNA #Z demonstrated the use of the Ultralift 2500 in the hallway of station 2. The lift was in the raised position and CNA #Z moved the red locking clip back and forth on the center pole several times to get the lift to lower. The lift did not go down. CNA #Z continued to move the red locking clip back and forth several times stating "the lift is not going down, it is not working." CNA #Z was not able to demonstrate the emergency lowering procedure. In an interview with CNA #K conducted on 2/06/14 at 11:25 AM, she said that on 1/11/14 she was helping CNA #Z transfer resident #1 from the bed to the reclining wheelchair with the mechanical lift. As they were lowering the mechanical lift, it stopped with the resident still suspended. As CNA #Z unhooked resident #1 from the lift they heard a cracking sound "like a knuckle being cracked." She said they put resident #1 into the wheelchair, then notified, LPN #HH, of what happened. CNA #K stated that prior to the event, they had been taught how to lower the mechanical lifts. In an observation conducted on 2/06/14 at 11:25 AM with CNA #K, she was able to demonstrate the emergency lowering procedure for the Ultralift 2500. When asked why she and CNA #Z did not use the emergency lowering procedure with resident #1, CNA #K paused for several seconds, shrugged her shoulders, and stated she did not know "sometimes you just panic." On 2/06/14 at 1:20 PM, CNA #I said she did not attend the in-service training for the Ultralift. She said they used an Ultralift on unit 4, but she also floats to the other units. She was asked to demonstrate the emergency lowering procedure for the 3500 lift and she was unable to do so. She also could not describe how to use the emergency lowering procedure for the Ultralift 2500. Review of the lift checklist dated 2/06/14 indicated she attended the training and received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. CNA #I received a rating code of 4 on 2/06/14, for a training she did not recall attending, and she was unable to demonstrate the emergency lowering process on the Ultralift 2500 and 3500 during the survey on 2/06/14 at 1:20 PM. On 2/06/14 at 1:50 PM, CNA #O was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. She stated had in-service training on the lift 2 weeks ago. She stated when using the lift you always need 2 staff. Review of the lift checklist dated 1/15/14, for CNA #O indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #O received a rating code of 4 on 1/15/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/06/14 at 1:50 PM. On 2/06/14 at 2:04 PM, LPN #W unit 1, was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. LPN #W stated her in-service training on the lifts was 3 weeks ago and only the Ultralift 3510 was used at the in-service training. Review of the lift checklist dated 1/15/14 for LPN #W indicated she received a rating code of 4. Although she received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/06/14 at 2:04 PM. An interview conducted on 02/06/14 at 3:30 PM with the Assistant Director of Nursing/Risk Manager (ADON/RM) revealed that she met with CNA #Z and CNA #K on 01/12/13 regarding the 01/11/14 incident involving resident #1. The ADON/Risk Manager said her investigation revealed that resident #1 was being mechanically lifted from the bed to the wheelchair by CNA #Z and CNA #K. As resident #1 was being lowered to the wheelchair, the mechanical lift stopped working about 1 foot above the wheelchair seat. One CNA cradled the resident "like a baby" to keep the resident safe while the other CNA unhooked the sling to lower the resident to the chair. The right side attachment loop was unhooked first. In the process of unhooking the left side attachment loop they heard a sound like "cracking a knuckle." With no response or grimacing by the resident, they manually lowered the resident the rest of the way into the wheelchair. CNA #Z immediately notified LPN #HH. Due to edema of the resident's left knee, LPN #HH notified the physician and an order was obtained to send resident #1 to the emergency room for an evaluation. Resident #1 returned to the facility on the same day with a [DIAGNOSES REDACTED]. An interview conducted on 02/07/14 at 3:20 PM with the ADON/RM revealed that she came into the facility the next day, on 1/12/14 at 7:00 AM, to start an investigation regarding resident #1's fracture. The 2 CNAs involved with the incident demonstrated exactly what they did step-by-step on a mechanical lift similar to the one used during the 01/11/14 event. The ADON/RM said "I observed everything that the CNAs did and determined that the CNAs did everything correctly to protect the resident's safety." During the same time, the ADON/RM said, starting on 1/15/14 the Staff Development Coordinator (SDC) and the ADON/RM initiated mandatory in-service training for all nurses and CNAs on all 3 shifts regarding what to do if the lift stops working. The in-service training consisted of using the "Mechanical Lift Competency Verification Checklist" (lift checklist). The Emergency Process to lower lift if electrical failure occurred was added to the checklist as of 1/15/14. The ADON/RM said the "Mechanical Total Lift Competency Verification Checklist" is used demonstrate the staff knowledge and ability to operate the facility's mechanical lifts. The checklist form has a "Note" at the top that reads, "The Mechanical Total Lift Competency Verification Checklist is a required annual skill checklist for SNF (skilled nursing facilities). All licensed nurses and all CNAs regardless of their role are to complete and pass this skill with a rating code of 4." The rating code read as follows: "4=skilled and able to work independently; 3=moderately skilled-needs limited supervision; 2=limited skill-requires close supervision; 1=no skill or knowledge. Must receive a score of four for each procedure step to prove competency." The reverse side of the form includes the section, "Signature verifying completion and date" and "Completion of all related training verified by and date." The ADON/RM continued to explain the facility has 2 different lifts and each one has a different procedure for emergency lowering. She said "one of them you twist to lower, and the other you lift the red button." Review of the form revealed 27 printed procedure steps. The "emergency process to lower lift if electrical failure" was handwritten on the reverse side of the checklist. The form did not indicate which lift was used to demonstrate competency, either the 2500 or the 3500 Ultralift. Review of the lift checklist dated 1/15/14 for CNA #Z, indicated she received a rating code of 4 in each of the 27 procedure steps and she demonstrated the "emergency process to lower lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #Z received a rating code of 4 on 1/15/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/06/14 at 12:45 PM. Review of the lift checklist dated 1/15/14 for CNA #K, indicated she received a rating code of 4 in each of the 27 procedure steps and she demonstrated the "emergency process to lower lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #K received a rating code of 4 on 1/15/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/06/14 at 11:25 PM. In an interview with the Director of Nursing (DON) on 02/08/14 at 10:15 AM, she provided written statements from #Z and #K involved in the incident in which resident #1 sustained a fractured leg on 01/11/14. In an interview with the ADON/RM on 2/08/14 at 11 AM regarding the written statements of CNA #Z and CNA #K dated 01/11/14, she said review of the statement for CNA #Z revealed that the CNAs were transferring resident #1 to the chair with the lift. When they were trying to put resident #1 down into the chair the lift did not go down. CNA #Z went into the hall to find the nurse, LPN #HH, but did not see her. The CNAs then slid the resident down, but caught her left leg in the sling. CNA #Z went to notify the 7 PM -7 AM nurse, LPN #HH, of what had just happened. The statement for CNA #K revealed CNA #Z called her to help transfer resident #1 from the bed to the chair. When the lift did not go down, CNA #Z went into the hallway to get the nurse, but she was not visible. The CNAs tried to slide resident #1 down into the chair, but her left leg got caught in the lift during the process. In an interview with the ADON/RM on 2/07/14 at 3:20 PM, she revealed that she has not continued to monitor the staff that attended the Ultralift in-service training to determine their retention of the training. The ADON/RM stated that the mechanical lift involved with the fracture for resident #1 was taken out of service on 1/11/14 at 6:35 AM. The lift used during the incident was documented as Ultralift 3500, model ML6500. She said on 1/13/14 at 8 AM she met with the Maintenance Director to discuss the mechanical lifts in the facility. She said, "The Maintenance Director assured me that he was going to check all the mechanical lifts in the building to make sure they were safe to use. He said he would also remove all mechanical lifts not functioning. I did follow up with the Maintenance Director to see if he had completed the check on all the lifts. I did not receive any documentation from the Maintenance Director related to the mechanical lift checks." 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G - ADLs indicated the resident is totally dependent with all ADLs. Review of the care plan dated 2/02/14 revealed the resident has limited physical mobility/stroke, weakness, non-ambulatory status, requires mechanical lift for transfers. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Spondylosis refers to "osteoarthritis of the joints between the center of the spinal vertebrae and/or neural foramina." (Wikipedia.org). Foramina is "an opening as in a bone." (Dictionary.com). Kyphosis is "a condition of over-curvature of the thoracic vertebrae (upper back)." (Wikipedia.org). Review of the MDS dated [DATE] Section G - ADLs indicated the resident is totally dependent with all ADLs. Review of the care plan dated 1/28/14 revealed the resident requires weight bearing support, total lift 2 staff assist, extra-large sling. 4. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] indicated the resident is totally dependent with all ADLs. Review of the care plan dated 11/13/13 revealed the resident requires weight bearing support total lift, 2 staff assist sling, medium size. 5. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Necrosis "is a form of cell injury that results in the premature death of cells in living tissue...." (Wikipedia.org). Review of the MDS dated [DATE] Section G - ADLs indicated the resident is totally dependent with all ADLs. Review of the care plan dated 7/08/13 revealed the resident requires weight bearing support total lift, 2 staff assist, sling extra-large. 6. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G - ADLs indicated the resident is totally dependent with all ADLs. Review of the care plan dated 6/01/13 revealed the resident is total lift, 2 staff assist, large sling. 7. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G - ADLs indicated the resident is totally dependent with all ADLs. Review of the care plan dated 6/22/13 revealed the resident requires weight bearing support total lift, 2 staff assist, sling large/extra-large. 8. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Acute myocardial infarction "is the medical term for....a heart attack." (Wikipedia.org). Review of the MDS Section - G ADLs indicated the resident is an extensive assist to total dependence with all ADLs. Review of the care plan dated 12/20/13 revealed the resident requires total lift, 2 staff assist, large sling. 9. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G - ADLs indicated the resident is extensive assist to total dependence with all ADLs. Review of the care plan dated 5/21/13 revealed the resident requires total lift, 2 staff assist, large sling. 10. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G-ADLs indicated the resident as extensive assist with all ADLs. Review of the care plan dated 11/15/13 revealed the resident requires 2 staff participation with transfers. The CNA kardex documents transfer: resident requires sit to stand lift with large harness, 2 staff assist. 11. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G-ADLs indicated the resident is an extensive assist to total dependence with all ADLs. Review of the care plan dated 6/25/13 revealed the resident requires weight bearing support, total lift, 2 staff assist a needed for fatigue or agitation. Review of the CNA kardex revealed transfers: resident requires weight bearing support, total lift, 2 staff assist sling medium. 12. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] indicated extensive assist to total dependence with all ADLs. Review of the care plan dated 6/10/13 revealed the resident requires weight bearing support total lift, 2 staff assist, extra-large sling. 13. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G- ADLs indicated extensive assist to total dependence with all ADLs. Review of the care plan dated 7/09/13 revealed the resident requires total lift, 2 staff assist, extra-large sling. 14. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G-ADLs indicated extensive assist with all ADLs. Review of the care plan dated 1/31/14 revealed the resident requires weight bearing support, total lift, 2 staff assist, large sling. 15. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G - ADLs indicated the resident is extensive assist to total dependence with all ADLs. Review of the care plan dated 6/01/13 revealed the resident requires weight bearing support total lift, 2 staff assist, large sling. On 2/08/14, at 6:30 PM resident #15 was interviewed. Resident #15, stated that she has to use the lift to get in and out of bed because she can't stand. In an observation conducted on 2/06/14 at 2 PM with Station 1 Unit Manager (UM) #DD, she stated that they had in-service training regarding the mechanical lifts. At that time, #DD was unable to demonstrate how to use the emergency lowering procedure for the Ultralift 3500. UM #DD stated "they did not use this lift at the in-service training, it was the other one." UM #DD was also unable to demonstrate how to lower the Ultralift 2500 in the event of electrical failure. UM #DD said "I don't know how to use the lift." Review of the lift checklist dated 2/06/14 for UM #DD indicated she received a rating code of 4. Although UM #DD received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 or the Ultralift 3500 on 2/06/14. In an observation conducted on 2/06/14 2:20 PM with LPN #E, she stated she went to the mechanical lift in-service training. LPN #E was not able to demonstrate the emergency lowering procedure for the Ultralift 2500 in the event of electrical failure. LPN #E stated we were trained on the Ultralift 3500. Review of the lift checklist dated 1/17/14 for LPN #E indicated she received a rating code of 4. Although LPN #E received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/06/14. An observation was conducted on 2/06/14 1:15 PM with CNA #S on Station 4. CNA #S said the facility requires 2 staff members to do a lift. In-service training is done annually and we were just in-serviced in January 2014. CNA #S was not able to demonstrate the emergency lowering procedure for the Ultralift 2500 in the event of electrical failure. Review of the lift checklist dated 1/15/14 for CNA #S indicated she received a rating code of 4. Although CNA #S received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/06/14. During an observation conducted on 2/06/14 at 1:30 PM with LPN #EE Nurse Supervisor, she was not able to demonstrate the emergency lowering procedure for the Ultralift 2500 in the event of electrical failure. Review of the lift checklist dated 02/06/14 for LPN #EE indicated she received a rating code of 4. Although LPN #EE received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/06/14. During an observation conducted on 2/06/14 at 1:30 PM Station 4 Unit Manager (UM) #N was not able to demonstrate the emergency lowering procedure for the Ultralift 2500 in the event of electrical failure. Review of the lift checklist on 1/15/14 for UM #N indicated she received a rating code of 4. Although UM #N received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/06/14. During observation conducted on 2/06/14 at 1:30 PM, Registered Nurse (RN) #B was not able to demonstrate the emergency lowering procedure for the Ultralift 2500 in the event of electrical failure. Review of the lift checklist on 1/15/14 for RN #B indicated she received a rating code of 4. Although RM #B received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/06/14. During an observation of CNA #U and CNA #GG on 2/07/14 at 6:30 PM the CNAs were unable to demonstrate how to lower the Ultralift 2500 manually. Both CNAs stated that they had attended the Mechanical Lift in-service training recently. CNA #GG moved the red locking clip back and forth stating "you have to have more weight on the lift to get it to go down." CNA #U moved the red locking clip back and forth and stated "it is not going down." Review of the lift checklist dated 1/15/14 for CNA #GG, indicated she received a rating score of 4. Review of the lift checklist dated 2/07/14 for CNA #U indicated she received a rating score of 4. Although the CNA #GG and #U received a rating of 4, indicating competency, they did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/07/14. On 2/08/14 at 6:36 AM, during an interview with CNA #BB, Unit 1, she said she attended an in-service about a month ago on the Ultralift. She said 2 people are required when using the lift. She was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. Review of the lift checklist dated 1/16/14, for CNA #BB indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #BB received a rating code of 4 on 1/16/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/08/14 at 6:36 AM. On 2/08/14 at 6:55 AM, CNA #J, Unit 3, said she had an in-service on the Ultralifts about 2 weeks ago. She said she works on all units. She was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. She stated the in-service training was on the newer Ultralift. Review of the lift checklist dated 1/16/14, for CNA #J indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #J received a rating code of 4 on 1/16/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/08/14 at 6:55 AM. On 2/06/14 at approximately 3 PM the Maintenance Director provided the "User Manual Ultralift, 2011." He said he received this manual approximately 6 months ago when a new lift was purchased. An interview was conducted on 2/07/14 at 9:45 AM with Maintenance Director. He said the facility had 10 Ultra lifts. There where 4 Ultralift 3500 series and 6 Ultralift 2500 series. One key feature that differentiates the Ultralifts is the emergency lowering mechanism. The Ultralift 3500 has a red emergency lowering lever at the bottom of the actuator near the motor. Lifting up on the this lever will lower the boom (lifting arm) in the event of loss of power/function. The Ultralift 2500 has a red locking clip located near the top of the actuator towards the boom. Staff have to open the locking clip, then grasp the actuator and rotate it to lower the boom. He stated that he was in the building this morning on 2/07/14 at 3 AM to inspect all of the lifts in the facility. Review of the 18 Lift inspection reports (10 Ultralift - sling type & 8 stand lift) received from the Maintenance Director, revealed that they were dated January 2014. An interview was conducted with the Maintenance Director to confirm the actual date the lift inspections reports were completed. The Maintenance Director verified that the date on the inspection reports was incorrect and at that time he changed the dates from January 2014 to February 7 2014. An interview was conducted on 2/07/14 at 1 PM with the Maintenance Director and the Administrator. The Maintenance Director verified that he did the lift inspections today, 2/07/14, and he changed the dates on the inspection reports that were dated January 2014 to February 7, 2014. The Maintenance Director verified that he did not have any lift inspection reports for the month of January 2014, including any inspection reports immediately following the incident in which resident #1 sustained a fractured leg on 1/11/14. An interview was conducted on 2/08/14 at 11:30 AM with the Maintenance Director and Maintenance Assistant. The Maintenance Assistant stated that on 1/11/14 at 11 AM, he received a call from the facility regarding a problem with a lift not working. He went to the facility on [DATE] at 11:30 AM and removed the Ultralift 3500 from Station 2 and put it in the maintenance department office. On Monday, 1/12/14, the Maintenance Director and Maintenance Assistant said they inspected the lift and determined that the motor, which raises and lowers the lift, was burned out. He stated that the emergency lowering lever was not checked at that time. On 2/08/14 at approximately 11 AM, the Administrator presented the Ultralift 2500X/3500X Electric Patient Lifter Operating Instructions Manual/Users Manual (2009). On page 12 the use of the emergency lowering Section 4.12 read, "In the event the actuator will not retract and the patient is suspended, raise a bed or chair high enough to safely support the patient to allow you to detach the sling. If this is impossible, then position the patient over a bed or chair and GENTLY lift upward on the red emergency down lever until the actuator starts to retract. Release the lever when the patient is supported enough to safely detach the sling. It will be helpful to raise the bed or chair to its highest position, reducing the amount of travel time needed by the emergency lowering feature." On 2/08/14 at 11:30 AM, the lift (Ultralift 3500 serial # ML6500), involved in the incident with resident #1, was observed with Maintenance Director and Maintenance Assistant. During this observation the emergency lowering lever was tested . The Maintenance Assistant applied weight to the spreader bar, the Maintenance Director lifted the emergency lowering lever, and the lift lowered. The Maintenance Director and the Maintenance Assistant confirmed that the Ultralift 3500 ML6500 emergency lowering lever was working at that time. On 2/08/14 at 12:20 PM, the Administrator confirmed that the Ultralift 2500x/3500x Electric Patient Lifter Operating Instructions Manual/Users Manual (2009) that she submitted, did not cover the emergency lowering procedure for the Ultralift 2500 lifts that the facility uses. During this interview, she stated she was aware that the in-service education provided to nursing staff regarding the emergency lowering procedure did not include the accurate procedure according to the 2500x/3500x Electric Patient Lifter Operating Instructions Manual/Users Manual (2009) page 12. In an interview with the Administrator on 2/08/14 at 11:11 AM regarding the manual for the 2500x/3500x Electric Patient Lifter Operating Instructions Manual/Users Manual (2009), she stated that she got this copy of the manual today, but she believes

Based on observation, record review, and interview, the facility failed to prevent an accident that resulted in a fractured leg for resident #1, and failed to ensure 15 of 15 sampled residents of 31 residents requiring a mechanical total lift transfer, (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 &15) were free from actual and potential serious injury during mechanical total lift transfers when using the Ultralift, a sling type person lifting piece of equipment. Resident #1 sustained a fracture to the left tibia on 1/11/14 during a mechanical total lift transfer. The resident was suspended in the air by the Ultralift 3500, and as the 2 certified nursing assistants (CNAs) were attempting to transfer the resident from the bed to wheelchair, the lift stopped working. The staff failed to follow the procedure and attempted to remove the resident from the lift sling while the resident was still suspended. The staff failed to follow the instructions in the Ultralift 2500X/3500X Electric Patient Lifter Operating Instructions Manual/Users Manual (2009) that directs them "in the event the actuator will not retract and the patient is suspended raise a bed or chair high enough to safely support the patient (resident) to allow you to detach the sling" (p.12), and this failure resulted in serious injury. The facility failed to ensure that all nursing staff, nurses and CNAs, were trained appropriately regarding the use of mechanical lifts. The facility failed to ensure nursing staff demonstrated an understanding of emergency procedures involving mechanical lifts. A total of 31 residents who reside on all 4 wings of the building, were identified to require a total mechanical lift transfer. One resident sustained [REDACTED]. These practices resulted in Immediate Jeopardy starting on 1/11/14 and it was determined to be ongoing at the exit date on 2/12/14. Findings: Cross reference to F456, F490, F498, F520. 1. Review of the medical record revealed that resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most current Minimum Data Set ((MDS) dated [DATE] Section G-Activities of Daily Living (ADLs) indicated the resident is totally dependent with all ADLs and two person physical assist with transfers. Review of the care plan initiated 6/01/13 revealed the resident requires weight bearing support total lift of 2 staff assist, sling method. Record review of the 1/11/14 7:13 AM progress note for resident #1 documented by LPN #HH, revealed that the CNAs tried to transfer the resident from the bed to the wheelchair and the resident's left leg got stuck in the mechanical lift string because the lift malfunctioned. The resident was manually removed from the malfunctioning lift and the CNAs heard a sound in the resident's left knee. The resident's left knee became swollen and the resident screamed every time the left knee was touched. The resident's physician was called and an order was obtained to send the resident to the hospital for evaluation. Review of the progress note dated 1/11/14 at 6:10 PM for resident #1 documented by Nurse Manager #JJ revealed, the hospital was called at 12 noon to check on the resident's progress. The emergency room nurse reported the X-ray results that revealed the resident had a left proximal tibia fracture and they were sending her back to the facility with a knee immobilizer on the affected leg. In an interview with CNA #Z on 2/06/14 at 11:30 AM, she said on 01/11/14 at 6:30 AM, she was in the process of mechanically lifting resident #1 from the bed to the wheelchair with CNA #K. As they attempted to mechanically lower the resident down to the wheelchair, the lift stopped with the resident suspended in the lift sling above the wheelchair seat. CNA #K had her hands underneath the resident and was trying to support the resident in the lift sling as it was suspended above the wheelchair. CNA #Z stated that she tried "pushing" the button on the lift several times, but the lift would not go down. CNA #Z took the bottom right attachment loop off the lift spreader bar and then took the bottom left attachment loop off the lift spreader bar so they could slide the resident from the suspended sling into the wheelchair. Suddenly they heard a noise "like when you snap your knuckle." The CNAs then slid the resident down into the wheelchair. CNA #Z immediately notified the 