**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and resident interview, the facility failed to ensure a resident was treated with dignity and respect when trying to assist with his own care for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 25 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including acute respiratory failure with hypoxia (low oxygen in the tissues) and chronic lung disease. The April 2025 Treatment Administration Record (TAR) documented the resident had the order to apply leg compression devices 2 times a day for 20 minutes. They were kept in the therapy room but the resident knew how to apply them. Apply 2 times a day to help decrease edema in lower extremities related to epidermal thickening and type 2 diabetes without complications. Leg pumps for 20 minutes, then remove with a start date 3/27/25. The Progress Notes dated 4/3/25 at 2:45 p.m. documented Resident #1 wanted to file a grievance on Staff E Registered Nurse (RN) and the way she acted putting his boots on the previous night. A concurrent observation and interview on 5/6/25 at 8:50 a.m. revealed the resident ambulated from his room across the hall independently with a walker. Resident #1 stated he had an appointment to one clinic with the physician and he told the Provisional Administrator to order him a pair of these compression deals that went on his legs and feet. They were Velcro, rolled on, and then you plugged them in and pushed the button. It ran for 20 minutes and it compressed and then released, compressed and released. When they first got there and doctor prescribed, a nurse had to put them on him. They were kept in the therapy room because they started him in there with them, and Staff D Certified Nursing Assistant (CNA) Restorative Aide (RA) was doing it. Her dad passed away so there was almost a week she wasn't there to put them on him so the other nurses brought them into his room for him to do it in there, but a nurse had to watch him put them on or help him put them on. Most of the time he was doing it, and the nurses did their watch cause they didn't know what he was doing. When you pushed the button it would run for 20 minutes and it shut itself off. Staff E Registered Nurse (RN) came in one night like 11:45, just before midnight to put them on him. She gave his night medications, and while he took them she started putting the one on. The resident said there's a Velcro deal goes across the foot, a smaller one here and a bigger one up here (pointed to the lower and upper leg). Staff E put the one on and there was a gap the resident could stick 2 or three fingers down. He thought that would not do any good if it wasn't tight, so he reached out and loosened it and then she scowled at him like he stole something. Then he tried to help with the 2nd boot and she didn't allow it. Resident #1 said the boots were his in the first place. He hadn't seen her since. He said he tried to help her and Staff E said he was not supposed to do this, she was. Staff E said let me do my job. He thought fine he would sit back let her do it. Like he said he could stick the fingers down and with compression on there it's got to be snug to your leg before you turn them on. And that's what he did. He tightened that up just a little bit and she didn't like that. On 5/6/25 at 3:28 p.m. Staff E stated she stopped several times while trying to put the resident's boots on because he kept putting his hands down in there. She stopped and waited a minute or two, and then she'd say could you please move your hands back. That's all she did. Staff E said Resident #1 knew they were supposed to be putting his boots on. She'd never had him do that with her before. Staff E just waited for him to get his hands out of the way and had to keep asking him to to let her do it. On 5/7/25 at 2:30 p.m. the Provisional Administrator stated Resident #1 did know how to apply his compression boots and should have been allowed to participate in their application. The facility, Resident's [NAME] of Rights reviewed 9/9/24 identified the purpose included the resident had the right to a dignified existence, self determination, and communication with access to persons and services inside and outside the facility. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The resident has the right to be informed of, and participate in his or her treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain an accurate record of medication administration for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 25 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including acute respiratory failure with hypoxia (low oxygen in the tissues) and chronic lung disease. The April 2025 Medication Administration Record (MAR) showed the resident had an order for Albuterol inhaler 2 puffs orally every 3 hours as needed for wheezing, with a start date of 3/14/25. The MAR lacked documentation of receiving the medication 4/1-13/25. On 5/6/25 at 4:20 p.m. Staff C Certified Nursing Assistant (CNA) stated one night the resident requested his inhaler. She told the nurse, Staff I Licensed Practical Nurse. Staff I could not find his inhaler. On 5/7/25 at 9:34 a.m. the Provisional Administrator stated he was on vacation for three days the 11th 12th and 13th (of April) and when she came back she found out that there had been something going on with the resident's inhaler. On 5/7/25 at 2:59 p.m. Staff I stated she was getting Resident #1's medication ready, and he had asked for his Albuterol inhaler a night or 2 before that, so she would take it with her, but it was not in the med cart. She checked to see if it got left in the resident's room and it wasn't. Since she had given it a day or 2 before she checked in her car, but didn't find it there. She said she had checked the med room once