Every finding on record at Warren Barr Buffalo Grove

Based on observation, interview, and record review the facility failed to keep a resident free from physical abuse. This applies to 2 of 4 residents (R1 & R2) reviewed for abuse in the sample of 6. The findings include:The facility's abuse report final form dated 7/8/26 shows, On 7/6/26, at around 2:20 PM, R1 was ambulating on the dementia unit when she entered R2's room and was allegedly reaching for items in the room when R2 said to her, do not touch my stuff and R1 allegedly reached her hand out and allegedly made contact with R2's cheek. On 7/15/26 at 10:18 AM, R2 was lying in bed. When asked if he had an incident with any other residents on his unit, R2 stated, a new resident (R1) had come into his room, messing with his stuff a week or so ago. He was laying in bed when the new resident (R1) came into his room messing with his stuff. She saw a belt that caught her eye and grabbed it. A care giver was with her and tried to get the belt but R1 would not let the belt go. R2 got up out of bed and tried to grab the belt from R1, when R1 scratched him. She had long nails and deliberately went for my face. He had a scratch on his face and pointed to the area by the right side of his cheek/nose. On 7/15/26 at 10:07 AM, V3 Certified Nursing Assistant (CNA) stated, she was doing rounds when she saw R1 go into R2's room. She followed R1 into the room and asked her to be leave because it was not her room but another resident's room. R1 would not leave the room. She grabbed R2's belt. R2 tried to get up and take the belt from R1. R1 did not want to give the belt to R2. R1 went towards him and scratched him a little bit in the face. On 7/15/26 at 10:35 AM, V4 Licensed Practical Nurse (LPN) stated, V3 CNA reported to her that an incident had happened in R2's room. The residents were already separated at that time. R1 was a confused, dementia patient. She was ambulatory and walked around the unit. R1 did scratch R2's face. R2's skin alteration nursing evaluation dated 7/6/26 shows, a new skin alteration on the right side of his cheek measuring 0.5 cm (centimeters) in length. resident scratched by fellow resident. The incident/offense report from the local police department dated 7/6/26 shows, a 911 call was made on 7/6/26 at 2:31 PM to the facility. The report shows, R2 is the complainant. In summary: On 7/6/26 at approximately 1431 (2:31 PM) hours, officer and I responded to a delayed battery that occurred at the facility. The complainant, [AGE] year old R2, called 911 to report a delayed battery that had occurred. Upon arrival, officer and I met with R2 on the third floor of the facility, which houses the memory care unit. Medical records provided by the facility indicated that R2 had been diagnosed with dementia. R2 stated, R1 entered his room and began going through his personal belongings. He told R1 to stop and notified facility staff of the situation. R2 stated he then approached R1, at which time she scratched him on the face with her finger nails. According to R2, nursing staff intervened and separated the two residents. I observed two scratches on R2's face, which he stated had already been treated by the facility's medical staff. R1's progress notes dated 7/6/26 shows, R1 tried to take the belongings of the another resident. During the accident R1 was noted to scratching the face of another resident. R1's progress notes dated 7/6/26 shows, The resident was noted with aggressive behavioral toward another resident. R1's previous progress notes dated 7/4/26 & 7/5/26 also show, R1 had behaviors of taking other residents belongings and the nurse's computer. The facility's abuse and retaliation policy dated 7/3/26 shows, Policy statement: The policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Definitions of abuse, neglect, exploitation, and abuse coordinator: Abuse: Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered. Types of abuse: 1. Physical. Types of abuse and examples: 1. Physical: Physical abuse includes but is not limited to infliction of injury that occurred other than by accidental means and requires medical attention. Examples hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling.

Based on observation, interview and record review the facility failed to accommodate residents' food preferences and allergies for 3 of 5 residents (R1-R3) reviewed for food preferences and allergies in the sample of 5.The findings include:1.R1's admission progress note dated 6/20/26 showed R1 was admitted to the facility with diagnoses of dementia and cerebrovascular accident (stroke). R1 was confused with a history of both short-term and long-term memory loss.R1's progress note dated 6/24/26 showed R1 was identified as having an allergy to eggs. The note showed Allergy to eggs was added to the patient file. Diet form indicating patient food allergy was highlighted and forwarded to the kitchen. A physician order for R1 dated 6/29/26 showed, General diet Regular Texture, Thin liquids consistency, NO EGGS, NO SALT PACKET.On 6/30/26 at 8:50 AM, R1 was seated on the side of her bed with her breakfast tray in front of her. No staff were present in R1's room. An egg and cheese sandwich was noted on R1's tray. R1 had not consumed any of the egg sandwich. R1 pointed to the sandwich and stated, I don't eat eggs. I haven't eaten them since I was a little girl. I am not exactly sure why I can't eat them. The meal ticket noted on R1's breakfast tray was reviewed and showed no documentation of R1's egg allergy.On 6/30/26 at 11:00 AM, V5 Registered Nurse stated on 6/24/26, she was informed of R1's allergy to eggs. V5 stated, on 6/24/26, I called the kitchen to tell them about (R1's) food allergy. I am not sure who I talked to. I didn't get a name. I also filled out a dietary communication form and sent it to the kitchen to let them know about the allergy.A facility Diet Order and Communication form dated 6/24/26 showed R1 was identified as having a food allergy to eggs. On 6/30/26 at 1:00 PM, V4 Food Service Supervisor stated V8 Dietary Technician is responsible for adding food allergies to a resident's meal ticket. V4 stated, The cook plates the food. If an allergy is not listed on the resident's meal ticket, the cook doesn't know what a resident can or can't have. On 6/30/26 at 1:15 PM, V8 Dietary Technician stated she was notified of R1's egg allergy on 6/24/26. V8 stated she did not add R1's egg allergy to R1's meal ticket. V8 stated, I am not responsible for adding food allergies to a resident's meal ticket. I believe nursing is. 2. On 6/30/26 at 8:45 AM, R2 was seated in her room with her breakfast tray in front of her. When R2 was asked how her breakfast was, R2 stated, Well not good. I again didn't get what I wanted. This has happened multiple times this week. I asked for Cheerios, they gave me Cream of Wheat. I wanted a banana and sliced oranges; they tried to give me diced apples. I sent the apples back. I don't want them. No Cheerios, bananas or oranges were noted on R2's tray. The meal ticket noted on R1's breakfast tray showed R1 had ordered Cheerios, one banana, and sliced oranges for breakfast. 3. On 6/30/26 at 10:50 AM, when R3 was asked about the facility's food service, R3 stated, Where do I start? No matter what I order, they keep giving me a chicken breast. One day this week, I ordered egg salad in a cup, but they sent me a chicken breast. I get a menu to fill out, one week ahead of time. I circle what I want on the menu. The CNA (Certified Nursing Assistant) sends my menu to the kitchen.On 6/30/26 at 12:19 PM, R3's lunch tray was delivered to R3 in her room. The meal ticket on R3's lunch tray showed R3 had ordered a bowl of cream of mushroom soup and potato wedges with lunch. No potato wedges were noted on R3's tray. A bowl of chicken noodle soup was noted on her tray. R3 stated, See I'm missing my potato wedges. I don't want chicken noodle soup. I wanted cream of mushroom.On 6/30/26 at 1:00 PM, V4 Food Service Supervisor stated residents are to receive their food preferences as requested. V4 stated each resident receives a weekly menu for the resident to circle what food they want based on what is being offered on the menu. V4 stated, The cook plates food for every resident. Each resident has a meal ticket. The cook is supposed to plate the food based on what the resident circled on their meal ticket. The dietary aide is then responsible for making sure the food matches what the resident ordered prior to covering the plate and taking the food to the resident.The facility's Resident Council Meeting Minutes date April 2026-June 2026 were reviewed. The minutes showed resident complaints of residents not receiving food that they ordered or requested. The facility's Food Preference Policy dated 6/30/25 showed, The facility will provide food that accommodates allergies and preferences. The facility will identify resident's allergies, intolerances, and preferences based on medical record and interviews. The facility will ensure that residents will not be given food that they are allergic too or food that gives them intolerance reactions.

Based on observation, interview, and record review the facility failed to follow the menu for residents on a puree diet for 4 of 4 residents (R5, R55, R151, R165)reviewed for pureed diet in the sample of 32. The findings include:On 3/23/26 at 11:09 AM, V10 [NAME] was plating the noon meal. V10 used one, 4-ounce scoop to plate the pureed ravioli onto plates for the residents on a pureed diet. V10 said they follow the spreadsheet for scoop sizes when plating resident's food. The facility's Diet Spreadsheet dated Week 1 Day 2 Lunch: Puree Ravioli Bake Pureed 2 #8 On 3/23/26 at 12:10 PM, V11 [NAME] said the spreadsheet says a #8 scoop for the puree ravioli which is 4 ounces. V11 said he was not sure what the 2 in front of the #8 scoop meant, he had never seen that before and thought it was an error. On 3/23/26 at 12:50 PM, V5 Dietician said if staff are not serving the portions according to the spreadsheet, residents not getting the appropriate protein for that meal. On 3/23/26 at 1:26 PM, V12 District Kitchen Manager said he reviewed spreadsheet with the supplier, and the serving is supposed to be 2 of the #8 scoops for total of 8 ounces served. V12 said not giving two scoops means residents not getting enough protein. The facility's Diet Type Report dated 3/23/26 shows R5, R55, R151, and R165 are on a puree diet. The facility's Meal Distribution Policy dated 9/1/2025 shows All meals will be assembled in accordance with the individualized diet order, plan of care, and preference.

Based on observation, interview and record review the facility failed to ensure staff applied a gait belt to safely transfer a resident at risk for falls. This applies to 1 of 32 residents (R182) reviewed for safety in the sample of 32. The findings include: R182's face sheet shows he has diagnoses including unspecified dementia, heart disease, history of falling, peripheral venous insufficiency, type 2 diabetes, and hypertension. On 3/24/2026 at 1:20 PM, V7 (Certified Nursing Assistant-CNA) transferred R182 from his wheelchair to his bed. V7's gait belt was secured around her waist. She did not apply the gait belt to R182 and grabbed the back of his pants and pulled him up to a standing position. R182 had difficulty going from a standing to sitting position. On 3/24/2026 at 1:50 PM, V4 (Licensed Practical Nurse-LPN) said R182 is fall risk, staff should use a gait belt with transfers. R182's Fall Risk assessment dated [DATE] shows he is a high risk for falls and has unsteady gait. R182's current care plan initiated 12/25 shows he has an ADL (activities of daily living) self-care performance deficit and impaired mobility. He requires substantial transfer assistance and is on a transfer program staff should place a safety gait belt during transfers. The facility's Gait Belt Policy revised 6/25 states, The facility will use gait belts to assist residents needed limited to total assistance with transfers.

Based on observation, interview, and record review the facility failed to ensure nutritional supplements were provided for a resident with a history of weight loss. This applies to 1 of 10 residents (R70) reviewed for weight loss in the sample of 32. The findings include: R70's face sheet shows she has diagnosis including unspecified dementia, alzheimer's disease, COPD, CHF and type 2 diabetes.R70's Dietary note dated 1/02/26 documents her weight at 129.6 pounds. It shows a weight loss during the last three months. R70's intake is poor, not eating breakfast, interventions include fortified foods and frozen nutritional treat for lunch and dinner. On 3/23/2026 at 11:45 AM, R70 was sitting in the dining room during the noon meal. R70's meal tray was served pasta, broccoli and mashed potatoes. R70's diet cart did not list her frozen nutritional supplement with her lunch and dinner meal. R70 was sleeping during the noon meal, staff attempted to wake her up, she would open her eyes and go back to sleep. R70's intake of the noon meal was poor. On 3/24/2026 at 11:32 AM, R70 was in the dining room during the noon meal. R70 was served her noon meal. R70 was not served her frozen nutritional supplement, and her diet card did not have the frozen nutritional supplement listed to give with her noon and dinner meal. On 3/24/2026 at 1:41 PM, V7 (Certified Nursing Assistant-CNA) said R70 has a poor appetite, she needs assistance with meals. She said on 3/23/26, R70 was really sleepy, and she did not each much. She said dietary sends supplements with the resident's meal tray and it the supplements should be listed on the diet card. On 3/25/26 at 8:52 AM, V1 (Administrator) confirmed R70's diet card did not have her frozen nutritional supplement listed to be given at lunch and dinner. On 3/25/26 at 8:59 AM, V5 (Dietitian) said R70 has a history of weight loss she should be receiving fortified foods and frozen nutritional supplements with her lunch and dinner meal. She emails dietary the supplements to be added with meals and they should add it to the diet card. V5 said she puts in the order through the electronic health record but does have access to dietary's system. R70's Physician Orders dated through March 2026 shows orders for dietary supplements including frozen nutritional treat twice a day with lunch and dinner.

Based on observation, interview, and record review the facility failed to ensure staff donned the correct personal protective equipment (PPE) for residents on isolation which applies to 2 of 32 residents (R106, R182) reviewed for infection control in a sample of 32.The findings include: 1. R106's admission Record printed on 3/24/26 showed R106 is a [AGE] year-old male resident admitted to the facility on [DATE]. R106's COVID-19 test results showed R106 was positive for COVID-19 on 3/21/26. On 3/23/26 at 2:25 PM R106's room had a PPE cart outside the room with a droplet isolation sign on the door. The isolation sign showed the PPE needed for COVID-19 is a N95 respirator mask, gown, gloves, and face shield when entering the room. On 3/24/26 at 9:00 AM, V7 Registered Nurse entered V106 room to administer V106's morning medications. V7 entered R106's without donning a N95 mask. On 3/24/26 at 9:10 AM, V7 stated the PPE needed for entering a COVID-19 room is gown, gloves, a N95 mask or a surgical mask and face shield. On 3/24/26 at 2:15 PM, V1 Administrator stated the facility entered COVID-19 outbreak on 3/23/26 with a third resident testing positive for COVID-19. On 3/35/36 at 1:00 PM, V8 Infection Control Preventionist stated a N95 mask is needed to enter a COVID-19 positive isolation room. A surgical mask and face shield is not the correct PPE for COVID-19 isolation. The facility's Isolation Policy dated 2/17/26 showed the COVID-19 isolation PPE needed to enter a COVID-19 positive residents' room is gown, gloves, face shield (eye protection), and a N95 respirator mask. 2. On 3/24/2026 at 1:20 PM, R182 was sitting in his wheelchair, his indwelling urinary catheter was hanging under his wheelchair. A sign posted outside of his for EBP (Enhanced Barrier Precautions). V7 (Certified Nursing Assistant) wheeled him into his room, she did not apply a gown and transferred him into his bed, handled the foley catheter and provided incontinence care. On 3/24/2026 at 1:39 PM, V7 said she did not know R182 was on enhanced barrier precautions and staff should wear a gown and gloves when providing direct care. R182's current care plan initiated 7/2025 shows he is on EBP for his indwelling urinary catheter and has ESBL (Extended-Spectrum Beta-Lactamase) colonized in his urine. Interventions include for staff to wear gown and gloves during high contact resident care including transferring, providing hygiene care, changing briefs.

Based on observation, interview and record review the facility failed to notify a resident's representative prior to starting a cognitively impaired resident on a new medication for 1 of 3 residents (R1) reviewed for resident notification of changes and/or treatments in the sample of 3.The findings include:R1's care plan dated 6/6/25 showed R1 was cognitively impaired related to her diagnoses of dementia and multiple sclerosis. The plan showed R1 was very forgetful. The plan showed all information provided to R1 should be provided directly to her advocate.R1's Power of Attorney (POA) for Health Care form dated 9/12/24 showed V7 (Family of R1) was R1's POA. On 1/5/26 at 8:32 AM, V7 (Family of R1) stated R1 was started on Losartan (medication to treat high blood pressure) in August 2025 however, V7 was not notified that R1 had been started the medication until 12/17/25. V7 stated, No one told me (R1) was even having high blood pressures. I am in the facility at least twice a week. I just happened to be talking to the cardiology nurse practitioner (on 12/17/25) when she informed me that (R1) had been on Losartan for high blood pressure. I had no idea. I have told the facility multiple times they are to call me with any changes. No one from the facility notified me of any of this despite it being all over (R1's) chart they are to call me day or night with any changes, including medications. V7 stated R1 is cognitively impaired and cannot remember what medications she is taking. Physician progress notes and a physician order, both dated 8/8/25 for R1, showed R1 was started on Losartan 25 mg (milligrams) once a day due to a new diagnosis of hypertension. The physician note showed the new medication was discussed with R1; however, the note showed no documentation V7 (Family of R1) was notified of R1's elevated blood pressures and/or R1 being started on Losartan.A cardiology note dated 12/17/25 showed the cardiology nurse practitioner contacted V7 (Family of R1) who reported that she (V7) was not aware R1 had taking Losartan for high blood pressure. On 1/5/26 at 10:15 AM, R1 was in bed. R1 was awake but confused to place and time. When R1 was asked what month it was, R1 responded, Sunday. R1 stated she didn't know if she was on a medication for high blood pressure. R1 stated, I don't know. They talk to (V7 Family of R1) about all my medications. On 1/5/26 at 10:03 AM, V3 Social Services stated, I have always known (R1) as confused and forgetful. Her short-term memory is impaired. (V7 Family of R1) is very involved in (R1's) care. (V7) has stated multiple times she wants to be informed of any changes involving (R1).On 1/5/26 at 11:35 AM, V2 Director of Nursing (DON) stated if a resident is started on a new medication, the resident and/or resident representative should receive education on the medication and consent to taking the medication prior to administration of the medication. V2 stated a resident's representative should be contacted if the resident is cognitively impaired. V2 stated R1 was confused, V2 stated V7 (Family of R1) had requested to be notified of any medication or condition changes for R1. V2 stated the facility did not notify V7 prior to starting R1 on Losartan in August 2025. V2 stated, (V7) was not notified that (R1) had been on Losartan for high blood pressure until December (2025). Best practice would have been that we had notified (V7) of the new medication for (R1) prior to starting the medication in August (2025).

Based on interview and record review the facility failed to ensure a resident was not restrained in bed for 1 of 3 residents (R1) reviewed for restraints in the sample of 3. The findings include:R1's Face Sheet shows that he admitted to the facility on [DATE] with diagnoses of: aphasia, restlessness and agitation, dementia, lack of coordination, abnormalities of gait/mobility and need for assistance with personal care. On 7/31/25 at 10:45 AM, V9 (R1's Daughter) said that when she walked into R1's room to visit, R1 was lying in bed and had a thick mattress positioned on its side along one side of his bed that was being held up with a chair and the other side of his bed was against the wall. V9 said that she went and got a nurse to take it down.On 7/31/25 at 11:40 AM, V4, Licensed Practical Nurse (LPN) said that she did go into R1's room and saw a fall mattress on its side up against R1's bed and it was being held up with a chair. V4 said that she is not sure who put the mattress in that position, but it was probably because he was aggressive and always trying to get out of bed but was not safe to do so by himself. On 7/31/25 at 11:50 AM, V5 (LPN) said that fall mats should be placed on the floor next to the resident's bed to prevent injuries if they try and get out of bed on their own. V5 said that fall mats should never be upright along the side of the bed. V5 said that propping the fall mat up wound not be ok because it would be trapping them in the bed. On 7/31/25 at 2:02 PM, V1 (Administrator) said that fall mats should not be positioned in an upright position along the side of a bed. V1 said that if done, it would be considered a restraint and not appropriate. The facility's Restraints Policy revised on 7/3/25 shows, It is the facility's policy to ensure that each resident is not restrained for the purposes of discipline or convenience. Physical restraint is defined as any manual method, physical or mechanical device, equipment or material that meets all of the following criteria: attached or adjacent to the residents body, that the individual cannot intentionally remove easily, and restricts freedom of movement or normal access to one's body.

