**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical review, staff interviews, facility policy and procedures and owner's manual for Hoyer lifts, the facility failed to ensure care and services related to pressure ulcer was provided for one resident (#39 and #24). The deficient practice could result in worsening and development of new pressure ulcers Findings include: -Resident #39 was admitted on [DATE] with diagnoses that included paraplegia, stage 4 pressure ulcer of left buttock, stage 4 pressure ulcer other site, gangrene not elsewhere classified and neuromuscular dysfunction of the bladder. The care plan dated March 29, 2023 revealed resident had self care deficit due to paraplegia, chronic pain syndrome, and anemia. Intervention included extensive assistance with 1 to 2 persons with transfers, bed mobility, dressing, and toileting. The skin integrity care plan dated March 29, 2023 revealed the resident was at risk for break in skin integrity to buttock and left foot heel. Interventions included following current treatment as ordered, pressure reducing mattress, and weekly skin checks. The Braden scale dated March 29, 2023 included a score of 17 indicating the resident was a mild risk for pressure ulcer. A wound care note dated March 29, 2023 included stage III pressure ulcer to the sacrum measuring 1 cm (centimeter) x 1 cm x 0.1 cm. The provider note dated March 31, 2023 included the resident had a chronic history of pressure ulcer to sacral and right buttock. The minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief mental status (BIMS) score of 13 indicating the resident was cognitively intact. The assessment also included that the resident was always incontinent of bowel and bladder and required a two-person extensive assistance with bed mobility, transfers, and toileting. Review of the clinical record revealed that on April 6, 2023, the resident had a stage III pressure ulcer to the sacrum which resolved on April 14, 2023. A wound note dated May 16, 2023 revealed the resident had an unstageable wound to the sacrum with 75% slough and serosanguineous drainage. Per the documentation, wound care and measurements were performed by the wound care nurse; and that, the true depth of the wound was unable to determined due to slough tissue to wound bed. The documentation also included that the wound care nurse practitioner was notified on May 16, 2023 of new areas to sacrum and bilateral buttocks; and that, new orders for SSD (silver sulfadiazine) daily and as needed (PRN). The documentation included that treatment to the sacrum and bilateral buttocks included to cleanse with NS (normal saline), pat dry and apply SSD impregnated gauze to wound bed secure with dry dressing daily and PRN. The wound care assessment dated [DATE] revealed the following pressure ulcer as facility acquired: -Sacral pressure ulcer (stage not included) that measured 1 cm (centimeter) x 2 cm x 0.1 cm; -Stage II pressure ulcer to right buttock that measured 2 cm x 1 cm x 0.1 cm, and unable to determine depth due to slough; -Stage II pressure ulcer to the left buttock with measurement of 2 cm x 2 cm x 0.1 cm. Per the documentation, the resident was educated on frequent repositioning, two hours or less in the wheelchair. The wound assessment dated [DATE] included: -Unstageable pressure ulcer to the sacrum, with 75% slough, serous drainage, measuring 1 cm x 2 cm x 0.1 cm, depth unable to be determined becaus of slough tissue with granutaiol tissue present; -Stage II pressure ulcer to the right buttocks, with epithelial tissue, serous drainage and measured 2 cm x 3 cm x 0.1 cm. -Stage II pressure ulcer to the left buttocks with epithelial tissue present, serous drainage and measures 3 cm x 2 cm x 0.1 cm. The wound assessment dated [DATE] included worsening unstageable pressure ulcer to the sacrum with measurement of 3 cm x 3 cm x 0.1 cm; and, worsening unstageable pressure ulcer to the right buttocks with 75% necrotic tissue. A screening dated July 13, 2023 was completed by the Director of Rehabilitation to determine the bed and wheelchair repositioning. The screening revealed that with use of the bed rails the resident was able to independently roll to both right an left sides; but when bed rails are let go, the resident was unable to sustain a side laying position. Per the documentation, the resident would require bed wedges or pillows to support her to maintain side laying position without holding onto the side rails. The resident was educated to use the tilt lift function every two hours for repositioning purposes. The resident was able to independently use both elbows to shift weight of both hips from front of chair to back. However, the documentation included that the resident performed these task as more of a shimmy motion as her buttocks does not rise off of the wheelchair seat. During an interview with a certified nursing assistant (CNA/staff #8) conducted on July 12, 2023 at 3:50 p.m., the resident was sleeping in a supine position. The CNA stated that the resident can reposition herself. An interview with resident #39 was conducted on July 13, 2023 at approximately 8:10 a.m. Resident #39 stated that staff say she can reposition herself in bed, turn to the side, hold herself by grasping onto the side bar while staff is changing her chuck. However, the resident stated that she cannot hold the position and she needed help with repositioning. She stated the wound nurse told her that she can be in her wheelchair only for 2 hours per day; however, there was not a CNA