Every finding on record at The Vinton Lutheran Home

Based on clinical record review, resident interviews, staff interviews, and policy review, the facility failed to ensure residents were offered and provided bathing at least two times per week as specified per resident care plans for 4 of 4 residents reviewed (Residents #1, #8, #10 and #11). The facility reported a census of 41 residents. Findings include: 1.The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating intact cognition. The MDS further indicated the resident had diagnoses of Cerebral Vascular Accident (CVA)(stroke) and Hemiplegia (paralysis on one side of the body) and required assistance with showers. The Care Plan initiated 1/15/18 revealed Resident #1 required assistance with activities of daily living (ADLs) secondary to stroke and directed staff to offer bath/shower two times per week and as needed, assist with bathing, and allow to bathe as prefers unless doctor/nurse specify otherwise. During an interview 8/10/26 at 12:58 PM, Resident #1 revealed last week she received 1 whirlpool and was not offered another whirlpool or shower. The resident reported she had a shower today and was scheduled to get her showers Mondays and Thursdays. The resident further revealed she would like to receive 2 showers per week. Review of shower records in the electronic health record (EHR) for the month of August 2026 revealed Resident #1 received showers on 8/5/26 and 8/10/26. 2. The MDS dated [DATE] for Resident #8 documented a BIMS of 15 out of 15, indicating intact cognition. The MDS further indicated the resident had diagnoses of heart failure and respiratory failure and did not require assistance with showers. The Care Plan initiated 3/15/26 revealed Resident #8 had a focus area of ADL functions. The Care Plan directed staff to offer bath/shower two times per week and as needed. During an interview 8/12/26 at 8:55 AM, Resident #8 revealed he did not receive nor offered 2 showers last week. The resident stated when he first admitted to the facility in 2025 he was offered 2 showers per week for a couple months however he had not been offered or received 2 showers for months. The resident further revealed he would like to receive a shower 2 times per week. Review of shower records in the EHR for the month of August 2026 revealed Resident #8 received showers 8/5/26 and 8/12/26. 3. The MDS dated [DATE] for Resident #10 documented a BIMS of 15 out of 15, indicating intact cognition. The MDS further indicated the resident had diagnoses including CVA and did not require assistance with showers. The Care Plan initiated 3/13/26 with a focus area of ADL functions directed staff to offer baths/showers two times per week and as needed. During an interview 8/12/26 at 8:55 AM, Resident #10 revealed she was not offered 2 showers or 1 whirlpool and 1 shower last week. The resident stated she received showers 2 times a week when she first admitted to the facility in 2025 however had not been offered 2 showers a week for months. The resident further revealed she would like to receive 2 showers or 1 shower and 1 whirlpool twice a week. Review of shower records in the EHR for the month of August 2026 revealed Resident #10 received showers on 8/4/26 and 8/10/26.4. The MDS dated [DATE] for Resident #11 documented a BIMS of 15 out of 15, indicating intact cognition. The MDS further indicated the resident had diagnoses including CVA and chronic obstructive pulmonary disease (COPD) and required assistance with showers. The Care Plan initiated 4/6/26 with a focus area of ADL functions directed staff to offer baths/showers two times per week and as needed. During an interview 8/12/26 at 10:07 AM, Resident #11 reported he got only 1 shower per week for quite some time, but would prefer to get 2 showers per week. Review of the shower record in the EHR for the month of August 2026 revealed Resident #11 received showers on 8/5/26 and 8/11/26. During an interview 8/12/26 at 10:25 AM, the Administrator revealed he would expect residents to be offered at least 2 showers per week as documented in their policy. The facility policy titled, Bath/Shower, reviewed 2/13/25, indicated residents were to be assisted with a shower twice a week on scheduled days, and on an as-needed basis.

Based on staff interview, facility investigation review, clinical record review, and facility policy review the facility failed to ensure a resident remained free from physical abuse by a staff member for 1 of 4 residents reviewed (Resident #2). The facility reported a census of 41 residents.On 5/12/26, the facility self -reported the incident to the Department of Inspections, Appeals, and Licensing. The facility corrected the deficient practice on 5/12/26 per past noncompliance through the following actions: -5/12/26: The facility suspended Staff A, Certified Medication Aide (CMA). -5/12/26: Assessment completed for Resident #2. -5/12/26: All staff education completed revealed to please remember that [staff] are tasked with taking care of at times, a very delicate population. When a resident is approached and they become agitated, aggressive or hostile, please just walk away, take a breath, and reapproach at a later time. If agitation persists, do not reapproach without having another staff member there to help. At no time should [staff] react physically or verbally to the resident who is agitated. As long as [staff] can do so in a safe manner, the best thing [staff] can do is walk away from the situation. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated severe cognitive impairment. The resident needed substantial/maximal assistance for dressing. The resident had other behavioral symptoms not directed towards others for one to three days of the review period. Diagnoses for Resident #2 included dementia, depression, and an anxiety disorder. Per the MDS assessment, the resident took antianxiety medication.The Care Plan Focus area dated 3/3/26 revealed Resident #2 had cognitive loss. Interventions dated 3/3/26 revealed the resident had a diagnosis of dementia, and [Resident #2's] level of cognitive impairment is severe which affected all areas of judgment. The intervention dated 3/3/26 further revealed [Resident #2] did not follow commands, and staff would provide 1 step directions when assisting [Resident #2] with cares and daily living skills.The Care Plan Focus area dated 3/4/26 reflected Resident #2 had behaviors. The intervention dated 3/4/26 revealed if behaviors were noted, staff would intervene appropriately based on behavior. An additional intervention dated 3/4/26 revealed if behaviors were noted, staff would attempt to determine the root cause of behavior i.e. toileting need, possible infection, boredom, etc.Review of an Incident Report, incident date and time of 5/11/26 at 7:20 AM, for Resident #2 completed by the Director of Nursing (DON) revealed the following incident in the memory care dayroom: Resident became agitated with Am medication pass et (and) bit staff member on left arm. Staff swiped resident across back of head. Per the incident report, there was no apparent injury, and staff was re-educated to walk away if/when a resident becomes agitated. The Incident Report further revealed no bruising or abrasions noted on exam. The Incident Report was completed by the DON on 5/12/26.Review of Facility Investigation documentation dated 5/12/26 revealed on 5/12/26 at approximately 1:00 PM the DON was completing incident report/investigation of a resident, [Resident #2] biting a staff member, [Staff A, Certified Medication Aide (CMA)]. Security camera footage was reviewed to confirm which part of the staff member's body was affected by the bite and this nurse noted an altercation between the staff member and the resident It was noted that the resident became agitated with the staff member during morning medication pass et bit the staff member on the Left forearm, at which time the staff swiped the resident across the back of the head and further physical altercations occurred. Continued review of the Facility Investigation documentation revealed the facility contacted Staff A, CMA. Staff A, CMA stated [Staff A] was giving [Resident #2] his pills, he smacked my arm, threw his water on me and bit my Left arm. [Staff A] was trying to put his hearing aides in too. [Staff A] just kind of stood there and said [Resident #2] No! No! After he [Resident #2] threw his water on [Staff A], [Staff A] walked away. [Staff A] learned that [Staff A] should have waited til he was up and moving around to try giving meds and hearing aides he was awake but maybe [Staff A] startled him [Staff A] never work in the morning with him [Staff A was] sorry [Staff A] didn't know.Review of information submitted by the DON as part of the self reported incident information revealed the following regarding further physical altercations: The resident threw water at the staff member, grabbed and bit her arm and was reaching out as if to grab her around the neck and the staff member grabbed the residents' hands/arms. On 8/11/26 at 1:39 PM the DON stated she was looking into the incident that Resident #2 had bit Staff A. The DON got to the portion of the video where it looked like they were having an altercation. It looked like Staff A approached Resident #2 to put in his hearing aids and when Staff A tried, Resident #2 was moving his head away like he didn't want them in. Staff A went to his other side and attempted to put the hearing aid in on that side. Resident #2 then threw the water and reached for her throat then he bit Staff A's arm and she swiped the back of Resident #2's head with her hand. Then DON stated she then went and told the Administrator because even if it was reactionary, [facility] took care of these people and no one should be treated that way. The DON explained then got her statement and suspended her.On 8/13/26 at 11:15 AM, the Administrator stated when he observed the video it was buffering. The Administrator explained it looked like Staff A swiped at the back of Resident #2's head, which may be normal but not in a care setting. Staff A, CMA was suspended indefinitely pending [State Agency] investigation on 5/12/26.The Facility Policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property and Reporting Guidelines reviewed 3/14/25 revealed the facility would provide a safe, non-threatening environment for and recognize the rights of our residents to be free from Abuse Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment when used to correct or control behavior, including but not limited to, pinching, spanking, slapping of hands, flicking, or hitting with an object.

Based on clinical record review, staff interview, and facility policy review the facility failed to keep a resident's care plan updated for falls for 1 of 3 residents reviewed. The facility reported a census of 47 residents.Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 admitted to the facility on [DATE]. The MDS identified the resident with diagnoses which included fractured right pubis (pelvis bone), diabetes, obesity and kidney failure. The resident required substantial assistance from staff to complete activities of daily living. He required substantial assistance for showering, standing and toileting, and used a walker or wheelchair to move about. The resident had a Brief Interview for Mental Status score of 12/15 which indicated the resident had moderate cognitive impairment, and had a fall in the last month prior to admission, entry, or reentry. Review of the resident's progress notes revealed the following falls: a. On 11/15/25 at 6:30 am, the staff found the resident sitting on the floor next to bed. The staff assessed him and assisted him up from the floor and reminded him to use his call light. b. On 11/17/25 at 9:43pm, the staff found the resident on his knees in front of his commode. The resident sustained a skin tear to his left elbow. c. On 11/20/25 at 2:00 pm the staff found the resident on the floor. After they assessed him they assisted him off the floor at that time. Later the resident was painful and could not stand as per normal. The nurse called and received an order for a portable x-ray. The portable x-ray company could not get to the resident timely so he was sent to a local emergency room. The resident found to have a re-fracture of the right pelvis and did not return to the facility. Review of the Care Plan dated 11/3/25 revealed the resident had a fall risk score of 5 upon admission, which revealed he had a low risk for falls. The staff were to encourage a slow transition from lying to sitting and from sitting to standing every day as needed. The Care Plan directed staff in an event of a fall give first aide, assess for causes and remedy as needed and report to the primary care physician as needed. The Care Plan directed the staff to keep the resident's call light within reach while in his room and could use half upper siderails on his bed. The Care Plan failed to include interventions for the falls on 11/15/25 and 11/17/25. Review of Resident #1's Mini Care Plan revealed at an unidentified date the staff determined the resident should have his bed in low position and an intervention dated 11/14/25 informed the staff the resident should not be left on the commode alone.During an interview with Staff A-RN (Registered Nurse)/Care plan coordinator on 1/6/25 at 10:45 revealed upon reviewing the care plan for Resident #1, she did not put any new interventions in place after his falls on 11/15/25 and 11/17/25. She did state they did put him in a low bed but stated she did not put it on the care plan and was unable to say when this was implemented. Review of the Fall Assessment and Management Policy and Protocol implemented on 11/16/2000 and last reviewed on 2/13/2025 revealed interventions/safety measures will be communicated to on duty care staff and added to the mini care plan immediately following fall .Interventions for reducting the residents' fall risk shall be resident specific and based on the fall in attempt to prevent the all from happening again Communicate safety measures to staff including care plan team to appropriate care plan interventions used for falls.

