Every finding on record at Union Co Health and Rehab Center, Inc

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that time/temperature control for safety (TCS) foods were maintained under appropriate temperature control and discarded when required, and failed to consistently monitor and document food storage and holding temperatures for one (1) of four (4) days of survey. Findings Include: Review of the facility policy titled, Monitoring Temperature of Cooked Foods with a revision date of 10/17, revealed, .3. Cooking and holding temperatures should be recorded at each meal . Review of facility policy titled Resident Nutrition Services undated revealed, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.2 .Reasonable efforts will be made to accommodate resident choices and preferences.4.b .Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than two (2) hours will be discarded. On 8/03/2026 at 10:21 AM, during a kitchen observation with the Certified Dietary Manager (CDM), review of the Food Holding Temperature Log and Refrigerator/Freezer Temperature Log revealed incomplete documentation on 8/01/2026 and 8/02/26. The Refrigerator/Freezer Temperature Log revealed no recorded AM refrigerator/freezer temperatures for 8/01/26 and 8/02/2026, and the Food Holding Temperature Log revealed no recorded temperatures on 8/01/2026 and 8/02/2026. During an interview on 8/03/2026 at 10:22 AM with the CDM, she stated, I have discussed with staff the importance of checking temperatures and keeping a temperature log of food storage and cooked foods to help ensure food safety. During an interview with the Administrator on 8/06/26 at 10:00 AM, he stated it was the facility's expectation that refrigerator and freezer temperatures are monitored and recorded twice daily, and that steam table temperatures are monitored and documented for each meal. On 08/03/2026 at 10:45 AM, Resident #24 was observed asleep in bed. An untouched breakfast tray containing a cooked sausage and biscuit remained on her bedside table. Record review of the tray delivery schedule confirmed Resident #24's breakfast tray was delivered at approximately 7:30 AM; therefore, the tray remained at bedside for approximately three hours and 15 minutes. The tray was not observed to be under hot or cold temperature control and contained no visible marking identifying its delivery or discard time. During an observation and interview on 08/03/2026 at 10:49 AM the Infection Control Nurse identified the tray as Resident #24's breakfast tray and confirmed that it contained an uneaten cooked sausage and biscuit. The nurse stated breakfast trays were usually collected by 9:00 a.m. When asked about the length of time the food should have remained at bedside, she stated, Not this long. The nurse further stated Resident #24 frequently slept late and that staff often left her breakfast tray at bedside for her to eat after awakening because she's very particular. During an interview on 08/04/2026 at 4:54 PM, the Director of Nursing confirmed that Resident #24 regularly slept late and that leaving her breakfast tray at bedside until she awakened was the usual practice. The DON did not identify a system for maintaining breakfast food at a safe temperature, tracking the length of time the food remained without temperature control, or discarding and replacing TCS food. After discussing safe food-handling requirements, the DON stated that leaving foods such as cooked sausage at room temperature for extended periods could result in foodborne illness. Record review of the admission Record indicated Resident #24 was admitted to the facility on [DATE] with medical diagnoses that included Hypertensive Heart Disease without Heart Failure. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/8/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #24 had moderate cognitive impairment.

Based on record review, facility policy review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected medications administered during the applicable seven-day look-back periods for two (2) of 20 residents reviewed for resident assessment accuracy. Residents #4 and Resident #46Findings include:Review of the facility policy titled Comprehensive Assessments, dated October 2023, revealed: .The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity using the Resident Assessment Instrument specified by Centers for Medicare and Medicaid Services (CMS).Resident #4Record review of Resident #4's most recent completed MDS assessment, with an Assessment Reference Date (ARD) of 06/11/2026, revealed Section N0350A, Insulin Injections-Record the number of days that insulin injections were received during the last seven days or since admission/entry or reentry if less than seven days, was coded 7, indicating the resident received insulin injections on seven days during the look-back period.Record review of Resident #4's June 2026 Medication Administration Record (MAR) revealed no physician's order for insulin and no documented administration of insulin during the seven-day look-back period for the MDS assessment.Record review of the admission Record indicated Resident #4 was admitted to the facility on [DATE] with medical diagnoses that included Anemia, Hypokalemia, and Hyperglycemia.Record review of the MDS, with an ARD of 7/27/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #4 was cognitively intact.Resident #46Record review of Resident #46's MDS assessment, with an ARD of 06/29/2026, revealed Section N0415F1 Antibiotic, was coded to indicate the resident was taking an antibiotic during the seven-day look-back period.Record review of Resident #46's June 2026 MAR revealed no documented administration of an antibiotic during the seven-day look-back period for the MDS assessment.Record review of the admission Record indicated Resident #46 was admitted to the facility on [DATE] with medical diagnoses that included Hypertensive Heart Disease without Heart Failure.Record review of the MDS, with an ARD of 6/29/2026, revealed under Section C a BIMS score of 5, indicating Resident #46 had severe cognitive impairment. During an interview and record review on 08/06/2026 at 4:08 PM, the Registered Nurse (RN) Consultant reviewed and confirmed the MDS findings for Residents #4 and Resident #46. She confirmed Resident #4's MDS assessment inaccurately reflected seven days of insulin injections and Resident #46's MDS assessment inaccurately reflected antibiotic use during the applicable seven-day look-back period. She stated that the accuracy of MDS assessments was very important because the assessments painted a picture of how residents should be cared for and assisted the facility in developing residents' care plans.

Based on observations, record review, interviews and facility policy review, the facility failed to implement infection-prevention and control practices for three (3) of five (5) resident care practices observed. Residents #4, Resident #6, and Resident#55 Findings Include: Review of the facility policy Enhanced Barrier Precautions with revision date of December 2024, revealed Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents .2. Enhanced barrier precautions apply when . b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained . Review of facility policy titled Infection Control Guidelines undated revealed, .4. Enhanced Barrier Precautions (EBP) will be used for residents with chronic wounds or indwelling medical devices during high-contrast resident care activities regardless of the resident's multidrug-resistant organism status. Review of facility policy titled Cleaning and Disinfection of Environmental Surfaces revised June 2009, revealed, Environmental surfaces will be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection of healthcare facilities and the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard. Review of facility policy titled Handwash Hygiene reviewed April 2018, revealed, .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water.for the following situations.e. Before and after handling an invasive device (e.g., urinary catheters.h. Before moving from a contaminated body site to a clean body site during resident care. Review of facility policy titled Standard Precautions reviewed December 2007, revealed, .Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents.Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another.Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces.and wash hands immediately to avoid transfer of microorganisms to other residents or environments.Remove gown and perform hand hygiene before leaving the resident's room . Review of facility policy titled Suctioning Upper Airway Oral revised October 2010, revealed, .Empty and rinse collection container if necessary or as indicated by facility protocol. Review of facility policy titled, Suprapubic Cath Care revised August 2019, revealed, The purpose of this procedure is to prevent skin irritation around the stoma site and prevent infection of the resident's urinary tract.Discard disposable items into designated containers. Remove gloves and discard in designated container. Wash and dry your hands thoroughly. Review of the facility policy titled Catheter Care Urinary revised 9/2014, revealed the purpose of this procedure was to prevent catheter-associated urinary tract infections. The policy directed staff to ensure catheter tubing and drainage bag are kept off the floor. Resident #4 Suction Canister On 08/03/2026 at 10:17 AM, a suction canister connected to Resident #4's suction machine was observed at the bedside. The canister was approximately 85% full of cloudy secretions. During the interview, Resident #4 stated the suction machine had not been used in approximately one month and that the secretions had remained in the canister throughout that time and that nobody had emptied it. During a follow-up observation and interview on 08/03/2026 at 10:24 AM, the Quality Assurance (QA) Nurse observed the suction canister and confirmed that it was full of retained secretions. She stated she could not confirm how long the secretions had remained in the canister. The QA Nurse stated she was uncertain of the facility's required replacement or disposal frequency but believed the canister should be emptied at least once per shift. During an interview on 08/04/2026 at 4:54 PM, the Director of Nursing (DON) confirmed that Resident #4's suction canister should not have been left at the bedside while full of retained respiratory secretions. They acknowledged that allowing respiratory secretions to remain in the canister at the bedside constituted an infection-control concern and stated staff should have emptied or replaced the canister. During an interview on 08/06/2026 at 1:18 PM, the Nurse Consultant stated the facility did not have a facility protocol specifying how frequently suction canisters should be emptied, cleaned, or replaced. She stated her expectation was for staff to empty and rinse the canister at the end of each shift and replace it weekly. Resident #4 Catheter Care During an observation and interview on 8/3/26 at 10:17 AM with Resident #4, he stated he had an indwelling urinary catheter that had been inserted during his recent hospitalization. The urinary drainage bag was attached to his wheelchair and the bottom of the drainage bag extended below the privacy cover and was observed in direct contact with the floor. During an observation and interview on 8/3/2026 at 10:23 AM, the QA Nurse confirmed that Resident #4's urinary drainage bag was touching the floor. The QA Nurse immediately repositioned the drainage bag off the floor and stated that a urinary drainage bag should never touch the floor because doing so creates a risk for infection. During an observation on 08/05/2026 at 11:39 AM, Certified Nursing Assistant (CNA) #1 and CNA #2 provided fecal incontinence and suprapubic catheter care to Resident #4. It was observed that there was stool in his brief, and after removing the stool and providing incontinent care, both CNAs proceeded directly to suprapubic catheter care without removing their contaminated gloves, performing hand hygiene, and applying clean gloves. While continuing to wear the same gloves used during fecal incontinence and suprapubic catheter care, CNA #2 opened and searched Resident #4's dresser drawers for a care item. When she was unable to locate the item, CNA #2 removed her gloves but did not perform hand hygiene. She then exited the resident's room while continuing to wear the gown used during the resident's fecal incontinence and catheter care. CNA #1 continued wearing the same gloves used during fecal incontinence and catheter care and touched the bathroom doorknob, dresser drawer, and soap bottle. Observation then revealed a transfer of Resident #4 back into his wheelchair, CNA #1 allowed the suprapubic catheter drainage bag to rest directly on the floor multiple times during the transfer. During an interview on 08/05/2026 at 12:24 PM, the DON stated CNA #1 and CNA #2 were relatively new facility employees but had worked as CNAs for many years. She stated both CNAs received training upon hire and completed competency evaluations that included catheter care and infection control practices. The DON stated she expected staff to follow infection control practices while providing resident care and acknowledged that failure to follow those practices could result in a spread of infections, particularly for a resident with a urinary catheter. Record review of the facility documents titled CNA Skills and Evaluation—On Hire and Annually revealed CNA #1 was evaluated and documented as competent in catheter care on 03/05/2026, and CNA #2 was evaluated and documented as competent in catheter care on 05/04/2026. Record review of the admission Record revealed Resident #4 was admitted to the facility on [DATE] with medical diagnoses that included Anemia, Hypokalemia, and Hyperglycemia. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/27/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #4 was cognitively intact. Resident #6 On 08/06/2026 at 9:25 AM, an observation revealed Licensed Practical Nurse (LPN) #2 administering medications to Resident #6 through her percutaneous endoscopic gastrostomy (PEG) tube without utilizing EBP. LPN #2 did not wear the required isolation gown while providing care involving the resident's indwelling device. Immediately following the medication administration, LPN #2 confirmed she had not worn a gown during the procedure and stated, I got distracted and forgot. She stated disposable gowns were available on hallway supply carts and that she normally obtained one before entering the resident's room. She acknowledged that facility protocol required the use of both a gown and gloves when providing care to residents requiring Enhanced Barrier Precautions. She further stated that failure to utilize the required personal protective equipment could cause the spread of germs and was intended to protect residents from contamination and possible infection. On 08/06/2026 at 10:05 AM, interview with the Infection Control Nurse revealed the purpose of Enhanced Barrier Precautions was to prevent the transmission of germs between staff and residents. She stated residents requiring EBP were identified by a red indicator on the outside of their room door. She confirmed Resident #6 had a PEG tube, which required staff to wear both gloves and a gown during care involving the device. She further explained that Enhanced Barrier Precautions are required for residents with open wounds, indwelling catheters, PEG tubes, and other indwelling medical devices. The Infection Control Nurse confirmed LPN #2 should have worn a gown while administering medications through the resident's PEG tube and acknowledged that failure to do so increased the risk for the spread of organisms, contamination, and potential infection. Record review of Resident #6's admission Record revealed that she admitted to the facility on [DATE] with diagnoses that included Encounter for Attention to Gastrostomy and Dysphagia. Record review of Resident #6's Quarterly MDS with ARD of 06/22/26 under Section K documented Yes that she had a feeding tube. Resident #55 On 08/03/2026 at 11:22 AM, a pungent odor was noted in Resident #55's room. An observation and an interview at that same time with Resident #55 revealed an uncovered basin containing an emesis-like substance was observed on the floor beside the resident's bed. Resident #55 stated the basin had remained on the floor since the previous day. She stated, I vomited several times yesterday. I don't know why that is still down there. During a follow-up observation and interview on 08/03/2026 at 11:25 AM, the Infection Control (IC) Nurse observed the uncovered basin on the floor and confirmed that it contained a substance that appeared to be emesis. She immediately removed and cleaned the basin. She further stated a nurse should have entered to administer morning medications and CNAs should have entered to provide care; therefore, a staff member should have identified and removed the basin. During an interview on 08/04/2026 at 4:56 PM, the DON stated that leaving an uncovered container of body fluids in the resident's room constituted an infection-control concern and that multiple staff would have been in the room the last 24 hours and should have removed it from the room. Record review of the admission Record revealed Resident #55 was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Atrial Fibrillation. Record review of the MDS, with an ARD of 7/20/2026, revealed under Section C a BIMS score of 13, indicating Resident #55 was cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement Activities of Daily Living (ADL) care plans for four (4) of 52 residents reviewed. Residents #2, Resident #26, Resident #38, and Resident #54 Findings include: Review of the facility's policy titled, Care Plan, Comprehensive Person-Centered with no revision date, revealed under Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Resident #2 Record review of Resident #2's ADL care plan revealed, .Interventions.Check nail length and trim and clean on bath day and as necessary. Record review of Resident #2's most recently completed Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/01/26, revealed Section GG0130I, Personal Hygiene, was coded 05—Set-up or clean-up assistance, indicating a helper provided assistance by setting up or cleaning up before or after the activity, while the resident completed the activity . On 08/03/2026 at 10:40 AM, Resident #2 was observed with fingernails approximately one-half inch in length and a dark-brown substance underneath the nails. On 08/05/2026 at 11:26 AM, an observation revealed Resident #2's fingernails remained approximately one-half inch in length with a dark-brown substance underneath. During an observation and interview on 08/05/2026 at 12:16 PM, Certified Nursing Assistant (CNA) #2 observed Resident #2's fingernails and confirmed they were dirty and needed to be trimmed. CNA #2 stated, Nail care should be done daily. She further stated that the wound-care nurses were responsible for trimming residents' fingernails. During an interview on 08/05/2026 at 12:25 PM, the Director of Nursing (DON) stated CNAs could file the fingernails of residents who did not have diabetes; however, she preferred that nurses' trim residents' fingernails. She stated she expected CNAs to ensure residents' fingernails were cleaned daily. An interview on 08/06/2026 at 12:50 PM with MDS Coordinator revealed that the comprehensive care plan was intended to communicate each resident's individualized needs and preferences to staff, including bathing schedules and required assistance. Record review of the admission Record revealed Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included Hypertensive Heart Disease without Heart Failure. Record review of the MDS, with an ARD of 7/1/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #2 had severe cognitive impairment. Resident #26 Record review of the Care Plan Report for Resident #26 revealed: The resident has an ADL self-care performance deficit related to (r/t) confusion and right sided hemiplegia due to stroke . Interventions: .Shave on shower days and prn (as needed). The resident is totally dependent on one staff to provide bath/shower . During an observation and interview on 08/03/2026 at 11:10 AM, and again on 8/04/2026 at 11:00 AM, Resident #26, was observed lying in bed with facial hair approximately 1/4 inch in length. Resident #26 stated he had not been shaved lately, and he would like a shave. He couldn't remember his shower days but stated they should shave me on shower days. Resident #26 was sitting in the hall near the shower room on 8/05/2026 at 10:30 AM, he had not been shaved. He stated he wanted a shave. Record review of Resident #26's Shower Sheet revealed he is showered on Tuesdays, Thursdays, and Saturdays. During an interview on 8/05/2026 at 10:40 AM with Director of Nursing (DON) revealed she was unaware Resident #26 had not been shaved this week. She stated the wound care coordinator shaves Resident #26, and he has been covering for another nurse and didn't have time. An interview on 08/06/2026 at 12:50 PM with MDS Coordinator revealed that the comprehensive care plan was intended to communicate each resident's individualized needs and preferences to staff, including bathing schedules and required assistance. Record review of Resident #26's MDS with ARD of 6/02/2026 under Section GG revealed he required partial/moderate assistance with his personal hygiene including shaving. Record review of Resident #26' s admission Record revealed he was admitted to the facility on [DATE] with a diagnosis that included atherosclerotic heart disease. Record review of Resident #26's MDS with an ARD of 6/02/2026 under Section C revealed a BIMS score of 05 which indicated he was severely cognitively impaired. Resident #38 An observation and interview on 08/03/2026 at 12:28 PM with Resident #38 revealed him resting in bed with visibly greasy, unwashed hair. The resident stated he had not received a shower in four days and commented that if he had to go home to get his showers, he would. He revealed that he had a fractured right elbow and required help with his showers. An interview on 08/05/2026 at 11:18 AM with Lead CNA revealed that Resident #38 was scheduled for showers every Tuesday, Thursday, and Saturday because he preferred not to shower before his early morning dialysis appointments. She stated she personally provided his shower on Thursday of the previous week and that the resident informed her on Monday, 08/03/2026, that he had not received another shower since then. An interview on 08/06/2026 at 9:15 AM with Director of Nursing (DON) revealed that she was unaware that Resident #38 had missed his scheduled showers over the weekend. She acknowledged that residents not receiving scheduled showers was not acceptable. An interview on 08/06/2026 at 12:50 PM with MDS Coordinator revealed that the comprehensive care plan was intended to communicate each resident's individualized needs and preferences to staff, including bathing schedules and required assistance. She further confirmed that by failing to provide Resident #38 with his showers on his scheduled shower days, the facility failed to follow the resident's care plan. Record review of Resident #38's Care Plan Report revealed that he has an ADL self-care performance deficit related to fractures of right olecranon requiring surgical repair and inferior pubic ramus. Interventions included, The resident requires partial assist by one staff with bathing/showering. Record review of Resident #38's admission Record revealed that he was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease and Hypertensive Heart Disease with Heart Failure. Record review of Resident #38's MDS with an ARD of 07/17/26 under Section C revealed a BIMS score of 15 which indicated that he was cognitively intact. Resident #54 Review of the Care Plan Report for Resident #54 revealed: The resident has an ADL self-care performance deficit r/t cognitive deficit .Interventions: .Shave on shower days and prn . During an observation and interview on 8/03/2026 at 10:50 AM, and again on 8/04/2026 at 11:05 AM, Resident #54 was observed in his wheelchair outside of his room, he was observed to have approximately one-fourth (1/4) inch in length facial hair. Resident #54 stated that he had not been shaved lately. He stated it wasn't his shower day on Monday, but he would have a shave and shower tomorrow hopefully. Resident #54 was sitting in his wheelchair near his room on 8/05/2026 at 8:00 AM, he had not been shaved. He stated he would like to be shaved. Record review of Resident #54's Shower Sheet revealed he is showered on Tuesdays, Thursdays, and Saturdays. During an interview on 8/05/2026 at 10:41 AM, with DON revealed that she was unaware Resident #54 had not been shaved this week. During an interview with MDS Coordinator on 8/05/2026 at 4:30 PM, she stated, If the resident did not have his shave on his shower day and he wanted his shave, the care plan was not implemented. She stated the purpose of a care plan is for the resident to receive the individualized care they need. Record review of Resident #54' s admission Record revealed that he was admitted to the facility on [DATE] with a diagnosis that included Unspecified Dementia. Record review of Resident #54's admission MDS with ARD of 6/16/2026 under Section C revealed a BIMS Score of 12 which indicated that he was moderately cognitively impaired.