Based on interview and record review the facility failed to ensure a resident's (Tablet Computer) was not misappropriated for 1 of 3 residents (R1) reviewed for misappropriation of property. The findings include: The facility's Abuse Report Final Form dated 6/18/25 shows, On 6/6/25 when [R1]'s friend came to visit her, she reported to the daughter that the (Tablet Computer) was missing and the daughter reached out to [V3] unit manager to inform her .On 6/9/25 [V1], administrator was able to identify that one of the daughter's friends came to see [R1] 6/4/25 around dinner. [R1] was sitting in the nurse's station with her (Tablet Computer) and when the friend arrived, she removed it from the nurse's station and place back in room .On 6/14/25, [V10], Nursing Supervisor called [V1], Administrator around 2:00 PM stating that [V7], [R1]'s daughter called her and informed her that the (Tablet Computer) had been pinged in a proximity of [local hotel] [Local Police] were informed of the allegation of the missing (Tablet Computer) and will investigate . The schedule for 6/4/25 and 6/5/25 was reviewed. V5, Certified Nursing Assistant (CNA) was assigned to R1 on 6/4/25 PM shift, V6 (Agency CNA) was assigned to R1 on 6/4/25 Night shift and V4 (CNA) was assigned to R1 on 6/5/25 Day shift. On 6/25/25 at 12:46 PM, V5 said that she took care of R1 on the PM shift of 6/4/25. V5 said that she remembers R1's (Tablet Computer) being on her night stand plugged in when she put her into bed for the evening. V5 said that R1 uses her (Tablet Computer) daily and she would have noticed if it was not there. On 6/25/25 at 12:16 PM, V6 was contacted with no answer. On 6/25/25 at 12:08 PM, V4 said that he went in to get R1 up around 7:20 AM on 6/5/25 and noticed the (Tablet Computer) was missing. V4 said that the (Tablet Computer) is always plugged in and placed on her night stand when she is not using it. V4 said that R1 uses her (Tablet Computer) daily. An undated Police Incident/Offense Report shows, On June 14, 2025, I was dispatched to [Facility] for a theft. According to dispatch, the complainant reported that her mother's (Tablet Computer) Wi-Fi + Cellular had been stolen . said that she was able to locate the (Tablet Computer) by using the Find My Phone app. According to the app, on today's date, the (Tablet Computer) was online at [Local Hotel] .[V1] noted that only one Certified Nursing Assistant [Redacted] was temporarily hired by [Facility] on 4/4/25 I requested [Local Police Department] visit [Local Hotel] to determine if anyone with the name [Redacted] was staying there. According to [Local Police Department] , they made contact with the hotel clerk, who stated that [Redacted] checked out from the motel on today's date . On 6/25/25 at 2:07 PM, V1 (Administrator) verified that it was V6's name that was redacted on the police report. V1 said that V6 is an agency CNA that only worked at the facility on 6/4/25 and was the CNA that provided care to R1 that night. V1 said that V6 was seen on camera going into R1's room a couple times throughout the night. V1 said that she has tried to contact V6 on multiple occasions with no returned call. V1 said that the police have also tried to contact her with no returned call. The facility's Abuse and Neglect Policy revised on 4/25/25 shows, It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect or mistreatment .Financial abuse includes, but not limited to deliberate misplacement, misappropriation, exploitation or otherwise taking advantage of a resident's money or property temporarily or permanently .

Based on observation, interview, and record review, the facility failed to ensure the dishwasher reached the desired temperature to sanitize dishes to prevent the spread of food borne illness, failed to ensure meat products were covered, dated, and labeled, failed to ensure staff wore beard coverings in the kitchen to prevent cross contamination and failed to ensure the kitchen was maintained in sanitary conditions. This failure has the potential to affect all residents residing at the facility. Findings include: The CMS 671 dated 1/26/25 show there were 153 residents residing at the facility. 1. On 1/26/25 at 9:10 AM, V5 (Dietary Manager-DM) was in the dishwashing area loading dish racks eight (8) times . V5 said he had to run the dish machine (dishwasher) at least five cycles so the final temperature (temp) reaches at 160 degrees Fahrenheit. (F). After V5 ran the dish machine eight (8) times, the final rinse noted at the dishwasher remained at 130F. V5 said it should be at least 160F. It was important to reach the desired temperature to kill the bacteria in the soiled dishes. At 9:20 AM, V7 and V8 (both Dietary Aides-DA) were in the dishwasher area loading the soiled dishes coming from the floors after breakfast. V11 (Dietary Aide) was scraping the food debris from the soiled plates, cups, glasses, spoons, and forks used at breakfast. V7 (DA) was loading the soiled dishes in the dirty area of the dishwasher and running the soiled dishes through the dishwasher. V8 (DA) was at the other end of the dishwasher, in the clean area removing the dishware from the dishwasher and placing them in the metal rack to dry. The final rinse in the dish machine was staying at 130F. At 9:45 AM, 10 AM, and at 10;30AM while V7 continued to load soiled dishes and V8 continued to remove the clean dishes and placing the dishes to the metal rack to dry, the final rinse stayed at 130F. V7 said the final rinse should be at least 135F. V8 said she does not pay attention to the temperatures of the dishwasher and does not know what the final rinse temperature should be. At 11:30 AM during lunch service, V5 (DM) said he was aware that the final rinse was at the 130's F. Lunch will be served using paper products (Styrofoam). Staff still used the regular silverware that was washed in the dishwasher earlier. Staff also used some regular cups and plates to serve salads, sandwiches, and dessert. V5 said the evening meal will be completely served with paper products. At 12:50 PM, V10 (Dishwashing Vendor Company Head) said the facility has a high temp dishwasher. They were at the facility a couple of weeks ago servicing the facility dishwasher which was a high temp. V10 said on a high temp dishwasher, the final rinse should be within 160-180F. At 2PM, V9 (Technician Dishwashing Vendor) was at the facility at this time fixing the dishwasher. V9 said he had fixed the dishwasher and the final rinse was now able to reach at 180F. V9 said he also fixed the wash cycle since when it reaches 150F it stops, it was now at 160F. Review of the facility dishwashing log dated 1/2025 show final rinse ranges from 160 to 180F except for the 20th which was 150F. The facility policy entitled Cleaning and Sanitation Warewashing (undated) states, check to make sure the machine is meeting the correct wash and rinse temperature .160F. 2. During the tour in the kitchen at 10:45 AM, with V5 (DM) the walk in freezer had boxes of frozen hamburgers, frozen breaded pork, and chicken patties that were all open to air, unlabelled, and not dated. V5 said it should be stored tightly to prevent freezer burn and growth of bacteria. The facility policy entitled Kitchen dated 8/16/24 show, all food products should be covered, dated and labeled. 3. On 1/26/25 from 9:02 AM to 10:30 AM, V6 (Cook) who had a thick beard had no facial hair covering while handling food throughout the kitchen. V5 said V6 should wear a facial hair covering to prevent contaminating the residents food. The facility policy entitled Kitchen dated 8/16/24 show, a. Hair restraints is required for those with facial hair that might fall on food. 4. During the lunch service at 11 AM, on the wall next to the ice machine is a bin where the ice scooper sits. Inside the bin where the ice scooper sits was covered with dust and whitish debris. There was a hanging rack above the meal service assembly where meal tickets were clipped that was covered with grayish dust. V5 said this was unacceptable and cleaning will be done. Kitchen should be kept clean and sanitary.

Based on observation, interview, and record review the facility failed to assist residents with feeding in a dignified manner. This applies to 5 of 30 (R6, R53, R17, R69, R81) residents reviewed for dignity in the sample of 30. The findings include: On 1/26/2025 at 12:43PM, general dining observations were made. At 12:43PM, V21 Activity Director was observed standing over R6 while assisting her with feeding her lunch. At 12:43PM, V20 CNA (Certified Nursing Assistant) was observed standing over R53 while assisting her with feeding her lunch. At 12:44PM, V22 CNA was observed standing over R17 while feeding him his lunch. At 12:45PM, V23 CNA was observed standing over R69 while feeding her lunch. At 12:48PM, V24 LPN (Licensed Practical Nurse) was observed leaning against the window standing over R81 while feeding him his lunch. On 1/26/2025 at 12:48PM, V2 DON (Director of Nursing) said staff should be seated when feeding residents. V2 said it is more comfortable for the resident if the staff sit next to them while they are being fed and it is also a dignity concern. The facility provided list of residents requiring feeding assistance lists [R53] as one person assist, [R6] as one person assist, [R69] as supervision, [R17] as one person assist, and [R81] as one person assist. The facility provided Privacy and Dignity policy dated 8/16/2024 states, it is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all times.

Based on observation, interview, and record review the facility failed to ensure a palm protector was in place for a resident with a contracture and failed to ensure restorative assessments were done for 4 of 5 residents (R38, R62, R65, R57) reviewed for restorative services in the sample of 30. The findings include: 1. 01/27/25 at 10:18 AM, R38 was sitting up in a chair at the bedside. R38's fingers of his left hand were contracted into his fist. There was nothing observed in R38's left hand. R38 said they usually put something in his hand. On 01/28/25 at 9:18 AM, R38 was up in a chair at the bedside. R38's left hand did not have a palm protector or other device. On 01/28/25 at 10:54 AM, V26 Restorative Nurse said R38 has a left hand contracture and a palm protector should be in on at all times except for hand hygiene and passive range of motion. V26 said the palm protector is to makes sure there is no further decline in R38's contracture and to maintain skin integrity. R38's most recent Restorative UDA Form is dated 12/5/23. R38's Care Plan dated 2/6/20 shows R38 requires restorative program for passive range of motion due to contracture of left hand with an intervention of palm protector on left hand to post range of motion exercises and check skin integrity to left hand daily post palm protector removal. On 01/28/25 at 12:30 PM, V26 said contracture assessment are on the Restorative UDA form and are supposed to be done quarterly. V26 said she has not able to do quarterly restorative assessments since 2023. V26 said there is no assessment for R38 for all of 2024, the last assessment was done 12/5/2023 for R38's contracture. 2. On 01/27/25 at 09:59 AM, R62 was in bed on her right side on an air mattress. R62 said staff help her turn and position in bed. R62's most recent Restorative UDA form is dated 9/11/23 and shows R62 requires extensive assistance with activities of daily living and is on a passive range of motion program. On 01/28/25 at 12:30 PM, V26 said contracture assessment are on the Restorative UDA form and are supposed to be done quarterly. V26 said she has not able to do quarterly restorative assessments since 2023. V26 said there is no assessment for R62 for all of 2024, the last assessment was done 9/11/23. 45540 3. The facility provided Restorative assessment for R65 shows the resident had an assessment last completed on 12/31/2023. The facility failed to provide a more current Restorative assessment for R65. On 1/28/2025 at 11:45AM, V26 Restorative Nurse said she started on 1/4/2024. V26 said she has been doing the quarterly assessments but has not been documenting them. 4. The facility provided Restorative assessment for R57 shows the resident had an assessment last completed on 12/13/2023. The facility failed to provide a more current Restorative assessment for R57. On 1/28/2025 at 11:45AM, V26 Restorative Nurse said she started on 1/4/2024. V26 said she has been doing the quarterly assessments but has not been documenting them. The facility provided Restorative Nursing Program revised 8/19/2024 states, . nursing and restorative services may include the following: splint/orthotic management. evaluation as to the need of adaptive equipment/enabling devices to help accommodate the resident's needs, promote optimal functioning and self-sufficiency in ADL's may be referred to the Therapy Department. for the most appropriate device/s recommendations. the restorative programs shall be evaluated on a quarterly basis.

Based on observation, interview, and record review the facility failed to ensure multi-use resident equipment was cleaned after being used by a resident on contact isolation, failed to ensure incontinence care was performed in a manner to prevent the spread of infections, failed to ensure staff removed their gloves and washed their hands to prevent to spread of infection and failed to ensure a resident with an indwelling medical device was placed on enhanced barrier precautions. This applies to 6 of 30 residents (R54, R70, R45, R25, R67 and R121) reviewed for infection control in the sample of 30. The findings include: 1. R54's Physician's Order Sheet printed on 1/27/25 shows an order dated 1/23/25 for, Strict contact isolation for Norovirus. On 1/27/25 at 10:49 AM, V18, Certified Nursing Assistant (CNA) wheeled R54 down the hallway in a dialysis chair to her room. V18 stopped before entering R54's room and took R54's blankets off of her and placed them in the soiled linen cart that was down the hallway. While carrying the soiled linens, they were touching her scrub top. V18 then placed R54's electronic tablet on a table that was in the hallway. V18 then placed R54's personal blanket and pillow onto a chair in the hallway. R54 stood up from her wheelchair and held onto the hallway grab bar and was assisted to sit down in her wheelchair. V18 then wrapped R54's blanket around her and gave her her tablet. V18 then brought the dialysis chair into the shower room and left. V18 did not sanitize the dialysis chair, table, chair or grab bar. On 1/28/25 at 2:08 PM, V27 (CNA) said that all shared equipment should be disinfected with a disinfecting wipe after being used on a resident who is on isolation for infection control reasons. V27 said that used linens should not be placed on a pubic surface without cleaning the surface afterwards. 2. On 1/27/25 at 2:07 PM, V18 (CNA) provided care to R70. V18 removed R70's soiled sheets and placed them onto the floor. V18 then started providing incontinence care. V18 cleaned R70's front perineal area and then turned him to the left side. V18 cleaned stool from R70's buttock. V18 then took the soiled incontinence brief off and placed it on the floor. V18 then took the soiled incontinence pad off and placed it on the floor With the same gloves on, V18 adjusted R70's shirt, used the bed control, put new sheets on and applied R70's positioning bolster. On 1/28/25 at 2:08 PM, V27 (CNA) said that when providing incontinence care soiled linen should be placed in a bag and soiled gloves and incontinence briefs should be placed in another bag. V27 said that they should not be placed on the floor for infection control reason. V27 said that gloves should be changed and hands sanitized after cleaning stool and before touching any other objects for infection control reasons. The facility Incontinent and Perineal Care Policy revised on 7/31/24 shows, Discard disposable items into designated containers/plastic bag. Remove gloves and dispose to designated plastic bag. Wash hands. Put on new set of clean gloves to put on clean briefs/incontinence pads, to make resident comfortable, groom and change clothing. The facility's Hand Hygiene Policy revised on 7/30/24 shows, Hand Hygiene using alcohol-based hand rub is recommended during the following situations: .Before moving from a soiled body site to a clean body site on the same resident. After contact with blood, body fluids or surface contaminated with blood and body fluids. 34506 3. R45's Admission Record dated January 26, 2025 shows she was admitted to the facility on [DATE] with diagnoses including cellulitis, history of covid 19, and history of falling. R45's Care Plan initiated May 17, 2024 shows R45 has had a urinary tract infection. On January 26, 2025 at 9:52 AM, V12 CNA performed perineal care on R45. V12 folded the front of R45's incontinence brief in between R45's legs while R45 was lying on her back. V12 wiped R45's front peri area and touched R45's body to help her turn onto her side. V12 then wiped the stool from R45's buttocks, placed a clean pad and clean brief under R45, touched R45's shirt, and then turned R45 back onto her back. V12 then pulled R45 up in bed and touched R45's pillows and blankets. V12 did not wash his hands nor change his gloves when going from clean to dirty items. 4. R25's Admission Record dated January 26, 2025 shows she was admitted to the facility on [DATE] with diagnoses including dysphagia, history of Covid-19, mid cognitive impairment, scoliosis, pain, and history of falling. R25's Care Plan initiated August 21, 2020 shows, [R25] is incontinent of bowel and bladder, check resident every two hours and assist in toileting as needed. On January 26, 2025 at 9:39 AM, V12 CNA provided peri care for R25. V12 folded R25's incontinence brief in between her legs while she was lying on her back. V12 wiped R25's front peri area, touched R25's body when he help her turn onto her side, then wiped the large soft stool from R25's buttocks. V12 placed a clean incontinence pad under R25 and placed a clean brief under R25 and helped R25 to turn. V12 then touched R25's shirt to fix the placement. V12 did not change his gloves nor perform hand hygiene when going from touching dirty surfaces to clean surfaces. 5. R121's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including major depressive disorder, pressure injury of the sacral region, and other mechanical complication of other urinary devises and implants. On January 26, 2025 at 10:44 AM, V12 performed peri care for R121. R121 had a urinary catheter in place and a pressure injury to his buttocks. R121 removed R121's incontinence brief, wiped R121's front peri area, turn R121 onto his side, and wiped his buttocks. V12 placed cream onto R121's buttocks, placed a new incontinence pad and brief under R121, and then helped R121 to turn back onto his back. V12 did not change his glove nor perform hand hygiene. On January 28, 2025 at 1:38 PM, V17 CNA said she changes her gloves and performs hand hygiene before entering residents room and before leaving residents rooms. At 2:07 PM, V18 CNA said she changes her gloves and performs hand hygiene before entering residents rooms and before leaving. Neither CNA stated that they change their gloves and perform hand hygiene when going from dirty to clean items. 35119 6. On 01/27/25 at 09:47 AM, R67 was in bed with her urine drainage bag (from her nephrostomy)laying on the bed. There was no signage for isolation precautions outside of R67's room. On 1/28/25 at 9:15 AM, R67 did not have isolation precaution signage on R67's door. On 01/29/25 at 9:45 AM, V4 Infection Control Registered Nurse said if a resident has a nephrostomy they should be on Enhanced Barrier Precautions (EBP). V4 said R67 should be on EBP. The facility's Enhanced Barrier Precaution Policy dated 7/26/24 shows The facility will use EBP to reduce the transmission of multi-drug resistant organisms in the nursing home. EBP will be used for any resident in the facility: has indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of Novel or Targeted Multidrug-Resistant Organisms colonization status.

Based on observation, interview, and record review, the facility failed to provided residents with privacy during personal cares for two of 30 residents (R81, R121) reviewed for privacy in the sample of 30. The findings include: 1. R81's Admission Record dated January 26, 2025 shows R81 was admitted to the facility on [DATE] with diagnoses including antistrophic lateral sclerosis, anemia, restlessness and agitation, and adult failure to thrive. On January 26, 2025 at 1:13 PM, V13 CNA (Certified Nursing Assistant) provided incontinence care for R81. R81's door was opened and R81 was visible from the hallway. V13 removed R81's incontinence brief leaving R81's perineal area exposed to the hallway while being turned from side to side. 2. R121's Admission Record dated January 29, 2025 shows she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, pressure injury of sacral region, and peripheral vascular disease. On January 26, 2025 at 10:44 AM, V12 CNA was providing incontinence care to R121. R121's roommate got up from his bed and looked around the curtain prior to walking to the bathroom. R121's curtain was not pulled all around R121's bed. R121's buttocks was exposed. On January 28, 2025 at 2:07 PM, V18 CNA said the residents doors should be closes and the curtain should be pulled all the way closed to provide privacy to the residents. The facility's Privacy and Dignity policy dated August 16, 2024 shows, It is the facility's policy to ensure that resident's privacy and dignity is respected by the staff at all all times. During care that requires privacy such as incontinence care, the resident will be placed in bed and the privacy curtain will be drawn to provide full visual privacy if the privacy curtain is not sufficient to provide full visual privacy, the combination of the privacy curtain and privacy screen will be used.

Based on interview, and record review the facility failed to request a level II PASSAR (Preadmission Screening and Resident Review) screening for residents with a psychiatric/mood disorder which was added after the resident was admitted to the facility. This applies to 2 of 5 (R99, R119) residents reviewed for PASSAR in the sample of 30. The findings include: R99's PASSAR level 1 screening dated 11/11/2023 shows a determination of No Level II Required. R99's MDS (Minimum Data Set) section I dated 11/11/2024 under psychiatric/mood disorder I5950 Psychotic Disorder (other than schizophrenia) is checked for R99. R119's PASSAR level 1 screening dated 2/1/2023 shows a determination of No Level II Required. R119's MDS (Minimum Data Set) section I dated 11/1/2024 under psychiatric/mood disorder I5950 Psychotic Disorder (other than schizophrenia) is checked for R119. On 1/28/2025 at 1:29PM, V19 Admissions said PASSARs are completed prior to admission to make sure we provide the services the residents needs while they are at the facility. V19 said she was unsure if the PASSAR should be re-run if additional psychiatric diagnosis gets added but will check on that. On 1/28/2025 at 1:59PM, V19 said both [R99] and [R119] should have been rescreened. V19 said the facility will be running those now. The facility provided PASSAR Screening of Residents with Mental Disorder or Intellectual Disability revised 8/16/2024 fails to address residents being rescreened in the event additional psychiatric diagnoses are added during the resident's stay at the facility.