Based on observations, clinical record review, facility investigation, manufacturers user manuals, staff interviews and policy review, the facility failed to operate a full body mechanical lift appropriately during resident cares, and failed to use the appropriate slings for the mechanical lift for 3 of 5 residents (Resident #1, #2, #3) reviewed for safe transfers. This failure resulted in an immediate jeopardy when Lift #1's (brand specific) spreader bar had over a 1 centimeter (CM) gap between the hook cradle and the rubber stopper. When staff failed to clear Resident #1 bottom over a bed wedge cushion, the lift sling strap lifted up off the spreader bar hook, resulting in Resident #1 falling to the floor with a 3 - 4 CM (centimeter) gash to the back of her head. Resident #1 was hospitalized on [DATE] with a subdural hemorrhage and intraventricular hemorrhage (a collection of blood that accumulates between the inner layer of the skull and the surface of the brain). On 9/26/25, Lift #1 was utilized for 6 residents that required a full body mechanical lift. The facility reported 8 residents utilized a full body mechanical lift as of 10/16/25. The facility also failed to appropriately utilize standing lift slings and communicate to staff regarding standing lift sling size for one of two residents reviewed for standing lifts (Resident #8). The State Agency informed the facility of the Immediate Jeopardy (IJ) on 10/16/25 at 5:12 PM. The Immediate Jeopardy to the residents' health and safety began on 9/26/25. The State Agency determined the facility removed the IJ from a K (pattern of deficiency with actual harm) to a G (isolated with actual harm) as of 10/17/25 through updated review of the full body mechanical lift manufacturer's user manuals, assessment of residents for appropriate sling size, staff education on appropriate use of the full body mechanical lift; education provided to maintenance personnel on lift inspection, and placement of a monthly lift inspection program. The facility corrected the IJ on 10/17/25 through the following:a. 10/16/25 lift slings were evaluated and all slings that did not meet standards of manufacturer recommendation were removed.b. 10/16/25 lift slings recommended by the manufacturer were obtained. c. The DON (Director of Nursing) and Maintenance Director reviewed the lift manual directions for proper use. The DON planned to conduct staff education for staff that operate the lifts.d. 10/16/25 the Maintenance Director reviewed the manufacturer recommendations for the brand specific full body mechanical lift and created a checklist to conduct monthly and as needed lift inspections. e. 10/16/25 at 5:30 PM the Maintenance Director evaluated all the facility lifts. f. 10/17/25 the DON provided staff education and full body mechanical lift and sling demonstration education. The DON created a Sling Size Guide Chart by weight (brand specific) for the full body mechanical lift and communicated each resident specific size of sling to be used with the full body mechanical lift. The Chart specified when transferring residents, when the resident is in the full body mechanical lift, the legs must be opened to provide a wide base to distribute the weight and prevent the lift from tipping over. If the open legs will not fit under the bed, close the legs only as long as it takes to position the lift over the resident and lift the resident off the surface of the bed. Reopen the legs when the legs of the lift are no longer under the bed. The facility reported a census of 48 residents.Findings include:1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 as rarely/never understood with a long/short term memory problem, unable to recall the current season, location of own room, staff names and faces, or that they are in a nursing home, and had severely impaired daily decision making. Resident #1 had upper and lower body functional limitations in range of motion and utilized a wheelchair. Resident #1 was dependent upon staff for chair/bed to chair transfers. The MDS listed diagnoses of non-traumatic brain dysfunction other Alzheimer's Disease, Alzheimer's Disease, seizure disorder, anxiety, and other chronic pain. The MDS noted Resident #1 had not had any falls since the prior assessment.The Activities of Daily Living (ADL) Function Care Plan dated 8/26/21 directed Resident #1 did not walk and to transfer the resident using a full body mechanical lift (Hoyer style lift will be referred to as a full body mechanical lift) with assistance of two staff. The Care Plan lacked direction to the staff of which full body mechanical lift to use, type or size of lift sling to use for transfer. The Transferring Section of the resident's Kardex (care guide) directed to use a full body mechanical lift with two staff and did not specify the type of lift of size of sling.A 9/04/25 Fall Assessment Tool documented Resident #1 scored 7, which indicated a moderate fall risk. A Facility Self Report filed with the Iowa Department of Inspection, Appeal and Licensing detailed the following Incident Summary:On 9/26/25 at approximately 10:35 AM the Director of Nursing (DON) heard over a Certified Nursing Assistant (CNA) call for a nurse STAT (immediately) to Resident #1's room. The DON ran to Resident #1's room and observed Resident #1 laying in the fetal position on her right side next to her bed, lying in between the full body mechanical lift and the wheelchair. Staff A, CNA supported Resident #1 back and Staff B, CNA applied pressure to the back of Resident #1 head. Staff B informed the DON there was blood coming from the back of Resident #1's head. The DON went to get the treatment cart and vital signs equipment. She instructed Staff C, Licensed Practical Nurse (LPN) to call for an ambulance STAT. The DON washed the back of Resident #1's head and noted a 3-4 CM gash. The DON applied pressure to stop the bleeding. Resident #1 was kept immobile until emergency services arrived at approximately 10:50 AM. The Emergency Medical Technicians (EMTs) placed a c-collar (cervical collar) to stabilize Resident #1 spine and the resident was transferred out to the hospital.A typed Facility Witness Statement for Staff A dated 9/26/25, untimed, revealed Staff A checked and changed Resident #1, put the lift sling under her, got the full body lift (lift #1) and lifted the resident up above the bed, hit the hump (wedge cushion) and Resident #1 fell. Investigation of the full body mechanical lift revealed there was a gap where the rubber closure part of the lift does not meet the hook and the lift sling strap slid out of the hook. A typed Facility Witness Statement for Staff B dated 9/26/25, untimed, revealed Staff B went in Resident #1's room, checked and changed the resident, put the sling under the resident, grabbed the full body lift and with Staff A hooked the sling to the full body mechanical lift. They raised Resident #1 up (from the bed) and started to pull the lift away from the bed. She was not sure how the strap came off (Lift #1), but Resident #1 fell straight to the ground. Resident #1 had long wedge cushions on her bed due to seizures, when Resident #1 bottom cleared the hump of the wedge, the strap (of the lift sling) came undone. A Fall Scene Investigation Report dated 9/26/25 documented Resident #1 sustained a fall at 10:35 AM which was witnessed by Staff A and B. The Fall Description Detail documented staff were getting Resident #1 up for lunch. She fell out of the sling and hit her head on the full body mechanical lift base with an injury of a gash on the back of her head 3-4 CM long. Under Factors Observed the Report documented the full body mechanical lift sling was not connected properly. Resident #1's Vital Signs at the time of the fall were temperature 97.6, pulse 86, respirations 20, blood pressure 140/97 (elevated) and oxygen saturation 90% (low). Resident #1 lay in a fetal position on her right side. Staff placed a pillow under her head and applied pressure to her wound. Emergency Medical Services (EMS) was called for transport to the hospital due to a head wound. Review of the Hospital Emergency Department (ED) to Hospital admission Progress Note dated 9/26/25 at 11:38 AM documented a Chief Complaint of Fall. The History and Physical documented a fall from a full body mechanical lift. The resident suffered a laceration on the back of her scalp. The Physical Exam documented a linear laceration across the back scalp 4 CM.The ED Note dated 9/26/25 at 12:00 PM documented Resident #1 arrived to the ED via EMS from the nursing home for a fall with head laceration. Per facility, the staff were getting the resident up from the bed to the chair using a full body mechanical lift, the strap was not connected appropriately. Because of this, the resident fell onto the ground from about 3 feet and hit her head on the bottom of the lift.A 9/26/25 1:18 PM Hospital Computed Tomography (CT, a medical imaging technique that uses x-rays to create detailed, cross sectional images of the body) of the head without contrast due to a laceration to the back of the head due to head trauma, moderate to severe showed documented findings of a right subdural hemorrhage measuring approximately 1-2 millimeters (MM) and a small amount of hemorrhage layering in the back horn of the right lateral ventricle (of the head) with a head laceration. A Major Injury Determination Form signed by the physician on 9/26/25 at 6:15 PM documented after reviewing the circumstances, injury and prognosis of the patient, the provider believed the injury sustained was a major injury. Review of CT of the head without contrast findings signed 9/26/25 at 6:29 PM documented increased right subdural hemorrhage. Recommend continued follow-up unenhanced head CT's. Increased layering intraventricular hemorrhage is present in the posterior horn of the right lateral ventricle (of the head). The Communication with Physician Progress Note dated 9/26/25 at 6:40 PM documented a telephone call was received from the hospital emergency department. They were trying to contact Resident #1's Power of Attorney (POA). They had repeated Resident #1 magnetic resonance imaging (MRI, medical imaging that uses strong magnets and radio waves to create a three-dimensional image of the body's internal structures) to the brain and found Resident #1 worsening with increased bleeding in her brain. A Communication with Physician Progress Note dated 9/27/25 at 4:00 AM documented the nursing home received a telephone call from the hospital regarding Resident #1's condition. Family had made the decision for palliative/comfort care and hospice would be coming to the hospital around 10 AM to assess and most likely admit Resident #1 to hospice care. A Hospital Post-Acute Discharge Report dated 9/28/25 directed Resident #1 to transfer back to the facility after a principal diagnosis of traumatic subdural hematoma and intraventricular hemorrhage with an order for hospice care. The admission Summary Note dated 9/28/25 at 12:50 PM documented Resident #1 returned to the nursing home alert, responsive and with facial grimacing with transfer from the stretcher to the bed. Vitals signs were temperature 97.1, pulse 112 (elevated), blood pressure 126/89 (elevated), oxygen saturation 93 % on 3 liters of oxygen per minute. Resident #1 returned with order for morphine sulfate to keep her comfortable. A Health Status Progress Note dated 9/30/25 at 2:51 PM documented Resident #1 admitted into hospice care. Observation on 10/16/25 at 9:39 AM revealed Resident #1 lay positioned to her left side in a low bed with the wedge cushions in place at the outer edges of the bed. On 10/16/25 at approximately 10:00 AM, the Administrator in Training (AIT) presented the spreader/hanger bar from full body mechanical lift #1 to show the gap between the cradle hook and the rubber stopper that held the lift sling strap. He reported they had sent pictures into the state office. Observation on 10/16/25 at 10:17 AM revealed a full body mechanical lift sling, gray with black piping, in Resident #1 wheelchair. Observation completed on 10/16/25 at 10:34 AM Staff D, CNA pushed full body mechanical lift #3 (brand specific) into Resident #1's room. Staff A and D placed the lift sling under Resident #1. Staff D crossed the straps between Resident #1's legs, then Staff A and D proceeded to attach the top sling straps and bottom sling straps to the lift hooks. Staff A raised Resident #1 from the bed without stopping the lift once the resident buttocks cleared the bed to check the placement of the straps before pulling the lift away from the bed. Staff A backed Lift #3 (brand specific) away from the bed with Lift #3 legs in the narrow position. Staff A did not try to position the Lift #3's legs to the open position before lifting Resident #1 from the bed. Staff A moved Resident #1 in Lift #3 in the narrow leg position over the wedge cushion on the bed away from the bed approximately 4 feet up off the ground, turned the lift and then opened Lift #3 legs to the wide position just before sitting Resident #1 in the wheelchair. Further observation revealed Staff A and D utilized Lift #3 (brand specific) full body mechanical lift and utilized the gray and black lift sling which was not a brand specific sling for Lift #3. During an interview on 10/16/25 at 10:41 AM, Staff A voiced the DON provided staff education on using the full body mechanical lift the same day as Resident #1's incident (9/26/25). If they couldn't make it that day, then they had to come in the next day to complete the education. They went over the steps of applying a lift sling and the steps to use the full body mechanical lift. They did the review and signed some papers. She doesn't recall if there was any demonstration or hands on training. Maintenance went through and looked at all the full body mechanical lifts. The full body mechanical lift (Lift #1, brand specific) that had been used for Resident #1 had an issue with one of the rubber stoppers where the sling connected at the top. Full body mechanical lift #1 was taken off the floor immediately. Staff A reported she didn't know what size sling each resident was supposed to use. She always put the sling up to the resident's body and looked at it to see if it just looked right. Staff A stated she didn't know what slings could be used with each full body mechanical lift. During an interview on 10/16/25 at 10:08 AM Staff E, CNA explained they only had lift slings for the standing lifts and the full body mechanical lifts. All full body lift slings could be used with the mechanical full body lifts. When queried how she knew what size of lift sling to use for the full body lift, Staff E explained she just held the sling up to the resident's body to gauge what size sling the resident needed. She stated there were different types of slings but they could all be used with the full body mechanical lift #3. She wasn't aware of any direction given by nursing management regarding the size or types of slings that could be used with the full body mechanical lifts. During an interview on 10/16/25 at 11:01 AM, Staff A explained the day of Resident #1 incident, when Resident #1 went over the bed wedge cushion, she was not sure if she hit the cushion just right, but Resident #1 was on the ground right after that. They had to raise Resident #1 high enough in the bed to go over the wedge cushion. She never noticed the gap between the hook and the rubber stopper at the top of the full body mechanical lift #1 before. The lift sling strap had to click into the stopper. Right after the incident she knew it wasn't right. The sling strap didn't click into position on that side. The strap came off the full body mechanical lift at the top hook. Staff A thought when Resident #1 hit the hump (wedge cushion) as the full body mechanical lift only goes so high, the sturdiness of the strap went up and over the stopper. It all happened so fast. Resident #1 fell out of the sling to the floor with her head laying on the leg of the full body mechanical lift which caused a head injury and her feet were laying toward the bed. Staff A recalled they had used a blue mesh sling with purple piping. It wasn't the kind of sling that crossed under the resident's legs. On 10/16/25 at approximately 11:20 AM the DON provided a blue mesh sling with purple piping and reported it was the type of sling that Resident #1 used the day of the incident. The DON provided a (Brand Specific, Universal) Patient Sling Reference Guide that stated their slings could be used with any competitive floor-style lift. The blue mesh sling with purple piping had a Reorder Tag #13223M. The Universal Patient Sling Reference Guide Under Lift #1 and #13223M had a dash in the column. Interview completed on 10/16/25 at 11:48 AM Staff H, Registered Nurse (RN) reported most of the aides had worked at the facility a while so they just knew what size sling each resident took. If not, they just put the sling up to the resident's body to look for the fit of the sling. She reported they had extra lift slings in the shower rooms. Inspection of the 100-hallway shower room full body mechanical lift slings revealed three full body lift slings two with worn labels which were unreadable as to the brand of sling, and one full body lift sling with the tag cut off. The slings were universal slings. Staff E also stated that they had extra slings in the middle closet. Inspection of the middle closet revealed no full body lift slings.During an interview on 10/16/25 at 12:57 PM the Administrator in Training (AIT) reported he thought there were there three full body mechanical lifts in use at the time of Resident #1's incident. They had a full body mechanical lift for the unit and one on each wing (100 and 200 wings). He wasn't sure if all the full body mechanical lifts were the same (brand).During an interview completed on 10/16/25 at 12:59 PM, the Maintenance Director reported he had inspected the full body mechanical lift #1 and found the malfunction after the 9/26/25 incident. Lift #1 was sitting in the maintenance room out of service since that time. Per the manufacturer, they are to check the rubber stoppers every year. Observation of Lift #1 spreader/hanger bar rubber stopper assembly revealed the rubber stopper was bent which created over a 1 CM gap between the cradle hook and stopper. The Maintenance Director thought the stopper could possibly bend if a lift sling got caught on it, but unknown if it got bent or if it came that way. He inspected the full body mechanical lifts by checking the spreader bar, boom, leg adjustment, controls/remote. He inspected the entire lift, but he just started keeping records on the lift inspections last month. He provided a Lift Monthly Cleaning and Maintenance Log which documented full body mechanical lift #1 was inspected on 9/22 (no year listed) by Staff F, Maintenance with a note the lift was oiled and cleaned. The Monthly Cleaning and Maintenance Log showed full body mechanical lift #3 removed from service on 9/23/25 due to missing a clip and full body mechanical lift #4 removed from service due to missing a release. The Log lacked documentation showing full body mechanical lift #1 had been removed from service or when full body mechanical lift #3 had been placed back in service. The Maintenance Director provided a Purchase Invoice showing full body mechanical lift #1 (brand specific) had been purchased 9/23/22.Observation on 10/16/25 at 1:20 PM revealed lift #1 (brand specific) sitting in the maintenance room with a hospital bracelet hanging from the mast with #1 on the bracelet. The Maintenance Director stated each lift had a numbered hospital bracelet to identify which lift it was. Lift #1 also had a bright green sticker on the boom titled November 2022 to indicate when the lift had been placed in service. Interview completed on 10/16/25 at 1:27 PM Staff B reported she and Staff A assisted Resident #1 with the full body mechanical lift on 9/26/25. Resident #1 had wedge cushions on the sides of her bed that connect under the mattress so the cushions were not removable. Resident #1 started going up (in lift #1) as soon as her bottom went over the wedge cushion, the sling strap came undone. She did not see the strap go. She was the running the full body mechanical lift remote and pulling the lift back away from the bed. All four straps were connected when they started to lift Resident #1 up from the mattress. Resident #1 laid on the floor on her right side. If were looking at the full body mechanical lift, her head would have been laying on the right leg of the lift with her feet closer to the bed. They had used a type of lift sling that did not cross under the legs. Staff B explained she immediately went to the resident to cushion Resident #1's head from the leg of the lift. As soon as she put her hand under Resident #1's head, she felt blood and called for a nurse right away. It wasn't a lot of blood but Resident #1 was definitely bleeding. Resident #1 didn't let out any verbal response but she could not respond verbally. Her face was grimacing. The sling was a blue mesh full body sling with purple border that didn't cross between the legs. They were using the solid white lift, but not sure on the exact brand. At the top where the straps connect at the base there was a gray rubber circle they push the strap over to secure the strap. That circle touches all points of the loops. After the incident they looked on the strap that came undone, the circle didn't contact that loop. There was a gap where the strap could come off. She had never noticed it before until she looked directly at it after the incident. She thought maintenance inspected the full body mechanical lifts. The lift was pulled from the floor. Staff B verified there were 6 total residents on the North hallway that would have used that full body mechanical lift (lift #1) that day (9/26/25). Interview on 10/16/25 at 2:02 Staff C, LPN explained she was at the nurses' desk. It came over the walkie for a nurse to come to Resident #1 room stat (immediately). She couldn't run so the DON took off. They thought Resident #1 was having a seizure. She went down to Resident #1 room and she couldn't open the door. The bathroom and the room door were locked together so the DON directed her to go call an ambulance right away. Staff C asked Staff A, how bad is Resident #1? Staff A responded she would have to talk with the DON. Staff C asked the DON what she was calling an ambulance for, and the DON said head injury. The DON took care of everything .They were all concerned about Resident #1. She felt sometimes the aides got busy talking to each other and Staff A and B had said for some time the lift straps had been coming off the full body mechanical lift hooks. Staff C thought if the lift wasn't working correctly, then why were they putting a resident up in the lift. She said several aides had made comments that they had told management about the issue and they weren't doing anything. There was a towel on the back of Resident #1 head when EMS took Resident #1 out on the gurney. During an interview on 10/16/25 at 2:14 PM Staff E reported there was an issue with the full body mechanical lift sling straps coming off the lift hooks, especially if there were no stoppers to keep the straps from coming off. She had noticed the issue probably two months ago when she came out of the unit and started working on the 100 and 200 wings. She stated especially if the slings were too large for the resident. The sling straps would lift off the hooks. They had to be looking at the straps and getting them quick to get them back in place before the resident was raised up in the lift. She had reported the issue to her charge nurse several times, but didn't recall which nurse she reported too. It was a known issue. Interview on 10/16/25 at 2:19 PM Staff C verbalized she had reported the issue regarding the lift sling straps coming off the full body mechanical lifts to the DON, the Maintenance Director and the AIT. On 10/16/25 at 2:30 PM Staff D voiced she had never had any issues with the full body mechanical lift sling straps coming off the lift, but explained the lift sling straps will go up but they don't come off the hooks and then when they raise the resident, the straps will go bam and seat back down on the lift hooks and the resident will kind of jerk down in the lift. Interview completed 10/16/25 at 2:43 PM Staff F, Maintenance verified full body mechanical lift #1 was out of commission. He was not sure why, but it was out of commission. He reviewed the Lift Monthly Cleaning and Maintenance Log and verified he had inspected the full body mechanical lift #1 on 9/22/(no year). He reported he oiled and cleaned lift #1. He takes all the hair out of the wheels and looks the lift over. Staff F inspected the spreader bar removed from full body mechanical lift #1 flipping it over and inspecting it several times, then stated the spreader bar was normal. Staff F voiced if it was the spreader bar from Lift #1, then yes it was the one he inspected 9/22. He stated he hadn't received any real training in how to inspect the full body mechanical lifts. He had never had anyone tell him there were any issues with the lift sling straps coming up off the hooks of the full body lifts. A second interview completed 10/16/25 at 2:48 PM the Maintenance Director voiced he never had anyone tell him there were any issues with the lift sling straps coming up off the lift hooks. There were maintenance slips at each nurses' station and the timeclock that they could place maintenance request in for that. He had not received any maintenance slips regarding that issue. During an Interview on 10/16/25 at 2:55 PM the DON reported she was in her office at her desk when a CNA came across the walkie for a nurse to Resident #1 room with run! Please run! She ran down to Resident #1's room and saw Resident #1 on the floor with Staff B's hand on the back of Resident #1 head with blood on Staff B's hand. Resident #1 was laying on her right side with her head on the right leg of the full body lift and her legs toward the base of the bed. She was wedged between the wheelchair and the full body mechanical lift. She ran down the North hall to get the treatment cart and the vital sign equipment. Staff C was in the med room getting Lorazepam for Resident #1. She told Staff C to call an ambulance. She cleaned Resident #1 head and found a 3-4 CM laceration. She applied pressure to Resident #1's head until EMS arrived. At 3:02 PM the DON reviewed the Brand Specific Universal Patient Sling Reference Guide provided by the facility. The DON reviewed under the full body mechanical Lift #1 (brand specific) the guide showed a dash indicating the company did not make a sling for that type of lift. She confirmed the label on the sling with sling size 13223M used for Resident #1 was not shown on the Patient Sling Reference Guide for Lift #1 (brand specific). When queried on how the CNA staff knew which slings and size of slings to use with specific lifts, the DON replied the CNA's would not know that information and the Maintenance Director ordered all the lift slings. She couldn't answer how the aides would know what size of sling or which sling to use with each lift. The DON further explained the only thing that made sense was Resident #1 was not lifted high enough to clear the bumper wedge cushion on the side of the bed. It released the tension on the sling which caused the strap to become disconnected from the full body mechanical lift. She had completed CNA education on how to use the full body mechanical lift on 9/26/25 after the incident. The DON confirmed they did not identify Resident #1 was not in an approved sling for full body mechanical lift #1 (per the brand specific Manufacturer User Manual) as part of the facility investigation. Lift #1 was on the North hallway on 9/26/25 and there were probably 7-8 others residents that used lift #1 that day. She took over in January 2025 and was under the understanding the lift had been used for a few years. Staff A had mentioned when she gave her statement that the full body mechanical lift straps come off really easily and then the Administrator looked at Lift #1 spreader and said it didn't look right. At 3:08 the DON denied any staff had informed her there were issues with the full body sling straps lifting up off the hooks prior to 9/26/25. The DON couldn't speak to what the facility full body mechanical lift policy directed on the use of appropriate lift slings and size of lift slings. She was not aware of the manufacturer's guidance on appropriate slings or size of sling. Interview on 10/16/25 at 5:02 PM, the Maintenance Director reported he had reviewed the (Brand Specific) Universal Patient Sling Reference Guide. He explained the dash in the column under Lift #1 only meant the company didn't make a (universal) sling for that type of full body mechanical lift. He wasn't aware the (Brand Specific) Lift #1 Manufacturer User Manual specified which lift slings were to be used with the #1 full body mechanical lift.Interview completed on 10/20/25 at 10:09 AM Staff L, CNA explained she had stopped at the facility on Friday, 10/17/25 and there were sling size charts that specified the sling size for each resident in the supply closet and in the nurses' station. She voiced she received full body mechanical lift education and learned that the leg base was to be in the wide position when a resident was lifted in the lift and that the brakes were not to be used when lifting/lower a resident. Prior to this they had lifted residents in the full body mechanical lift with the legs in the narrow position and had locked the brakes on the lift when raising and lowering residents.Interview on 10/20/25 at 10:16 AM Staff G, CNA stated prior to 10/16/25 the facility didn't have tags or anything to indicate what size lift sling a resident needed. She just based on how big she thought the resident was. If the lift sling seemed too big, she would switch it out for different sling. She had been taught not to lock the brakes on the full body mechanical lift as it can put off the center balance and tip the lift. They would have the lift legs narrow on the lift, then once they were away from the bed they would open the legs wide just before they would move the lift by the chair. During an interview completed 10/21/25 at 12:29 PM, the DON reported the staff were complacent in not ensuring they had cleared Resident #1 over the bumper wedge cushion of the bed and moved too fast. They were experienced CNA's. The DON voiced if they would have slowed down, they would have caught the strap from lifting off the hook. She expected the staff to slow down, have two staff, clear the bed and check the lift sling straps to ensure the straps are in the cradle hook and tight before moving the resident from the bed to the chair, or chair to bed. During an interview on 10/21/25 at 12:59 PM the Administrator reported they had implemented a lot between the staff education, new slings being ordered, using the manufacturer's guides and implementing the monthly maintenance program. Nursing also talked about implementing regular observations as part of the quality assurance program. He expected the staff to slow down and look at the resident when they are lifting them in the lift and to use the tools to ensure the resident is properly placed in the right sling, right lift and paying attention that the lift sling straps are securely in the hooks. If staff notice something is not right with a lift, he expected the staff to inform maintenance so the lift can be taken out of service. The Full Body Mechanical Lift #1 (Brand Specific) Service Part Manual HPL 500 Model under Statement of Intended Use directed Lift #1 HPL 500 lift incorporates a 6-point cradle, loop style spreader bar, as standard and is designed to be used in conjunction with the specific Lift #1 Product professional range of slings. The examples of the slings suitable for use with the device are listed as follows:1. Brand Specific Quickfit Sling2. Brand Specific Access Sling3. Brand Specific Full Back Sling4. Brand Specific Long Seat Sling5. Brand Specific Quickfit Deluxe Xling6. Brand Specific Comfort SlingThe Full Body Mechanical Lift #1 (Brand Specific) Maintenance Schedule and Daily Checklist listed the company stro[TRUNCATED]