Based on observation, resident and staff interviews, record review and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care for four (4) of 52 residents reviewed for ADL care. Resident # 2, Resident #26, Resident #38, and Resident #54. Findings include: Review of the facility policy Activities of Daily Living (ADLs) with revision date of April 2025 revealed, .Residents who are unable to carry out activities of daily living independently receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene . Resident #2 An observation on 08/03/2026 at 10:40 AM, revealed Resident #2 with fingernails approximately one-half inch in length and a dark-brown substance underneath the nails. During an observation on 08/05/2026 at 11:26 AM, Resident #2's fingernails remained approximately one-half inch in length with a dark-brown substance underneath. An observation and interview on 08/05/2026 at 12:16 PM, Certified Nursing Assistant (CNA) #2 observed Resident #2's fingernails and confirmed they were dirty and needed to be trimmed. CNA #2 stated, Nail care should be done daily. She further stated that the wound-care nurses were responsible for trimming residents' fingernails. During an interview on 08/05/2026 at 12:18 PM, the Wound Care Coordinator stated that only a Registered Nurse (RN) could trim the fingernails of residents with diabetes. He stated CNAs could trim the fingernails of residents who did not have diabetes, but nail trimming usually became the nurses' responsibility. An interview with the Director of Nursing (DON) on 08/05/2026 at 12:25 PM, she revealed CNAs could file the fingernails of residents who did not have diabetes; however, she preferred that nurses' trim residents' fingernails. She stated she expected CNAs to ensure residents' fingernails were cleaned daily. Record review of the admission Record revealed Resident #2 was admitted to the facility on [DATE] with medical diagnoses that included Hypertensive Heart Disease without Heart Failure. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/1/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident #2 had severe cognitive impairment. Resident #26 An observation and interview on 08/03/2026 at 11:10 AM, and again on 8/04/2026 at 11:00 AM with Resident #26, revealed that the resident was lying in bed with facial hair approximately 1/4 inch in length. Resident #26 stated he had not been shaved lately, and he would like a shave. He couldn't remember his shower days but stated that they should shave him on his shower days. On 8/05/2026 at 10:30 AM, an observation of Resident #26 revealed he was sitting in the hall near the shower room and he had not been shaved, but confirmed he wanted a shave. Record review of Resident #26's Shower Sheet revealed he is showered on Tuesdays, Thursdays, and Saturdays. An interview on 8/05/2026 at 10:40 AM with DON revealed she was unaware Resident #26 had not been shaved this week. She stated the wound care coordinator shaves Resident #26, and he has been covering for another nurse and didn't have time this week. Record review of Resident #26' s admission Record revealed he was admitted to the facility on [DATE] with diagnoses that included heart disease. Record review of Resident #26's MDS with ARD of 6/02/2026 under Section C revealed a BIMS score of 05 which indicated he was severely cognitively impaired. Resident #38 On 08/03/2026 at 12:28 PM, an observation and interview with Resident #38 revealed the resident resting in bed with visibly unwashed, greasy hair. Resident #38 stated he had not received a shower in four days and commented that if he had to go home to get his showers, he would. He had an intact half-cast on his right arm and stated he required help with his showers. On 08/04/2026 at 3:25 PM, interview with Resident #38's wife revealed the only concern she had with the facility was the lack of scheduled showers. She stated she visited the resident daily and learned on Monday, 08/03/26, that he had not received a shower since Thursday, 07/30/26, resulting in four days without bathing. She reported requesting assistance from staff on both Saturday and Sunday to help the resident receive a shower, but staff advised they would check on it and never returned. Resident #38's wife stated that prior to admission, the resident showered and washed his hair every day and it was important to him to be clean. She further stated they had visitors over the weekend, and she wanted him to be clean and presentable. She confirmed the resident finally received a shower on Monday afternoon after returning from dialysis, which was not his scheduled shower day. She also reported that after the resident informed nursing staff that surveyors had asked about his missed showers, staff immediately assisted him with a shower. She expressed that it was upsetting to know he had gone without appropriate hygiene care and stated she simply wanted him to be properly cared for. On 08/05/2026 at 11:18 AM an interview with the Lead CNA revealed that Resident #38 was scheduled for showers every Tuesday, Thursday, and Saturday because he preferred not to shower before his early morning dialysis appointments. She stated she personally provided his shower on Thursday of the previous week and that the resident informed her on Monday, 08/03/2026, that he had not received another shower since then. Lead CNA stated that Resident #38 told her he felt dirty going to dialysis without bathing. She revealed that she apologized and assured him she would personally make sure he received his scheduled showers going forward. On 08/06/2026 at 9:15 AM an interview with the DON revealed that she was unaware Resident #38 had missed his scheduled showers over the weekend. She acknowledged that residents not receiving scheduled showers was unacceptable. She also agreed that failing to provide scheduled bathing could negatively impact a resident's dignity, self-esteem, hygiene, and cause embarrassment due to feeling or appearing unclean. Record review of Resident #38's admission Record revealed that he was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease and Hypertensive Heart Disease with Heart Failure. Record review of Resident #38's admission MDS with ARD of 07/17/26 under Section C revealed a BIMS score of 15 which indicated that he was cognitively intact. Resident #54 Aan observation and interview on 8/03/2026 at 10:50 AM, and again on 8/04/2026 at 11:05 AM with Resident #54 it revealed the resident in his wheelchair outside of his room, he was observed to have approximately 1/4 inch in length facial hair. Resident #54 stated that he had not been shaved lately and his shower day was on Monday. An observation and interview with Resident #54 on 8/05/2026 at 8:00 AM revealed he had not been shaved and stated he would like to be shaved. An interview on 8/05/2026 at 10:41 AM, with the DON revealed that she was unaware Resident #54 had not been shaved this week. She stated the Wound Care Coordinator shaves Resident #54 and he has been covering for another nurse and didn't have time. During an interview on 8/06/2026 at 8:10 AM with the Wound Care Coordinator, he stated he was really busy on 8/05/2026 with extra work and forgot to ask Resident #54 if he wanted to be shaved. Record review of Resident #54' s admission Record revealed that he was admitted to the facility on [DATE] with a diagnosis that included Unspecified Dementia. Record review of Resident #54's admission MDS with ARD of 6/16/2026 under Section C revealed a BIMS Score of 12 which indicated that he had moderate cognitive impairment.

Based on observations, interviews and facility policy review, the facility failed to store medications safely and securely for two (2) of four (4) days of survey.Findings include:Review of facility policy titled Storage of Medications revised April 2007, revealed, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.Resident #46On 8/3/2026 at 10:50 AM an observation revealed an unlabeled medication cup containing a residual amount of an unidentified pink, cream-like substance unsecured on Resident #46's bedside nightstand. Resident #46 occupied a shared room.During a follow-up observation and interview on 8/3/2026 at 10:52 AM, the Minimum Data Set (MDS) Coordinator observed the substance and stated that it looks like Calmoseptine, and confirmed that a medicated cream should not have been left at the bedside.Resident #49An observation and interview on 8/3/2026 at 10:29 AM, it was observed an unlabeled medication cup approximately one-third full of an unidentified white, cream-like substance left unattended at Resident #49's bedside. Resident #49 occupied a shared room and stated, The nurse brought it in. She is coming back to do my treatment.On 8/3/2026 at 10:36 AM, the medication cup remained unattended at Resident #49's bedside. During a concurrent observation and interview, the Wound Care Coordinator confirmed that the medication cup contained a white, cream-like substance and should not have been left at the bedside. He stated, Another resident could get it and use it inappropriately or even possibly eat it if they weren't of sound mind.During an interview on 8/4/2026 at 4:55 PM, the DON confirmed that medication cups containing medicated creams should never be left unattended at a resident's bedside. She stated that leaving medicated creams unsecured at the bedside presented a safety concern because they could be accessed by other residents.During an observation in the hallway near the nurses' station on 8/5/2026 at 12:16 PM, the medication cart assigned to the 400 Hall was observed unlocked and unattended. The cart's push-lock mechanism was extended in the unlocked position, and the medication-containing drawers, which contained prescription medications was accessible. The medication cart remained unlocked and unattended for approximately two minutes while the assigned nurse was inside a resident's room and was not in a position to maintain immediate control of the cart. During this time, residents, visitors, and staff passed through the hallway near the cart.During an interview on 8/5/2026 at 12:18 PM, the medication-cart nurse, Licensed Practical Nurse (LPN) #2, stated, I just grabbed something really quick and walked away for a minute. LPN #2 confirmed that the medication cart should never be left unlocked and stated, Anyone could get something out of the cart and accidentally take the wrong medication.During an interview on 8/5/2026 at 12:30 PM, the DON confirmed that medication carts should be locked whenever left unattended. She stated that leaving a medication cart unlocked created a risk because anyone could access and remove medications from the cart.