Based on observation, interview, and record review the facility failed to ensure a resident was screened prior to admission for 1 of 5 residents (R96) reviewed for preadmission screenings (PASARR) in the sample of 30. The findings include: On 01/27/25 at 10:03 AM, R96 was sitting up in a reclining chair in his room sleeping. On 01/28/25 at 12:00 PM, V1 Administrator said there was no PASARR done for R96. V1 said he has not left the facility since he was admitted . V1 said admissions is doing a screening now. R96's Face Sheet shows R96 was admitted to the facility on [DATE] with a diagnoses of unspecified dementia and schizophrenia. The facility's PASSAR Screening of Residents with Mental Disorder or Intellectual Disability dated 8/16/24 shows The facility will not allow admission form the hospital without a preadmission screening which includes PASSAR screening for those with mental or intellectual disorder.

Based on observation, interview, and record review the facility failed to provide ADL (Activities of Daily Living) assistance for residents that are dependent on staff for two of 30 residents (R25, R1) reviewed for ADLs assistance in the sample of 30. The findings include: 1. R25's Admission Record dated January 26, 2025 shows she was admitted to the facility on [DATE] with diagnoses including dysphagia, history of Covid-19, mid cognitive impairment, scoliosis, pain, and history of falling. R25's Care Plan initiated August 21, 2020 shows, [R25] is incontinent of bowel and bladder, check resident every two hours and assist in toileting as needed. Provide incontinence care after each incontinence episode. The resident requires extensive one staff participation with personal hygiene and oral care. On January 26, 2025 at 9:39 AM, V12 CNA (Certified Nursing Assistant) provided incontinence care for R25. R25's incontinence brief was saturated with dark urine and soft stool. There was creases in R25's buttocks. V12 said R25 was last changed during the night shift. On January 28, 2025 at 2:07 PM, V18 CNA said that residents should be checked and changed at least every two hours. The facility's Incontinent and Perineal Care policy revised July 31, 2024 shows, It is the policy of the facility to provide perineal care to ensure cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition. Do rounds at least every two hours to check for incontinence during shift. 2. R1's Admission Record dated January 27, 2025 shows she was admitted to the facility on [DATE] with diagnoses including dementia, renal dialysis, adjustment disorder, anxiety disorder, and morbid obesity. R1's Care Plan dated January 26, 2025 shows, R1 has an ADL Self Care Performance deficit and Impaired Mobility. R1 requires weight bearing assistance with personal hygiene and oral care. R1's MDS (Minimum Data Set) dated January 15, 2025 shows R1 is cognitively intact, is dependent on staff for showering and bathing, and is always incontinent of bowel and bladder. On January 26, 2025 at 10:25 AM, R1 said she hasn't gotten a bed bath. R1 said she doesn't get in the shower, but staff give her a bed bath. R1 said she asked staff about her bed bath yesterday (January 25, 2025) but facility staff told R1 there was not enough staff. R1 said she is supposed to get two showers per week. On January 26, 2025 at 11:03 AM, V13 CNA (Certified Nursing Assistant) was finishing up changing R1 incontinence brief and V13 said R1 was supposed to get a bad bath yesterday, (January 25, 2025) but V13 did not know if R1 did. R1's shower/bathing and skin monitoring shows she has received three showers in the last 14 days. R1's showering/bathing and skin monitoring task documentation shows R1 did not receive a bed bath on January 23-28, 2025. On January 28, 2025 at 2:07 PM, V18 CNA said residents should get at least two showers/bed baths per week. V18 said she doesn't remember the last time R1 got a bed bath. The facility's Shower and Hygiene policy revised August 19, 2024 shows, It is the policy of this facility to ensure that resident shower/hygienic care is provided by the nursing staff to promote cleanliness, provide comfort to the resident and observed the condition of the resident's skin.

Based on observation, interview, and record review, the facility failed to obtain daily weights on a resident with a history of fluid overload and failed to ensure protective arm sleeves were applied as ordered for two of 39 residents (R37, R70) reviewed for quality of care in the sample of 30. The findings include: 1. R37's Admission Record dated January 27, 2025 shows she was admitted to the facility on [DATE] with diagnoses including reduced mobility, need for assistance with personal care, prosthetic heart valve, pleural effusion, acute respiratory failure with hypoxia, pulmonary hypertension, chronic diastolic congestive heart failure, and stage four chronic kidney disease. R37's Order Review Report dated January 27, 2025 shows an order was entered on January 9, 2025 for daily weight due to diagnosis of congestive heart failure, notify doctor with patient gains three pounds in one day or five pounds in one week, in the morning. R37's Care Plan shows potential for fluid overload. Weight will be obtained as ordered by the doctor. R37's Progress Notes dated December 28, 2024 shows, Spoke with [registered nurse] from [local hospital] who stated resident is being admitted for hypervolemia (fluid overload) and renal failure. R37's Physician Progress Note dated January 9, 2025 shows, Patient is seen after returning from [local hospital]. She went to the hospital because of shortness of breath, hypoxia (low oxygen), and lethargy. She was fluid overloaded. On January 27, 2025 at 10:06 AM, R37 said she is supposed to be weighed daily because she retains fluid. R37 said staff do not always weigh her every day. R37's Weights and Vital Signs summary shows her weight was not obtain on January 18, 19, 23, and 25, 2025. On January 28, 2025 at 2:01 PM, V16 RN (Registered Nurse) said R37 is daily weight because she is a congestive heart failure resident. V16 said daily weights are obtain to watch for weight gain and fluid overload. The facility's Weights policy revised August 19, 2024 shows, It is the facility's policy to obtain resident's monthly weight unless otherwise ordered differently by the physician. 34490 2. R70's Physician's Order Sheet (POS) printed on 1/28/25 shows an order dated 6/16/24 for: Tubigrip (protective arm sleeve) on both arms in the morning. On 1/26/25 at 10:43 AM, R70 had a large brown/black discoloration and multiple small areas of discoloration on his right lower arm just below his elbow. R70 had multiple areas of discoloration to his left lower arm. R70 did not have any protective arm sleeves on. On 1/27/25 at 2:07 PM, V18, Certified Nursing Assistant (CNA) provided incontinence care to R70. R70 did not have protective arm sleeves on. On 1/28/25 at 12:10 PM, R70 did not have protective arm sleeves on. A pair of protective arm sleeves were on R70's night stand. On 1/28/25 at 2:15 PM, V18 (CNA) said that R70 is supposed to wear covers on his arms to prevent bruising but she did not put them on yesterday (1/27/25). V18 said that he is supposed to wear them throughout the day. R70's Care Plan shows, Alteration in musculoskeletal status r/t (related to) history of right hand amputation .5/28/24 right elbow contusion 2/2 (secondary to) ASA (Aspirin)/plavix (blood thinner) and advanced age, fragile skin .Tubigrip both arms. The facility's Physician Orders Policy revised on 8/16/24 shows, It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS.

Based on observation, interview and record review the facility failed to ensure fall interventions were in place for a resident that is at high risk for falls. This applies to 1 of 30 residents (R39) reviewed for safety in the sample of 30. The findings include: R39's Face Sheet shows diagnoses of: parkinson's disease with dyskinesia, lack of coordination, unstreadiness of feet and history of falling. On 1/26/25 at 11:22 AM, R39 was in the common area. R39 had a wheelchair pressure sensor alarm attached to his wheelchair. R39 lifted his buttocks off of the seat of the wheelchair multiple times and the alarm did not sound. The In Use light on the alarm box was not on. At 2:16 PM, V29 (Certified Nursing Assistant) had R39 stand from his wheelchair. R39's alarm did not sound when he stood up. V29 turned the alarm box on and it sounded and there was a green light on the alarm box that was blinking In Use. On 1/27/25 at 2:07 PM, V18 (CNA) said that R39 is at fall risk. V18 said that R39 will try and stand on his own but he is not stable and that is why he has an alarm. V18 said that the alarm should be on when he is in his wheelchair. R39's Care Plan shows, [R39] is at high risk for falls related to history of falling, parkinson's, unsteady feet, unspecified lack of coordination, CHF (congestive heart failure), HTN (hypertension) .Interventions: Bed alarm and chair alarm to alert staff when resident attempts to get out of bed or wheelchair unassisted, so staff can assist resident. The facility's Fall Occurrence Policy revised on 7/26/24 shows, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary .

Based on observation, interview, and record review the facility failed to maintain a nephrostomy and urinary drainage bag below the level of the bladder for 2 of 7 residents (R67, R121) in the sample of 30. The findings include: 1. On 01/27/25 at 09:47 AM, R67 was in bed with her nephrostomy drainage bag containing urine laying on the bed. R67's foot of the bed was elevated making the urine pool at the opening of the nephrostomy drainage bag, and up into the nephrostomy tubing. The urine in the tubing unable to drain into the bag. On 01/27/25 at 12:26 PM, R67's nephrostomy drainage bag remained on the bed in the same position, with the urine unable to drain into the bag. On 01/27/25 at 3:00 PM. R67's nephrostomy drainage bag remained in the same position, with urine backing up into the nephrostomy tubing. On 01/29/25 at 09:31 AM, V2 Director of Nursing said you should position the nephrostomy drainage bag so the flow of urine can go into the bag to prevent infection. V2 said care is provided the same way as an indwelling urinary catheter. R67's Care Plan shows R67 has left side nephrostomy due to acute kidney injury and renal calculi. The facility's Urinary Catheter Care Policy dated 8/19/24 shows The purpose of this procedure is to prevent catheter-associated urinary tract infections. The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent urine in the tubing and drainage bag from flowing back into the urinary bladder. 34506 2. R121's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including major depressive disorder, pressure injury of the sacral region, and other mechanical complication of other urinary devises and implants. R121's Care Plan initiated November 26, 2023 shows, Please position catheter bag and tubing below the level of the bladder and away from entrance room door. On January 26, 2025 at 10:44 AM, V12 CNA (Certified Nursing Assistant) performed peri care on R121. R121's urinary drainage bag had about 200-300 milliliters in it. The tubing was filled with amber colored urine. V12 lifted R121's urinary drainage bag above the level of R121's bladder when V12 was repositioning R121. V12 then set the urinary drainage bag on R121's bed at R121's feet. On January 28, 2025 at 2:07 PM, V18 CNA said urinary drainage bags should be kept below the level of the residents' bladder. The facility's Urinary Catheter Care policy revised August 19, 2024 shows, The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

Based on interview and record review the facility failed to provide necessary care and services to a resident exhibiting a change of condition after an initial fall. This failure resulted in R1 sustaining a second fall approximately 12 hours later that resulted in a subarachnoid hemorrhage (brain bleed). This applies to 1 of 3 resident (R1) reviewed for quality of care in the sample of 3. The findings include: R1's face sheet shows he is a [AGE] year-old male with diagnosis including cerebral infarct, hemiplegia and hemiparesis following cerebral infarct affecting left non-dominant side, muscle weakness, unspecified dementia, history of falling, atrial fibrillation, type diabetes, chronic embolism and thrombosis, presence of cardiac pacemaker and hypertension. R1's Physician Orders dated October 2023 shows orders for Plavix 75 mg (milligrams) daily for prophylaxis and coumadin (anticoagulant) 3.5 mg daily. R1's Final Incident Report dated 10/18/23 documents (R1) had an unwitnessed fall on 10/18/23 around 5:00 AM. (R1) was observed lying on the floor in the dining room in a prone position. At 5:04 AM, (R1) noted to have jerking/shaking movements to his lower extremities. (R1) was sent out to the local hospital and admitted for subarachnoid bleeding (brain bleed), diabetic ketoacidosis, and sepsis. R1's Fall Report dated 10/17/23 shows at around 5:00 PM, a noise was heard from (R1's) room with R1's roommate calling out for help. Upon entering the room, (R1) was found on the floor next to his wheelchair. Head to toe assessment performed with a bump to the back of his head with a cut and bleeding present. (R1) sent out to the local hospital for evaluation. R1's nurses note dated 10/17/23 documents (R1) returned back to the facility at 8:41 PM, after a fall at 5:00 PM. A CT scan was done in the hospital and showed a bruise on the left scalp. (R1) complained about a headache and Tylenol was given. Blood Pressure 221/97. Hydralazine (blood pressure medication) was given for the blood pressure .will keep monitoring the patient. On 10/30/23 at 11:17 AM, V6 (LPN) Licensed Practical Nurse stated, she was R1's nurse on 10/18/23. She worked third shift, and it was reported to her R1 fell earlier that day but was okay. Prior to him falling at 5:00 AM, he was very restless, he kept on calling us, many times to use the bathroom. V8 (Certified Nursing Assistant-CNA) and I assisted him to the bathroom, but he wouldn't go. V8 did not want to keep taking R1 to the bathroom so she placed him in the dining room. It was time to pass morning medications, I had spent a lot of time with R1 and was busy. R1 kept moving and yelling when he was in the wheelchair in the dining room then he was quiet, I thought he was watching TV. V8 notified me about 5:00 AM, R1 was on the floor. When I went to the dining room he was on his laying on his stomach with his face on the floor and his extremities flat to the side of him. His forehead was reddened, and his left knee had a scratch. He looked shocked. Then a few minutes later his legs were shaking involuntary. I thought something was going on. Prior to the fall his blood pressure was really high I kept monitoring it, but it kept on going higher. At 4:30 AM, I gave him a blood pressure medication and called the physician. The physician called me back after his fall and I reported the fall and forgot to report the blood pressure. R1 was sent out to the local hospital and admitted with a brain bleed. That would explain the symptoms he was having on my shift. Maybe I should have called the physician earlier to report his restlessness/agitation and increased blood pressure. I needed time to figure things out if we call the physician they may get upset if it's not serious. Residents should be monitored for 72 hours post fall and any condition changes should be reported. That night, I maximized my time with him, he was on the call light constantly. I don't know what else I could have done; it was really stressful. On 10/30/23 at 12:00 PM, V8 (CNA) Certified Nursing Assistant stated, she cared for R1 when he had a fall on 10/18/23. She started her shift at 11:00 PM, the nurse reported to her he had a fall earlier that day. That evening he kept on calling for help to go the bathroom. We would take him to the bathroom, he couldn't go, and then we assisted him back to bed. This went on several times maybe 6-7 times. He was calling so much I had to put him in the dining room about 4:00 AM, because I had to help other residents and had things to do. About 5:00 AM, I was at the end of the hall from the dining room, I saw him stand up and fall forehead hitting his head on the floor, lying face down. I thought he would be okay in the dining room by himself. I reported this to V6 (LPN). That evening he was not himself; he was restless and calling out for help throughout the night. On 10/30/23 at 1:18 PM, V3 (ADON) Assistant Director of Nursing stated, residents should be monitored 72 hours after a post, to monitor any change of condition. Residents with head injuries and residents who are on blood thinners are at greater risk for bleeding. Staff should be monitoring their vitals and perform neuro checks and report any changes to the physician right away. R1 had a fall on 10/17/23 about 5:00 PM, he hit his head and sustained a cut, because he was on blood thinner's he was sent out to the local hospital. The following day it was reported he had another fall and was sent out to the local hospital. V6 reported he was restless that evening (after the first fall, before the second fall) and was placed near the nurse's station to be monitored. V6 did not report any changes of his blood pressure. A high blood pressure could indicate several things including a brain bleed. They should call the physician right away with any changes. V3 said she did not know R1's blood pressure was elevated and not reported. On 10/30/23 at 3:30 PM, V4 (Medical Director) said staff should report a condition change right away. Any reports of a headache, elevated blood pressure, and change of function after a fall could be a sign of a hemorrhage. Residents on blood thinners are at greater risk for bleeding. I don't know the sequence of events of R1, and confirmed R1 sustained a brain bleed after a fall. R1's Vitals Report dated for October 2023 documents: 10/17/23 @ 9:05 PM- 221/97 10/17/23 @ 11:38 PM- 221/97 10/17/23 @ 11:41 PM - 211/89 10/17/23 @ 23:43 PM- 210/96 10/18/23 @ 12:00 AM- 208/94 10/18/23 @ 1:00 AM - 211/96 10/18/23 @ 4:32 AM - 210/100 R1's nurses noted showed the physician was notified on 10/18/23 at 5:05 AM regarding R1's fall. There was no documentation in R1's medical record that showed R1's elevated blood pressures were reported to the physician. The facility's Notification of Change of Condition Policy revised 7/23, states, The facility will provide care to residents and provide notification of resident change in status. The facility must immediately inform the resident; consult with the resident's physician .a significant change in the resident's physical, mental, or psychosocial status .physician also need to be notified if a resident experiences symptom such as chest pain, loss of consciousness or other signs or symptoms of heart attack or stroke.

