Every finding on record at Winkler Court

Based on record review, facility policy review and staff interviews, the facility failed to monitor skin integrity and treat skin ulceration related to the use of a splinting device for 1 (Resident #1) of 3 residents reviewed, resulting in the development and worsening of an avoidable pressure ulcer.The findings included:Review of the facility provided Wound Prevention Treatment and Overview Policy and Procedure with an effective date of August 2026 revealed, The facility strives to ensure that a resident entering the facility without ulcers does not develop them unless the individual's clinical condition demonstrates they were unavoidable. The facility implements the following interventions to prevent the development of pressure ulcers: Identify residents at risk and the specific factors placing them at risk then implement an individualized Plan of Care based on the identified factors; reduce occurrence of pressure over bony prominences to minimize injury; protect against the adverse effects of external mechanical forces (pressure, friction, shear). Increase the awareness of ulcer prevention through educational programs.Review of the facility provided Weekly and prn (as needed) Skin Check with an effective date of October 2021 revealed, The Weekly and PRN Skin Check is used to document skin condition throughout the resident's stay in the facility. The nurse will conduct weekly skin check and/or a PRN check when applicable as a proactive measure to identify impairment or suspected impairment timely to reduce the risk of further decline in skin integrity . If a new area of impairment is identified during or between scheduled checks, it should be documented the weekly and PRN Skin Check and the appropriate skin grid initiated depending on the cause . Procedure: 1) Once a week and when an area of skin impairment is reported the skin check should be documented on the Weekly & PRN Skin Check documentation tool. If a new area is identified the appropriate skin grid should be initiated within 8 hours . Document actions taken based on the skin check .Review of the facility provided investigations revealed on 7/28/26, the Director of Nursing informed the Administrator that Resident #1 was directly admitted to the hospital related to a pressure ulcer that may have been caused by the splint on the resident's right hand.Review of the clinical record for Resident #1 revealed an admission date of 1/3/26. Diagnoses included sequelae of cerebral infarction (stroke), aphasia (brain disorder that affects ability to speak/understand speech), and chronic diastolic heart failure. The physician's orders dated 4/6/26 included to perform skin check and document Skin Check Weekly & PRN evaluation. Every Thursday during the evening shift.Review of the Quarterly Minimum Data Set (MDS) with an assessment date of 7/5/26 revealed Resident #1's cognition was severely impaired. Resident #1 required partial/moderate assistance with bathing, dressing, and personal hygiene; substantial/maximal assistance with bed mobility, sit to stand, chair/bed-to-chair transfer: and was dependent on staff for toilet transfer.Review of the progress notes revealed that on 4/21/26 Resident #1 fell to the floor on his right side next to the bed. Resident #1was attempting to ambulate independently. The fall was witnessed. Resident #1 complained of pain to his right thumb. An X-Ray of the right hand fingers was obtained on 4/22/26. The X-Ray results noted:Subluxation/dislocation at the first metacarpophalangeal joint with possible avulsion (torn or pulled away by force) at this site. The X-Ray noted there appeared to be an avulsed bony fragment at this site.An Orthopedic Consult dated 4/24/26 noted a soft cast and ace wrap were placed on Resident #1's right hand/wrist.An Orthopedic Consult dated 5/22/26 noted that Resident #1was placed in a Velcro splint to protect the right thumb. The provider documented May remove brace for cleaning and reapply. Follow up in 2 months.Review of the physician's order dated 5/22/26 revealed, Velcro splint to the right hand to protect and aid in pain reduction. May remove brace for cleaning and then reapply. Every shift for: subluxation/dislocation at the first metacarpophalangeal joint for 63 days.Review of the Treatment Administration Record (TAR) from 5/22/26 through 6/22/26 (day, evening and night shift), and 6/23/26 (day shift) revealed the licensed nursing signed for, Velcro splint to the right hand to protect and aid in pain reduction. May remove brace for cleaning and then reapply. Every shift for: subluxation/dislocation at the first metacarpophalangeal joint for 63 days.On 6/23/26, the previous order for the splint was discontinued and a new order entered that read, Splint Type: Velcro splint to right hand, to protect and to aid in pain reduction. May remove brace for cleaning and then reapply.Review of the TAR for July 2026 revealed the licensed nurses signed each shift from 7/1/26 through 7/25/26 for, Splint Type: Velcro splint to right hand, to protect and to aid in pain reduction. May remove brace for cleaning and then reapply. The order was discontinued on 7/25/26.Review of the Medication Administration (MAR) revealed that LPN Staff A signed that the skin check was done on 7/2/26, 7/16/26 and 7/23/26. LPN Staff A documented on the Skin Check Weekly & PRN form that Resident #1 had no new areas of skin impairment.On 7/9/26, RN Staff B signed on the MAR that the skin check was done. No corresponding Skin Check Weekly & PRN form was found in the clinical record for 7/9/26.Review of the Orthopedic Consult dated 7/22/26 revealed that Resident #1 presented to the office with a removal of the thumb spica brace. Resident #1 had a large ulcer into the metacarpophalangeal joint on the ulnar aspect of the thumb. The provider documented the resident needed wound care versus amputation of the thumb to prevent this from becoming an infected hand. He noted that an amputation if allowed would be the most efficient method to get this metacarpophalangeal joint and cellulitis to heal.Review of the hospital physician's progress note dated 7/24/26 revealed that Resident #1's spouse agreed to the surgery.Review of the hospital physician's progress note dated 7/28/26 revealed that Resident #1 had a fracture of the right stump with dislocation 6 weeks ago. He was initially in a cast and then in splint. Unfortunately, the splint eroded into the soft tissue and this resulted in an unhealing ulcer. The provider documented Resident #1 had weakness on the right side and not using the right hand, therefore it was decided the best way to promote healing was to amputate the thumb.Review of the facility provided investigation related to Resident #1's pressure ulcer from the Velcro splint revealed:Unit Manager LPN Staff G wrote in an undated statement, I asked nurse (LPN Staff A) if he had checked resident (Resident #1) hand around/under splint on resident's right hand. Nurse verbalized, No I have not ever looked at it. On 7/29/26, LPN Staff A documented in a statement that he did not notice an open area before July 23rd. He wrote, I only notice it on the last day of skin check with the Unit Manager.On 7/28/26, RN Staff B documented in a statement that she took care of Resident #1 (no date), small pressure area noted in right thumb, cleaned and put the splint back on.The Director of Nursing (DON) documented on 7/29/26 she conducted a telephone interview with Registered Nurse (RN) Staff C who said that she worked with Resident #1 over the last couple months. She always checked circulation, range of motion, touch, odor and sensation. RN Staff C said that she did not take the splint off.In an undated telephone interview, Weekend Supervisor RN Staff E stated that she worked as a floor nurse with Resident #1. She indicated that it was a busy day. She said she could not remember if she took the splint off or not since it had been several days.On 7/28/26, Licensed Practical Nurse Staff F wrote in a statement that he had not removed the splint because he did not see an order to remove it.On 8/17/26 at 12:56 p.m., in an interview, LPN Staff H stated that she was assigned to Resident #1 on 7/20/26 during the day shift. She verified that she signed on the Treatment Administration Record (TAR) for Splint type: Velcro splint to right hand to protect and to aid in pain reduction. May remove brace for cleaning and then reapply. Every shift for subluxation/dislocation at the first metacarpal phalangeal joint. She said that the order said May and it was not scheduled. She would take the splint off if the resident complained of pain. She said Resident #1 had good range of motion to the right hand. She did not remove the splint since there was no change and Resident #1 did not complain of pain.On 8/18/26 at 3:19 p.m., in an interview, Unit Manager RN Staff J said the expectation is for the splint to be removed to check the skin, unless there is a physician's order not to remove the splint. Removing the splint, if documented on the Kardex (provides instructions for care) is part of the Certified Nursing Assistants (CNAs) task. The CNAs can remove the splint for bathing, including bed baths. Unit Manager RN Staff J said if there is an order, the skin should be checked every shift, on shower days and during weekly skin checks.On 8/18/26 at 8:48 a.m., in an interview, CNA Staff K said he gave Resident #1 a bed bath on 7/2/26, 7/9/26, 7/13/26 and 7/16/26. CNA Staff K said he did not see an order to remove the splint, he never removed Resident #1's splint.On 8/18/26 at 3:52 p.m., in an interview, the Director of Nursing (DON) said there was a breakdown in the process when Resident #1 returned from the orthopedic consult on 7/22/26. The DON said there was a lack of communication between therapy and nursing. The DON said the Director of Rehabilitation enters the splints orders into the electronic record. The DON said, I am responsible for adding the schedule and task to the splint orders. She explained the schedule is to notify the nurses to remove the splint and check the skin integrity every shift and the task is for the CNAs to remove the splint during hygiene care and showers. The DON said that since a schedule was not entered, there was no order for the nurses to check Resident #1's skin integrity every shift. She said she did not know the last time Resident #1's splint was removed and his skin checked. The expectation is to remove the splint every shift and check the skin.On 8/18/26 at 5:10 p.m., in an interview, the Registered Nurse Consultant said that the therapist wrote May remove splint on the order for Resident #1. She said it was the nurses' responsibility to clarify the order and they did not. The order should have been written to remove the splint and check the skin every shift. She said that the nurses signed on the TAR for the order that said may remove splint for cleaning and then reapply. When they spoke to the nurses during the investigation, the nurses verified that they signed the TAR but did not remove the splint. She said when they interviewed RN Staff B, she said that on 7/9/26 she observed a small pressure ulcer on Resident #1's right hand. She cleaned it and reapplied the splint. RN Staff B did not document the pressure ulcer and did not notify anyone of the findings. On 8/19/26 at 8:56 a.m., in an interview, Resident #1's physician said surgery would have been the best option when Resident #1 dislocated his thumb joint. He said the brace was not the best treatment for the resident. The resident's spouse refused the surgery and agreed to trial a brace. He said Resident #1 was at risk for wearing a brace due to him being diabetic and having heart disease.

Based on interviews, record review, and review of facility policy, the facility failed to ensure that one resident (Resident #1) of 3 residents reviewed was free from neglect when staff did not recognize, act upon, and report a critical change in condition in a timely manner. This failure resulted in a significant delay in emergency medical intervention for a resident experiencing severe hyperglycemia, metabolic acidosis, and suspected diabetic ketoacidosis (DKA). The findings included:The facility Lab/Radiology Process Guidelines states STAT (immediate) and critical labs must be called into the physician as soon as they have resulted, with the nurse documenting the communication and follow-up in the electronic medical record.Record review for Resident #1 showed she was admitted on [DATE] with a diagnosis of Type 1 Diabetes. Review of Resident #1's admission notes on 4/9/26 said The patient was admitted to the hospital on [DATE] with symptoms consistent with diabetic ketoacidosis (DKA) (a life-threatening complication of diabetes that occurs when the body produces high levels of blood acids called ketones) . The DKA was appropriately managed with aggressive Intravenous fluid resuscitation, insulin therapy, and electrolyte replacement, with subsequent resolution.The American Diabetes Association list symptoms of DKA as nausea and vomiting; abdominal pain; rapid or heavy breathing; confusion or difficulty concentrating; extreme fatigue; fruity odor smell; blood glucose higher than 200 mg/dl; thirst or very dry mouth; flushed skin. Symptoms can worsen quickly, so early recognition is critical.The Medication Administration record for Resident #1 shows on 4/23/2026 at 8:39 a.m. a blood glucose fingerstick result of 439 (Normal blood glucose 74-104) with 12 units of Insulin given Subcutaneously per Sliding scale Insulin instructions.The next blood glucose check was 2 hours and 20 minutes later at 10:59 a.m. with a result of 413 and another 12 units of Insulin were administered.Then at 12:43 p.m. the blood glucose check read 535. There was no further documentation for Insulin administration, resident assessment, or notification to provider of elevated blood glucose per Physician orders. The Insulin sliding scale orders are to Notify provider for blood glucose levels over 450.Review of Resident #1's change in condition form completed on 4/23/26 at 2:40 p.m. noted Resident #1 of having a lab result of a glucose level of 592 and CO2 level of less than 5 (both critical results). The results of the labs were electronically faxed to the facility on 4/23/26 at 11:58 a.m. The date and time of clinician notification was 4/23/26 at 2:00 p.m.Review of the provider note completed on 4/23/26 at 2:46 p.m. noted Patient is critically ill with suspected DKA and severe metabolic acidosis (a severe condition in which acids build up in your body). Transferred emergently to ER (Emergency Room) via EMS (Emergency Medical Services) for higher level of care.Review of EMS documentation noted the call was received on 4/23/26 at 2:50 p.m. and an on-scene time of 3:10 p.m. The EMS documentation noted arrived to find a 77 yof (year old female) in bed reaching into the air for something that is not there, apparently hallucinating. Patient appears very somnolent (feeling sleepy, drowsy, or inclined to sleep). Facility staff report patient has been increasingly confused with hyperglycemia in excess of 500 since approximately 9 am this morning despite receiving insulin. Staff reports lab work were obtained, and patient was found to have a low critical Co2 <5, results were recorded at 11:38 a.m., fax noted to have been received at 11:39 a.m. No clear reasoning for delay in activating 911 for the reported confusion and persistent hyperglycemia was provided by the staff. Staff were unable to provide much further detail other than the physician is requesting patient be sent to the ED. Patient reports feeling tired, denies any other complaints. Patient unable to answer basic questions aside from her name, unable to obtain what her baseline mental status is, staff does state she is more confused and disoriented then typical.During a telephone interview on 5/11/26 at 9:56 a.m. the Paramedic who assisted Resident #1 said it seemed like it was a significant delay in activating 911. The blood work showed her levels were way off. When we arrived, she was unable to follow command. She was alert to verbal. She was reaching in the air, hallucinating and grabbing things. They said she had been like that since 9:00 a.m. We were concerned since this started around 9:00 a.m. and emergency services were not activated until later that afternoon. They said the reason they called was for the critical CO2. They did not give any reason for delay. This was just very concerning due to the delay in activating 911.Review of emergency room documentation of 4/23/26 noted the resident being admitted to the intensive care unit for workup and management of her DKA.Review of Resident #1's labs completed on 4/23/26 showed a blood glucose of 592 (normal range 74-104) and a CO2 <5 (normal range 22-30).During a telephone interview on 5/11/26 at 9:44 a.m. the Advanced Registered Nurse Practitioner (APRN) for Resident #1 said he reviewed her labs that day. I saw the results and the numbers were super weird. I saw that it was DKA. The facility did not record the labs in the system. With this facility especially they do the labs on paper. When I arrived at the facility on 4/23/26 at around 2:00 p.m. she was hyperglycemic, altered mental status, she was confused and they handed me the labs. Her CO2 showed it was acidosis. I saw the labs and saw the critical CO2, gap and sugar were 592. We can't handle that at the facility, so we sent her out. As soon as I saw labs, I said to call 911. This was around 2:00 p.m. If it is a STAT lab they should call me if I was on call. No one called me. I entered the facility, they handed me the labs, and I immediately sent her out. They should have called those labs into me or the person who is on call. As soon as they got the results, they should have called me. It was a critical CO2 and DKA so I should have been called immediately.During an interview on 5/11/26 at 3:50 p.m. the RN (Registered Nurse) Unit Manager said if it is a critical lab, the lab company will call us at the facility and notify our DON (Director of Nursing). They call the DON and send it to her cell phone and email. They also call the facility and let us know. When we get the critical labs, we notify the provider and do a progress note. If the provider is in the facility, they come look at the resident and do a progress note as well. That morning the speech therapist said Resident #1 was not her normal self. At that time, we got orders for a STAT lab and a chest x-ray. We had the results from the labs of a critical lab CO2. She had a history of a critical low CO2, and her glucose was critical as well. Her CO2 was alarming. At that time, I pulled up the labs in the lab companies' portal. STAT labs are typically 4 hour turn arounds. If a STAT lab was drawn at 9:00 a.m. it would be around 1:00 p.m. before we get the results. When asked the timeline on how often she should be checking the portal for STAT lab results, she was unable to give a definitive timeline.During an interview on 5/12/26 at 11:50 a.m. the Speech Therapist said when I walked in that morning (4/23/26 at approximately 8:30 a.m.), Resident #1 was in the bathroom holding on the handrails by herself. I saw something was all over her and she was wet. She looked weak and clammy. So, I grabbed her and she said she did not feel good. I called for help. When I went around the corner I saw a large amount of emesis on the floor. We got her sitting down; we got her cleaned up and changed. She did not make too much sense and was not able to answer questions like she normally was. I notified the CAN Certified Nursing Assistant), the Director of Rehab and the nurse. I stormed into the conference stand-up meeting because I was very concerned about her that morning. The DON and all of the heads were there. I notified them of what I found at that time.Review of Resident #1 Speech Therapy Patient Note documented on 4/23/2026 and signed at 3:57 p.m. read Patient #1was observed with emesis on self and surrounding the floor. Per staff report, patient consumed excessive amounts of water overnight without supervision, resulting in repeated episodes of vomiting and subsequent fatigue. Education was provided to both patient and staff regarding implementation of appropriate precautions and monitoring of intake. A stat chest x-ray and laboratory workup were ordered for further evaluation. Patient was found awake and standing in the bathroom, holding onto a handrail, covered in emesis with feeding tube materials observed on the floor. Clinician assisted the patient into a seated position and alerted nursing staff for immediate assistance. Patient presented with slurred speech, reduced levels of alertness, and difficulty responding to WH-questions. With maximal support, patient followed 1-step directions to complete hygiene task and returned to bed. Patient demonstrating preservation on the window, repeatedly pointing toward the bathroom despite no window being present. Finding were communicated to the nurse for further assessment. A Progress note in Resident #1 medical record dated 4/23/2026 at 4:18 p.m. stated Resident #1 experiencing altered mental status at start of shift, provider notified and STAT labs and chest x-ray ordered.Review of Resident #1's medical records showed an order on 4/23/26 at 8:50 a.m. for STAT CBC/BMP (urgent, high priority blood test frequently ordered in emergency rooms or critical care setting to provide a rapid, comprehensive overview of your organ function, electrolyte balance, and overall cellular health).Review of Resident #1's medical record and progress notes showed no documented provider notification of the elevated blood glucose, critical lab results, resident confusion, resident assessment, resident vomiting and drinking excessive amounts of water.During an interview on 5/12/26 at 11:22 a.m. the DON said she received no email or phone call about Resident #1's labs.Review of the lab documentation provided by the contracted facility lab company showed the labs were electronically faxed on 4/23/26 at 11:58 a.m.During an interview on 5/12/26 at 12:40 p.m. the DON said when I got the call on 4/23/26 at 1:07 p.m., the provider was in the building, I went down there, saw them and so I assumed that her and the ARNP were working on it. The DON confirmed the change in condition and stated the provider was notified on 4/23/26 at 2:00 p.m.During an interview on 5/13/26 at 10:23 a.m. the APRN said we should have got the results immediately. The STAT lab results should have been called in at 11:58 a.m. This case had to be treated in a hospital. DKA must be treated in a hospital setting, there is no way they can be treated here. For DKA, they need IV insulin and IV fluids. She was early DKA, I sent the patient out and saved her life. I do not recall the DON calling me with the critical lab results. I never tried to direct admit the resident, the labs were handed to me, and I sent her out immediately.

Based on record review, resident representative and staff interview the facility failed to ensure all refunds due the resident representative were refunded within 30 days of discharge for 1(Resident #1) of 1 resident as required.The findings included:Review of the facility policy and procedure titled, Refunds with a revised date of [DATE] revealed, Refunds will be issued within the timeframe required by federal and or state law.Review of the clinical record revealed Resident #1 was admitted on [DATE] and expired at the facility on [DATE].On [DATE] at 10:03 a.m., in a telephone interview Resident #1's spouse said the facility owed her a refund in the amount of $1546.00 and she has not received it yet. She said, They keep giving me excuses.On [DATE] at 11:11 a.m., in an interview the Business Office Manager (BOM) said she has been in constant communication with Resident #1's spouse and a refund was issued. The BOM said Resident #1 was Medicaid pending. The resident representative was responsible to pay $1500.00 which would be refunded once Medicaid was approved. The BOM said Resident #1owed no money to the facility for his stay when Medicaid took over on [DATE]. The refunds do not come from the facility but from the Corporate's offices. She said they have had a lot of turnover in the Corporate Office and each time someone new started, the process restarted. The BOM manager said the refund has been issued but not within the required timeframe.Review of the facility provided invoice dated [DATE] for Resident #1 revealed a voucher paid amount of $1,546.00. The payment status was Paid.