7:00 PM -7:00 AM nurse, LPN #HH, of what had just happened. LPN #HH filled out a report, took CNA #Z statement and the resident was sent to the hospital. CNA #Z stated she received in-service training on the lifts when she first started working at the facility and has attended a mechanical lift training every year. "I was just in-serviced 2 weeks ago." On 02/06/14 at 12:45 PM, CNA #Z demonstrated the use of the Ultralift 2500 in the hallway of station 2. The lift was in the raised position and CNA #Z moved the red locking clip back and forth on the center pole several times to get the lift to lower. The lift did not go down. CNA #Z continued to move the red locking clip back and forth several times stating "the lift is not going down, it is not working." CNA #Z was not able to demonstrate the emergency lowering procedure. In an interview with CNA #K conducted on 2/06/14 at 11:25 AM, she said that on 1/11/14 she was helping CNA #Z transfer resident #1 from the bed to the reclining wheelchair with the mechanical lift. As they were lowering the mechanical lift, it stopped with the resident still suspended. As CNA #Z unhooked resident #1 from the lift they heard a cracking sound "like a knuckle being cracked." She said they put resident #1 into the wheelchair, then notified, LPN #HH, of what happened. CNA #K stated that prior to the event, they had been taught how to lower the mechanical lifts. In an observation conducted on 2/06/14 at 11:25 AM with CNA #K, she was able to demonstrate the emergency lowering procedure for the Ultralift 2500. When asked why she and CNA #Z did not use the emergency lowering procedure with resident #1, CNA #K paused for several seconds, shrugged her shoulders, and stated she did not know "sometimes you just panic." On 2/06/14 at 1:20 PM, CNA #I said she did not attend the in-service training for the Ultralift. She said they used an Ultralift on unit 4, but she also floats to the other units. She was asked to demonstrate the emergency lowering procedure for the 3500 lift and she was unable to do so. She also could not describe how to use the emergency lowering procedure for the Ultralift 2500. Review of the lift checklist dated 2/06/14 indicated she attended the training and received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. CNA #I received a rating code of 4 on 2/06/14, for a training she did not recall attending, and she was unable to demonstrate the emergency lowering process on the Ultralift 2500 and 3500 during the survey on 2/06/14 at 1:20 PM. On 2/06/14 at 1:50 PM, CNA #O was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. She stated had in-service training on the lift 2 weeks ago. She stated when using the lift you always need 2 staff. Review of the lift checklist dated 1/15/14, for CNA #O indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #O received a rating code of 4 on 1/15/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/06/14 at 1:50 PM. On 2/06/14 at 2:04 PM, LPN #W unit 1, was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. LPN #W stated her in-service training on the lifts was 3 weeks ago and only the Ultralift 3510 was used at the in-service training. Review of the lift checklist dated 1/15/14 for LPN #W indicated she received a rating code of 4. Although she received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/06/14 at 2:04 PM. An interview conducted on 02/06/14 at 3:30 PM with the Assistant Director of Nursing/Risk Manager (ADON/RM) revealed that she met with CNA #Z and CNA #K on 01/12/13 regarding the 01/11/14 incident involving resident #1. The ADON/Risk Manager said her investigation revealed that resident #1 was being mechanically lifted from the bed to the wheelchair by CNA #Z and CNA #K. As resident #1 was being lowered to the wheelchair, the mechanical lift stopped working about 1 foot above the wheelchair seat. One CNA cradled the resident "like a baby" to keep the resident safe while the other CNA unhooked the sling to lower the resident to the chair. The right side attachment loop was unhooked first. In the process of unhooking the left side attachment loop they heard a sound like "cracking a knuckle." With no response or grimacing by the resident, they manually lowered the resident the rest of the way into the wheelchair. CNA #Z immediately notified LPN #HH. Due to edema of the resident's left knee, LPN #HH notified the physician and an order was obtained to send resident #1 to the emergency room for an evaluation. Resident #1 returned to the facility on the same day with a [DIAGNOSES REDACTED]. An interview conducted on 02/07/14 at 3:20 PM with the ADON/RM revealed that she came into the facility the next day, on 1/12/14 at 7:00 AM, to start an investigation regarding resident #1's fracture. The 2 CNAs involved with the incident demonstrated exactly what they did step-by-step on a mechanical lift similar to the one used during the 01/11/14 event. The ADON/RM said "I observed everything that the CNAs did and determined that the CNAs did everything correctly to protect the resident's safety." During the same time, the ADON/RM said, starting on 1/15/14 the Staff Development Coordinator (SDC) and the ADON/RM initiated mandatory in-service training for all nurses and CNAs on all 3 shifts regarding what to do if the lift stops working. The in-service training consisted of using the "Mechanical Lift Competency Verification Checklist" (lift checklist). The Emergency Process to lower lift if electrical failure occurred was added to the checklist as of 1/15/14. The ADON/RM said the "Mechanical Total Lift Competency Verification Checklist" is used demonstrate the staff knowledge and ability to operate the facility's mechanical lifts. The checklist form has a "Note" at the top that reads, "The Mechanical Total Lift Competency Verification Checklist is a required annual skill checklist for SNF (skilled nursing facilities). All licensed nurses and all CNAs regardless of their role are to complete and pass this skill with a rating code of 4." The rating code read as follows: "4=skilled and able to work independently; 3=moderately skilled-needs limited supervision; 2=limited skill-requires close supervision; 1=no skill or knowledge. Must receive a score of four for each procedure step to prove competency." The reverse side of the form includes the section, "Signature verifying completion and date" and "Completion of all related training verified by and date." The ADON/RM continued to explain the facility has 2 different lifts and each one has a different procedure for emergency lowering. She said "one of them you twist to lower, and the other you lift the red button." Review of the form revealed 27 printed procedure steps. The "emergency process to lower lift if electrical failure" was handwritten on the reverse side of the checklist. The form did not indicate which lift was used to demonstrate competency, either the 2500 or the 3500 Ultralift. Review of the lift checklist dated 1/15/14 for CNA #Z, indicated she received a rating code of 4 in each of the 27 procedure steps and she demonstrated the "emergency process to lower lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #Z received a rating code of 4 on 1/15/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/06/14 at 12:45 PM. Review of the lift checklist dated 1/15/14 for CNA #K, indicated she received a rating code of 4 in each of the 27 procedure steps and she demonstrated the "emergency process to lower lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #K received a rating code of 4 on 1/15/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/06/14 at 11:25 PM. In an interview with the Director of Nursing (DON) on 02/08/14 at 10:15 AM, she provided written statements from #Z and #K involved in the incident in which resident #1 sustained a fractured leg on 01/11/14. In an interview with the ADON/RM on 2/08/14 at 11 AM regarding the written statements of CNA #Z and CNA #K dated 01/11/14, she said review of the statement for CNA #Z revealed that the CNAs were transferring resident #1 to the chair with the lift. When they were trying to put resident #1 down into the chair the lift did not go down. CNA #Z went into the hall to find the nurse, LPN #HH, but did not see her. The CNAs then slid the resident down, but caught her left leg in the sling. CNA #Z went to notify the 7 PM -7 AM nurse, LPN #HH, of what had just happened. The statement for CNA #K revealed CNA #Z called her to help transfer resident #1 from the bed to the chair. When the lift did not go down, CNA #Z went into the hallway to get the nurse, but she was not visible. The CNAs tried to slide resident #1 down into the chair, but her left leg got caught in the lift during the process. In an interview with the ADON/RM on 2/07/14 at 3:20 PM, she revealed that she has not continued to monitor the staff that attended the Ultralift in-service training to determine their retention of the training. The ADON/RM stated that the mechanical lift involved with the fracture for resident #1 was taken out of service on 1/11/14 at 6:35 AM. The lift used during the incident was documented as Ultralift 3500, model ML6500. She said on 1/13/14 at 8 AM she met with the Maintenance Director to discuss the mechanical lifts in the facility. She said, "The Maintenance Director assured me that he was going to check all the mechanical lifts in the building to make sure they were safe to use. He said he would also remove all mechanical lifts not functioning. I did follow up with the Maintenance Director to see if he had completed the check on all the lifts. I did not receive any documentation from the Maintenance Director related to the mechanical lift checks." 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G - ADLs indicated the resident is totally dependent with all ADLs. Review of the care plan dated 2/02/14 revealed the resident has limited physical mobility/stroke, weakness, non-ambulatory status, requires mechanical lift for transfers. 3. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Spondylosis refers to "osteoarthritis of the joints between the center of the spinal vertebrae and/or neural foramina." (Wikipedia.org). Foramina is "an opening as in a bone." (Dictionary.com). Kyphosis is "a condition of over-curvature of the thoracic vertebrae (upper back)." (Wikipedia.org). Review of the MDS dated [DATE] Section G - ADLs indicated the resident is totally dependent with all ADLs. Review of the care plan dated 1/28/14 revealed the resident requires weight bearing support, total lift 2 staff assist, extra-large sling. 4. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] indicated the resident is totally dependent with all ADLs. Review of the care plan dated 11/13/13 revealed the resident requires weight bearing support total lift, 2 staff assist sling, medium size. 5. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Necrosis "is a form of cell injury that results in the premature death of cells in living tissue...." (Wikipedia.org). Review of the MDS dated [DATE] Section G - ADLs indicated the resident is totally dependent with all ADLs. Review of the care plan dated 7/08/13 revealed the resident requires weight bearing support total lift, 2 staff assist, sling extra-large. 6. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G - ADLs indicated the resident is totally dependent with all ADLs. Review of the care plan dated 6/01/13 revealed the resident is total lift, 2 staff assist, large sling. 7. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G - ADLs indicated the resident is totally dependent with all ADLs. Review of the care plan dated 6/22/13 revealed the resident requires weight bearing support total lift, 2 staff assist, sling large/extra-large. 8. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Acute myocardial infarction "is the medical term for....a heart attack." (Wikipedia.org). Review of the MDS Section - G ADLs indicated the resident is an extensive assist to total dependence with all ADLs. Review of the care plan dated 12/20/13 revealed the resident requires total lift, 2 staff assist, large sling. 9. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G - ADLs indicated the resident is extensive assist to total dependence with all ADLs. Review of the care plan dated 5/21/13 revealed the resident requires total lift, 2 staff assist, large sling. 10. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G-ADLs indicated the resident as extensive assist with all ADLs. Review of the care plan dated 11/15/13 revealed the resident requires 2 staff participation with transfers. The CNA kardex documents transfer: resident requires sit to stand lift with large harness, 2 staff assist. 11. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G-ADLs indicated the resident is an extensive assist to total dependence with all ADLs. Review of the care plan dated 6/25/13 revealed the resident requires weight bearing support, total lift, 2 staff assist a needed for fatigue or agitation. Review of the CNA kardex revealed transfers: resident requires weight bearing support, total lift, 2 staff assist sling medium. 12. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] indicated extensive assist to total dependence with all ADLs. Review of the care plan dated 6/10/13 revealed the resident requires weight bearing support total lift, 2 staff assist, extra-large sling. 13. Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G- ADLs indicated extensive assist to total dependence with all ADLs. Review of the care plan dated 7/09/13 revealed the resident requires total lift, 2 staff assist, extra-large sling. 14. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G-ADLs indicated extensive assist with all ADLs. Review of the care plan dated 1/31/14 revealed the resident requires weight bearing support, total lift, 2 staff assist, large sling. 15. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] Section G - ADLs indicated the resident is extensive assist to total dependence with all ADLs. Review of the care plan dated 6/01/13 revealed the resident requires weight bearing support total lift, 2 staff assist, large sling. On 2/08/14, at 6:30 PM resident #15 was interviewed. Resident #15, stated that she has to use the lift to get in and out of bed because she can't stand. In an observation conducted on 2/06/14 at 2 PM with Station 1 Unit Manager (UM) #DD, she stated that they had in-service training regarding the mechanical lifts. At that time, #DD was unable to demonstrate how to use the emergency lowering procedure for the Ultralift 3500. UM #DD stated "they did not use this lift at the in-service training, it was the other one." UM #DD was also unable to demonstrate how to lower the Ultralift 2500 in the event of electrical failure. UM #DD said "I don't know how to use the lift." Review of the lift checklist dated 2/06/14 for UM #DD indicated she received a rating code of 4. Although UM #DD received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 or the Ultralift 3500 on 2/06/14. In an observation conducted on 2/06/14 2:20 PM with LPN #E, she stated she went to the mechanical lift in-service training. LPN #E was not able to demonstrate the emergency lowering procedure for the Ultralift 2500 in the event of electrical failure. LPN #E stated we were trained on the Ultralift 3500. Review of the lift checklist dated 1/17/14 for LPN #E indicated she received a rating code of 4. Although LPN #E received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/06/14. An observation was conducted on 2/06/14 1:15 PM with CNA #S on Station 4. CNA #S said the facility requires 2 staff members to do a lift. In-service training is done annually and we were just in-serviced in January 2014. CNA #S was not able to demonstrate the emergency lowering procedure for the Ultralift 2500 in the event of electrical failure. Review of the lift checklist dated 1/15/14 for CNA #S indicated she received a rating code of 4. Although CNA #S received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/06/14. During an observation conducted on 2/06/14 at 1:30 PM with LPN #EE Nurse Supervisor, she was not able to demonstrate the emergency lowering procedure for the Ultralift 2500 in the event of electrical failure. Review of the lift checklist dated 02/06/14 for LPN #EE indicated she received a rating code of 4. Although LPN #EE received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/06/14. During an observation conducted on 2/06/14 at 1:30 PM Station 4 Unit Manager (UM) #N was not able to demonstrate the emergency lowering procedure for the Ultralift 2500 in the event of electrical failure. Review of the lift checklist on 1/15/14 for UM #N indicated she received a rating code of 4. Although UM #N received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/06/14. During observation conducted on 2/06/14 at 1:30 PM, Registered Nurse (RN) #B was not able to demonstrate the emergency lowering procedure for the Ultralift 2500 in the event of electrical failure. Review of the lift checklist on 1/15/14 for RN #B indicated she received a rating code of 4. Although RM #B received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/06/14. During an observation of CNA #U and CNA #GG on 2/07/14 at 6:30 PM the CNAs were unable to demonstrate how to lower the Ultralift 2500 manually. Both CNAs stated that they had attended the Mechanical Lift in-service training recently. CNA #GG moved the red locking clip back and forth stating "you have to have more weight on the lift to get it to go down." CNA #U moved the red locking clip back and forth and stated "it is not going down." Review of the lift checklist dated 1/15/14 for CNA #GG, indicated she received a rating score of 4. Review of the lift checklist dated 2/07/14 for CNA #U indicated she received a rating score of 4. Although the CNA #GG and #U received a rating of 4, indicating competency, they did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/07/14. On 2/08/14 at 6:36 AM, during an interview with CNA #BB, Unit 1, she said she attended an in-service about a month ago on the Ultralift. She said 2 people are required when using the lift. She was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. Review of the lift checklist dated 1/16/14, for CNA #BB indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #BB received a rating code of 4 on 1/16/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/08/14 at 6:36 AM. On 2/08/14 at 6:55 AM, CNA #J, Unit 3, said she had an in-service on the Ultralifts about 2 weeks ago. She said she works on all units. She was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. She stated the in-service training was on the newer Ultralift. Review of the lift checklist dated 1/16/14, for CNA #J indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #J received a rating code of 4 on 1/16/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/08/14 at 6:55 AM. On 2/06/14 at approximately 3 PM the Maintenance Director provided the "User Manual Ultralift, 2011." He said he received this manual approximately 6 months ago when a new lift was purchased. An interview was conducted on 2/07/14 at 9:45 AM with Maintenance Director. He said the facility had 10 Ultra lifts. There where 4 Ultralift 3500 series and 6 Ultralift 2500 series. One key feature that differentiates the Ultralifts is the emergency lowering mechanism. The Ultralift 3500 has a red emergency lowering lever at the bottom of the actuator near the motor. Lifting up on the this lever will lower the boom (lifting arm) in the event of loss of power/function. The Ultralift 2500 has a red locking clip located near the top of the actuator towards the boom. Staff have to open the locking clip, then grasp the actuator and rotate it to lower the boom. He stated that he was in the building this morning on 2/07/14 at 3 AM to inspect all of the lifts in the facility. Review of the 18 Lift inspection reports (10 Ultralift - sling type & 8 stand lift) received from the Maintenance Director, revealed that they were dated January 2014. An interview was conducted with the Maintenance Director to confirm the actual date the lift inspections reports were completed. The Maintenance Director verified that the date on the inspection reports was incorrect and at that time he changed the dates from January 2014 to February 7 2014. An interview was conducted on 2/07/14 at 1 PM with the Maintenance Director and the Administrator. The Maintenance Director verified that he did the lift inspections today, 2/07/14, and he changed the dates on the inspection reports that were dated January 2014 to February 7, 2014. The Maintenance Director verified that he did not have any lift inspection reports for the month of January 2014, including any inspection reports immediately following the incident in which resident #1 sustained a fractured leg on 1/11/14. An interview was conducted on 2/08/14 at 11:30 AM with the Maintenance Director and Maintenance Assistant. The Maintenance Assistant stated that on 1/11/14 at 11 AM, he received a call from the facility regarding a problem with a lift not working. He went to the facility on [DATE] at 11:30 AM and removed the Ultralift 3500 from Station 2 and put it in the maintenance department office. On Monday, 1/12/14, the Maintenance Director and Maintenance Assistant said they inspected the lift and determined that the motor, which raises and lowers the lift, was burned out. He stated that the emergency lowering lever was not checked at that time. On 2/08/14 at approximately 11 AM, the Administrator presented the Ultralift 2500X/3500X Electric Patient Lifter Operating Instructions Manual/Users Manual (2009). On page 12 the use of the emergency lowering Section 4.12 read, "In the event the actuator will not retract and the patient is suspended, raise a bed or chair high enough to safely support the patient to allow you to detach the sling. If this is impossible, then position the patient over a bed or chair and GENTLY lift upward on the red emergency down lever until the actuator starts to retract. Release the lever when the patient is supported enough to safely detach the sling. It will be helpful to raise the bed or chair to its highest position, reducing the amount of travel time needed by the emergency lowering feature." On 2/08/14 at 11:30 AM, the lift (Ultralift 3500 serial # ML6500), involved in the incident with resident #1, was observed with Maintenance Director and Maintenance Assistant. During this observation the emergency lowering lever was tested . The Maintenance Assistant applied weight to the spreader bar, the Maintenance Director lifted the emergency lowering lever, and the lift lowered. The Maintenance Director and the Maintenance Assistant confirmed that the Ultralift 3500 ML6500 emergency lowering lever was working at that time. On 2/08/14 at 12:20 PM, the Administrator confirmed that the Ultralift 2500x/3500x Electric Patient Lifter Operating Instructions Manual/Users Manual (2009) that she submitted, did not cover the emergency lowering procedure for the Ultralift 2500 lifts that the facility uses. During this interview, she stated she was aware that the in-service education provided to nursing staff regarding the emergency lowering procedure did not include the accurate procedure according to the 2500x/3500x Electric Patient Lifter Operating Instructions Manual/Users Manual (2009) page 12. In an interview with the Administrator on 2/08/14 at 11:11 AM regarding the manual for the 2500x/3500x Electric Patient Lifter Operating Instructions Manual/Users Manual (2009), she stated that she got this copy of the manual today, but she believe

Based on observation, record review, and interview, the facility failed to ensure 10 of 10 resident mechanical lifts, Ultralift 2500 and 3500, were maintained in a safe operating condition according to the manufacturers recommendations and failed to monitor implementation of the maintenance program for Ultralifts. A total of 31 residents require a mechanical total lift, Ultralift, Hoyer-style lift, to transfer. Resident #1 sustained a fracture to the left tibia on 1/11/14 during a mechanical total lift transfer. The resident was suspended in the air by the Ultralift 3500, and as the 2 certified nursing assistants (CNAs) were attempting to transfer the resident from the bed to wheelchair, the lift stopped working. The staff failed to follow the procedure and attempted to remove the resident from the lift sling while the resident was still suspended. The staff failed to place the resident on a stable support surface prior to removing the resident from the lift that resulted in serious injury. The facility failed to follow a routine preventive maintenance program, including required maintenance as indicated by the manufacturer. As a result of this failure, one resident sustained [REDACTED]. These practices resulted in Immediate Jeopardy starting on on 1/11/14 and it was determined to be ongoing at the exit date on 2/12/14. Findings: Cross reference to F323, F490, F498, F520 During an interview on 2/06/14 at 11:26 AM Certified Nursing Assistant (CNA) #K indicated that resident #1 fractured her leg during a mechanical lift transfer via the Ultralift 3500. She stated she was assisting CNA #Z and they were transferring the resident to a reclining wheelchair. As they were lowering the resident to the chair the Ultralift stopped working and the resident was suspended in air. As the CNAs were removing the resident from the lift sling they heard a cracking sound. CNA #K described the sound similar to a "knuckle being cracked." She stated that after the incident particular Ultra Lift (3500) was taken to maintenance. On 2/06/14 at 2:56 PM the Maintenance Director (MTD) was interviewed. At that time a tour of all units was completed with the MTD. During the tour, 7 Ultralifts were observed throughout the facility. Two of the lifts were the Ultralift 3500 and the other five were the Ultralift 2500. The MTD stated he had 2 Ultralifts 3500 in the maintenance shop for repair. One of the lifts that was in the maintenance shop had the serial # ML6500. This was the lift that stopped working when resident #1 fractured her leg. The other Ultralift that was in the maintenance shop had the serial #ML6937. The MTD stated he pulled this lift of the floor 3 days ago. He stated that he does a visual inspection of the lifts each day, but does not document his inspection. He was not able to provide the manufacturer's recommendation for routine maintenance for both the 2500 and 3500 lifts. He stated that he does a monthly maintenance for all lifts that includes the use of the Lift Inspection Form. He provided the "Lift Inspection" forms for the inspections he did in December 2013. However, he only provided Lift Inspection forms for six lifts. At that time he did not have the December 2013 Lift Inspection form for the lift that failed when resident #1 sustained a fractured leg. He was not able to provide the Lift Inspection forms for any of the lifts for January 2014. The manufacturer's user manual/maintenance recommendations was requested at that time. Approximately 15 minutes later the MTD provided a user manual titled "User Manual Ultralift 2011. He stated this manual came with with the newest Ultralift 3500 serial #ML8124 that was purchased 6 months ago. He was not able to provide user manuals for the other lifts. Review of the User Manual Ultralift 2011 indicated the lift is preset to prompt service every 1,000 lifts and shuts down after 6,000 lifts. At 6,000 lifts, the lift shuts down for [MEDICATION NAME] replacement