and decided to check again and she found an inhaler with the residents name on the box, hidden. She then spilled her drink, which ruined the label on the box, so she put the inhaler in a baggie with his name and instructions on it. She put on the pharmacy sheet to order a new inhaler. She knew this inhaler did not look like the one he had been using but it was the same dose. She showed it to the resident and explained it was the same medication, same dose. The resident was aware it was different. She said the resident did not need the inhaler that night. A Workflow and Delivery Details sheet showed a new inhaler delivered for the resident April 13, 2025 at 8:04 p.m. On 5/8/25 on 9:01 a.m. Resident #1 stated one night he asked for his Albuterol inhaler and they couldn't find it. They came to his room to see if got left in there. They ended up finding another inhaler that was a different color than the one he had, but it was the same medication, same dose. He used the inhaler. Staff I failed to document the resident received the inhaler the night she had to search for the inhaler, or a night or 2 before. The facility policy, Medication Administration revised 10/22/24, included the individual who administered the medication dose recorded the administration on the resident's MAR directly after the dose was given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide adequate assessment and timely intervention for a change in condition for 1 of 5 residents reviewed. The facility reported a census of 25 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #4 scored 99 on the Brief Interview for Mental Status (BIMS) indicating the resident's inability to complete the interview. Staff Assessment determined the resident had both long and short term memory problems, and severely impaired cognitive skills for daily decision making. The resident had diagnoses including Ahlzheimer's disease. The resident did not hold food in his mouth/cheeks after meals, or cough or choke during meals. The resident was on a mechanically altered diet. The Care Plan initiated 11/18/21 identified the resident at risk for weight change related to altered nutrition intake and changes in hydration status secondary to diagnoses of Alzheimer's, vascular dementia, little communication; need for mechanically altered diet due to difficulty swallowing and pocketing food. Interventions included serving a pureed diet with thin liquids as ordered. The resident needed close supervision for meals. Staff would provide him with cues/prompting and encouragement as needed for eating meals. He may fluctuate on amount of assistance needed. A Speech Therapy Evaluation and Plan of Treatment with a certification period of 9/16/24 to 12/14/24 documented the resident had Ahlzeimer's disease and dysphagia (difficulty swallowing). A Speech Therapy Discharge Summary with dates of service 9/16/24 to 10/11/24 documented interventions provided included swallow treatment instruction in alternating liquis/[NAME] to increase pharyngeal clearance, modification to bolus sizes and order/method of food/liquid presentation and facilitation of rate control during oral intake. Instructed nursing caregivers in safe swallow techniques in order to enable patient to safely consume the highest level of intake with the least amount of supervision with 100% carryover demonstrated by primary caregivers. The intake protocol to facilitate safety and efficiency, it was recommended the patient use the following straegies and/or maneuvers: a. Lingual sweep (sweeping the tongue along the inside of the mouth to remove lingering food or debris), reswallow, b. Alternation of liquids/solids, c. Rate modification and bolus size modification, d. Upright posture during meals and upright posture for >30 minutes after meals. The Progress Notes dated 4/21/25 at 5:07 p.m. documented the nurse received a summons to the resident's dining room table, because he had pocketed food in his mouth. The nurse removed whole kernels of corn from the resident's mouth and gave him water to wash it down. The resident had a pureed diet. They questioned if the resident took corn off his spouse's plate at lunch. The resident's spouse educated to put plate on left side of the table when done eating. The Progress Notes dated 4/22/25 at 1:20 p.m. documented the resident had a poor appetite. He was given cranberry juice and sipped some. The Progress Notes dated 4/23/25 at 8:05 a.m. documented the nurse called to the resident's room. The resident had labored breathing. The vitals obtained showed the resident's oxygen 82% on room air, increased heart rate, and fever. Oxygen applied. At 8:10 a.m. family called to update. At 8:12 a.m. the ambulance called At 8:14 a.m. ER called and report given. At 8:20 a.m. O2 88% on 2L increase to 3. At 8:25 a.m. O2 at 91% on 3L. The admission History and Physical dated 4/23/25 documented the resident brought from the facility by ambulance with the complaint of lethargy, fever, and hypoxia. Apparently he had not felt well the past few days. He ate some of his spouses food and they had the impression that he aspirated because of a different consistency. Initially his oximetry was 82% before he started oxygen. He was febrile on arrival, quite lethargic, and not responding well. A Discharge summary dated [DATE] documented the principle discharge diagnosis of aspiration pneumonia of the left lower lobe. Patient started on intravenous (IV) hydration, antibiotics, and required oxygen at 4 liters to maintain his saturation over 90%. His condition was discussed with family and they did not want aggressive treatment due to his age and dementia. They agreed on hospice care and transferring him back to the nursing home. The IV medications were discontined and the resident discharged to the facility on oxygen and