Based on resident and staff interviews, record review and facility policy review, the facility failed to ensure a resident's right to be treated with respect for one (1) of 52 residents reviewed. Anonymous Resident #1Findings Include:Review of facility policy, Resident Rights, revision date October 2025 revealed .Employees shall treat all residents with kindness, respect, and dignity . During an interview with Anonymous Resident #1 on 08/03/2026 at 11:30 AM, the resident stated that Certified Nursing Assistant (CNA) #5 entered her room the previous week while her roommate was attempting to get out of bed without assistance. Anonymous Resident #1 stated she had yelled out for help because she was afraid her roommate would fall and she did not have time to activate the call light. The resident stated that CNA #5 entered the room and yelled, Stop yelling, crazy lady! Anonymous Resident #1 stated CNA #5 frequently talks roughly to her and yells at her. The resident stated she had not reported the behavior because she feared retaliation.On 08/05/2026 at 8:35 AM during an interview with CNA #4, she revealed she had personally witnessed CNA #5 speaking to residents in a hateful and disrespectful manner, specifically Anonymous Resident #1. CNA #4 stated management was aware residents had previously complained regarding CNA #5 and the manner in which she communications with residents.During a telephone interview on 08/05/2026 at 11:00 AM with CNA #5, she revealed she was aware residents had complained to administration regarding the way she communicated with them. CNA #5 stated she talks loudly but did not believe she was being rude. CNA #5 acknowledged administration had counseled her in April and again in May of this year regarding resident complaints about her tone of voice. CNA #5 stated she could understand how residents might perceive her communication as rude and stated she would try to improve the loudness of her voice and her tone.Record review of the Resident Grievance/Complaint Form dated 5/3/26 revealed I turned on my light and CNA #5 knocked very hard and loud on my door. I asked her not to knock so loud and she was rude and said 'That's how I knock. What do you want?' I asked for pain pill and she did not tell my nurse.Recommendations/corrective actions taken: none. Unsubstantiated.CNA #5 agreed to be more aware of how hard she knocks.Record review of the Resident Grievance/Complaint Investigation Report Form dated 4/15/2026 revealed CNA #5 received counseling regarding her conduct while working with residents. The attachment revealed the resident stated, at times (CNA #5) is nice to her but most of the time she 'gets smart'. Resident said when she asked (CNA #5's) name, (CNA #5) asked her 'why are you going to report me?'. Then later she stuck her head inside her door and asked if the reason (Resident) needed her name was because she was going to be reported.(Resident).wants to be spoken to respectfully. Documentation indicated residents perceived her tone of voice and communication as rude and disrespectful. Record review of a Teachable Moment counseling form dated 4/15/2026 revealed CNA #5 was instructed to be mindful of her tone of voice and how her communication may be perceived by residents.Record review of Record of In-service Training by the Medicaid Fraud Control Unit of the Attorney General's office revealed CNA #5 completed an Abuse, Neglect and Exploitation in-service on 4/09/2026.Record review revealed CNA #5 also completed Resident Rights education on 7/01/2026.During an interview on 08/04/2026 at 4:00 PM, the Director of Nursing (DON) stated she had not received any recent complaints regarding CNA #5's communication with residents.During an interview on 08/05/2026 at 3:00 PM, the Administrator stated CNA #5 had previously been counseled regarding resident complaints related to the manner in which she spoke to residents. The Administrator stated CNA #5 She does talk loud, and stated he was unaware of any recent complaints.

Based on observation, resident and staff interviews, record review and facility policy review, the facility failed to ensure a clean home-like environment as evidenced by dirty wheelchairs for two (2) of fifty-five residents utilizing wheelchairs. Resident #43 and Resident #53 Findings Include Review of the facility policy titled, “Homelike Environment,” undated, revealed, “Residents are provided with a safe, clean, comfortable, and homelike environment.” An observation and interview on 8/12/2025 at 10:25 AM revealed Resident #43 sitting in a wheelchair with a thick grayish substance and food-like particles on the base of the wheelchair. Resident #43 revealed, I guess they don’t clean it very often, but it sure is dirty. An observation and interview on 8/12/2025 at 10:30 AM revealed Resident #53 sitting in her wheelchair; the spokes and base of the wheelchair have a thick grayish dried substance on it. Resident #53 stated that her wheelchair is dirty, and she didn't know when they last cleaned it. During an interview and observation on 8/13/2025 at 2:00 PM, Certified Nurse Aide (CNA) #1 revealed that the night shift CNAs are responsible for cleaning the wheelchairs. She confirmed that Resident #43 and Resident #53’s wheelchairs were dirty and needed cleaning. An interview on 8/13/2025 at 2:20 PM, Licensed Practical Nurse (LPN) #1 confirmed that the night shift CNAs were responsible for cleaning the residents' wheelchairs. She revealed there was a list that was kept in the nurses' unit that listed which wheelchairs they were responsible for cleaning each night, but she was unsure if the list was still there. During an observation and interview on 8/13/2025 at 2:57 PM, the Director of Nurses (DON) confirmed that Residents #43 and 53’s wheelchairs had thick gray substances and food particles on them and needed cleaning. The DON stated, We talked a while back about cleaning all the wheelchairs. Record review of Resident #43’s “admission Record” revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Retroperitoneal Fibrosis and Anxiety Disorder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of April 22, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #43 is cognitively intact. Record review of Resident #53’s “admission Record” revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Heart Failure, and Type 2 Diabetes Mellitus. Record review of the MDS with an ARD of July 17, 2025, revealed a BIMS score of 13, indicating Resident #53 is cognitively intact.

Based on observation, staff interview, record review, and facility policy review the facility failed to prevent the possibility of the spread of infection as evidenced by a urinary catheter bag and drainage tubing laying on the floor for (Resident #26) and failure to perform hand hygiene after handling a urinary catheter bag during wound care for (Resident #38) for (2) two of (7) seven care area observations. Findings include: A review of the facility policy titled, Urinary Tract Infections (Catheter-Associated). Guidelines for Preventing, revised September 2017, revealed Purpose: The purpose of this procedure is to guide guidelines for the prevention of catheter-associated urinary tract infections .Steps in the Procedure . 4. Always practice vigilant hand hygiene and standard precautions when handling catheter systems .6. c. Do not place the drainage bag on the floor . A review of the facility policy titled, Changing a Dressing, undated, revealed Procedure Guideline for Changing a Dressing: 1. Perform hand hygiene .14. Dispose of the gloves and soiled dressing . Perform hand hygiene . Apply clean gloves .16. Dispose of gloves and perform hand hygiene . Resident #26 In an observation of Resident #26 on 8/5/34 at 10:10 AM, the resident was observed to have a urinary catheter hanging on the right side of the bed, with the bottom of the catheter bag and drainage tubing observed sitting on the floor beside the bed. An observation of Resident #26 on 8/05/24 at 12:00 PM revealed a catheter bag and catheter drainage tube to be sitting on the floor. An observation of Resident #26 on 8/05/24 12:02 PM with Certified Nurse Assistant (CNA) #2 confirmed the bag should not be hanging down touching the floor because it was an infection control concern. In an interview with Licensed Practical Nurse (LPN) #2 on 8/06/24 at 9:27 AM revealed that catheters should not be touching the floor because it increases the risk of the transmission of infection. In an interview with the Infection Preventionist on 8/06/24 at 9:33 AM, she confirmed that Resident #26 catheter bag should never be touching the floor because of what might be on the floor and increases the risk of transmission of infection. Review of the Admission Record revealed Resident #26 was admitted by the facility on 7/17/20 with diagnoses that included Cerebral Infarction. Resident #38 An observation of wound care for Resident #38 on 8/7/24 at 10:15 AM, with LPN #1 revealed she entered the room, sanitized her hands and applied gloves, she then picked up the resident's catheter bag and sat in on the side of the resident's bed. She then continued setting up the wound supplies on the bedside table on a clean barrier after handling the catheter bag that was laying on the floor. LPN #1 then cleansed Resident #38's wound bed to his sacrum and applied the clean dressing supplies with the same gloves that were placed on her hands when she initially entered the room. In an interview with LPN #1 on 8/7/24 at 10:30 AM, she confirmed she did not perform hand hygiene after handling the catheter bag and cleaning the sacral wound bed. She also confirmed she did not perform hand hygiene before applying the clean dressing to the sacral wound bed. She then revealed by failing to perform hand hygiene, she placed the resident at risk for the transfer of bacteria to the wound and increased the risk for a wound infection. In an interview with the Director of Nursing (DON) on 8/07/24 at 10:32 AM, she confirmed that hand hygiene should have been performed after handling the catheter bag and during wound care. She revealed by not performing proper hand hygiene that it placed the resident at increased risk for infection. Review of the Admission Record revealed Resident #38 was admitted by the facility on 9/29/23 with diagnoses of Pressure ulcer of unspecified buttock, unspecified stage and Neuromuscular dysfunction of bladder. Record review of Resident #38's the Minimum Data Set (MDS) with an Assessment Reference Date of 5/07/24, Section C , revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was severely cognitively impaired Section H0300: was coded Resident #38 had a catheter for last seven days Section M0300 : was coded Resident #38 had one Stage 3 pressure ulcer.

Based on observation, resident, and staff interviews and facility policy review, the facility failed to maintain the building in a safe manner for one (1) of 47 resident rooms observed. (Resident #41). Findings include: Record review of the facility policy titled, Maintenance Service undated, revealed .Policy Interpretation and Implementation 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . An observation on 8/5/24 at 10:30 AM, of Resident #41's room revealed a 22 inch by 10 inch panel surrounded with a one (1) and one-half (1/2) inch metal frame on the wall that was one (1) inch above the headboard of the resident's bed. A three (3) inch section of the bottom part of the metal frame was noted to be bent and protruding outward from the wall. During an interview on 8/5/24 at 10:32 AM, with Resident #41 stated that the metal frame of the panel had been bent for quite some time, but she could not recall how long. In an interview on 8/5/24 at 10:40 AM, with the Maintenance, he stated that the panel was the door to the sprinkler system controls and that he was not aware that the metal frame was bent. He agreed that the metal frame protruding from the wall was dangerous and could cause an injury to the resident. On 8/5/24 at 11:00 AM, during an interview with Certified Nursing Assistant (CNA) #1, she stated that she did notice that the metal frame of the sprinkler panel was bent, protruding outward from the wall this morning, and she should have notified the Charge Nurse, but she did not. She stated that the bed did have a metal bar to keep the headboard from hitting the wall, but it is only used if the resident has a trapeze bar or equipment that may damage the wall. She denied knowing that the metal bar needed to be down on Resident #41's bed to prevent it from bending the sprinkler panel frame. In an interview on 8/6/24 at 8:45 AM, with the Housekeeper, she stated that she usually cleans Resident 41's room and that she had never noticed the sprinkler panel frame being bent. The Housekeeper also stated that she was not aware of the metal bar on the bottom of the bed that would keep the headboard from hitting the bed, and that no one ever informed her that it needed to be down to prevent Resident 41's headboard from hitting the sprinkler panel frame. During an interview on 8/6/24 at 9:23 AM, the Director of Nursing (DON) stated she was not aware that there was a sprinkler panel located in Resident 41's room or that the metal frame around the panel was bent. She stated she was not aware that the metal bar on the frame of the bed should have been down to prevent the headboard from hitting and bending the sprinkler panel frame. The DON agreed that there was nothing in place to prevent the headboard from bending the metal frame on the sprinkler panel and that it was dangerous and could cause an injury to the resident. Record review of the Admission Record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarct. Record review of the Quarterly Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 6/26/24 revealed, Resident 41's Brief Interview for Mental Status (BIMS) score was 12, indicating that she had moderate cognitive impairment.

Based on staff interview, record review, and facility policy review, the facility failed to notify the physician before holding a resident's long-acting insulin for (1) one of 14 residents reviewed. (Resident #30) Findings include: Review of the facility policy titled, Change in a Resident's Condition or Status, revised February 2021 revealed Policy Statement: Our facility promptly notifies the attending physician . of changes in the resident's medical/mental condition and/or status Review of the August 2024 Medication Administration Record for Resident #30 revealed Insulin Glargine Solution Pen-Injector 100 unit/milliliters (ml)-Inject 40 units subcutaneously two times a day related to Type 2 Diabetes was not administered on 8/1/24-8/4/24 at 2100 hours (9:00 PM) and 8/5/24 at 0600 hour (6:00 AM). An interview with the Director of Nursing (DON) on 8/07/24 at 9:09 AM, revealed that she spoke with Licensed Practical Nurse (LPN) #4, and she stated that she had held the scheduled insulin Glargine on those days because Resident #30's blood sugars were low and stated she had notified the charge nurse of the blood sugars but did not notify the physician. The DON confirmed that LPN # 4 should not have held the long-acting insulin Glargine without notifying the physician. LPN #4 was not available for an interview during the survey. In an interview with LPN #3 on 8/7/24 at 9:45 AM, she revealed she would notify the physician before holding a scheduled long-acting insulin and stated that the physician would be notified of any changes in the resident's condition. A phone interview with the Nurse Practitioner on 8/7/24 at 10:14 AM, confirmed she was made aware that Resident #30 had recent episodes of low blood sugars at night but confirmed she was not notified that the staff were not giving her long-acting insulin Glargine because of low blood sugars. She revealed the long-acting insulin Glargine would not have affected the low blood sugars, and she should have been notified before holding the insulin because she would have instructed staff not to hold the insulin. Review of the Admission Record revealed Resident #30 was admitted by the facility on 3/29/23 with diagnoses that included Type 2 Diabetes Mellitus. Record review of Resident #30's of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/2/24, Section C revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident was severely cognitively impaired. Section N0350 Insulin Injections : coded received seven injections during the last 7 days.

Based on observation, staff interview, record review, and facility policy review, the facility failed to promote the dignity of a resident who was observed with a urinary catheter with no privacy bag for (1) one of (5) five residents with catheters. (Resident #26) Findings include: A review of the facility policy titled, Dignity, dated February 2021, revealed Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction, with life, and feeling of self-worth and self-esteem Policy Interpretation and Implementation .12. a. Helping the resident to keep urinary catheter bags covered. An observation of Resident #26 from the open doorway of her room on 8/5/24 at 10:10 AM, revealed the resident to have a urinary catheter with no privacy bag hanging on the side of the bed facing the doorway. An observation of Resident #26 on 8/05/24 at 12:00 PM, revealed the door to the room to be open, a catheter bag and catheter drainage tube were observed to contain light yellow colored liquid with no privacy bag in use. An observation of Resident #26 on 8/05/24 at 12:02 PM, with Certified Nurse Assistant (CNA) #2 she confirmed the urine in the catheter bag was visible from the resident's doorway and that there was no privacy bag in use for the catheter. She revealed that it was a dignity issue because the bag with urine was visible from the doorway and stated anyone walking by could see it. Review of the Order Summary Report with active orders as of 8/6/24, revealed an order dated 8/2/24 Urinary Catheter .related to Obstructive and Reflux Uropathy In an interview with Licensed Practical Nurse (LPN) #2 on 8/06/24 at 9:27 AM, she revealed all residents with catheters should have a privacy bag in place to keep others from seeing the urine for the resident's dignity. In an interview with the Infection Preventionist on 8/06/24 at 9:33 AM, she confirmed that Resident #26 should have had a privacy bag covering her catheter bag to promote dignity. Review of the Admission Record revealed Resident #26 was admitted by the facility on 7/17/20 with diagnoses that included Obstructive and Reflux Uropathy.