and major service, page 19 of the manual. The [MEDICATION NAME] is a center rod that attaches to the motor towards the bottom of the lift and attaches to the lifting boom on top. The [MEDICATION NAME] is a part that actually lowers/raises the lift boom and by extension, the resident. Comparison with the manufacturer's "inspection chart" included on page 37 of the manual with the facility Lift Inspection form revealed several differences. The manufacturer's inspection chart lists 32 items to check while the facility Lift Inspection form only lists 16 items. The manufacturer inspection chart listed 9 items to inspect/test in regards to the [MEDICATION NAME] including the lift's emergency down function. The Lift Inspection form did not give any indication that the facility inspects/tests the [MEDICATION NAME] to the degree listed on the manufacturer inspection chart. The facility Lift Inspection form did not include any test of the lift's emergency down function, a safety feature. On 2/07/14 on or about 9:45 AM the MTD provided 10 monthly Ultralift inspection reports all dated for January 2014. When asked when he actually performed the maintenance inspections, he stated today, 2/07/14. At that time the MTD changed the dates on the reports to reflect 2/07/14. At 1 PM the MTD stated he performed the January 2014 maintenance on the Ultralifts, but did not have any documentation to support his claim. The MTD said the facility had 10 Ultralifts. There where 4 Ultralift 3500 series and 6 Ultralift 2500 series. One key feature that differentiates the Ultralifts is the emergency lowering mechanism. The Ultralift 3500 has a red emergency lowering lever at the bottom of the [MEDICATION NAME] near the motor. Lifting up on this lever will lower the boom (lifting arm) in the event of loss of power/function. The Ultralift 2500 has a red locking clip located near the top of the [MEDICATION NAME] towards the boom. Staff have to open locking clip, then grasp the [MEDICATION NAME] and rotate it to lower the boom. On 2/07/14 at 3:20 PM the ADON said she investigated resident #1's fracture and said all lifts were checked for function and safe use. She stated she met with the MTD on 1/13/14 at 8 AM to discuss the lifts. The ADON stated that the MTD informed her that maintenance checks (Lift Inspection forms) for the lifts had been completed, but he did not show her any documentation. On 2/07/14 at 5:44 PM, the Quality Assurance (QA) Nurse was interviewed. She stated the QA Committee met on 1/15/14, 4 days after resident #1 fractured her leg, and that resident #1's fracture was briefly discussed. She stated the MTD attends the monthly QA meetings and submits his monthly maintenance reports to include Lift Inspection forms. At that time maintenance reports for the 1/15/14 QA meeting were reviewed with the QA nurse. There were reports for only 7 of the 10 Ultralifts. The QA nurse stated the committee does not review the content of the maintenance checks for the lifts. She stated the packet of reports looked thick enough and they assumed that all lifts had been checked/inspected. Missing from the reports was the Lift Inspection form for the Ultralift 3500 serial # ML6500, the lift that failed when resident #1 fractured her leg. Several minutes from the start of the interview, the MTD entered the room. He provided the December 2013 Lift Inspection form for the failed lift. He stated he had this report in a different binder. On 2/08/14 at 11:11 AM the Administrator (ADM) provided the "Ultralift 2500x/3500x Electric Patient Lifter Operating Instructions Manual" 2009. She stated she received this manual today and believes there is a copy of it in the Staff Developer's Office. The Staff Developer is responsible for staff education. When asked to see the copy that was in the staff developer's office for comparison, the ADM stated she did not think she had access to it due to the manual being in locked drawer. She stated that this manual covers both 2500 & 3500 series lifts. She added that the staff are not given the manual to read, but instead information from the manual is given to the staff. She referenced the Mechanical Total Lift Competency Verification Checklist is used for the staff's return demonstration for the lifts. Review of this manual indicated on page 12 the use of the emergency lowering. Section 4.12 read, "In the event the [MEDICATION NAME] will not retract and the patient is suspended, raise a bed or chair high enough to safely support the patient to allow you to detach the sling. If this is impossible, then position the patient over a bed or chair and GENTLY lift upward on the red emergency down lever until the [MEDICATION NAME] starts to retract. Release the lever when the patient is supported enough to safely detach the sling. It will be helpful to raise the bed or chair to its highest position, reducing the amount of travel time needed by the emergency lowering feature." On 2/08/14 at 12:20 PM the ADM confirmed that the Ultralift 2500x/3500x Operating Instruction Manual that she presented does not cover the emergency lowering procedure for the Ultralift 2500 that the facility uses. She stated she was aware that the facility's education on the Emergency Lowering does not match the manufacturer's instructions in the manual. Further review of the use manual noted on page 14 that "lift [MEDICATION NAME] must be serviced regularly (annually) by a factory authorized representative to ensure proper, safe operation." Also the manufacturer indicated the "lift [MEDICATION NAME] used in patient lifts are either replaced or or subjected to a full service inspection at an approved centre when it has run 10,000 lift cycles or after a had a period of so many years of operation, depending on the design and usage. The [MEDICATION NAME] should be checked within a period of maximum 3 years or more often if used with a high frequency in an institutional environment" (p. 14). On 2/12/14 on or about 10:45 AM the MTD indicated that he had not replaced any lift [MEDICATION NAME] and the lifts had never been inspected by a factory authorized representative in the 3 years he has been employed. He was aware that the 3500 series had a lift counter that was on the digital display. He stated the 2500 series lifts do not have a counter and he did not know how many lifts had been performed on each of the 6 Ultralift 2500s. When asked about his maintenance program for both series of Ultralifts he said he used the maintenance documentation forms that were in use prior to his employment. He was unable to provide any other evidence of a maintenance program for the Ultralifts.

Based on observation, record review and interview, the administration failed to effectively coordinate resources to provide a safe environment. This failure caused resident #1 to sustain a fracture, and put 30 other residents who required a mechanical total lift transfer at risk for potential serious injury when using the Ultralift, a sling-type lift used to lift a person from one place to another. The administration failed to effectively use all resources, including Quality Assurance, Maintenance, Staff Development and Nursing, to prevent additional serious injury or risk of injury. The administration failed to: - ensure all nursing staff, nurses and certified nursing assistants (CNAs) were trained appropriately regarding the use of mechanical lifts - ensure staff demonstrated an understanding of emergency procedures involving mechanical lifts - identify the potential for serious injury when using a mechanical total lift - evaluate and analyze the risk once a serious injury occurred - implement measures to reduce the risk of serious injury - monitor the outcome and effectiveness, or lack thereof - follow a routine preventive maintenance program, including required maintenance as indicated by the manufacturer - include the manufacturer's emergency procedures in the staff education for use of the total mechanical lift - identify quality deficiencies and quality improvement in education, maintenance, and nursing in regards to the Ultralift Resident #1 sustained a fracture to the left tibia on 1/11/14 during a mechanical total lift transfer. The resident was suspended in the air by the Ultralift 3500, and as the 2 CNAs were attempting to transfer the resident from the bed to wheelchair, the lift stopped working. The staff failed to follow the procedure and attempted to remove the resident from the lift sling while the resident was still suspended. The staff failed to place the resident on a stable support surface prior to removing the resident from the lift, as indicated in the Ultralift manual, and resulted in serious injury. As a result of this failure, one resident sustained [REDACTED]. These practices resulted in Immediate Jeopardy starting on on 1/11/14 and it was determined to be ongoing at the exit date on 2/12/14. Findings: Cross reference to F323, F456, F498, F520. Resident #1 sustained a [MEDICAL CONDITION] tibia on 1/11/14 during a mechanical lift transfer. The staff were using an Ultralift 3500 to lower the resident to a reclining wheelchair. The lift failed and the resident was suspended in air. The staff failed to place the resident on a stable support surface prior to removing the resident from the lift. A review of the Ultralift "Operating Instructions Manual 2009" read, "In the event the [MEDICATION NAME] will not retract and the resident is suspended, raise a bed or chair high enough to safely support the resident to allow you to detach the sling." (p.12). The QA subcommittee failed to fully investigate the incident of 1/11/14. They did not identify the root cause of the incident and arrived at an incorrect conclusion. Therefore, staff development failed to provide the proper training to staff as they did not follow the manufacturer's recommendations on how to lower resident in an emergency situation. The education plan to inservice all clinical staff on the use of Ultralifts was initiated on 1/15/14, four days after the incident occurred. A review of the inservice checklist included emergency process to lower the lift, but the content of the in-service training was never provided despite several requests. The administrator on 2/08/14 at 12:20 PM stated that the staff were taught how to lower a suspended resident in a lift by using the emergency manual device and not what was recommended by the lift manufacturer. Since there were two types of lifts with two different types of manual emergency devices, the administrator could not provide information on which model of lift was used in training. Interviews were conducted during the survey with 33 direct care staff. Fourteen of 33 staff interviewed were not able to demonstrate the proper procedure for emergency lowering. Six of the 14 staff unable to demonstrate the proper procedure for emergency lowering were supervisory staff. Based on the interviews, it was determined that the nursing supervisory staff would not be able to assist the CNAs with emergency lowering procedure when required because they were unaware of the proper procedure. Furthermore, there monitoring was not in place to assess whether the training provided was effective. It was also noted that by 1/18/14, 60 out of 156 staff still had not been trained, and 45 of these staff had continued to work with residents requiring lift transfers. An interview was held with the QA subcommittee on 2/08/14 at 2:25 PM. The committee verified that there was no monitoring mechanism in place to assess the effectiveness of the training. The director of nursing stated that the training for all staff would be completed by 2/15/14. An interview was held with the administrator and the Quality Assurance (QA) nurse on 2/07/14 at 5:44 PM. They stated that the incident of 1/11/14 was briefly discussed at the last QA meeting held on 1/15/14 and a sub-committee was set up to investigate the incident. A review of the QA agenda for January 2014 failed to show any mention of the incident or the conception of the sub-committee. The initial plan discussed at the January 15, 2014 QA meeting was to check all lifts. The administrator and the QA nurse stated that the maintenance director checks all lifts in the facility and submits a report to the QA committee. They also stated that he had submitted all the checks for December 2013 at the January 15, 2014 QA meeting. A review of the completed checks on 2/07/14 revealed only 7 Ultralift checks were submitted. However, there were 10 Ultralifts in the facility. Further review of the checks showed that there was no check in December 2013 for the lift that failed on 1/11/14. It was also noted that there was no documentation for the January 2014 checks. The administrator stated that the maintenance director had lost the checks for January 2014. The QA nurse confirmed that the QA committee failed to ensure that all lifts were checked in December 2013 and January 2014. A review of the "Ultralift Operating Instructions Manual" 2009 read, "the lift must be serviced regularly (annually) by a factory authorized representative to ensure proper, safe operation." (p.14). An interview with the maintenance director on 2/12/14 at 2:45 PM revealed that the lifts had not been checked by the factory authorized representative for at least 3 years since he had been employed by the facility. The QA committee failed to ensure that there was a monitoring program for the maintenance department, and had failed to implement the "New Mechanical Lift Program" which was noted on their corrective action plan written after the incident. The administrator stated that the facility was on a waiting list from the corporate office to approve initiation of the new lift program. Therefore, the Administrator could not provide an anticipated date of implementation.