Based on observation, staff interview, and policy review, the facility failed to ensure proper food handling practices and further failed to ensure the kitchen and equipment was kept clean and sanitary to reduce the risk of contamination and food-borne illness. The facility reported a census of 47 residents. Findings include: On 4/7/25 at 9:55 AM during the initial tour of the facility kitchen, the following sanitation concerns were noted relating to the potential risk of contamination and food-borne illness: a. The walk-in cooler was noted to have 2 large trays of white rice on a shelf at the back of the cooler that were not covered or dated. b. The 2 large trays of white rice were located in the walk-in cooler on a shelf beneath a ham covered with plastic wrap, a large beef roast in a plastic cover and roast beef slices in a foil pan. c. The walk-in freezer was noted to have a plastic tub of chicken pot pie filling with the plastic wrap pulled back and the chicken pot pie filling exposed to the cold with frost/ice covering the top of it. On 4/7/25 at 9:55 AM during the initial tour of the facility kitchen, the following issues were noted with cleanliness of the area: a. The stove, warmer, refrigerator, and general equipment in the kitchen area was dirty on the outside. b. The inside of the two door refrigerator was dirty with debris, food splatters, and crumbs. c. The inside of the single door freezer was dirty with debris and crumbs. d. The ice machine in the hall outside the kitchen was noted to be dirty and had a lot of lime build up down the front of the machine and around the door. The inside rim of the ice machine door was noted to have a darker moist lime around the seal and close to the ice itself. The Maintenance Director provided the Ice Machine Cleaning Log which indicated the machine had been cleaned on 4/2/24, 8/5/24, and 1/21/25. Review of the Cleaning and Sanitizing General Guidelines for the ice machine dated 5/17, stated the machine was to be cleaned and sanitized every 6 months for efficient operation. It further stated if the ice machine required more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. The Dietary Director supplied a copy of the kitchen cleaning checklist which included: a. Scrub down equipment surfaces (prep tables, oven, flat-top, steam wells, sinks, etc). b. Sweep the kitchen. c. Take out all trash and replace trash liners. d. Mondays - check dates and clean out the stand-up cooler. Scrub and sanitize the bottom area. e. Thursdays - sweep and mop walk-in cooler and check dates. In an interview on 4/9/25 at 12:54 PM, the Dietary Director stated it was the expectation food be covered when placing it in the refrigerator or freezer and that staff were not to place food products under thawing meats. In an interview on 4/9/25 at 12:55 PM, the Dietary Director acknowledged the staff were not following the cleaning schedule he had posted for them and that the kitchen lacked cleanliness. He stated it was the expectation the staff follow the cleaning list on a daily and weekly basis as directed. In an interview on 4/9/25 at 1:05 PM, the Maintenance Director reported the ice machine was to be cleaned every 6 months but he cleaned it anywhere from 3-6 months. He acknowledged there was a lot of lime deposit on the ice machine and stated it was last cleaned in January. A facility provided policy titled Cleaning Schedules, last reviewed 3/5/24, stated: a. All staff will follow the cleaning schedules. b. All staff will clean and sanitize what they use daily. c. Meat is not to be mixed in with other frozen products. Place all fresh, raw meat on the bottom shelf. d. Morning and night cooks were to: Keep worktable cleaned and sanitized. 1) Keep stove and grill clean. 2) Wipe all spills inside and out of the stove, floor and counters. 3) Clean trays out on the stove. 4) Clean and sanitize three compartment sinks after each shift. 5) Keep spice shelf straightened and wiped off. 6) Make sure your equipment is kept cleaned and sanitized. 7) Send can opener through the dishwasher daily. 8) When using any equipment, clean, and sanitize after use. 9) Tell the Dining Services Director about any repairs that need to be done on any equipment. 10) Mop everyday. 11) Everyone helps clean the walk-in freezer, walk-in cooler, storeroom and janitor closet. 12) Clean stove when scheduled, clean the top, burners, grill, shelf and back after every meal. Pull the trays out after every meal. 13) Wipe off all food bins. 14) Wipe down outside of combi oven daily and run self cleaning as needed. 15) Clean the oven when scheduled. Wipe off the bottom of the oven. A facility provided policy titled Storage of Food and Food-Items, last reviewed 3/5/24 stated meat is not to be mixed in with other frozen products. Place all fresh, raw meat on the bottom shelf.