Based on observation, interview, and record review the facility failed to ensure a resident on oxygen had an oxygen supply, failed to ensure a resident with a recent hospitalization for pulmonary edema (buildup of fluid in the lungs leading to shortness of breath) followed physician orders, failed to have a policy and procedure for weaning a resident off oxygen, failed to ensure oxygen tubing was dated, and failed to ensure oxygen tubing not in use was stored in a bag for 6 (R1, R2, R3, R5, R6, R7) of 6 residents reviewed for oxygen in the sample of 9. This failure resulted in R1 being admitted to the hospital for a second time within a month for pulmonary edema. The findings include: R1's face sheet showed she was originally admitted to the facility on [DATE] from an acute care hospital with diagnoses of type 2 diabetes, pulmonary hypertension, heart failure, chronic obstructive pulmonary disease, stage 5 chronic kidney disease, acute respiratory failure with hypoxia, pleural effusion, and dependence on renal dialysis. On 4/10/23 at 4:06 PM, V5 (local fire department paramedic) said R1 told him she had shortness of breath, called the nurse, she put the thing on her (R1) finger and told her (R1) she was fine. V5 said he was called to the facility after a basic life support ambulance was to transfer her to a medical appointment and found R1 with a nasal cannula in her nose without oxygen running, a low oxygen saturation, high respiratory rate, high heart rate and three empty nonfunctional oxygen apparatus' in R1's room. V5 stated, The facility did absolutely nothing but print a face sheet which we already had from the first ambulance crew. On 4/11/23 at 11:25 AM, V4 (Certified Nursing Assistant/CNA) said on 4/10/23, R1 was supposed to go to a doctor appointment and the emergency medical tech (EMT) found her oxygen low. On 4/11/23 at 11:30 AM, V6 (Transportation) said on 4/10/23 around 9:15 AM, the lady from the ambulance told V9 (Unit Manager) and V7 (Registered Nurse/RN) R1 was having trouble breathing and they wanted to send R1 to the emergency room . On 4/11/23 at 12:21 PM, V11 (Emergency Medical Tech/EMT) said on 4/10/23 he and another crew member arrived to transport R1 to a medical appointment. V11 said it was a prescheduled transport and non-emergent. When they arrived at R1's bedside, R1 could only speak in one-to-two-word sentences before needing to take a deep breath to continue. R1's respiratory rate and heart rate were elevated. R1's oxygen saturation was 86-87% and she had a nasal cannula in her nose connected to an empty portable oxygen tank. V11 said he turned on an oxygen concentrator that was next to R1's bed and it was inoperable. V11 then turned on a portable oxygen tank attached to R1's wheelchair and it was empty. V11 said as there was no supplemental oxygen available in R1's room, he connected R1 to his portable oxygen tank. R1 was able to tell him she had been short of breath for about a day and was normally on oxygen. V11 said he contacted his company to send an Advanced Life Support (ALS) unit to transport R1 to the emergency room and the company told him it would be about an hour. V11 said he then called 911 for transport to the emergency room . V11 said he didn't know how long she was without oxygen, but it was long enough to make her oxygen level low and short of breath. V11 said the facility was made aware of the resident's respiratory difficulties, issues with the oxygen being empty, and the plan to call 911. 0n 4/11/23 at 12:29 PM, V3 (Medical Director) said generally speaking, if a resident is connected to an empty oxygen tank and requires oxygen, it could cause low saturations and increased respiratory and heart rates. On 4/11/23 at 12:31 PM, V12 (R1's spouse) said R1 remained hospitalized for basically had difficulty getting oxygen. V12 said, The night before last, Sunday (4/9/23) R1 had difficulty breathing and felt like she wasn't getting enough oxygen. They had to change the oxygen tank because it was empty. R1 requires oxygen and gets short of breath without it. I would have expected more from the rest home. There's a lack of urgency, experience, and TLC (tender loving care). V12 said this is the second time R1 had ended up in the hospital since admission for this. V12 stated, One time it's the oxygen tank, the next time it's the machine (concentrator). I absolutely would expect the facility would make sure she wouldn't run out of oxygen. On 4/11/23 at 12:33 PM, V2 (Director of Nursing/DON) said she and V1 (Administrator) called the ambulance transport company around 11:00 AM today to find out why they didn't notify facility staff before calling 911. V2 said she wasn't aware of the situation until today. V2 said there was no facility policy or procedure to wean oxygen. V2 stated, This can result in inconsistent interpretation of how weaning of oxygen is done and the facility's expectations. One nurse could do it one way and another nurse do something different. There's no clear guideline on what to do and when. We have quite a few new graduates (nurses). On 4/11/23 at 1:46 PM, V2 (DON) stated, Oxygen tubing should not be on the floor. Bacteria or germs can get into the cannula and enter the respiratory system of the patient. Oxygen tubing should be labeled weekly for infection control. You only want to use it for so long to maintain the quality of the product and prevent wear and tear. When oxygen tubing is not in use, it should be placed in a plastic bag if not in use for infection control. Portable oxygen tanks should be checked every 1-2 hours to make sure they're not empty. We don't use tanks unless something is wrong with the concentrator. Like the concentrator wasn't working for R1 on Sunday. I believe. We only keep oxygen tanks in storage. Concentrators are rented as needed. If a resident is connected to an empty or defective oxygen apparatus, they're not going to provide oxygen as intended. If this occurs, hypoxia, shortness of breath, a resident could be adversely affected, cause hospitalization or death. R1's medical record had no documentation showing oxygen weaning attempts, interventions and outcomes. There was no documentation showing if or when oxygen was applied or removed. R1's 3/27/23 1:20 PM Nurse Practitioner note showed she was paged by the nurse due to R1's increased shortness of breath (SOB) that started 3/26/23. This note showed R1 had chest pain since last night and increased SOB since last night. R1's 3/27/23 5:56 PM discharge summary note showed R1 was sent by ambulance to a local hospital for shortness of breath (SOB), lethargy and poor intake. R1's 4/1/23 7:39 PM progress note showed R1 was readmitted from a local hospital. R1's local hospital discharge instructions showed R1 was hospitalized from 3/27/23 to 4/1/23. This instruction sheet showed R1 was diagnosed with heart failure and for heart failure, daily weight monitoring was crucial. Common symptoms of heart failure included: chest pain, fatigue and weakness, rapid or irregular heartbeat, shortness of breath, persistent cough, and decreased alertness. R1's 4/1/23 hospital discharge orders showed daily weights and oxygen at 3 liters per nasal cannula. A 3/27/23 hospital diagnosis included acute respiratory failure with hypoxia (low oxygen). R1's 4/1/23 9:35 PM progress note showed the doctor verified the hospital transfer orders. R1's 4/2/23 2:03 PM, progress note authored by V3 (Medical Director) showed R1 was sent to the hospital for shortness of breath (SOB) and was found to be volume overloaded. R1 was currently on oxygen at 3 liters per nasal cannula (NC) on exam. R1 was alert and oriented X 3. R1's 4/5/23 1:20 PM note showed the Nurse Practitioner was notified due to a productive cough. R1's 4/5/23 2:30 PM nurse practitioner note showed a registered nurse requested a follow up due to a congested cough that started that afternoon. This note showed R1 was on oxygen at 3 liters and had an intermittent congested cough. R1's 4/5/23 10:06 PM note showed R1 was on oxygen at 2 liters. R1's 4/6/23 6:00 AM note showed R1 was alert and oriented and reported a productive cough. R1's 4/7/23 nurse practitioner note showed R1 was unable to feed herself, oxygen was on at 3 liters per NC (Nasal Cannula). R1's 4/10/23 3:43 PM notes showed R1 was sent to a local hospital emergency room and admitted with a diagnosis of pulmonary edema. R1's physician order sheet (POS) showed orders for follow up appointment with a physician on 4/10/23 at 9:45 AM, (4/2/23) oxygen (O2) to be administered at 3 liters per minute via nasal cannula (NC) and maintain O2 saturation at 90% or greater every shift, wean off oxygen if O2 saturation is greater than 93% one time a day, and weigh three times a week on hemodialysis days, every day shift Tuesday, Thursday, and Saturday (ordered 4/1/23). R1's weights showed no weights recorded for 4/5, 4/7, 4/9, or 4/10/23. R1's 4/3/23 care plan showed the resident has oxygen therapy at 3 liters per minute per NC. Maintain O2 saturation at 90% or greater. Stay with resident during episodes of respiratory distress. R1's 4/6/23 transportation referral showed V1 (Administrator) authorized ambulance transportation for R1 to go to an appointment 4/10/23. This referral form showed R1 was on oxygen at 3 liters per nasal cannula. The facility's 7/22 Oxygen Administration policy showed to check the tank/device being used to be sure they are in good working order. Observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. The tubing will be dated to assist with tracking of when tubing should be changed. If the nasal cannula/mask/tubing is not in use, it must be stored in a clean bag. The facility's 6/21 Weight Policy showed weekly weights will be done with a significant change in condition or with a physician's order. The Mayo Clinic website showed pulmonary edema is caused by too much fluid in the lungs making it difficult to breathe. Pulmonary edema can sometimes cause death. Treatment includes additional oxygen. Symptoms include difficulty breathing, a cough that produces frothy sputum, a rapid, irregular heartbeat, new or worsening cough, rapid weight gain, fluid buildup due to kidney disease can cause pulmonary edema. 2. R2's face sheet showed a [AGE] year old male admitted on [DATE] with diagnoses of end stage renal disease, dependence on renal dialysis, acquired absence of right leg above the knee, acquired absence of toes, left foot, pleural effusion, cardiomegaly, hypertension, obesity, and Type 2 diabetes. On 4/11/23 at 9:35 AM, R2 was in his bed. His oxygen was on at 4 liters per nasal cannula. R2 said the oxygen is new to him. He just started it about three months ago. R2's oxygen tubing in his nose was not dated. There was an oxygen concentrator in the bathroom with tubing extending from the bathroom along and on the floor to the top of R2's mattress where the nasal cannula laid on top of the mattress. R2's bed was the furthest away from the bathroom. R2's oxygen tubing that was not in use was not in a bag. There was an open gallon of distilled water on the bathroom floor next to the toilet. At 11:45 AM, R2 was assisted by therapy with ambulation in the hallway. R2 had an oxygen cannula in his nose that was not labeled. R2 was short of breath and sat down in the wheelchair. This surveyor checked the oxygen tank and the needle on the gauge was on the border of the red (empty). This surveyor asked V8 to look at the gauge and the tank was replaced with a full one. On 4/11/23 at 12:04 PM, V8 (Occupational Therapist/OT) said she usually checks a resident's oxygen tank at the beginning of a session to ensure there's enough to get through a session. V8 said she joined the session (started by someone else) with R2 today in the gym, so she did not check his oxygen tank. V8 stated, The tank was on the border of red when we (this surveyor and V8) looked at it. I would not have used that tank to begin a therapy session. I would have exchanged it for a full one first. R2's POS showed 3/13/23 order for oxygen at 3 liters per NC, maintain O2 saturation at 92% or greater. R2's oxygen care plan showed to administer oxygen per physician's orders. This care plan showed the oxygen is prn (as needed) to keep his oxygen saturation greater than 90%. 3. R3's face sheet showed a [AGE] year old male admitted to the facility 3/4/23 with diagnoses of pleural effusion, dependence on renal dialysis, respiratory failure with hypoxia, end stage renal disease, myocardial infarction, hypertension, and cerebral infarction. On 4/11/23 at 9:53 AM, R3 was not in his room. There was a portable oxygen tank in the room and the attached nasal cannula was not in a bag. An oxygen concentrator was next to the bed and the attached nasal cannula was not in a bag. At 11:25 AM, R3 was in bed on his side with his eyes closed. R3 did not have oxygen on. At 9:55 AM, R3's spouse entered the room and said R3 would be returning from dialysis soon. R3's spouse said she had difficulty speaking English and requested I speak to her son. R3's spouse called her son, V14 (Physician) on the phone. V14 said there was a problem with R3's oxygen tank running out every night. V14 stated, That's why they have the machine in there now. I started making them change the tank before I left so it wouldn't run out during the night. R3 would call me at 4:00 AM to tell me the oxygen ran out. Then, I'd call the facility to have them change the tank. R3's medical record showed an oxygen saturation at 10:04 AM was 95% and R3 was on a nasal cannula. At 12:15 PM, V10 (Registered Nurse) said she had not rechecked R3's oxygen saturation since 10:04 AM when he was on oxygen. V10 was unaware of any facility procedure for weaning oxygen. R3's medical record had no documentation showing oxygen weaning attempts, interventions and outcomes. There was no documentation showing if or when oxygen was applied or removed. R3's POS showed a 3/24/23 order for oxygen at 3 liters per nasal cannula to maintain an oxygen saturation of 92% or greater every shift. There was a 4/3/23 order to wean off oxygen as able if oxygen saturation was greater than 92% every shift. R3's oxygen care plan showed to administer oxygen per physician's orders. 4. R5's face sheet showed an [AGE] year old male with diagnoses of acute respiratory failure, cardiac pacemaker, pulmonary hypertension, malignant neoplasm of the prostate, deaf, non-speaking, senile degeneration of the brain, and chronic kidney disease stage 4. On 4/11/23 at 1:08 PM, R5 was in bed. R5's oxygen tubing was lying on the floor. The tubing and nasal cannula were unlabeled and connected to an oxygen concentrator. The concentrator was on and set at 4 liters per minute. R5's physician order sheet showed an 11/10/22 order for oxygen 2-4 liters per nasal cannula to maintain an oxygen saturation of (blank) or greater every shift. There were no saturation parameters identified in the order. 5. R6's face sheet showed a [AGE] year old female with diagnoses of chronic obstructive pulmonary disease, dependence on supplemental oxygen, heart failure, obesity, developmental disorder of speech and language, dementia, and end stage renal disease. On 4/11/23 at 1:16 PM, R6 was in bed. R6 had oxygen tubing in her nose. The oxygen tubing was not labeled. R6's oxygen was running at 2 liters per nasal cannula via a concentrator. R6 was unable to communicate. R6's 9/20/22 physician order showed to administer oxygen at 2-3 liters per minute per NC to maintain an oxygen saturation of 92% or greater. 6. R7's face sheet showed an [AGE] year old female with diagnoses of sleep apnea, rheumatoid arthritis, heart failure, cardiac pacemaker, obesity, and type 2 diabetes. On 4/11/23 at 1:20 PM, R7 was in a chair in her room. R7 had a nasal cannula in her nostrils. The cannula tubing was not labeled. R7's 2/9/22 physician order showed to administer oxygen at 2-3 liters per NC to maintain an oxygen saturation of 92% or greater.

Based on observation, interview, and record review the facility failure to ensure residents were safely transferred with a mechanical lift for 2 of 3 residents (R1, R3) reviewed for safety in the sample of 6. These failures resulted in R1 sliding from the mechanical lift and sustaining a subdural hematoma (brain bleed); left temporal hematoma with a skull fracture; left clavicle fracture; and left humerus fracture. R1 is currently hospitalized and was transitioned to hospice care. Findings include: 1. The facility's Final Incident Report dated 6/28/22 showed that R1 was being transferred by Certified Nursing Assistant (V11) from the bed to the chair when R1 slipped from the lift sling and onto the floor. R1 hit her feet first then hit her head on the floor. R1 was assessed by the nurse and was bleeding from her head. R1 was sent to the emergency department via 911. The hospital reported R1 was admitted with an [CONDITION(S)] (brain bleed). R1's Face Sheet dated 7/5/22 showed R1 had diagnoses to include, but not limited to heart failure, previous heart attack, [CONDITION(S)], dementia, left hand contracture, [CONDITION(S)], severe protein-calorie malnutrition, generalized muscle weakness, dysphagia, weakness, reduced mobility, presence of a gastrostomy tube (G-tube, feeding tube inserted directly into stomach), [MEDICATION(S)], nutritional deficiency, age related [CONDITION(S)], and Alzheimer's disease. R1's facility assessment dated [DATE] showed R1 had severe cognitive impairment and was dependent on two staff members for bed mobility, transfers, and toilet use. R1's ADL (Activities of Daily Living - ADLs) Care Plan revised 2/15/22 showed R1 required assistance with ADLs related to Alzheimer's Disease, ataxic gait, dementia, weakness, left hand contracture, and reduced mobility. This care plan showed R1 required a mechanical lift for all transfers, with a two person assist. R1's Fall Event dated 6/25/22 at 11:50 AM, showed R1 slid from the mechanical lift during a transfer. This document showed R1 was alert, her pupils were equal and reactive, she was non-verbal (resident's baseline), and had pain to the left lower extremity when it was touched. R1's Progress Note dated 6/25/22 at 12:25 PM, showed, CNA assigned to the patient told me to go and check the patient who fell during [mechanical lift] transfer. Noted patient lying down with blood underneath her head. The nurse called 911, V7 (R1's Power of Attorney - POA) and supervisor. R1 was transferred to the local hospital via ambulance. On 7/5/22 at 12:13 PM, V11 (CNA) said she had been working at the facility a little over a month. V11 said she was assigned to R1 on 6/25/22 (the day of the incident). V11 said she was passing the noon meal trays and knew that R1 required feeding assistance. R1 is dependent on us for all her care. I got her dressed, provided incontinence care, and placed the sling under her. I was trained with the slings that have four straps, but that one, that had six straps. I don't know why I didn't ask for help. It was lunch time, and we were all busy. I should have had someone else in the room with me. We are supposed to have two staff for all lift transfers, but I tried to do the transfer myself. R1's sling had longer legs and was shaped a little differently. I guess I was supposed to crisscross the lower (leg) straps, between her legs to hold her in place, but I didn't. I just attached them to the bar like I do with the normal straps. I had R1 in the air, above her wheelchair and I was having trouble. The base of the lift was opened around R1's wheelchair and I was positioned behind the wheelchair. I moved the lift and R1's left foot bumped the arm rest on the wheelchair, and she swayed in the air. When she swayed to the side, she slid out of the sling. Her feet landed first, then she hit her head. She landed on her left side. It happened so fast that I couldn't get to her fast enough to stop her from hitting her head. R1 wasn't yelling in pain and she didn't lose consciousness, but I noticed her head was bleeding on the left side, above her ear. I tried yelling for help, but everyone was busy. I ran in the hall to V10 (R1's RN) and told her I needed help, then I went back to R1. The nurses (V9 and V10, RNs) checked R1 and called the ambulance. After they assessed her, I put a pillow under her head and put light pressure on the left side of her head, where she was bleeding. R1 went to the hospital. I'm not sure what happened after that. I received more lift training and was suspended. I haven't worked at the facility since the incident. On 7/5/22 at 11:27 AM, V10 (RN) said she was working the day R1 fell from the mechanical lift. V10 said she was in the hall, passing medications. V10 said V11 ran down the hall and said she needed help that R1 had fallen during a mechanical lift transfer. She said when she went in the room R1 was lying on her left side, on the floor. I saw blood on the floor and I wasn't sure of the extent of the injury. I did an assessment, then went to call the ambulance. She had blood coming from the left side of her head, so I had V11 put a small pillow under her head and put light pressure on her head. V10 said R1 was non-verbal most of the time but would smile occasionally. V10 said R1 was so skinny and stiff. When I touched her left leg, R1 screamed. I knew something was wrong. V10 said V9 (RN) helped me to get the vital signs. V10 said R1 was sent to the hospital and had not returned to the facility. V10 said V11 (CNA) had been on R1's assignment for about a week and had not reported any concerns with using the mechanical lift or the sling. V10 said we all get training on the lifts when we get hired and at least once a year. On 7/5/22 between 9:00 AM and 4:00 PM, V9 (Licensed Practical Nurse - LPN), V10 (RN) and V12-V16 (CNAs) said they were working on 6/25/22 and none of them assisted V11 with R1's mechanical lift transfer. They all said there should always be two staff members during a mechanical lift transfer for resident safety. On 7/5/22 at 1:52 PM, V2 (Director of Nursing) said V2 said R1 was dependent on staff for all care. R1 was immobile, stiff, and small in stature. R1 slid from the mechanical lift because V11 didn't follow the facility's mechanical lift policy. V2 said V11 was performing the lift alone and had placed the sling on the lift improperly. V2 stated, There should always be two staff when they perform a mechanical lift transfer for resident safety. V2 said if any staff member is unsure about something, they should ask for help. V2 stated, It's very unfortunate, but that's why she (V11) was provided 1:1 counseling/training and suspended from work. V2 said V11 had not worked since the incident occurred. On 7/5/22 at 1:41 PM, V8 (Hospital RN) said she was caring for R1 at the hospital. V8 said R1 fell from a mechanical lift and underwent a full workup. V8 said R1 had subdural hematoma (brain bleed); left temporal hematoma with a skull fracture; left clavicle fracture; and left humerus fracture. V8 said R1 did not have any surgical intervention and was placed on hospice care on 6/29/22. V8 said R1 was receiving intravenous pain medication. On 7/5/22 at 2:34 PM, V3 (R1's Physician) said R1's health had been slowly declining due to her dementia. R1 was non-ambulatory, not eating, had a G-tube for nutrition, nonverbal, and not interactive. V3 said R1 had an extended hospitalization earlier in the year and was slowing declining since. V3 was notified of R1's subdural hematoma (brain bleed); left temporal hematoma with a skull fracture; left clavicle fracture; and left humerus fracture. V3 said the fall from the mechanical lift definitely could have caused these injuries. V11's Employee Disciplinary Report dated 6/25/22 showed V11 was suspended immediately for Failure to follow facility policies on using (a mechanical lift) transfer safely. The facility's undated Safe Patient Lifting Policy showed, Purpose: The Safe Patient Lifting Policy exists to ensure a safe working environment for resident handlers . Total Lift Transfer with 2 or more caregivers (Total Assist) . This policy will be included in orientation and direct staff will not be allowed to transfer residents until they have completed the transfer competency . 2. On 7/5/22 at 9:30 AM, V12 (Certified Nursing Assistant - CNA) and V13 (CNA/Restorative Aide) transferred R3 from the bed to his wheelchair using a mechanical lift. R3 was well-groomed, sitting in his wheelchair after the transfer. R3 had a liner skin tear to his left, lateral elbow (antecubital) area. The skin tear was scabbed with two steri strips intact. R3 said he didn't know how he got the skin tear. R3's Fall Event dated 6/7/22 showed R3 sustained a skin tear to his left elbow. This document showed R3 was sling broke while transferred. R3's Progress Noted dated 6/7/22 showed, Patient transferred by CNA using mechanical lift. Sling broke. Patient fell slowly to floor with CNA. Did not hit head . R3's Nurse Practitioner Noted dated 6/8/22 showed R3 was evaluated for follow-up with chronic conditions and the nurse reported R3 had a witnessed fall on 6/7/22. This document showed resident denied hitting his head. The only injury was a skin tear. The nurse reported while R3 was being transferred with a mechanical lift and the sling broke as R3 was being lowered to the wheelchair. R3's Face Sheet dated 6/5/22 showed diagnoses to include, but not limited to: [CONDITION(S)], chronic kidney disease, [CONDITION(S)], diabetes, history of falling, obesity, arthritis, and chronic heart failure. R3's facility assessment dated [DATE] showed R3 had moderate cognitive impairment and was dependent of two or more staff for transfers. R3's Care Plan for transfers revised 6/15/21 showed, R3 exhibits decreased ability to transfer self from wheelchair to chair/bed due to decreased functional mobility and generalized weakness. Requires (total) mechanical lift with 2 person assist. On 7/5/22 at 2:12 PM, V18 (Licensed Practical Nurse - LPN) said he was working on 6/7/22. I was charting at the desk when V17 (CNA) came and got me. When I went to R3's room he was sitting on his butt on the floor. V18 said V17 told me he was transferring R3 with the mechanical lift, the sling broke, and R3 fell slowly to the floor. V18 said he doesn't remember where the sling broke, but he does remember it was 2 of the hooks, like a whole part broke. V18 said R3 sustained a skin tear to his left elbow area. V18 said cleaned R3's wound and applied steri-strips. V18 stated, R3 ended up on the floor because the sling completely snapped. I'm not sure how many staff were doing the transfer because I wasn't in there when it happened. I've never seen that happen before. On 7/5/22 at 2:21 PM, V17 (CNA) said he was transferring R3 with a total mechanical lift by himself. V17 said he looked at the sling before he started the transfer and didn't notice any concerns. If I would have noticed anything I would have replaced the sling. I was lifting R3, and he was over the bed a little bit and the front straps (by the legs) broke. He started to slide out. R3 was partially on the bed, so I put my knee there to slowly assist him to the floor. He didn't hit the floor hard. He slid from the bed to his butt. He cut his arm a little, but that was it. I went to tell V18 (R3's LPN) and he took care of it. On 7/5/22 between 9:00 AM and 4:00 PM, V9 (Licensed Practical Nurse - LPN), V10 (RN) and V12-V16 (CNAs) said there should always be two staff members during a mechanical lift transfer for resident safety. On 7/5/22 at 1:52 PM, V2 (Director of Nursing) stated, There should always be two staff when they perform a mechanical lift transfer for resident safety. V2 said if any staff member is unsure about something, they should ask for help. The facility's undated Safe Patient Lifting Policy showed, Purpose: The Safe Patient Lifting Policy exists to ensure a safe working environment for resident handlers . Total Lift Transfer with 2 or more caregivers (Total Assist) . Laundry staff and all staffing with patient contact will conduct inspections of the slings; if slings are found to be impaired then the sling is to be removed from use .