Based on staff interviews, record review, and facility policy review, the facility failed to maintain accurately documented medical records on pressure ulcers for one (1) of five (5) residents reviewed. Resident #1. Findings Include: Record review of facility policy titled Charting and Documentation with revision date of July 2017 under Policy Interpretation and Implementation was documented, . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Record review of Resident #1's Wound Assessment Report for her left heel and right heel with Date of Assessment and Date wound identified documented as 05/22/23. Record review of Wound Assessment Report dated for 05/22/23 and for 06/13/22 also revealed under Wound Type as a Fluid filled blister with bruising. Record review of Resident #1's Wound Assessment Report for left heel and right heel with Date of Assessment and Date wound identified documented as 06/20/23. Record review also revealed under Wound Type as Pressure Ulcer, Unstageable due to suspected deep tissue injury. Record review of Resident #1's Matrix for Providers, provided to this State Agency (SA) on 08/08/23 revealed under Pressure Ulcer(s) that Resident #1 had a Pressure Ulcer that was Present on Admission (POA) from the hospital on 06/20/23. On 08/09/23 at 9:00 AM, an interview with Registered Nurse (RN) #1, who was also the charge nurse, confirmed that the fluid filled blisters were on Resident #1's bilateral heels when she left for the hospital. She also revealed that they had been providing wound care to these areas prior to her leaving the facility. She also stated, It is my understanding if someone had a fluid filled blister with bruising and you couldn't see anything underneath, it should have been staged as a suspected deep tissue injury to start with. RN #1 confirmed that Resident #1's fluid filled blisters had not opened and they had not been staged prior to leaving for the hospital. On 08/09/23 at 10:30 AM, an interview Registered Nurse (RN) #2, who was the Wound Care Supervisor, confirmed that the wounds were documented as Present on Admission from the hospital because they had worsened while resident was there in the hospital and not in the facility. On 08/09/23 at 3:00 PM, an interview with Director of Nursing (DON), revealed that Resident #1 was being treated for fluid filled blisters on her bilateral heels. She revealed that RN #2, Wound Care Supervisor, typically staged the wounds and she (DON) went by what she said because RN #2 had the training. DON revealed that resident had been sent out to the hospital earlier in the day for other issues besides the wound and that there was no documentation noted where the wounds had been assessed on this date prior to departure to the hospital. DON revealed that the blisters opened while in the hospital and when resident came back, the wounds looked a lot worse. DON confirmed that she knew about the blisters but was not aware of the bruising. She confirmed that this resident had these wounds prior to this hospital stay and confirmed that this should not have been documented to look like they were hospital acquired and that they did not accurately document this information on the medical record. On 08/10/23 at 4:00 PM, an interview with Administrator (ADM), confirmed that they had messed up, that there was a problem with accuracy of the wound documentation. He revealed that they had staff in place who were trained in these areas, and he would make sure they fixed it. Record review of Resident #1's Face Sheet revealed that resident was admitted on [DATE] and readmitted on [DATE] with the following diagnoses to include: Pneumonia, Hypertensive Heart Disease without heart failure, Type 2 Diabetes Mellitus, Alzheimer's Disease, Pain, Age-related physical debility, Pressure-induced Deep Tissue Damage of Right Heel, and Pressure-induced deep tissue Damage of Left Heel. Record review of Resident #1's Electronic Medical Records (EMR) documented that her most recent readmitted was 06/20/23 and documentation reflected that bilateral heels were Pressure-induced Deep Tissue Damage. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date of 06/26/2023 documented under Section C that resident had Brief Interview for Mental Status (BIMS) Score of 99 which indicated that resident was unable to participate in the interview.

Based on observation, staff interview, record review and facility policy review the facility failed to implement the care plan related to the proper handling of a catheter bag for one (1) of thirteen (13) care plans reviewed. Resident #15 Findings include: Review of the facility policy titled, Using the Care Plan, revealed the care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. Record review of the Care Plan with a problem onset date of 2/2/23 revealed, Problem/Need: Potential for urinary tract infection related to presence of indwelling catheter . Approaches: . Position catheter tubing and urine collection bag below level of bladder . On 05/02/23 at 3:20 PM, an observation of catheter and incontinent care for Resident #15 revealed the resident up in her wheelchair and was transferred to the bed by Certified Nursing Assistants (CNA) #2 and CNA #3 with a sit to stand lift. The observation revealed that CNA #3 removed the resident's catheter bag from the privacy cover and handed it to CNA #2 who held the urinary catheter bag at chest level to the resident during the transfer, then moved the urinary catheter bag to the arm/hand support area of the lift before finally placing the catheter bag on the lower bed rail after the resident was in bed. An interview on 05/02/23 at 3:40 PM, with CNA #2 revealed they should always hang the catheter bag on the bed and keep it below the bladder and stated that holding the bag too high can cause a urinary tract infection. CNA #2 confirmed that she had attended an in-service on incontinent care within the past year. An interview on 05/03/2023 at 11:15 AM. with the DON revealed the CNAs know they are supposed to keep the catheter bag below the bladder to prevent backflow and stated that this could cause a urinary tract infection. She confirmed that it is the only catheter they have in the building and these two CNAs don't normally take care of this resident, but all CNA's should know to keep the catheter bag below the bladder. An interview on 5/04/23 at 10:00 AM, with the Director of Nurses (DON) confirmed the care plan had not been followed if the resident's catheter bag had been held above the level of the bladder. Review of the facility Face Sheet for Resident #15 revealed a readmitted [DATE] with diagnoses that included Obstructive Uropathy, and Hypertensive Heart Disease without Heart Failure. Review of Section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/9/23 revealed a Brief Interview for Mental Status score of 15 which indicated Resident #15 was cognitively intact.

Based on observation, staff and resident interview, and facility policy review, the facility failed to provide privacy to a resident during incontinent care as evidenced by failure to close the window blinds for one (1) of three (3) residents observed for incontinent care. Resident #31 Findings include: Record review of the facility Procedural Guideline for Performing Perineal Care for a Female Patient, revealed, .#4 Provide privacy . An observation on 05/02/23 at 1:13 PM, revealed Certified Nursing Assistant (CNA) #1 provided incontinent care to Resident #31 and failed to close the window blinds on the large window in the resident's room to provide privacy to the resident. The observation revealed a large open area outside of the resident's window with a walkway and a busy parking lot present outside of the window. An interview on 05/02/23 at 1:25 PM. with CNA #1 revealed that she pulled the privacy curtain to provide privacy from the door but forgot to close the window blinds for privacy at the window and stated, I was in a hurry and just didn't do it. An interview on 5/3/23 at 8:35 AM, with Resident #31 revealed that she did not know the window blind was open when they did her care, but it should have been closed where nobody would see her that might be walking by outside. An interview on 5/3/23 at 11:20 AM, with the Director of Nursing (DON) revealed the blinds should have been closed to provide privacy in case anyone was outside. Record review of the in-service forms revealed CNA #1 attended an in-service/check off on perineal care and catheter care on 4/26/23, which included providing privacy. Review of the facility Face Sheet for Resident #31 revealed an admitted [DATE] with diagnoses that included Epilepsy, Heart Failure, and Anemia. Review of Section C of the significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/27/23 revealed a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated Resident #31 had severely impaired cognition.

Based on observation, staff interview, record review and facility policy review the facility failed to prevent the possibility of the spread of infection by failure to perform hand hygiene during incontinent care for one (1) of three (3) residents observed for incontinent care. Resident #15 Findings include: Review of the in-service education titled, Procedural Guidelines for Providing Catheter Care, revealed under #1. Perform hand hygiene and under #19. Dispose of all contaminated supplies in the appropriate receptacles. remove your gloves and perform hand hygiene. On 05/02/23 at 3:20 PM, an observation of catheter care and incontinent care for Resident #15 revealed Certified Nursing Assistant (CNA) #3 proceeded to perform catheter care and incontinent care and did not change her gloves during the procedure. After placing a clean brief on the resident, CNA #3 removed her gloves, adjusted the resident's shirt, and bed linens, placed a wedge under the resident's legs, adjusted her own glasses, and then handled the bed control and call light before washing her hands. An interview on 05/02/23 at 3:45 PM with CNA #3 confirmed she should have washed her hands when she took her gloves off because it could spread germs. Record review revealed CNA #3 had attended a check off/ in-service on perineal care and catheter care on 4/25/23. Review of the facility Face Sheet for Resident #15 revealed a readmitted [DATE] with diagnoses that include Displaced bimalleolar fracture left lower leg, Obstructive Uropathy, and Hypertensive Heart Disease without Heart Failure.

Based on observation, interview and facility policy review, the facility failed to prevent the possible spread of infection by failure to wear a face mask covering by dietary employees in the dietary department for three (3) of three (3) observations. Findings include: Review of facility's COVID-19, Prevention and Control Of policy, dated September 2020, revealed, this facility follows current guidelines and recommendations for the prevention and control of COVID-2019. This facility will follow the CDC (Centers for Disease Control and Prevention) recommendations to assist in prevention of respiratory germs into the facility in relation to COVID-19. This policy also revealed, facemask will be worn, covering the nose and mouth by all staff and visitors while in the building, except when actively eating in designated areas while observing social distancing. On 03/15/2021, at 10:30 AM , during the initial observation of the kitchen, two (2) dietary employees were in the kitchen area, the Dietary Manager, and another employee. Both employees were observed to not be wearing masks. During an interview on 03/15/2021, at 10:30 AM, the Dietary Manager (Dietary Staff #1) stated the facility is no longer in a COVID-19 outbreak, so the dietary employees are not wearing masks while in the kitchen. She stated they do wear masks when they leave the kitchen area. She stated most of the dietary staff have either had COVID-19 or have received the COVID-19 vaccinations. An observation on 3/16/2021, at 11:15 AM, revealed three (3) dietary employees in the kitchen area preparing food without wearing masks. An observation on 3/16/2021, at 2:30 PM, revealed the same three (3) dietary employees as observed earlier, in the kitchen area without wearing masks. An interview on 3/16/2021, at 2:35 PM, with the Dietary Manager (Dietary Staff #1), revealed the kitchen staff wore masks in the kitchen area when the facility was in a COVID-19 outbreak. She stated since they are not in an outbreak at this time, masks are not worn in the kitchen area. She stated they try to distance themselves in the kitchen. She stated they have been short staffed at times, so the three (3) of them work long days together and are almost like family since they spend up to 13 hours a day together. She stated since the governor of the state has decreased the mask mandate requirements, she thought it would be acceptable to not wear a mask in the kitchen area. She stated she has not had COVID-19 and has chosen not to take the vaccine at this point. She stated she has been in-serviced on Personal Protective Equipment (PPE) and mask use and knows the purpose is to decrease the transmission of diseases. An interview on 3/16/2021, at 2:38 PM, with Dietary Staff #2, revealed she tested positive for COVID-19 the week before Christmas. She stated she wore a mask at work when the facility was in a COVID-19 outbreak, but she has not worn a mask since facility is out of an outbreak. She stated most of the time, the employees are socially distanced while working so she thought it was fine to not wear a mask. She stated she had been in-serviced on PPE and mask use and knows the reason for wearing a mask is to decrease the spread of infections. An interview on 3/16/2021, at 2:40 PM, with Dietary Staff #3, revealed she tested positive for COVID-19 in March/April 2020. She stated she wore a mask while the facility was in an outbreak, but since the facility is not in an outbreak, she does not use one. She stated she is aware that masks decrease the spread of infection and stated she has been in-serviced on PPE and mask use. An interview on 3/18/2021, at 1:50 PM, with the Infection Control Nurse (ICN), revealed the facility employees have been in-serviced on PPE and mask use. The ICN stated all employees should be wearing a mask throughout the facility, including in the kitchen. The ICN stated none of the facility employees, including the dietary employees, have been instructed of a change in mask use requirements and should still be following recommended guidelines. The ICN stated signs were posted to remind employees that even though the facility is not in an outbreak, masks are still required. An interview on 3/18/2021, at 1:55 PM, with the Director of Nursing (DON), revealed the employees are required to be wearing masks while in the facility and have been in-serviced on PPE and mask use. The DON stated the state mask mandate changes made were not changed for health care facilities/long term care facilities and masks are still required in this facility. The DON confirmed the facility failed to follow infection control guidelines to decrease the likelihood of the spread of infection. An interview on 3/18/2021, at 1:55 PM, with the Administrator (ADM), revealed the employees are required to be wearing masks while in the facility. The ADM stated the kitchen staff should be wearing masks while in the facility, both in the kitchen area and out of the kitchen area. The ADM stated the kitchen employees have not been informed that mask requirements have changed. The ADM confirmed the facility failed to follow infection control guidelines. Record review of facility's in-service titled, PPE/COVID-19 Education dated 4/17/2020, revealed Dietary Staff #2's signature was on the in-service sign in sheet. Signatures of Dietary Staff #1 and Dietary Staff #3 were not on the in-service sign in sheet.

Based on record review, interviews and facility policy review, the facility failed to notify the family in writing of a hospital transfer for one (1) of one (1) hospitalization investigated, Resident #41. Findings include: Review of the facility's Transfer or Discharge, Emergency policy, revised December 2016, revealed, to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures which includes, notify the representative (sponsor) or other family member in writing and verbally. On 03/15/21, at 02:43 PM, on initial tour an interview with Resident #41 revealed he did go to the hospital recently but cannot remember why. He thinks it was during the snow and ice storm. On 03/17/21, at 03:00 PM, an interview with the Administrator revealed the facility is not sending any written transfer notifications to the family of residents being transferred. The Administrator revealed he is aware of the regulation that requires a written notification, but the facility has not been mailing any notifications to the families. On 03/17/21, at 03:10 PM, an interview with the Director of Nursing (DON) and Social Services (SS) revealed they did not know that a written notice was supposed to be mailed to families when a resident is transferred to the hospital. They revealed they did not know of any staff currently mailing notification of transfers to families. On 03/17/21, at 03:23 PM, an interview with Registered Nurse #1, revealed she works in medical records and she has not and did not know if she was supposed to be sending notifications to families in writing when a resident is transferred to the hospital. Record review revealed Resident #41 was transferred to the hospital on [DATE]. Resident #41 returned to facility on 2/16/21 to his existing room with [DIAGNOSES REDACTED]. The 5-day Minimum Data Set ((MDS) dated [DATE] for Resident #41 documented a Brief Interview for Mental Status (BIMS) score of 15 which reveals no cognitive impairment.