2. The MDS dated [DATE] for Resident #19 revealed a BIMS of 99 indicating the interview was not able to be completed. The MDS further revealed the resident had diagnoses including Alzheimer's disease and depression. The EHR for Resident #19 included the following physician order: a) Sertraline 25 mg daily for depression The Care Plan for Resident #19 revised 4/6/21 directed staff to administer Sertraline as ordered by the physician and to monitor and document side effects and effectiveness. On an annual GDR recommendation for Resident #19's Sertraline dated 9/30/24, the nurse assessment requested the current dose not be changed. The GDR recommendation lacked a rationale from the provider to continue Sertraline at the current dose. The GDR recommendation was signed by the provider 10/10/24. No other GDR recommendations regarding Sertraline were located in Resident #19's EHR in the past year. During an interview 4/9/25 at 8:16 AM, Staff A, Registered Nurse (RN) revealed a rationale for the continued dose of Sertraline without a rationale for Resident #19 had not been written by the provider because he was the doctor. During an interview 4/09/25 at 8:44 AM the Director of Nursing (DON) revealed she was not able to locate rationales for the continuation of the GDR recommendations and she was not sure of the expectation. Review of the facility policy titled Pharmacy-Consulting, reviewed 2/14/25, revealed the attending physician must review pharmacy concerns/noted irregularities and provide recommendations. If the physician does not follow the recommendations of the consulting pharmacist, the physician must document clinical rationale as to why. Based on record review, staff interview, and policy review, the facility failed to ensure a psychotropic medication (a medication that affects a person's mental state) gradual dose reduction (GDR) was attempted or declined with a physician rational for 2 of 4 residents reviewed (Resident #19 and #25). The facility reported a census of 47 Residents. Findings included: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #25 revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. It included diagnoses of Alzheimer's disease, heart failure, depression, dementia, diabetes, hypertension, sleep apnea, and anxiety disorder. It also revealed the resident was independent with eating, toileting, personal hygiene, and transfers but required moderate assistance with bathing. The Electronic Health Record (EHR) included physician's orders for: a) Seroquel 12.5 milligrams (mg) daily related to Alzheimer's disease with late onset b) Sertraline 50 mg; give 1.5 tabs (75 mg) daily for depression The EHR included an order dated 1/2/25 to monitor resident every shift for increased signs and symptoms of depression, assess possible reasons why and if resident is feeling depressed notify the physician if not improving. The EHR also included an order dated 1/20/25 to monitor every shift for targeted behaviors of Seroquel including increased agitation, being rude to table mates, and refusing showers. Notify the physician if continuously noted. The Care Plan dated 12/4/24 directed staff to administer psychotropic medications as directed by the physician, and to monitor and document for effectiveness and side effects. An annual GDR for Sertraline dated 2/12/25 had no provider response to the request and was signed by the provider on 3/13/25. A GDR for Seroquel dated 3/25/25, the nurse assessment indicated the resident had done well on the medication but did not recommend a change at this time. The provider agreed with the nurse assessment and stated no change. The request was signed by the provider on 4/7/25. No other GDR's were located in the resident's EHR in the past year.

Based on observation, record review, staff interview, and policy review, the facility failed to document oxygen tubing changes as ordered to protect against potential infections for 1 of 1 residents reviewed on oxygen (Resident #2). The facility reported a census of 47 residents. Findings Include: The Annual Minimum Data Set (MDS) assessment dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS revealed resident's diagnoses included fibromyalgia, anxiety, venous insufficiency, atrial fibrillation, heart failure, acute embolism and thrombosis, pulmonary hypertension, myocardial infarction, dyspnea (shortness of breath), pneumonia, and dependence on supplemental oxygen. The resident was coded as independent for eating, and requiring maximal staff assistance for toileting, bathing, personal hygiene, and transfers. The MDS documented resident was short of breath with exertion and used oxygen. In an observation on 4/8/25 at 1:41 PM, an oxygen concentrator was noted in Resident #2's room. The concentrator was set to 3 liters/minute and was being administered to the resident via nasal cannula. The oxygen tubing was not dated. An observation on 4/8/25 at 2:05 PM, with the Director of Nursing (DON), revealed the oxygen tubing for Res #2's oxygen concentrator was not marked with a date of the last change. The DON stated she had seen Resident #2's oxygen tubing on the floor in the dining room last Thursday or Friday (4/3 or 4/4), so she picked it up and threw it away. She asked the staff to get her a new one. She felt the staff may have forgotten to date the new tubing. We then went and looked at Resident #46's and Resident #48's oxygen tubing and neither of them were dated when changed either. The Care Plan dated 4/8/25 directed staff to ensure the resident had oxygen on at 3 liters continuously even in the bathroom. A Physician Order dated 2/5/24 was received for oxygen at 3 liters per nasal cannula continuously related pulmonary hypertension and pneumonia. A Physician Order dated 1/26/24 was received to change the oxygen tubing and accessories on the 15th of each month. Review of the treatment administration record (TAR) for the previous 6 months revealed Resident #2 did not have her oxygen tubing signed as changed 11/15/24, 2/15/25, and 3/15/25. In an interview on 4/8/25 at 2:12 PM, the DON stated it was the expectation the oxygen tubing be changed on the 15th of every month by the night shift and it be signed on the TAR when completed. She stated going forward, she plans to have staff date the tubing when changed as well. Review of the facility provided policy titled Nebulizer and Oxygen Equipment last reviewed on 2/14/25 indicated the oxygen tubing, and masks were to be changed at least monthly. Documentation of changing oxygen equipment was to be maintained in the treatment record.