Based on interview and record review, the facility failed to perform a safe transfer with a mechanical lift for a resident (R1), failed to train staff on mechanical lift emergency procedures and the facility failed to ensure the safety of a resident during a pivot transfer for 2 of 3 residents (R1, R3) reviewed for falls in the sample of 3. These failures resulted in R1 sustaining a right clavicular fracture, right femoral fracture, and a humeral (upper arm) fracture and expiring 48 hours after her fall, and R3 sustaining a tibia and fibula fracture of her leg. The Immediate Jeopardy began on [DATE] when staff failed to perform a safe transfer with a mechanical lift. The Immediate Jeopardy was identified on [DATE]. V1 Administrator and V2 Director of Nursing were notified of the Immediate Jeopardy on [DATE] at 7:50AM . The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. The findings include: 1. R1's electronic face sheet printed [DATE] showed R1 had diagnoses including but not limited to dementia with behaviors, [CONDITION(S)], heart failure, muscle weakness, and [CONDITION(S)] (swelling). R1's facility assessment on [DATE] showed R1 was a two person assist for transfers and toilet use and required a mechanical lift. R1's fall risk assessment dated [DATE] showed R1 was a high fall risk. R1's Restorative/Mobility Screen dated [DATE] showed, Toilet use: Extensive x 2 person assist at times. R1's documented weight in the facility dated ,d+[DATE] showed R1 weighed 285.1lbs. R1's care plan dated [DATE] showed, The resident has an activities of daily living self-care performance deficit related to dementia and muscle weakness. Toilet use: The resident requires extensive assist with ,d+[DATE] staff participation to use toilet. Transfer: The resident requires extensive staff assistance with 2 staff participation with transfers using a mechanical lift. R1's fall event dated [DATE] showed, Resident using (mechanical lift) in bathroom. Resident calling help,help! Alert, resident did not hit her head, ambulation status was assist of one with or without the device, unable to complete assessment of range of motion, no rotation/deformity/shortening, laceration on right lower leg. R1's emergency medical services record from local emergency transportation company dated [DATE] showed, Patient was found on the floor wedged underneath the toilet and against the wall. Staff on scene stated they were helping patient using a lift when the patient fell on to the floor. Staff stated the patient cut her leg open on the bottom of the lift that had an exposed screw head sticking out .Patient was awake and screaming at the crew. Patient stated both her shoulders and her leg hurt. Patient stated she remembers the fall .Secondary trauma assessment revealed a laceration above the right ankle, a large contusion to the right side of the patient's forehead, and pain upon palpation of patient's right knee. R1's trauma history and physical note from the local hospital dated [DATE] showed, Right lower extremity rotated and immobile, several small contusions. Right shoulder, right upper arm, left shoulder and left knee tender to palpation and bruised. R1's imaging reports from the local hospital dated [DATE] showed, There is a soft tissue laceration overlying the right frontal bone. There is a nondisplaced mid-shaft fracture of the right clavicle. There is a fracture of the distal right femoral diaphysis (shaft) with fragment displacement by 3.5cm. There is a nondisplaced fracture of the mid right humeral diaphysis. Diffuse soft tissue swelling in the medial aspect of the distal right leg. R1's laceration repair notes from the local hospital dated [DATE] showed, 10cm x 5cm laceration to right lower leg repaired with 10 sutures. R1's inpatient progress notes from local hospital dated [DATE] showed, Hemorrhagic shock (severe blood loss) secondary to trauma. Treatment for [CONDITION(S)]. R1's Inpatient Discharge Summary/Expiration Note from the local hospital dated [DATE] showed, Patient was admitted to the trauma team with lacerations, right femur fracture, right humerus fracture and right clavicular fracture .She was started on [MEDICATION(S)] for [CONDITION(S)] coverage although [CONDITION(S)] was unlikely .she continued to worsen and required more oxygen. The critical care team had goals of care discussions with the son and was notified she was actively dying. She became more bradycardic (decreased heart rate) and died at 11:05AM on [DATE]. R1's discharge diagnosis list from the local hospital showed R1 was discharged with diagnoses including but not limited to fall with multiple fractures, multisystem organ failure, and shock. R1's Certificate of Death dated [DATE] showed, Date of injury: [DATE] due to a fall from a lift at the nursing home. Cause of death was noted as multiple injuries and fall. Manner of death was noted as accident. On [DATE] at 10:19AM, V7 (Registered Nurse) stated, I was the nurse working the day that (R1) was sent to the hospital. I heard (R1) calling for help and when I went into the bathroom, (R1) was sliding out of the mechanical lift and (V4-Certified Nursing Assistant-CNA) told me the lift wouldn't lower (R1) down to the toilet. (R1) told me she needed help and was falling out of the sling. I called for help and (V6-CNA) came. I then ran out of the room to call a code blue to get as many staff members as I could to come help and when I came back into the room, (V6) told me he assisted (R1) to the floor and (V4) was not in there. On [DATE] at 11:42AM, V2 (Director of Nursing) stated, The mechanical lift that was being used for (R1) is not in use at this time. We found during our incident investigation that the remote was not working to raise and lower the resident. Observation of the mechanical lift that was used for R1 was made during this time and showed a strap located at the knee pad of the lift where the resident is supposed to have their legs strapped to prevent their legs from coming off of the lift. On [DATE] at 12:21PM, V6 (CNA) stated, I saw (R1) on the mechanical lift and she was halfway up and halfway down. We were trying to get her back on the toilet. I lowered her to the floor by the toilet but I can't remember if anyone helped me or not. There is an emergency button on the lift but I don't think it works. There is a buckle on the mechanical lift sling that goes around the resident but we don't need a gait belt with these types of transfers. On [DATE] at 12:30PM, V4 (CNA) stated, I got (R1) on the mechanical lift because she insisted on going to the bathroom. I took her from her bed to the bathroom in the lift and then the remote would not work to sit her down on the toilet. I called for the nurse and she came in and told me to go get more help so I called (V6). I never saw (V6) assist (R1) to the floor. When I came back into the bathroom, (R1) was on the floor with her head and shoulders between the wall and toilet. There is an emergency button on the mechanical lift but I don't know how to use it. They trained me on the lift but nothing about what to do in an emergency or if the lift stops working. I have never used a gait belt on a resident during transfers with a sit to stand lift and I wasn't using one when I transferred (R1). On [DATE] at 1:16PM, V9 (Restorative Nurse) stated, (R1) was labeled as an extensive assist with 2 staff at times. This means that a staff member may ask for assistance with (R1) if they are uncomfortable transferring her on their own. I asked for physical therapy to re-evaluate (R1) because I noticed that staff were asking for assistance more often when transferring her. I don't think we would ever use a gait belt for a mechanical lift transfer. If a mechanical lift quit working, I would unclip the sling with one staff member on each side of the resident and assist them to the floor or nearest surface. There is an emergency button that I suppose you could use to help lower the lift during a malfunction but I don't know much about it. On [DATE] at 9:57AM, V7 (Registered Nurse) stated, When I entered the room, (R1) was straight up in the mechanical lift and the lift sling was up around the front of her neck. I told (V4-CNA) to go get help and she left to get (V6-CNA). I left the room after (V4,V6) arrived and called a code blue. When I came back, (V6) was the only aide in the bathroom with (R1) and she was laying on her right side between the toilet and the wall with her head by the back of the toilet. I did not assess her except for her vital signs and blood sugar. There is an emergency release on the mechanical lift but I don't think (R1) was in a position where we could have used that because it would have taken too long. On [DATE] at 11:02AM, V6 (CNA) stated, When I was called to (R1's) room, her feet were flat on the floor, she was not hanging onto the lift and her arms were up in the air. She was standing straight up, legs slightly bent. I took her right arm out of the sling and she dropped down a bit and then her left arm came out of the sling and she fell to her knees and twisted backwards and went down on the floor behind the toilet. Her lips were starting to turn blue when I was helping her. We usually use more than one person to transfer (R1) because she doesn't always bear weight. The emergency button on the lift could not be used because of the position that (R1) was in. I don't think it would have worked. On [DATE] at 12:31PM, V11 (Therapy Director) stated, We used a mechanical lift for (R1) and were asked to evaluate her for her appropriateness in this lift because some of the aides were having doubts about transferring her because of her size and strength. We only did a one-time assessment which means that we only did one transfer with her to see how she would do and she seemed okay with that transfer so we kept her as a stand lift. Again, this was a one-time assessment and we never saw her again. The safest way to transfer a resident with a mechanical lift is by going from one surface to another. It's risky to use it as a transport device because the resident can become weak and staff have less control if the resident begins to weaken before they reach another surface to sit them down on. If a lift malfunctions there is an emergency button that will bring the lift arms down so the resident can be safely seated on a surface. On [DATE] at 2:31PM, V3 (Assistant Director of Nursing) stated, I think the emergency button on the mechanical lift is to lower the resident down in an emergency but I'm not really sure. If a resident is stuck in the lift you could either take the resident out of the sling or use the emergency button. Either scenario would have the same outcome. On [DATE] at 2:42PM, V2 (Director of Nursing) stated, I did the incident investigation for R1's incident. (V4-CNA) was taking (R1) from her bed to her bathroom using the mechanical lift and when they got to the toilet, the lift would not go down. (R1) was all the way up in the lift standing straight up. (V4) called for assistance from (V7-RN) and was told to go get help from (V6-CNA). When (V6) entered (R1's) bathroom, her legs went under her and the lift sling was up under (R1's) arms and he couldn't lower the lift so he detached the sling and lowered her to the floor. I don't know how she sustained all of those injuries from being assisted to the floor. I don't know if the leg strap was behind her legs or not during the transfer. I would expect the aide to take the resident out of the lift if it malfunctioned during a transfer. (V6) did not use the emergency release because it's too slow. I don't believe that the lift was being used as a transport device in this situation because it's not that far from (R1's) bed to her bathroom even though her bed was on the far side of the room. On [DATE] at 3:01PM, V4 (CNA) stated, I did not have the safety strap behind (R1's) legs during the transfer. I don't even know if I really ever use that. I know there was blood on one of the wheels from (R1's) leg but I don't know what exactly she cut her leg on. When I had (R1) in the lift, she was standing straight up, knees slightly bent. After I asked (V6) for help, he told me to leave (R1's) bathroom and go get more help. When I came back to the bathroom, (R1) was on the floor with her head and shoulders between the toilet and the wall. Had I been familiar with the emergency button I would have definitely used it in this situation. Now that I know what it's used for, it would have been completely appropriate to use in this situation. As far as I have been told, there is only one emergency button on the lift. On [DATE] at 8:45AM, V5 (emergency room physician) stated, When (R1) arrived at the emergency room , she was alert and oriented. She knew she was injured and she was in a lot of pain. She told me she fell out of the lift at the nursing home. She stated she was being helped into the bathroom and fell and was wedged between the wall and toilet. Her injuries were consistent with a traumatic fall, not an assisted fall. Even if you considered her diagnoses and diseases these injuries were significant and are consistent with a traumatic fall. Her injuries definitely contributed to her death, there's no question about it. I am still puzzled as to how those significant injuries were obtained while a resident was in a lift. The lifts are designed to be an added safety measure during transfers. This particular case is very clear to me and in my professional opinion it never should have happened. The manufacturer's manual for the mechanical lift dated ,d+[DATE] showed, The patient lift is NOT a transport device. It is intended to transfer an individual from one seated surface to another (such as bed to wheelchair) .Activating a Mechanical Emergency Release: Primary Emergency Release: This procedure will bring the boom (lift arms) down if the hand control is not functioning properly. To activate the emergency release, insert the tip of a pen into the Emergency Down hold in the control box. Secondary Emergency Release: All patient lift actuators are equipped with a mechanical emergency release. The mechanical release will enable the [MEDICATION(S)] to retract without power. Use the primary emergency release first before using the secondary emergency release. This procedure should only be used of the primary emergency release procedure is not functioning or is unreachable. To activate the secondary emergency release, pull up on the RED emergency grip and pull down on the boom (lift arms) at the same time. The facility's undated policy titled, Safe Patient Lifting Policy showed, The Safe Patient Lifting Policy exists to ensure a safe working environment for resident handlers .Gait belt usage is mandatory for all resident handling with the exception of bed mobility and medical contraindications. 2. R3's electronic face sheet printed on [DATE] showed R3 was admitted to the facility with diagnosis including but not limited to [CONDITION(S)], chronic diastolic congestive heart failure, intervertebral disc degeneration, muscle weakness, difficulty in walking, and unsteadiness on feet. R3's care plan dated [DATE] showed, The resident has an activities of daily living self care performance deficit related to weakness. The resident requires extensive assistance staff participation with transfers. May need ,d+[DATE] staff assistance at times. R3's facility assessment dated [DATE] showed R3 was cognitively intact and required 2+ staff assistance for transfers. R3's restorative/nursing assessment dated [DATE] showed R3 required 2 staff assistance for transfers and toileting. R3's fall risk screen dated [DATE] showed R3 was a moderate fall risk, unable to independently come to a standing position, exhibited loss of balance while standing, and had decreased muscle coordination. R3's nursing progress notes dated [DATE] showed, Around 12:45PM the assigned aide came and called writer and reported that Resident fell . When writer went into room, found the resident on the floor in her washroom, sitting on the floor on her buttocks, as per resident, This girl was helping me to transfer from my wheelchair to toilet seat and my right leg gave up and I went down and I think I hurt my good knee. R3's nursing progress notes dated [DATE] showed, Around 1:10PM, the activity aide brought resident back from a visit and said resident wants to see the nurse and wants Tylenol. Noted swelling on her left knee, transferred her back to bed, applied ice, and administered Tylenol. Obtained order for x-ray of left knee. X-ray results show acute comminuted fracture of the proximal tibia and fibula shafts are seen, there is some impaction and anterior displacement of the distal tibia shaft, moderate soft tissue swelling. Received order from physician to send resident to (local emergency room ). R3's local emergency room records dated [DATE] showed, Patient states earlier today she was in the bathroom when her other leg caused her to fall and twist the injured leg. Immediate severe pain, tried [MEDICATION(S)] and Tylenol without relief. Now swollen with bruising. Pain worse with movement, cannot ambulate .Imresssion: left tibial fracture, closed fracture of proximal end of left fibula. On [DATE] at 8:05AM, R3 stated, The day I fell I was in the bathroom and the aide said she knew how to transfer me and apparently she didn't. Instead of putting my wheelchair behind me she pushed it further away and then told me to sit down so I did and then I fell to the floor because there was nothing behind me. There was no gait belt on me and there was only 1 aide assisting me. Usually they used ,d+[DATE] staff members to tranfer me but this girl said she knew how to do it herself so I trusted her. I shouldn't have trusted her because I haven't walked since and I was able to walk before. On [DATE] at 8:10AM, V14 (certified nursing assistant-CNA) stated, Before her fall, I think (R3) was a 1 assist for transfers. We should always be using a gait belt for transfers because if a resident starts to fall you have something to hold onto. If you don't use a gait belt and a resident starts to fall then you have no way to try and prevent them from falling. On [DATE] at 8:25AM, V10 (CNA) stated, A gait belt should be used for all transfers except mechanical lift transfers. If you don't use a gait belt then the resident could start falling and you can't catch them and they could get injured. Before (R3's) fall I think she was a 1 assist for transfers and now she is a mechanical lift with 2 staff assist. On [DATE] at 8:34AM, V9 (Restorative Nurse) stated, Gait belts should be used for all 1 person assist transfers. They should be used for patient safety so that if a resident begins to fall the staff can either prevent the fall or assist them to the floor to hopefully prevent injury. The restorative assessment shows what assistance a resident requires and residents transfer status should not change unless they are evaluated by restorative or physical therapy first. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy. The facility must ensure that the residents environment remains as free of accident hazards as is possible; and each resident receives safe transfers during a mechanical lift transfer. 1. Corrective action which was accomplished for those resident(s) affected by the deficient practice: R1 no longer in facility. Sit to stand lift has been serviced and being used for competencies. Certified nursing assistant is taken off schedule until she is trained and gone through competency training on emergency release mechanism during lift malfunctions. All resident transfer status were updated to ensure proper transfer status to ensure they are safely transferred. We have no residents currently that require sit to stand lifts for transferring. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice: All residents that are on a mechanical lift have the potential to be affected by the same deficient practice. No other resident was found affected by this purported deficiency. 3. Measures the facility will take or system the facility will alter to ensure that the problem will be corrected: All nursing staff will be in-serviced and competencied on all shifts. The training includes: slings or leg strap properly secured, aware of emergency mechanism and knows how to utilize it in the event of a malfunction, proper number of staff present for transfer and appropriate distance being used between transfer from and transfer to. Preventative maintenance audit completed to ensure that all lifts are working properly. This is done monthly and will continue to be completed monthly ongoing. Quick reference reminders per the manufacturer's manual are posted at all lift battery charging stations and on the lifts to ensure staff are aware of emergency mechanisms and reminders of safely operating the mechanical lifts. No staff will be able to work the floor until they have gone through a safe transfer and emergency mechanism competency. Current staff in the building on [DATE] have been educated regarding lift procedure. Robocall Message was sent out to all nursing staff to inform them that they cannot work until they come and do competency training. Any new devices the facility will put in place will have competency training first before putting into use. 4. The facility has developed a Quality Assurance Audit Tool to monitor for compliance: A QA tool has been developed to monitor and ensure compliance with safe transferring and proper knowledge of how to use the emergency mechanism during a mechanical lift transfer. This audit will be completed 3 times a day for 3 days and 1 time a week for 1 week by the restorative nurse or nurse managers/designee and oversite by the Director of Nursing and the Administrator to ensure compliance. The results of the audits will be reviewed weekly with the facility Interdisciplinary Team and then presented during the monthly Quality Assurance and Performance Improvement meetings. Methods for improvement and overall performance will be discussed by the team to achieve improved results. ADHOC meeting was completed immediately and reviewed by the medical director on [DATE]. Completion Date: [DATE] On [DATE] at 2:00PM, In-service records were reviewed and showed 40% of nursing staff have received training on the following: number of staff required for a safe transfer, how to apply slings to a resident using the mechanical lifts, ensuring leg straps are used for all residents during transfers with a mechanical lift, using a mechanical lift as a transfer device only (not for transport), gait belt use, activation of the emergency mechanisms on the mechanical lifts, and location of quick refernce guides for mechanical lifts.