Based on staff and resident interviews, record review, and facility policy review, the facility failed to report an injury of unknown origin to the appropriate agencies for one (1) of four (4) incidents reviewed, Resident #29. Findings include: Review of the facility's Accidents and Incidents - Investigating and Reporting policy , not dated, revealed that all accidents or incidents involving residents, employees, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Record review of the facility's Resident Incident Report, dated 10/19/20 at 7:15 AM, revealed Resident #29 was found in her bathroom by Certified Nursing Assistant (CNA) #1 with a shower cap on her head. Blood was observed on the sink and toilet. An actively bleeding laceration measuring 3 1/2-centimeter (cm) x 4 cm with a pecan size hematoma was identified on the crown Resident #29's head. Resident was transferred to the emergency room (ER) for evaluation and received treatment which included three (3) staples to the laceration. On 03/17/21, at 11:20 AM, an interview with the Director of Nursing (DON) revealed Resident #29 had an unwitnessed incident causing a laceration to her head. Certified Nursing Assistant (CNA)#1 found a laceration on Resident #29's head when she took her to the shower and removed her shower cap. The DON stated the resident put her shower cap on to hide it. On 03/17/21, at 2:12 PM, an interview with the Administrator (ADM) confirmed that he was aware of the incident . He stated that incidents are discussed every morning in the stand-up meeting. He stated that the person who sent reports into the state no longer works here. He stated that he reviews the incident notebook about every week. The Administrator stated that he was responsible for reporting or making sure incidents were reported to the state. The Administrator confirmed the incident was not reported to the state. He stated that he just dropped the ball. On 03/18/21, at 12:59 PM, an interview with Resident #29 revealed she did not remember the incident but stated that she did not have anything on her head and showed the top of her head to this surveyor who observed the area to be healed. On 03/18/21, at 01:27 PM, an interview with Certified Nursing Assistant (CNA) #1 revealed she had gone into the resident's room the morning of the incident and found the resident up in the bathroom with blood smeared on the sink, floor, and commode. CNA #1 stated that Resident #29 had her shower cap on. She stated that she took the resident to the shower and when she removed the shower cap, Resident #29 had blood in her hair and CNA #1 reported it to the nurse. She stated that the resident could not tell her what happened.

Based on observation, accident and incident reports review, nurses notes review, family interview, staff interview and facility policy review, the facility failed to implement appropriate interventions to decrease the likelihood of falls for residents with dementia for one (1) of 20 resident records reviewed; Resident #8. The facility's failure to implement appropriate interventions for falls for Resident #8, who had dementia and who received a blood thinning medication caused a situation that was likely to cause serious injury, harm, impairment or death to Resident #8 and other residents at risk for falls. Resident #8 had a total of 24 falls from 10/19/16 through 10/05/17. Review of the incident reports and nurses' notes for Resident #8 revealed interventions implemented were not effective for a resident with severe cognitive impairment. A review of the incident reports from the date of admission through 10/05/17 identified that Resident #8 had 18 fall incidents. A review of the nurses' notes from 10/19/16 through 10/05/17 revealed Resident #8 had six (6) additional falls that the facility did not complete an incident report. On 10/17/17 at 11:05 A.M., the State Agency (SA) notified the facility's Administrator of Immediate Jeopardy at 42 CFR 483.25 (d) (2) as of 10/23/16 when Resident #8 fell while taking a blood thinner and the facility failed to initiate interventions to decrease the fall risk of Resident #8. The SA determined that the facility's noncompliance with the requirements of participation was likely to cause serious injury, harm, impairment or death to the resident. An acceptable, credible Allegation of Compliance was received 10/18/17. The State Agency (SA) determined the Immediate Jeopardy was removed on 10/18/17 prior to SA exit on 10/19/17. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.25 (d) (2), F323, was lowered to an D, while the facility monitors the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy entitled Falls and Fall Risk, Managing undated, revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks for falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified. Resident #8 Review of the face sheet revealed the facility admitted Resident #8 on 10/19/16 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/14/17 revealed a score of three (3) on the Brief Interview for Mental Status (BIMS) assessment which indicated severely impaired cognition. Review of the Physician order [REDACTED].#8 taking Eliquis (blood thinner). Review of incident reports and nurses' notes revealed Resident #8 had a total of 24 falls from 10/19/16 through 10/05/17. A review of Resident #8's incident reports since her admission on 10/19/16 through 10/05/17, revealed the reports identified that Resident #8 had 18 fall incidents. Review of the nurses' notes for Resident #8 from 10/19/16 through 10/05/17 revealed six (6) additional falls that the facility did not have incident reports completed. Review of the nurses' notes and fall incident reports dated 10/23/16 through 10/05/17 revealed the following injuries associated for Resident #8 who had a Brief Interview for Mental Status (BIMS) score of three (3) which indicated severe cognitive impairment and who was receiving anticoagulant therapy and interventions implemented: On 10/23/16, the facility found Resident #8 on the floor beside her bed and the resident was unable to recall if she hit her head. The resident had a one (1) centimeter (cm) skin tear to her right elbow. The facility's Immediate Post-Incident Action was, Encouraged resident to utilize call light for assistance. On 11/26/16, Resident #8 had two (2) separate falls. The first fall was at 2:30 A.M. which resulted in a skin tear to the left elbow. The second fall occurred at 8:50 A.M. resulted with another skin tear to the left elbow. The facility's Immediate Post-Incident Action was the resident was encouraged to utilize call light for assistance, taught the importance of personal alarm, and clip alarm checked and placed on resident. On 12/10/16, Resident #8 had an unwitnessed fall which resulted in a fracture to left pinky finger; scratch to left pinky finger and hematoma/bruising to right middle finger. The facility's Immediate Post-Incident Action was the facility removed clip alarm with new order for sensor alarm to bed and wheelchair at all times. On 01/12/17, Resident #8 had a fall which resulted in a lesion to the right brow and right pinky, skin tear to left finger and skin tear to right wrist. The facility sent the resident to the emergency room . The facility's Immediate Post-Incident Action was continued with clip alarm to wheelchair and bed. On 02/02/17, Resident #8 had a fall which resulted in a skin tear to the right knee. The facility's Immediate Post-Incident Action was Certified Nursing Assistant (CNA) to stay with resident when not in bed or wheelchair. Review of the resident's care plan and facility documentation failed to reveal the initiation of this intervention. On 02/06/17, Resident #8 had a fall which resulted in a laceration to left side of forehead, hematoma to left side of forehead and a laceration to second finger and ring finger of left hand. The facility sent Resident #8 to the emergency room . The facility's Immediate Post-Incident Action was to continue with sensor to wheelchair at all times. On 04/17/17, Resident #8 had a fall which resulted in a deep laceration to left side of forehead. The facility sent Resident #8 to the emergency room . The facility's Immediate Post-Incident Action was, Personal alarm clip to bed and wheelchair and fall mat to beside at all times. On 04/20/17, Resident #8 had a fall which resulted in a skin tear to the right hand. The facility laundry staff pushed the resident into the hallway and left the resident unattended. The facility's Immediate Post-Incident Action was to talk with staff and laundry about leaving resident. On 04/27/17, Facility staff found Resident #8 lying on the floor of her room and resident said she hit her head. The fall resulted in a hematoma to the occipital lobe. The facility's Immediate Post-Incident Action were neurological checks and Alarms already in place. Resident encouraged to wait for assistance when needing transfer. Encouraged staff to check resident frequently between rounds. On 06/19/17, The facility heard Resident #8's alarm and resident yelling help me. The facility incident report document the resident was found on the the floor beside the bed on her buttocks with her legs on top of the garbage can with undergarment pulled down. The facility documented the resident's fall resulted in a skin tear to the right ring finger. The facility started neurological checks, removed the garbage can, and documented, sensor alarm to bed remains and functioning properly. On 07/05/17, Resident #8 had a fall which resulted in a two (2) cm skin tear to the right thumb and 2 cm skin tear to the right outer forearm. The facility's Immediate Post-Incident Action was resident encouraged to call for assistance and wait for help. On 10/05/17, the facility found Resident #8 on the floor on buttocks. The incident report read, alarm not sounding and resident had apparently turned alarm off. The fall resulted in a skin tear to the left hand. The facility's Immediate Post-Incident Action read, keep alarm out of reach/sight from resident. Review of the nurses' notes for Resident #8 from 10/19/16 through 10/05/17 revealed six (6) additional falls without injuries and interventions: Nurses' note documentation revealed: 11/07/16 - Unwitnessed fall, no injury; will continue to monitor. 11/08/16 - Unwitnessed fall, no injury; instructed resident to call for assist with transfer, alarms put in use to wheelchair and sensor alarm added to bed at night. 11/19/16 - Unwitnessed fall, no injury; patient teaching implemented. 11/22/16 - Unwitnessed fall, no injury; encourage resident to use call light when needing assistance and explained to resident to lock wheelchair. 01/12/17 - Witnessed fall; no injury; no interventions documented. 04/02/17 - Unwitnessed fall; no injury; no interventions documented. Observation on 10/16/17 at 12:55 PM and on 10/17/17 at 3:45 PM revealed Resident #8 was confused and unable to respond appropriately to questions. Interview on 09/21/17 at 8:45 AM with the Director of Nursing (DON) revealed she was told that residents have the right to fall. The DON stated the facility had initiated an alarm for Resident #8. Interview on 9/21/17 at 9:00 AM with the current Administrator revealed that she had only been at this facility for the past two months and she was unaware of Resident #8's multiple falls. The Administrator stated that the falls should have be reported and the facility should have been tracking the falls. An interview on 9/21/17 at 12:30 PM with the QA Nurse revealed Resident #8 had experienced multiple falls. The QA Nurse revealed the facility had tried clip alarm, sensor pad and fall mat, but resident had been non-compliant with those devices. QA Nurse stated that she was aware that Resident #8 had received Restorative nursing services. Interview on 10/17/17 at 2:25 PM with Certified Nursing Assistant (CNA) #1 revealed Resident #8 alarm on wheelchair, alarm pad on bed, and fall mat have been used to help with falls. CNA #1 revealed Resident #8 is placed at the nurses' station to be watched and toileted every two (2) hours. Interview on 10/17/17 at 4:00 PM with CNA #2 revealed Resident #8 has a bed alarm that sounds to alert staff when resident is on the floor. Interview on 10/17/17 at 8:53 AM with the Responsible Party (RP) for Resident #8 revealed he was aware of the resident having multiple falls. RP stated she doesn't understand that she is not to get up. RP revealed the facility had applied alarms to the bed and wheelchair and taking her to the bathroom as ways to prevent falls. The facility provided an acceptable Allegation of Compliance on 10/19/17 at 3:40 PM for the Immediate Jeopardy (IJ). Review of the facility's A(NAME) revealed the facility took the following actions to remove the IJ: A Quality Assurance meeting was held on 10/17/2017 at 1:22 PM with the following staff present: (MD) Medical Director, (DON) Director of Nursing, (ADM) Administrator, (QA) Quality Assurance/ Infection Control Nurse, (MDS 1) MDS Nurse 1, (MDS 2) MDS Nurse 2, (MDS 3) MDS Nurse 3 and (TDS) Therapy Department Supervisor. During this meeting, fall policy, Care plan policy and Accident/ Incident policies were reviewed. It was determined no revisions were needed to these policies. During the 10/17/2017 QA meeting Resident #8's care plan interventions for falls, restraint, low bed use and medication regimen were discussed. On 10/17/2017 immediate interventions for Resident #8 included 1:1 observations at nursing station. On 10/17/2017 at 1:30 PM the MD ordered medication changes: Remeron, Percocet and Eliquis were discontinued. Xanax was decreased to 0.25 mg 1 tablet by mouth at bed time as needed. The frequency of Tylenol dosing was increased from every 8 hours as needed to every 6 hours as needed. On 10/17/2017 at 1:39 PM the MD ordered a low bed and a self-releasing alarm belt. Resident # 8 was assessed by MDS 3 for use of a self-releasing alarm belt to wheelchair and low bed and it was determined that these interventions were appropriate to prevent falls for Resident #8. The responsible party was notified via phone by MDS 1 and MDS 2 on 10/17/2017 at 1:22 PM with verbal consent received for use of self-releasing alarm belt to wheelchair and low bed. The self-releasing alarm belt was applied to Resident # 8 at 1:45 PM 10/17/2017 by MDS 2. Resident #8's care plan interventions related to falls were revised by DON and MDS 2 on 10/17/2017 at 1:50 PM. In an attempt to determine if any other residents were at risk for this immediate jeopardy situation, the DON, MDS 2 and Administration in Training (AIT) conducted 100 percent audit of all fall care plans on 10/17/2017 at 10:15 PM to ensure that listed fall interventions were appropriate. Of the 51 total resident fall care plans reviewed, 8 residents' care plans were updated per DON, AIT and MDS 2. All residents currently residing in the facility since last survey on 07/22/2016 had fall risk assessments reviewed and updated on 10/17/2017 at 4:30 PM per MDS 3, DON and MDS 2. An in-service was initiated by the DON on 10/17/2017 at 3:00 PM with CNAs, Nurses, Laundry personnel, Housekeeping personnel and Dietary personnel that were on duty (CNA- 11; LPN- 6; RN- 4; Laundry- 1; Dietary- 6; Housekeeping- 2; Activities Director- 1; Administrator- 1; Therapy- 1; Administrative Assistant- 1; Administrator in Training - 1). Additional in-services were held at 4:00 PM per MDS 1 with Dietary staff x 3, Social Services Director x 1, Medical Records x 1, and Maintenance Supervisor x 1. At 11:15 PM, this in-service continued per DON with LPN x 3 and CNA x 3. In-services included appropriate actions to take if a resident falls. In addition, nurses were also in-serviced on A & I reporting, updating care plans with appropriate interventions. No staff will be allowed to work until they are in-serviced. Based on QA meeting held on 10/17/2017 at 1:22 PM, the facility will monitor for the effectiveness of these changes for all residents. The facility alleges the immediate jeopardy was removed on 10/18/2017. On 10/19/17, the State Survey Agency (SA) validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable Credible Allegation of Compliance was validated by staff interviews and record review in-services on 10/19/17, across all disciplines. The SA validated through review of in-service sign in sheets and staff interviews that four (4) Registered Nurses (RNs) and nine (9) Licensed Practical Nurses (LPNs) were in-serviced on proper Accident and Injury (A&I) reporting and the updating of care plans with appropriate interventions, during the in-services held on 10/17/17. The SA further validated through in-service sign in sheets and staff interviews that 14 Certified Nursing Assistants (CNAs), one (1) Laundry personnel, nine (9) Dietary personnel, two (2) Housekeeping personnel, one (1) Activity personnel, two (2) contract Therapy personnel, one (1) Administrative Assistant, one (1) Social Services personnel, one (1) Medical Records personnel, and one (1) Maintenance personnel were in-serviced on the appropriate actions to take if a resident falls, during the in-services held on 10/17/17. The SA validated by facility record review that all residents currently residing in the facility since last survey (7/22/2016) had fall risk assessments reviewed and updated. By review of the facility's sign in sheet with discussion topics and interview of attending staff members, the SA validated a Quality Assurance meeting was held on 10/17/2017 at 1:22 P M with the following staff present: (MD) Medical Director, (DON) Director of Nursing, (ADM) Administrator, (QA) Quality Assurance/ Infection Control Nurse, (MDS 1) MDS Nurse 1, (MDS 2) MDS Nurse 2, (MDS 3) MDS Nurse 3 and (TDS) Therapy Department Supervisor. The SA further validated through a review of a synopsis of this meeting that the facility's Fall policy, Care plan policy, and Accident/ Incident policies were reviewed with no revisions made. The meeting synopsis also validated that during the 10/17/2017 QA meeting Resident #8's care plan interventions for falls, restraint, low bed use and medication regimen were discussed. The SA validated by direct observation, Resident #8's immediate interventions of 1:1 observations at nursing station were put into place on 10/17/17. The SA validated Resident #8's medication changes ordered by the Physician on 10/17/17 at 1:30 PM to include: Remeron, Percocet and Eliquis were discontinued. Xanax was decreased to 0.25 mg 1 tablet by mouth at bedtime as needed. The frequency of Tylenol dosing was increased from every 8 hours as needed to every 6 hours as needed. These orders were validated by review of the handwritten physician's orders [REDACTED]. The SA validated the ordering of a low bed and a self-releasing alarm belt by reviewing the physician's orders [REDACTED]. This was validated by direct observation of self-releasing alarm belt on Resident #8 and the presence of the low bed in resident's room. The SA validated responsible party notification by telephone interview and review of the alarm belt and low bed consent. The SA reviewed Resident #8's care plan and validated that interventions included the self release alarming seat belt and the low bed. The SA reviewed and validated the 100 percent (100%) audit of all fall care plans that were conducted by the DON, Administrator in Training (AIT), and the MDS Nurse on 10/17/2017 at 10:15 PM to ensure that listed fall interventions were appropriate. It was also validated that the eight (8) residents identified care plans were updated to include appropriate fall interventions.