Based on observation, record review and interview, the administration failed to effectively coordinate resources to provide a safe environment. This failure caused resident #1 to sustain a fracture, and put 30 other residents who required a mechanical total lift transfer at risk for potential serious injury when using the Ultralift, a sling-type lift used to lift a person from one place to another. The administration failed to effectively use all resources, including Quality Assurance, Maintenance, Staff Development and Nursing, to prevent additional serious injury or risk of injury. The administration failed to: - ensure all nursing staff, nurses and certified nursing assistants (CNAs) were trained appropriately regarding the use of mechanical lifts - ensure staff demonstrated an understanding of emergency procedures involving mechanical lifts - identify the potential for serious injury when using a mechanical total lift - evaluate and analyze the risk once a serious injury occurred - implement measures to reduce the risk of serious injury - monitor the outcome and effectiveness, or lack thereof - follow a routine preventive maintenance program, including required maintenance as indicated by the manufacturer - include the manufacturer's emergency procedures in the staff education for use of the total mechanical lift - identify quality deficiencies and quality improvement in education, maintenance, and nursing in regards to the Ultralift Resident #1 sustained a fracture to the left tibia on 1/11/14 during a mechanical total lift transfer. The resident was suspended in the air by the Ultralift 3500, and as the 2 CNAs were attempting to transfer the resident from the bed to wheelchair, the lift stopped working. The staff failed to follow the procedure and attempted to remove the resident from the lift sling while the resident was still suspended. The staff failed to place the resident on a stable support surface prior to removing the resident from the lift, as indicated in the Ultralift manual, and resulted in serious injury. As a result of this failure, one resident sustained [REDACTED]. These practices resulted in Immediate Jeopardy starting on on 1/11/14 and it was determined to be ongoing at the exit date on 2/12/14. Findings: Cross reference to F323, F456, F498, F520. Resident #1 sustained a [MEDICAL CONDITION] tibia on 1/11/14 during a mechanical lift transfer. The staff were using an Ultralift 3500 to lower the resident to a reclining wheelchair. The lift failed and the resident was suspended in air. The staff failed to place the resident on a stable support surface prior to removing the resident from the lift. A review of the Ultralift "Operating Instructions Manual 2009" read, "In the event the [MEDICATION NAME] will not retract and the resident is suspended, raise a bed or chair high enough to safely support the resident to allow you to detach the sling." (p.12). The QA subcommittee failed to fully investigate the incident of 1/11/14. They did not identify the root cause of the incident and arrived at an incorrect conclusion. Therefore, staff development failed to provide the proper training to staff as they did not follow the manufacturer's recommendations on how to lower resident in an emergency situation. The education plan to inservice all clinical staff on the use of Ultralifts was initiated on 1/15/14, four days after the incident occurred. A review of the inservice checklist included emergency process to lower the lift, but the content of the in-service training was never provided despite several requests. The administrator on 2/08/14 at 12:20 PM stated that the staff were taught how to lower a suspended resident in a lift by using the emergency manual device and not what was recommended by the lift manufacturer. Since there were two types of lifts with two different types of manual emergency devices, the administrator could not provide information on which model of lift was used in training. Interviews were conducted during the survey with 33 direct care staff. Fourteen of 33 staff interviewed were not able to demonstrate the proper procedure for emergency lowering. Six of the 14 staff unable to demonstrate the proper procedure for emergency lowering were supervisory staff. Based on the interviews, it was determined that the nursing supervisory staff would not be able to assist the CNAs with emergency lowering procedure when required because they were unaware of the proper procedure. Furthermore, there monitoring was not in place to assess whether the training provided was effective. It was also noted that by 1/18/14, 60 out of 156 staff still had not been trained, and 45 of these staff had continued to work with residents requiring lift transfers. An interview was held with the QA subcommittee on 2/08/14 at 2:25 PM. The committee verified that there was no monitoring mechanism in place to assess the effectiveness of the training. The director of nursing stated that the training for all staff would be completed by 2/15/14. An interview was held with the administrator and the Quality Assurance (QA) nurse on 2/07/14 at 5:44 PM. They stated that the incident of 1/11/14 was briefly discussed at the last QA meeting held on 1/15/14 and a sub-committee was set up to investigate the incident. A review of the QA agenda for January 2014 failed to show any mention of the incident or the conception of the sub-committee. The initial plan discussed at the January 15, 2014 QA meeting was to check all lifts. The administrator and the QA nurse stated that the maintenance director checks all lifts in the facility and submits a report to the QA committee. They also stated that he had submitted all the checks for December 2013 at the January 15, 2014 QA meeting. A review of the completed checks on 2/07/14 revealed only 7 Ultralift checks were submitted. However, there were 10 Ultralifts in the facility. Further review of the checks showed that there was no check in December 2013 for the lift that failed on 1/11/14. It was also noted that there was no documentation for the January 2014 checks. The administrator stated that the maintenance director had lost the checks for January 2014. The QA nurse confirmed that the QA committee failed to ensure that all lifts were checked in December 2013 and January 2014. A review of the "Ultralift Operating Instructions Manual" 2009 read, "the lift must be serviced regularly (annually) by a factory authorized representative to ensure proper, safe operation." (p.14). An interview with the maintenance director on 2/12/14 at 2:45 PM revealed that the lifts had not been checked by the factory authorized representative for at least 3 years since he had been employed by the facility. The QA committee failed to ensure that there was a monitoring program for the maintenance department, and had failed to implement the "New Mechanical Lift Program" which was noted on their corrective action plan written after the incident. The administrator stated that the facility was on a waiting list from the corporate office to approve initiation of the new lift program. Therefore, the Administrator could not provide an anticipated date of implementation. On 2/13/14, the facility implemented sufficient measures to decrease the severity/scope to E, but the facility remains out of compliance with F 490.

Based on observation, record review and interview, the facility failed to ensure staff were able to demonstrate competency with mechanical lift emergency procedures. All 156 certified nursing assistants (CNAs) and nurses did not receive timely and appropriate training to use the Ultralift 2500 and 3500 series to ensure that 31 residents requiring mechanical total lift transfer remained free from actual and potential serious injury during total mechanical lift transfers when using the Ultralift, a Hoyer-style lift. Resident #1 sustained a fracture to the left tibia on 1/11/14 during a mechanical lift transfer. The resident was suspended in the air by the Ultra Lift 3500 and as the certified nursing assistants (CNAs) were attempting to transfer the resident from the bed to wheelchair, the lift stopped working. The staff failed to follow the procedure and attempted to remove the resident from the lift sling while the resident was still suspended. The staff failed to follow the instructions in the Ultralift 2500X/3500X Electric Patient Lifter Operating Instructions Manual/Users Manual (2009) that directs them "in the event the [MEDICATION NAME] will not retract and the patient is suspended raise a bed or chair high enough to safely support the patient (resident) to allow you to detach the sling" (p. 12), and this failure resulted in serious injury. The facility did not attempt to begin staff education for the Ultralifts until 4 days after the incident, on 1/15/14, and failed to include the manufacturer's emergency procedures in the staff education for use of the total mechanical lifts for both the 2500 and 3500 series. As of 2/12/14, all staff providing care to residents who require mechanical total lift transfer had not been trained. A total of 31 residents who reside on all 4 wings of the building, were identified to require a mechanical total lift, Ultralift, transfer. The failure to educate staff regarding use of the Ultralift, including appropriate emergency procedures, resulted in one resident with actual serious injury and placed all 31 residents at risk for serious injury. These practices resulted in Immediate Jeopardy starting on 1/11/14 and it was determined to be ongoing at the exit date on 2/12/14. Findings: Cross reference to F323, F456, F490, F520. Record review of the 01/11/14 7:13 AM progress note for resident #1 documented by LPN #HH, revealed that the CNAs tried to transfer the resident from the bed to the wheelchair and the resident's left leg got stuck in the mechanical lift string because the lift malfunctioned. The resident was manually removed from the malfunctioning lift and the CNAs heard a sound in the resident's left knee. The resident's left knee became swollen and the resident was screaming every time the left knee was touched. The resident's physician was called and an order was obtained to send the resident to the hospital for evaluation. Review of the progress note dated 1/11/14 at 6:10 PM for resident #1 documented by Nurse Manager #JJ revealed, the hospital was called at 12 noon to check on the resident's progress. The emergency room nurse reported the X-ray results that revealed the resident had a left proximal tibia fracture and they were sending her back to the facility with a knee immobilizer on the affected leg. On 2/06/14 at 11:25 AM, CNA #K said, on 1/11/14 she was helping CNA #Z transfer resident #1 from the bed to the wheelchair using the Ultralift. They were lowering the resident into the chair when the lift stopped while the resident was still suspended in the lift sling. She said she cradled the resident while Staff #Z unhooked the resident from the lift. They heard a cracking sound like a "knuckle being cracked." Staff #K said after the incident there was an in-service on the use of all lifts. She said they were in-serviced on how to manually lower the lift. She said the lift used with resident #1 on 1/11/14, had a latch near the bottom and when unhooked, the lift would lower. When CNA #K was asked why she and CNA #Z removed resident #1 from the lift sling while still suspended over the chair, she said, "she did not know, sometimes you just panic." During an interview on 2/06/14 at 11:30 AM, CNA #Z said, on 1/11/14 at 6:30 AM, she was in the process of mechanically lifting resident #1 from the bed to the wheelchair with CNA #K. As they attempted to mechanically lower the resident down to the seat of the wheelchair, the lift stopped with the resident suspended in the lift sling above the wheelchair seat. She said she tried pushing the button on the lift several times, but the lift would not go down. She said she knew that the lift has a manual mode, "you just press a button and the lift should come down." She said CNA #K then cradled the resident underneath "like a baby" and she took the bottom right sling strap off the lift hanger bar and then took the bottom left sling strap off the lift hanger bar and slid the resident from the suspended sling into the wheelchair and heard a noise "like when you snap your knuckle." She said she notified Licensed Practical Nurse (LPN) #HH of the incident. The nurse notified the physician who requested the resident be sent to the hospital. CNA #Z said the she was in-serviced on the lifts when she first started working at the facility and every year. "I was just in-serviced 2 weeks ago. During the in-services we have to demonstrate both lifts using our co-workers." In an interview with the Maintenance Director on 2/07/14 at 9:40 AM, he said the facility had 2 different models of Ultralifts, the 2500 and the 3500. Of a total of 10 Ultralifts, 4 of them were the 3500 model and 6 of them were the 2500 model. The emergency lowering mechanism for the 2500 was different than the emergency lowering mechanism for the 3500. The Ultralift 3500 has a red emergency lowering lever at the bottom of the [MEDICATION NAME] near the motor. Lifting up on this lever will lower the boom (lifting arm) in the event of loss of power/function. The Ultralift 2500 has a red locking clip located near the top of the [MEDICATION NAME] towards the boom. Staff have to open locking clip, then grasp the [MEDICATION NAME] and rotate it to lower the boom. Both types of lifts were in use throughout the facility. On 2/07/14 at 3:20 PM, the Assistant Director of Nursing/Risk Manager (ADON/RM) said, starting on 1/15/14, four days after the resident was injured while using the Ultralift, the Staff Development Coordinator (SDC, ADON/RM, and the Nurse Educator initiated mandatory in-service training for all nurses and CNAs on all 3 shifts regarding what to do if the lift stops working. The in-service training consisted of using the "Mechanical Lift Competency Verification Checklist" (lift checklist). The Emergency Process to lower lift if electrical failure