comfort medications. Tho Progress Notes on 4/25/25 at 9:35 a.m. documented on readmission the resident had O2 via nasal cannula, and the head of the bed (HOB) elevated. The resident had a moist/loose non-productive cough noted. On 5/6/25 at 11:17 a.m. Staff F Certified Nursing Assistant (CNA) stated he worked for agency. The resident always had a cough and stuffiness until one day it got worse. When the resident came back from the hospital he was already hospice. On 5/6/25 at 12:19 p.m, Staff B CNA said she had not heard anything about the resident pocketing food. She didn't know the exact time frame he was struggling with the whole business of eating. On 5/6/25 at 2:12 p.m. Staff G CNA stated Resident #4 had been going downhill 2-3 weeks before his hospitalization. Staff G remembered one night the resident was sitting in his recliner it was after supper and his one cheek looked huge so she went and told the nurse and said something's in his mouth, and we need to go down and try to get it out. The nurse said they tried, so I went back down there and I wrote on his whiteboard if he could swallow what was in his mouth. He shook his head yes. He opened his mouth and he kind of pushed it up into the front of his mouth and then he just put it right back and he didn't swallow it. Staff G went and told the nurse again and she don't know if he ever swallowed it. He sat up in his recliner. She said it was pureed food, because it was all mushy inside his cheek and he just was holding it. You couldn't go to a meal without him coughing, whether they fed him or he fed himself. When he fed himself it was almost like he rushed it too much and then he would cough. On 5/6/25 at 3:12 p.m. Staff H CNA agency stated her frustration with Resident #4 was that not only herself but several other staff that had worked with him that knew, and had been telling nurses that something was not right with him. She said the resident died from aspiration pneumonia. While their dining room was right there by the nurse's station, it's not like the nurses couldn't see what was going on with him. It got progressively worse to where it would happen with every bite and every drink. Then they finally decided they were gonna do a swallow study. They had made an appointment for that, and then a couple days later he was shipped out to the hospital and even then, it took one of the CNA's to say hey Resident #4's not right, you need to come see him. The nurse was like go get him ready and bring him out and she would examine him out there. The CNA said she needed to go to his room now. Staff H had gone in there the night before he was shipped out because she was on night shift that night and there untill 10:00 a.m. the morning he shipped out. She noticed he sat up pretty high for him, he always slept flat. The nurse on duty that night was on her first or 2nd night. Staff H told the nurse, Resident #4 was not right. His lips were purple. The day nurse said the night nurse told her nothing was wrong with Resident #4. Staff H looked at the day nurse and said absolutely not, she said she told the night nurse things were not right with him, and she didn't even acknowledge it. On 5/8/25 at 2:30 p.m. the Provisional Administrator stated she had been reviewing Resident #4's chart and saw that the nurse did not assess, or notify the physician when the resident was found with regular food pocketed in the cheeks. She said he should have gone on hot charting and assessed routinely for 72 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure appropriate interventions were in place to prevent falls for 1 resident reviewed (Resident #2). The facility reported a census of 25 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 scored 5 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident required partial/moderate assist with sit to stand, chair to bed transfer, toilet transfer, and supervision or touching assist walking 10 feet, 50 feet and 150 feet. The resident had diagnoses including hypertensive chronic kidney disease, atrial fibrillation, and repeated falls. The Care Plan revised 9/27/24 identified the resident at risk for decline in functional status and falls/injury due to a need for assist at times. The interventions included a sign placed on her walker to remind her to use her walker for assistance 10/3/24, and resident to wear a gait belt with all transfers 3/2/25. On 1/19/25 a chair and bed alarm were added (to notify staff if the resident tried to get up unattended). The Care Plan identified the resident at risk for altered skin integrity related to needing assist with some self care & mobility tasks. The diagnoses included chronic kidney disease, diabetes, and depression. The interventions included walker in reach for safety 4/18/25. The Progress Notes dated 3/2/25 at 11:45 a.m. documented the resident had a witnessed fall that ocurred in the resident's room. The resident walked to the bathroom with a walker and her knees gave out. The nurse paged to the resident's room over the walkie. When entering the room, Staff A Registered Nurse (RN) stood next to the resident who knelt on the floor, holding onto her walker. The floor dry and free of debris. The resident did have her shoes on, but did not have a gait belt on. On 5/5/25 at 2:30 p.m. the resident sat in the recliner in her room, her walker by the bathroom, not in the resident's reach. On 5/6/25 at 12:19 p.m. Staff B Certified Nursing Assistant (CNA) stated they did not leave the resident's walker within reach because she would try to get up by herself. On 5/6/25 at 1:28 p.m. the resident laid on her bed. Her walker was not in reach. On 5/6/25 at 4:20 p.m. Staff C CNA stated they were told by management they could not leave the walker within her reach. She said that was not what her care plan directed. On 