Based on observation, clinical record review, facility policy review, and staff interviews, the facility failed to provide appropriate supervision while transporting a resident in the wheelchair that resulted in injury for one of three residents' reviewed. (Resident #1). The facility reported a census of 44 residents. Findings include: The MDS (Minimum Data Set) dated 10/10/2024 revealed Resident #1 had severe cognitive impairment, required substantial/maximum assistance of staff for transfers from one surface to another, and used a wheelchair for locomotion. The resident had diagnoses including Alzheimer's disease, osteoarthritis and hypertension. Resident #1's Care Plan revealed the resident required assistance with ADL's (activities of daily living) related to cognitive decline, created on 2/2/2021. The Care Plan instructed staff to transfer the resident with an E-Z stand (mechanical) lift, provide her with a wheelchair for locomotion, and allow her to self propel. On 8/2/2022 the Care Plan identified the resident had a fall risk related to incontinence, impaired daily decision making skills, decreased cognition, and pain. On 10/16/2024 the Care Plan instructed staff to assist the resident to sit in the dayroom recliner for closer supervision. On 11/2/2024 the Care Plan revealed the resident had a fall that resulted in a facial injury and fracture. It directed staff to provide a mechanical soft diet and nosey cups (a drinking cup with a cut out on one side), administer antibiotic Cephalexin four times a day for ten days, and monitor the bruises. On 11/4/2024 the Care Plan directed staff to remove sutures on top of her nose. The resident's nurse Progress Notes included: 11/2/2024 at 8:30 A.M., Staff D, LPN (Licensed Practical Nurse) responded to a call for help from the memory care unit. Staff D observed Resident #1 on the floor. Staff D learned the resident sustained a fall while being transported to the dining room table in her wheelchair. The resident's foot got caught, she fell forward and hit her head and nose on the table. Staff D applied pressure to the wound while Staff A, RN (Registered Nurse) called the family. EMS (Emergency Medical Services) transported the resident to the ER (emergency room ) and she returned at 12:30 P.M. with orders to monitor the right and left orbital bruises until healed, and administer Cephalexin for ten days. 11/3/2024 - the physician ordered a mechanical soft diet with nosey cups due to the resident's facial fracture. 11/4/2024 - statements were obtained and investigation completed. Resident #1 got her foot caught while being transported approximately four feet to the table. The resident fell forward, hitting the table. 11/14/2024 - stitches removed, area healed without drainage. The facility Fall Scene Investigation Report initiated 11/2/2024 revealed Resident #1 fell at 8:30 A.M. while being placed closer to the table. The resident's foot got caught in the wheelchair and the resident fell forward, hit her nose on the table and landed on the floor on her side. The resident sustained a laceration to the nose. Staff determined the immediate intervention for this fall was to add foot pedals during transfers. Resident #1's Emergency Department note dated 11/2/2024 at 9:26 A.M. included: Chief complaint: Fall and facial laceration (oozing complex laceration to bridge of nose). Patient fell with forward lunge out of the wheelchair approximately one hour prior to arrival. She was reportedly in a wheelchair when a wheel got stuck while the staff pushed it, causing the resident to fall forward out of the wheelchair. Physical Exam: Raccoon eyes, contusion and laceration present. There is a V-shaped, 4 cm (centimeter) laceration over the bridge of the nose and bruising to bilateral orbits and forehead. There is bruising and swelling over bilateral knees. CT findings: Comminuted (a bone that is broken in at least two places), displaced fracture of the nasal bone with soft tissue swelling. Associated fracture of the anterior (nearer the front) nasal septum. ED staff sutured the resident's 4 cm. nasal laceration with 10 sutures, and applied antibiotic ointment and a bandage. The resident discharged with orders for an antibiotic, pain medication, fall precautions, no straws, no blowing the nose, and ice to the area up to four times a day for pain control. The Wound - Weekly Observation Tool dated 11/2/2024 included: 1. Left Eye - Bruise. 50 mm (millimeters) length and 70 mm width. Initial assessment. 2. Right Eye - Bruise. 50 mm length and 85 mm width. Observation on 12/2/2024 at 9:20 A.M. revealed Resident #1 seated at the dining room table with activity staff. The resident sat in a wheel chair with foot pedals and a foot buddy (cushion). The resident wore gripper socks, glasses, and appeared alert and interested in the activity. The resident's face had a healed nasal laceration and no bruising. Staff G and Staff H, C.N.A. removed the resident from the table, transported her to the lounge, and transferred her using a stand up mechanical lift from the wheelchair to a recliner. Staff explained the procedure and the resident remained calm. The resident, nonverbal at the time of the observation, had no response to questions. On 12/2/2024 at , Staff F, RN (Registered Nurse), DON (Director of Nursing) reported Resident #1 fell on Saturday, 11/2/2024. Staff F received a call regarding the fall and she instructed staff to send the resident to the ER. Staff F learned Staff G, C.N.A. pushed the resident in the wheelchair without foot pedals. The resident fell forward, hit her face on the table. Staff wrote statements and Staff F did an investigation on Monday, 11/4/2024. Staff G indicated the resident normally self propelled, but she knew she should have applied the foot pedals. Staff F put out an education for all staff to read and sign regarding the need for foot pedals with all residents in wheelchairs. If the resident self propels the wheelchair, the foot pedals need to be off to the side. Staff G received education and a one day suspension, and could lose her job if she had another same incident. Orientation to the facility always includes transfer assistance. On 12/2/2024 at 9:30 A.M., Staff G, C.N.A. reported working for two years at the facility. On 11/2/2024 the resident sat in the wheelchair about three feet from the dining room table. Staff G positioned the resident in that spot after she got her up and ready for the day. Normally, the resident would self propel the wheel chair. When breakfast began, Staff G moved the resident closer to the table without foot pedals. Normally, the resident would move her feet, however she must have gotten her foot stuck. The resident leaned forward, hit her face on the table. Staff G pulled the wheelchair away from the table so she could attend to the resident. Staff H, C.N.A. grabbed a wash cloth to place on the resident's bleeding nose, and Staff A, RN came from the medication cart to assist. Other staff came to assist, the resident transferred to the ER and returned with sutures. Staff G wrote a statement and received education regarding the need for foot pedals on all wheelchairs during transport. Staff G also received a one day suspension without pay. Staff G learned during C.N.A. classes the need to apply foot pedals when transporting a resident in a wheelchair. On 12/2/2024 at 9:50 A.M., Staff A., RN reported working on 11/2/2024 when Resident #1 fell . Staff A heard the resident fall as she passed medication nearby. Staff A saw Staff G push the resident forward, the resident hit her nose on the table and fell out of the wheelchair. Staff G reported the wheelchair had no foot pedals, and resident got her foot caught, twisted it, and fell forward. Now, they make sure foot pedals are always used. If a resident self propels the wheelchair, the foot pedals are off to the side. Staff F put up a form for staff to read and sign regarding the use of foot pedals. In the past, Resident #1 would self propel the wheel chair around the unit. On 12/2/2024 at 10:20 A.M., Staff B, C.N.A. reported working on 11/2/2024 when Resident #1 fell . Staff B sat at the dining room table assisting another resident with breakfast when Staff G pushed the resident to the table. Staff B heard a loud thud and the resident said ouch when she landed on the floor. Staff B grabbed a towel and applied it to the resident's nasal laceration. Staff B knew to always use foot pedals when transporting residents. Staff received re-education after the incident. On 12/2/2024 at 10:00 A.M., Staff H, C.N.A. reported she did not work in the memory unit on 11/2/2024. Since Resident #1's incident, they received education regarding the use of foot pedals. Staff H learned during C.N.A. class that foot pedals were required when transporting a resident. Resident #1 could self propel the wheel chair and enjoys wandering around the unit. On 12/3/2024 at 10:30 A.M., Staff C, C.N.A. reported working full time in the memory care unit on the night shift. Resident #1 enjoys scooting around the unit in her wheel chair, and often carries a baby doll. Staff need to have foot pedals on Resident #1's wheelchair because she puts her feet on the floor and attempts to stop staff from pushing her. Even with foot pedals, the resident will attempt to put her feet on the floor. The resident now has a foot buddy on the wheelchair. After the resident's fall, staff received education regarding the facility policy that all wheelchairs must have foot pedals if you are transporting a resident. On 12/2/2024 at 11:00 A.M., Staff D, LPN reported working on 11/2/2024 when Resident #1 fell . Staff D responded to a call for assistance in the memory care unit. Staff D observed the resident on the floor with Staff G holding a wash cloth over the resident's nose. Staff D took Staff G's place and comforted the resident while other nursing staff called the family and physician. After the incident, all nursing staff received education regarding the need for foot pedals on all wheelchairs at all times. According to the facility Progressive Discipline Notification, Staff G received a written discipline signed on 11/4/2024, related to pushing a resident without foot pedals that resulted in the resident falling and hitting the table and floor. The resident received multiple facial fracture. Staff G received education regarding the need for foot pedals, and another incident will result in disciplinary action up to termination. Staff G served a one day suspension without pay on 11/11/2024. The facility Wheelchair Policy dated May 1, 1997 and reviewed February 1, 2024 included: Policy: to give guidance to employees when assisting residents in wheelchairs. 1. Resident will be assisted in wheelchair correctly and safely. 2. Staff will assist resident without strain or injury to self or resident. 3. Staff will explain to resident safety measures: a. Place hands on arms of wheelchair or in lap. b. Place feet on wheelchair pedals. Residents are not to be pushed in wheelchair without resident's feet on pedals. Any resident who would like at times to self propel, may fold pedals in an upright to do so. Only resident's who always propel themselves in the wheelchair, may be without foot pedals on their wheelchair. c. If foot pedals are missing, staff shall obtain foot pedals for wheelchair. d. If foot pedals are unavailable for any reason, residents shall self propel wheel chair until able to obtain. e. Interventions shall be implemented if residents are unable to safely keep feet on wheel chair foot pedals. f. If staff are noted pushing residents without foot pedals, discipline/education shall be given up to and including termination. 4. Do not push/pull residents backwards down the hallway. You may back residents out or in the doorways. 5. Do not push wheelchairs swiftly. 6. Observe for other residents, staff, and visitors when exiting a hallway or turning a corner.

Based on clinical record review, staff and resident interviews, and observations the facility failed to follow their policy and procedures regarding intravenous therapy for 1 of 5 residents reviewed (Resident #2). The facility reported a census of 44 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had diagnoses which included pneumonia, septicemia, and diabetes mellitus. The resident had a Brief Interview for Mental Status score of 13 out of 15, which indicated she had intact cognitive ability. The resident received daily antibiotics via a peripheral inserted central catheter (PICC line). Review of the Care Plan dated 10/17/24 informed the staff the resident had dehydration and required fluid maintenance related to pneumonia. The Care Plan directed the staff to administer intravenous antibiotic therapy once daily for severe sepsis. Review of a Progress Note dated 11/3/24 at 9:00 pm revealed Staff E-RN attempted 3 times to place a peripheral intravenous line in Resident #2 as requested by Staff F-RN/Director of Nurses. The Progress Notes on 11/3 at 11:40 pm revealed Staff E-RN could not administer the ordered antibiotic via the PICC line due to the base of the PICC port leaking blood after she changed the resident's PICC line dressing. The notes indicated Staff E had difficulty removing the dressing as it was adhering/sticking too strongly. Staff E documented she was able to tape the base of the port to prevent leaking and would continue to monitor the line. During an interview with Staff E-RN on 12/3/24 at 9:00 am, Staff E stated she worked the night shift from 6 pm-6 am 11/3-11/4/24 and was responsible for the administration of the IV antibiotic for Resident #2. Staff E indicated between 8-9 pm on 11/3 she changed the resident's PICC line dressing prior to administering her antibiotics via the PICC line. The RN indicated she had difficulty changing the dressing as it was not changed when scheduled but was 3 days late, she indicted she had to use scissors to cut some of the dressings but reports she did not cut the PICC line. The RN stated the dressing was stuck firmly to the resident's skin and difficult to remove. She indicated she finally got the dressing changed and attempted to flush the PICC site with a maintenance flush of 10 cc of sodium chloride as per the order but could not flush the site. At that time she noted the resident had bloody oozing from the the line directly above the hub. Staff E stated she inspected the tubing and hub but couldn't find a break or cut in the line but the resident continued to have bloody drainage. Staff E said she first attempted to place tape on the tubing but it did not stop the oozing of blood. Staff E wanted to stop the leak so she placed a drop of glue on the PICC line tubing, she reported the bloody oozing stopped. The RN stated she waited about 20-30 minutes after placing the Gorilla glue on the tubing before she attempted to flush the PICC line. She stated she could not flush the PICC line as the line seemed to be occluded. Staff E said due to this she could not administer the resident's antibiotic as ordered. Staff E called Staff F-RN/Director of Nurses who directed her to place a peripheral line in the resident to administer the antibiotic but she was unable to place the IV after 3 attempts. She again called Staff F who stated to wait until the morning and she would contact the physician for orders. Staff E-RN stated the policy was to call the Physician when leakage is noted from the PICC line. The policy does not direct the staff to place glue on the PICC line. She stated it was a poor judgement call and does not know why she did it. Review of a Progress Note dated 11/4/24 revealed Resident #2 went to a local emergency room to have another PICC line inserted in order to receive the remainder of her antibiotic therapy. During an interview with Staff F-RN/DON on 12/2/24 at 11:30 am, Staff F stated Resident #2 initially had her PICC line inserted on 10/9/24 due to sepsis, on 11/4/24 the resident had another PICC placed at a local emergency room . Staff F-DON spoke with the resident's physician on 11/4 who reported somehow the PICC line got cut. Staff F stated Staff E-RN called her to report the resident's PICC line was leaking on 11/3, she directed the RN to place in a peripheral line but the RN was not successful. Staff F stated she spoke with the resident's primary care physician who wanted the PICC line replaced. The resident went to the emergency roiagnom on ,d+[DATE] to have it replaced. Staff F-DON stated the emergency room staff were not happy when they discovered Staff E-RN tried to fix the leaking PICC line with glue. Staff F-DON stated Staff E-RN should have called the emergency room and sent her out for a new PICC line. The resident did miss one dose of antibiotic that day but did finish up her prescribed course of antibiotic therapy. During an interview with Staff I-LPN/ADON on 12/2/24 at 2:45 pm, Staff I stated when she spoke to Staff E-RN regarding Resident #2's PICC line, the RN indicated she did not cut the line but that it pulled apart when she was changing the dressing to the insertion site. Staff E-RN informed Staff I-ADON that she placed glue on the PICC line tubing to stop the leakage. Staff I-LPN/ADON stated the resident's Primary Care Physician made rounds in the facility on 11/5/24 and commented to Staff I that they should review the policy regarding PICC lines with their staff. Staff I-LPN/ADON stated she would have expected Staff E-RN to place tape on the PICC tubing line, call the doctor and send her to the emergency room . During an interview with Resident #2's Primary Care Physician on 11/4/24 at 11:30 am, the PCP stated the PICC nurse told her that the resident's PICC line was cut and that the facility nurse put glue on the cut She stated the resident was alert and oriented and made these comments to her nurse when she was replacing her PICC line. The PCP stated this is not a good practice as the glue could dislodge and get into the resident's blood stream which could result in an embolus. Review of a local emergency room procedure note dated 11/4/24 at 1:00 pm, the note revealed Resident #2 presented to the emergency room for a change in PICC line as the PICC line was damaged at the facility. The PICC line was replaced with a peripheral line as the resident only had several doses of antibiotics left. The dressing from the PICC line was removed by the hospital staff and at that time the patient reported the facility staff accidentally cut the PICC line and it started to bleed. The resident indicated to the hospital staff the nurse at the facility used glue to put it back together and to help stop the bleeding. The facility nurse wrapped it with tape to help keep it together. The resident returned to the facility after the new IV was placed. Review of the facilities Intravenous Therapy Policy and Procedure updated 2/1/2024 in regards to PICC Line/Midline Catheter Maintenance directed the staff of evaluate residents at least every shift for evidence of cannula related complications. The staff should notify the resident's physician and the DON if any of the following are noted: a. swelling or pain in the affected arm, chest or neck b. fluid leaking from the site or damaged catheter c. neck vein distension d. catheter migration either in or out e. excess bleeding or drainage from the catheter site f. redness or swelling in the insertion site g. pain or discomfort during the IV infusion h. numbness or tingling in the affected extremity i. any time there is a concern