Based on observation, accident and incident record review, staff interview and facility policy review, the facility failed to revise the care plan related to falls to include effective interventions to decrease falls for residents with dementia for three (3) of 20 resident care plans reviewed; Resident #8. The facility's failure to revise the care plan interventions for falls for a resident with dementia and who was receiving a blood thinning medication caused a situation that was likely to cause serious injury, harm, impairment or death to Resident #8 as well as other residents. The facility admitted Resident #8 taking a blood thinner medication (Eliquis) and failed to initiate interventions to decrease the resident's likelihood for repeated falls. The facility assessed Resident #8 with a Brief Interview for Mental Status (BIMS) of three (3) which indicated the resident had severe cognitive impairment. Resident #8 had a total of 24 falls from 10/19/16 through 10/05/17. Review of the incident reports and nurses' notes for Resident #8 revealed interventions implemented were not effective for a resident with severe cognitive impairment. A review of the incident reports from the date of admission through 10/05/17 identified that Resident #8 had 18 fall incidents. A review of the nurses' notes from 10/19/16 through 10/05/17 revealed Resident #8 had six (6) additional falls that the facility did not complete an incident report. On 10/17/17 at 11:05 A.M., the State Agency (SA) notified the facility's Administrator of Immediate Jeopardy at 42 CFR 483.21 Resident Assessment (F280) as of 10/23/16 when Resident #8 fell while taking a blood thinner and the facility failed to revise the care plan for interventions to decrease the fall risk of Resident #8. The SA determined that the facility's noncompliance with the requirements of participation was likely to cause serious injury, harm, impairment or death to the resident. An acceptable, credible Allegation of Compliance was received 10/18/17. The State Agency (SA) determined the Immediate Jeopardy was removed on 10/18/17. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.21 (F280), was lowered to an D, while the facility monitors the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy entitled Care Plans-Comprehensive undated, revealed, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans when the desired outcome is not met. Resident #8 A review of Resident #8's Multiple Falls care plan, with an onset date of 04/25/17 for Resident #8, revealed goals and interventions that were not appropriate for a resident with the Dementia. Resident #8's goals included Resident will ask for assist with transfers. Resident #8 had a [DIAGNOSES REDACTED]. Comparison of the accident and incident reports for Resident #8 from 10/23/16 through 10/05/17 to the care plan revealed interventions for frequent checks, toilet every hour, toilet every two hours, one to one observation and keep alarm out of sight were not listed on the resident's care plan. Interventions on the care plan included 2 person assist with transfers, sensor alarm to bed at all times for multiple falls and resident removing clip alarm, fall mat to bedside when in bed, sensor alarm to W/C (wheelchair) at all times to alert staff of unassisted transfers, Bowel and Bladder program x 14 days (without a start date), maintain resident environment free of clutter, place items frequently used by resident within easy reach, and analyze previous falls by resident to determine whether pattern/trend can be addressed. Review of the facility's Bladder Roster for Resident #8 revealed the facility did not document 14 days of Bowel and Bladder program. The facility provided the following evidence of staff documented bladder assistance for Resident #8: on 2/6/17 at 2:23 AM, 2:06 PM, 7:14 PM; 2/7/17 at 3:10 AM, 2:14 PM, and 7:44 PM; on 4/17/17 at 3:34 AM, 6:42 AM, 1:55 PM, 3:57 PM, 6:32 PM, 9:13 PM; on 4/18/17 at 6:28 AM, 2:04 PM, 10:02 PM; 4/27/27 at 3:46 AM, 2:20 PM, 4:27 PM and on 4/28/17 at 5:46 AM, 10:15 AM, and 7:31 PM. Interview on 10/17/17 at 11:10 AM with the Administrator and Director of Nursing (DON) revealed the Minimum Data Set (MDS) nurses make the determination as to what goes on the care plan. Interview on 10/17/17 at 11:45 AM with the MDS Nurse, Registered Nurse (RN) #2, revealed Resident #8 had severely impaired cognition. After review of the fall care plan, RN #2 and agreed the care plan was not updated with goals and interventions that were appropriate for Resident #8 with dementia. Interview on 10/17/17 at 3:20 PM with Licensed Practical Nurse (LPN) #3 revealed it would not be appropriate to have an intervention to call for assistance on a resident with a Brief Interview for Mental Status (BIMS) score of three (3). LPN #3 stated They don't have the recall ability to remember that. LPN #3 further revealed immediate interventions are initiated when a fall occurs, however; it is the staff responsibility to review what is currently in place to see if these interventions have failed. Observation on 10/16/17 at 12:55 PM and on 10/17/17 at 3:45 PM revealed Resident #8 was confused and unable to respond appropriately to questions. A review of the face sheet revealed the facility admitted Resident #8 on 10/19/16 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/14/17 revealed a score of three (3) on the Brief Interview for Mental Status (BIMS) which indicated severely impaired cognition. The facility provided an acceptable Allegation of Compliance on 10/19/17 at 3:40 PM for the Immediate Jeopardy (IJ). Review of the facility's A(NAME) revealed the facility took the following actions to remove the IJ: A Quality Assurance meeting was held on 10/17/2017 at 1:22 PM with the following staff present: (MD) Medical Director, (DON) Director of Nursing, (ADM) Administrator, (QA) Quality Assurance/ Infection Control Nurse, (MDS 1) MDS Nurse 1, (MDS 2) MDS Nurse 2, (MDS 3) MDS Nurse 3 and (TDS) Therapy Department Supervisor. During this meeting, fall policy, Care plan policy and Accident/ Incident policies were reviewed. It was determined no revisions were needed to these policies. During the 10/17/2017 QA meeting Resident #8's care plan interventions for falls, restraint, low bed use and medication regimen were discussed. On 10/17/2017 immediate interventions for Resident #8 included 1:1 observations at nursing station. On 10/17/2017 at 1:30 PM the MD ordered medication changes: [MEDICATION NAME] and Eliquis were discontinued. [MEDICATION NAME] was decreased to 0.25 mg 1 tablet by mouth at bed time as needed. The frequency of Tylenol dosing was increased from every 8 hours as needed to every 6 hours as needed. On 10/17/2017 at 1:39 PM the MD ordered a low bed and a self-releasing alarm belt. Resident # 8 was assessed by MDS 3 for use of a self-releasing alarm belt to wheelchair and low bed and it was determined that these interventions were appropriate to prevent falls for Resident #8. The responsible party was notified via phone by MDS 1 and MDS 2 on 10/17/2017 at 1:22 PM with verbal consent received for use of self-releasing alarm belt to wheelchair and low bed. The self-releasing alarm belt was applied to Resident # 8 at 1:45 PM 10/17/2017 by MDS 2. Resident #8's care plan interventions related to falls were revised by DON and MDS 2 on 10/17/2017 at 1:50 PM. In an attempt to determine if any other residents were at risk for this immediate jeopardy situation, the DON, MDS 2 and Administration in Training (AIT) conducted 100 percent audit of all fall care plans on 10/17/2017 at 10:15 PM to ensure that listed fall interventions were appropriate. Of the 51 total resident fall care plans reviewed, 8 residents' care plans were updated per DON, AIT and MDS 2. All residents currently residing in the facility since last survey on 07/22/2016 had fall risk assessments reviewed and updated on 10/17/2017 at 4:30 PM per MDS 3, DON and MDS 2. An in-service was initiated by the DON on 10/17/2017 at 3:00 PM with CNAs, Nurses, Laundry personnel, Housekeeping personnel and Dietary personnel that were on duty (CNA- 11; LPN- 6; RN- 4; Laundry- 1; Dietary- 6; Housekeeping- 2; Activities Director- 1; Administrator- 1; Therapy- 1; Administrative Assistant- 1; Administrator in Training - 1). Additional in-services were held at 4:00 PM per MDS 1 with Dietary staff x 3, Social Services Director x 1, Medical Records x 1, and Maintenance Supervisor x 1. At 11:15 PM, this in-service continued per DON with LPN x 3 and CNA x 3. In-services included appropriate actions to take if a resident falls. In addition, nurses were also in-serviced on A & I reporting, updating care plans with appropriate interventions. No staff will be allowed to work until they are in-serviced. Based on QA meeting held on 10/17/2017 at 1:22 PM, the facility will monitor for the effectiveness of these changes for all residents. The facility alleges the immediate jeopardy was removed on 10/18/2017. On 10/19/17, the State Survey Agency (SA) validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable Credible Allegation of Compliance was validated by staff interviews and record review in-services on 10/19/17, across all disciplines. The SA validated through review of in-service sign in sheets and staff interviews that four (4) Registered Nurses (RNs) and nine (9) Licensed Practical Nurses (LPNs) were in-serviced on proper Accident and Injury (A&I) reporting and the updating of care plans with appropriate interventions, during the in-services held on 10/17/17. The SA further validated through in-service sign in sheets and staff interviews that 14 Certified Nursing Assistants (CNAs), one (1) Laundry personnel, nine (9) Dietary personnel, two (2) Housekeeping personnel, one (1) Activity personnel, two (2) contract Therapy personnel, one (1) Administrative Assistant, one (1) Social Services personnel, one (1) Medical Records personnel, and one (1) Maintenance personnel were in-serviced on the appropriate actions to take if a resident falls, during the in-services held on 10/17/17. The SA validated by facility record review that all residents currently residing in the facility since last survey (7/22/2016) had fall risk assessments reviewed and updated. By review of the facility's sign in sheet with discussion topics and interview of attending staff members, the SA validated a Quality Assurance meeting was held on 10/17/2017 at 1:22 P M with the following staff present: (MD) Medical Director, (DON) Director of Nursing, (ADM) Administrator, (QA) Quality Assurance/ Infection Control Nurse, (MDS 1) MDS Nurse 1, (MDS 2) MDS Nurse 2, (MDS 3) MDS Nurse 3 and (TDS) Therapy Department Supervisor. The SA further validated through a review of a synopsis of this meeting that the facility's Fall policy, Care plan policy, and Accident/ Incident policies were reviewed with no revisions made. The meeting synopsis also validated that during the 10/17/2017 QA meeting Resident #8's care plan interventions for falls, restraint, low bed use and medication regimen were discussed. The SA validated by direct observation, Resident #8's immediate interventions of 1:1 observations at nursing station were put into place on 10/17/17. The SA validated Resident #8's medication changes ordered by the Physician on 10/17/17 at 1:30 PM to include: [MEDICATION NAME] and Eliquis were discontinued. [MEDICATION NAME] was decreased to 0.25 mg 1 tablet by mouth at bedtime as needed. The frequency of Tylenol dosing was increased from every 8 hours as needed to every 6 hours as needed. These orders were validated by review of the handwritten physician's orders [REDACTED]. The SA validated the ordering of a low bed and a self-releasing alarm belt by reviewing the physician's orders [REDACTED]. This was validated by direct observation of self-releasing alarm belt on Resident #8 and the presence of the low bed in resident's room. The SA validated responsible party notification by telephone interview and review of the alarm belt and low bed consent. The SA reviewed Resident #8's care plan and validated that interventions included the self release alarming seat belt and the low bed. The SA reviewed and validated the 100 percent (100%) audit of all fall care plans that were conducted by the DON, Administrator in Training (AIT), and the MDS Nurse on 10/17/2017 at 10:15 PM to ensure that listed fall interventions were appropriate. It was also validated that the eight (8) residents identified care plans were updated to include appropriate fall interventions.