Based on observation, record review, resident and staff interviews, the facility failed to ensure medications were administered in accordance with professional standards of practice for 1 (Resident #12) of 3 sampled residents by leaving prescribed medications at the bedside without ensuring ingestion. This practice has the potential to result in medication errors, including missed doses, and incorrect administration.The findings included:Review of the facility provided policy and procedure titled, Medication Administration General Guidelines (2007) revealed, Medications are administered as prescribed in accordance with . good nursing principles and practices . Procedures: . 4. Medications are to be administered at the time they are prepared. 5. The person who prepares the dose for administration is the person who administers the dose. 20. The resident is always observed after administration to ensure that the dose was completely ingested .On 3/5/26 at 9:12 a.m., during an interview with Resident #12, a medication cup with seven pills was observed on the resident's bedside table. A large pink pill was observed on the bedside table. When asked about the medications, Resident #12 picked up the medication cup and said, They gave them to me. I guess I'm supposed to take them, but she just handed them to me and walked out. The nurse was not in the resident's room at the time of the observation. Photographic evidence obtained.On 3/5/26 at 9:20 a.m., Registered Nurse (RN) Staff A was observed at a medication cart in the hallway. In an interview, RN Staff A verified she administered medications to Resident #12. The observation of the unattended pills on the resident's bedside table was shared with RN Staff A. RN Staff A replied, Oh no. I watched her take the whole cup, she swallowed them down.On 3/5/26 at approximately 9:23 a.m., Resident #12's room was observed with RN Staff A. The medication cup with the seven pills and the pink pill remained on the resident's bedside table. RN Staff A loudly told Resident #12, Why did you not take them?. RN Staff A verified she gave the medications to Resident #12 and did not ensure the resident ingested the medications before leaving the room. She said, I know it was wrong.

Based on observation and interview, the facility failed to provide a safe, clean, comfortable and home-like environment for residents, staff and the public. The findings included: During an observation of the memory care unit on 4/21/25 from 8 a.m. to 12 p.m. the following was observed: Cracked walls with exposed plaster above air conditioning units, walls and corners including Rooms 208, 205, 204, 201, 206, 203, dining room and main hallway. Missing/broken closet doors including rooms [ROOM NUMBERS]. Foam sprayed in the bottom corner of the window near the back exit door. Chair/Bed rail missing off wall in room [ROOM NUMBER]. Broken window blinds including Rooma 204, 201, 207, 206, and 209. Peeling cove base in common hallway, dining room, and rooms [ROOM NUMBER]. The floors of the common hallway were cracked, stained and missing pieces. Tile was missing from the bathroom wall with exposed plaster in room [ROOM NUMBER]. Sink in Rom 208 was separated from the wall and wiggled when you touched it. On 4/21/25 at 3:15 p.m., the Memory Care dining room cabinets were noted to have ground in dirt in the corners between floor and cabinets, the cabinet under the sink contained a Styrofoam cup with a half-eaten chicken wing, scattered debris, used napkin, dried spilled brown substance and small black particles. A second cabinet was opened which contained an empty opened milk container, and a third cabinet which contained staining, a sandwich bag with some type of bread substance inside it, and assorted debris. On 4/21/25 at 3:25 p.m., the Director of Housekeeping was shown the findings in the dining cabinets. He said his department was responsible for cleaning these. He said they should not look like that and they should be cleaning the cabinets every Monday and Friday. On 4/22/25 at 9:24 a.m., the Director of Housekeeping said he had spoken in error, and the cabinets should have been cleaned on the weekend. He said it had been scheduled to be cleaned on the previous Sunday and it was missed. He said he had been aware of issues with bugs in the memory care unit and agreed leaving the cabinets with half eaten food and debris could attract bugs. On 04/23/25 at 09:43 a.m., the Administrator entered the Memory care unit, was shown the photographic evidence and walked through a few rooms to point out the findings. The Administrator said he had only been with the facility about a month and agreed the unit is old and could use room by room updates. He said half eaten food should not be in the cabinets and the dining room cabinets should not be left in that condition. He also said he would call pest control back in and that it had been an ongoing issue. The facility policy and procedure Work Orders documented Work orders outside of the service reports and equipment records are a mandatory means of maintenance communication. Work orders should be used and completed with priority classification noted by either the department head or the administrator. If upon examination of the job site, outside help is necessary this should be noted and sent to the administrator. On 4/21/25 at 8:00 a.m., during initial rounds, the following was observed: room [ROOM NUMBER] in the shared bathroom a urinal was stored on the handrail of the shared bathroom. The urinal was not labeled to identify the resident using the urinal. The bathroom door did not have a doorknob, only the whole in the door where it once was. Anyone who needed to use the bathroom would need to place their fingers in the hole and pull the door open and closed. The privacy curtain separating the two beds was soiled and had brown stains. room [ROOM NUMBER] had broken blinds on the window with several blinds missing. The corner of the wall next to the closet was chipped and cracked and the molding was pulling away from the wall. Rooms 329 and room [ROOM NUMBER] the closet door was missing on one side of the closet. On 4/22/25 at 8:43 a.m., Resident #75 was observed in his room in bed. He is noted with his feet pressed against the foot board of the bed. He said I'm 6'2 and I have asked for a bigger bed but I never got one. On 4/22/25 at 8:44 a.m., in an interview Licensed Practical Nurse Staff C said he observed the broken blinds in room [ROOM NUMBER] and said we place a concern for maintenance in the Tells system. On 4/22/25 at 8:46 a.m., the Assistant Director of Nursing (ADON) said she observed the broken blinds in room [ROOM NUMBER]. They are visible from the hallway of the nurse's station. On 4/22/25 at 8:48 a.m., the Regional Nurse Consultant said she spoke with maintenance regarding the broken blinds and missing closet doors. On 4/22/25 at 8:55 a.m., during an interview the ADON was notified of Resident #75's request for a longer bed. The ADON said the facility did not have bed extenders. Review of the documentation presented by the administrator showed no order had been placed for the blinds or closet doors. The documentation was a quoted price for the supplies. In a phone interview the supply company confirmed the facility made no purchase of the blinds or closet doors. On 4/22/25 at 9:30 a.m., during walking rounds with the Regional Plant Manager he confirmed the findings of the necessary building repairs On 4/22/25 at 12:35 p.m., observed Resident #102 in room [ROOM NUMBER]B. Resident #102 said the bifold door panel broke 3 months ago and the facility removed it. The resident said the missing panel has been that way for 3 months. The resident said it bothers her and does not like to have her clothing exposed. On 4/23/25 at 9:12 a.m., observed Resident #102's door panel was still missing. Observed 1/2 the clothing on hangers. On 4/24/25 at 8:47 a.m., during an interview with the Director of Nursing (DON) in room [ROOM NUMBER], she said the closet door should not be that way. On 4/24/25 reviewed the completed work order #4399 created on 12/3/24. Closet Door Broken in room [ROOM NUMBER]B. On 12/19/24, the status was updated as Set to Completed.

Based on observation, review of facility policy and procedure, record review and staff interviews, the facility failed to treat 5 (Resident's #94, #26, #3, #220 and #221) of 5 residents observed with respect and dignity during in room meal tray administration. The findings included: On 4/21/25 at 9:01 a.m., during an observation of the morning in room tray service on the Ford Unit the following was noted: Resident #94 had a diagnosis of polyarthritis and dementia. She was observed drinking the milk from the carton. Resident's #26, #3 and #220 had no glass and the milk cartons were not opened. Resident #221 had no glass for the milk, the tray was sitting uncovered in front of him for 14 minutes with no assistance provided. Resident #221 was unresponsive to verbal stimuli. On 4/22/25 at 8:51 a.m., during an observation of morning meal tray pass noted residents who received milk did not receive glasses to serve the milk and had to drink from the carton. On 4/23/25 at 9:23 a.m., Resident #3 had no glass for her milk and the staff did not open the carton for her. Resident #3 said she was not able to open the milk herself. No cups, glasses or straws were provided to serve the milk and residents had to drink from the carton. On 4/22/25 at 9:05 a.m., in an interview Certified Nursing Assistant Staff B said I know the residents do not have glasses for the milk and it shouldn't be like that. The kitchen never sends the cups, and I have to get them straws so they can drink the milk.

Based on interview and record review, the facility failed to ensure the physician signed the State of Florida Do Not Resuscitate (DNR) order in a timely fashion for 3 residents (#39, #72, and #78) of 3 reviewed who chose a DNR status. Failure to have the physician sign the Florida DNR order. leaves the resident at risk of receiving cardiopulmonary resuscitation (CPR) against their wishes during transfer by Emergency Medical Services (EMS). The findings included: A Florida DNR form is considered an advance directive. It's a specific type of advanced directive that instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) if the patient's heart or breathing stops. In Florida, a DNR order is a legal document, specifically DH Form 1896, directs medical professionals not to perform CPR on a person in the event of cardiac or respiratory arrest. The form must be on yellow paper and signed by both the resident (or their authorized representative) and the resident's physician. Review of the Standard and Procedure for CPR Code Status Orders and Response updated February 2023, page 1 of 5: Code status physician's orders (DNR or Full Code), state specific forms and/or resident preference documentation will be filed as the first item within the medical record. Review of the Standard for Physician Orders, effective [DATE], page 1 of 3: .Physician orders will be dated and signed at next physician visit . Page 2: 7. Obtain physician's countersignature within the required time frame as defined by State Law. In the absence of State law, the countersignature will be obtained on the next visit. 8. Receive and utilize a physician's faxed orders. Photocopy the facsimile to maintain the integrity of the order in the medical record if necessary if subject to fading . Page 3 of 3: Physician signature will be required on next visit. Place signed orders in the medical record. Review of the Policy and Procedure for Advance Medical Directives - DNR: Page 2 of 2: #2. Obtain any current Advance Medical Directive from the resident or their representative and place in the medical record. Resident #78 was admitted to the facility on [DATE]. Diagnoses included diabetes, cerebrovascular disease, paralysis on one side, and depression. On [DATE], a DNR order was initiated by the physician and placed in the medical (paper) chart. On [DATE] review of the paper and electronic charts revealed there was no corresponding Florida State specific yellow DNR order signed by the physician. The yellow DNR form is necessary for transport out of the facility and prevents CPR in a medical emergency. On [DATE], Registered Nurse (RN) Staff G documented in a progress note Resident #78 wanted to change to a DNR status. On [DATE] at 10:00 a.m. Resident #78 said she told the facility she wanted to be DNR status. On [DATE] at 5:36 p.m. RN Staff G, responsible for care plan meetings and care plan revisions, said she wrote the progress note, but did not update the care plan or have the resident or physician sign the state specific form. On [DATE] at 6:04 p.m., the Social Services Director (SSD) said she did not have Resident #78 sign the state specific DNR order. On [DATE] at 6:08 p.m., the Unit Manager RN Staff I said he did not have the resident sign the state specific DNR order. On [DATE] at 9:10 a.m., the SSD said she had the resident sign the Florida State specific yellow DRN order yesterday, only after learning it had not been done yet. The SSD said they are waiting for the physician to sign the form. Resident #39 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), diabetes (DM), heart failure, and dementia. On [DATE], the resident's responsible party signed the state specific DNR order. On [DATE], review of the paper chart revealed there was no state specific DNR form in the paper chart. On [DATE], the Director of Nursing (DON) located the form in the physician's folder. It was not signed by the physician. Resident #72 was admitted on [DATE]. Diagnoses included diabetes, hypertension, and surgical aftercare. On [DATE], the physician wrote an order for DNR. On [DATE], the resident signed the state specific DNR order. On [DATE], the resident signed a 2nd state specific DNR order. On [DATE], review of the hard chart determined there was no state specific form in the chart as required. On [DATE], the state specific form was located in the physician's folder. It was not signed by the physician. On [DATE], the DON said the Florida State specific DNR order form is necessary to transport the resident out of the facility. She said the forms are handed to EMS personnel upon transfer out of the facility. She said the forms are necessary and should be signed timely by residents and physicians and placed in the chart.

Based on observation, interview, and record review, the facility failed to implement an effective Infection Prevention and Control Program (IPCP) for 5 (Residents #111, #25, #27, #68, and #216) of 5 residents sampled for Infection control practices putting the residents at risk for transmission of multidrug-resistant organisms (MDROs). The findings included: Review of the facility's IPCP policy stated, The IPCP is a comprehensive program that addresses detection, prevention, and control of infections and communicable diseases among residents, visitors, volunteers, those individuals providing services under contractual agreement, and personnel. The IPCP, in addition, will facilitate activities to improve antibiotic use to reduce adverse events, prevent the emergence of antibiotic resistance, and promote better outcomes for residents. The goals of the IPCP are to: a. Provision of a safe, sanitary, and comfortable environment b. Decrease the risk of infection and communicable diseases development and transmission to residents, volunteers, visitors, individuals providing services under a contractual arrangement, and personnel. c. Monitor for the occurrence of infections and communicable diseases and implement appropriate prevention measures to reduce occurrences d. Identify and correct problems relating to infection control and prevention practices. e. Focus on activities to optimize the treatment of infections, while reducing potential for the occurrence of adverse events associated with antibiotic use. Review of the facilities Enhanced Barrier precautions (EBP) policy showed EBP refers to an infection control intervention designed to reduce transmission or MDROs that employs targeted gown and glove use during high contact resident activities. EBP are used in conjunction with standard precautions and expand the use of Personal Protective Equipment (PPE) to include donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP is indicated for residents with any of the following: 1. Infection or colonization with a CDC-targeted multi-drug-resistant organism when Contact Precautions do not otherwise apply, or 2. Wounds and/or indwelling medical devices, even if the resident is not known to be infected or colonized with an MDRO. Residents #25 and #111, residing in the Memory Care Unit, were both on EBP related to wound care. A third resident, #68, located outside of the Memory Care Unit, was also under EBP for wounds, a Foley catheter, tube feeding, and a colostomy bag. During observation of the Memory Care Unit on 4/21/25 from 8:00 a.m., through 11:30 a.m., staff were not observed wearing gowns at any time when providing care to residents #25 and #111 on EBP. On 4/22/25 at 10:15 a.m., during an interview and resident room audit for PPE, the DON reported the facility's policy is to post EBP signage above the resident's bed, and PPE is to be stored in the resident's bathroom cubby. Observations of Resident #25's and Resident #111's room revealed no gowns stored in the resident bathroom cubby. The DON explained PPE audits are to be done daily but acknowledged the daily PPE audit was not done on 4/22/25. On 4/23/25 at 1:10 p.m., Resident #25 was observed seated in her wheelchair outside her room, repeatedly asking for assistance to use the bathroom. No licensed staff were visible in the hallway. Resident #25 became agitated and began to navigate down the hallway in search of help. On 4/23/25 at 1:25 p.m., Certified Nursing Assistant (CNA), Staff A, responded to Resident #25. The staff member was observed wearing gloves but did not don a gown while providing direct toileting care. After assisting the resident, Staff A said the resident was on EBP and she did not wear a gown when assisting Resident #25 with toileting, and stated she only used gowns when the residents had scabies. On 4/24/25 at 10:00 a.m., in an interview Licensed Practical Nurse (LPN) Staff D said PPE was not consistently available at the entrance of the resident rooms and should be more accessible, especially to staff entering to perform care. She confirmed receiving EBP training this year but could not recall the date. On 4/24/25 at 10:35 a.m., in an interview the Memory Care Unit Manager, Staff E said he relies on frequent rounding of the nursing staff to monitor PPE compliance. When informed of the missing PPE in resident rooms in the memory care unit and Staff A not donning a gown when assisting Resident #25 with toileting, he said There was a failure there. On 4/24/25 at 2:20 p.m., in an interview Infection Preventionist Staff C said she dedicates more than 20 hours a week to infection control, along with daily PPE rounds that are also conducted by the unit managers and nursing staff. She explained that the facility follows CDC guidelines. She said the facility intentionally omits door caddies for EBP residents in Memory Care due to concerns over resident confusion and cost effectiveness. She said she last conducted staff gown donning and doffing training in February 2025, and spot checks for PPE compliance are conducted every other day. Staff C admitted that making PPE more accessible to staff in the Memory Care Unit is an area needing improvement. 41155 The facility Policy obtained from the Director of Nursing from the Lippincott Manual 9th Edition Management of the Patient with an indwelling catheter and closed drainage System documented Maintaining a closed drainage system: a. Keep the drainage bag in a dependent position, below the level of the bladder. b. Keep the bag off of the floor. c. Change the drainage bag if contamination occurs. Review of the clinical record revealed Resident #216 was [AGE] years old and had an admitted [DATE]. Diagnoses included a history of metastatic prostate cancer with bilateral nephrostomy tubes (thin catheters placed into the kidney to drain urine) and anasarca (fluid accumulates in the body's tissues causing widespread swelling). On 4/21/25 at 8:05 a.m., during an interview, Resident #216 was observed in bed with his wife sitting at the bedside. Resident #216 said he has two drainage bags going directly to his kidneys. The right drainage bag was on the floor and the left drainage bag was under his pillow. On 4/22/25 at 8:14 a.m., in an interview Resident #216 said he was diagnosed with stage 4 prostate and bladder cancer and unable to void. He said I skipped stage 1, 2 and 3 and went straight to stage 4. They put the drainage bags into my kidneys because I couldn't urinate. On 4/23/25 at 8:32 a.m., Resident #216's right nephrostomy drainage bag was on the floor verified by Licensed Practical Nurse (LPN) Staff D. LPN Staff D said the resident rolls in bed and the bag falls on the floor. Resident #216 said I can't roll. I can't turn myself and I can't walk. The left nephrostomy drainage bag was observed on the bed under the resident's back. On 4/23/25 at 11:15 a.m., in an interview CNA Staff E said the catheter bag is covered with a blue bag for privacy and you hang it from the bed or the w/c, it is not supposed to be on the floor. The facility policy Vascular Access Devices and Infusion Therapy Procedures documented purpose To prevent local and systemic infection related to the IV catheter. A sterile dressing is maintained on all peripheral and central vascular access devices, to protect the site, provide a microbial barrier, and to provide vascular access device securement. Central venous access device are changed every 7 days or when the integrity of the dressing is compromised. On 4/21/25 at 8:06 a.m., Resident #216 said he was receiving antibiotics but did not remember what they were for. He had a PICC (peripheral Inserted Central Catheter) line in the right arm. Resident #216 was in bed and his wife was seated next to him. He said the dressing had been covering the PICC since he was in the hospital. Resident #216's wife agreed and said no one had changed the dressing since they put the IV in. The date on the PICC line dressing was 4/8/25. Resident #216 said I was not aware that it had to be changed but I can tell you no one has changed the dressing. Resident #216 and his wife confirmed the date on the PICC line dressing was 4/8/25 the day the resident was admitted to the hospital. Review of the clinical record revealed a physician order dated 4/16/25 for ceftriaxone sodium Injection solution reconstituted 2 GM (gram) Ceftriaxone Sodium use 2 grams intravenously one time a day for Bacteremia until 4/24/2025. The Medication Administration Record (MAR) documented the nurse had changed the PICC line dressing on 4/17/25. On 4/22/25 at 10:16 a.m., in an interview the Director of Nursing (DON) said IV dressings are to be changed every 7 days. Review of the Medication Administration Record (MAR) revealed on 4/17/25 the nurse signed the record indicating Resident #216's dressing had been changed. The DON said I understand. On 4/23/25 at 8:47 a.m., in an interview the DON said I don't understand how you can have a photo of the PICC line and the MAR said the dressing was changed. I had my nurse go through the garbage last night looking for any PICC line dressings and they do not match your photos. The DON reviewed the photo's and verified that they have a date and time stamp on them. No evidence of a dressing change on 4/17/25 was produced by the facility at the time of exit from the facility. On 4/21/25 at 10:27 a.m., Resident #27 said he was receiving antibiotics via a PICC line in the right antecubital, he said he did not know why he was receiving the antibiotics. The resident showed his arm where the PICC line was inserted. The dressing covering PICC was dated 4/12/25 but was difficult to read as it had been written over several times with a darker pen. Review of the clinical record documented a physician order to Change IV Dressing every 7 days as well as PRN for soiling and/or dislodgement., every evening shift, every 7 day(s) and as needed. Review of the MAR documented the PICC line dressing was changed on 4/11/25 and 4/18/25. On 4/22/25 at 10:10 a.m., during an interview the Director of Nursing (DON) said she was not aware the resident had a PICC line. Reviewing the findings with the DON, and the photographic evidence obtained on 4/21/25 showing dates of 4/4/25, 4/11/25 or 4/14/25. The DON confirmed it was not clear when the dressing was actually changed for Resident #27 as it was written over with a darker ink. 51818 Resident #68 was admitted on [DATE] with end stage renal disease, type 2 diabetes, weakness, cognitive communication deficit, heart failure, need for assistance with personal care, feeding tube, colostomy tube, and indwelling urinary catheter. On 4/22/25 at 4:12 p.m., during an observation, Staff R, CNA, and Staff S, CNA, were observed providing urinary catheter care, and changing a adult brief without wearing protective gowns during the care. Above the bed of Resident #68 hangs a sign that reads, providers and staff must wear gloves and gown for the following high contact care activities: changing briefs, and urinary catheter care. On 4/22/25 at 4:15 p.m., Registered Nurse (RN) Unit Manager Staff Q entered the room to assess a sacral dressing while the CNA's were providing care, but did not address the staff about needing to wear gowns. On 4/22/25 at 4:20 p.m., during an interview, Staff Q, said that the staff should be wearing gowns when providing urinary catheter care and changing briefs. On 4/22/25 at 4:30 p.m., during a interview, Staff R, CNA and Staff S, CNA both said they believed the reason they were not wearing the gowns is because they were in a hurry to help the resident who recently returned from dialysis. *** Photographic evidence obtained ***