occurred was added to the checklist as of 1/15/14. The ADON/RM said the "Mechanical Total Lift Competency Verification Checklist" is used demonstrate the staff knowledge and ability to operate the facility's mechanical lifts. The checklist form has a "Note" at the top that reads, "The Mechanical Total Lift Competency Verification Checklist is a required annual skill checklist for SNF (skilled nursing facilities). All licensed nurses and all CNAs regardless of their role are to complete and pass this skill with a rating code of 4." The rating code read as follows: "4=skilled and able to work independently; 3=moderately skilled-needs limited supervision; 2=limited skill-requires close supervision; 1=no skill or knowledge. Must receive a score of four for each procedure step to prove competency." The reverse side of the form includes the section, "Signature verifying completion and date" and "Completion of all related training verified by and date." The "emergency process to lower lift if electrical failure" was handwritten on the checklist. The form did not indicate which lift was used to demonstrate competency, either the 2500 or the 3500. On 2/07/14 at 6:30 PM, an observation revealed Staff #GG, Certified Nursing Assistant (CNA) and CNA #U, were unable to demonstrate how to use the emergency lowering procedure for the 2500 Ultralift. CNA #GG moved the red locking clip lever and then stated "you have to have more weight on the lift to get it to go down." CNA #U moved the red locking clip lever back and forth and stated "it is not going down." Staff #GG and #U could not demonstrate how to manually lower the 2500 Ultralift. They stated they both had attended the lift in-service training held recently. Review of the lift checklist dated 1/15/14 for CNA #GG indicated she received a rating score of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #GG received a rating code of 4 on 1/15/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/07/14 at 6:30 PM. Review of the lift checklist dated 02/07/14 for CNA #U indicated she received a rating score of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #U received a rating code of 4 on 2/07/14, earlier that same day, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/07/14 at 6:30 PM. On 02/06/14 at 12:45 PM, CNA #Z demonstrated the use of the Ultralift 2500 in the hallway of station 2. The lift was in the raised position and CNA #Z moved the red locking clip back and forth on the center pole several times to get the lift to lower. The lift did not go down. CNA #Z continued to move the red locking clip back and forth several times stating "the lift is not going down, it is not working." CNA #Z was not able to demonstrate the emergency lowering procedure. On 2/08/14 at 1:05 PM, CNA #Z, who was working on unit 2, was interviewed. When asked what she would do if the emergency lowering mechanism did not lower, she said "that scenario was not taught at the in-service training I attended on 1/15/14. Review of the lift checklist dated 1/15/14 for CNA #Z indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #Z received a rating code of 4 on 1/15/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/06/14 at 12:45 PM. An observation was conducted on 2/06/14 at 1:15 PM with CNA #S on the Station 4. CNA #S said the facility requires 2 staff members to do a lift. In-service training is done annually. CNA#S was not able to demonstrate the emergency lowering procedure for the Ultra Lift 2500. Review of the lift checklist dated 01/15/14 for CNA #S indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #S received a rating code of 4 on 1/15/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/06/14 at 1:15 PM. On 2/06/14 at 1:20 PM, CNA #I said she did not attend the in-service training for the Ultralift. She said they used an Ultralift on unit 4, but she also floats to the other units. She was asked to demonstrate the emergency lowering procedure for the 3500 lift and she was unable to do so. She also could not describe how to use the emergency lowering procedure for the Ultralift 2500. Review of the lift checklist dated 2/06/14 indicated she attended the training and received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. CNA #I received a rating code of 4 on 2/06/14, for a training she did not recall attending, and she was unable to demonstrate the emergency lowering process on the Ultralift 2500 and 3500 during the survey on 2/06/14 at 1:20 PM. On 2/06/14 at 1:30 PM, during an observation of Licensed Practical Nurse (LPN) #EE, Nurse Supervisor, she was not able to demonstrate the emergency lowering procedure for the Ultralift 2500. Review of the lift checklist dated 2/06/14 for LPN #EE indicated she received a rating score of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although LPN #EE received a rating code of 4 on 2/06/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/06/14 at 1:30 PM. On 2/06/14 at 1:30 PM, during an observation of LPN #N, Nurse manager Station 4, she was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. Review of the lift checklist dated 1/15/14, for LPN #N indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although LPN #N received a rating code of 4 on 1/15/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/06/14 at 1:30 PM. On 2/06/14 at 1:35 PM, during an observation of Registered Nurse (RN), #B, she was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. Review of the lift checklist dated 1/15/14, for RN #B indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although RN #B received a rating code of 4 on 1/15/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/06/14 at 1:35 PM. On 2/06/14 at 1:50 PM, CNA #O was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. She stated had in-service training on the lift 2 weeks ago. She stated when using the lift you always need 2 staff. Review of the lift checklist dated 1/15/14, for CNA #O indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #O received a rating code of 4 on 1/15/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/06/14 at 1:50 PM. In an observation conducted on 2/06/14 at 2 PM with Station 1 Unit Manager (UM) #DD, she stated that they had in-service training regarding the mechanical lifts. At that time, #DD was unable to demonstrate how to use the emergency lowering procedure for the Ultralift 3500. UM #DD stated "they did not use this lift at the in-service training, it was the other one." UM #DD was also unable to demonstrate how to lower the Ultralift 2500 in the event of electrical failure. UM #DD said "I don't know how to use the lift." Review of the lift checklist dated 2/06/14 for UM #DD indicated she received a rating code of 4. Although UM #DD received a rating of 4, earlier that same day, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 or the Ultralift 3500 on 2/06/14. On 2/06/14 at 2:04 PM, LPN #W unit 1, was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. LPN #W stated her in-service training on the lifts was 3 weeks ago and only the Ultralift 3510 was used at the in-service training. Review of the lift checklist dated 1/15/14 for LPN #W indicated she received a rating code of 4. Although she received a rating of 4, indicating competency, she did not demonstrate competency with the emergency lowering procedure for the Ultralift 2500 on 2/06/14 at 2:04 PM. On 2/06/14 at 2:20 PM during an observation with LPN #E, she said the policy and procedure requires 2 staff members for mechanical lifts. She was not able to demonstrate manual mode with the Ultralift 2500. She said she was trained the Ultralift 3510. Review of the lift checklist dated 1/17/14, for LPN #E indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although LPN #E received a rating code of 4 on 1/17/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/06/14 at 2:20 PM. On 2/08/14 at 6:36 AM, during an interview with CNA #BB, Unit 1, she said she attended an in-service about a month ago on the Ultralift. She said 2 people are required when using the lift. She was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. Review of the lift checklist dated 1/16/14, for CNA #BB indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #BB received a rating code of 4 on 1/16/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/08/14 at 6:36 AM. On 2/08/14 at 6:55 AM, CNA #J, Unit 3, said she had an in-service on the Ultralifts about 2 weeks ago. She said she works on all units. She was unable to demonstrate the emergency lowering procedure for the Ultralift 2500. She stated the in-service training was on the newer Ultralift. Review of the lift checklist dated 1/16/14, for CNA #J indicated she received a rating code of 4 in each of the 27 procedures and she demonstrated the "emergency process to lower the lift if electrical failure." The checklist did not indicate what model lift was used to demonstrate competency. Although CNA #J received a rating code of 4 on 1/16/14, she was unable to demonstrate the emergency lowering process on the Ultralift 2500 during the survey on 2/08/14 at 6:55 AM. On 2/08/14 at approximately 3 PM, the Director of Nursing (DON) provided copies of the lift checklist for 140 staff members who received in-service training between 1/15/14 and 2/08/14. Review of in-service training documentation of the lift checklists revealed on: 1/15/14, 59 staff attended 1/16/14, 28 staff attended 1/17/14, 8 staff attended 1/30/14, 1 staff attended 2/02/14, 1 staff attended 2/06/14, after the start of the survey, 13 staff attended 2/07/14, 23 staff attended 2/08/14, 7 staff attended Between 1/15/14 and 1/18/14 a total 95 staff attended in-service training of the 140 copies provided by the administrator. As of 1/18/14, 45 staff still had not attended the in-service training and they continued to provide care to residents who required transfer with Ultralifts in the facility, putting them at risk for injury. It was not until after the start of the survey on 2/06/14, between 2/06/14 and 2/08/14, that an additional 45 staff attended the in-service training. On 2/08/14, the DON said 11 employees still needed to receive in-service training on the Ultralifts. The DON reported of those 11, they worked shifts between dates of 1/11/14 and 2/05/14. When the Administrator was asked for any documentation for the mechanical lift program on 2/07/14 at 2:30 PM, she provided "Mechanical Lift/Transfer Resource Packet" May 2013. Review that documentation under "II. Required In Service Education" read "Mechanical lift training is required with new hire orientation and return demonstrations documented and a completed checklist placed in the employee file. Annual in-service and return demonstration competency for mechanical lifts is required." On 2/12/14 at 4:25 PM, the DON, ADON, the Corporate Rehab Consultant (CRC) were interviewed regarding the "Mechanical Total Lift Competency Verification Checklist" (lift checklist). The DON said the facility decided to implement the use of the lift checklist this year and used it for the first time to train staff starting on 1/15/14, although the Mechanical Lift/Transfer Resource Packet dated May 2013 indicated the lift checklist was to be used upon new hire and annually. In an interview on 2/12/14 at 4:15 PM, RN #KK, Nurse educator, provided orientation checklists and documentation for lift competency for CNAs #K and #Z, but she could not provide complete documentation of their last annual performance evaluation. An interview was held with the Quality Assurance (QA) sub-committee which consisted of the Administrator, Director of Nursing (DON), ADON/RM, QA Nurse, and the Maintenance Director on 2/08/14 at 2:25 PM. The director of nursing (DON) stated that the plan was to train all staff regarding lifts with a competency check list. When asked why there was no written plan, the DON pointed to her head and stated that it was all in there. When asked when the in-service training would be completed, she stated that she was doing the best she could, but at a later interview provided the date of 2/15/14 as the completion date. When asked why it would take more than a month after the incident to train all staff, the administrator said that they could not possibly ask all staff to attend training on the same day. It was noted that 60 out of 156 clinical staff had still not been trained by 1/18/14 and 45 staff had continued to work with residents requiring lift transfers. The committee verified that the monitoring mechanisms were not in place to assess whether the training was effective. Thus, the committee failed to develop or revise training for staff and failed to deploy any monitoring mechanisms. The training did not focus on staff being fully aware of the emergency procedure in the instructions in the Ultralift 2500X/3500X Electric Patient Lifter Operating Instructions Manual/Users Manual (2009) to include "in the event the [MEDICATION NAME] will not retract and the patient is suspended raise a bed or chair high enough to safely support the patient (resident) to allow you to detach the sling" (p. 12). Ultralift manuals were not available for staff to read or use as reference, including the Administrator and DON. The checklists used did not include the proper procedure because the QA committee still did not refer to the manual even after the incident. The emergency lowering procedure as listed in the manual, was pointed out during the survey. On 2/12/14, review of their in-service training still did not include the emergency lowering procedure as listed in the manual to include a stable support surface prior to removing a resident from the lift. They did not include both models of Ultralift in the training, 2500 and 3500 series. They also did not have any plan to monitor the effectiveness of the training even though the 2 CNAs had competency checklists that said they were competent, but did not demonstrate competency on 1/11/14. The training did not address how the CNAs should properly remove a resident from a sling, to include ensure the resident is not removed from the lift sling while they are still suspended to prevent serious injury.