5/7/25 at 10:15 a.m. the resident sat in the recliner, her walker not in reach. On 5/8/25 at 3:15 p.m. the Provisional Administrator stated residents needing assistance should have a gait belt in use for transfer and ambulation. She put a note on the resident's walker to keep it in her reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record and policy review, the facility failed to investigate new bruising on a resident for 1 of 4 residents reviewed for accidents, (Resident #25). On 10/1/24 staff discovered bruising on Resident #25, the administration indicated that the bruising was explained by an incident with the EZ stand mechanical lift that happened on 9/7/24. The facility reported a census of 26 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #25 was admitted to the facility on [DATE] and had a BIMS score of 4 (severe cognitive deficit). The resident required partial/moderate assistance with sit to stand, chair to bed transfers and toilet transfers. Resident #25 was frequently incontinent of urine and bowel and she had physical and verbal behavior directed toward others 4-6 days a week. Her diagnosis included diabetes mellitus, Alzheimer's disease, anxiety disorder. The Care Plan revised on 9/12/24, showed Resident #25 had impaired function and required the assistance of 2 staff with walking, and toileting. Staff used the EZ Stand (mechanical lift) at times if unable to complete tasks. The resident had impaired cognitive function with a history of yelling, wandering, swearing at staff. She was at risk for skin breakdown, staff were to observe skin for abnormal signs of bruising due to use of antiplatelet medication. An Incident Report dated 10/1/24 at 2:20 PM, showed that Resident #25 was found to have purple bruising on the left side of her rib cage that measured 6.0 centimeters (cm) x 3.0 cm. Another bruise was found on her left hand that measured 7.4 cm x 5.3 cm. The resident was unaware of bruising. On 10/23/24 at 1:59 PM, when asked about an investigation on the source of the bruising, the Administrator said she thought it was related to an incident where Resident #25 had a near miss on the EZ stand and she became unhooked from the lift which may have caused the bruising. On 10/24/24, Staff E, Assistant Director of Nurse (ADON), presented hand written notes dated 9/9/24 that showed on 9/7/24 Resident #25 had a near miss fall using the EZ stand. The resident had been agitated and stomping her feet, and shaking the machine. At some point the loop unhooked, the resident swung to the left, and Staff D caught her to prevent her from falling to the floor. The chart lacked a nursing assessment after the incident. Weekly Skin Integrity Assessments dated 9/10 and 9/17 showed that there were no new skin issues. On 10/24/24 at 10:32 AM, Staff I, CNA stated that she had first noticed the bruising on Resident #25 on 10/1/24 and she reported it to Staff G, RN. She said she did all of baths for resident #25 in Sept and did not see any marks before this date. A review of the Shower/Bath documentation showed that on 9/10, 13, 17, and 24, Staff I completed the showers for Resident #25 and reported no new skin issues. On 10/25/24 at 12:02 PM, the Administrator, Director of Nursing (DON) and Staff E, Registered Nurse (RN) all agreed that the timing for a bruise to appear after an injury, depended on the individual and that it was reasonable to conclude that the bruising that first appeared on 10/1/24 could have been caused by the EZ stand incident on 9/7/24. They stated that they did some staff interviews when the bruising was found but did not have documentation of the interviews and they did not do further investigation of the possible causes. They said that when they came into work on 9/9/24, they did as assessment of the resident and there were no injuries noted. They would have expected that the nurse would have done an assessment that evening. According to Medical News Today; What Do the Colors of Bruising Mean? Retrieved on 10/28/24 from: https://www.medicalnewstoday.com/articles/322742#bruise-colors Within 24 hours of an injury a bruise often turned red. After 1-2 days the bruise that was a few days old would often appear blue, purple, black or slightly darker than surrounding skin. After 5-10 days the bruise may turn yellow or green, and after 10-14 days the bruise may turn yellowing-brown or light brown. The bruise would disappear within 2 weeks. According to a facility policy titled: Accidents, Incidents, Investigation and Reporting. Reviewed 4/22/24, All accidents or incidents involving a resident .shall be investigated. The nursing supervisor .shall promptly initiate and document an investigation of the accident or incident. The Director of Nursing would ensure that the incident report was completed. According to the Abuse Prevention; Incidents, Investigations, Reporting, revised on 9/9/24, examples of injuries that could indicate abuse include; bruises, including those found in unusual locations, head, neck arms torso and trunk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that staff assessed residents after incident for 1 of 4 residents reviewed, (Resident #25). Resident #25 slid from the EZ Stand mechanical lift when the sling hook disengaged. The chart lacked a nursing assessment. The facility reported a census of 26 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #25 was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 4 (severe cognitive deficit). The resident required partial/moderate assistance with sit to stand, chair to bed transfers and toilet transfers. Resident #25 was frequently incontinent of urine and bowel and she had physical and verbal behavior directed toward others 4-6 days a week. Her diagnosis included; diabetes mellitus, Alzheimer's disease, anxiety disorder. The