Based on observation, interview, and record review the facility failed to transport a resident with cognitive impairment (R1) in a safe manner to avoid injury. The facility failed to apply footrests on the wheelchair and continued transporting the resident while she was grabbing hold of the handrail. These failures contributed to R1 leaning forward and falling out of the chair. R1 struck her head on the floor sustaining a fractured nose, and laceration to her forehead. This applies to 1 of 5 resident (R1) reviewed for accidents and injuries. The findings include: R1's Current Care Plan on 02/20/2020 shows, R1 has multiple [DIAGNOSES REDACTED]. R1's Minimum Data Set, dated dated dated [DATE] Brief Interview for Mental Status shows, 99-Resident was unable to complete interview. R1's Progress Notes dated [DATE]20 at 10:09PM, by V10 LPN-Licensed Practical Nurse shows: While I was in the nursing station, I heard an impact that sounded like somebody fell . As soon as I looked at the hallway, I saw CNA (Certified Nursing Assistant) by the wheelchair and observed R1 already on the floor. I went to assess, while resident remained on the floor and noticed residents face bleeding. I called for help and the other nurse came over and stayed with resident while I called 911. The Paramedics came and took R1 to ER-emergency room . R1's Progress Notes dated [DATE]20 at 10:09PM, by V10 LPN shows, report from ER-emergency room , R1 is admitted (to the hospital) with the [DIAGNOSES REDACTED]. The facility's Incident Report dated 02/07/2020 at 7:00PM, shows, R1 is an [AGE] year-old female that resides on our Dementia Unit. Resident is alert to self at times with confusion. She uses her wheelchair for locomotion on the unit, she can self-propel with direction from staff. R1 has impaired cognition due to Dementia disease process but is usually redirectable. The facility investigation interviews showed R1's CNA reports that prior to incident, she was noted at times reaching out and attempting to grab onto the hallway rail. On [DATE]20 at 11:58AM, V8 CNA-Certified Nursing Assistant said, On February 7, 2020 at 7:00PM, I was pushing R1 in the wheelchair down the hallway from the dining room. While she was holding onto the handrail on the wall, she suddenly fainted or fell . R1 normally pushes herself, but it takes her a long time. No leg rests were on the wheelchair when I was pushing her. On [DATE]20 at 12:21PM, V7 PTA-Physical Therapy Assistant said, leg rests are used to ensure residents do not drag their feet on the floor. Sometimes the resident's legs are so weak they cannot bring them up. When a staff member transports a resident the leg rests should be on the wheelchair. When transporting a resident, we always put leg rests on the wheelchair. On 0[DATE]20 at 9:30AM, R1 was sitting at a table in the dining area in a high-backed wheelchair with leg rests attached. R1's head was limp and leaning forward, her torso slightly forward and leaning to the right. R1's eyes were closed. R1 did not respond to verbal stimulation when her name was spoken. R1 had right sided facial [MEDICAL CONDITION] with bruising over her right eye down to the right side on her lower neck extending down under her shirt. R1's care plan for fall prevention prior to the incident, dated [DATE]20 shows no specific interventions for how R1 should be transported by the staff in her wheelchair. The facility's Wheelchair Leg/Footrests policy dated September 2016 shows: Wheelchair leg rests are extremely important to any resident who uses a wheelchair as they assist the resident in sitting up in the optimum sitting position, improving posture, and promoting better blood circulation. Guideline: Therapy and or Restorative nurse performs screen to ensure appropriateness of wheelchair use and use of proper leg or footrests that may require adjustments as indicated. During transfers with assistance: Make sure resident's feet are safely positioned and elbows, clothing, bags are tucked in safely. Look well ahead for possible hazards.

Based on interview and record review the facility failed to ensure fall interventions were implemented for a resident who has had multiple falls and is a high fall risk. These failures resulted in R1 rolling off the bed and sustaining a laceration to the eye that required sutures. This applies to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 3. The findings include: R1's current facesheet shows he was admitted to the facility on (MONTH) 16, (YEAR), and has [DIAGNOSES REDACTED]. R1's (MONTH) 17, 2019, Minimum Data Set (MDS) shows R1 is cognitively impaired, and requires extensive assistance performing Activities of Daily Living (ADLs) that include turning and repositioning when in bed. R1's active care plan shows he is high risk for falls and has had multiple falls. Interventions to the same care plan were initiated on (MONTH) 31, (YEAR), to include support pillow when lying in bed, thick fall mat in place when resident is lying in bed. The same care plan additionally shows that R1 has behavioral issues and can become physically and verbally aggressive. R1's (MONTH) 26, 2019, Fall Risk Screening shows R1 has had multiple falls and is high risk for falls. R1's (MONTH) 14, 2019, Nursing Progress Notes show at 9:55 AM a Certified Nursing Assistant (CNA), called for a nurse to report R1 had fallen out of bed. R1 was lying on the floor on his left side close to the bed. R1 had a cut on the left eyebrow and was complaining of back pain. 911 was called and R1 was transported to a local community hospital emergency room for evaluation. R1's (MONTH) 14, 2019, Nursing Progress Note shows R1 returned to the facility at 3:54 PM and had received 6 sutures to his left eyebrow. The Facility Incident Report Investigation shows on (MONTH) 14, 2019, at 9:55 AM, V7 (CNA) was completing morning care for R1 and was in the process of positioning R1's recliner along the side of the bed when R1 made a sudden motion and rolled off the side of the bed onto the floor. On (MONTH) 19, 2019, at 11:25 PM, V7 said he was in the room with R1 on (MONTH) 14, 2019, and was completing morning care and getting him dressed. V7 said R1 had been agitated that morning, he was upset and striking out at him while he was dressing and positioning him. V7 said he turned R1 onto his side, the side rail to the bed was down, the bed was not at the lowest position, and he had already removed the fall mat from the floor. V7 said he turned his back to R1 and went to get R1's reclining wheelchair to move it closer to the bed and by the time he turned back around R1 was on the floor. V7 said R1's fall mats should always be down. On (MONTH) 19, 2019, at 2:10 PM, V2 (Director of Nursing) said she was called the day R1 fell . V2 said when she got to R1's room he was lying on his floor on his left side and was ultimately sent to the emergency room for evaluation of a laceration on his left eyebrow. V2 said she spoke with V7 who was the CNA providing care to R1 when he fell out of bed and she was upset because she didn't understand how this could happen that fast. V2 said she had to re-educate V7 to make sure that he always places the resident's bed is in the lowest position especially if he is turning away from the resident, and to re-position a resident in a manner that would not allow for them to roll off the bed. V2 said R1 should have had fall mats down when he was in bed. On (MONTH) 19, 2019, at 12:11 PM, V3 Registered Nurse (RN) said he is the fall coordinator for the facility and went to R1's room when he was informed R1 had fallen. V3 said R1 should have fall mats down when he is in bed but the fall mats were not down because V7 was getting R1 ready to get up. V3 said R1 had falls on (MONTH) 31, (YEAR), (MONTH) 7, 2019, (MONTH) 19, 2019, and (MONTH) 26, 2019. V7 said on (MONTH) 31, (YEAR), interventions were added for R1 to include fall mats when resident is in bed. V7 said R1 has poor safety awareness and he turns without knowing he will fall. R1's current care plan shows that interventions including ensuring the resident is properly positioned, and to maintain the bed in the lowest position were not added until (MONTH) 16, 2019 (after R1's most recent fall). On (MONTH) 19, 2019, at 11:15 AM, V1 (Administrator) said R1 should have fall mats on both sides of his bed. On (MONTH) 19, 2019, between 1:20 PM and 1:50 PM, V6 Licensed Practical Nurse (LPN), V8, V9, V10 (CNA's), said R1 could be aggressive, he was a fall risk and had fallen before, and should have had fall mats beside his bed and his bed should be in the low position when he is in bed. On (MONTH) 19, 2019, at 1:48 PM, V4 (Special Unit Director) said R1 could be aggressive and had sudden quick jolts. V4 said that interventions for residents who are high risk for falls should include, bed in the lowest position, increased supervision, mats on the floor next to the beds.

Based on record review and interviews the facility failed to monitor and provide toileting assistance to prevent accident to a resident identified as high risk for falls and with history of multiple falls. This applies to 1 of 10 residents (R22) reviewed for fall in the sample of 26. This failure resulted in R22's fall incident on 2/22/13 requiring emergency room evaluation and treatment due to head trauma. R22 was diagnosed with [REDACTED]. Findings include: R22 has multiple [DIAGNOSES REDACTED]. R22's most recent significant change MDS (Minimum Data Set) dated 12/12/12 was coded to reflect that the resident has temporal orientation and recall problems. R22 requires extensive assistance x one person physical assist with transfers, ambulation, locomotion on and off the unit, toilet use and personal hygiene. R22's fall risk assessment dated [DATE] reflected a score of "13", indicating that the resident is high risk for falls R22's records showed evidence that the resident had history of unwitnessed falls on: - 4/20/12 (6:10 PM), R22 attempted to transfer herself to the toilet but did not make it. No injury was sustained. - 5/27/12 at 6:50 PM, R22 was found on the floor screaming for help inside the bathroom. R22 sustained hematoma and skin tear on the right lower extremity. R22's occurrence report dated 2/22/13 indicated that at approximately 11:25 AM inside the shower room, the resident was found on the floor in front of the toilet laying on her right side with her right arm under her. R22 had a large laceration noted on the right forehead with large amount of bleeding with reports of pain. R22 was also noted with skin tears on both knees and between first and 2nd fingers on the left hand. R22 was transported to the emergency room via 911 for evaluation and treatment of [REDACTED]. R22's progress notes dated 2/22/13 indicated that the resident came back to the facility from the hospital with laceration over the middle of the forehead, 8 cm in length with 12 sutures. R22 also had laceration over the palmar surface of the left thumb with dressing in place. The same progress notes reflected that the resident was also diagnosed in the hospital with UTI (Urinary Tract Infection). R22's physician progress notes [REDACTED]. R22's hospital x-ray result indicated an acute fracture of the left distal phalanx of the thumb. R22's occurrence follow up report dated 2/26/13 indicated that R22 requested to be toileted prior to her fall but was not taken to the washroom immediately. R22 attempted to toilet herself without assistance from the staff and subsequently fell . On 3/13/13 at 10:20 AM, E10 (Activity Aide) stated that on 2/22/13 around 11:00 AM, (E10) brought R22 to the 3rd floor small dining room because the resident wanted to use the washroom. Per E10 she informed E11 (CNA) about R22's request to use the washroom. According to E10, E11 told her to place R22 by the 3rd floor nursing station with the other residents, to which she complied. E10 stated that after placing R22 by the 3rd floor nursing station, she left the 3rd floor unit and went back to the 1st floor to assist other residents. E10 stated that she did not toilet R22 nor did she inform any other staff about R22's need to use the washroom. On 3/13/13 at 10:32 AM, E11 stated that on 2/22/13 at around 11:00 AM, E10 told E11 that R22 wanted to use the washroom. According to E11 she told E10 to go to the 3rd floor nursing station and tell the other CNA to take R22 to the washroom because, she (E11) was watching and attending to the other residents inside the small dining room. E11stated she saw E10 wheel R22 towards the 3rd floor nursing station, but she does not know if E10 told the other CNA about R22's request to use the washroom and/or who took R22 to the washroom. On 3/13/13 at 10:50 AM, E12 (CNA) stated that he was the assigned staff for R22 on 2/22/13 during the 7 - 3 shift. According to E12 no one informed him that R22 needed to use the washroom on 2/22/13, prior to the fall incident. E12 stated that R22 normally would inform the staff if she wants to use the washroom. Per E12, R22 is capable of wheeling herself to the washroom, can open door and would attempt to transfer self from wheelchair to the toilet. E12 stated that, if R22 verbalized the need to use the washroom, the resident should be assisted immediately because she will attempt to toilet herself without assistance, which is not safe. R22's high risk fall care plan indicated multiple approaches dated 12/13/12, which included close monitoring of the resident and toileting the resident according to the care plan. Further review of R22's care plan dated 12/13/12, indicated that the resident had limited ability to toilet self safely related to cognitive and functional issues. There were multiple approaches which included; toileting the resident upon request and reminding the resident not to transfer independently or attempt to toilet without assistance. On 3/12/13 at 3:00 PM, E2 (Director of Nursing) stated that upon investigation of the fall incident of R22 on 2/22/13, it was concluded that the resident requested to be toileted, but was not taken immediately by the staff. R22 attempted to toilet herself without assistance from the staff and in the process, R22 fell and sustained injury.

Based on observation, interview and record review, the facility failed to: - provide supervision to residents (R 1, R 2, R 3 and R 4) who were identified as high risk for fall and to R1, R2 and R 3 who require supervision. - follow and consistently implement the plan of care to provide assistive devices (1) call light and chair sensor pad to R 1 and (2) to follow R 2's plan of care to use gait belt during transfer. - develop a plan of care to address R 3's risk for fall/ accidents. - monitor the effectiveness of the interventions for R 1, R 2, R 3 and R 4 and to modify the interventions consistent with the resident's specific needs to prevent further falls/incidents with significant injuries. - thoroughly investigate and analyze the root causes of R 1, R 2, R 3 and R4's fall incidents to prevent continuous fall incidents. These failures resulted in: (1) R 1 sustaining additional significant injury (fracture of left femur on 09-05-12). (2) R 2 and R 3 continued to fall after R 2 sustained fracture of the lumbar area (L1) compression fracture 05-02-12. (3) R 3 sustained a right hip fracture on 05-02-12 and (4) R 4 sustained contusion on the face, scalp/neck and fracture of the left 5th finger during toileting by the staff. This is for 4 of 9 residents (R 1, R 2, R 3, and R 4) who had incidents of falls and sustained significant injuries in the facility. Findings include: (I) Review of R 1's event report dated 09-05-12 at 8:08 PM under notes reads: resident (R1) heard by CNA calling for help from her room ...observed resident sitting on the floor leaning against her wheelchair. Complained of left hip pain (verbally expressed in Spanish) ... cannot move her left lower extremity ...911 called ...resident taken to hospital for evaluation ...admitted with [DIAGNOSES REDACTED]. Review of the CNA (E5) statement dated 09-06-12 reads: resident did not have the call light on. On 09-07-12 at 3:00 PM, the Director of Nursing (E 1) stated " she (R1) had a fall in her room on 09-05-12. She was sent in the hospital and diagnosed with [REDACTED]. They (hospital) did an Open Reduction Internal Fixation yesterday (09-06-12). She's still in the hospital right now. Yes, she has history of falls, she needs supervision. " Interview with R 1's husband (Z1) by phone on 09-07-12 at 6:42 PM, Z 1 claimed " she (R 1) always needs help to go to bathroom but there's no help. She (R1) said she wants to go (bathroom) but can't go by herself. She is not walking very well. She broke bone in the leg so they operated yesterday (09-06-12) at 7:15 PM. She fell a lot in the nursing home. She broke bones before (01-01-12 sustained fracture of the left humerus) this year and now again ((09-05-12 sustained fracture of the left femur). They even dropped her from the machine ... " Phone interview with the 3-11 shift (PM) Supervisor (E 2) on 09-07-12 at 7:15 PM, E 2 relayed " I was the PM supervisor at the time, around 5:00 PM, I got a call from the Nurse (E 4) and said patient's (R1) on the floor. The 2 CNA's (E3 and E 6) found her on the floor. I went to the patient's room and found her sitting on the floor leaning on her wheelchair near her bed ... she was holding her left leg, she was talking to me in Spanish. The two CNA' s (E3 and E6) translated to me that she' s (R1) complaining of pain on the left leg and when she move. I instructed the nurse (E 4) to call 911. In between (while 911 were working on R 1) the husband came in. " When E 2 was asked on R 1's cognition, E 2 replied and said " she's alert X1 or sometimes 2 with confusion ... she ' s not alert. She had fall(en) before. The CNA (E3 and E 6) said she was in her wheelchair in her room at 3:30 PM. The incident (happens) was around 5:00PM; we serve dinner at 5:00 to 5:30 PM ... " On 09-07-12 at 7:40 PM via phone, the CNA (E3) assigned to R 1 stated " my shift starts at 3:00 PM, I saw her (R1) at 3:30 PM she was sitting on her wheelchair in her room. We heard someone screaming for help in Spanish ... we (E3 and E6) went to her(R 1) room and found her on the floor complaining of pain in her left hip. When we asked her (R1) what happened she said she was trying to go to the bathroom and tried to walk but she cannot walk that's why she fell . " E 3 also disclosed she didn't toilet R 1 and said "I didn't toilet her when I came in (at 3:00 PM), she's incontinent. She goes to dialysis you know! She doesn't pee that much. When I came in (at 3:00 PM) I asked her if she's okay. She was sitting in her wheelchair in her room. She said she's okay! No, I didn ' t ask her if she wants to use the washroom. " E 3 also described R 1's activities of daily living and stated " she (R 1) doesn't walk. She stands up with one assist. She transfers during dialysis days (Monday, Wednesday s and Friday at 6:00 AM) they (night shift) use the lift, when they bring her to her dialysis only because she's weak. But we don't use the lift on my shift. She usually goes back to bed at around 7:00 PM or 7:30 PM. " On 09-08-12 at 12:35 PM, R 1's son (Z 2) stated " the facility is negligent! First they transfer my mom (R 1) on a (mechanical) lift and they drop her. She ends up with a fracture of her arm (on 01-01-12). This recent fall (on 09-05-12) she had to use the bathroom, she didn't get help on time. She doesn't walk by herself, she needs help and she's not capable of walking by herself. Her (R 1) roommate was sleeping and heard a noise and saw mom (R 1) on the ground. It was her dialysis day, so she's weak too. They're (the facility) not fully staffed as they should be. They're very caring but they need more staff. They don't put her back to bed after dialysis. Her dialysis time is at 6:00 AM, she stays sitting on her chair until bed time. They need to watch her more. " Interview with R 1's roommate (R 5) on 09-08-12 at 1:10 PM, R 5 stated " I was here half awake; when I look she was standing up. She (R1) told me she had to go to the bathroom then, she started to stumble. I heard the loud noise when she fell . I know someone fell . I'm so sorry for her because this is her second time to break her bone so we were both screaming for help. I tried to use my call light but my call light doesn't work at times. What they did (facility) is to switch it with her call light. Normally when I press my call light, there's a wait, sometimes 20 to 30 minutes. If they're real busy it's longer wait and it depends on the group (who's working) ... " R 5's call light was observed non functional. When the red button's pressed it did not light up outside the resident's room. Phone interview with E 5 (CNA) on 09-08-12 at 2:00 PM, E 5 said " I was passing by the nursing station. I was working on the other side we heard someone screaming. We went looking every where then finally we found her (R1) the patient in room 114. All of us run looking where the screaming coming from. I saw the patient (R 1) at around 3:00 PM; I didn't see her call light with her. I didn't see the call light with her before the incident. On 09-11-12 at 1:15 PM the Restorative Nurse (E 11) said "I know she fell trying to go to the bathroom by herself ... This could be possibly be prevented if she was toileted. " Review of R 1 plan of care dated 08-18-12 reads: PROBLEM: high risk for falls due to both cognitive and functional impairments. Resident safety awareness poor at times, resident fell on [DATE], 01-01-12 at 10:15 AM, 12-31-11 at 8:30 PM, 12-10-11 on 7-3 shift and 11-08-11 at 3:00 AM. APPROACH: (A) The resident will have the following interventions in place chair sensor pad ... (B) Call light to be kept within reach ... (E) Ensure resident is wearing visual and auditory assistive devices ... and to monitor resident closely ... These interventions were not followed and implemented based on interviews with the following staffs: E 5 (CNA) on 09-08-12 at 2:00 PM via phone, E 5 said " I didn't see her call light with her. I didn't see the call light with her before the incident. " On 09-08-12 at 2:15 PM, E 1 confirmed and stated " I asked the staff; they said she (R 1) didn't have her call light. " And on 09-11-12 at 2:00 PM E 1 said " she didn't have an alarm at that time. Her (R 1) chair alarm was not on, the staff told me. " E 11 stated on 09-11-12 at 2:20 PM declared " her (R1) care plan was not updated, some interventions are not appropriate. I was backed up with my work. The end of June 2012, she was discontinued from skilled therapy. Our problem happens when she was moved (from 2nd floor to 1st floor) there was a break in communication regarding the alarm, the chair sensor pad. It didn't remain on her after the move (June 2012), it wasn't communicated that she needed a replacement. No, she didn't have her chair alarm. " "I was passing by the nursing station. I was working on the other side we heard someone screaming, we went looking every where then finally we found her (R1) in room 114. All of us run looking where the screaming coming from. I saw the patient (R 1) at around 3:00 PM. On 09-11-12 at 2:00 PM E 1 confirmed and stated "she (R1) didn't have her chair alarm, the staff told me. " R 1's room was six (6) rooms' away and 37 paces from her room to the nursing station. R 1 ' s Care Area Assessment: Care Area Assessment # 11 FALL: has history of multiple falls with injury, last fall been with multiple fractures. (R1) is non -ambulatory. Has poor safety awareness, poor cognition and confused ...High risk for fall. Care Area Assessment # 5 activities of daily living's functional status/ rehabilitation potential -dated 12-28-11 reads: Requires extensive to total assist with all care needs. Is a 2 assist Hoyer lift transfer ... Care Area Assessment # 6. Urinary incontinence and indwelling catheter stated: Is incontinent of B&B, total care is provided ... Review of the facility investigation form dated 03-30-12 reads: heard somebody yelling; found resident (R1) sitting on the floor. Had pad alarm intact but not sounding off. (II) Review of the facility fall tracking log showed that R 2 had 5 incidents of fall (1) 03-19-12, (2) 04-20-12, (3) 05-02-12 diagnosed with [REDACTED]. On 09-11-12 at 3:00 PM, the Dementia Unit Coordinator (E 8) stated " she (R2) tries to stand up (from her wheelchair) when she wants to go to the bathroom. At times she can verbalize her needs, she ' s got Dementia; she needs supervision, she has had some falls. Yes, she is high risk for falls. " A functional deficit in transfer assessment was developed for R 2, dated 04-26-12, related to generalized weakness and cognitive impairments. The plan showed an approach to apply gait belt. This intervention was not followed during toileting on 09-11-12 at 3:15 PM. R 2 was observed on the toilet with a CNA (E 9). E 9 was noted to put her arm under R 2's right under arm and then grabbed and pulled R 2's pants in order to lift R 2 from the toilet. E 9 stated " she (R2) needs supervision; she tries to stand up from her wheelchair. " Review of R 2's event (incident) reports reads as follows: 1. 03-29-12 at 4:23 AM- R 2 was found on the floor sitting ...tried to get up and fell off the bed. 2. 04-26-12 at 2:53 PM -heard screaming in her room ...laying on her left side on the floor ...urine noted on the bedside mattress ...she is alert and oriented to self, confused ...complaint of pain to right elbow and her back .... 3. 05-02-12 at 3:15 PM- complaint of low back pain and difficulty walking. Was noted to have hunchback posture ...MRI result-recent benign appearing fracture involving L1 ... MRI spinal cord result findings: L1 Compression Fracture. 4. 07-09-12 at 9:35 PM -had a fall in the nursing station. Complaint of lower back pain ... 5. 07-16-12 at 3:20 PM- found sitting on the floor in the dining room ... These incidents were not thoroughly investigated by the facility. R 2's plan of care disclosed that R 2 is at risk for falls indicating that this problem has been identified by the facility on quarterly care plans of 01-03-12 on 03-07-12 and on 06-21-1. However, the facility has not revised or implemented individualized interventions based on R 2's needs to prevent further fall incidents. This was confirmed by the E 11 during phone interview on 09-14-12 at 12:05 PM, "we implemented the sensor pads (care plan dated 06-21-12). " Interview with E 12 by phone on 09-14-12 at 12:55 PM, stated " Yes, she didn't make any changes. " (III) R 3 ' s event report dated 05-02-12 at 12:00 AM read: heard a noise ...found patient on the floor in sitting position next to toilet. Per patient (R 3) she ' s heading to toilet to urinate but unable to reach the toilet, she urinated on the floor and slip down ... admitted in the hospital with [DIAGNOSES REDACTED]. On 06-06-06 at 1:11 PM R 3 ' s event report showed found crawling out of bed. Found kneeling on the floor ...had removed her clothing and had been incontinent of stool ... Review of R 3 ' s plan of care dated 01-21-12 reads: has a memory/recall problem related to [DIAGNOSES REDACTED]. Review of R 3 ' s fall risk assessment dated [DATE] and 01-20-12 shows a score of 40. Both Director of Nursing (E 1) and E 12 confirmed score higher than 15 is considered high risk. R 2's incidents of falls were not thoroughly investigated and there were no plans of care developed to address R 3's risk for fall until 08-07-12. This was confirmed by E 1 by phone on 09-12-12 R 3 ' s Fall Care Area assessment dated [DATE] reads: at risk for fall related to weakness secondary to right hip fracture, s/p Open Reduction Internal Fixation, history of fall ...Dementia and gait disorder ... IV. Review of R 4 ' s event report dated 05-06-12 at 8:57 PM and Investigation form reads: called by the CNA (E 13) resident (R4) is on the floor, face down. CNA said she "transferred the resident from the wheelchair to toilet and she turned around to push the wheelchair out of the toilet". She (E 13) heard the noise and found her (R 4) on the floor ...noted bump on the right side of brow, laceration on the nose bridge, bruise on the right peri orbital area ... R 4 ' s progress note dated 05-07-12 at 4:32 AM showed: Back from hospital diagnosed with [REDACTED]. R 4's Cognitive Care Area Assessment (#2) reads: is 90 y/o with [DIAGNOSES REDACTED]. She (R4) has short term memory loss and needing cues for getting around the building ... R 4's Fall Care Area Assessment (# 11) dated 05-01-12 reads: is at risk for fall related to gait abnormality, muscle weakness, history of fall and multiple medical problems. Review of R 4's plan of care showed no individualized plan developed for fall prevention. Interview with E 12 on 09-07-12 at 3:10 PM, E 12 said " the CNA (E 13) took the patient (R 4) in the toilet, she sat her down then the CNA took the wheelchair out (of the bathroom) the patient fell face down. " On 09-14-12 at 3:00 PM, the CNA (E 13) assigned with R 4 on 05-06-12 stated " I put her in the toilet and she fell in the toilet on (floor) face down. I work at 3-11 shifts, the patient came back from dialysis, I took her in the toilet then I took the wheelchair outside. She ' s in a wheelchair but she walks sometimes but, she needs assistance. Someone needs to be with her because she's not steady. It 's unfortunate that she fell but that was not the first time that I took her. We leave her in the toilet by herself even after dialysis. I gave her the call light so when she finish, she call then I come. After the incident they (supervisor) said I should have stayed with her (R4)".