Based on record review, staff interview and facility policy review, the facility failed to report falls with injury to the State Agency for one (1) of 13 resident records reviewed for falls; Resident #8. The facility admitted Resident #8 taking a blood thinner medication (Eliquis) and failed to initiate interventions to decrease the resident's likelihood for repeated falls. The facility assessed Resident #8 with a Brief Interview for Mental Status (BIMS) of three (3) which indicated the resident had severe cognitive impairment. Review of incident reports and nurses notes revealed Resident #8 had a total of 24 falls from 10/19/16 through 10/05/17. Review of the incident reports and nurses' notes for Resident #8 revealed interventions implemented were not effective for a resident with severe cognitive impairment. A review of the incident reports from the date of admission through 10/05/17 identified that Resident #8 had 18 fall incidents. A review of the nurses' notes from 10/19/16 through 10/05/17 revealed Resident #8 had six (6) additional falls for which the facility did not complete an incident report. The facility's failure to protect the resident by reporting injuries of unknown origin to the State Agency (SA) for a resident with dementia and who was receiving a blood thinning medication caused a situation that was likely to cause serious injury, harm, impairment or death to Resident #8 as well as other residents. On 10/17/17 at 11:05 A.M., the State Agency (SA) notified the facility's Administrator of Immediate Jeopardy at 42 CFR 483.12 (c) (1), Report Injuries of Unknown Origin (F225) as of 10/23/16 when Resident #8 experienced the first of 24 falls in the facility, in which the facility failed to revise the care plan and initiate appropriate interventions for a resident with severe cognitive impairment on blood thinners to decrease the resident's fall risk. The SA determined that the facility's noncompliance with the requirements of participation was likely to cause serious injury, harm, impairment or death to the resident. An acceptable, credible Allegation of Compliance was received 10/18/17. The State Agency (SA) determined the Immediate Jeopardy was removed on 10/18/17. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.21 (F280), was lowered to an D, while the facility monitors the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's policy entitled Abuse Investigations dated 04/14, revealed all reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The Administrator will provide a written report of the results of all investigations and appropriate action taken to the state survey and certification agency. A review of the facility's policy entitled Reporting Abuse to Facility Management dated 04/14, revealed injury of unknown source is defined as an injury that was not observed by any person or the source of the injury could not be explained by the resident; and the incidence of injuries over time. Review of the facility's policy entitled Reporting Abuse to State Agencies and Other Entities/Individuals dated 12/09, revealed The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. Resident #8 A review of the State Agency record of Facility Reported Incidents (FRI) revealed there were no incidents reported since the last survey in 07/16 for any residents including Resident #8. A review of Resident #8's incident reports since her admission on 10/19/16 through 10/05/17, revealed the reports identified that Resident #8 had 18 fall incidents. Review of the nurses' notes for Resident #8 from 10/19/16 through 10/05/17 revealed six (6) additional falls that the facility did not have incident reports completed. Resident #8 had a total of 24 falls from 10/19/16 through 10/05/17. Of these unwitnessed falls, the facility documented five (5) falls with serious injury. Review of Resident #8's incident reports and nurses notes revealed the following: On 12/10/16, Resident #8 had an unwitnessed fall which resulted in a fracture to left pinky finger; scratch to left pinky finger and hematoma/bruising to right middle finger. On 01/12/17, Resident #8 had a fall hitting her head which resulted in a lesion to the right brow and right pinky, skin tear to left finger and skin tear to right wrist. Resident sent to the emergency room . On 02/06/17, Resident #8 had a fall which resulted in a laceration to left side of forehead, hematoma to left side of forehead and a laceration to second finger and ring finger of left hand. Resident sent to emergency room . On 04/17/17, Resident #8 had a fall which resulted in a deep laceration to left side of forehead. Resident sent to emergency room . On 04/27/17, Resident #8 had a fall hitting her head which resulted in a hematoma to the occipital lobe. Observation on 10/16/17 at 12:55 PM and on 10/17/17 at 3:45 PM revealed Resident #8 was confused and unable to respond appropriately to questions. Interview on 09/21/17 at 8:45 AM with the Director of Nursing (DON) revealed I wasn't aware we had to report falls. The DON stated that the facility could not assume that someone pushed a resident when a residents had a fall. The DON stated, she was now aware that it should be reported and would report unwitnessed falls with injury. Interview on 9/21/17 at 9:00 AM with the current Administrator revealed she had been at this facility for a couple of months. The Administrator stated, anything that is unwitnessed and the resident can't tell you what happened should be reported to the State Agency. The Administrator revealed that she was unaware that Resident #8 had multiple unwitnessed falls with injury and that it had not being reported to the State Agency. An interview on 9/21/17 at 12:30 PM with the Quality Assurance (QA) nurse, Licensed Practical Nurse (LPN) #2, revealed she confirmed Resident #8 had experienced multiple falls that were not reported. Review of the face sheet revealed the facility admitted Resident #8 on 10/19/16 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/14/17 revealed a score of three (3) on the Brief Interview for Mental Status (BIMS) which indicated severely impaired cognition. The facility provided an acceptable Allegation of Compliance on 10/19/17 at 3:40 PM for the Immediate Jeopardy (IJ). Review of the facility's A(NAME) revealed the facility took the following actions to remove the IJ: A Quality Assurance meeting was held on 10/17/2017 at 1:22 PM with the following staff present: (MD) Medical Director, (DON) Director of Nursing, (ADM) Administrator, (QA) Quality Assurance/ Infection Control Nurse, (MDS 1) MDS Nurse 1, (MDS 2) MDS Nurse 2, (MDS 3) MDS Nurse 3 and (TDS) Therapy Department Supervisor. During this meeting, fall policy, Care plan policy and Accident/ Incident policies were reviewed. It was determined no revisions were needed to these policies. During the 10/17/2017 QA meeting Resident #8's care plan interventions for falls, restraint, low bed use and medication regimen were discussed. On 10/17/2017 immediate interventions for Resident #8 included 1:1 observations at nursing station. On 10/17/2017 at 1:30 PM the MD ordered medication changes: [MEDICATION NAME] and Eliquis were discontinued. [MEDICATION NAME] was decreased to 0.25 mg 1 tablet by mouth at bed time as needed. The frequency of Tylenol dosing was increased from every 8 hours as needed to every 6 hours as needed. On 10/17/2017 at 1:39 PM the MD ordered a low bed and a self-releasing alarm belt. Resident # 8 was assessed by MDS 3 for use of a self-releasing alarm belt to wheelchair and low bed and it was determined that these interventions were appropriate to prevent falls for Resident #8. The responsible party was notified via phone by MDS 1 and MDS 2 on 10/17/2017 at 1:22 PM with verbal consent received for use of self-releasing alarm belt to wheelchair and low bed. The self-releasing alarm belt was applied to Resident # 8 at 1:45 PM 10/17/2017 by MDS 2. Resident #8's care plan interventions related to falls were revised by DON and MDS 2 on 10/17/2017 at 1:50 PM. In an attempt to determine if any other residents were at risk for this immediate jeopardy situation, the DON, MDS 2 and Administration in Training (AIT) conducted 100 percent audit of all fall care plans on 10/17/2017 at 10:15 PM to ensure that listed fall interventions were appropriate. Of the 51 total resident fall care plans reviewed, 8 residents' care plans were updated per DON, AIT and MDS 2. All residents currently residing in the facility since last survey on 07/22/2016 had fall risk assessments reviewed and updated on 10/17/2017 at 4:30 PM per MDS 3, DON and MDS 2. An in-service was initiated by the DON on 10/17/2017 at 3:00 PM with CNAs, Nurses, Laundry personnel, Housekeeping personnel and Dietary personnel that were on duty (CNA- 11; LPN- 6; RN- 4; Laundry- 1; Dietary- 6; Housekeeping- 2; Activities Director- 1; Administrator- 1; Therapy- 1; Administrative Assistant- 1; Administrator in Training - 1). Additional in-services were held at 4:00 PM per MDS 1 with Dietary staff x 3, Social Services Director x 1, Medical Records x 1, and Maintenance Supervisor x 1. At 11:15 PM, this in-service continued per DON with LPN x 3 and CNA x 3. In-services included appropriate actions to take if a resident falls. In addition, nurses were also in-serviced on A & I reporting, updating care plans with appropriate interventions. No staff will be allowed to work until they are in-serviced. Based on QA meeting held on 10/17/2017 at 1:22 PM, the facility will monitor for the effectiveness of these changes for all residents. The facility alleges the immediate jeopardy was removed on 10/18/2017. On 10/19/17, the State Survey Agency (SA) validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable Credible Allegation of Compliance was validated by staff interviews and record review in-services on 10/19/17, across all disciplines. The SA validated through review of in-service sign in sheets and staff interviews that four (4) Registered Nurses (RNs) and nine (9) Licensed Practical Nurses (LPNs) were in-serviced on proper Accident and Injury (A&I) reporting and the updating of care plans with appropriate interventions, during the in-services held on 10/17/17. The SA further validated through in-service sign in sheets and staff interviews that 14 Certified Nursing Assistants (CNAs), one (1) Laundry personnel, nine (9) Dietary personnel, two (2) Housekeeping personnel, one (1) Activity personnel, two (2) contract Therapy personnel, one (1) Administrative Assistant, one (1) Social Services personnel, one (1) Medical Records personnel, and one (1) Maintenance personnel were in-serviced on the appropriate actions to take if a resident falls, during the in-services held on 10/17/17. The SA validated by facility record review that all residents currently residing in the facility since last survey (7/22/2016) had fall risk assessments reviewed and updated. By review of the facility's sign in sheet with discussion topics and interview of attending staff members, the SA validated a Quality Assurance meeting was held on 10/17/2017 at 1:22 P M with the following staff present: (MD) Medical Director, (DON) Director of Nursing, (ADM) Administrator, (QA) Quality Assurance/ Infection Control Nurse, (MDS 1) MDS Nurse 1, (MDS 2) MDS Nurse 2, (MDS 3) MDS Nurse 3 and (TDS) Therapy Department Supervisor. The SA further validated through a review of a synopsis of this meeting that the facility's Fall policy, Care plan policy, and Accident/ Incident policies were reviewed with no revisions made. The meeting synopsis also validated that during the 10/17/2017 QA meeting Resident #8's care plan interventions for falls, restraint, low bed use and medication regimen were discussed. The SA validated by direct observation, Resident #8's immediate interventions of 1:1 observations at nursing station were put into place on 10/17/17. The SA validated Resident #8's medication changes ordered by the Physician on 10/17/17 at 1:30 PM to include: [MEDICATION NAME] and Eliquis were discontinued. [MEDICATION NAME] was decreased to 0.25 mg 1 tablet by mouth at bedtime as needed. The frequency of Tylenol dosing was increased from every 8 hours as needed to every 6 hours as needed. These orders were validated by review of the handwritten physician's orders [REDACTED]. The SA validated the ordering of a low bed and a self-releasing alarm belt by reviewing the physician's orders [REDACTED]. This was validated by direct observation of self-releasing alarm belt on Resident #8 and the presence of the low bed in resident's room. The SA validated responsible party notification by telephone interview and review of the alarm belt and low bed consent. The SA reviewed Resident #8's care plan and validated that interventions included the self release alarming seat belt and the low bed. The SA reviewed and validated the 100 percent (100%) audit of all fall care plans that were conducted by the DON, Administrator in Training (AIT), and the MDS Nurse on 10/17/2017 at 10:15 PM to ensure that listed fall interventions were appropriate. It was also validated that the eight (8) residents identified care plans were updated to include appropriate fall interventions.