Based on record review, observation, and interview, the facility failed to ensure residents receive accurate assessments for 1 Resident (#68) of 3 residents reviewed. The findings included: Resident #68 was admitted on [DATE] with end stage renal disease, type 2 diabetes, weakness, cognitive communication deficit, heart failure, need for assistance with personal care, feeding tube, colostomy tube, and indwelling urinary catheter. He was admitted to the facility with multiple pressure wounds. He was also cognitively impaired based on a Brief Interview of Mental Status (BIMS) score of 3. He attends dialysis at an outside facility. Record review showed an admission skin assessment, completed by Staff M, Registered Nurse (RN) Unit Manager, did not document the presence of a wound on the coccyx or on the right flank. Record review of the Admission Minimum Data Set (MDS) dated [DATE] did not assess a Stage 3 pressure injury or an unstageable pressure injury upon admission. There was no slough (yellow, stringy) or eschar (black, hard) tissue assessed. Record review of the weekly skin assessments showed the following newly identified wounds that were not found in the admission assessment. On 4/8/25, a Stage 2 wound right rear flank, inferior, and on 4/8/25, a Stage 3 wound on the coccyx. As of 4/21/25 the resident's care plan had not been updated to include these findings. On 4/21/25 at 12:25 p.m., Resident #68 was observed lying in bed with multiple dressings seen on his legs. His heels were directly on the mattress, and he was laying on his back. On 4/21/25 at 4:14 p.m., Resident #68 seen laying in bed. his heels directly on mattress, laying on his back. On 4/22/25 at 9:30 a.m., during an interview, Staff M, Registered Nurse, (RN) Unit Manager, said that Resident #68 was seen on nursing wound rounds, but there is no wound provider assigned to this resident. She is a designated wound-round nurse and performs weekly skin checks. She said that wound evaluations and measurements are performed on the facility provided tablet which has an app (application). She said there are a number of variables as to why part of an assessment recorded on the app might be inaccurate including the technique of the user. On 4/22/25 at 10:27 a.m., during an interview, Staff I, RN, Unit Manager, said he is a designated wound-round nurse. He stated, the facility uses the tablet, we take the picture, it measures the wound, and we describe and stage it, then it is uploaded to the electronic health record. He also said that the wound measurements and uploaded graphic can be inaccurate due to a number or reasons, including the technique of the person operating the tablet. On 4/22/25 at 4:12 p.m., during an observation of Resident #68 arriving back to the facility from dialysis, there is no offloading device for right flank present and the offloading device for the coccyx was obstructed by a thick blanket. On 4/23/25 at 10:30 a.m., during an interview, Staff I, RN, Unit Manager, said the coccyx and flank wounds on Resident #68 are improving but are also stable. He said that the coccyx wound he recently assessed has less exudate and is stable. On 4/23/25 at 11:10 a.m., during an interview with the Assistant Director of Nursing (aDON), who is also the Staff Educator said she does not provide staging training for wounds. Education is provided by the dressing supply vendor. On 4/23/25 at 11:52 a.m., during an interview the Risk Manager said the facility has not investigated the resident's right flank wound. She stated that, the assessment was not finalized on 4/6/24 therefore we were not aware of it until 4/22/25. She said she looked at the wound, but used the electronic nursing assessment to describe what she saw. On 4/23/25 at 1:00 p.m., the DON said that the facility has a dressing supply vendor who rounds on Tuesdays with the staff, assesses wounds with them, and provides staging education to the supervisors. She said that she does not go by the wound measurements, only by the description and relies on the nurses assessing the wounds on a weekly basis, to determine the status of the wounds because the measurements can fluctuate depending on the person using the device. Record review of the assessment on 4/22/25 for coccyx wound showed, Stage 3 pressure injury, area 5.52cm x length 2.37 x width 2.85 x depth 1.2 cm and was described as: 80% granulation, 10% slough, no eschar documented. Light serosanguinous drainage. Record review of the assessment on 4/23/25 for coccyx wound showed, Stage 3 pressure injury, area 74.81 cm x length 10.62cm x 9.31 cm x depth 1.0 cm and was described as 100% slough. No eschar documented. Heavy serous drainage. On 4/23/25 at 5:00 p.m., obsered the wound assessment of Resident #68 right flank performed with Staff I, RN Unit Manager, Staff M, RN Unit Manager and Staff Q, RN, Unit Manager Staff M, RN, Unit Manager said that the wound appeared to be unchanged from 4/22/25 to the best of her recollection. Staff Q, RN, Unit Manager stated, I would say this wound is unstageable, and I will document that it is stable. Staff M, RN, Unit Manager stated, I would say that due to the slough, it is unstageable but is the same as yesterday. Resident #68 observed to have a right flank wound with black tissue in the center of the wound bed. Record review of the right flank wound assessment on 4/22/25 showed, Stage 2 pressure injury, area 7.2 cm x length 2.2 cm x width 6.6 cm, depth 0.2 cm. Wound bed 100% epithelial, no slough, no granulation, no eschar. Record review of the right flank wound assessment on 4/23/25 showed, Pressure injury, Stage 2, area 3.5cm x length 2.85cm x width 2.17cm. Eschar, 100%. Progress: Stable. On 4/23/25 at 5:30 p.m., during a phone interview, the Physician for Resident #68 stated that he does not recall seeing the wound, but the facility should be making efforts to prevent and assess his wounds. He had not had any recent communication from the nursing staff about changes to the wounds. On 4/24/25 at 9:15 a.m., the DON said that she was not aware of black tissue in the right upper flank wound of Resident #68. On 4/24/25 at 9:30 a.m., during a phone interview, the Physician's Assistant (PA) said that he has not seen the wounds on Resident #68 because he relies on the wound team to assess them. He also said that staff has not informed him of black tissue on the right flank wound. On 4/24/25 at 11:30 a.m., during an interview the dressing supply vendor said the she is not a practitioner, and the facility has not asked her to look at the wound of Resident #68. She said she only gives suggestions. She stated, I do not train them to stage wounds, I tell them that they should not be staging . I tell them to describe what they are looking at. It has been at least 5-6 months since I have observed staff assessing a wound.

Based on record review, observation, and interview, the facility failed to update/revise the comprehensive care plan related to pressure injuries for 1 Resident (#68) of 3 residents reviewed with pressure injuries. The findings included: Resident #68 was admitted on [DATE] with end stage renal disease, type 2 diabetes, weakness, cognitive communication deficit, heart failure, need for assistance with personal care, feeding tube, colostomy tube, and indwelling urinary catheter. He was admitted to the facility with multiple pressure wounds. He had a Brief Interview of Mental Status (BIMS) score of 3 which indicateshe is cognitively impaired. Record review of the admission assessment did not reflect identification of a Stage 2 flank wound or a Stage 3 coccyx wound. Record review of the weekly skin assessments showed the following newly identified wounds. on 4/8/25, a Stage 2 pressure injury right rear flank, inferior and on 4/8/25, a Stage 3 pressure injury on the coccyx. On 4/21/25, the care plan did not reflect goals or interventions for a Stage 2 pressure injury to the flank, or a Stage 3 pressure injury to the coccyx. Record review of the dialysis communication binder showed no documentation of communication the resident had newly diagnosed pressure injuries or that he required offloading or repositioning. On 4/21/25 at 12:25 p.m., Resident #68 was observed lying in bed with a home health aide sitting next to him. He was laying on an air mattress with multiple dressings seen on his legs. On 4/22/25 at 4:15 p.m., Resident #68 was observed being wheeled to his room after returning to the facility from dialysis. He was sitting low in his wheelchair, with his feet hanging off the footrest. He was not able to reposition himself and said he was in pain. Three staff members from physical therapy, including Staff U, Director of Therapy, arrived to assist the resident using the mechanical lift to get him back to bed. When resident #68 was lifted out of his wheelchair, it was observed that he did not have any type of offloading devices for his flank, and he had been sitting on a thick blanked that covered the offloading cushion. * On 4/23/25 at 9:23 a.m., Staff W, Physical Therapy (PT) said that the provided wheelchair did not provide any offloading support for the right flank wound, and the offloading cushion is intended to prevent pressure injuries to the coccyx. On 4/23/25 at 9:45 a.m., Staff U, Therapy Director, said strict repositioning procedures should be followed by the healthcare provider while using the offloading cushion. On 4/23/25 at 10:30 a.m., during an interview, Staff X, Occupational Therapy (OT) and Staff Y, OT said that an offloading cushion is sufficient, and repositioning is not required. On 4/23/25 at 10:35 a.m., during an interview, Staff Z, CNA said that you do not need to reposition someone who is sitting on an offloading cushion because it is doing its job. On 4/23/25 at 10:40 a.m., during an interview, Staff AA, CNA, said a resident on an offloading cushion does not need to be repositioned. On 4/23/25 at 11:52 a.m., during an interview, the Risk Manager stated everyone just knows that the resident needs to be turned and repositioned, we don't have a scheduled turning program. On 4/23/25 at 12:00 p.m., the Director of Nursing (DON) said that if a resident has a worsening wound, she would expect to be notified so that she can assist with managing the wound and ensure the orders and interventions are correct. She also stated that, we don't have a turn and reposition program or policy, it depends on the needs of the resident's needs. On 4/23/25 at 4:30 p.m., during a wound care observation, the right flank wound on Resident #68 had black tissue that was not noted in the documentation, and a dressing that was dated 4/22/25. Staff Q, RN Supervisor stated, I would say that due to the slough, this wound is unstageable, I have not seen this wound for at least a week, I would say that it is stable. On 4/23/25 at 5:00 p.m., the resident's physician said that he does not recall seeing the wound on Resident #68 and does not know if there is black tissue in the wound bed because he has staff to address the wounds. He also said that the facility still needs to turn and reposition the resident regardless of whether he is high risk for developing additional wounds. Record reviews show that a significant change in condition was not documented for the unstageable wound that was assessed with three RN managers present, Staff Q, RN, Staff M, RN and Staff I, RN. On 4/24/25 at 9:15 a.m., the DON said that the nursing staff had not reported any black tissue on Resident #68. On 4/24/25 at 9:20 a.m., an observation of Resident #68 was made, he was sitting in a wheelchair in his room, with no offloading to right flank. On 4/24/25 at 9:30 a.m., during a phone interview, the Physician's Assistant said that he relies on the facility's wound team to accurately describe the wound and that he had not seen it. He was not aware that there was black tissue on the wound. He also said that he would want to be informed if the wound tissue was black so he could ensure the resident receives the proper care. *Photographic Evidence Obtained.

Based on record review, interview, and observation, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services and prevention of new ulcers from developing for 1 Resident (#68) of 3 residents reviewed. The findings included: Resident #68 was admitted on [DATE] with end stage renal disease, type 2 diabetes, weakness, cognitive communication deficit, heart failure, need for assistance with personal care, feeding tube, colostomy tube, and indwelling urinary catheter. He was admitted to the facility with multiple pressure wounds. He was also cognitively impaired based on a Brief Interview of Mental Status (BIMS) score of 3. He attends dialysis at an outside facility. Record review of the admission History and Physical said that Resident #68 was high risk for skin breakdown and unavoidable wounds due to malnourishment. Record review showed an admission skin assessment, completed by Staff M, Registered Nurse (RN) Unit Manager, did not find a wound on the coccyx or on the right flank. Record review of the Admission Minimum Data Set (MDS) dated [DATE] did not identify a stage 3 pressure injury or an unstageable pressure injury upon admission. There was no slough or eschar identified. There were no venous or arterial ulcers present. The MDS did not identify a pressure reducing device for the bed, turning/repositioning program, or nutrition/hydration interventions. On 4/21/25, record review of the care plan included interventions for pressure injury prevention such as turn and reposition as needed, and cushion to chair. Record review of the weekly skin assessments showed the following newly identified wounds that were not found in the admission assessment: 4/8/25, a Stage 2 wound right rear flank, inferior. 4/8/25, a Stage 3 wound coccyx. On 4/21/25 at 12:25 p.m., Resident #68 was observed lying in bed with the home health aide sitting next to him. He was laying on an air mattress with multiple dressings seen on his legs. The home health aide said that he does not provide turning or repositioning assistance, he is only there to stimulate him, talk with him, or help with feedings. On 4/22/25 at 9:30 a.m., Staff M, Registered Nurse, (RN) Unit Manager, said that Resident #68 was seen on nursing wound rounds, but there is no wound provider assigned to this resident. On 4/22/25 at 4:15 p.m., Resident #68 was observed being wheeled to his room after returning to the facility from dialysis. He was found to be sliding out of his wheelchair, with his feet hanging off the footrest. He was not able to reposition himself and was saying he was in pain. Three Staff Members from physical therapy, including Staff U, Director of Therapy, arrived to assist with using the mechanical lift to get him back to bed. When Resident #68 was lifted out of his wheelchair, it was observed he did not have any type of offloading devices or pillows for his flank, and he had been partially sitting on a thick blanket that was obstructing the offloading cushion for the seat of the wheelchair. * On 4/23/25 at 9:23 a.m., Staff W, Physical Therapy (PT) said that the wheelchair did not provide any offloading support for the right flank wound, and the offloading cushion is intended to prevent pressure injuries to the coccyx. On 4/23/25 at 9:45 a.m., Staff U, Therapy Director, said strict repositioning procedures should be followed while using the offloading cushion. On 4/23/25 at 10:30 a.m., during an interview, Staff X, Occupational Therapy (OT) and Staff Y, OT said that an offloading cushion is sufficient, and repositioning is not required while in wheelchair . On 4/23/25 at 10:35 a.m., during an interview, Staff Z, CNA said that you do not need to reposition someone who is sitting on an offloading cushion because it is doing its job. On 4/23/25 at 10:40 a.m., during an interview, Staff AA, CNA, said that while sitting on an offloading cushion, a resident does not need to be repositioned. On 4/23/25 at 11:52 a.m., during an interview, the Risk Manager said everyone just knows the resident needs to be turned and repositioned, we don't have a scheduled turning program. On 4/23/25 at 12:00 p.m., the Director of Nursing (DON) said that if a resident has a worsening wound, she would expect to be notified so that she can assist with managing the wound and ensure the orders and interventions are correct. She stated, we don't have a turn and reposition program or policy, it depends on the needs of the resident. On 4/23/25 at 4:30 p.m., during a wound care observation, the right flank wound on Resident #68 had black tissue that was not previously assessed in the wound assessment. Staff Q, RN Supervisor stated, I would say that due to the slough, this wound is unstageable, I have not seen this wound for at least a week, but since it looks the same, I would say that it is stable. On 4/23/25 at 4:25 p.m., Staff M, RN verified that the wound to the right flank was unchanged from the prior day and agreed that it is an unstageable wound. On 4/23/25 at 5:00 p.m., the resident's physician said that he does not recall seeing the wound on Resident #68 and does not know if there is black tissue in the wound bed because he has staff to address the wounds. He also said that the facility still needs to turn and reposition the resident regardless of whether he is high risk for developing additional wounds. Record review showed that a significant change in condition was not documented for the unstageable wound that was assessed with 3 RN managers present, Staff Q, RN, Staff M, RN and Staff I, RN. On 4/24/25 at 9:15 a.m., the DON said that the nursing staff had not reported any black tissue that was identified on Resident #68. On 4/24/25 at 9:20 a.m., an observation of Resident #68 was made, he was sitting in a wheelchair in his room, with no offloading to the right flank. * On 4/24/25 at 9:30 a.m., during a phone interview, the Physician's Assistant said that he relies on the facility's wound team to accurately describe the wound and that he had not seen it. He was not aware that there was black tissue on the wound. He said he would want to be informed if the wound tissue was black so he could ensure the resident receives the proper care.

Based on record review, staff interviews, and observations, the facility failed to complete a PASRR Level II referral for 1 (Resident #43) resident who demonstrated the return of a serious mental illness. This resulted in a lack of appropriate psychiatric assessment and increased risk of unmet care needs. The findings included: Review of the facilities PASRR Requirements Level 1 and Level 2, effective February 2021. The policy does not address a process for a PASRR assessment after the reemergence of a serious mental illness after the residents have been admitted to the facility. Resident #43 was admitted to the facility on [DATE] from another skilled nursing facility with a diagnosis of schizoaffective disorder. A PASRR Level II determination completed on 6/6/2024 indicated that specialized services were not needed. On 1/29/2025, a psychiatric evaluation documented the resident's schizoaffective disorder was considered resolved. A Gradual Dose Reduction (GDR) was initiated, reducing Ziprasidone from 60 mg to 40 mg daily (nn antipsychotic used for the treatment of schizophrenia). A Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] coded 0 - No for serious mental illness, despite the resident continuing to receive antipsychotic medication and exhibiting cognitive impairment. Review of nursing progress notes dated between 3/11/2025 and 4/7/2025 revealed progressive behavioral changes, including increased agitation, verbal outbursts, territorial guarding of her room, and physical aggression. On 4/8/2025, Resident #43 struck her roommate in the face after the roommate mistakenly sat in her wheelchair, resulting in bruising and scratches to the roommate's face and neck. Review of a psychiatric evaluation performed on 4/8/2025 confirmed the return of psychotic symptoms, including hallucinations and confusion. Resident #43 was re-diagnosed with schizoaffective disorder. Following the incident, psychiatric interventions were initiated: Ziprasidone was increased back to 60 mg daily, Give 1 capsule by mouth one time a day for Schizoaffective disorder/failed GDR. Clonazepam was prescribed for agitation, and laboratory tests were ordered for medication monitoring. The facility updated the resident's diagnosis list on 4/22/2025 to include schizophrenia (F20.9). On 4/21/25 at 9:30 a.m.: Resident #43 was observed in the hallway seated in a wheelchair. The resident was non-verbal, communicating only through low grunting sounds. When other residents or staff walked by, Resident #43 demonstrated increased tension in her posture and visually tracked their movements with narrowed, guarded expressions. On 4/22/25 at 9:56 a.m., when approaching the resident's room, a staff member cautioned, be careful, she doesn't like anybody in her room. The resident was observed eating breakfast but remained highly vigilant toward the hallway, pausing between bites to look sharply at any movement near her door. On 4/23/25 at 12:28 p.m., Resident #54 was observed stationed directly in front of her door in her wheelchair. As staff and residents approached, the resident exhibited visible agitation: defensively raising her arms, emitting low guttural vocalizations, and posturing her wheelchair aggressively to block the entrance. On 4/24/25 at 10:00 a.m., in an interview Licensed Practical Nurse, Staff H said Resident #43 displayed increased aggressive territorial behavior, especially when placed on GDR. Although some behavioral notes were documented in nursing progress notes, they were not consistently recorded on the Medication Administration Record (MAR) or addressed in the resident's care plans. On 4/24/25 at 4:00 p.m., in an interview the Director of Nursing (DON) confirmed the active schizophrenia diagnosis following the failed GDR. The DON said after the re-emergence of the schizophrenia, a Level II PASRR should have been completed The DON confirmed there was no documentation in the residents' medical records of a PASRR Level II referral being initiated or completed.

Based on interview and record review, the facility failed to develop a comprehensive care plan reflective of the resident's choice of code status for 1 (Resident #78) of 3 residents reviewed for advanced directives care planning. The findings included: Review of Resident #78's record revealed a physician's order dated [DATE] for Do Not Resuscitate (DNR) status, meaning that if breathing or heart beats stop, cardiopulmonary resuscitation (CPR) would not be initiated. Review of the nursing progress note by Registered Nurse (RN) Staff G dated [DATE], shows Resident #78 wanted a DNR code status. Review of Resident #78's care plan for advanced directives initiated [DATE], the resident requests Full Code status, meaning CPR would be initiated. On [DATE] at 10:00 a.m., during an interview Resident #78 said she told the facility she wanted a change to DNR status. On [DATE] at 5:36 p.m., during an interview RN Staff G she said she did not revise the care plan for advanced directives as the resident requested on [DATE]. On [DATE] at 6:08 p.m., Unit Manager RN Staff I said he did not revise the care plan to DNR. On [DATE] at 9:02 a.m., during an interview, the Director of Nursing said the care plan should have been revised at the time the resident requested the DNR status.