Based on observations, interviews and record review, the facility failed to ensure : 1. The facility's direct care staff implement and follow safety measures, while transferring one residents (R3) using a mechanical lift. 2. Assistive devices / equipment (e.g., mechanical lifts and transfer aids) are used properly or according to manufacturer's specifications and implement interventions as planned to meet the resident's needs across various shifts. 3. Ensure a system is in place to monitor staff's performance to prevent avoidable incidents and accidents. This failure resulted in two different nursing staff members (E15/Certified Nurses Aide on 12/10/2011 and E16/Certified Nurses Aide on 12/14/2011) causing an avoidable accidents/incidents during the care/transfer of a resident (R3). This failure resulted in R3 sustaining multiple serious injuries (such as: Contusion/Close Head Injury, Fractures of the Right Shoulder/Scapula and 3 chest ribs.) Findings include: Review of the facility's Accidents and Incidents Reports documented the following: "Date of Incident: 12/10/2011 Time of Incident: 10 AM Location: Resident's (R3's) room... Type of Injury: Right Cheek hit by ...(mechanical lift)... Describe the Incident... CNA (E16, certified nurses aide) reported to writer when he was transferring resident with ...(mechanical lift), the mechanical lift accidently hit the resident's right cheek. Resident (R3) complained of slight pain... Actions taken to prevent further injury: Always use two people for ...(mechanical lift) with transfers to and from wheel chair and bed..." The Accident and Incident Reports documented a second incident of staff not following safety measures while transferring R3, as follows: "Date of Incident: 12/14/2012 Time of Incident: 5:30 PM Describe the Incident... What did the resident state what happened?: Nurse giving med to the resident (R3), resident talking to her husband (Z2) in Spanish. Husband (Z2) asked the nurse if the resident fell ? Nothing was reported to this nurse. Will ask the CNA (E15). CNA (E15) denies that the resident fell . Resident (R3) said she fell , hit her right shoulder and back of head on the floor."... hospitalization Required: Yes... Where: ...(local hospital) emergency room " The following was documented in the community hospital's emergency room , on 12/14/2011 regarding R3's medical condition: "Date: 12/14/2011... Time: 9:30 PM... Chief Complaint: status [REDACTED]. After performing several assessments and diagnostic evaluations on 12/15/2011, the hospital physician documented the following assessment of R3's medical condition: "Concussion/closed head injury-S/P fall...Right Scapula Fracture... Right Multiple Rib Fractures (3-6th)..." Review of the facility's Investigation of the 12/14/2011 incidents involving R3 documented the following: "Investigation Form (dated 12/21/2011)... Description of Occurrence: ...By all accounts the patient (R3) was functioning at baseline and did not complain of pain until the time of the alleged incident. The patient's roommate did not witness the incident due to the fact that the privacy curtain was pulled closed.... Resident (R3) was sent to... (local community hospital) reports that the patient (R3) was admitted with a [DIAGNOSES REDACTED]. Occurrence Resolution... The employee named above was terminated for failure to follow the facility's resident transfer policies." Review of R3's Face Sheet documented R3 is [AGE] year old female with [DIAGNOSES REDACTED]. The manufacturer's instruction for the mechanical lift used in the care of R3 on 12/14/2011 was reviewed. The manufacturer of this mechanical lift recommends that "two (2) assistants be used for all lifting preparation..." R3's Physical Therapy Assessment, dated 12/08/2011, documented physical limitations, which required R3 to bear no weight on her lower extremities, and required use of a mechanical lift to transfer her. The facility's Policy and Procedure for Transferring resident documented that mechanical lift required total assistance. However, this policy did not document clearly if it was two persons assist or one person. On 12/30/2011, R3 was observed in recliner. R3 was alert and her husband (Z2) was at her side. R3 was going to dialysis. So, Z1 was interviewed. Z2 told surveyor he visited his wife on 12/14/2011. Z2 said he came to his wife room and a CNA was in the room during something with his wife, and asked him to wait outside of the room. When he went into the room, Z2 said he found his wife crying and complaining of being in severe pain. Z2 stated: "She (R3) said she fell when she came from dialysis. One lady (CNA) changed her to the bed with the lift. She (R3) fell down. She (R3) got broken ribs and shoulder... My wife was in too much pain!" Z1, R3's primary physician was interviewed by phone on 1/5/2012 at 1:34 PM. When asked, Z1 told surveyor R3 went to the hospital after experiencing a fall in the facility. When asked what caused R3's injuries, Z1 stated that her fractures were caused by trauma. Z4 (an emergency room nurse, who worked at the community hospital, R3 was sent to for evaluation and treatment.) was interviewed by phone on 1/10/2012 at 2:59 PM. Z4 stated she received a report from a facility nurse R3 fell from a sling during a transfer with a mechanical lift. Z4 told surveyor R3's family also talked to the CNA, who transferred R3 on 12/14/2011. Z4 said the family wanted to know what happened to R3. Z4 stated the CNA told the family that she (CNA) was not sure how to put the strap on, the sling slipped off the hook of the mechanical lift, and she (the CNA) did not know what to do. The CNA, E15, was involved in R3's incident of 12/14/2011. E15 was interviewed by phone on 1/10/2012. E15 said she could not recall her last inservice on transferring a resident. E15 complained inservice and training was usually offered to her after something happening or an incident. E15 stated it would be better if the training was given before something bad occurred. E15 also said she was rushing to get R3 back into bed on 12/14/2011. She reported looking for other staff to help her and found no body to assist her. So, E15 said she transferred the resident by herself. E15 stated, "I'm not the only one doing this." E15 said, it's not unusual for other nursing staff to transfer resident by themselves, while using a mechanical lift. E15 said a supervisor is on duty, but she stays in her office doing paper work. E15 described the sling not being positioned appropriately, which caused her weight to be unevenly disturbed, during the transfer. E15 claimed that R3 got "jerked" hard, and complained of shoulder pain. E15 said she was going to inform the nurse of R3's complaints of shoulder pain, but got distracted caring for other residents. E15 said she never returned to the facility after she left work on 12/14/2011 at 11:30 PM, and received a call from the facility's ADON (Assistant Director of Nursing) that she was terminated. E4,who was R3's nurse on 12/14/2011, was interviewed on 12/30/2011. E4 said, "It was around 5:30 PM, the resident had dialysis, and I was passing medications. The resident (R3) was talking in Spanish. The husband (Z2) at her side. Then he asked me if she fell . I told him No. ...She (R3) had pain in her shoulder... Then the husband complained of her shoulder swelling... Then, the husband complained of her head hurting... I called the medical doctor because she was on heparin. He order her to the emergency room ." E4 told surveyor that R3 should have two persons transferring her while using the mechanical lift. When asked why, E4 stated: "She (R3) can't stand because of her broken leg." E13, was the nurse caring for R3 on 12/13/2011, was interviewed on 1/05/2012. E13 described R3 as alert and oriented times 3. E13 stated: "If something happens to her (R3), she knows. If she (R3) has pain she can speak that too." When asked what safety measures should be implemented while transferring R3, E13 stated: "At the time (in December 2011), she (R3) had a brace on the right leg. So, no weight bearing on the lower extremities, especially right... The physical therapist evaluated her and according to their assessment she needed two person with the mechanical lift... It's also our policy it should be 2 persons." E5 (physical therapist) was interviewed on 12/ 1 at 3:23 PM. E5 stated: R3 was evaluated on 12/08/2011. R3 was very weak... None weight bearing on the right leg because her leg was broken. She was also very nervous and worried. She can't help in anyway." E5 stated the safest way to transfer R3 with the use of mechanical lift with two persons. E5 said, "It suppose to be 2 people (using the mechanical lift). It's the rule here and safe." E18 was the nurse caring for R3 on 12/10/2011, when E16 transferred R3 by himself and hit R3 in the face on 12/10/2011. E18 was interviewed by phone at 1/05/2012 at 11:46 AM. E18 stated, "I remember sometime in the afternoon, he (E16) stated, he had to tell me something, because the residents's (R3's) husband was upset with him. He (E16) said the ...(mechanical lift) accidently hit one side of her (R3's) cheek. He (E16) was operating the lift by himself... He said it occurred around 10 AM. He came and told me at 12 PM. Yes, they should report any accident right away... Yeah, whenever using the ...(mechanical lift), they tell us to ensure that we should have two people." E18 also reported R3 was on Heparin and was at risk for brushing, and bleeding at the site she was hit with the mechanical lift. So, the physician order [REDACTED]. E14 is a CNA and restorative aide, who was identified by the director of nursing (DON) as the person providing staff training for the use of the mechanical lift and monthly inservices to CNA's. E14 stated she provided the monthly training for CNA's. E14 said direct care staff are trained to have two people present to transfer resident using the mechanical lift. E14 stated one person is required to operate the lift and the other person is required to support the resident in the sling. When asked how she (E14) monitor to ensure CNA's continued to performed transfer as trained, E14 stated: "After they (CNA's) get training they should know. I don't follow up unless there is an incident, then I retrain. Once we train them (CNA's), we assume they (CNA's) know." The director of nursing was interviewed on 12/30/2011 and 1/05/2012. E2 reported that the nursing staff was provided with inservice /training on the facility's abuse and transfer policy and procedures. When asked how the facility ensure that staff continued to followed or implement the training they received, E2 told surveyor by receiving monthly training, and re-inservice. But, E2 did not identify any other method being in place to ensure that staff was effectively trained, or monitored to ensure nursing staff performed as trained. During the Daily Status Meetings on 1/05/2012 and 1/06/2012, surveyor asked E1 (administrator) about any method being put in place to ensure/monitor the nursing staff performed duties as trained. E1 identified the Quality Assurance Tool he would be implementing as part of his abatement plan. However, E1 did not identify any other method/plan having been implemented until start of abatement plan on 1/05/2011 other than monthly inservice. But the facility's monthly inservice had been ineffective in giving the nursing staff an understanding of the need to perform duties as trained, as demonstrated by their failure to follow facility's policy and procedures. On 1/06/12 at 5 PM, the Immediate Jeopardy was removed when the facility took the following actions to reduce the severity to Level 2: 1. Corrective actions which will be accomplished for those residents found to have been affected by the deficient practice; -All direct care staff, on all (3) shifts, are receiving ongoing education regarding the requirements to precisely follow the resident transfer policy and procedures. This training will be provided by the physical therapy supervisor. -All direct care staff, on all (3) shifts, are receiving ongoing education regarding the requirement to have 2 staff members present when transferring a resident with a ...(mechanical lift). This training will be provided by the physical therapy supervisor. -All direct care staff members, on all (3) shifts, are receiving ongoing inservice education regarding the requirement to immediately report any resident injuries to the resident's nurse. -The facility's Medical Director has been made aware of this alleged deficient practice and has been consulted regarding the facility's plan of abatement. -The facility has reviewed the Limited Lift Policy (Transfer policy) with the Medical Director and updated the limited lift policy (The facility updated transfer policy/limited lift policy to consistently and clearly define "Total Assistance-use ...mechanical lift" as requiring 2 persons. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice: -All residents who are transferred using a ...mechanical lift have the potential to be affected by the alleged deficient practice. 3. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not reoccur: -The DON/designee will review all incidents in order to ensure that every incident has been reported immediately. -The DON/designee will review the clinical record of any residents involved in incident/accident to ensure appropriate interventions are in place. The DON/designee will conduct random observations of patient transfers on all 3 shifts, daily, using the Quality Assurance Tool that the facility has developed in order to monitor for compliance for 3 months. (The Quality Assurance Audit Tool will be evaluating and monitoring the following: "Were the two staff members present as per the resident transfer policy? Was the resident transferred correctly? Is the resident's transfer status clearly indicated on the door? Was the transfer done safely with no injury to the resident?") -100% of patients (residents) who are transferred with a ...mechanical lift have been observed being transferred using the Quality Audit Tool on all 3 shifts as of 1/06/2012. 4. The facility has developed A Quality Assurance Audit Tool to monitor for compliance: (Reviewing the following areas: "Were the two staff members present as per the resident transfer policy? Was the resident transferred correctly? Is the resident's transfer status clearly indicated on the door? Was the transfer done safely with no injury to the resident?" -100% of residents who are transferred with a ...mechanical lift have been observed being transferred using the Quality Assurance Audit Tool on all (3) shifts as of 1/06/2012. -The Quality Assurance Audit Tool will be done at random times daily on all (3) shifts for 3 months by the DON/designee. -The DON/designee will review data from the Quality Assurance Audit Tool daily for 3 months. -The results of the Audit will be discussed monthly at the facility's Quality Assurance meeting for 3 months.