available to help her transition out of her wheelchair within two hours. Resident #39 stated that she needed two staff to transfer her from the wheelchair with the Hoyer lift; and that, she was put in a wrong position in the wheelchair when only one CNA transfers her. She stated that a certified nursing assistant (CNA/staff #57) tells her that she was picky. She stated that her sling went missing and staff were using the shower sling when transfering her into the wheelchair and staff were leaving the shower chair under her. The resident stated she was not supposed to use the shower sling for transfer because she has pressure ulcers on her bottom. Resident #39 stated that the shower sling had a hole in the middle and she was sitting on the edge of the hole where the material was thicker and this created additional pressure on her bottom. She stated that she was a paraplegic and cannot feel if she was sitting on the thicker yellow trim around the hole area. During the interview, an observation was conducted and revealed there was a sling made of blue netting with a thicker yellow trim around the hole in the middle of the sling placed on the resident's wheelchair. At 8:21 a.m. a CNA (staff #57) entered the room and the resident told the CNA that she wanted to get up. Staff #57 and staff #8 assisted the resident with transfers into the wheelchair. At 8:37 a.m., the resident's door opened and the resident told staff that she was probably going to be back for lunch. At approximately 8:39 a.m., the resident exited her room; and, the resident was sitting on the shower sling which was on her wheelchair. An observation with the CNA (staff #57) was conducted on July 13, 2023 at 8:44 a.m. Resident #39 was sitting in her wheelchair and staff #57 stated that the resident was sitting on the shower sling; and that, the sling was made of netting to dry fast and it has a hole in it. When asked if it was the correct sling to use with a wheelchair, staff #57 stated that it was the only sling available; and that, she did not know if the shower sling was supposed to be used with the wheelchair.The CNA stated that she knew resident #39 had pressure ulcers. After the resident left the room, the CNA looked at another shower sling and stated that the thicker yellow trim around the hole could create additional pressure and create a risk of additional skin damage to skin, pressure ulcers.She stated there were no other slings available for resident #39; and that, there were no slings in the building that could be used. She stated that the resident can reposition herself in the wheelchair and in bed. The CNA said that she does not check on the resident when the resident was outside, by the gazebo, by the fountain, or nearby and all the residents are allowed in these areas. She stated that she was supposed to check on the resident every two hours for continence care; and that, the resident had never stayed outside for more than two hours. In an interview with the Director of Rehabilitation (DOH/staff #51) conducted on July 13, 2023 at 10:34 a.m., the DOH stated resident #39 was evaluated by therapy on March 30, 2023 and was discharge from therapy on April 26, 2023. A review of the clinical record was conducted with the DOH who stated that resident #39 would need assistance to help fully reposition; and that, per the treatment notes dated April 21, 2023 the resident cannot reposition independently in wheelchair. The DOH said that she stated that therapy would not make a recommendation regarding the type of sling to be used; however, in theory and at other facilities, they have two different types of slings: a shower sling and a mobility sling. On July 13, 2023 at 11:08 a.m. an interview was conducted with (CNA/staff #8) who stated that the mobility slings do not have holes in it and the are shower slings. She went to a resident's room to get a green sling without the hole and stated that the green mobility slings are located throughout the facility; however, she does not know how many there were or where they were all located. The CNA stated that she tries to remove the mobility sling once the resident was in the wheelchair because she needed to wash it before another resident can use it. Regarding resident #39, the CNA stated that the resident had sores on her bottom; but, the resident does not want the shower sling removed from the wheelchair. She said that she tries to pull the shower sling up, so the hole on the sling was by the resident's back to try to prevent marks in the skin. An interview with a registered nurse (RN/staff #42) was conducted on July 13, 2023 at 11:27 a.m The RN stated stated the facility has two slings: the shower sling and the mobility sling. She stated the shower sling has a hole in it; and that, she had concerns if the staff were leaving the shower sling under the resident's bottom in the wheelchair because the stitching around the hole area would bother the resident. She stated that there was a risk of friction when using the shower sling with the wheelchair and she was not aware of CNAs leaving the shower sling in any of the resident's wheelchairs. She also stated that therapy would assess for type and size of sling and the resident's preference. During an interview with the Assistant Director of Nursing (ADON/staff #12) conducted on July 13, 2023 at 1:43 p.m., the ADON stated that as far as she knows, resident #39 would not be able to use the grab bar to turn herself and maintain the turn without assistance. The ADON stated that based on the clinical