Based on observation, review of facility policy and procedures and family and staff interviews, the facility failed to ensure the physician was notified and the residents spouse was properly trained to administer medications for 1 (Resident #93) of 5 residents reviewed for medication observation. The findings included: The facility policy 7.1 Medication Administration General Guidelines documented Medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the prescriber. Medications are to be administered at the time they are prepared. The person who prepares the dose for administration is the person who administers the dose. Review of the clinical record revealed Resident #93 was [AGE] year old with an admitted [DATE]. Diagnoses include protein calorie malnutrition, convulsions, muscle weakness and the need for assistance with personal care. On 4/21/25 at 9:06 a.m., in an interview Resident #93's spouse said my wife is [AGE] years old and they are not giving her the medications like they should. They give them to her on an empty stomach and she is on Keppra, (medication used to prevent seizures) and they gave her a double dose this weekend. They put all the medication in apple sauce and try to force her to take them all at one time and she can't do that, she will vomit. I come in daily, and they give me the cup of pills and I make sure she takes them. I give them to her, they trust me here that I know what I'm doing. No one has to stay and babysit me, I know how to give them to her. On 4/21/25 at 12:54 p.m., a review of the physician orders for Resident #93 revealed no order for the spouse to administer the residents' medications. There was no documentation in the plan of care indicating the spouse would administer the medications and no facility assessment of his capability. On 4/22/25 at 9:03 a.m., in an interview Resident #93's spouse said last night they ran out of her Eliquis (a blood thinner) and they told me there was none in the building. He said I come twice a day to give her the medications. I knew she was missing a pill because I count them before I gave them to her and they were short one pill last night. A review of the Medication Administration Record revealed the nurse had administered the medications including the Eliquis. On 4/22/25 at 9:25 a.m., observed Licensed Practical Nurse (LPN) Staff C taking Resident #93's morning medications into the room and handed them to the spouce, and then returned to the medication cart. Staff C did not stay with the resident to ensure the medications were given. On 4/22/25 at 9:35 a.m., in an interview LPN Staff C said the resident will not take her medications for anyone but the husband. I give them to him, but I stand there and make sure she takes them all. LPN Staff C said he did not know if there was a physician order to allow the spouse to administer the medications. On 4/22/25 at 10:06 a.m., in an interview the Director of Nursing (DON) said she was not aware the staff were permitting Resident #93's husband to administer the medications and that they were signing the MAR that they had administered the medications. The DON said there was no documentation the physician was notified, no physician order and no assessment of the spouse's ability to administer the medications. On 4/23/25 at 8:45 a.m., in an interview LPN Staff D said Resident #93 will not take the medications for anyone but her husband, I mean no one. I get the medications, and I give them to him, it is the only way she will take them. On 4/23/25 at 4:31 p.m., in an interview the DON confirmed Resident #93's husband was giving her the medications. The DON said I spoke with the nurses, and they said Resident #93 absolutely will not take her medications for anyone but him. They did say they stood there while he gives her the medications. I know what you mean, there is no assessment, and no documentation the spouse can give the medications. The nurse should be administering the medications. 41905

Based on observation, review of clinical records and resident and staff interviews, the facility failed to assist in making an appointment with a practitioner specializing in the treatment of vision impairments and failed to ensure the resident's glasses were in good repair for 1 (Resident #50) of 1 resident reviewed for vision loss. The findings included: The facility policy Referral - Vision and Hearing Services documented The facility will assist residents in obtaining routine and prompt vision or hearing care period the social services department will work to assist and or coordinate services, such as but not limited to the following: 1. Appointments. 2. Prompt referrals (i.e , broken hearing aids glasses etcetera). 3. Identify those residents who require a prompt referral. Examples include but are not limited to: Damaged or broken hearing aids, glasses, or other assistive devices. Review of the clinical record revealed Resident #50 was [AGE] years old and had an admitted [DATE] with diagnoses including: type 2 diabetes mellitus, hemiplegia of the dominant right side and glaucoma. Review of the Quarterly MDS dated [DATE] noted the residents cognitive skills for daily decision making were moderately impaired. The care plan for Resident #50 identified the resident has potential for impaired visual function related to Glaucoma, and wears glasses while awake. The interventions instructed staff to Assist with cleaning or placing glasses as needed. Report any damage to nurse/social service. On 4/21/25 at 8:16 a.m., Resident #50 was observed in bed with broken bi-focal glasses on that were missing the left arm of the frame. He said he wanted new glasses, but no one would repair or replace them. On 4/22/25 at 9:18 a.m., in an interview and observation Resident #50's glasses remained broken and he glasses were sitting crooked on his face. He said he wanted them to be fixed. On 4/23/25 at 8:19 a.m., in an interview the Director of Nursing (DON) said she was unaware Resident #50 's glasses were broken and she would check into it. On 4/23/25 at 10:14 a.m., in an interview the DON said the process for vision concerns was the staff notify the nurse and a Resident Concern form is initiated by the Social Service Director (SSD), and then we review it in the morning meeting. The DON said no one knew his glasses were broken. The DON provided a Physician Order for Eye Care dated 8/20/24 with a plan for a follow up visit in 6 months. The visit on 8/20/24 was for Eye Care Consultation Examination with no mention of the residents glasses. There was no documentation the facility followed up with the recommended 6 month visit. On 4/23/25 at 11:00 a.m., in an interview the SSD said she has been at the facility for 2 months, and the process for anyone requiring a vision or hearing appointment was the nurse identifies the concern during rounds with the residents and notifies me and then I make the appointments. The SSD said she was not aware Resident #50's glasses were broken and in need of repair. On 4/23/25 at 11:12 a.m., in an interview CNA Staff E said Resident #50's glasses have been broken for months. He told me he rolled over in bed with them on and they broke. Everyone knows they have been broken like that for a long time now. You tell the nurse, and they are supposed to take care of it.

Based on observation, interview, and record review, the facility failed to ensure that 1 (Resident #54) of 1 residents reviewed for activities received services designed to meet their interests, physical, mental, and psychosocial well-being. The findings included: Resident #54 was admitted to the facility with diagnoses including dementia and cognitive impairment. Review of the resident's care plan, initiated 2/25 and last revised 4/25, identified goals for Resident #54 to participate in activities of choice daily, with interventions including encouraging engagement with a general activities program and providing in-room activities if preferred. Observations across multiple days (4/21/25 at 8:15 a.m., 4/21/25 at 11:14 a.m., 4/21/25 at 3:00 p.m., 4/22/25 at 9:25 a.m., 4/22/25 at 10:39 a.m., 4/22/25 at 12:32 p.m., and 4/23/25 at 9:53 a.m.) demonstrated a lack of activities. Throughout these observations, no activity materials, music, television, or staff-led activities were present or offered to the resident. The only item observed was a Daily Chronicle paper at the bedside, which contained no individualized activities documented for the resident. A review of Resident #54's activity records revealed no documented refusal of activities and no recorded participation in either individual or group activities over the past 30 days. On 4/23/25 at 10:09 a.m., Licensed Practical Nurse, Staff H, was observed briefly checking on Resident #54 but did not initiate any activity. On 4/22/25 12:32 p.m. in an interview Resident #54 verbalized an interest in watching TV. He pointed at the TV, and indicated there was no TV remote, no TV remote was obsered in residents' room [ROOM NUMBER]/21/25 to 4/24/25. On 4/24/25 at 10:00 a.m., Staff H, LPN stated that Resident #54 is not receiving enough stimulation and said more could be done. Staff H, LPN, said the facility's Director of Activities (DOA) visits the unit about once a month and that engagement is primarily handled by the activity's assistant, Staff DD, or CNAs in her absence. On 4/24/25 at 11:30 a.m. during an interview Registered Nurse Unit Manager, Staff I, stated that Resident #54's situation represented a failure in providing adequate engagement. On 4/24/25 at 12:05 p.m., in an interview the Social Services Director (SSD) said when a resident appears lonely or withdrawn, the intervention would be to talk with the family, involve nursing, and consider a psychiatric consult. There was no evidence of any interdisciplinary team response documented for Resident #54 despite ongoing observations of disengagement. On 4/24/25 at 1:30 p.m., in an interview the DOA said activity preferences were gathered at admission or quarterly, and daily rounds were conducted. When asked about Resident #54's recent activity participation, the DOA said he had not personally engaged the resident, and that documentation was lacking

Based on record review, interview, and observation, the facility failed to offer a therapeutic diet for 1 (Resident #60) of 2 reviewed for nutrition. The findings included: Resident #60 was admitted on [DATE] with muscle wasting and atrophy, type 2 diabetes, anemia, heart failure, chronic ulcers, and kidney failure. He goes to the dialysis center 3 times per week. He scored a 15 on his Brief Interview of Mental Status (BIMS) which indicates he is cognitively intact. On 4/21/25 at 4:08 p.m., Resident #60 was interviewed in his room after arriving from the dialysis center He stated, I'm waiting for dinner, they need to hurry I am starving. On 4/21/25 at 4:25 p.m., during an interview, Staff V, Registered Nurse (RN) said that he ate 100% of his breakfast and the facility provides him a lunch, she does not know why he is so hungry. Record review of the Dialysis Communication log dated 4/21/25 showed that at 8:30 a.m, Resident #60 ate breakfast at the facility, and he traveled to dialysis with a bagged lunch. The dialysis center did not document if the lunch had been eaten. On 4/21/25 at 4:30 p.m. during an observation, Resident #60 had an empty lunchbox in his room hanging from his wheelchair. He said that he didn't remember eating lunch that day but was very hungry and requested something to eat. Record review of the diet order for Resident #60 showed that there was an order for the resident to receive a chronic kidney disease diet (CKD) with extra portions. On 4/22/25 at 9:10 a.m., during an observation, the contents of the dialysis lunchbox for Resident #60 who was leaving for dialysis, included a sandwich, 2 packs of crackers, an empty water bottle, and a napkin. On 4/23/25 at 9:33 a.m., during an interview, Dietician Staff J, said that Resident #60 is stable on a CKD diet, and she is frequently monitoring him. She said that in general, residents going to dialysis should be getting sandwiches, applesauce, water or juice, unless they are to receive large portions for lunch. Staff J said she was not aware Resident #60 had been saying he was starving when he arrived back from Dialysis on 4/21/25. On 4/23/25 at 9:35 a.m., during an interview Kitchen Manager Staff K, said that today, Resident #60 should have received 1 beef sandwich, 1 juice, 2 packs of graham crackers. She read this from a list that was posted on the wall. Staff K, Kitchen Manager, also said that if there is a concern, staff or the resident can come down to the kitchen at any time to let them know. She said she was not aware of an issue with Resident #60's lunch. On 4/23/25 at 9:40 a.m., Kitchen Manger Staff K said that she does not double check the meal once it's packed by the kitchen staff, instead she picks up the lunch box and checks its weight and contents with her hands, but does not open the box and look. She demonstrated this with another prepacked lunch box. On 4/23/25 at 10:15 a.m., Dietician Staff J, and Kitchen Manager Staff K, said they had reviewed the orders for Resident #60, and he should be receiving double portions, which would include an additional half sandwich, a juice, a fruit and a snack.

Based on record review and interview, the facility failed to ensure licensed nurses have the specific competencies and skill sets to provide nursing and related services to care for residents needs for 2 (Residents #1 and #2) of 3 residents reviewed for medication orders. The findings included: Facility policy Physician Orders 4.3.1 effective October 2021 indicated on page 3: The nurse will review each hard chart for new orders and compare to the electronic order listing report to ensure each written order has been entered into the electronic medical record. If a written physicians order is found on the chart and not on the order listing, transcribe the order and notify the resident/representative. Medication/Treatment variance may be completed if needed with physician notification. Facility Policy titled Event Reporting effective 2019, change date March 2022 indicated: An event report will be completed by the nurse assigned to the resident, for any occurrence outside the routine operational expectation of the facility. This includes but may not be limited to: Medication variance. Events/accidents will be investigated thoroughly, completely and timely. On 9/5/24 at 4:04 p.m., the Director of Nursing (DON) said the process for entering orders when a patient is transferred in from the hospital is: Hospital nurse to facility nurse report is given. Admissions provides nursing with the patients' paperwork prior to admission, which is reviewed, and orders are placed into the electronic chart (PCC). Once the patient arrives at the facility the doctor is contacted for clarification of any medications. Medications are not activated until they speak to the provider. As soon as activated it is sent automatically to the pharmacy. The paper chart never gets sent to pharmacy; the pharmacy only orders what is entered in PCC. Provider will come into building after they've already done verbal orders, on the phone, to review the orders and sign off on them. The orders are printed out on a Medication Review Report and put in a folder to be signed off by the provider. The DON said there were 3 checks on the medications: you will see a check mark on the medication reconciliation from the hospital which indicates the initial review by nurse that entered the meds into PCC, night shift fills out a form that they did a 24 hour chart check, and in the morning meeting all new resident charts are brought to the meeting and gone through one by one. This is documented on the admission checklist. Record review revealed that on 8/13/24 Resident #1 returned to the facility after a hospitalization for problems with her feeding tube and aspiration pneumonia. The discharge orders from hospital included an order for Hydrocortisone sodium succinate 100 mg (milligram) injection, inject 20 mg into vein every morning. (corticosteroid medication used to replace the hormone cortisol which the body can no longer produce on its own) Record review of Resident #1's Medication Administration Record (MAR) for August 2024 did not reveal an order for daily hydrocortisone. Instead, it showed an order for Hydrocortisone inject 20 mg intramuscularly one time a day for Aspiration Pneumonia with an order date of 8/13/24 and discontinued on 8/14/24. This intramuscular injection was given one time on 8/14/24. No further hydrocortisone was given to Resident #1 following this injection during this stay. Chart review revealed no documentation in nursing progress notes, Advanced Registered Nurse Practitioner (ARNP) notes, or physician notes about discontinuing daily hydrocortisone for Resident #1. On 9/5/24 at 1:54 p.m., the ARNP said Resident #1 had a history of respiratory distress related to aspiration pneumonia. She said she ordered a one-time dose of intramuscular hydrocortisone related to respiratory distress. ARNP said she was not aware of the hospital order for daily steroids and was not aware Resident #1 did not get steroids beyond 8/14/24. ARNP said it was never brought to her attention about the daily order and said it was not something she discontinued. She said had she known about it, she would definitely have put her on a daily oral steroid dose. ARNP said her order for a one-time dose had nothing to do with the daily hydrocortisone order from the hospital, but with pneumonia. On 9/5/24 at 3:06 p.m., Staff A Registered Nurse (RN) Unit manager said she entered the hospital orders for Resident #1 into the computer. She said the facility does not do intravenous push (IVP) medications. She said she had discussed the hydrocortisone order with the ARNP and received a verbal order for a one-time dose to be given intramuscularly for pneumonia and Staff A discontinued the daily order. She said the only documentation of this would be the entry of the order into PCC. There were no progress notes for either nursing or the ARNP of the discussion of a one-time dose and discontinuance of daily hydrocortisone order. On 9/5/24 at 4:04 p.m., the Director of Nursing (DON) said the process for entering orders when a patient is transferred in from the hospital is: Hospital nurse to facility nurse report is given. Admissions provides nursing with the patients' paperwork prior to admission, which is reviewed, and orders are placed into the electronic chart (PCC). Once the patient arrives at the facility the doctor is contacted for clarification of any medications. Medications are not activated until they speak to the provider. As soon as activated it is sent automatically to the pharmacy. The paper chart never gets sent to pharmacy; the pharmacy only orders what is entered in PCC. Provider will come into building after they've already done verbal orders, on the phone, to review the orders and sign off on them. The orders are printed out on a Medication Review Report and put in a folder to be signed off by the provider. The DON said there were 3 checks on the medications: you will see a check mark on the medication reconciliation from the hospital which indicates the initial review by nurse that entered the meds into PCC, night shift fills out a form that they did a 24 hour chart check, and in the morning meeting all new resident charts are brought to the meeting and gone through one by one. This is documented on the admission checklist. The DON was asked for documentation the 3-step review had been completed for Resident #1's readmission orders on 8/13/24. The DON was unable to provide the 24-hour chart check that was supposed to be completed by night shift, unable to provide the admission checklist verifying the record had been reviewed at morning meeting and when she provided the Medication Review Report that was supposed to be reviewed by the provider, it had never been signed off by the provider. The DON said: Looks like wasn't put in the providers folder. She said there was no documentation that the medication orders had been checked through the 3-step process and/or verified by the provider. On 9/6/24 at 9:00 a.m., the Administrator said he reviewed everything regarding Resident #1 the previous evening. He said Resident #1 came to the facility initially on 7/13/24 and then was sent out again for a feeding tube issue. He said the first round she was with them; she received her daily corticosteroid but, on her return from hospital, it was missed. The Administrator said they will be doing education with all licensed staff about admission orders and medication reconciliation, including the doctors and their extensions. Record review revealed Resident #2 was admitted to the facility on [DATE]. The discharge orders from the hospital included an order for Gabapentin 100 mg cap, take 200 mg by mouth two times daily (medication used to prevent seizures or nerve pain). Record review of Resident #2's MAR for August 2024 shows the order was entered as Gabapentin 100 mg, give 1 tab by mouth two times a day for nerve pain. The 100 mg dose was given twice on 8/17/24, twice on 8/18/24 and once in the morning on 8/19/24. The order was then discontinued on 8/19/24 and changed to Gabapentin 100 mg give 2 capsules by mouth two times a day for nerve pain. Give TWO caps to = 200 mg. No documentation was found in the chart of discussion with the doctor to change dosage or notification to the doctor that Resident #2 had not been receiving the correct prescribed amount of Gabapentin. On 9/6/24 at 9:12 a.m., the DON said she had not been made aware of any discrepancies with medications for Resident #2. She said the initials and the red check mark on the medication reconciliation would mean the medication had been double checked. She said it would have been entered on admission and then the Unit Manager would have checked it the next morning during morning meeting. The DON said she would need to look into it and see what had happened. On 9/6/24 at 1:37 p.m., the DON said after looking into what happened with Resident #2's Gabapentin order she discovered Staff A RN Unit Manager had put in the order and had entered it wrong. The DON said Staff B RN weekend supervisor was the nurse who did the second check, initialed it and did not identify the mistake. The DON said on Monday morning Staff C RN Unit Manager found the mistake and adjusted it but did not notify her and nothing was documented that the doctor was made aware or notified. The DON said with any medication error/variance the doctor should be notified and this notification documented. The DON said all nurses had previously been trained in entering/checking medications and this was an error on all parts that it was overlooked.

Based upon interview and record review, the facility failed to ensure residents were free from significant medication errors by not administering medications in accordance with prescribers' orders for 2 (Resident #1 and #2) of 3 residents reviewed for medication orders. The findings included: Facility policy Physician Orders 4.3.1 effective October 2021 indicated on page 3: The nurse will review each hard chart for new orders and compare to the electronic order listing report to ensure each written order has been entered into the electronic medical record. If a written physicians order is found on the chart and not on the order listing, transcribe the order and notify the resident/representative. Medication/Treatment variance may be completed if needed with physician notification. Facility Policy titled Event Reporting effective 2019, change date March 2022 indicated: An event report will be completed by the nurse assigned to the resident, for any occurrence outside the routine operational expectation of the facility. This includes but may not be limited to: Medication variance. Events/accidents will be investigated thoroughly, completely and timely. On 9/5/24 at 4:04 p.m., the Director of Nursing (DON) said the process for entering orders when a patient is transferred in from the hospital is: Hospital nurse to facility nurse report is given. Admissions provides nursing with the patients' paperwork prior to admission, which is reviewed, and orders are placed into the electronic chart (PCC). Once the patient arrives at the facility the doctor is contacted for clarification of any medications. Medications are not activated until they speak to the provider. As soon as activated it is sent automatically to pharmacy. The paper chart never gets sent to pharmacy; the only orders they get is what is entered in PCC. Provider will come into building after they've already done a verbal on the phone to review the orders and sign off on the orders. The orders are printed out on a Medication Review Report and put in a folder to be signed off by the provider. DON said there were 3 checks on the medications: you will see a check mark on the medication reconciliation from the hospital which indicates the initial review by nurse that entered the meds in PCC, night shift fills out a form that they did a 24 hour chart check, and in morning meeting all new resident charts are brought to the meeting and gone through one by one and this is documented on admission checklist. Record review revealed that on 8/13/24 Resident #1 returned to the facility after a hospitalization for problems with her feeding tube and aspiration pneumonia. The discharge orders from hospital included an order for Hydrocortisone sodium succinate 100 mg (milligram) injection, inject 20 mg into vein every morning. (corticosteroid medication used to replace the hormone cortisol which the body can no longer produce on its own) Record review of Resident #1's Medication Administration Record (MAR) for August 2024 did not reveal an order for daily hydrocortisone. Instead, it showed an order for Hydrocortisone inject 20 mg intramuscularly one time a day for Aspiration Pneumonia with an order date of 8/13/24 and discontinued on 8/14/24. This intramuscular injection was given one time on 8/14/24. No further hydrocortisone was given to Resident #1 following this injection during this stay. Chart revealed no documentation in nursing progress notes, Advanced Registered Nurse Practitioner (ARNP) notes, or physician notes about discontinuing daily hydrocortisone for Resident #1. Record review of Resident #1's progress notes revealed on 8/27/24 she had a significant decline in condition with projectile vomiting and eventual unresponsiveness with a blood pressure of BP 61/38, Pulse 109, Respiratory Rate of 24, a temp of 102.6 and a mental status evaluation of unresponsiveness. Per progress note dated 8/27/24 at 22:42 Resident #1 was taken to the hospital and was intubated in the Emergency Department. No admitting diagnosis was available at that time. Further progress note on 8/28/24 at 08:24 indicated Resident #1 was admitted with a diagnosis of Adrenal insufficiency related to corticosteroid withdrawal. On 9/5/24 at 10:30 a.m., the DON said she was not aware there had been any concerns regarding Resident #1's hydrocortisone. She agreed Resident #1 had a diagnosis adrenal insufficiency. She reviewed the hospital discharge records and agreed hydrocortisone was ordered daily and reviewed the orders entered at facility. She said it would be the physician who discontinued medications. She agreed there was nothing in the nursing or provider progress notes regarding discontinuing order for daily hydrocortisone. DON said she had been under the impression Resident #1 had been admitted to the hospital for multiple organ failure and was not aware of progress note dated 8/28/24 indicating admission for adrenal insufficiency due to corticosteroid withdrawal. On 9/5/24 at 3:06 p.m., Staff A Registered Nurse (RN) Unit manager said she entered the hospital orders for Resident #1 into the computer. She said the facility does not do intravenous push (IVP) medications. She said she had discussed the hydrocortisone order with the ARNP and received a verbal order for a one-time dose to be given intramuscularly for pneumonia and Staff A discontinued the daily order. She said the only documentation of this would be the entry of the order into PCC. There were no progress notes for either nursing or the ARNP of the discussion of a one-time dose and discontinuance of daily hydrocortisone order. On 9/5/24 at 1:54 p.m., the ARNP said Resident #1 had a history of respiratory distress related to aspiration pneumonia. She said she ordered a one-time dose of intramuscular hydrocortisone related to respiratory distress. ARNP said she did not remember that she had diagnosis of critical adrenal insufficiency or that she was on steroids. ARNP said she was not aware of the hospital order for daily steroids and was not aware Resident #1 did not get steroids beyond 8/14/24. She said the facility never does IV hydrocortisone and that had been policy there for years. ARNP said it was never brought to her attention about the daily order and said it was not something she discontinued. She said had she known about it, she would definitely have put her on a daily oral steroid dose. ARNP said her order for a one-time dose had nothing to do with the daily hydrocortisone order from the hospital, but with pneumonia. On 9/5/24 at 4:04 p.m., the DON was asked for documentation the 3-step review had been completed for Resident #1's readmission orders on 8/13/24. DON was unable to provide 24-hour chart check that was supposed to be completed by night shift, unable to provide the admission checklist verifying the record had been reviewed at morning meeting and when she provided the Medication Review Report that was supposed to be reviewed by the provider, it had never been signed off by the provider. DON said, Looks like wasn't put in the providers folder. She said there was no documentation that the medication orders had been checked through the 3-step process and/or verified by the provider. On 9/6/24 at 9:00 a.m., the Administrator said he reviewed everything regarding Resident #1 the previous evening. He said Resident #1 came to the facility initially on 7/13/24 and then was sent out again for a feeding tube issue. He said the first round she was with them; she received her corticosteroid but, on her return from hospital, it was missed. The Administrator said they will be doing education with all licensed staff about admission orders and medication reconciliation, including the doctors and their extensions. Record review revealed Resident #2 was admitted to the facility on [DATE]. The discharge orders from the hospital included an order for Gabapentin 100 mg cap, take 200 mg by mouth two times daily (medication used to prevent seizures or nerve pain) Record review of Resident #2's MAR for August 2024 shows the order was entered as Gabapentin 100 mg, give 1 tab by mouth two times a day for nerve pain. The 100 mg dose was given twice on 8/17/24, twice on 8/18/24 and once in the morning on 8/19/24. The order was then discontinued on 8/19/24 and changed to Gabapentin 100 mg give 2 capsules by mouth two times a day for nerve pain. Give TWO caps to = 200 mg. No documentation was found in the chart of discussion with the doctor to change dosage or notification to the doctor that Resident #2 had not been receiving the correct prescribed amount of Gabapentin. On 9/6/24 at 9:12 a.m., the DON said she had not been made aware of any discrepancies with medications for Resident #2. She said the initials and the red check mark on the medication reconciliation would mean the medication had been double checked. She said it would have been entered on admission and then the Unit Manager would have checked it the next morning during morning meeting. DON said she would need to look into it and see what had happened. On 9/6/24 at 1:37 p.m., the DON said after looking into what happened with Resident #2's Gabapentin order she discovered Staff A RN Unit Manager had put in the order and had entered it wrong. DON said Staff B RN weekend supervisor was the nurse who did the second check, initialed it and did not identify the mistake. DON said on Monday morning Staff C RN Unit Manager found the mistake and adjusted it but did not notify her and nothing was documented that the doctor was made aware or notified. DON said with any medication error/variance the doctor should be notified and notification documented. DON said all nurses had previously been trained in entering/checking medications and there was an error on all parts that it was overlooked.