Care Plan revised on 9/12/24, showed Resident #25 had impaired function and required the assistance of 2 staff with walking, and toileting. Staff could use the EZ Stand (mechanical lift) at times if unable to complete tasks. The resident had impaired cognitive function with a history of yelling, wandering, and swearing at staff. She was at risk for skin breakdown, staff were directed to observe her skin for abnormal signs of bruising due to the use of antiplatelet medication. On 10/23/24 at 1:59 PM, the Administrator said Resident #25 had a near miss on the EZ stand when the sling unhooked from the lift during transfer. She did not know if there was an incident report. On 10/24/24, Staff E, Assistant Director of Nurse (ADON), presented hand written notes dated 9/9/24 that showed on 9/7/24 Resident #25 had a near miss fall using the EZ stand. The resident had been agitated and stomping her feet, and shaking the machine. At some point the loop unhooked, the resident swung to the left, Staff D caught her and held onto her until Staff K could get the WC under the resident. Immediate action to double check all hook ups, loops and belt. A statement from Staff K showed that the charge nurse had been told immediately after the incident and the CNA's were told that since it wasn't a fall, they did not need to fill out an incident report. The intervention was to include a Time Out period after a resident was up on the EZ stand and check belt and hooks before proceeding with transfer. A review of the Nursing Notes for Resident #25 revealed that on the overnight shift of 9/7 - 9/8 the only progress notes entered, included references to the resident hollering at staff, and that she made no attempts to exit the building. The chart lacked reference to incident on the EZ Stand transfer. The Standard Assessments tab in the electronic chart lacked any assessments on 9/7/24 or 9/8/24. On 10/24/24 at 10:05 AM, Staff D, CNA said that on the evening of 9/7/24, Resident #25 was having a rough night with lots of hitting, kicking and screaming. Staff D and Staff K decided to use the EZ stand to transfer the resident to the toilet because the resident wasn't standing very well. Resident #25 had been incontinent of bowel, and Staff D was cleaning the resident from behind, while Staff K pulled the EZ stand from the bathroom to the bed room. The resident became increasingly angry and yelled that's enough. The staff tried to explain that they needed to get her cleaned and the resident stomped her feet, and shook back and forth on the machine while holding onto side of machine. As she was rocking the machine, one of the slide loops came undone and the resident slid to the side. Staff D grabbed onto the resident and held her so she would not fall, while Staff K got the wheel chair and slid it under her. The CNA's reported the incident to the nurse on duty and were told that because she didn't hit the floor they didn't need to do an incident report. Staff D did end up filling out an employee incident report because she hurt her back when she held onto the resident. On 10/24/24 at 9:46 AM, Staff L, RN, said that she knew the CNA's were having issues with the Resident #25 on the evening of 9/7/24. She tried to recall if there were any incidences reported to her she thought that when they went to lower the resident into the chair she sat down hard She denied knowing anything about the sling coming unhooked but she remembered that Staff D had hurt her back. Staff L denied any knowledge of the EZ stand sling coming unhooked. She said that she did not do an assessment or fill out an incident report because the resident came out to the dining room later and she was okay. On 10/25/24 at 12:02 PM, the Administrator, and Director of Nursing (DON) said that they would have expected that the nurse to complete a full assessment of the resident after the accident. They would also expect that the nurse would have completed an incident report at that time and were not sure why she hadn't. The facility policy titled: Nurse Assessment; Accident and Change in Condition showed that when an accident or change condition occurred, nursing will place resident on hot chart to identify follow up needs. Nursing staff would monitor and document in the resident's progress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to safely transfer residents with the mechanical lifts for 2 of 4 residents reviewed (Resident #10 and #25). Resident #25 slid from the EZ Stand mechanical lift when the loop on the sling disengaged. Resident #10 sustained bruising when she was hit in the head with the arm of the Hoyer mechanical lift during transfer. The facility reported a census of 26 residents. Findings include: 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #10 had a Brief Interview for Mental Status (BIMS) score of 99 (unable to participate). She was totally dependent on staff for her hygiene needs, dressing, toileting, transferring and for rolling in bed. The Care Plan for Resident #10, dated 9/20/24, showed she had severe cognitive impaired function and impaired communication due to Alzheimer's disease. The resident was non-ambulatory, nonverbal, and required the use of a Hoyer mechanical lift with the assistance of two staff. She had a terminal prognosis, was on hospice services and her diagnosis included; type 2 diabetes mellitus, heart disease, chronic kidney disease and Alzheimer's Disease. On 10/21/24 at 12:30 PM, Resident #10 was in her wheel chair getting assistance with lunch. She had yellow bruising on the right side of her face. An Incident Report dated 10/10/24 at 3:30 PM, showed that after transfer, the top bar of the Hoyer lift had swung over and bumped Resident #10 on the side of her head and caused a hematoma 4 centimeters (cm) x 4.5 cm. with purple bruise