record, resident #39 was able to assist with repositioning and can grab the bar and assist which means that she needs assistance. The ADON said that there were two different types of slings: shower slings and the mobility slings which has no holes in it. She stated that when transfering the resident to a wheelchair, staff should be using the mobility sling and not the shower sling. The ADON also said that the mobility sling is left under the resident in the wheelchair, so staff can get the resident out of the wheelchair. She stated that if the shower sling was left under the resident, it creates the risk of skin breakdown because of the netting and the thickness of the stitching around the hole in the shower sling. The ADON further stated that if the resident was sitting in her wheelchair on the shower sling, this could be a contributing factor to pressure ulcers not healing for resident #39. On July 14, 2023 at 2:36 p.m., an interview was conducted with the Director of Nursing (DON/staff #73) who stated the CNAs check on residents approximately every two hours to reposition and provide continence care as needed. The DON said that it was her expectation that the CNAs offer to transfer the resident at least twice a day and if the resident refuses, it should be documented in the progress notes or under tasks. She stated that there was a risk of wounds developing when a resident was not repositioned. The facility's owner's manual and instructions for Hoyer lifts revealed that to use a sling that is recommended by the individual's doctor, nurse, or medical attendant for the comfort and safety of the individual being lifted. The facility's policy on Limited Lift Program (Safe Patient Handling) revised August 11, 2022 included the facility will establish protocols that will provide the safest possible methods to lift, transfer or reposition patients. The facility will assess residents for the need for assistance with transfer activities, mobility or repositioning utilizing a validated mobility assessment by either nursing or therapy. Associates will be responsible for utilizing mechanical lifting devices, transferring devices, proper body mechanics to lift, transfer, and/or pivot non-ambulatory patients as indicated. -Resident #24 was admitted on [DATE] with diagnoses of stage IV pressure ulcer to the right hip, stage III pressure ulcer right ankle and Alzheimer's Disease. The care plan dated June 27, 2022 included the resident had an activities of daily living (ADL)self-care deficit related to Alzheimer's Disease. Interventions included for staff to give total assistance with bed mobility, dressing, transfers with the Hoyer lift, and set up assist with meals. The skin care plan dated June 27, 2022 included the resident was at risk for break in skin integrity. Interventions included pressure reducing mattress and treatment as ordered. Review of the bed mobility task documentation revealed assistance with bed mobility was only provided during one shift on May 3, 7, 8, 12, 13, 15, and 20, 2023. Review of the order summary report revealed an order dated May 20, 2023 for treatment to right buttock, cleanse with NS or wound, cleanser, pat dry then apply manuka honey ointment and leave open to air daily and prn (as needed) for right buttock. The skin/wound note dated June 6, 2023 revealed that the resident was tolerating treatment and the right hip wound was stable. The documentation included right hip surgical wound, with a narrow tunneling, moderate amount of serous exudate, surrounding tissue within normal limits; and that, the resident had moisture associated skin damage (MASD). The documentation did not include pressure ulcer to the right buttocks. The Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status score of 2 indicating a severe cognitive impairment. It also included that the resident required extensive two-person assistance with bed mobility, two-person assist with transfers, total dependence with toileting and bathing. The MDS also included that the resident was at risk of developing pressure ulcers/injuries; and that, the resident did not have unhealed pressure ulcers. The order for treatment to the right buttocks were transcribed onto the treatment administration records (TARs) for June and July 2023. Review of the TARs for June and July 2023 revealed treatment to the right buttocks were documented as not administered on June 7, 14, 25, July 7 and 10, 2023. There was no documentation in the clinical record that the treatment was administered as ordered on dates not marked as administered in the TAR. The clinical record revealed no documentation of reason why treatment was not administered and that, the physician was notified. An interview was conducted on July 14, 2023 at 1:54 p.m. with a certified nurse assistant (CNA/staff #111) who stated that she checks on each resident a minimum of every 2 hours and as needed, repositions residents and documents that it was done on the task sheet in the clinical record. Regarding resident #24, the CNA stated the resident was not able to reposition independently in bed. In an interview with a registered (RN/staff #42) conducted on July 14, 2023 at 2:04 p.m., the RN stated that the CNAs were supposed to document on the task sheet when they reposition the resident; and that, if it was not documented, reposition was not done. The RN also stated that if the TAR was not initialed by the nurse, this means the treatment was not done. On July 14, 2023 at 2:36 p.m., an interview was conducted with (DON/staff #73) who stated that