Based on observations, record review, review of policies and procedures, and staff interviews, the facility failed to protect the residents' right to be free from neglect by failing to ensure full body mechanical lifts were in safe operating condition, failing to ensure staff followed safety protocol when using mechanical lifts, and failure to ensure staff responsible for the inspection and maintenance of mechanical lifts was knowledgeable and competent to perform the job duties. Resident #1 was dependent on staff and required the use of a mechanical lift for transfer. On 1/22/24 Resident #1 fell from the full body mechanical lift during transfer. The motor of the lift used to transfer Resident #1 had been removed since July 2023, preventing the legs of the base to remain locked into position during the transfer. Resident #1 sustained cuts to the left arm, complained of pain and head trauma requiring an emergent transfer to an acute care hospital for evaluation and treatment. The facility's failure to ensure necessary structure and processes to prevent neglect placed other residents who require the use of mechanical lifts at a likelihood of avoidable accidents and falls which could result in serious injury, impairment, or death, and resulted in the determination of Immediate Jeopardy. On 2/15/24 at 6:58 p.m., the Administrator was notified of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The Immediate Jeopardy began on 1/22/24. The facility census was 113 with 19 residents who were transferred with full body mechanical lifts. The facility used three different brands of mechanical lifts. On 2/16/24, after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/16/24. The scope and severity were reduced to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference to F689, F835 and F908. 1. The facility's policy and procedure titled, Abuse Prevention Program, with a date reviewed/revised August 2022 noted, The facility has designated and implemented processes, which strive to reduce the risk of . neglect . These policies guide the identification, management, and reporting of suspected, or alleged . neglect . It is expected that these policies will assist the facility with reducing the risk of . neglect . through education of staff and residents . Neglect: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Procedure: The facility has implemented the following processes in an effort to provide residents . with a safe and comfortable environment . Prevention . Facility leadership will identify situations in which . neglect . may be more likely to occur . The facility policy and procedure titled, Back Injury and Body Mechanics effective March 2022 noted, Mechanical Lifts for Residents . Complete Mechanical Lift competency (Appendix B) at orientation and annually . The facility's Skills Check for Total Lift included to, Identify correct lift and sling size by matching the color-coded sticker to the color of the piping on the sling. Inspect lift and sling for condition . The facility's policy and procedure titled, Lock Out/ Tag out Policy effective March 2022 noted, The facility will use the Lock Out/ Tag Out practices to secure inoperable equipment . Other Physical Equipment . Mechanical lifts .When an issue is identified, remove the equipment from use . Review of the manufacturer's guidelines for full body mechanical lift (Brand A) used to transfer Resident #1 noted under operation section, The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position. Review of the clinical record for Resident #1 revealed an admitted [DATE]. Diagnoses included morbid obesity; muscle wasting and atrophy; need for assistance with personal care; and difficulty in walking. The Admission Minimum Data Set (MDS) assessment with a reference date of 1/22/24 noted Resident #1 was totally dependent on the physical assistance of two persons for bed mobility and required extensive physical assistance of two persons for transfer. The care plan initiated on 1/20/24 noted Resident #1 had an activities of daily living (ADL) self-care performance deficit. The interventions included the use of a, total mechanical lift to chair. The Physical Therapy Plan of Care with a start of care date of 1/20/24 noted Resident #1 was currently unable to ambulate and performed all functional transfers with total assist/dependent. Review of the progress notes revealed on 1/22/24 at 8:40 p.m., Registered Nurse (RN) Staff K documented, Rental bed arrives at the facility. Upon arrival, 3 CNA (Certified Nursing Assistant) and nurse assist resident with transferring from old bed to new bed. Upon transfer, resident began moving, twisting, flailing his arms and grabbing bed causing the lift to tip to the side and resident to attain [sic] skin tear. Staff attempt to calm and reassure resident with no resolve. Staff brace resident and lower resident to the ground. Assessment finds resident alert, denies pain, denies being hurt or hitting his head. No other injuries or skin alterations noted. MD (Physician) notified with orders to send to ER (emergency room ) for evaluation . The facility's fall incident dated 1/22/24 at 10:24 p.m., noted the resident did not hit his head during the transfer. The incident noted, Resident attempts to grab and self-position side to side during transfer causing lift to tip to side. Review of the EMS (Emergency Medical Services) Patient Care record dated 1/22/24 noted, Medic two arrived on scene to a skilled nursing facility where (Resident #1) was found lying on the floor. Staff explained that they were using a [brand name] mechanical lift to move the patient which he then fell out of and hit the floor. Patient was found lying on his right side in his room. Patient was complaining of pain all over that he could not pinpoint. A cervical collar was used to immobilize the patient's neck . Review of the emergency room Physician's progress note dated 1/23/24 at 1:35 a.m., noted, Today, while at rehab, patient sustained a fall from a (brand name) lift onto the ground. Patient endorses head trauma but denies loss of consciousness . On 2/12/24 the facility provided the following witness statements from staff as part of their investigation: On 1/22/24 CNA Staff B signed a witness statement written by Unit Manager Registered Nurse (RN) Staff J which noted, . The resident started shaking the straps attached to the lift. We tried to calm him down. He said he was afraid and continued to shake the straps. We got him close to the bed. He twist [sic] in the lift, that is when he went to the floor. As he was going down to the floor he grabbed the side rail he scraped his arm on the wall causing a skin tear. The nurse (RN Staff K) was present in the room at that time. On 1/22/24 CNA Staff A documented in a statement Resident #1 was connected to the mechanical lift with three person assist to go to the new bed. The resident was moving and shaking and the mechanical lift tipped over to the side, the resident was twisting. Staff A wrote, Resident did not fall, lowered to ground inside sling. She noted Resident #1 was positioned on the floor with pillows and had no acute pain complaint. On 1/22/24 the Administrator documented an interview with CNA Staff C. The statement noted CNA Staff C went in the room to assist CNA Staff A and CNA Staff B to transfer Resident #1. They used a mechanical lift to transfer the resident. During the transfer Resident #1 began twisting and flaying his arms and the lift started to fall to the one side. The legs of the lift were spread but because resident was twisting and moving his arms around, the lift fell to the side. The statement noted CNA Staff B guided the resident and he then went on down slowly to the floor. On 1/22/24 at 8:40 p.m., RN Staff K documented in a statement Resident #1 was transferred from the wheelchair to the mechanical lift in an extra-large sling and three person assist. While positioning the mechanical lift on the side of the new bed, the resident became anxious. The resident was moving his arms and grabbing the side of the bed. The resident continued to shake and pull himself aside. RN Staff K wrote the mechanical lift tips to left side. [Brand name] lift did not tip over. Resident #1 was lowered to the floor by the mechanical lift, in sling. The statement noted Resident #1 sustained a skin tear to the left arm where he attempted to grab the bed bar. RN Staff K wrote the resident did not hit his head or complained of pain. The investigation did not include documentation CNA Staff A, CNA Staff B, CNA Staff C, or RN Staff K inspected the mechanical lift and the sling for condition as per the facility's Skills Check for Total Lift to ensure the mechanical lift was in safe operating condition. The investigation did not include verification that staff used safe transfer technique per manufacturer's guidelines when using the mechanical lift. On 2/12/24 at 10:00 a.m., in an interview the Administrator said Resident #1's fall was witnessed. The documented root cause of the fall was, The resident was self-positioning, twisting, moving and grabbing during transfer. She said Resident #1's fall did not meet criteria of an alleged violation and was not reportable to the Florida State Survey Agency. On 2/12/2024 at 3:25 p.m., in an interview CNA Staff C said on 2/1/24 she assisted with the transfer of Resident #1 with the mechanical lift. CNA Staff C said the resident was getting a new bed. She said, We tried to turn the lift to put him in the bed. He started twisting, and he started to tip over. He did not fall out. We grabbed him in the sling. I grabbed him and the other CNA grabbed him, the CNA used the machine and lowered to floor with the lift. He was frightened and grabbed onto the bed. He had a scrape on his left arm was his only injury. CNA Staff C said, we know if a person can't move, then we know they are a total mechanical lift. When asked about selecting the size of the sling, CNA Staff C said, Slings are in the laundry room, I know the sizes. I just look at the resident and hold up to see if the sling will fit. I know the slings and how they will fit. From experience I know how to pick the right size. When asked, CNA Staff C described the process for mechanical lift transfers as, I put the sling under resident with a second person on the other side of the bed. I put the lift with the base closed under the bed and then open the legs. Under the bed it is wide then when I pull out the lift from under the bed, I close the base so we can turn and move. CNA Staff C said she did not know if the legs of the base were opened or close when Resident #1 fell on [DATE]. She said she was not operating the lift and, I just know it started to tilt over. Review of the employee file for CNA Staff C revealed a date of hire of 5/4/21. A computer based training for mechanical lift and transfers was dated 11/9/2023. The most recent skills competency was dated 10/22/23. On 2/12/24 at 4:00 p.m., in an interview CNA Staff A said on 2/1/24 she was assisting transferring Resident #1 to a new bed with a full body mechanical lift. She said there were people on all sides. There were three people because, he was so big. When he was very close to the bed, Resident #1 grabbed the straps and twisted himself. The lift started to tip to the left and he tried to grab the bed. CNA Staff A said, Yes, he fell to the floor because he was twisting. We tried to catch and guide him but we can do nothing. She said CNA Staff B held the machine to control him to the ground and the machine tilted over. CNA Staff A said she knew the size of sling for each resident since the sling was already in the room. If there is no sling, she'll get one from the laundry room, We just know what will fit. CNA Staff A demonstrated the process to transfer residents with a Brand C full body mechanical lift. She did not open the legs of the base when simulating placing and lifting a resident in the lift and wheeling the lift. She only opened the legs of the base when simulating lowering the resident in the chair. CNA Staff A said, We open (the legs of the base) when we stop moving before we put the resident in the bed or chair. It will tip if the bottom (legs of the base) is open when moving. On 2/12/24, review of CNA Staff A's employee file revealed a date of hire of 9/6/21. The most recent computer based training for mechanical lifts and transfers was completed on 9/5/23, and a competency completed on 10/23/23. On 2/12/24 at 4:35 p.m., in an interview CNA Staff B confirmed on 1/22/24 she was operating the full body mechanical lift to transfer Resident #1. CNA Staff B said Resident #1 kept shaking and saying, I'm going to fall. She said, When we were moving to the bed he turned and twisted, the machine tipped over but did not fall over. The machine did not fall on him. The other CNAs grabbed him and held him while I lowered him to the floor. The bottom of the lift is always open. We open it with our feet but sometimes it closes again. I know I opened it, but it might have closed on its own, I don't know for sure. When asked how to select the sling for each resident, she replied, We find them in the room, just what fits right. On 2/12/24, review of CNA Staff B's employee file revealed a date of hire of 4/27/2010. The most recent computer based training for mechanical lifts and transfers was completed on 12/11/23. The last competency skill for mechanical lifts was dated 10/22/23. On 2/13/24 at 9:10 a.m., in an interview RN Staff K verified on 2/1/24 she was in the room when Resident #1 was being transferred with the mechanical lift. RN Staff K said, I went with three care givers. Everything was fine until the last part when moving him to the new bed. He got upset; he fell . The CNA in the corner tried to carry the man's weight on her. Unfortunately, we had to put him on the floor. I assessed the resident, and I stayed in the room. I had one nurse text the ARNP (Advanced Registered Nurse Practitioner) and one call 911. RN Staff K said she did not receive too much training on mechanical lifts. She said she never participate in the actual lift. She helps placing the sling but the CNAs do all the work. RN Staff K said she did not know the size of the sling used to transfer Resident #1 but she never tells the CNAs what size of sling to use. She said, They all know, they know what to use, they are very smart. On 2/12/24 review of RN Staff K's employee file revealed a date of hire of 9/6/22 and a competency for mechanical lift use dated 9/2/23. On 2/13/24 at 9:30 a.m., in an interview the Director of Nursing (DON) said the expectation was to widen the legs of the base for patient safety. He said as they clear the lift from under the bed, the legs of the base need to be open. It is very important so that it leveled and weight distribution is even, and a wide center of gravity. The DON said, correct base widening decreases the tipping potential. On 2/13/24 at 9:41 a.m., CNA Staff H and CNA Staff I were observed using a Brand A full body mechanical lift to transfer Resident #20 from bed to wheelchair with a size large Brand A sling with visible green trim. Staff H placed the legs of the base under the resident's bed and lifted the resident in the sling. The CNA did not open the legs of the base. She pulled the legs of the base from under the bed, turned the lift to the right and wheeled the resident in the lift approximately three feet without opening the legs of the base. She opened the legs of the base when she lowered Resident #20 into the wheelchair. On 2/13/24 at approximately 10:00 a.m., CNA Staff H verified she did not open the legs of the base when transferring Resident #20 with the full body mechanical lift. She said, If I try to move her with the legs open it could tip over. We only open them when we are placing the resident in the bed or the chair. CNA Staff H verified she used a (Manufacturer A) large sling to transfer Resident #20 and said the CNAs choose the sling based on the resident's weight. Review of the clinical record for Resident #20 revealed the resident's current weight was 163.8 lbs. Review of Manufacturer A's Full Body & Stand-Up Lift Sling Sizing Chart noted sling size and fit can vary significantly depending on patient weight and girth. Consult physician before sling selection. The sling sizing chart noted a medium sling was for weight range of 90 t0 200 lbs. The Owner's Operator and Maintenance Manual for Brand A Patient Slings noted under warning, [Brand A] slings are made specifically for use with [Brand A] lifts. For the safety of the patient, DO NOT intermix slings and lifts of different manufacturers. Review of Brand C mechanical lift owner manual noted to use only Manufacturer Brand C branded slings. On 2/13/24 at 12:50 p.m., the DON said the facility ordered standard medium and large slings. He said the CNAs evaluate the residents to determine the size of sling to use. He verified the sling size was not on the CNA Kardex (provides instructions for care) and the lack of documentation the CNAs were trained and competent to determine the size of sling to use in accordance with manufacturer's instructions. On 2/15/24 at 9:20 a.m., in an interview Unit Manager RN Staff J said on 1/22/24 she was working when Resident #1 fell from the lift. She said, I was sitting at the desk on 300 hall, and I heard a noise. We jumped up and ran into the room where he was sitting against the wall; the [brand name] lift was tilted over and was leaning on his wheelchair. The sling was still under him, and the loops were still attached. They told me they got him up, weighed him because they got him a new, wider bed, and air mattress with the little side rails. The staff said that the resident grabbed side rail and that is how he scratched his arm. Unit Manager RN Staff J said she did not remember the color of the sling used. Said she notified the administrator of the fall. The Administrator came in with the maintenance man. They took the lift into the conference room and had the staff demonstrate how they did the procedure. Unit manager RN Staff J confirmed the staff demonstrated that the legs in the lift base were closed when they were moving the resident in the lift, the lift tilted over and leaned against wheelchair. RN Staff J said, He did not fall. I know technically it was a fall since he was on the floor, but it was controlled. RN Staff J said when she entered the room after the event, the base was straight because that is the way they have it when they are moving to the bed. Unit Manager Staff J confirmed the legs of the base were closed, and straight, and the mechanical lift was tilted against the resident's wheelchair. She said, The CNA was half under him trying to hold up the resident, so we moved him to the floor. He was a big man. On 2/15/24 at 8:50 a.m., in a follow up telephone interview CNA Staff B said on 1/22/24 she opened the base wide with the foot control when transferring Resident #1 with the full body mechanical lift. She said it (legs of the base) is supposed to stay open but when they turned the machine it closed on its own. CNA Staff B said, The resident was upset and moving. He was grabbing at the bed and the machine tilted over. We did everything we could but could not stop it. She confirmed the legs of the base closed on their own when the machine tilted over and she reported it to the Administrator. On 2/15/24 at 10:30 a.m., in an interview the Administrator said the CNA did not tell her the legs of the base closed on their own when the fall occurred. She said, The statement that I took was that the legs were open. We removed the lift, and an outside company is coming next week to check the lift. The Administrator said after the incident on 1/22/24 they did a reenactment with the lift used to transfer Resident #2. She said she did not have documentation of the reenactment or the Maintenance Director assessing the lift after the incident. The Administrator verified the facility did not identify the failure of the legs of the base to lock into place as a contributing factor of Resident #1's fall on 1/22/24. On 2/15/24 at 10:45 a.m., mechanical lift (Brand A) used on 1/22/24 to transfer Resident #1 was observed with the Maintenance Director. The Maintenance Director verified on 1/22/24 he inspected the mechanical lift used to transfer Resident #1 and did not think it was broken. He verified the motor of the lift was missing. The Maintenance Director said the motor had been missing since he started employment at the facility on 7/5/23. He demonstrated how staff opened the legs of the base by kicking the frame of the legs. The legs of the base did not lock into place. The Maintenance Director said it was possible for the legs to move easily during transfer if the base was bumped. He said the motor was connected to the legs and would lock them in place. He said since the motor has been removed, there was no locking feature. He said he has been checking the lift monthly since 7/2023 and did not realize it should have had a brake handle or a motor to ensure the legs of the base stayed open while in use. On 2/15/24 at 11:00 a.m., the mechanical lift used to transfer Resident #1 on 1/22/24 was observed with the Administrator, the Maintenance Director, and the DON. The Maintenance Director opened the legs of the base by kicking them with his foot. The DON demonstrated and verified the legs of the base closed easily and did not lock into position. When asked if this was the condition of the lift on 1/22/24 when Resident #1 fell from the lift, the Administrator said, Yes it is. When asked if staff kicked open the legs of the base during the reenactment she conducted on 1/22/24, the Administrator said, I don't remember. I can only go by the witness statements I obtained where she said the base was open. When asked if the lift was safe to use she said, No it's not. On 2/15/24 at 11:15 a.m., the DON verified the mechanical lift used to transfer Resident #1 on 1/22/24 did not have a motor and the legs of the base did not lock into place. He said it was unacceptable and unsafe for resident use. He said he was not aware the lift was broken and didn't know how unsafe it was. He said, The staff should never have been using it. On 2/15/24 at 12:50 p.m., in an interview the Maintenance Director said he previously worked at an Assisted Living Facility and they did not use mechanical lifts. He said when he started employment at the facility, There was no orientation. He said the person who hired him filled out a list by asking him if he knew about different systems like fire alarms and HVAC (Heating, Ventilation, Air Conditioning) but, I don't think it comprised any medical equipment. He said he was told to review the electronic maintenance system and follow the checklists for the inspection and maintenance of the mechanical lifts. He said he did not know the lift used to transfer Resident #1 had a motor at one time. The first time he inspected the lift, he asked a CNA how it worked. The CNA demonstrated by using her feet to open the legs of the base. The Maintenance Director said, I thought it was okay since the staff showed me and did not tell me it was wrong. I did not have enough knowledge to safely assess the lifts. The Maintenance Director job description noted, The Maintenance Director is responsible for the overall maintenance of the Facility . ensures the facility, equipment and utilities are maintained in good working order . Ensure equipment . are clean, safe, and orderly . Maintain and repair specialized equipment and machinery . Coordinates maintenance services with all other departments and services . The job description was not signed. On 2/15/24 at 2:00 p.m., the Administrator verified she did not have any documentation that the Maintenance Director was oriented and knowledgeable to perform his job duties. Said she was unaware that the Maintenance Director didn't have experience checking some of the medical equipment. The Administrator said, Ultimately it is my responsibility as the facility administrator. On 2/16/24 at 2:45 p.m., the DON said the nurses were responsible to supervise the CNAs and nursing leadership was responsible to ensure care is provided safely. He verified the lift used to transfer Resident #1 on 1/22/24 was broken and should not have been in use. 2. On 2/12/24 observation showed the facility used three different brands of mechanical lifts. Review of the manufacturer's instructions for slings for full body mechanical lift (Brand A) noted, (Brand A) slings are made specifically for use with (Brand A) lifts. For the safety of the patient, DO NOT intermix slings and lifts of different manufacturers. Review of the manufacturer's instructions of (Brand B) mechanical lift for slings noted, For safety of the patient, DO NOT intermix slings and patient lifts of different manufacturers . Review of the manufacturer's instructions of (Brand C) mechanical lift for slings noted, Use ONLY (Brand C) branded slings. DO NOT use a sling unless it is recommended for use with the lift. On 2/13/24 at 12:05 p.m., during a tour with Unit Manager RN Staff G, three of the 19 residents who use full body mechanical lifts had manufacturer's (Brand A) slings in their rooms. The other 16 residents did not have a sling. Review of (Brand A) manufacturer's Full Body & Stand-Up Lift Sling sizing Chart noted, Sling size and fit can vary significantly depending on patient weight and girth. These are general guidelines. Consult physician before sling selection. Small: 55 to 100 pounds (lbs.) Medium: 90 to 200 lbs. Large: 175 to 285 lbs. Extra-large: 265 to 500 lbs. Extra-Extra Large: 265 to 600 lbs. On 2/14/24 the facility provided a list of 19 residents who used Brand A, Brand B, and Brand C full body mechanical lifts with manufacturer's Brand A slings assigned to them. 13 of the 19 residents had the incorrect size of slings. Resident #2's current weight was 133.2 lbs. and assigned a size large sling by facility. Resident #3's current weight was 167 lbs. and assigned a size large sling by facility. Resident #4's current weight was 157.4 lbs. and assigned a size large sling by the facility. Resident #5's current weight was 160.4 lbs. and assigned a size large sling by facility. Resident #7's current weight was 208 lbs. and assigned an extra- large sling by facility. Resident #8's current weight was 169 lbs. and assigned a size large sling by facility. Resident #9's current weight was 170 lbs. and assigned a size large sling by facility. Resident #11's current weight was 146 lbs. and assigned a size large sling by facility. Resident #14's current weight was 101 lbs. and assigned size large sling by facility. Resident #17's current weight was 204 lbs. and assigned an extra-large sling by facility. Resident #18's current weight was 224 lbs. and assigned an extra-large sling by facility. Resident #19's current weight was 168.4 lbs. and assigned size large sling by facility. Resident #20's current weight was 163.8 lbs. and assigned a size large sling by facility. On 2/14/24 at 12:25 p.m., the Administrator said she was not aware each manufacturer specified to only use their brand of slings with their mechanical lifts. She said, That's not what the rental company told me. They said the slings were universal. She verified the facility only had (Brand A) slings available. On 2/15/24 at 9:45 a.m., the Regional Nurse Consultant said, All of the slings can hold up to 450 lbs. They are not going to break. The different sizes are more about comfort than safety. On 2/15/24 the Administrator provided a letter from (Brand B) lift Manufacturer dated 2/15/24 that read, Please be advised that (Brand B) Patient lifts are versatile and compatible with slings from other manufacturers, as well as being suitable for use with our own slings. The Administrator also provided a letter from (Brand C) lift manufacturer which documented, Most manufacturers recommend the use of their own slings with their lifts. While this may reduce risk of non-compatibility it also reduces health care professionals' flexibility in meeting the needs of their clients. (Brand C) floor and sit to stand patient lifts are compatible with most other manufacturer's slings with loop style attachments . On 2/16/24 at approximately 4:00 p.m., in an interview the Administrator said she contacted (Brand A) manufacturer. They would not give her a letter stating their slings were compatible with other brands of lift. The immediate actions implemented by the facility to remove the Immediate Jeopardy, and verified by the surveyor on 2/26/24 included: To protect the residents that require mechanical lift transfers the lift Identified was removed from services and Maintenance activated the Lock-out Tag-out process and sequestered the lift 1/22/24 in a locked storage room to prevent reintroduction into care areas. On 2/15/24 the surveyor verified through observation of the lift which was removed from patient care area. A Federal immediate report was completed and submitted 2/15/24. On 2/16/24 the surveyor verified through review of the Federal Immediate Report submitted to the State Survey Agency on 2/15/24. A comprehensive facility investigation has been reopened. On 2/16/24 the surveyor verified through review of documentation of facility's investigation and interview with the Administrator. Resident #1 involved in identified transfer 1/22/24 no longer resides in facility. On 2/12/24 the surveyor verified through record review Resident #1 was admitted to the acute care hospital on 2/1/24 and has not returned to the facility. Director of Nursing/Designee educated CNAs identified from lift transfer 2/13/24 using checklist for total lift transfer. On 2/16/24 the surveyor verified through review of the education provided using the checklist for total lift transfer. The surveyor interviewed four CNAs, two Licensed Practical Nurses and one Unit Manager. All were able to describe the process for transfer using a full body mechanical lift. The nurse identified as being a participant in the 1/22/24 transfer was suspended pending investigation. On 2/16/24 the surveyor verified through record review, and interview with the Administrator. The three CNAs identified performing the transfer 1/22/24 were educated regarding proper mechanical lift transfer and suspended pending investigation outcome. On 2/16/24 the surveyor verified through review of the education provided and interview with the Administrator. The Administrator and Director of Nursing reviewed the events for the last 30 days to identify any other issues with lift transfers. No events related to lift transfers were identified. On 2/16/24 the surveyor verified through review of the events for the last 30 days and interview with the Administrator and the Director of Nursing. The Physical Plant Consultant Inspected the lifts currently in services and determined they were in safe operating condition 2/14/24. On 2/16/24 the surveyor verified through review of the inspection report