Based on observation, record review, interview, and facility policy review the facility failed to take a resident to the restroom timely to prevent his brief from soiling his clothing for 1 of 3 residents reviewed (Resident #46). The facility further failed to ensure resident's fingernails were cleaned and trimmed for 1 of 3 residents reviewed (Resident #21). The facility reported a census of 50 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #46 dated 3/28/24 included diagnoses of non-Alzheimer's dementia and anxiety. The Brief Interview for Mental Status (BIMS) documented a score of 1, which indicated severe cognitive impairment. It documented the need for substantial/maximal assistance with toileting with the helper completing more than half of the effort. The Care Plan focus area for Resident #46, initiated 9/27/23, documented he was at risk for pressure ulcer/skin breakdown related to frequent urine incontinence. A section titled falls documented risk related to incontinence. An area titled ADL (Activities of Daily Living) function noted the resident required assistance with toileting. A focus area titled bladder & bowels indicated the resident was frequently incontinent of urine. Interventions included the resident wore a pull up for incontinence products with a toileting program of check and change. The Care Plan lacked a check and change time frame. A Progress Note dated 4/18/24 at 2:33 PM, documented as a late entry and titled Behavior Note, documented the reason the resident spent most of the shift going into another resident's room was to look for the bathroom. On 4/17/24 the following was observed: 10:52 AM - The resident walked towards his room from the common area television. He had a grapefruit sized dark grey area on his light grey pants near the base of his brief on the left leg. 10:57 AM - The resident pulled at the back left leg of his pants with his left hand. Staff B, Certified Nursing Assistant (CNA), redirected him to his room and went into another room. When Staff B shut the door the resident swore and pushed at the door frame. He walked back to the chair in the common area and sat down with the wet spot of his pants on the seat of the chair. He got up and walked to Staff A, Licensed Practical Nurse (LPN). She asked if he had to go to the bathroom. He said yes. She said the girls would be out soon and walked away. 11:04 AM - The resident sat in the common area chair with wet pants. 11:12 AM - The resident walked towards another resident's room. The stain remained on the back of his left leg. Staff A redirected him to his bathroom and she walked away. 11:17 AM - Staff A told the CNAs the resident was waiting for them. 11:20 AM - The Staff B and Staff C, CNA, helped another resident move from a recliner to a dining room chair. 11:22 AM - The resident left his room. He adjusted the waistband of his pants and pulled at the stained area. He returned to his chair in the common area and sat down. 11:25 AM - Staff B asked the resident if he had to use the restroom. The CNAs walked him to his room, one on each side. Observed the brief was full enough to push his pants downward, exposing the waistband of the brief. The stain remained. 11:35 AM - The resident left his room in different pants and Staff C carried his bagged pants to the laundry. The facility failed to sanitize the chair the resident sat in with wet pants before he sat down again for lunch. On 4/18/24 at 10:22 AM Staff C stated Resident #46 could sometimes take himself to the restroom. She acknowledged he needed to be changed the day before due to a wet spot on his pants and stated two staff were needed to take him to the restroom due to combative behavior. On 4/22/24 at 11:16 AM Staff E, Housekeeping, stated she didn't clean the furniture in common areas. An interview with Staff D, Housekeeping/Laundry Director on 4/22/24 at 11:21 AM revealed furniture was supposed to be sprayed once per day. A policy titled Furniture Cleaning reviewed by the facility 4/3/24 documented furniture was expected to be clean and odor free. Staff were expected to use a diluted solution of quaternary disinfectant cleaner, a pad center or utility pad solution, and wipe down the entire piece of furniture working from the top down when soiled. 2. The MDS assessment for Resident #21 dated 2/22/24 included diagnoses of non-Alzheimer's dementia, aphasia (loss of ability to understand or express speech), and hemiplegia/hemiparesis (weakness/inability to move one side of the body). The Brief Interview for Mental Status (BIMS) documented a score of 0, which indicated severe cognitive impairment. It documented the need for partial to moderate assistance with personal hygiene. The Care Plan focus area for Resident #21, initiated 10/7/20, documented she required assistance with ADLs related to weakness secondary to diagnoses of epilepsy and and history of CVA (cerebral vascular accident). An intervention dated 10/8/20 included offer bath/shower two times per week and as needed, providing assistance. A focus area created 1/30/23 documented cognitive loss with a diagnosis of dementia. Interventions included re-approaching resident at a later time if agitated, and determine resident's physical and mental limitations and adjust accordingly. Another focus area titled behaviors dated 9/22/20 documented if behaviors are noted staff will attempt to determine root cause. The Care Plan lacked documentation of personal care refusal. An activity log titled Manicures dated 4/8/24 at 1:30 documented Resident #21 refused participation in the group activity. Progress Notes dated 4/5/24 to 4/16/24 lacked documentation of the resident's refusal of nail care, root cause, or attempted re-approaching. A Progress Note dated 4/17/24 indicated the resident's nails were cut and cleaned. On 4/15/24 at 11:07 AM observed staff take the resident her meal. Staff did not ask the resident if she wanted to wash her hands prior to eating. On 4/16/24 at 09:42 AM observed the resident's nails were chipped, varied lengths, and a thick brown substance with white flecks was noted under all of the nails on her left hand. On 4/17/24 at 10:38 AM observed the resident reading in her recliner. The nails on her left hand remained long with brown and white matter underneath all 5 nails. She repeatedly touched her book page, her hair, her face, and ate popcorn with that hand. An interview with Staff A on 4/17/24 at 12:49 PM revealed that the resident had a scabbed area on her forehead that was cancerous. She picked at it regularly and would sometimes decline treatment. She stated that could be what was under her nails. She didn't know why they were not cleaned and said if the resident was not diabetic a CNA could do it. An interview with the ADON on 4/18/24 at 10:06 AM indicated if a resident was not diabetic a CNA could trim nails. A CNA could always clean a resident's hands. If residents were diabetic a nurse would clip them. On 4/22/24 at 11:34 AM the Administrator stated they had documentation the resident refused a manicure on 4/8/24. He said he could not expect the activities staff to go back 100 times and ask her again. A policy titled Resident's [NAME] of Rights, reviewed by the facility 3/1/23, documented the resident's right to be treated with dignity and respect, and to be free from abuse and neglect.

Based on record review, resident interview, and staff interview the facility failed to complete a Preadmission Screening and Resident Review (PASRR) for 1 of 1 residents reviewed (Resident #8). The facility reported a census of 50 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS listed diagnoses of Anxiety Disorder, Depression, and Bipolar Disorder. A document with a mailing date of 6/28/19 titled Status Change Review Outcome documented a current PASRR Level II Summary of Finding report, dated 4/30/19 remained valid for the resident's nursing facility stay. The summary report on Page 6 revealed the resident was approved for 150 days of nursing facility care. The facility lacked documentation that a follow up PASRR was completed. On 04/15/24 at 10:38 AM the resident stated she lived here because of her mental illness. She could do a lot of things independently but needed help taking care of herself. On 04/18/24 at 02:49 PM an interview with the DON confirmed that Resident #8 has not had a PASRR completed since 2019. She confirmed she was responsible for PASRR completion.

Based on observation, clinical record review, and staff interviews, the facility failed to reassess the effectiveness of fall interventions and to modify the resident's care plan to meet the resident's needs for 1 of 1 Residents reviewed (Resident #4). The Care Plan failed to identify specific staff interventions to mitigate future falls. The facility reported a census of 50 residents. Findings include: The Re-admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 identified a Brief Interview for Mental Status (BIMS ) score of 10 which indicated moderate cognitive impairment. The MDS documented the resident had diagnoses of fracture of left femur, cancer, arthritis, osteoporosis, and malnutrition. The MDS documented the resident required substantial/maximal assistance for mobility and walking was not attempted due to medical condition or safety concerns. The Care Plan initiated 4/24/14 with a target date of 4/10/24 identified the resident at risk for falls. The Care Plan informed staff the resident often attempted to ambulate independently and encouraged staff to keep call light within reach at all times when in room. Resident is at risk for falls related to possible side effects of medications and incontinence. The Care Plan documented the following falls: a. 9/12/23 Fall no injury b. 9/27/23 Fall hit head c. 2/22/24 Post fall no injury d. 2/24/24 Post fall noted injury The Care Plan lacked documentation regarding the following falls: a. 2/2/24 Fall no injury b. 3/12/24 Fall with Major injury The Fall Scene Investigation Report dated 2/2/24 documented a brief summary of how fall happened: resident was getting up to go to the bathroom. The resident was not care-planned for hourly checks. No injury noted. Invention for this fall-continue to educate resident to call for assistance and increase visual checks. The Fall Scene Investigation Report dated 2/24/24 documented a brief summary of how fall happened: resident stated she was trying to reach gait belt on bed so she could go to the bathroom. The resident was not care-planned for hourly checks. No injury noted. Intervention for this fall-reminded to use call light. Keep items within reach. The Fall Scene Investigation Report dated 3/12/24 documented a brief summary of how fall happened: resident up walking by self and lost balance landing on left hip. The resident is care-planned for hourly checks. Checks were completed as care-planned. Injury to left hip. Intervention for this fall-Sent to ER broken hip. Documentation provided by the DON titled, February 2024 Post Falls documented on 2/2/24 resident got up to take herself to the bathroom. Found lying on left side at an angle by bed. No injuries noted. Intervention: Continue to educate resident to call for assistance and increase visual checks. Resident was added to Falling Star Program on 2/4/24. Documentation provided by the DON titled, February 2024 Post Falls documented on 2/24/24 resident stated she was trying to reach for gait belt on bed so she could go to the bathroom. No injuries noted. Intervention: Remind to use call light. Keep items within reach. Documentation provided by the DON titled, March 2024 Post Falls, Follow up 4/3/24 documented on 3/12/24 resident was up walking by herself and lost balance landing on left hip. Noted pain in left hip. Intervention: Sent to hospital for evaluation: (Dx: Fractured left hip) Follow up: No other falls noted. Resident was readmitted to hospice. Has not been getting out of bed much per her request. The Progress Note dated 3/12/24 18:36 Health Status Nursing Note Text: resident got up and walked by self and fell in room and when nurse got to room resident was sitting on left side and c/o left hip and pelvis pain resident was unable to move so son called and wanted her to be sent to local hospital for evaluation, 1800 ER notified and gave order to transport, hospice notified of need to transfer and they agreed, will meet resident at ER, son will meet at ER, DON and ADON notified 1828, ambulance arrived and 1840 left facility with resident. The Progress Note dated 3/12/24 21:43 Health Status Nursing Note Text: This nurse called to check on the resident's condition. She was admitted to another hospital with diagnosis of a fractured left hip. In an interview on 4/17/24 at 4:55 PM with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON advised Care Plan interventions are not necessarily updated or documented on the resident's Care Plan but the interventions are documented on the mini Care Plans located on the inside of the resident's wardrobe cabinets. The mini Care Plan from this resident's room was retrieved and reviewed with both the DON and the ADON. The DON advised this resident's mini Care Plan interventions are updated and referenced the bottom left corner of the stock card where reportedly the undated and illegible documentation reads *transfers-toe touch to left leg, wheelchair only. No ambulation. The mini Care Plan provided had numerous hand written revisions and items written on it with various dates with some entries highlighted. When queried, the DON advised the highlighted areas are discontinued and the staff member would know of the revisions because they are also discussed during report at the start of shift change. If a staff member is absent upon their return they would know to refer to the mini Care Plan for updates. The DON advised she failed to date the most current revisions on resident #4 mini Care Plan. The DON also advised this resident was placed on the Fallen Stars list which denotes the resident is a fall risk by a purple wrist band. In an interview on 4/18/24 at 10:56 AM, Staff F, Certified Nurse Aide (CNA), stated the mini Care Plans are in the resident's rooms. She stated the Care Plans are in the resident's closets and they tell them how to care for the resident. For example, how they transfer, how to provide care, if they need tubi grips. Staff F stated there is a star by the room door to let them know if the resident fell . Any new resident interventions are received in report and the nurse puts them on the mini Care Plan. If there are any changes to the mini Care Plans they get this information in report and also look at the mini Care Plan in the resident room and make sure the cares are correct. In an interview on 4/18/24 at 11:08 AM Staff G, Certified Nurse Aide (CNA), stated the mini Care Plans are in the resident's rooms. The mini Care Plan is in the residents closet and is used to see if they are independent or what assistance they need. Staff G stated she usually looks at it every day. The mini Care Plan would tell if the resident wears TED hose, tubi grips etc. Staff G was not sure if fall interventions were on the mini Care Plans but she thinks the interventions are to monitor the resident so they do not get up independently. During report staff are told what the most recent directives are with the residents. Staff G stated the nurses usually date the changes on the mini Care Plans and sometimes they use a yellow highlighter or a red pen. They also will put on the mini Care Plan last reviewed and the date. In an interview on 4/18/24 at 11:20 AM Staff H, Certified Nurse Aide (CNA), advised the mini Care Plans are in the residents rooms and this tells the staff how to transfer, things they need such as dentures, how they transfer and what their mobility is. Staff H advised she thought there were some fall precautions on the mini Care Plans like low bed and mats on the floor. The nurses give them the information in report each morning before the start of the shift. She stated when she was familiar with a resident she doesn't necessarily look at the mini Care Plan every day. If the residents are new she will look at the mini Care Plan to make sure she is doing what she is supposed to. Staff H will also look at the mini Care Plan if she can't remember what the change in intervention was that was shared with them in report. In an interview on 4/24/24 at 11:15 AM the ADON was queried regarding Care Plan and intervention updates. When a resident returns to the facility from the hospital the DON would update the Care Plan. It would be an expectation the Care Plan would be updated with any new orders or new interventions. In an interview on 4/22/24 at 11:28 AM the DON was queried regarding Resident #4 fall with a major injury on 3/12/24 in which she advised this fall was added to the resident's Care Plan. When asked to provide this documentation, upon review, the DON responded, it is not entered on the Care Plan. The facility policy titled The Lutheran Home For The Aged Association-East Policies and Procedures-Fall Assessment and Management Policy and Protocol revised 3/24/22 and reviewed 2/1/24 documented it is to provide guidelines on Fall Assessment and Management. 2. Fall Protocol-In the event of a resident fall, a Nurse shall: (j) Determine immediate interventions/safety measures to be taken by staff to prevent further falls. (k) Interventions/safety measures will be communicated to on duty care staff and added to the mini care plan immediately following fall. Information will be placed on report sheet. (l) The Director of Nursing or designee will review the Fall Scene Investigation Report for the appropriate intervention(s) to the fall and completeness of the Fall Scene Investigation Report. (m) Interventions for reducing the residents fall risk shall be resident specific and based on the fall in an attempt to prevent the fall from happening again. (n) Interventions shall be followed up on to determine if the intervention is still appropriate. Falling Star Program: 1. Any resident identified by Nurse Managers and/or therapy shall be placed on the Falling Star Program. 2. Indications a resident would benefit from the Falling Star Program include, but are not limited to: a. Residents who are routinely noted ambulating without assistance. b. Residents who are having an increased number of falls. c. New admissions that present with risk factors such as cognitive impairment for 7 days following admission until facility staff can become accustomed to the resident's routine. d. Residents that are noted to be acutely weak due to an acute illness, such as URI, UTI, etc. 3. Residents who are in the Falling Star Program shall have: a. Documentation of this placed in their Plan of Care. b. A Purple Falling Star Magnet placed on the resident's door frame. c. A Falling Star Band placed on the resident's primary mode of locomotion (w/c, walker, cane). 4. The Purple Falling Star Magnet and Band shall alert all staff that the resident is at a high risk for falls and of the increased need for surveillance of the resident's activity when going by them or their room to assure safety. 5. The Falling Star Program may be discontinued per nurse manager and/or therapy judgement.