Based on Quality Assurance (QA) meeting sign in sheets, record review, staff interview, and facility policy review, the facility failed to initiated tracking and trending of falls or identify the extent of Resident #8's falls and failed to identify and implement preventative measures to reduce the amount of resident falls through a review of the Quality Assessment and Assurance Committee (QAAC) program for one (1) of 20 residents reviewed for falls and for seven (7) of eight (8) Quality Assurance (QA) meeting sign in sheets reviewed as evidenced by Resident #8 had a total of 24 falls from 10/19/16 through 10/05/17. Resident #8 sustained a fracture of her finger and wrist, hematomas to head with stitches, various skin tears, and contusions. The facility admitted Resident #8 taking a blood thinner medication (Eliquis) and failed to initiate interventions to decrease the resident's likelihood for repeated falls. The facility assessed Resident #8 with a Brief Interview for Mental Status (BIMS) of three (3) which indicated the resident had severe cognitive impairment. The facility's failure to track and trend falls or identify quality deficiencies related to falls for residents with dementia and/or residents receiving a blood thinning medication caused a situation that was likely to cause serious injury, harm, impairment or death to Resident #8 and other residents at risk for falls. On 10/17/17 at 11:05 A.M., the State Agency (SA) notified the facility's Administrator of Immediate Jeopardy at 42 CFR 483.75 Quality Assessment and Assurance as of 10/23/16 when Resident #8 experienced the first of 24 falls in the facility, in which the facility failed to initiate appropriate interventions for a resident with severe cognitive impairment on blood thinners, nor initiated tracking and trending of the falls or identify the extent of falls. An acceptable, credible Allegation of Compliance was received 10/18/17. The State Agency (SA) determined the Immediate Jeopardy was removed on 10/18/17. The Scope and Severity for Immediate Jeopardy at 42 CFR 483.75 (F520), was lowered to an D, while the facility monitors the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the facility's policy entitled Quality Assessment and Assurance Committee (QAAC) dated 08/06 revealed the facility shall establish and maintain a QAAC that oversees the identification and handling of quality issues. Primary goals of the QAAC included to monitor and evaluate the appropriateness and quality of care provided, to help identify negative outcomes relative to resident care and resolve them appropriately and to help departments, consultants and ancillary services establish effective accountability for care quality. The committee will oversee the development and implementation of actions to correct quality concerns and promote overall quality of care and services in the facility. Review of the QA sign in sheets dated 7/29/16, 10/25/16, 12/20/16, 1/04/17, 3/02/17, 6/01/17 and 8/16/17 revealed the Medical Director, Administrator, Director of Nurses, Quality Assurance Nurse, Minimum Data Set Nurse, Certified Occupational Therapist Assistant, Medical Records, Social Services and Activities Director attended the QA meetings. Interview on 9/19/17 at 11:50 AM with Registered Nurse (RN) #1 and observation of Resident #8 revealed she was not interviewable, but propels herself in a wheelchair. The RN stated the resident was incontinent of bowel and bladder and had a history of [REDACTED]. Interview on 10/17/17 at 11:20 AM with the Director of Nursing (DON) revealed fall incidents are randomly addressed during the QA meeting. The DON further revealed the facility had not discussed or attempted any other interventions such as a seatbelt or another assistive device to help prevent falls. An interview on 9/21/17 at 12:30 PM with the QA Nurse, Licensed Practical Nurse (LPN) #2, revealed she was aware Resident #8 had experienced multiple falls. The QA Nurse explained the facility had tried clip alarm, sensor pad and fall mat, but resident had been non-compliant with those devices. QA Nurse revealed that Resident #8 had not been specifically discussed and tracked by the QA committee, but falls were discussed in general. The QA Nurse revealed that along with the QA role, she also served as the Infection Control nurse, Staff Development nurse, and ordered supplies for the facility. Interview on 10/17/17 at 3:05 PM with the Medical Director (MD) revealed that he and his partner rotate attending Quality Assurance (QA) meetings and the number of overall falls in the facility are discussed in the meetings. The MD stated the number of falls are discussed but not necessarily the residents involved. The MD revealed the facility had just caught him up to the number of falls experienced by Resident #8. The MD further revealed he had spoken to the Administrator and was told the facility had initiated some things now that should have been initiated already. MD stated, I can assure you that the QA meetings will be more in depth. Interview on 10/17/17 at 8:53 AM with the Responsible Party (RP) for Resident #8 revealed he was aware of the multiple falls. RP stated, she doesn't understand that she is not to get up. RP revealed the facility had applied alarms to the bed and wheelchair and taking her to the bathroom as ways to prevent falls. A review of the face sheet revealed the facility admitted Resident #8 on 10/19/16 with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/14/17 revealed a score of three (3) on the Brief Interview for Mental Status (BIMS) which indicated severely impaired cognition. The facility provided an acceptable Allegation of Compliance on 10/19/17 at 3:40 PM for the Immediate Jeopardy (IJ). Review of the facility's A(NAME) revealed the facility took the following actions to remove the IJ: A Quality Assurance meeting was held on 10/17/2017 at 1:22 PM with the following staff present: (MD) Medical Director, (DON) Director of Nursing, (ADM) Administrator, (QA) Quality Assurance/ Infection Control Nurse, (MDS 1) MDS Nurse 1, (MDS 2) MDS Nurse 2, (MDS 3) MDS Nurse 3 and (TDS) Therapy Department Supervisor. During this meeting, fall policy, Care plan policy and Accident/ Incident policies were reviewed. It was determined no revisions were needed to these policies. During the 10/17/2017 QA meeting Resident #8's care plan interventions for falls, restraint, low bed use and medication regimen were discussed. On 10/17/2017 immediate interventions for Resident #8 included 1:1 observations at nursing station. On 10/17/2017 at 1:30 PM the MD ordered medication changes: [MEDICATION NAME] and Eliquis were discontinued. [MEDICATION NAME] was decreased to 0.25 mg 1 tablet by mouth at bed time as needed. The frequency of Tylenol dosing was increased from every 8 hours as needed to every 6 hours as needed. On 10/17/2017 at 1:39 PM the MD ordered a low bed and a self-releasing alarm belt. Resident # 8 was assessed by MDS 3 for use of a self-releasing alarm belt to wheelchair and low bed and it was determined that these interventions were appropriate to prevent falls for Resident #8. The responsible party was notified via phone by MDS 1 and MDS 2 on 10/17/2017 at 1:22 PM with verbal consent received for use of self-releasing alarm belt to wheelchair and low bed. The self-releasing alarm belt was applied to Resident # 8 at 1:45 PM 10/17/2017 by MDS 2. Resident #8's care plan interventions related to falls were revised by DON and MDS 2 on 10/17/2017 at 1:50 PM. In an attempt to determine if any other residents were at risk for this immediate jeopardy situation, the DON, MDS 2 and Administration in Training (AIT) conducted 100 percent audit of all fall care plans on 10/17/2017 at 10:15 PM to ensure that listed fall interventions were appropriate. Of the 51 total resident fall care plans reviewed, 8 residents' care plans were updated per DON, AIT and MDS 2. All residents currently residing in the facility since last survey on 07/22/2016 had fall risk assessments reviewed and updated on 10/17/2017 at 4:30 PM per MDS 3, DON and MDS 2. An in-service was initiated by the DON on 10/17/2017 at 3:00 PM with CNAs, Nurses, Laundry personnel, Housekeeping personnel and Dietary personnel that were on duty (CNA- 11; LPN- 6; RN- 4; Laundry- 1; Dietary- 6; Housekeeping- 2; Activities Director- 1; Administrator- 1; Therapy- 1; Administrative Assistant- 1; Administrator in Training - 1). Additional in-services were held at 4:00 PM per MDS 1 with Dietary staff x 3, Social Services Director x 1, Medical Records x 1, and Maintenance Supervisor x 1. At 11:15 PM, this in-service continued per DON with LPN x 3 and CNA x 3. In-services included appropriate actions to take if a resident falls. In addition, nurses were also in-serviced on A & I reporting, updating care plans with appropriate interventions. No staff will be allowed to work until they are in-serviced. Based on QA meeting held on 10/17/2017 at 1:22 PM, the facility will monitor for the effectiveness of these changes for all residents. The facility alleges the immediate jeopardy was removed on 10/18/2017. On 10/19/17, the State Survey Agency (SA) validated the facility had implemented the following measures to remove the Immediate Jeopardy. The acceptable Credible Allegation of Compliance was validated by staff interviews and record review in-services on 10/19/17, across all disciplines. The SA validated through review of in-service sign in sheets and staff interviews that four (4) Registered Nurses (RNs) and nine (9) Licensed Practical Nurses (LPNs) were in-serviced on proper Accident and Injury (A&I) reporting and the updating of care plans with appropriate interventions, during the in-services held on 10/17/17. The SA further validated through in-service sign in sheets and staff interviews that 14 Certified Nursing Assistants (CNAs), one (1) Laundry personnel, nine (9) Dietary personnel, two (2) Housekeeping personnel, one (1) Activity personnel, two (2) contract Therapy personnel, one (1) Administrative Assistant, one (1) Social Services personnel, one (1) Medical Records personnel, and one (1) Maintenance personnel were in-serviced on the appropriate actions to take if a resident falls, during the in-services held on 10/17/17. The SA validated by facility record review that all residents currently residing in the facility since last survey (7/22/2016) had fall risk assessments reviewed and updated. By review of the facility's sign in sheet with discussion topics and interview of attending staff members, the SA validated a Quality Assurance meeting was held on 10/17/2017 at 1:22 P M with the following staff present: (MD) Medical Director, (DON) Director of Nursing, (ADM) Administrator, (QA) Quality Assurance/ Infection Control Nurse, (MDS 1) MDS Nurse 1, (MDS 2) MDS Nurse 2, (MDS 3) MDS Nurse 3 and (TDS) Therapy Department Supervisor. The SA further validated through a review of a synopsis of this meeting that the facility's Fall policy, Care plan policy, and Accident/ Incident policies were reviewed with no revisions made. The meeting synopsis also validated that during the 10/17/2017 QA meeting Resident #8's care plan interventions for falls, restraint, low bed use and medication regimen were discussed. The SA validated by direct observation, Resident #8's immediate interventions of 1:1 observations at nursing station were put into place on 10/17/17. The SA validated Resident #8's medication changes ordered by the Physician on 10/17/17 at 1:30 PM to include: [MEDICATION NAME] and Eliquis were discontinued. [MEDICATION NAME] was decreased to 0.25 mg 1 tablet by mouth at bedtime as needed. The frequency of Tylenol dosing was increased from every 8 hours as needed to every 6 hours as needed. These orders were validated by review of the handwritten physician's orders [REDACTED]. The SA validated the ordering of a low bed and a self-releasing alarm belt by reviewing the physician's orders [REDACTED]. This was validated by direct observation of self-releasing alarm belt on Resident #8 and the presence of the low bed in resident's room. The SA validated responsible party notification by telephone interview and review of the alarm belt and low bed consent. The SA reviewed Resident #8's care plan and validated that interventions included the self release alarming seat belt and the low bed. The SA reviewed and validated the 100 percent (100%) audit of all fall care plans that were conducted by the DON, Administrator in Training (AIT), and the MDS Nurse on 10/17/2017 at 10:15 PM to ensure that listed fall interventions were appropriate. It was also validated that the eight (8) residents identified care plans were updated to include appropriate fall interventions.

Based on record review, staff interview, and policy review, the facility failed to ensure that one (1) of six (6) resident's reviewed was not neglected by the failure of CNA #4 to use the lift and/or assistance when transferring Resident #5. Resident #5 was identified to require the use of a lift and two (2) person transfers. On 12/25/10 at 8:10 p.m. CNA #4 transferred Resident #5 without assistance or the use of the lift. Resident #5 sustained a six (6) centimeter (cm) by six (6) cm laceration to the lower left leg. Resident #5 was transferred to the emergency room and required six (6) sutures to close the laceration. Findings include: Record review revealed that Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/30/2011 revealed that Resident #5 was moderately impaired in cognitive skills for daily decision making. Resident #5 required extensive assistance of two (2) or more with transfers. Required extensive assistance of one (1) person to walk in room or corridor. Resident #5 had impairments on one (1) side in the upper and lower extremity. Mobility devices were identified as being a walker and a wheelchair. Review of the resident's December 02, 2010 admission orders [REDACTED]. Review of the Nursing Notes dated 12/25/10 at 8:10 p.m. revealed: "Called to room per CNA. Resident up in w/c (wheelchair) beside bed, blood running down her left calf... 6 cm x 6 cm laceration noted to area with a whitish yellow fatty substance showing." The Physician was notified and Resident #5 was transferred to the emergency room . Resident #5 returned from the emergency roiagnom on [DATE] at 12:10 a.m. She had six (6) sutures in place to close the laceration. Review of the physician's orders [REDACTED]. Cleanse et (and) dry, apply TAO (Triple Antibiotic Ointment). Apply dry dressing Q (every) day et prn (as needed) until healed. Remove sutures in 14 days on Jan. 8, 2011." Review of the "Fall Risk Assessment" dated 12/2/10 revealed that Resident #5 had a score of 22. The assessment stated that score of 10 - 14 was determined to be at high risk for falls and care planned as such. Review of the "Resident Assessment for Lift/Transfers/Assistance" dated 12/2/2010 revealed that Resident #5 required the use of the sit to stand lift with two (2) persons to assist with transfers. Review of the "Resident Care Plan for Nursing Assistants-Care instructions" with a beginning date of 12/2/10 revealed: "Mechanical Lift - use sit to stand lift with a large sling." Transfers skills stated extensive assistance of two (2) persons." Review of the Care Plan dated 12/21/10 revealed the problem: "ADLS - Requires supervision to extensive assist (assistance)." An approach stated: "Vera lift with transfers". Interview with CNA #4 was conducted on 03/02/2011 at 4:25 p.m. CNA #4 confirmed that she did not use the lift when she transferred Resident #4 on 12/25/10. CNA #4 also confirmed that she knew to use the lift with the assistance of another person. CNA #4 stated that she thought she could transfer her without the lift. CNA #4 said that when Resident #5 turned she bumped her leg on the toilet paper holder and cut her leg. Review of the facilities in service records revealed on 04/27/2010 at 2:00 p.m. CNA #4 attended an in-service on "Lift Safety". Interview on 03/02/2011 at 5:00 p.m. with CNA #1 revealed that they have a care plan on all the residents. It indicates that what kind of lift is required. CNA #1 stated that anytime there is a lift used that two (2) persons are required for transfer for safety reasons. Interview on 03/02/2011 at 5:05 p.m. with CNA #2 revealed that the type of lift for use with Resident's is on the assignment sheet and ADL (Activities of Daily Living) book. CNA #2 stated that the total lift requires two (2) persons to assist with transfers. CNA #2 stated that the sit to stand lift requires one (1) person to assist with transfers. Interview on 03/02/2011 at 5:23 p.m. with CNA #3 revealed that they always have the ADL book to refer to for the type of lift to be used. CNA #3 stated that Resident #5 is a two (2) person assist with the lift. Interview on 03/03/2011 at 6:20 p.m. with LPN #1 confirmed that CNA #4 did not use the lift as ordered. Interview on 03/03/2011 at 7:30 p.m. with the DON confirmed that CNA #4 did not use the lift as ordered.

Based on record review, staff interview, and policy review, the facility failed to use the lift when transferring one (1) of six (6) residents reviewed which resulted in an avoidable accident. Resident #5 was identified to require the use of a lift and two (2) person transfers. On 12/25/10 at 8:10 p.m. CNA #4 transferred Resident #5 without assistance or the use of the lift. Resident #5 sustained a six (6) centimeter (cm) by six (6) cm laceration to the lower left leg. Resident #5 was transferred to the emergency room and required six (6) sutures to close the laceration. Findings include: Record review revealed that Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/30/2011 revealed that Resident #5 was moderately impaired in cognitive skills for daily decision making. Resident #5 required extensive assistance of two (2) or more with transfers. Required extensive assistance of one (1) person to walk in room or corridor. Resident #5 had impairments on one (1) side in the upper and lower extremity. Mobility devices were identified as being a walker and a wheelchair. Review of the December 2010 physician's orders [REDACTED]. Review of the Nursing Notes dated 12/25/10 at 8:10 p.m. revealed: "Called to room per CNA. Resident up in w/c (wheelchair) beside bed, blood running down her left calf... 6 cm x 6 cm laceration noted to area with a whitish yellow fatty substance showing." The Physician was notified and Resident #5 was transferred to the emergency room . Resident #5 returned from the emergency roiagnom on [DATE] at 12:10 a.m. She had six (6) sutures in place to close the laceration. Review of the physician's orders [REDACTED]. Cleanse et (and) dry, apply TAO (Triple Antibiotic Ointment). Apply dry dressing Q (every) day et prn (as needed) until healed. Remove sutures in 14 days on Jan. 8, 2011." Review of the "Fall Risk Assessment" dated 12/2/10 revealed that Resident #5 had a score of 22. The assessment stated that score of 10 - 14 was determined to be at high risk for falls and care planned as such. Review of the "Resident Assessment for Lift/Transfers/Assistance" dated 12/2/2010 revealed that Resident #5 required the use of the sit to stand lift with two (2) persons to assist with transfers. Review of the "Resident Care Plan for Nursing Assistants-Care instructions" with a beginning date of 12/2/10 revealed: "Mechanical Lift - use sit to stand lift with a large sling." Transfers skills stated extensive assistance of two (2) persons." Review of Resident #5`s nursing care plan dated "12/21/10" stating: ADLS... page 4 of 21 ...Requires Supervision of Extensive Assist ..." There was no documentation of any Lift equipment on the care plan. A hand written approach was listed stating: "Vera lift with transfers". An interview on 03/03/2011 with LPN #1 revealed that the care plan did not have the "Vera Lift to Stand Lift" on it on 12/21/10. LPN #1 stated that she had just updated the care plan for the use of the "Vera Lift" on 03/02/2011. Interview with CNA #4 was conducted on 03/02/2011 at 4:25 p.m. CNA #4 confirmed that she did not use the lift when she transferred Resident #4 on 12/25/10. CNA #4 also confirmed that she knew to use the lift with the assistance of another person. CNA #4 stated that she thought she could transfer her without the lift. CNA #4 said that when Resident #5 turned she bumped her leg on the toilet paper holder and cut her leg. Review of the facilities in service records revealed on 04/27/2010 at 2:00 p.m. CNA #4 attended an in-service on "Lift Safety". Interview on 03/02/2011 at 5:00 p.m. with CNA #1 revealed that they have a care plan on all the residents. It indicates that what kind of lift is required. CNA #1 stated that anytime there is a lift used that two (2) persons are required for transfer for safety reasons. Interview on 03/02/2011 at 5:05 p.m. with CNA #2 revealed that the type of lift for use with Resident's is on the assignment sheet and ADL (Activities of Daily Living) book. CNA #2 stated that the total lift requires two (2) persons to assist with transfers. CNA #2 stated that the sit to stand lift requires one (1) person to assist with transfers. Interview on 03/02/2011 at 5:23 p.m. with CNA #3 revealed that they always have the ADL book to refer to for the type of lift to be used. CNA #3 stated that Resident #5 is a two (2) person assist with the lift. Interview on 03/03/2011 at 6:20 p.m. with LPN #1 confirmed that CNA #4 did not use the lift as ordered. Interview on 03/03/2011 at 7:30 p.m. with the DON confirmed that CNA #4 did not use the lift as ordered. Review of the "Lifting Policy" dated 3/09 revealed: "The specific lift to be used for each patient will be shown via a color coded sticker and other charting methods. Any staff member found physically lifting a patient who has been designated a Lift or Lift and Stand candidate could be subject to disciplinary action unless 2 person lifting assistance is used when the lift will not fit in small areas such as bathrooms and other tight areas." "Procedures - (2) Staff will follow the documented lifting protocol deemed appropriate for each resident. This information is documented in the resident's chart, on the ADL sheets and a color coded sticker system is used to help identify the appropriate lift to be used." "This information should be referred to prior to lifting/transferring or assisting each resident."