Based on observation, record review, review of facility's policies and procedures, and staff interviews, the facility failed to implement processes to prevent accidents by failing to ensure staff followed manufacturer's safety recommendations during transfer with mechanical lift, and failing to ensure mechanical lifts were in safe operating condition. On 1/22/24 staff used a full body mechanical lift to transfer Resident #1. The motor of the lift had been removed making the locking mechanism inoperable. Resident #1 fell from the lift, sustained cuts to the left arm, complained of head trauma and pain all over. Resident #1 required an emergent transfer to an acute care hospital for evaluation and treatment. The failure of staff to follow manufacturer's safety recommendations for transfer with mechanical lifts created an unsafe environment of avoidable accidents or falls which has a likelihood to result in serious injury (i.e. Fractures, head injuries), impairment, or death of residents from avoidable accidents, and resulted in the determination of Immediate Jeopardy. On 2/15/24 at 6:58 p.m., the Administrator was notified of the determination of Immediate Jeopardy (IJ) and provided the IJ templates. The Immediate Jeopardy began on 1/22/24. The facility census was 113 with 19 residents who were transferred with full body mechanical lifts. The facility used three different brands of mechanical lifts. On 2/16/24, after verification of an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/16/24. The scope and severity were reduced to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross reference to F600, F835 and F908. 1. Review of the clinical record for Resident #1 revealed an admitted [DATE]. Diagnoses included morbid obesity; muscle wasting and atrophy; need for assistance with personal care; and difficulty in walking. The care plan initiated on 1/20/24 noted Resident #1 had an activities of daily living (ADL) self-care performance deficit. The interventions included the use of a, total mechanical lift to chair. Review of the progress notes revealed on 1/22/24 at 8:40 p.m., Registered Nurse (RN) Staff K documented Resident #1 was being transferred with a mechanical lift to a new bed with three staff members. The resident was moving, twisting, flailing his arms and grabbing the bed, causing the lift to tip to the side. Staff lowered the resident to the floor. The fall investigation dated 1/22/24 at 10:24 p.m., noted Resident #1 was oriented to person, place, time, and situation at the time of the incident. The investigation did not list any predisposing environmental factors, and noted, Resident attempts to grab and self-position side to side during transfer causing lift to tip to side. Resident #1 was transferred to an acute care hospital via Emergency Medical Services (EMS). The facility's internal investigation of the fall included staff statements but did not include documentation Certified Nursing Assistant (CNA) Staff A, CNA Staff B, CNA Staff C, or RN Staff K inspected the mechanical lift and the sling for condition as per the facility's Skills Check for Total Lift to ensure the mechanical lift was in safe operating condition. The investigation did not include verification that staff used safe transfer technique per manufacturer's guidelines. Review of the manufacturer's guidelines for full body mechanical lift (Brand A) used to transfer Resident #1 noted under operation section, The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position. The facility's policy and procedure titled, Lock Out/ Tag out Policy effective March 2022 noted, The facility will use the Lock Out/ Tag Out practices to secure inoperable equipment . Other Physical Equipment . Mechanical lifts .When an issue is identified, remove the equipment from use . The facility's Skills Check for Total Lift included to, Identify correct lift and sling size by matching the color-coded sticker to the color of the piping on the sling. Inspect lift and sling for condition . On 1/22/24 the Administrator documented an interview with CNA Staff C. The statement noted CNA Staff C went in the room to assist CNA Staff A and CNA Staff B to transfer Resident #1. They used a mechanical lift to transfer the resident. During the transfer Resident #1 began twisting and flaying his arms and the lift started to fall to the one side. The legs of the lift were spread but because resident was twisting and moving his arms around, the lift fell to the side. The statement noted CNA Staff B guided the resident and he then went on down slowly to the floor. CNA Staff C's statement did not include documentation staff verified the lift was in safe operating condition before the transfer. On 2/12/2024 at 3:25 p.m., in an interview CNA Staff C said on 2/1/24 she assisted with the transfer of Resident #1 with the mechanical lift. CNA Staff C said the resident was getting a new bed. She said, We tried to turn the lift to put him in the bed. He started twisting, and he started to tip over. He did not fall out. We grabbed him in the sling. I grabbed him and the other CNA grabbed him, the CNA used the machine and lowered to floor with the lift. He was frightened and grabbed onto the bed. He had a scrape on his left arm was his only injury. When asked to describe the process for mechanical lift transfers, CNA Staff C said, I put the sling under resident with a second person on the other side of the bed. I put the lift with the base closed under the bed and then open the legs. Under the bed it is wide then when I pull out the lift from under the bed I close the base so we can turn and move. CNA Staff C did not say if the lift was inspected prior to use or if the legs of the base were opened during the transfer. She said, I don't know, I was not the one who was controlling the lift itself I was just there to help. I don't know if his base was open or closed when we were moving to put resident #1 back into the bed. I just know it started to tilt over. On 1/22/24 CNA Staff A documented in a statement Resident #1 was connected to the mechanical lift with three person assist to go to the new bed. The resident was moving and shaking and the mechanical lift tipped over to the side, the resident was twisting. Staff A wrote, Resident did not fall, lowered to ground inside sling. She noted Resident #1 was positioned on the floor with pillows and had no acute pain complaint. CNA Staff A statement did not include verification that the lift was inspected before the transfer. On 2/12/24 at 4:00 p.m., in an interview CNA Staff A said on 2/1/24 she was assisting transferring Resident #1 to a new bed with a full body mechanical lift. She said there were people on all sides. There were three people because, he was so big. When he was very close to the bed, Resident #1 grabbed the straps and twisted himself. The lift started to tip to the left and he tried to grab the bed. CNA Staff A said, Yes, he fell to the floor because he was twisting. We tried to catch and guide him but we can do nothing. She said CNA Staff B held the machine to control him to the ground and the machine tilted over. CNA Staff A simulated the process to transfer residents with a brand C full body mechanical lift. She did not inspect the lift before simulating the transfer. She did not open the legs of the base when simulating placing and lifting a resident in the lift and wheeling the lift. She only opened the legs of the base when simulating lowering the resident in the chair. CNA Staff A said, We open (the legs of the base) when we stop moving before we put the resident in the bed or chair. It will tip if the bottom (legs of the base) is open when moving. On 1/22/24 CNA Staff B signed a witness statement written by Unit Manager Registered Nurse (RN) Staff J which noted, . The resident started shaking the straps attached to the lift. We tried to calm him down. He said he was afraid and continued to shake the straps. We got him close to the bed. He twist [sic] in the lift, that is when he went to the floor. As he was going down to the floor he grabbed the side rail he scraped his arm on the wall causing a skin tear. The nurse (RN Staff K) was present in the room at that time. The statement did not include CNA Staff B verified the lift was in safe operating condition before the transfer. On 2/12/24 at 4:35 p.m., in an interview CNA Staff B confirmed on 1/22/24 she was operating the full body mechanical lift to transfer Resident #1. CNA Staff B said Resident #1 kept shaking and saying, I'm going to fall. She said, When we were moving to the bed he turned and twisted, the machine tipped over but did not fall over. The machine did not fall on him. The other CNAs grabbed him and held him while I lowered him to the floor. The bottom of the lift is always open. We open it with our feet but sometimes it closes again. I know I opened it, but it might have closed on its own, I don't know for sure. When asked how to select the sling for each resident, she replied, We find them in the room, just what fits right. On 1/22/24 at 8:40 p.m., RN Staff K documented in a statement Resident #1 was transferred from the wheelchair to the mechanical lift in an extra-large sling and three person assist. While positioning the mechanical lift on the side of the new bed, the resident became anxious. The resident was moving his arms and grabbing the side of the bed. Staff attempted to calm and reassure the resident of safe transfer. The resident continued to shake and pull himself aside. RN Staff K wrote the mechanical lift tips to left side. [Brand name] lift did not tip over. Resident #1 was lowered to the floor by the mechanical lift, in sling. The statement noted Resident #1 sustained a skin tear to the left arm where he attempted to grab the bed bar. RN Staff K wrote the resident did not hit his head or complained of pain. RN Staff K's statement did not include staff verified the lift was in safe working condition before the transfer. RN Staff K's statement did not include verification staff used safe transfer technique and ensure the legs of the base were opened when the lift tipped to the side. On 2/13/24 at 9:10 a.m., in an interview RN Staff K verified on 2/1/24 she was in the room when Resident #1 was being transferred with the mechanical lift. RN Staff K said, I went with three care givers. Everything was fine until the last part when moving him to the new bed. He got upset; he fell . The CNA in the corner tried to carry the man's weight on her. Unfortunately, we had to put him on the floor. I assessed the resident, and I stayed in the room. I had one nurse text the ARNP (Advanced Registered Nurse Practitioner) and one call 911. RN Staff K said she did not receive too much training on mechanical lifts. She said she never participate in the actual lift. She helps placing the sling but the CNAs do all the work. On 2/13/24 at 8:30 a.m., in an interview the Maintenance Director said he started employment at the facility on 7/5/23. He said on 1/22/24 when Resident #1 fell from the lift, he came in to inspect the lift. He said the lift was not broken but it was removed from service due to the incident and possible investigation. The Maintenance Director said he did not have the owner's operator and maintenance manual for the three brands of lifts used at the facility. The Maintenance Director said he followed the checklist on their maintenance computer system but the checklist was not specific to each brand or model of mechanical lift. Requested the Maintenance Director obtained the owner's operator and maintenance manual for each brand of lift used at the facility. On 2/13/24 at 9:41 a.m., CNA Staff H and CNA Staff I were observed using a Brand A full body mechanical lift to transfer Resident #20 from bed to wheelchair with a size large Brand A sling with visible green trim. Staff H placed the legs of the base under the resident's bed and lifted the resident in the sling. The CNA did not open the legs of the base. She pulled the legs of the base from under the bed, turned the lift to the right and wheeled the resident in the lift approximately three feet without opening the legs of the base. She opened the legs of the base when she lowered Resident #20 into the wheelchair. On 2/13/24 at approximately 10:00 a.m., CNA Staff H verified she did not open the legs of the base when transferring Resident #20 with the full body mechanical lift. She said, If I try to move her with the legs open it could tip over. We only open them when we are placing the resident in the bed or the chair. CNA Staff H verified she used a (Manufacturer A) large sling to transfer Resident #20 and said the CNAs choose the sling based on the resident's weight. Review of the clinical record for Resident #20 revealed the resident's current weight was 163.8 lbs. Review of Manufacturer A's Full Body & Stand-Up Lift Sling Sizing Chart noted sling size and fit can vary significantly depending on patient weight and girth. Consult physician before sling selection. The sling sizing chart noted a medium sling was for weight range of 90 to 200 lbs. On 2/15/24 at 8:50 a.m., in a follow up telephone interview CNA Staff B said on 1/22/24 she opened the base wide with the foot control when transferring Resident #1 with the full body mechanical lift. She confirmed the legs of the base closed on their own when the machine tilted over and she reported it to the Administrator. On 2/15/24 at 10:30 a.m., in an interview the Administrator said the CNA did not tell her the legs of the base closed on their own when the fall occurred. She said, The statement that I took was that the legs were open. We removed the lift, and an outside company is coming next week to check the lift. The Administrator said she did not have documentation of the reenactment or the Maintenance Director assessing the lift after the incident. The Administrator verified the facility's investigation did not consider the failure of the legs of the base to lock into place as a contributing factor of Resident #1's fall on 1/22/24. On 2/15/24 at 10:45 a.m., mechanical lift (Brand A) used on 1/22/24 to transfer Resident #1 was observed with the Maintenance Director. The motor of the lift was missing. The Maintenance Director said the motor has been missing since he started employment at the facility on 7/5/24. He demonstrated how staff opened the legs of the base by kicking the frame of the legs. The legs of the base did not lock into place. The Maintenance Director said it was possible for the legs to move easily during transfer if the base was bumped. He said the motor was connected to the legs and would lock them in place. He said since the motor has been removed, there was no locking feature. He said he has been checking the lift monthly since 7/2023 and did not realize it should have had a brake handle or a motor to ensure the legs of the base stayed open while in use. On 2/15/24 at 11:00 a.m., the mechanical lift used to transfer Resident #1 on 1/22/24 was observed with the Administrator, the Maintenance Director, and the DON. The Maintenance Director opened the legs of the base by kicking them with his foot. The DON demonstrated and verified the legs of the base closed easily and did not lock into position. When asked if this was the condition of the lift on 1/22/24 when Resident #1 fell from the lift, the Administrator said, Yes it is. When asked if staff kicked open the legs of the base during the reenactment she conducted on 1/22/24, the Administrator said, I don't remember. I can only go by the witness statements I obtained where she said the base was open. When asked if the lift was safe to use she said, No it's not. On 2/15/24 at 11:15 a.m., the DON verified the mechanical lift used to transfer Resident #1 on 1/22/24 did not have a motor and the legs of the base did not lock into place. He said it was unacceptable and unsafe for resident use. He said he was not aware the lift was broken and didn't know how unsafe it was. He said, The staff should never have been using it. 2. On 2/12/24 observation showed the facility uses three different brands of mechanical lifts. Review of the manufacturer's instructions for slings for full body mechanical lift (Brand A) noted, (Brand A) slings are made specifically for use with (Brand A) lifts. For the safety of the patient, DO NOT intermix slings and lifts of different manufacturers. The instructions noted, Sling size and fit can vary significantly depending on patient weight and girth. These are general guidelines. Consult physician before sling selection. Review of the manufacturer's instructions of (Brand B) mechanical lift for slings noted, Specific slings are made for the Electric Patient Lifts. For the safety of the patient, DO NOT intermix slings and patient lifts of different manufacturers . Warranty will be voided. Review of the manufacturer's instructions of (Brand C) mechanical lift for slings noted, Use ONLY (Brand C) branded slings. DO NOT use a sling unless it is recommended for use with the lift. On 2/12/24 at 11:15 a.m., in an interview Unit Manager RN Staff G said the CNAs choose the sling based on the resident's size. The slings are left in the room. If soiled, they are sent to laundry and returned. On 2/12/24 at 1:30 p.m., in an interview CNA Staff D said the CNAs decide what size sling to use for each resident. She said, We just look at the resident. She said the facility uses all different types of slings. On 2/12/24 at 2:02 p.m., in an interview CNA Staff E said the CNAs decide what sling to use for each resident. She said, When I am looking at them [residents], I see them, so I know what size to get. When asked about the process to transfer residents with a full body mechanical lift, CNA Staff E said, I start raising the lift, I put chair in good spot after pulling out from under bed, pull out, go over to the chair and then open legs so I can fit under chair. When asked to clarify when to open the legs of the base, CNA Staff E confirmed she only opens the legs of the base when she has stopped moving the lift and is placing the resident in bed or chair. On 2/12/24 at 2:35 p.m., in an interview CNA Staff F said the CNAs choose the sling size for the residents. She said, Large is the best, I always use large. You can't go wrong. On 2/12/24 at 3:25 p.m., in an interview about mechanical lifts, and choosing sling sizes, CNA Staff C said, We know if a person can't move, they we know they are a total mechanical lift. The slings are in the laundry room, I know the sizes. I just look at the resident and hold up to see if the sling will fit. I know the slings and how they will fit. From experience I know how to pick the right size. On 2/12/24 at 4:00 p.m., in an interview about sling sizes, CNA Staff A said she knew the sling size since they were in the residents' rooms. She said if there is no sling in the room, she gets one from the laundry. She said, We just know what will fit. On 2/12/24 at 4:35 p.m., in an interview about choosing the right sling size, CNA Staff B said, We find them in the room, just what fits right. On 2/13/24 at 9:10 a.m., in an interview RN Staff K verified on 2/1/24 she was in the room when Resident #1 was being transferred with the mechanical lift. RN Staff K said she did not know the size of the sling used to transfer Resident #1 but she never tells the CNAs what size of sling to use. She said, They all know, they know what to use, they are very smart. On 2/13/24 at 9:30 a.m., in an interview the Director of Nursing (DON) said the CNAs choose the size of the sling based on weight. He said, I noticed they go by color coding on the slings themselves. On 2/13/24 at 12:05 p.m., during a tour with Unit Manager RN Staff G, three of the 19 residents who use full body mechanical lifts had manufacturer's (Brand A) slings in their rooms. The other 16 residents did not have a sling. On 2/14/24 at 12:25 p.m., the Administrator said she was not aware each manufacturer specified to only use their brand of slings with their mechanical lifts. She said, That's not what the rental company told me. They said the slings were universal. She verified the facility only had (Brand A) slings available. Review of (Brand A) manufacturer's Full Body & Stand-Up Lift Sling sizing Chart noted, Sling size and fit can vary significantly depending on patient weight and girth. These are general guidelines. Consult physician before sling selection. Small: 55 to 100 pounds (lbs.) Medium: 90 to 200 lbs. Large: 175 to 285 lbs. Extra-large: 265 to 500 lbs. Extra-Extra Large: 265 to 600 lbs. On 2/14/24 the facility provided a list of 19 residents who used full body mechanical lifts with manufacturer's Brand A slings assigned to them. 13 of the 19 residents had the incorrect size of slings. Resident #2's current weight was 133.2 lbs. and assigned a size large sling. Resident #3's current weight was 167 lbs. and assigned a size large sling. Resident #4's current weight was 157.4 lbs. and assigned a size large sling. Resident #5's current weight was 160.4 lbs. and assigned a size large sling. Resident #7's current weight was 208 lbs. and assigned an extra- large sling. Resident #8's current weight was 169 lbs. and assigned a size large sling. Resident #9's current weight was 170 lbs. and assigned a size large sling. Resident #11's current weight was 146 lbs. and assigned a size large sling. Resident #14's current weight was 101 lbs. and assigned size large sling. Resident #17's current weight was 204 lbs. and assigned an extra-large sling. Resident #18's current weight was 224 lbs. and assigned an extra-large sling. Resident #19's current weight was 168.4 lbs. and assigned size large sling. Resident #20's current weight was 163.8 lbs. and assigned a size large sling. On 2/15/24 the Administrator provided a letter from (Brand B) lift Manufacturer dated 2/15/24 that read, Please be advised that (Brand B) Patient lifts are versatile and compatible with slings from other manufacturers, as well as being suitable for use with our own slings. The Administrator provided a letter from (Brand C) lift manufacturer which documented, Most manufacturers recommend the use of their own slings with their lifts. While this may reduce risk of non-compatibility it also reduces health care professionals' flexibility in meeting the needs of their clients. (Brand C) floor and sit to stand patient lifts are compatible with most other manufacturer's slings with loop style attachments . On 2/16/24 at approximately 4:00 p.m., in an interview the Administrator said she contacted (Brand A) manufacturer. They would not give her a letter stating manufacturer their slings were compatible with other brands of lift. The immediate actions implemented by the facility to remove the Immediate Jeopardy, and verified by the surveyor on 2/26/24 included: Lift identified from the 1/22/24 event was removed from service on 1/22/24 through the lock-out Tag-out process. On 2/15/24 the surveyor verified through observation of the lift used on 1/22/24 to transfer Resident #1. Resident #1 involved in the identified transfer 1/22/24 no longer resides in the facility. On 2/12/24 the surveyor verified through record review. Resident #1 was transferred to an acute care hospital on 1/22/24 and has not returned to the facility. CNAs identified performing transfer 1/22/24 were educated regarding proper mechanical lift transfer and suspended 2/14/24 pending investigation. On 2/16/24 the surveyor verified through record review and interview with the Administrator. The Administrator and Director of Nursing reviewed the events for the last 30 days to identify any other issues with lift transfers. No events related to lift transfers were identified. On 2/16/24 the surveyor verified through record review and interview with the Administrator. The facility utilized the Manufacturers guidance to reevaluate sizing for each resident requiring mechanical lift transfer for each brand of mechanical lift as specified by the individual manufacturer to ensure the safety of the residents during transfers with the mechanical lift. On 2/16/24 the surveyor verified through review of residents reevaluation of sizing as specified by individual manufacturer to ensure the safety of the residents during transfers with the mechanical lift. Residents requiring the total lift were reevaluated using the Manufactures' sizing guidelines to determine the correct sling size. On 2/16/24 the surveyor verified through review of residents reevaluation of sizing as specified by individual manufacturer to ensure the safety of the residents during transfers with the mechanical lift. The Nurse Consultant provided education for the facility administration related to utilizing the Manufacturers' resources effectively for mechanical lifts 2/16/24. On 2/16/24 the surveyor verified through review of the education provided to the facility administration and interview with the Administrator and DON. The Physical Plant Consultant provided education to administrative staff related to the Lock-out, Tag-out process 2/16/24. On 2/16/24 the surveyor verified through review of the education provided and interview with the Administrator. The Facility Plant Consultant educated the Director of Maintenance related to the Monthly inspection process for Mechanical Lifts 2/16/24. On 2/16/24 the surveyor verified through review of the education provided to the Maintenance Director and interview with the Maintenance Director. The Facility Director of Nursing/Designee provided education to facility staff related to the Lock-Out Tag-out process and reporting & removing faulty equipment from service. Percentage of education completed as of 2/16/24 is 77%. The remaining staff will not work until the education is completed. On 2/16/24 the surveyor verified through review of the education provided to facility staff. Four CNAs, two Licensed Practical Nurses and one Unit Manager were interviewed and able to verbalize the content of the education. Sling selection sizing guidelines were placed at each nursing station in the resource binder 2/15/24. On 2/16/24 the surveyor verified through observation of the sizing guidelines at each nursing station. The sizing results from the individual resident evaluation have been scribed into the plan of care and into the Kardex (Provides instructions for care) for Certified Nursing Assistant use. 2/15/24. On 2/16/24 the surveyor verified through review of individual resident evaluation and Kardex. The facility implemented a mechanical lift monitor to oversee sling selection and observation of lift use for transfer technique. 2/16/24. On 2/16/24 the surveyor verified through record review and interview with the Administrator. The Nurse Consultant provided education to the facility Director of Nursing related to sling sizing per manufacturer guidelines and mechanical lift transfer techniques on 2/14/24. On 2/16/24 the surveyor verified through review of the education provided and interview with the Director of Nursing. The Director of Nursing/Designee initiated education with licensed nurses on proper mechanical lift transfer procedures to provide Certified Nursing Assistants supervision on 2/16/24. On 2/16/24 the surveyor verified through review of the education with the licensed nurses. Two Licensed Practical Nurses and one Unit Manager were interviewed and able to verbalize understanding of education provided. The Director of Nursing/Designee educated Facility Certified Nursing Assistants on proper mechanical lift transfer procedures using the Checklist for Total Lift Transfer which was initiated 2/14/24. The percentage completed is 93%. The 4 remaining certified nursing assistants will not work until the education is completed. On 2/16/24 the surveyor verified through review of the education provided and interview with four CNAs. The Director of Nursing/Designee completed education with licensed staff regarding sling sizing 2/15/24. The percentage of education completed is 91%. The remaining three licensed staff members will not work until the education is completed. On 2/16/24 the surveyor verified through review of the education, and interview with two Licensed Practical Nurses and one Unit Manager. The MDS (Minimum Data Set) nurse to evaluate resident using total lift and place sling size on Kardex (provides instructions for care). Completed 2/14/24. On 2/16/24 the surveyor verified through review of education provided and review of Kardex.