Based on record review, interviews, and policy review the facility failed to notify the pharmacist of a resident's admission in a timely manner to complete a drug regimen review (DRR) for 1 of 5 residents reviewed for unnecessary medications (Resident #33). The facility reported a census of 50 residents. Findings include: The MDS for Resident #33 dated 4/1/24 revealed diagnoses of anxiety disorder, depression, and diabetes mellitus II. The entry MDS was dated 11/6/23 and the Medicare 5 day admission MDS was dated 11/13/23. The Medication Administration Record (MAR) documented escitalopram Oxalate 20 mg for depression (11/7/23) and buspirone HCl 10 mg for anxiety (12/6/23). A document titled Doctor's Order Sheet, dated 11/6/23 at 9:00 AM, documented medications were listed on the resident's transfer sheet and was signed by the resident's provider. A document titled Order Summary Report from the resident's prior facility, dated 11/2/23 at 11:53 AM, revealed the resident was prescribed 24 medications at the time of the transfer to this facility. Each page was signed by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) and dated 11/6/23. An untitled, undated document headed with the resident's name, date of birth, room number, and provider documented pharmacy reviews were conducted on 12/5/23, 1/31/24, 2/29/24, and 3/28/24. It included a note that the resident was a skilled new admit on 11/6/23 and a DRR was NOT done initially because it was not requested. It documented a DRR date of 12/5/24. Additional documentation indicated the resident had blood sugars between 53 and 556 in the first month. The section was initialed by the pharmacist. Progress Notes, dated 11/30/23 at 14:02 titled Pharmacy indicated a late entry was made for a monthly pharmacist mediation regimen review was completed with recommendations. A physician response was not documented. A note dated 12/5/23 at 15:58 labeled Pharmacy indicated a late entry was made for a monthly pharmacist medication regimen review with recommendations. A note labeled Order Note on 12/9/23 at 01:31 documented received fax back related to dietician FYI of weight loss and blood sugar control and many med changes as well. Dr. response: acknowledged. An interview with Staff A, LPN at 12:49 PM on 1/17/24 revealed DRR and Gradual Dose Reduction (GDR) reviews were initiated by the pharmacy every month. A form was sent to the facility, reviewed by staff, and then sent to the provider for review and comments. An interview with the DON on 4/18/24 at 10:11 AM confirmed she and the ADON signed the initial admission documents and were aware the resident was prescribed psychotropic medications. She further stated nursing was responsible for communicating with the pharmacist and provider. The policy titled Pharmacy - Consulting, reviewed by the facility on 2/1/24, indicated Medication Regimen Reviews were conducted within one week of new admission, upon starting an antibiotic, and monthly.

Based on observation, policy review, and staff interview, the facility failed to ensure they were not serving expired food items to reduce the risk of contamination and food-borne illness. The facility reported a census of 50 residents. Findings include: On [DATE] at 9:16 AM, the initial tour of the facility kitchen with the Dining Services Director (DSM), revealed the following: a. 5 unopened boxes of fudge cream icing mix with an expiration date of [DATE] b. 2 unopened boxes of cinnamon streusel topping mix with an expiration date of [DATE] c. 1 unopened box of cinnamon streusel topping mix with an expiration date of [DATE] d. 10 cans of evaporated milk with an expiration date of [DATE] e. 1 opened box of grape nuts cereal with a resident's name on it and an expiration date of [DATE] f. 1 unopened box of grape nuts cereal with an expiration date of [DATE] g. 12 unopened quart containers of half and half with an expiration date of [DATE] h. 2 unopened containers of whipping cream with an expiration date of [DATE] i. 1 unopened container and 1 opened container of whipping cream with expiration date of [DATE] In an interview on [DATE] at 2:35 PM, the DSM stated it was the expectation that staff check for expired food items each day as they go, with new delivery orders, and at a minimum of twice a week. The facility provided policy titled Date Marking/Leftovers/Discarding Food, last reviewed on [DATE] lacked direction for monitoring for expired food items.

Based on clinical record reviews, staff and resident interviews and observations the facility failed to report an allegation of abuse within 24 hours or the next business day for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 50. Findings include: According to the Minimum Data Set, dated dated dated [DATE], Resident #1 had a Brief Interview for Mental Status score of 11 out of 15 which indicated moderate cognitive impairment. The resident required limited assistance of 1 staff for transfers, ambulation and hygiene. The resident had diagnoses which included hemiplegia, history of fractured left femur, history of falls and syncope. Review of the resident's Care Plan dated 1/6/22 informed the staff the resident is hard of hearing and wears hearing aides, to assist with activities of daily living and ambulate with assistance of 1 staff with the use of a front wheeled walker. Review of a State Agency (SA) intake form, Resident #1 reported to Staff A-Certified Nurses Aide on 3/24/23 that on the previous weekend of 3/17/23 a staff member purposefully stepped on his toes. Staff A-Certified Nurses Aide reported the incident to Staff B-LPN who then failed to report it to the administration for investigation and reporting to SA as required. During an interview with Staff A-C.N.A. on 9/12/23 at 10:00 am, the staff stated she provided assistance to Resident #1 on 3/24/23 and during this time Resident #1 told the staff that on the previous weekend, not sure of the day, Staff C-Certified Nurses Aide purposefully stepped on his toes and did not apologize to him. Staff A-C.N.A. reported the incident to Staff B-LPN/Charge Nurse on 3/24/23. During an interview with Staff D-Director of Nursing on 9/12/23 at 10:30 am revealed she was not informed of an incident involving Resident #1 and Staff-C-Certified Nurses Aide that occurred on or about 3/17/23. Staff D stated she first became aware of the incident on 4/3/23. Staff D stated she started an investigation and reported the incident to the SA as required. Review of a written statement provided by Staff B-LPN/Charge Nurse dated 4/3/23 revealed Staff A-C.N.A. made her aware of an allegation made by Resident #1 that Staff C-C.N.A. purposefully stepped on his toes on or about 3/17/23. Staff B stated she was coming back from break, finishing up passing medications and forgot about the situation was the reason she failed to report the incident to administration. Review of facility policy last updated on March 1, 2023 directed the staff when they suspect adult abuse, neglect, mistreatment or misappropriation of property, as a mandatory reporter the staff member is obligated to tell the appropriate people.

Based on review of personnel files and staff interviews, the facility failed to ensure that the Director of Food and/or Nutrition Services met minimum qualifications. This has the potential to affect the total census of 35 residents. Findings include: Interview with the Dining Services Director on 1/17/23 at 9:45 AM revealed the Dietician visits one time weekly for eight hours. He went on to state that he did not have a Certificate for Dietary Manager. He is enrolled in a Dietary Manager Certificate program as of May of 2022 but has not completed the first segment of the program. Review of the Dining Services Director personnel file revealed a hire date of April 21, 2021 as a cook and then later got promoted to the Dining Services Director in April of 2022. The personnel file lacked a Dietary Manager Certificate. The personnel file included an educational program enrollment form dated May 10, 2022. The form lacked completion for any portion of the program. The Dining Services Director/Certified Dietary Manager Job Description, dated 7/15/19 revealed under qualifications that the employee would be a Certified Dietary Manager. Interview with the Administrator and Director of Nursing on 1/20/23 at 5:15 PM determined that both thought the new Dining Services Director worked on completing the program over the past 12 months. It is the expectation of both that the program be completed as soon as possible after registration in May of 2022.

Based on review of the facility menus, resident observations, observations of meal service, resident, and staff interviews the facility failed to ensure that one of four residents reviewed (Resident (R)33) on a pureed diet had food choices. In addition, the facility failed to have one of seven lunch menus reviewed for nutritional adequacy. Findings include: Review of the Electronic Medical Record (EMR) for R33 included diagnoses of dysphagia and weakness. In addition, the resident was receiving palliative care services. The Weights/Vitals tab revealed that from August 2022 to January 2023, R33 has lost 15.36% of her body weight, 114.6 pounds to 97.0 pounds. R33's Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/27/22 indicated an eating status of independent with assistance of setting up the tray. The MDS identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The Care Plan Focus dated 5/3/22 listed Altered Nutrition related to poor to fair meal intake. R33 needed assistance with meals due to poor vision and oriented to her meal. R33 had a chewing and swallowing problem. R33 received a mechanically altered diet and a supplement. The included Goals indicated that R33 would maintain her weight at 114 plus (+) in a quarter and she would consume an average of 50 percent (%) to 75% of her meals. The included Intervention dated 5/3/22 directed to monitor for chewing, swallowing, and/or oral problems. The Speech Therapist (ST) determined that R33 could tolerate an upgrade to a mechanical soft diet but she preferred to stay on a pureed diet. R33 could have mechanical soft snacks between meals if she desired. The staff should serve fluids in a 4 ounce (oz) glass and/ior cups. R33 could have straws, encourage small bites, eat slowly, encourage her to alternate bites and sips. On 1/18/23 at 9:26 AM observed that R33 appeared asleep while lying in her bed with her breakfast on her overbed table. At 9:45 AM on 1/18/23 the surveyor determined the resident ate nothing for breakfast. Interview with the Cook and Dining Service Director on 1/19/23 at 1:30 PM indicated the decision on which entree to serve during any meal for the four residents receiving pureed diets is random and determined by the dietary staff, not the resident. Review of the pureed diet, for January 17-20, 2023 revealed that pureed diets had at least two options per meal (lunch and dinner). On 1/19/23 at 1:00 PM R33 just received her meal as she drank a nutritional shake. R33 explained that she supposed it would be nice if they asked what she wanted for each meal. R33 stated she did not get a choice of entree during any of the meals served. Interview with the Dietician on 1/19/23 at 2:10 PM indicated that she did not know that the residents did not get a choice for the pureed menu prior to the survey. She stated she heard of the problem from the Dining Services Director and stated that the facility allows R33 to make a choice of her entree. Interview with the Director of Nursing (DON) and Administrator on 1/20/23 at 5:15 PM indicated that all residents should have meal choices. 2. The lunch menu for Wednesday 1/18/23 revealed one choice menu item to read one serving of chicken Caesar Salad with dressing. These salads were provided to 25 residents through a choice menu. Observations of the meal service in the kitchen on 1/18/23 at 11:15 AM revealed staff were serving four ounces of salad, no specified amounts of chicken or cheese and two ounces Caesar dressing. Interview with the Dining Services Director on 1/18/23 at 11:30 AM verified the method for determining the amount of chicken and cheese served is based on the recipe book not the menu. Interview with the facility Cook on 1/18/23 at 11:45 AM indicated she serves four pieces of chicken slices for each salad. When asked how she knew this, she stated it's in the recipe book. In addition, the facility used a 1/4 cup scoop for distributing the cheese on each tray. Interview with the Cook again regarding the cheese amount also replied that the recipe book guides her decisions for amounts served. Interview with the Dietician on 1/19/23 at 2:10 PM indicated the amounts for cheese served and chicken were in the recipe book and did not realize the menu was lacking portions for salads, however, she would add portions to the menu for clarification. Interview with the DON and Administrator on 1/20/23 at 5:15 PM indicated that the menu should reflect what is being served with the salads including the chicken and cheese amounts.