Based on observation, record review and interview, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) program that led resident #1 sustaining a fractured leg, and put 30 other residents requiring a mechanical total lift transfer at potential serious injury during mechanical total lift transfers when using the Ultra lift, a Hoyer-style lift. Resident #1 sustained a fracture to the left tibia on 1/11/14 during a mechanical total lift transfer. The resident was suspended in the air by the Ultra Lift 3500 and as the certified nursing assistants (CNAs) were attempting to transfer the resident from the bed to wheelchair, the lift stopped working. The staff failed to follow the procedure and attempted to remove the resident from the lift sling while the resident was still suspended. The staff failed to place the resident on a stable support surface prior to removing the resident from the lift, as indicated in the manufacturer's manual, that resulted in serious injury. The QA&A failed to identify quality deficiencies and quality improvement in education, maintenance and nursing in regards to mechanical total lifts. As a result of this failure, one resident sustained [REDACTED]. These practices resulted in Immediate Jeopardy starting on 1/11/14 and was determined to be ongoing at the exit date of 2/12/14. Findings: Cross reference to F323, F456, F490, F498. An interview was held on 2/07/14 at 5:44 PM with the administrator and the Quality Assurance (QA) nurse. The QA nurse was the lead for the QAA meetings. She stated that the incident of 1/11/14 was briefly discussed at the QAA meeting held on 1/15/14 and a sub-committee was formed to review the incident. The sub-committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON/RM), QA Nurse, and the Maintenance Director. A review of the QA agenda for the month of January 2014 did not reflect a discussion of the incident or any mention of the formation of the sub-committee. The initial response was to ensure all staff were retrained on the use of Ultralifts and staff development started in-service training on 1/15/14. The maintenance director submitted the checks for the lifts done in December 2013. A review of the checks showed only 7 for Ultralifts, but the facility had a total of 10 Ultralifts. It was noted that a check for the lift that failed on 1/11/14 was not documented and when asked, the QA nurse stated that the package of lift checks which the maintenance director submitted looked thick enough and the committee did not substantiate whether all lifts were checked. She verified that the incomplete lift checks were not identified by the QA committee in January 2014 and stated that they assumed that all lifts were checked and did not inquire whether the failed lift was checked in December 2013. The maintenance director submitted a check form for the failed lift for December 2013 on 2/08/14, during the survey, and confirmed that he did not submit the form for the QA committee in January 2014. A copy of the policy and procedure for equipment maintenance was requested. The administrator stated that they did not have a specific policy for the maintenance of the lifts, but the standard was to check the lifts monthly and complete the monthly lift inspection form. She also stated that the lifts are checked daily, but there was no documentation for the daily checks. She verified that the monthly lift checks for December 2013 were incomplete and documentation of the checks for January 2014 was done, but they could not provide evidence of the checks. She also confirmed the QA committee was not involved in monitoring the maintenance program and did not review the lift checks to see if the lift that failed on 1/11/14 was checked in December 2013 prior to the incident. The committee also failed to ensure that all lifts were checked in January 2014 post incident. A review of the of the "Operating Instructions Manual (2009)" for the Ultralift showed that the"lift must be serviced regularly (annually) by a factory authorized representative to ensure proper, safe operation." (pg.14). However, the maintenance director confirmed that this had not been done in the last 3 years since he had been employed. The facility also failed to implement the "New Mechanical Lift Program" as noted on their corrective action plan listed on the adverse incident report. The administrator stated that the facility was on a waiting list from the corporate office to begin implementation. The education plan to inservice all clinical staff on the use of lifts was implemented on 1/15/14. A review of the the inservice checklist included emergency process to lower the lift in case of electrical failure. The content of the in-service training was requested several times throughout the survey but was not provided. The administrator stated that staff were taught how to lower a resident in a lift by using the manual lowering device. Observations of the lifts revealed two different types of emergency lowering mechanisms. The Ultralift 3500 had an emergency lowering lever at the base of the [MEDICATION NAME] arm. The procedure to manually lower it was to pull up on the lever. This would cause the [MEDICATION NAME] arm to bring the boom down, thereby lowering the lift/resident. The older lift, Ultralift 2500, had an emergency lowering mechanism which had a red lever on the top part of the [MEDICATION NAME] proximal to the boom. The procedure to manually lower this lift was to flip open the red lever, grasp the [MEDICATION NAME] pole and rotate it clock wise to lower the lift/resident. The facility, however, had failed to identify that there were two types of lifts with two different types of lowering mechanisms, and could not identify which lift was used for the training. When the administrator was asked on 2/08/14 at 12:20 PM what the manufacturer's recommendations were for safely lowering a resident, she stated that she was not sure. At that time, it was pointed out to her that the manufacturer indicated that "It will be helpful to raise the bed or chair to it's highest position, reducing the amount of travel time needed by the emergency lowering feature" in order to detach the sling. She stated that this was not what was taught in the staff training. She confirmed that the plan to train staff on the emergency lowering process was ineffective because it did not take into account the manufacturer's recommendations for emergency lowering. An interview was held with the QA sub-committee on 2/08/14 at 2:25 PM. The DON stated that the plan was to train all staff regarding lifts with a competency check list. When asked why there was no written plan, the DON pointed to her head and stated that it was all in there. When asked when the in-service training would be completed, she stated that she was doing the best she could but at a later interview provided the date 2/15/14 as the completion date. When asked why it would take more than a month after the incident to train all staff, the administrator stated that they could not possibly ask all staff to attend training on the same day. It was noted that 60 out of 156 clinical staff still had not been trained by 1/18/14 and 45 staff had continued to work with residents requiring lift transfers. The committee verified that the monitoring mechanisms were not in place to assess whether the training was effective. Thus, the committee failed to develop and failed to revise training for staff or deploy any monitoring mechanisms. The QA subcommittee failed to fully investigate the incident of 1/11/14. They did not identify the root cause of the incident and arrived at an incorrect conclusion. Therefore, staff development failed to provide the proper training to staff as they did not follow the manufacturer's recommendations on how to lower resident in an emergency situation. The education plan to inservice all clinical staff on the use of Ultralifts was initiated on 1/15/14, four days after the incident occurred.

Based on observation, record review and interview, the facility failed to maintain an effective Quality Assessment and Assurance (QAA) program that led resident #1 sustaining a fractured leg, and put 30 other residents requiring a mechanical total lift transfer at potential serious injury during mechanical total lift transfers when using the Ultra lift, a Hoyer-style lift. Resident #1 sustained a fracture to the left tibia on 1/11/14 during a mechanical total lift transfer. The resident was suspended in the air by the Ultra Lift 3500 and as the certified nursing assistants (CNAs) were attempting to transfer the resident from the bed to wheelchair, the lift stopped working. The staff failed to follow the procedure and attempted to remove the resident from the lift sling while the resident was still suspended. The staff failed to place the resident on a stable support surface prior to removing the resident from the lift, as indicated in the manufacturer's manual, that resulted in serious injury. The QA&A failed to identify quality deficiencies and quality improvement in education, maintenance and nursing in regards to mechanical total lifts. As a result of this failure, one resident sustained [REDACTED]. These practices resulted in Immediate Jeopardy starting on 1/11/14 and was determined to be ongoing at the exit date of 2/12/14. Findings: Cross reference to F323, F456, F490, F498. An interview was held on 2/07/14 at 5:44 PM with the administrator and the Quality Assurance (QA) nurse. The QA nurse was the lead for the QAA meetings. She stated that the incident of 1/11/14 was briefly discussed at the QAA meeting held on 1/15/14 and a sub-committee was formed to review the incident. The sub-committee consisted of the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON/RM), QA Nurse, and the Maintenance Director. A review of the QA agenda for the month of January 2014 did not reflect a discussion of the incident or any mention of the formation of the sub-committee. The initial response was to ensure all staff were retrained on the use of Ultralifts and staff development started in-service training on 1/15/14. The maintenance director submitted the checks for the lifts done in December 2013. A review of the checks showed only 7 for Ultralifts, but the facility had a total of 10 Ultralifts. It was noted that a check for the lift that failed on 1/11/14 was not documented and when asked, the QA nurse stated that the package of lift checks which the maintenance director submitted looked thick enough and the committee did not substantiate whether all lifts were checked. She verified that the incomplete lift checks were not identified by the QA committee in January 2014 and stated that they assumed that all lifts were checked and did not inquire whether the failed lift was checked in December 2013. The maintenance director submitted a check form for the failed lift for December 2013 on 2/08/14, during the survey, and confirmed that he did not submit the form for the QA committee in January 2014. A copy of the policy and procedure for equipment maintenance was requested. The administrator stated that they did not have a specific policy for the maintenance of the lifts, but the standard was to check the lifts monthly and complete the monthly lift inspection form. She also stated that the lifts are checked daily, but there was no documentation for the daily checks. She verified that the monthly lift checks for December 2013 were incomplete and documentation of the checks for January 2014 was done, but they could not provide evidence of the checks. She also confirmed the QA committee was not involved in monitoring the maintenance program and did not review the lift checks to see if the lift that failed on 1/11/14 was checked in December 2013 prior to the incident. The committee also failed to ensure that all lifts were checked in January 2014 post incident. A review of the of the "Operating Instructions Manual (2009)" for the Ultralift showed that the"lift must be serviced regularly (annually) by a factory authorized representative to ensure proper, safe operation." (pg.14). However, the maintenance director confirmed that this had not been done in the last 3 years since he had been employed. The facility also failed to implement the "New Mechanical Lift Program" as noted on their corrective action plan listed on the adverse incident report. The administrator stated that the facility was on a waiting list from the corporate office to begin implementation. The education plan to inservice all clinical staff on the use of lifts was implemented on 1/15/14. A review of the the inservice checklist included emergency process to lower the lift in case of electrical failure. The content of the in-service training was requested several times throughout the survey but was not provided. The administrator stated that staff were taught how to lower a resident in a lift by using the manual lowering device. Observations of the lifts revealed two different types of emergency lowering mechanisms. The Ultralift 3500 had an emergency lowering lever at the base of the [MEDICATION NAME] arm. The procedure to manually lower it was to pull up on the lever. This would cause the [MEDICATION NAME] arm to bring the boom down, thereby lowering the lift/resident. The older lift, Ultralift 2500, had an emergency lowering mechanism which had a red lever on the top part of the [MEDICATION NAME] proximal to the boom. The procedure to manually lower this lift was to flip open the red lever, grasp the [MEDICATION NAME] pole and rotate it clock wise to lower the lift/resident. The facility, however, had failed to identify that there were two types of lifts with two different types of lowering mechanisms, and could not identify which lift was used for the training. When the administrator was asked on 2/08/14 at 12:20 PM what the manufacturer's recommendations were for safely lowering a resident, she stated that she was not sure. At that time, it was pointed out to her that the manufacturer indicated that "It will be helpful to raise the bed or chair to it's highest position, reducing the amount of travel time needed by the emergency lowering feature" in order to detach the sling. She stated that this was not what was taught in the staff training. She confirmed that the plan to train staff on the emergency lowering process was ineffective because it did not take into account the manufacturer's recommendations for emergency lowering. An interview was held with the QA sub-committee on 2/08/14 at 2:25 PM. The DON stated that the plan was to train all staff regarding lifts with a competency check list. When asked why there was no written plan, the DON pointed to her head and stated that it was all in there. When asked when the in-service training would be completed, she stated that she was doing the best she could but at a later interview provided the date 2/15/14 as the completion date. When asked why it would take more than a month after the incident to train all staff, the administrator stated that they could not possibly ask all staff to attend training on the same day. It was noted that 60 out of 156 clinical staff still had not been trained by 1/18/14 and 45 staff had continued to work with residents requiring lift transfers. The committee verified that the monitoring mechanisms were not in place to assess whether the training was effective. Thus, the committee failed to develop and failed to revise training for staff or deploy any monitoring mechanisms. The QA subcommittee failed to fully investigate the incident of 1/11/14. They did not identify the root cause of the incident and arrived at an incorrect conclusion. Therefore, staff development failed to provide the proper training to staff as they did not follow the manufacturer's recommendations on how to lower resident in an emergency situation. The education plan to inservice all clinical staff on the use of Ultralifts was initiated on 1/15/14, four days after the incident occurred. On 2/13/14, the facility implemented sufficient measures to decrease the severity/scope to E, but the facility remains out of compliance with F 520.