Based on observation, record review, and staff interviews, the facility failed to implement processes to ensure resident equipment was in safe operating condition. On 1/22/24 Staff used a full body mechanical lift to transfer Resident #1. Resident #1 fell from the mechanical lift, sustained cuts, complained of head trauma and generalized pain requiring an emergent transfer to an acute care hospital. The motor of the lift had been removed since July 2023 causing the legs of the base to not lock to ensure a safe transfer. Staff responsible for the inspection and maintenance of the mechanical lifts did not have the training and competency to ensure the mechanical lifts were in safe operating condition. The facility failure to implement processes and ensure resident care equipment were in safe operating condition created an unsafe environment of avoidable falls and accidents with a likelihood of serious harm, impairment or death of residents who use a mechanical lift for transfers and resulted in the determination of Immediate Jeopardy (IJ). On 2/15/24 at 6:58 p.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the IJ templates. The facility census was 113 with 19 residents who were transferred with mechanical lifts. The facility used three different brands of mechanical lifts for transfers. The Immediate Jeopardy began on 1/22/24. On 2/16/24, after the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/16/24 and the scope and severity were reduced to no actual harm, with no more than minimal harm. The findings included: Cross reference to F600, F689, and F835 On 2/12/24, review of facility incident and accident log revealed on 1/22/24 Resident #1 was being transferred with a total body mechanical lift which tipped over resulting in the resident falling to the floor. Resident #1 was transferred via Emergency Medical Services to an acute care hospital. The fall investigation dated 1/22/24 at 10:24 p.m., noted Resident #1 was oriented to person, place, time, and situation at the time of the incident. The investigation did not list any predisposing environmental factors, and noted, Resident attempts to grab and self-position side to side during transfer causing lift to tip to side. The investigation included statements of staff who used the mechanical lift to transfer Resident #1 and did not include a lift inspection to ensure the full body mechanical lift was in safe operating condition at the time of the fall. On 2/12/24 at 4:35 p.m., in an interview Certified Nursing Assistant (CNA) Staff B confirmed on 1/22/24 she was operating the full body mechanical lift to transfer Resident #1to a new bed. CNA Staff A, CNA Staff C, and Registered Nurse (RN) Staff K assisted with the transfer. CNA Staff B said Resident #1 kept shaking and saying, I'm going to fall. She said, When we were moving to the bed he turned and twisted, the machine tipped over but did not fall over. The machine did not fall on him. The other CNAs grabbed him and held him while I lowered him to the floor. The bottom of the lift is always open. We open it with our feet but sometimes it closes again. I know I opened it, but it might have closed on its own, I don't know for sure. The facility's policy and procedure titled, Lock Out/ Tag out Policy effective March 2022 noted, The facility will use the Lock Out/ Tag Out practices to secure inoperable equipment . Other Physical Equipment . Mechanical lifts .When an issue is identified, remove the equipment from use . On 2/13/24 at 8:30 a.m., in an interview the Maintenance Director said he started employment at the facility on 7/5/23. He said on 1/22/24 when Resident #1 fell from the lift, he came in to check the lift. He said the lift was not broken but it was removed from service due to the incident and possible investigation. The Maintenance Director said he did not have the owner's operator and maintenance manual for the three brands of lifts used at the facility, he followed the checklist on their maintenance computer system. He said the checklist was not specific to each brand or model of mechanical lift. The Maintenance Director provided a copy of the electronic form with steps to conduct the mechanical lifts safety inspection. Review of the electronic checklist for mechanical lifts noted to conduct mobile lift safety inspection and inspect all that apply. The tasks included, Inspect the [NAME] base, check for missing hardware . Inspect the shifter handle: Ensure that shifter operates smoothly. Verify that base is locked when handle is engaged . Inspect the brakes . Ensure that the brakes engage when pressure is applied . The Maintenance Director provided documentation he inspected the mechanical lifts on 7/25/23, 8/16/23, 10/5/23, 11/7/23, 12/5/23, and 1/22/24. On 2/14/24 at 1:50 p.m., in a telephone interview the Assistant Director of Nursing (ADON) said on 1/22/24 after the fall involving Resident #1, We got called in, we had them reenact the situation in both the conference room and in the resident's room with (Brand A) mechanical lift and sling and all four staff members. I saw no concerns in the reenactments. The resident became anxious and fearful and grabbed onto bed. That is when it tipped towards staff. They were in the process of spreading out the base, is what they told me. She confirmed she did not document the reenactments or any additional post fall staff education. On 2/15/24 at 8:50 a.m., in a follow up telephone interview CNA Staff B said on 1/22/24 she opened the base wide with the foot control when transferring Resident #1 with the full body mechanical lift. She confirmed the legs of the base closed on their own when the machine tilted over and she reported it to the Administrator. On 2/15/24 at 10:30 a.m., in an interview the Administrator said the CNA did not tell her the legs of the base closed on their own when the fall occurred. She said, The statement that I took was that the legs were open. We removed the lift, and an outside company is coming next week to check the lift. The Administrator said she did not have documentation of the reenactment or the Maintenance Director assessing the lift after the incident. On 2/15/24 at 10:45 a.m., mechanical lift (Brand A) used on 1/22/24 to transfer Resident #1 was observed with the Maintenance Director. The motor of the lift was missing. The Maintenance Director said the motor has been missing since he started employment at the facility on 7/5/24. He demonstrated how staff opened the legs of the base by kicking the frame of the legs. The legs of the base did not lock into place. The Maintenance Director said it was possible for the legs to move easily during transfer if the base was bumped. He said the motor was connected to the legs and would lock them in place. He said since the motor has been removed, there was no locking feature. He said he has been checking the lift monthly since 7/2023 and did not realize it should have had a brake handle or a motor to ensure the legs of the base stayed open while in use. Photographic evidence obtained. On 2/15/24 at 11:00 a.m., the mechanical lift used to transfer Resident #1 on 1/22/24 was observed with the Administrator, the Maintenance Director, and the Director of Nursing (DON). The Maintenance Director opened the legs of the base by kicking them with his foot. The DON demonstrated and verified the legs of the base closed easily and did not lock into position. When asked if this was the condition of the lift on 1/22/24 when Resident #1 fell from the lift, the Administrator said, Yes it is. When asked if staff kicked open the legs of the base during the reenactment she conducted on 1/22/24, the Administrator said, I don't remember. I can only go by the witness statements I obtained where she said the base was open. When asked if the lift was safe to use she said, No it's not. On 2/15/24 at 11:15 a.m., the DON verified the mechanical lift used to transfer Resident #1 on 1/22/24 did not have a motor and the legs of the base did not lock into place. He said it was unacceptable and unsafe for resident use. He said he was not aware the lift was broken and didn't know how unsafe it was. He said, The staff should never have been using it. On 2/15/24 at 12:35 p.m., in an interview the Administrator said she was the Risk Manager for the facility and participated in the interviewing and hiring process of the Maintenance Director. The Maintenance Director job description noted, The Maintenance Director is responsible for the overall maintenance of the Facility . ensures the facility, equipment and utilities are maintained in good working order . Ensure equipment . are clean, safe, and orderly . Maintain and repair specialized equipment and machinery . Coordinates maintenance services with all other departments and services . The job description was not signed. On 2/15/24 at 12:40 p.m., the Regional Physical Plant Consultant said the process for checking the lifts is that the equipment should be working to manufacturer's recommendations. If not, it needs to be removed from service. The Regional Physical Plant Consultant said the electronic maintenance checklist said to check the bar on the mechanical lift. He would have expected the Maintenance Director to notice the missing part and identify the lift should not have been in use. He said he was surprised the Maintenance Director did not have more experience with medical equipment. On 2/15/24 at 12:50 p.m., in an interview the Maintenance Director said he previously worked at an Assisted Living Facility and they did not use mechanical lifts. He said when he started employment at the facility, There was no orientation. He said the person who hired him filled out a list by asking him if he knew about different systems like fire alarms and HVAC (Heating, Ventilation, Air Conditioning) but, I don't think it comprised any medical equipment. He said he was told to review the electronic maintenance system and follow the checklists for the inspection and maintenance of the mechanical lifts. He said he did not know the lift used to transfer Resident #1 had a motor at one time. The first time he inspected the lift, he asked a CNA how it worked. The CNA demonstrated by using her feet to open the legs of the base. The Maintenance Director said, I thought it was okay since the staff showed me and did not tell me it was wrong. I did not have enough knowledge to safely assess the lifts. On 2/15/24 at 2:00 p.m., the Administrator verified she did not have any documentation that the Maintenance Director was oriented and knowledgeable to perform his job duties. Said she was unaware that the Maintenance Director didn't have experience checking some of the medical equipment. The Administrator said, Ultimately it is my responsibility as the facility administrator. On 2/16/24 at 2:45 p.m., the DON said the nurses were responsible to supervise the CNAs and nursing leadership was responsible to ensure care is provided safely. He verified the lift used to transfer Resident #1 on 1/22/24 was broken and should not have been in use. He said on 1/22/24 the ADON should have identified the mechanical lift was broken and should not have been in use. When asked how the facility monitored to ensure the CNAs followed safety precautions when using mechanical lifts, the DON said, We only do the skills check, but we have not done any spot check or observe them. The immediate actions implemented by the facility to remove the Immediate Jeopardy, and verified by the surveyor on 2/26/24 included: The Facility obtained the Manufacturers manuals for the three types of lifts utilized at the facility. On 2/16/24 the surveyor verified by review of the manufacturer's manuals for the three types of lifts utilized by the facility. Lift identified from the 1/22/24 event was removed from service 1/22/24. On 2/15/24 the surveyor verified the mechanical lift used on 1/22/24 to transfer Resident #1 was removed from service. The Physical Plant Consultant provided education with the maintenance director related to the maintenance of the mechanical lifts, and the monthly maintenance of mechanical lifts 2/16/24. On 2/26/24 the surveyor verified by review of the education provided to the Maintenance Director and interview with the Maintenance Director. The Physical Plant Consultant provided education to the Facility Maintenance Director related to the removal of faulty equipment from services and implementation of the lock-out Tag-out process 2/16/24. On 2/26/24 the surveyor verified by review of the education provided to the Maintenance Director and interview with the Maintenance Director. The Physical Plant Consultant Educated the Facility Maintenance Director on maintaining mechanical lifts in a safe operating condition 2/16/24. On 2/26/24 the surveyor verified by review of the education provided to the Maintenance Director and interview with the Maintenance Director. The Physical Plant Consultant Inspected the lifts currently in service and determined they were in safe operating condition on 2/14/24. On 2/26/24 the surveyor verified through review of the inspection of the lifts currently in service. The Physical Plant Consultant educated the Director of Maintenance related to the Monthly inspection process for Mechanical Lifts on 2/16/24. On 2/16/24 the surveyor verified through review of the education provided to the Maintenance Director and interview with the Maintenance Director. The Facility Director of Nursing/Designee will provide education to facility staff related to the Lock-out, Tag-out process regarding the removal of faulty equipment and sequestering from the patient care areas which was initiated 2/15/24 and the percentage is 77%. The remaining staff will not work until the education is completed. On 2/16/24 the surveyor verified through review of the education provided to the facility staff using the mechanical lifts. A total of four CNAs, two Licensed Practical Nurses, one Unit Manager and the DON were interviewed. All were able to verbalize understanding of the content of education provided and the process to identify, report and remove faulty equipment from patient care areas.