in the center. The Hoyer lift leg had gotten stuck under the wheel chair and when staff pulled the machine back, the sling bar hit the resident. On 10/21/24 at 12:36 PM, Staff B, Certified Nurse Aide (CNA) said that she was present when the Hoyer arm hit the resident on the side of her head. She said that the wheel chair was sitting sideways, and straddled the left leg of the Hoyer. They lowered the resident to the chair, unhooked the sling, and when Staff D, CNA went to pull the Hoyer out from under the wheel chair, it got stuck. As Staff D pulled back, the arm with the 6 latches (where the sling was hooked) swung back and hit the resident on the head. On 10/23/24 at 9:06 AM, Staff D said that when the arm hit Resident #10, she was guiding the Hoyer, and Staff B was guiding the chair. She said that she placed the wheel chair sideways because the resident was so tall it worked better to lower her safely in the chair from that direction. She said that when she went to move the Hoyer back, she had asked Staff B to hold onto the arm so it wouldn't swing, but Staff B did not help stabilize it. 2. According to the MDS dated [DATE], Resident #25 was admitted to the facility on [DATE] and had a BIMS score of 4 (severe cognitive deficit). The resident required partial/moderate assistance with sit to stand, chair to bed transfers and toilet transfers. Resident #25 was frequently incontinent of urine and bowel and she had physical and verbal behavior directed toward others 4-6 days a week. Her diagnosis included diabetes mellitus, Alzheimer's disease, anxiety disorder. The Care Plan revised on 9/12/24, showed Resident #25 had impaired function and required the assistance of 2 staff with walking, and toileting. Staff could use the EZ Stand if they were unable to complete tasks. The resident had impaired cognitive function with behaviors, had a history of yelling, wandering, and swearing at staff. She was at risk for skin breakdown, staff were to observe skin for abnormal signs of bruising due to use of antiplatelet. On 10/23/24 at 1:59 PM, the Administrator mentioned that Resident #25 had a near miss on the EZ stand and she became unhooked from the lift. A review of the Incident Reports for Resident #25 from May - October revealed there was no report for an EZ stand accident. Staff E, Assistant Director of Nurse (ADON), presented hand written notes dated 9/9/24 that showed on 9/7/24 Resident #25 had a near miss fall using the EZ stand. The resident had been agitated and stomping her feet, and shaking the machine. At some point the loop unhooked, the resident swung to the left, Staff D caught her and held onto her until Staff K could get the WC under the resident. Immediate action to double check all hook ups, loops and belt. A statement from Staff K showed that the charge nurse had been told immediately after the incident and the CNA's were told that since it wasn't a fall, they did not need to fill out an incident report. The intervention was to include a Time Out period after a resident was up on the EZ stand and check belt and hooks before proceeding with transfer. On 10/24/24 at 10:05 AM, Staff D, CNA said that on the evening of 9/7/24, Resident #25 was having a rough night with lots of hitting, kicking and screaming. Staff D and Staff K decided to use the EZ stand to transfer the resident to the toilet because the resident wasn't standing very well. Resident #25 had been incontinent of bowel, and Staff D was cleaning the resident from behind, while Staff K pulled the EZ stand from the bathroom to the bed room. The resident became increasingly angry and yelled that's enough. The staff tried to explain that they needed to get her cleaned and the resident stomped her feet, and shook back and forth on the machine while holding onto side of machine. As she was rocking the machine, one of the slide loops came undone and the resident slid to the side. Staff D grabbed onto the resident and held her so she would not fall, while Staff K got the wheel chair and slid it under her. The CNA's reported the incident to the nurse on duty and were told that because she didn't hit the floor they didn't need to do an incident report. Staff D did end up filling out an employee incident report because she hurt her back when she held onto the resident. On 10/24/24 at 10:59 AM, Staff K said that they used the EZ stand on 9/7/24 because Resident #25 was very unstable and agitated. She said that they were trying to clean up because she had bowel movement (BM) all down her back. The resident became increasingly upset and started bouncing up and down and having a tantrum. The right side strap came off of the lift and then Staff D supported the resident while Staff K, got the wheel chair under her. Staff K said that they told the nurse right away but she did not know if there was an assessment or documentation. On 10/24/24 at 9:46 AM, Staff L, RN, said that she knew the CNA's were having issues with the Resident #25 on 9/7/24. She tried to recall if there were any incidences reported to her she thought that when they went to lower the resident into the chair she sat down hard She denied knowing anything about the sling coming unhooked but she remembered that Staff D had hurt her back. Staff L denied any knowledge of the EZ stand sling coming unhooked. She said that she did not do an assessment or fill out an incident report because the resident came out to the dining room later and she was okay. On 10/25/24 at 12:02 PM, the Administrator, Director of Nursing, and Staff E, RN said that since the incident, they had established a checklist for the operation of the EZ stand and taught staff to stop and double check that all the straps were secured and the belt was tightened before transferring a resident. They said that they did a skin assessment on 