Based on observations, interviews and record reviews, the facility staff failed to implement and follow, it's abuse policy and procedure: -By not immediately reporting a resident (R3) involvement in an accident or incident when, direct care staff/certified nurses aides (CNA's) E15, inappropriately transferred her using a mechanical lift. -By not ensuring an ongoing method/system of supervising direct care staff is in place to monitor their (staff's) performance, and resident's care/environment to prevent avoidable incidents and accidents. Findings include: Review of the facility's Incident Reports and Abuse Investigations documented several occurrences of direct care staff not providing residents with appropriate care, or as described by Employee's Disciplinary Report incidents of staff "violation of safety rules." "Date: 9/08/2011 Facts of the Incidents: Employee left the resident (R5) in the shower standing... holding on to the grab bar. ...Twice... causing resident to fall.... An interview with the resident (R5) revealed the following information; A. Resident (R5) advised that nursing assistant was not aware of her particular shower procedures... The resident (R5)stated that she felt the nursing assistant needed more training..." But, the investigation of R3's incident of 12/10/2011 and 12/14/2014 documented staff's "violation of safety rules", which resulted in R3 sustaining multiple serious injuries. The following was documented: -"Date of Incident: 12/10/2011 Time of Incident: 10 AM Location: Resident's (R3's) room... Type of Injury: Right Cheek hit by ...(mechanical lift)... Describe the Incident... CNA (E16) reported to writer (E18, nurse at 12 PM, which was 2 hours after occurrence of this incident.) that when he (E16) was transferring resident with ...(mechanical lift), the mechanical lift accidently hit the resident's (R3's) right cheek. Resident (R3) complained of slight pain... to prevent further injury: Always use 2 people for ..." -"Date of Incident: 12/14/2012 Time of Incident: 5:30 PM Describe the Incident... What did the resident state what happened?: Nurse giving med to the resident (R3), resident talking to her husband in Spanish. Husband asked the nurse if the resident fell ? Nothing was reported to this nurse. Will ask the CNA (E15). CNA (E15) denies that the resident (R3) fell . Resident (R3) said she fell , hit her right shoulder and back of head on the floor."... hospitalization Required: Yes..." After performing several assessments and diagnostic evaluations on 12/15/2011, the hospital physician documented the following assessment of R3's medical condition: "Concussion/closed head injury-S/P fall...Right Scapula Fracture... Right Multiple Rib Fractures (3-6th)..." On 12/30/2011, R3 was observed in recliner. R3 was alert and her husband (Z2) was at her side. R3 was going to [MEDICAL TREATMENT]. So, Z2 was interviewed. Z2 said he visited his wife on 12/14/2012, found his wife crying and complaining of being in severe pain. Z2 stated R3 told him she fell from the sling, while being transferred. But Z2 said she asked his wife nurse (E4) and E4 told that no one informed her that R3 fell . The CNA, E15, was involved in R3's incident of 12/14/2011. E15 was interviewed by phone on 1/10/2012. When asked, E15 confirmed R3 was not appropriately transferred on 12/14/2011 and an incident occurred. E15 stated R3 complained of shoulder pain after being transferred on 12/14/2011. But, E15 said she became busy and forget to report the incident immediately to the nurse on duty (E4). E4 was interviewed on 12/30/2011. E4 said, "It was around 5:30 PM, R3's husband reported concerns R3 had fell . E4 confirmed no staff member reported to her that R3 had fallen. E18 was the nurse caring for R3 on 12/10/2011. On 12/10/2011, E16 transferred R3 by himself and hit R3 in the face. E18 was interviewed by phone at 1/05/2012 at 11:46 AM. E18 said, "I remember sometime in the afternoon, he (E16) stated, he (E16) had to tell me something, because the residents's (R3's) husband was upset with him. ...He (E16) said it occurred around 10 AM. He (E16) came and told me at 12 PM. Yes, they (any staff/CNA) should report any accident right away..." But E16 reported to the nurse 2 hours after the incident. The director of nursing was interviewed on 12/30/2011 and 1/05/2012. E2 reported the nursing staff was provided with inservice /training on the facility's abuse policy and procedures. When asked how the facility ensure staff continued to followed or implement abuse policy and duties as trained, E2 said by receiving monthly training or re-inservice. But, E2 did not identify any other method being in place to ensure or monitored that staff performed duties and implement policy and procedures as trained. During the Daily Status Meetings on 1/05/2012 and 1/06/2012, surveyor asked E1 (administrator) about any method being put in place to ensure/monitor the nursing staff performed duties appropriately. E1 identified the use of the Quality Assurance Tool he would be implementing as part of his abatement plan. However, E1 did not identify any other method/plan having been implemented until 1/06/2012. Review of the facility's abuse policy and procedure documented the following instructions for facility's staff to implement: III. Establishing a Resident Sensitive Environment This facility desires to prevent abuse, neglect, mistreatment ...by establishing a resident sensitive and resident secure environment. This will be accomplished by a comprehensive quality management approach involving the following: ...Staff Supervision. On a regular basis, supervisors will monitor the ability of the staff to meet the needs of residents, staff understanding of individual resident care needs, and situations... IV Internal Reporting Requirements and Identification of Allegations. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, or mistreatment they observe, hear about,, or suspect to the administrator or an immediate supervisor who must then immediately report it to the administrator... The nursing staff is a However, facility's nursing staff demonstrated a lack of understanding, or supervision by not following the above policy and procedures. E15 and E16 transferred R3, using a mechanical lift, not as trained or in a safe manner. E15 and E16 failed to immediately report the incident involving R3 to a nurse, which did not ensure that R3 need for medical attention and care was given, and R3 not neglected.

Based on observation, record reviews and interviews, the facility failed to ensure the Certified Nurse Aides (CNAs) demonstrated competency in providing nursing care and services in the areas of transfer and use of assistive devices for two residents (R3 and R5 in a sample of 5 resident, who were identified experiencing avoidable falls or a serious incident.) This failure resulted in the one residents (R3) sustaining an avoidable accident with serious injuries, including: Contusion/Closed Head Injury, Fractures of the Right Shoulder/Scapula and 3 Ribs. Findings including: Review of the facility's Accidents and Incidents Reports documented the following: "Date of Incident: 12/10/2011 Time of Incident: 10 AM Location: Resident's (R3's) room... Type of Injury: Right Cheek hit by ...(mechanical lift)... Describe the Incident... CNA (certified nurses aide) reported to writer (at 12 PM, which was two hours after the occurrence of the incident) that when he was transferring resident with ...(mechanical lift), the mechanical lift accidently hit the resident's (R3's) right cheek. Resident (R3)complained of slight pain..." The Accident and Incident Report documented a second incident of staff not following safety measures while transferring R3, as follows: "Date of Incident: 12/14/2012 Time of Incident: 5:30 PM Describe the Incident... What did the resident state what happened?: Nurse giving med to the resident (R3), resident (R3) talking to her husband in Spanish. Husband asked the nurse if the resident fell ? Nothing was reported to this nurse. Will ask the CNA. CNA denies that the resident fell . Resident (R3) said she fell , hit her right shoulder and back of head on the floor."... hospitalization Required: Yes... Where: ...(local hospital) emergency room " The CNA involved was terminated. The following was documented at the emergency room , on 12/14/2011 regarding R3's medical condition: "Date: 12/14/2011... Time: 9:30 PM... Chief Complaint: status [REDACTED]. After performing several assessments and diagnostic evaluations on 12/15/2011, the hospital physician documented the following assessment of R3's medical condition: "Concussion/closed head injury-S/P fall...Right Scapula Fracture... Right Multiple Rib Fractures (3-6th)..." Review of the facility's Accidents/Incidents reports and Employee Files documented another occurrence that indicated a need for additional staff training, because staff displayed a "Violation of safety rules": "Date: 9/08/2011 Facts of the Incidents: Employee (E17) left the resident (R5) in the shower standing... holding on to the grab bar. Employee (E17) went out twice to get wheel chair and linen leaving her (R5) in that position causing resident to fall.... An interview with the resident (R5) revealed the following information; A. Resident (R5) advised that nursing assistant was not aware of her particular shower procedures... The resident (R5)stated that she felt the nursing assistant needed more training... The resident (R5)stated that after the shower was completed she (R5) stood up in the shower stall using the grab bar, she (R5) then stated that she (R5) looked back and noted that the wheelchair was not in the shower room with her and asked the nursing assistant to go outside the room for the chair and bring it into the shower area. The resident (R5)stated that the nursing assistant brought the wheel chair to the room but did no towel or sheet... The nursing assistant again left the shower room leaving the resident (R5) in the standing position for a second time... During the time the nursing assistant was out of the room she (R5) lost her grip on the handrail in the shower room and she (R5) ended up on a sitting position on the floor... The resident (R5) also stated that the nursing assistant attempted to get her up immediately and had to be instructed by her (R5) to go get the nurse to evaluate her prior to attempting to get her up." The CNA involved in this incident was terminated because this was her second occurrence of not following "safety rules" of the facility. Review of the Facility's Inservice Schedule documented that the facility conducted inservice on Abuse Policy and Resident Transfer Procedures. Also, the facility provided copies of the staff signing that they understood the policy. However, review of the policy for transferring resident (Limited Lift Resident Handling Policy), given to staff after inservice, did not clearly identify how many people were needed to safety use the mechanical lift. The policy and procedure just document Total Assist-mechanical lift. But, other type of transfer documented identified number of required staff to do the task. Review of the facility's abuse policy documented the following instructions for staff to implement: -"Reporting of Unusual Occurrence: ...4. The resident will be assessed after the occurrence to determine injury..." "Abuse Policy... -II. Orientation and Training of Employees During orientation of new employees, the facility will cover at least the following topics: ...Staff obligations to prevent and report abuse, neglect... -III. Establishing a Resident Sensitive Environment... Staff Supervision. On a regular basis, supervisors will monitor the ability of the staff to meet the needs of residents, staff understanding of individual residents care needs, and situation... However, facility's nursing staff demonstrated a lack of understanding or ineffective training by not following the above policy and procedures. E15 and E16 transferred R3, using a mechanical lift, not as trained. They also failed to report the incident immediately as trained to prevent possible neglect. E17 also failed to failed to follow safety measures and tried to move a resident after failing, which staff is not trained to do. Z4 (a emergency room nurse, who worked at the hospital's emergency room , that R3 was sent to for evaluation and treatment.) was interviewed by phone on 1/10/2012 at 2:59 PM. Z4 stated a facility nurse that R3 fell from a sling during a transfer with a mechanical lift. Z4 said that R3's family also talked to the CNA, who transferred R3 on 12/14/2011. Z4 stated that the CNA told the family that she (the CNA) was unsure of how to put the strap on, the sling sipped off the hook of the mechanical lift and she (the CNA) did not know what to do. The CNA (E15) involved in R3's incident of 12/14/2011. E15 was interviewed by phone on 1/10/2012. E15 said she could not recall her last inservice on transferring a resident. E15 complained that inservice and training was usually offered to her after something happened or an incident. E15 stated it would be better if the training was given before something bad occurred. E15 also said that she was rushing to get R3 back into bed on 12/14/2011. She reported looking for other staff to help her and found no body to assist her. So, E15 said she transferred the resident by herself. E15 stated I'm not the only one doing this. E15 said, it's not unusually for other staff to transfer resident by themselves, while using a mechanical lift. E15 said a supervisor is on duty, but she stays in her office doing paper work. E15 said she worked until 11:30 PM on 12/14/2011, and later received a call from the facility's ADON (Assistant Director of Nursing) that she was terminated. E11 was a CNA, who was observed currently on duty on 1/05/2012. So, E11 was interviewed on 1/05/2012. When asked how she could tell if a resident was two person assistance, E11 gave no reply (A Spanish interpreter was present in the to help E11 understand and answer questions. After the interview, E1 (administrator) stated he would re-inservice E with the help of a Spanish Interpreter. When asked, E1 had no inservice information instruction in Spanish for native Spanish speaking CNA's.) E14 is a CNA and restorative aide, who was identified by the director of nursing (DON) as the person providing staff training for the use of the mechanical lift and monthly inservice to CNA's. E14 stated she provided the monthly training for CNA's. When asked how she monitor to ensure CNA's continued to performed transfer as trained, E14 stated: "After they (CNA's) get training they should know. I don't follow up unless there is an incident, then I retrain. Once we train them (CNA's), we assume they (CNA's) know." The director of nursing was interviewed on 12/30/2011 and 1/05/2012. E2 reported that the nursing staff was provided with inservice /training on the facility's abuse and transfer policy and procedures. When asked how the facility ensure that staff continued to followed or implement the training they received, E2 told surveyor by receiving monthly training. But, E2 did not identify any other method being in place to ensure that staff was effectively trained, or monitored to ensure nursing staff performed duties daily as trained. During a meeting with E2 on 1/11/ 2, E2 stated she had changed the Transfer Lift Policy to clearly define Total Assist-...mechanical lift as requiring 2 persons. E2 also said she added 2 persons assist to the direct care nursing staff card being carried with staff's identification cards. During the Daily Status Meetings on 1/05/2012 and 1/06/2012, surveyor asked E1 (administrator) about any method being put in place to ensure/monitor that the nursing staff performed duties as trained. E1 identified the Quality Assurance he would be implementing as part of his abatement plan. However, E1 did not identify any other method/plan having been implemented until start of abatement plan on 1/05/2011 other than monthly inservice. But the facility's monthly inservice had been ineffective in giving the nursing staff an understanding of the need to perform duties as trained, as demonstrated by their failure to follow facility's policy and procedures.

Based on interviews and record reviews the facility failed to ensure that one out of 3 sampled residents (R1) identified by the facility as being at risk for fall was provided adequate assistance during transfer to prevent accident. R1 has [DIAGNOSES REDACTED]. R1 was assessed by the facility as requiring total assistance x 2 or more person physical assist for transfers. This failure resulted in R1 falling on top of E4 (CNA/Certified Nursing Assistant) during a 1 person transfer on 3/1/11. R1 complained of left leg and knee pain and was noted with left knee swelling. R1 was sent to the hospital for further evaluation and treatment. R1 was diagnosed in the hospital with left tibia fracture and a nondisplaced fracture at the neck of the left fibula. Findings include: R1 was originally admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of R1's incident/accident report dated 3/1/11 (7:00 PM) shows, "Found pt (patient) sitting on floor leaning against w/c. CNA attempted to pivot transfer from w/c to recliner, lost balance and eased pt to floor with pt landing partially on CNA." The incident report documented that R1 sustained swelling on the left knee. Review of facility's detailed account of the occurrence for the incident on 3/1/2011 shows, "Aide was transferring resident from wheelchair to recliner with gait belt when resident said: she couldn't move and started leaning forward with all body weight. Aide eased/lowered resident to the floor with resident landing partially on top of her (aide). Resident is a 1 person assist for transfer." Review of R1's entire MDS (minimum data set) since admitted d 6/26/2010 (initial), 9/23/2010, 12/23/10 and 3/2/2011 (quarterlies), all indicated that the resident is totally dependent and would require 2 or more persons physical assist with transfers, between surfaces to or from bed, chair, wheelchair and standing position. These MDS assessments shows evidence that R1's transfer status and support have not changed since admission up to the last quarterly assessment made on 3/2/11 (a day after the fall incident on 3/1/11). The facility was informed on 3/17/11 regarding R1's MDS coding for transfers, the facility submitted an MDS correction request on 3/18/11, showing a change in the coding for transfers for the MDS dated [DATE], from total dependence to extensive assistance, but still requiring 2 or more person physical assist. Review of R1's fall risk assessment tool dated 6/14/10 shows a score of "10". On 9/23/10 and 12/22/10, R1 was reevaluated and showed a score of "20" on both assessments. According to the fall risk assessment tool, the facility will implement fall precaution for scores of 15 or greater. R1's weight history shows that the resident weight for 2/1/11 was 127 pounds and for 3/3/11 was 130 pounds. Review of R1's care plan dated 12/24/2010 with a goal date of 3/24/2011 shows that R1 requires hands on assistance from staff for all functional transfers to help lift body weight and support balance while the resident is moving, secondary to decreased strength/endurance, decreased balance and left [DIAGNOSES REDACTED]. The goal indicated, "Resident will transfer from bed to wheelchair & back, from w/c (wheelchair) to toilet & back, from w/c to chair & back with extensive assistance of one to two persons daily." Multiple approaches were written to include, "Staff to provide assist as needed to support/correct balance & support weight while resident pivots feet." This care plan approach was not specific to indicate the number of support/assistance the staff would provide during the transfer. On 3/17/11 at 3:30 PM , E2 (Director of Nursing) was asked to explain, why the care plan approach stated, "staff to provide assist as needed," when it was indicated on the same care plan that R1 requires hands on assist for all functional transfers. E2 did not respond. Further review of R1's records shows a care plan dated 12/24/10 with a goal date of 3/24/2011, indicating that the resident is at risk for fall related to left [DIAGNOSES REDACTED]. The goal is for R1 to remain free from injury. The approaches did not indicate any transfer assistance and/or number of support/assistance the staff would provide during transfer to prevent fall. During an interview held on 3/17/11 at 12:30 PM, E4 (CNA) stated that she was the staff assigned to take care of R1 on 3/1/11. E4 stated that she is familiar with R1's care. Per E4, R1 is paralyzed on the left side of the body. According to E4, prior to the fall incident on 3/1/11, R1 was being transferred using a gait belt and a 1 person physical assist. Per E4, the staff used to transfer R1 using a mechanical lift, but sometime on December 2010, E5 (physical therapy aide) told the nursing staff that R1 does not need the mechanical lift anymore, and that the resident can be transferred using a gait belt with 1 person assist. E4 stated that on 3/1/11 between 7:00 and 7:30 PM, R1 wanted to be transferred from the wheelchair to the recliner. E4, placed the wheelchair close to the recliner (by R1's right side), applied the gait belt on R1's waist and instructed R1 to help with the transfer by pivoting using the right leg. However, when R1 was assisted up, the "resident did not pivot but instead leaned forward and fell towards me (E4)." According to E4, R1 landed on top of her. E4 stated that she maneuvered to reposition the resident on her right side, got up (E4) and called for help. Per E4, E7 (nurse) came to the room, assessed R1 (while the resident was on the floor) and they both (E4 and E7) placed the resident on the recliner. R1 did not complain of any pain nor was there any injury noted at that time. E4 stated that it was only at around 9:00 PM on 3/1/11, when R1 complained of pain on the left leg. Per E4, E7 was informed of R1's pain. During an interview held on 3/21/11 at 10:50 AM, E7 stated that on 3/1/11 at around 7:00 PM, E4 came out of R1's room and informed her that the resident was on the floor. When E7 reached R1's room, the resident was sitting up on the floor and was leaning against the wheelchair. R1 was assessed, no injury was noted at that time, so R1 was transferred from the floor to the reclining chair by E4 and herself (E7). During the assessment and the transfer, R1 did not complain of any pain or injury. Per E7, she notified E8 (nursing supervisor) of the fall incident and E8 notified R1's family and physician. According to E7, about half an hour after the incident R1 complained of pain all over the body,including left leg. However, no visible injury was noted at that time. E7 stated that even prior to the fall incident, R1 usually complains of pain all over her body. Per E7, at around 8:30 PM, after R1 was placed in bed by E4 and E6 (CNA), R1 was observed with swelling on the left knee. R1's physician was notified and an order for [REDACTED]. Review of the portable x-ray done in the facility shows an irregularity of the proximal tibial metaphysis of the left knee. The result concluded that a subtle fracture cannot be excluded. Review of R1's nurses' notes dated 3/2/11 (6PM) shows evidence that the physician was notified and gave the order to sent R1 to the hospital for evaluation. Review of R1's hospital records shows a scan of the left lower extremity dated 3/2/11 which shows, "There is a V-shaped fracture arising along the posterior aspect of the proximal metadiaphysis of the tibia and there is a nondisplaced fracture at the neck of the fibula." During an interview held on 3/17/11 at 2:00 PM, E5 stated that based on her PT (physical therapy) notes dated 12/17/10, R1 is able to transfer from wheelchair to bed and vice-versa with minimum assistance through right side with CNA's help. Per E5, R1 has a very, very weak left side, that is why all transfers are done on the resident's right side with the use of a gait belt. E5 stated that there is a possibility that R1's transfer status and mental status could have changed since last seen on 12/17/10, up to the time of the fall incident on 3/1/11 due to R1's CVA. E5 stated that R1's physical and mental status could be affected by the medications the resident takes and the history of CVA with left sided weakness. R1 has [DIAGNOSES REDACTED]. R1 was assessed by the facility based on the MDS's to be needing two or more person physical assist for transfers. R1's care plans for fall and transfers did not have a specific intervention/approach to indicate the number of support/assistance the staff would provide to ensure safe transfer. The facility attempted to transfer R1 on 3/1/11 from wheelchair to recliner with 1 person assist (E4). R1 leaned forward during this transfer and both R1 and E4 fell on the floor with R1 landing on top of E4. R1 sustained a left tibia fracture and a nondisplaced fracture at the neck of the left fibula. R1's fractured site is the resident's weak side.