Based on observation, record review, and interviews, the facility's Administration failed to utilize resources effectively to protect the residents right to be free from neglect by failing to ensure staff competency in the areas of inspecting, identifying, and removing unsafe resident equipment from use, and safe transfer techniques with mechanical lifts. On 1/22/24 Staff used a full body mechanical lift to transfer Resident #1. The motor of the lift had been removed since July 2023 causing the legs of the base to not lock to ensure a safe transfer. Resident #1 fell from the mechanical lift, sustained cuts, complained of head trauma and generalized pain requiring an emergent transfer to an acute care hospital. The facility's administration failure to ensure effective use of resources to ensure residents safety and prevent neglect created a likelihood of avoidable falls and accidents from mechanical lifts with a likelihood of serious injury, impairment or death of residents and resulted in the determination of Immediate Jeopardy. On 2/15/24 at 6:58 p.m., the facility's Administrator was informed of the Immediate Jeopardy (IJ) and provided the IJ Templates. The Immediate Jeopardy began on 1/22/24. The facility census was 113 with 19 residents who were transferred with full body mechanical lifts. The facility used three different brands of mechanical lifts. On 2/16/24, after the facility submitted an acceptable Immediate Jeopardy removal plan, the Immediate Jeopardy was removed as of 2/16/24. The scope and severity were reduced to no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The findings included: Cross Reference to F600, F689, and F908. The Nursing Home Administrator job description signed on 7/8/22 noted, Nursing Home Administrator . is responsible and accountable for . all aspects of the Facility including but not limited to establishing and implementing policies and procedures, quality of care, quality of life, regulatory compliance . Provides supervision either directly or indirectly to all facility employees including the selection, hiring, orientation, training, and coaching of employees. Identifies facility needs or issues and obtains consulting assistance, as needed in the root-cause analysis, recommendation for improvement, education assistance or monitoring . The Director of Nursing job description signed on 8/14/23 noted, The Director of Nursing as a member of The Board of Managers of Operator is responsible for developing, organizing, evaluating, and administering patient care programs and services of the Center. The DON (Director of Nursing) has twenty-four (24) hour responsibility for the overall delivery of nursing services and ensures the implementation of all clinical policies and procedures . Makes daily patient rounds with the appropriate manager/supervisor(s) to note resident/patient conditions and to ensure nursing personnel are performing their work assignments in accordance with acceptable nursing standards. Accountable for adherence by staff to policies, procedures and standards; delivery and proper documentation of patient care. 1. On 2/12/24, review of facility incident and accident log revealed on 1/22/24 Resident #1 was being transferred with a total body mechanical lift which tipped over resulting in the resident falling to the floor. Resident #1 was transferred via Emergency Medical Services to an acute care hospital. Review of the Emergency Medical Services Patient Care record dated 1/22/24 noted, Medic two arrived on scene to a skilled nursing facility where (Resident #1) was found lying on the floor. Staff explained that they were using a [brand name] mechanical lift to move the patient which he then fell out of and hit the floor. Patient was found lying on his right side in his room. Patient was complaining of pain all over that he could not pinpoint. A cervical collar was used to immobilize the patient's neck . Review of the emergency room Physician's progress note dated 1/23/24 at 1:35 a.m., noted, Today, while at rehab (rehabilitation), patient sustained a fall from a (brand name) lift onto the ground. Patient endorses head trauma but denies loss of consciousness . Review of the clinical record for Resident #1 revealed an admitted [DATE]. Diagnoses included morbid obesity; muscle wasting and atrophy; need for assistance with personal care; and difficulty in walking. The care plan initiated on 1/20/24 noted Resident #1 had an activities of daily living (ADL) self-care performance deficit. The interventions included the use of a, total mechanical lift to chair. Review of the progress notes revealed on 1/22/24 at 8:40 p.m., Registered Nurse (RN) Staff K documented, Rental bed arrives at the facility. Upon arrival, 3 CNA (Certified Nursing Assistant) and nurse assist resident with transferring from old bed to new bed. Upon transfer, resident began moving, twisting, flailing his arms and grabbing bed causing the lift to tip to the side and resident to attain [sic] skin tear. Staff attempt to calm and reassure resident with no resolve. Staff brace resident and lower resident to the ground. Assessment finds resident alert, denies pain, denies being hurt or hitting his head. No other injuries or skin alterations noted. MD (Physician) notified with orders to send to ER (emergency room ) for evaluation . On 1/22/24 CNA Staff B signed a witness statement written by Unit Manager Registered Nurse (RN) Staff J which noted, . The resident started shaking the straps attached to the lift. We tried to calm him down. He said he was afraid and continued to shake the straps. We got him close to the bed. He twist [sic] in the lift, that is when he went to the floor. As he was going down to the floor he grabbed the side rail he scraped his arm on the wall causing a skin tear. The nurse (RN Staff K) was present in the room at that time. On 2/12/24 at 4:35 p.m., in an interview CNA Staff B confirmed on 1/22/24 she was operating the full body mechanical lift to transfer Resident #1 to a new bed. CNA Staff A, CNA Staff C, and Registered Nurse (RN) Staff K assisted with the transfer. CNA Staff B said Resident #1 kept shaking and saying, I'm going to fall. She said, When we were moving to the bed he turned and twisted, the machine tipped over but did not fall over. The machine did not fall on him. The other CNAs grabbed him and held him while I lowered him to the floor. The bottom of the lift is always open. We open it with our feet but sometimes it closes again. I know I opened it, but it might have closed on its own, I don't know for sure. CNA Staff B did not say she verified the lift was in safe operating condition before the transfer. On 2/13/24 at 8:30 a.m., in an interview the Maintenance Director said he started employment at the facility on 7/5/23. He said on 1/22/24 when Resident #1 fell from the lift, he came in to check the lift. He said the lift was not broken but it was removed from service due to the incident and possible investigation. The Maintenance Director said he did not have the owner's operator and maintenance manual for the three brands of lifts used at the facility. The Maintenance Director said he followed the checklist on their maintenance computer system but the checklist was not specific to each brand or model of mechanical lift. Review of the electronic checklist for mechanical lifts noted to, Conduct mobile lift safety inspection 2. Inspect the shifter handle; ensure that shifter operates smoothly; verify that base is locked when handle is engaged. On 2/15/24 at 8:50 a.m., in a follow up telephone interview CNA Staff B said on 1/22/24 she opened the base wide with the foot control when transferring Resident #1 with the full body mechanical lift. She confirmed the legs of the base closed on their own when the machine tilted over and she reported it to the Administrator. On 2/15/24 at 10:30 a.m., in an interview the Administrator said the CNA did not tell her the legs of the base closed on their own when the fall occurred. She said, The statement that I took was that the legs were open. We removed the lift, and an outside company is coming next week to check the lift. The Administrator said she did not have documentation of the reenactment or the Maintenance Director assessing the lift after the incident. The Administrator verified the facility's investigation did not consider the failure of the legs of the base to lock into place as a contributing factor of Resident #1's fall on 1/22/24. On 2/15/24 at 10:45 a.m., mechanical lift (Brand A) used on 1/22/24 to transfer Resident #1 was observed with the Maintenance Director. The motor of the lift was missing. The Maintenance Director said the motor has been missing since he started employment at the facility on 7/5/24. He demonstrated how staff opened the legs of the base by kicking the frame of the legs. The legs of the base did not lock into place. The Maintenance Director said it was possible for the legs to move easily during transfer if the base was bumped. He said the motor was connected to the legs and would lock them in place. He said since the motor has been removed, there was no locking feature. He said he has been checking the lift monthly since 7/2023 and did not realize it should have had a brake handle or a motor to ensure the legs of the base stayed open while in use. On 2/15/24 at 11:00 a.m., the mechanical lift used to transfer Resident #1 on 1/22/24 was observed with the Administrator, the Maintenance Director, and the DON. The Maintenance Director opened the legs of the base by kicking them with his foot. The DON demonstrated and verified the legs of the base closed easily and did not lock into position. When asked if this was the condition of the lift on 1/22/24 when Resident #1 fell from the lift, the Administrator said, Yes it is. When asked if staff kicked open the legs of the base during the reenactment she conducted on 1/22/24, the Administrator said, I don't remember. I can only go by the witness statements I obtained where she said the base was open. When asked if the lift was safe to use she said, No it's not. On 2/15/24 at 11:15 a.m., the DON verified the mechanical lift used to transfer Resident #1 on 1/22/24 did not have a motor and the legs of the base did not lock into place. He said it was unacceptable and unsafe for resident use. He said he was not aware the lift was broken and didn't know how unsafe it was. He said, The staff should never have been using it. On 2/15/24 at 12:35 p.m., in an interview the Administrator said she was the Risk Manager for the facility and participated in the interviewing and hiring process of the Maintenance Director. On 2/15/24 at 12:40 p.m., the Regional Physical Plant Consultant said he took over the facility in December 2023 and did not hire the Maintenance Director. He said the Administrator was the Maintenance Director's supervisor. He said the process for checking the lifts is that the equipment should be working to manufacturer's recommendations. If not, it needs to be removed from service. The Regional Physical Plant Consultant said the electronic maintenance checklist said to check the bar on the mechanical lift. He would have expected the Maintenance Director to notice the missing part and identify the lift should not have been in use. He said, I was unaware, I would have pulled it myself if I was aware. He said he was surprised the Maintenance Director did not have more experience with medical equipment. On 2/15/24 at 12:50 p.m., in an interview the Maintenance Director said he previously worked at an Assisted Living Facility and they do not use mechanical lifts. He said when he started employment at the facility, There was no orientation. The person who hired him filled out a list by asking him if he knew about different systems like fire alarms and HVAC (Heating, Ventilation, Air Conditioning). I don't think it comprised any medical equipment. He said he was told to review the electronic maintenance system and follow the checklists. He said he did not know the lift used to transfer Resident #1 had motor at one time. The first time he inspected the lift, he asked a CNA how it worked. The CNA demonstrated by using her feet to open the legs of the base. The Maintenance Director said, I thought it was okay since the staff showed me and did not tell me it was wrong. I did not have enough knowledge to safely assess the lifts. The Maintenance Director job description noted, The Maintenance Director is responsible for the overall maintenance of the Facility . ensures the facility, equipment and utilities are maintained in good working order . Ensure equipment . are clean, safe, and orderly . Maintain and repair specialized equipment and machinery . Coordinates maintenance services with all other departments and services . The job description was not signed. On 2/15/24 the Administrator provided a letter dated 2/15/24 that noted, Maintenance Director Job Description was not located signed in Employee File. On 2/15/24 at 1:40 p.m., the Risk Consultant said he was not part of the hiring process for the Maintenance Director. He said when he became aware of the incident he instructed the facility to remove and replace the lift immediately. He said overall it seemed reasonable there would have been a concern if he had seen the lift as described. He said, I would have investigated further. On 2/15/24 at 2:00 p.m., the Administrator verified she did not have any documentation that the Maintenance Director was oriented and knowledgeable to perform his job duties. Said she was unaware that the Maintenance Director didn't have experience checking some of the medical equipment. The Administrator said, Ultimately it is my responsibility as the facility administrator. She stated the facility has initiated an investigation into the event of 1/22/24 and submitted a report to the State Survey Agency as required. 2. Review of the manufacturer's guidelines for full body mechanical lift (Brand A) used to transfer Resident #1 noted under operation section, The legs of the lift must be in the maximum open position for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed, return the legs of the lift to the maximum open position. On 2/12/24 at 2:02 p.m., in an interview, when asked about the process to transfer residents with a full body mechanical lift, CNA Staff E said, I start raising the lift, I put chair in good spot after pulling out from under bed, pull out, go over to the chair and then open legs so I can fit under chair. When asked to clarify when to open the legs of the base, CNA Staff E confirmed she only opens the legs of the base when she has stopped moving the lift and is placing the resident in bed or chair. On 2/12/24 at 4:00 p.m., in an interview CNA Staff A said on 2/1/24 she was assisting transferring Resident #1 to a new bed with a full body mechanical lift. She said there were people on all sides. There were three people because, he was so big. When he was very close to the bed, Resident #1 grabbed the straps and twisted himself. The lift started to tip to the left and he tried to grab the bed. CNA Staff A said, Yes, he fell to the floor because he was twisting. We tried to catch and guide him but we can do nothing. She said CNA Staff B held the machine to control him to the ground and the machine tilted over. CNA Staff A simulated the process to transfer residents with a full body mechanical lift. She did not inspect the lift or the sling before simulating the transfer. She did not open the legs of the base when simulating placing and lifting a resident in the lift and wheeling the lift. She only opened the legs of the base when simulating lowering the resident in the chair. CNA Staff A said, We open (the legs of the base) when we stop moving before we put the resident in the bed or chair. It will tip if the bottom (legs of the base) is open when moving. On 2/13/24 at 9:10 a.m., in an interview RN Staff K verified on 2/1/24 she was in the room when Resident #1 was being transferred with the mechanical lift. RN Staff K said, I went with three care givers. Everything was fine until the last part when moving him to the new bed. He got upset; he fell . RN Staff K said she did not receive too much training on mechanical lifts. She said she never participate in the actual lift. She helps placing the sling but the CNAs do all the work. On 2/13/24 at 9:41 a.m., CNA Staff H and CNA Staff I were observed using a full body mechanical lift (Brand A) to transfer Resident #20 from bed to wheelchair with a size large sling with visible green trim. Staff H placed the legs of the base under the resident's bed and lifted the resident in the sling. The CNA did not open the legs of the base. She pulled the legs of the base from under the bed, turned the lift to the right and wheeled the resident in the lift approximately three feet without opening the legs of the base. She opened the legs of the base when she lowered Resident #20 into the wheelchair. On 2/13/24 at approximately 10:00 a.m., CNA Staff H verified she did not open the legs of the base when transferring Resident #20 with the full body mechanical lift. She said, If I try to move her with the legs open it could tip over. We only open them when we are placing the resident in the bed or the chair. Review of employee files of staff using the mechanical lift on 1/22/24 when Resident #1 fell during transfer documented: Certified Nursing Assistant (CNA) Staff A date of hire 9/6/2021and computer-based training for mechanical lifts and transfers completed 9/5/2023. Most recent mechanical lift skills competency documented on 10/23/23. CNA Staff B employee files documented a hire date 4/27/2010 and computer-based training for mechanical lifts and transfers completed 12/11/2023. Most recent skills competency demonstrated on 10/22/23. CNA Staff C employee files documented a hire date 5/4/21 and computer-based training for mechanical lifts and transfers completed on 11/9/2023. Most recent skills competency demonstrated on 10/22/23. Registered Nurse (RN) Staff K documented a hire date of 9/6/22 and required nurse competency for mechanical lift use completed on 9/2/23. On 2/14/24 at 1:50 p.m., in a telephone interview the Assistant Director of Nursing (ADON) said on 1/22/24 after the fall involving Resident #1, We got called in, we had them reenact the situation in both the conference room and in the resident's room with (Brand A) mechanical lift and sling and all four staff members. I saw no concerns in the reenactments. The resident became anxious and fearful and grabbed onto bed. That is when it tipped towards staff. They were in the process of spreading out the base, is what they told me. She confirmed she did not document the reenactments or any additional post fall staff education. On 2/16/24 at 2:45 p.m., the DON said the nurses were responsible to supervise the CNAs and nursing leadership was responsible to ensure care is provided safely. He verified the lift used to transfer Resident #1 on 1/22/24 was broken and should not have been in use. When asked how the facility monitored to ensure the CNAs followed safety precautions when using mechanical lifts, the DON said, We only do the skills check, but we have not done any spot check or observe them. 3. On 2/12/24 observation showed the facility uses three different brands of mechanical lifts. On 2/14/24 the facility provided a list of 19 residents who used full body mechanical lifts Brand A, Brand B, or Brand C with manufacturer's Brand A slings assigned to them. Review of the manufacturer's instructions for slings for full body mechanical lift (Brand A) noted, (Brand A) slings are made specifically for use with (Brand A) lifts. For the safety of the patient, DO NOT intermix slings and lifts of different manufacturers. The instructions noted, Sling size and fit can vary significantly depending on patient weight and girth. These are general guidelines. Consult physician before sling selection. Review of the manufacturer's instructions of (Brand B) mechanical lift for slings noted, Specific slings are made for the Electric Patient Lifts. For the safety of the patient, DO NOT intermix slings and patient lifts of different manufacturers . Warranty will be voided. Review of the manufacturer's instructions of (Brand C) mechanical lift for slings noted, Use ONLY (Brand C) branded slings. DO NOT use a sling unless it is recommended for use with the lift. On 2/12/24 at 11:15 a.m., in an interview Unit Manager RN Staff G said the CNAs choose the sling based on the resident's size. The slings are left in the room. If soiled, they are sent to laundry and returned. On 2/12/24 at 1:30 p.m., CNA Staff D said the CNAs decide what size sling to use for each resident. She said, We just look at the resident. She said the facility uses all different types of slings. On 2/12/24 at 2:02 p.m., in an interview CNA Staff E said the CNAs decide what sling to use for each resident. She said, When I am looking at them [residents], I see them, so I know what size to get. On 2/12/24 at 2:35 p.m., in an interview CNA Staff F said the CNAs choose the sling size for the residents. She said, Large is the best, I always use large. You can't go wrong. On 2/12/24 at 3:25 p.m., in an interview about mechanical lifts, and choosing sling sizes, CNA Staff C said, We know if a person can't move, they we know they are a total mechanical lift. The slings are in the laundry room, I know the sizes. I just look at the resident and hold up to see if the sling will fit. I know the slings and how they will fit. From experience I know how to pick the right size. On 2/12/24 at 4:00 p.m., in an interview about sling sizes, CNA Staff A said she knew the sling size since they were in the residents' rooms. She said if there is no sling in the room, she gets one from the laundry. She said, We just know what will fit. On 2/13/24 at 9:10 a.m., in an interview RN Staff K said she did not receive too much training on mechanical lifts. She said she never participates in the actual lift. She helps placing the sling but the CNAs do all the work. On 2/13/24 at 9:41 a.m., CNA Staff H and CNA Staff I were observed using a full body mechanical lift (Brand A) to transfer Resident #20 from bed to wheelchair with a size large sling with visible green trim. On 2/13/24 at approximately 10:00 a.m., CNA Staff H verified she used a (Manufacturer A) large sling to transfer Resident #20 and said the CNAs choose the sling based on the resident's weight. Review of the clinical record for Resident #20 revealed the resident's current weight was 163.8 lbs. Review of Manufacturer A's Full Body & Stand-Up Lift Sling Sizing Chart noted sling size and fit can vary significantly depending on patient weight and girth. Consult physician before sling selection. The sling sizing chart noted a medium sling was for weight range of 90 to 200 lbs. On 2/13/24 at 9:30 a.m., in an interview the Director of Nursing (DON) said the CNAs choose the size of the sling based on weight. He said, I noticed they go by color coding on the slings themselves. On 2/15/24 at 9:45 a.m., the Regional Nurse Consultant said, All of the slings can hold up to 450 lbs. They are not going to break. The different sizes are more about comfort than safety. On 2/15/24 the Administrator provided a letter from (Brand B) lift Manufacturer dated 2/15/24 that read, Please be advised that (Brand B) Patient lifts are versatile and compatible with slings from other manufacturers, as well as being suitable for use with our own slings. The Administrator also provided a letter from (Brand C) lift manufacturer which documented, Most manufacturers recommend the use of their own slings with their lifts. While this may reduce risk of non-compatibility it also reduces health care professionals' flexibility in meeting the needs of their clients. (Brand C) floor and sit to stand patient lifts are compatible with most other manufacturer's slings with loop style attachments . On 2/16/24 at approximately 4:00 p.m., in an interview the Administrator said she contacted (Brand A) manufacturer. They would not give her a letter stating manufacturer (Brand A) slings were compatible with other brands of lift. The immediate actions implemented by the facility to remove the Immediate Jeopardy, and verified by the surveyor on 2/26/24 included: Lift identified from the 1/22/24 event was removed from service 1/22/24. On 2/15/24 the surveyor verified through observation. The lift used to transfer Resident #1 on 1/22/24 was removed from service. Resident involved in identified transfer 1/22/24 no longer resides in facility. On 2/12/24 the surveyor verified through record review. Resident #1 was transferred to an acute care hospital on 1/22/24 and has not returned to the facility. The facility utilized the lift companies resource guideline to establish the standard for sling sizing and lift usage. On 2/16/24 the surveyor verified through review of training provided using the manufacturer's resource guideline for standard for sling sizing and lift usage. The Administrator and Director of Nursing reviewed the events for the last 30 days to identify any other issues with lift transfers. No events related to lift transfers. On 2/16/24 the surveyor verified through record review and interview with the Administrator. The Physical Plant Consultant reviewed each lift to ensure they were in a safe operating condition on 2/14/24. On 2/16/24 the surveyor verified through review of the lift inspections to ensure each lift was in safe operating condition. Risk Management Consultant completed directed in-service with the Nursing Home Administrator and Director of Nursing related to the Abuse prevention Program 2/16/24. On 2/16/24 the surveyor verified through review of the in-service and interview with the Administrator and Director of Nursing. The Administrator and Director of Nursing were educated by the Physical Plant Consultant related to the requirement to educate staff regarding the reporting of faulty equipment, removal from service, and activating the lock-out Tag-out process through maintenance. 2/16/24. On 2/16/24 the surveyor verified through review of the education and interview with the Administrator and Director of Nursing. The Nurse Consultant educated the Facility Administrator and the Director of Nursing related to ensuring staff were educated related to use of the correct brand and sling size as specified by the individual manufacturer to ensure the safety of residents during transfer with the lifts. 2/14/24. On 2/16/24 the surveyor verified through review of the education and interview with the Administrator.