9/9/24 and there were no injuries noted. According to the facility policy titled EZ Stand (Sit to Stand) revised on 10/3/24. Staff were to adjust the belt for tight fit, once the resident was in standing position on the lift, double check that the strap was flush against the attachment knob. According to the undated facility policy titled; Hazardous Area/ Devices and Equipment, data from accident and incident reports would be used as part of the hazard's assessment and analysis, including trends in accident types, areas in the facility, associations with particular staff or shifts and equipment use. Resident specific interventions would include changes to the plan of care and/or increased supervision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record and policy review the facility failed to complete accurate and timely records for 1 of 12 residents reviewed, (Resident #25). Resident #25 slid from the EZ Stand mechanical lift when the loop came off. Staff failed to fill out an incident report and failed to document the incident in the nursing notes. The facility reported a census of 26 residents. Findings include: According to the MDS dated [DATE], Resident #25 was admitted to the facility on [DATE] and had a BIMS score of 4 (severe cognitive deficit). The resident required partial/moderate assistance with sit to stand, chair to bed transfers and toilet transfers. Resident #25 was frequently incontinent of urine and bowel and she had physical and verbal behavior directed toward others 4-6 days a week. Her diagnosis included diabetes mellitus, Alzheimer's disease, anxiety disorder. The Care Plan revised on 9/12/24, showed Resident #25 had impaired function and required the assistance of 2 staff with walking, and toileting. Staff used the EZ Stand (mechanical lift) at times if unable to complete tasks. She had impaired cognitive function behavior, had a history of yelling, wandering, and swearing at staff. She was at risk for skin breakdown, staff were directed to observe skin for abnormal signs of bruising due to use of antiplatelet medication. On 10/23/24 at 1:59 PM, the Administrator said that Resident #25 had a near miss on the EZ stand. She did not know if there was an incident report completed for the accident. A review of the incident reports for Resident #25 from May - October revealed there was no report for EZ stand accident. A hand written note dated 9/9/24 from Staff E, Assistant Director of Nurse (ADON), showed that on 9/7/24 Resident #25 had a near miss fall when the loop on the sling unhooked from the EZ Stand mechanical lift during transfer. The resident swung to the left, and Staff D, Certified Nurse Aide (CNA) caught her and held onto her until Staff K got the wheel chair under the resident. Staff D injured her back when she caught and held the resident. Staff K indicated that they told the charge nurse immediately and the response was that since it wasn't a fall, they did not need to fill out an incident report. The Nursing Notes for the overnight shift of 9/7 - 9/8, included references to the resident hollering at staff and that she made no attempts to exit the building. The chart lacked reference to an incident on the EZ Stand transfer. On 10/24/24 at 9:46 AM, Staff L, Registered Nurse (RN), said that she knew the CNA's were having issues with Resident #25 on 9/7/24, but she denied knowing anything about the sling coming unhooked from the EZ Stand. She said that Staff D hurt her back during an incident. Staff L said that she did not do an assessment or fill out any incident report that evening. The resident came out to the dining room later and she was okay. The Standard Assessments tab in the electronic chart lacked any assessments for 9/7/24. On 10/25/24 at 12:02 PM the Administrator and the Director of Nursing (DON) said that they did an assessment on Resident #25 on 9/9/24 and there were no injuries noted. They would have expected that the nurse would have done an assessment the evening of the incident but were not sure that she knew about the incident. They would also expect that the nurse would have completed an incident report and a nursing progress note. According to a facility policy titled: Accidents, Incidents, Investigation and Reporting, reviewed 4/22/24, All accidents or incidents involving a resident .shall be investigated. The nursing supervisor .shall promptly initiate and document an investigation of the accident or incident. The Director of Nursing would ensure that the incident report was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure staff practiced appropriate infection control practices for 1 of 12 residents reviewed (Resident #8). The facility reported a census of 26 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #8 scored 9 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident was dependent on staff for lower body dressing and undressing. The resident had diagnoses including chronic heart failure, and swelling of the bilateral lower legs. The current Care Plan identified the resident at risk for altered skin integrity related to obesity, incontinent episodes of bowel and bladder, a history of moisture associated skin damage (MASD) and use of diuretics for edema & congestive heart failure (CHF). The resident moved minimally and her norm. She required assistance with self care and mobility tasks. Her motivation was poor which placed her at risk for skin breakdown. She suffered from dependent edema to her legs and needed assist with getting/keeping her legs elevated. The interventions included: a. 10/11/24 Skin Tear to right lower leg. 10/22/24 cellulitis with antibiotic started. b. 10/11/24 treatment to right lower leg daily until healed. Observe effectiveness and report signs of infection. Updated 10/19/24: antibiotic treatment started for cellulitis