Based on observations, staff interviews, review of policy and procedures, the facility failed to ensure that it stored and served food in accordance with the product food label. The problem can affect all 35 residents. Findings include: 1. On 1/17/23 at 11:15 AM observed the resident's food refrigerator located in the medication room on the 2-North unit revealed two Mighty Shakes in the refrigerator section. Each shake lacked a thaw date. The product label reads, store frozen, thaw at or below 40 degrees. Use the thawed product within 14 days. Keep Refrigerated. Interview with the Dining Service Director at the time of the observation indicated the dining room staff stock the 2-north refrigerator and are responsible for the storage of these two Mighty Shakes. He also verified the shakes do not have a thaw date or a date 14 days beyond the thaw date to indicate when to use the product. He went on to state he does not know how long the shakes have been thawed. The product contains skim milk. He stated there was no policy for the distribution of these nutrition shakes. Interview with the Assistant Director of Nursing on 1/17/23 at 11:20 AM indicated as the Nursing Manager, she did not know how long the Mighty Shakes had been thawed or if they were safe to use. Interview with the Director of Nursing on 1/17/23 at 11:45 AM indicated she heard about the problems and will follow the labels in the future. Interview with the Dietician on 1/19/23 at 2:10 PM indicated she did not know of the need to use the thawed shakes within 14 days but will now follow the labels. Three residents currently use the Mighty Shakes. Interview with the Administrator and Director of Nursing on 1/2/23 at 5:15 PM indicated the shakes should have been distributed correctly. 2. Observation of the only facility ice machine in the storage area behind the kitchen revealed on 1/18/23 at 10:30 AM the interior top section containing plastic white channels. The white channels were used for the ice to fall from the freezing area to the storage bin inside the ice machine. These white channels have black spots throughout. The spots could be scraped off with a fingernail and appeared to be mold. Interview with the Dining Service Director at the time of the observation indicated the machine was under repair about six months ago. He stated major components had to be updated but now the machine is working well. When asked when the ice machine was last cleaned, he stated he was not sure but thought it was near the same time the major components were replaced or six months ago. He stated he used the quat sanitizer used in the three compartment sink to rinse and wash the interior of the ice machine. He has no records for cleaning the ice machine. Interview with the Director of Nursing and Administrator on 1/2/23 at 5:15 PM indicated the ice machine cleaning should have been done. Review of the facility's policy titled, Maintenance-[NAME] Lutheran Home Ice Machine revised on 3/4/21, indicated that records should be maintained of the ice machine cleaning and that the ice machine would be cleaned every three months.

Based on clinical record reviews, resident, family, and staff interviews, the facility failed to ensure facility residents were updated regarding the number of new COVID-19 positive cases for residents and staff, the cumulative number of COVID-19 cases for residents and staff, and the mitigating factors the facility was using to help control/stop the spread of the virus by 5:00 PM the day after a positive test result. This systemic failure had the potential to affect the knowledge, health, and decisions of any of the 35 residents in the facility at the time of the survey. Findings include: During the survey entrance conference, when asked for the identity of the responsible staff member that notifies residents and resident representatives/families, the Director of Nursing (DON) stated residents were told if the resident were to ask if there were any COVID-19 positive cases or the residents will know who is positive by the isolation carts on the doors, but there was no formal process. The facility reported four residents were positive for COVID-19 at the start of the survey. During an interview on 1/19/23 at 11:05 AM, when asked how she got notified of COVID activity in the facility, Resident (R) 7 responded that they would tell her if she asked about it. R7's Admission Record listed an admitted [DATE] with medical diagnoses of osteoarthritis, hyperkalemia (high potassium), hypothyroidism, hyperlipidemia, and hypertension. R7's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/17/22 showed a Brief Interview for Mental Status [BIMS] score of 15, indicating intact cognition. During a joint interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 1/20/23 at 3:47 PM regarding notification to the residents, resident representative / family, the DON stated they (she and the ADON) used to call resident families and that was documented in the electronic health record (EHR). Now the Administrator notifies every week on Monday by letter. When asked who notified residents, the DON stated they don't. The DON explained that she meant that they tell them if they ask and they will know when an isolation cart appears in front of a room, but they don't notify the residents. Review of the facility policy titled Infection Control Practices, reviewed 2/9/22, revealed: F-885: COVID-19 Reporting to Residents, their Representatives and Families: The facility administrator will coordinate the response to inform to residents, their representatives and families at least weekly; or by 5 PM the next calendar day following the subsequent occurrence of either: (1) a single laboratory confirmed infection of COVID-19, or (2) three or more residents or staff with new-onset respiratory symptoms within 72 hours of each other. This notification must include information on: -actions being taken to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; -cumulative updates following the subsequent occurrence; and -not include personally identifiable information (The facility will utilize communication mechanisms that make this information easily available to all residents, their representatives and families, including: -Written memos -Email, and -Website postings (For purposes of this reporting requirement, facilities are not expected to make individual telephone calls).

Based on observations, staff interviews, and review of the manufacturer's instructions, the facility failed to ensure bed frames and rails were inspected regularly to minimize the risks of resident entrapment. This failure had a potential to affect any of the 29 residents with bed rails of the 35 residents currently living in the facility. Findings include: Observation on 1/18/23 at 10:51 AM showed Resident (R) 7 had bilateral bed rails attached to the bed. Observation on 1/17/23 at 3:03 PM showed R16 had bilateral bed rails attached to the bed. Observation on 1/17/23 at 1:57 PM showed R29 had bilateral bed rails attached to the bed. Review of a list provided by the facility, approximately 83% of the residents had bed rails. In response to a request for the maintenance records of the facility beds, on 1/19/23 at 12:52 PM the Director of Nursing (DON) provided the facility bed manufacturer instructions for use (MIFU) and a three-ring binder of bed maintenance records. The review of the binder of bed maintenance records showed the most recent form was dated 8/17/21 and the DON stated, We are out of compliance anyway. We've had 3 maintenance men since December 2021. During an interview on 1/20/23 at 5:35 PM, the Maintenance Director (MD) stated he did not know until that week that he should be inspecting the beds or the bed rails. The MD stated the facility did not have a policy regarding bed maintenance and the MIFUs should be used. Review of the facility policy titled, Bed Safety Program: Bed Rail Use/Bed Inspection Policy reviewed May 3, 2022, revealed, Policy.In an effort to prevent entrapment and other safety hazards associated with resident bed rails, frames and mattress the facility will maintain a bed safety program which will include: -Resident assessment to ensure safe and appropriate bed environment including bed rail use; -Equipment management and maintenance; . Maintenance, Nursing Management and Housekeeping will cooperatively be responsible for completion of bed inspections.Procedure:. 2. Equipment Management and Maintenance:.b. The Maintenance department in conjunction with Nursing department will conduct a regular preventative maintenance inspection of all bed systems, including rails, frames, mattresses and operational components to ensure they are-clean, comfortable;-well-constructed;-approximately (5) five inches thick and standard in size for the bed;-properly maintained as evidenced by documentation showing when visible signs of disrepair are identified, reported to maintenance and corrections made;-evaluated to identify areas of potential entrapment or other safety hazards according to FDA guidelines and/or manufacturer's Bed System Measurement Device instructions (Appendix A) when side rails are installed. A work order will be completed and forwarded to Maintenance by Nursing management when side rails need installed. All measurements are to be properly recorded on the Bed System Measurement Device Test Results Worksheet and Records Maintained for (7) seven years; -reevaluated, re-measured and documented according to guidelines when/if --mattresses or bed rails are changed, or accessories are added or removed. A work order will be completed and forwarded to Maintenance by Nursing management. --components become worn (wobbly or damaged rails, aging soft mattresses.) Review of the undated facility provided manufacturer maintenance: MIFU for the Alterra 1385 Long Term Care Bed, revealed .Maintenance and cleaning procedures should be performed at least once every three months. Mechanical Inspection and Maintenance 1. Inspect all bed components for damage or excessive wear. 2. Visually examine all welds for cracks. 3. Inspect the deck components for any bending, damage or excessive wear. 4. Check the ends of the actuators and mounting hardware for any bending, damage or excessive wear. 5. Inspect all bolts and fasteners for proper functioning (Do not over tighten bolts at pivot points) 6. Check the casters to ensure they are both locking and rolling properly. Electrical Inspection and Maintenance 1. Inspect all electrical bed components for damage or excessive wear (i.e. broken housings or worn components). 2. Check handset, power and actuator cords for chafing, cuts or excessive wear. 3. Ensure all plugs are fully plugged in and free of damage. 4. Ensure all cords are properly routed with cable ties and free of moving parts. 5. Check all bed functions a. Head raises and lowers properly. b. Foot raises and lowers properly. c. Bed raises and lowers properly. d. Check for malfunctions, recalls, or safety notices. Review of the undated MIFU for the facility Panacea beds showed: Maintenance and Cleaning Maintenance and cleaning procedures should be performed at least once a year or as required. Cleaning and Disinfecting the Bed 1. (exclamation point in a triangle) Unplug power cord before cleaning or performing maintenance on the electric bed. 2. Do not submerge the pendant in liquid. 3. Do not steam or pressure wash the bed or any of its components. 4. Wipe down actuators, control box, and pendant with a damp, well wrung out cloth or with a disinfecting wipe. 5. Excess water or liquid may damage electrical parts and pose a shock hazard. 6. Wipe down the remainder of the bed with a disinfectant. 7. Allow the bed to dry completely before using. Periodic Inspection 1. Perform the procedure STEPS TO PREVENT BED FIRES listed in this manual.

Based on record review and staff interviews and review of facility policy/procedure, the facility failed to provide adequate supervision to ensure against hazards from self and failed to supervise the implementation of the plan of care for 1 of 9 residents reviewed (Resident #3). The facility reported a census of 58 residents. The Care Plan for Resident #3 identified the resident had a problem with falls and directed staff to have the resident sleep in a low bed with a mat beside the bed. The interventions also included the staff to have the resident in supervised areas at all times when up. On 8/7/2011 at 7:00 a.m. the staff person left the resident sitting on the side of the bed while the staff person left the room to obtain a mechanical lift. The resident fell from the elevated bed and no mat laid on the floor by the bed. The resident ' s injury consisted of a 1 centimeter laceration above the right eye and a hematoma underneath. Findings include: 1. Resident #3 had a Minimum Data Set (MDS) assessment do to a significant change in condition with a reference date of 7/07/11. The assessment identified Resident #3 had problems with short and long term memory and had impaired cognitive decision making skills. According to the MDS the resident needed extensive assist of two staff for bed mobility, transfers, and did not walk. The Care Plan identified a problem with falls on 10/05/07 related to the resident rocking forward in a chair at times, [DIAGNOSES REDACTED]. The Care Plan goal indicated the resident would not have any falls through 10/21/11, which revealed the goal as not met. The Care Plan directed staff to have the resident in supervised areas at all times when up, and to provide a low bed with a floor mat by the bed. The physician's orders [REDACTED]. A Fall Investigation report dated 8/07/11 at 7:00 a.m. revealed Staff JJ (Certified Nurse Aide) finished providing cares and left the resident sitting on the edge of the bed to grab the transfer lift. When returning to the room, the resident had been in the act of falling to the floor. The resident received a one centimeter laceration to the right forehead with a hematoma. The Fall Investigation report documented the root cause of the fall had been the bed was elevated and no mat on the floor and the Certified Nurse Aide left the resident without proper supervision. The Progressive disciplinary Form dated 8/07/12 documented the Staff JJ, received a verbal warning for her actions related to Resident #3's fall. On 3/08/12 at 4:00 p.m. Staff BBB, Certified Nurse Aide reported she had been assisting the other resident in the room with the privacy curtains drawn when Resident # 3 fell . Staff BBB stated Staff JJ had entered the room with the EZ Stand and the resident fell on the floor. Staff BBB reported the bed was in the elevated position, and the floor mat was not on the floor beside the bed. Staff BBB reported the bed should have been in the low position with the floor mat next to the bed. On 3/08/12 at 4:15 Staff OO (Certified Nurse Aide) reported prior to the resident ' s fall, the following interventions should have been in place: don't leave the resident alone when awake, have a low bed, and place a floor mat beside the bed. On 3/07/12 at 3:45 p.m. Staff DD (Certified Nurse Aide) reported the resident had a history of [REDACTED]. The Falls Assessment Policy and Procedure dated 11/16/2000 and updated on 3/18/2011 indicated the purpose for the Fall Assessment was to implement interventions to prevent or reduce the incident of further falls. The Fall Protocol indicated immediate safety measures are to be taken by staff to prevent further falls.