the CNAs need to be reposition the resident every two hours and document that it was done on the task sheet. She stated that if there was no documentation on the task sheet, the resident was not repositioned. A review of the clinical record was conducted during the interview. The DON stated that she did not see anything in the progress notes that the resident was refusing to reposition. She stated that there is risk of developing wounds if the resident is not being repositioned. The DON also stated that if the nurse did not document that the treatment was done on the TAR, she would assume that the treatment did not occur and was not administered. The facility's policy on Skin Integrity & Pressure Ulcer/Injury Prevention and Management reviewed March 31, 2023 states that based on the comprehensive assessment of a resident, the facility must ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, observations, and review of policy and procedure, the facility failed to provide services to one resident (#9) that were necessary to avoid physical harm or pain. The deficient practice resulted in major injury to the resident. Findings Include: Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] after a hospitalization, with diagnoses that included a fracture of the left femur, rheumatoid arthritis, neuropathy, and chronic kidney disease. Active Physicians orders included acetaminophen for pain dated 6/8/23 and gabapentin for neuropathy. She also had an order for bed rails to help with bed mobility and positioning. An occupational therapy evaluation and plan of treatment dated 2/22/22 identified that resident #9 level of function was wheelchair bound and transferred with a mechanical lift. According the Minimum Data Set (MDS) assessment from 05/16/23, Resident #9 was an extensive assist for transfers from two+ persons. Review of her comprehensive care plan initiated on 11/07/2019 revealed that Resident #9 required extensive assist with most of her Activity of Daily Living (ADL) tasks related to her limited mobility and pain from severe rheumatoid arthritis, contracture/deformity of back, neck, bilateral hands, feet, and ankles. She requires the use of a mechanical lift (Sara-sit to stand) for transfers. A review of progress notes from 06/03/23 at 03:15am reveals that Resident #9 was being transferred to bed, and was complaining of pain to her left hip, left knee and left ankle. Nursing staff follow up with the Nurse Practitioner (NP) who ordered x-rays of her hip, knee, and ankle. Resident # 9 also spoke with the activity director who notified the Executive Director by phone. An interact change in condition evaluation dated 6/3/23 identified marked localized bruising and swelling and an increase in pain. A radiology report dated 6/03/23 revealed a femoral fracture. On 6/3/23 at 5:46pm, the on call nurse practitioner reviewed results of the x-ray and ordered Resident #9 be sent to the emergency room. When the resident returned on 6/8/23, she had a soft brace in place and a diagnosis of fracture to distal end of left femur. During an interview on 6/30/23 at 12:25p with Resident #9 regarding the incident on 6/2/23, she stated that she was in her wheelchair, which she had used the Sara lift to get into earlier in the day. She stated Staff #7 picked her up, then pivoted and put her to bed. According to Resident #9, she stated Staff #7 pulled her up to stand and said Hold on to me. Resident #9 stated she is unable to put her arms around her to hold on due to her arthritis and surgery on knees, hips, and hands, and during the pivot was when her leg broke. Resident #9 said she pushes herself in the wheelchair, and typically in the mornings and evening, staff will bring in a Sara lift and one staff will help her go from her wheelchair to bed and vice versa. She said Staff #9 is not allowed in her section or in room since incident. During interviews with 3 other residents on the same hall that also use mechanical lifts, they all stated they had no concerns with their lifts, and felt safe in the facility. During an interview conducted on 6/30/23 at 12:40, CNA Staff #33, stated she is made aware that a resident uses a mechanical lift, [NAME] or Hoyer, by other nurses and CNAs verbally communicating the information at shift change or checking the care plan. If a resident was ordered to use a Sara lift, it would have to be used all the time. She has never seen a worker not use an ordered lift when transferring a patient and would never do so herself. It is important to use the lift because the patient cannot stand by themselves and otherwise it might cause them damage/injury. If during a transfer a resident says they cannot stand, she stated she would get another coworker, and see if a Hoyer lift is more appropriate or reassess. She stated she did receive training on abuse and neglect, but cannot recall a recent training on using lifts. In an interview on 6/30/23 at 1:45p with another CNA, Staff #44, she also stated a resident who is ordered to be a Hoyer or Sara lift cannot be manually transferred. If a lift is not available due to no battery or being broken, they would not be able to transfer the patient. When asked if the battery ever dies, she said she could go get a charged battery from the storage room and there is a charger for the lifts. During an interview with LPN Staff #55, at 1:49p, she stated a resident who is ordered for mechanical lift cannot ever be manually transferred unless therapy has evaluated, and upgraded the order. If a lift is not available, they will need to locate another lift and update the patient. The next step would be to call the fire department. It is very seldom that there is not one available. They could go to the other station and/or bring it to them. Maintenance department is responsible for maintaining the lifts and they will reach out to manufacturer if there is services that need to be done. She stated she has not seen anyone ignoring the mechanical lifts, and if she ever did she would intervene. An interview was conducted over the phone with Staff #7 on 6/30/23 at 1pm. Staff #7 stated that on June 2nd between midnight to 2am, Resident #9 was in her wheelchair and her light was on the whole time. After she finished rounding early, she went to help out the other CNAs and offered to help Resident #9 go to bed. Staff #7 went to find the Sara lift, but stated the batteries were all dead. While Resident #9 was not her patient, she had helped before and had transferred manually before. She explained the situation to Resident #9 and asked if she would be okay being transferred manually. She explained her technique and that she made sure both of Resident #9s legs were between hers. She stated she talked to Resident #9 the whole time so that she did not become afraid or uncomfortable. She could recall they discussed Resident #9's husband and she did not make any sounds of distress or pain. She said the next day a nurse had called and said Resident #9 was complaining of pain all over her body, and asked how she had transferred her the night before. Stated she had to come in and demonstrate how she did the transfer for management. She was reiterated she was dismayed because at the time, Resident #9 thanked her afterwards. She had told her about the batteries being dead and Resident #9 said she had been waiting so long, and just wanted to manually transfer then to go to bed. She recalled she was suspended for a week, and when she returned she was placed on a different hall. A review of the staff schedule for 6/3/23 shows that Certified Nursing Assistant (CNA) #7 was scheduled to work on 6/2/23 and 6/3/23, but her punch details show she did not clock in on 6/3/23. 11:50a A review of abuse training and inservices showed Staff #7 took abuse prevention, mental health, and psychosocial needs and person-centered care in long term care on 6/14/23. She also took lift technique/ Lippincott procedures on 6/22/23. During an interview on 6/30/23 at 1:15p with the Director of Nursing (DON) Staff #5, she stated when determining if a self report for abuse is necessary, that would only be done if it was very obvious based on the information originally received that the incident can immediately be identified as not suspicious. Regarding the incident with Resident #9 on 6/2/23, she stated Resident #9 was being transferred and when put to bed, a CNA not her own put her to bed. She told her CNA that she was hurting. They followed up with the patient in the morning who stated she still had pain and ended up being sent to the ER. She had a fracture. The CNA was suspended. Resident #9 stayed at the hospital. An internal investigation was completed to determine what happened. It was determined not to be neglect/abuse, but if there was something deliberate done they would have reported it. The patient was at high risk for such injuries due to her osteoarthritis, rheumatoid arthritis, and therefore the injury was not suspicious. When interviewed other residents around them were able to say they were fine and had no problems and the staff was not a concern. When a staff member is implicated in any incidents, policy is to suspend the staff and send them home immediately. When asked whether a resident who requires a mechanical lift can ever be manually lift, DON stated it depends on if they can safely pivot, or do a 2 person lift. Hoyer lifts don't get up at all, if it isn't available. Eligible individuals would be those who can sit on edge of bed or move themselves in bed. They have a inservice/ training coming up in July for this exact thing. This is policy in order to keep residents safe. The following observations were made on 6/30/23 at the facility: At 1:48p viewed storage room [ROOM NUMBER] on station 2 which housed the lifts. The hoyer lift had a note on it that noted it was out of order and could not steer straight. The CNA, Staff #44 said it was not in use, and said she was very particular about lift protocol and for example would never use a hoyer without 2 people. At 2:50 pm- 3:00 pm on 6/30/23 a walk through was conducted with Restorative Nursing Assistant (RNA) Staff #66, of Station 4 and the on unit gym to look at 5 lifts (3 hoyers and 2 [NAME]). Of the 3 hoyers lifts, 1 had a dead battery. 1 Sara lift had a dead battery, and the other Sara lift had no battery in it. Review of Facility Abuse policy- Protection of Residents: Reducing the Threat of Abuse & Neglect last revised 8/10/32- stated that it was the facility's policy that to minimize the threat of abuse and/or neglect, nursing homes must incorporate clear cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. Residents must not be subjected to abuse by anyone including staff. For resident protect from abuse there is employee screening, training, and policies for prevention, identification, investigation, protection, reporting and response. There will be training on what is considered abuse and neglect so that staff can identify it. If the events that cause the allegation involve abuse or result in serious bodily injury, the report must be made in two hours.