to right lower extremity. c. Administer antibiotic for cellulitis to right lower leg as ordered. Observe effectiveness of use and for adverse side effects. Report worsening signs of cellulitis or to surrounding 10/22/2024. e. Perform skin assessment as ordered, per skin integrity flow sheet. Report changes to skin integrity if indicated. The Progress Notes dated 10/11/24 at 11:04 p.m. documented staff reported to the nurse that during transfer with the resident, a skin tear occurred on the outer lower right leg. The resident had a 3 by 2 cm crescent shaped skin tear. The edges were well approximated, and the area weeped serosanguinous drainage. A non adherent dressing applied and covered with gauze. The Progress Notes dated 10/12/24 at 10:55 a.m. documented clear weeping noted to the resident's right lower leg. The dressing was saturated along with a bed pad placed under the area. The open area was deep purple in color. No pain noted with the dressing change. The Physician's Order included cleansing the right lower leg with wound cleanser, covering with an oil emulsion dressing, non adherent telfa, and securing with Medipore tape. The dressing changed daily until dry, then leave open to air, one time a day for skin tear/weeping dated 10/12/24. The Progress Notes dated 10/19/24 at 1:37 p.m. documented the resident had a cellulitis wound to her right lower leg, with copious amount of serous drainage noted. The wound measured 1.8 cm x 1.5 cm. An oil emulsion dressing applied, covered with 2 abdominal (ABD) pads, wrapped with kling and secured with Medipore tape. The resident had no complaints of pain with the leg. The Physician's Orders included Keflex 500 mg by mouth three times a day for cellulitis to the resident's right lower leg for 10 days The Progress Notes dated 10/23/24 at 8:29 a.m. documented the resident remained on antibiotic for cellulitis of the right lower leg with no adverse effects noted. Performed daily dressing change per orders. The old dressing removed and both ABD pads saturated with clear drainage, et the bed pad under the leg wet. The right lower leg appeared light red in color, warm to the touch, and painful to touch. The resident verbalized pain at 9/10 when touched or lifted her leg up. The resident grimaced et moaned out during the dressing change. During an observation on 10/22/24 at 10:12 AM Staff A Registered Nurse (RN) went to do the resident's treatment. Staff A placed the treatment supplies on the resident's tray table without a barrier (dressings, tape). Resident #8 had a rectangle dressing on her right anterior lower leg with plastic wrap around the right leg and partially around the dressing. A black wound to the more lateral right lower leg was draining and uncovered. Staff A put gloves on and then removed them to leave the room. She returned and without performing hand hygiene, put on the pair of gloves she removed before putting on a second pair of gloves over them. Staff A removed the dressing and had to tear the plastic wrap away from around the resident's right leg. She removed the top gloves and threw them and the dressing away. A bunched up dressing laid on the floor near the bed. She applied an oil emulsion dressing to the dark area after measuring at 1.8 by 1.3 cm. She covered the dark lateral wound with telpha, ABD's and gauze wrap to keep in place, and taped. The resident's slipper was wet from clear drainage from the resident's wound per Staff A. Staff A removed gloves and washed her hands, then left the room with the tape, and without changing the resident's slippers. The dressing near the bed remained on the floor. On 10/23/24 at 3:16 p.m. the Director of Nursing (DON) stated she didn't know about double gloving. She said when your gloves were soiled you changed gloves and washed your hands. She said wound supplies should be placed on a barrier in a resident's room. Any dressing on the floor should be picked up and disposed of immediately. The slippers should have been changed right away The facility Handwashing and Glove Use policy revised 9/9/20 directed using an alcohol based hand rub after handling used dressings, contaminated equipment, etc . after removing gloves. Applying and removing gloves included performing hand hygiene before applying non-sterile gloves.

Based on observation, interview and policy review the facility failed to ensure that dietary staff performed proper glove use while serving meals. The facility reported a census of 26 residents. Findings include: In an observation of the lunch service on 10/22/24, at 11:06 AM, Staff H, Dietary Aide (DA) had disposable gloves on and he touched many surfaces such as the counter, carts and utensils. He then grabbed a bread bag, reached into the bag and pulled out 6 pieces of bread with same gloves. He then buttered the bread, put it on a plate and covered it with wrap. Staff H then disposed off the gloves. On 10/22/24 at 1:30 PM, the Dietary Manager (DM) said that she taught kitchen staff to use gloves only when they would be handling food directly. She said that glove use was a challenge when staff feel like they can touch any surface with them on and then touch food. According to the undated facility policy titled: Gove Use Policy; if staff used gloves they must still follow hand washing guidelines, change gloves and wash hands between possible contaminations and before starting a new task.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record, and policy review, the facility failed to notify the family and the doctor after a resident fell from the mechanical lift for 1 of 1 resident reviewed (Resident #12). While staff transferred Resident #12 with the mechanical lift, the machine tipped over, resulting in him falling into the recliner. Following the incident, the staff failed to call the family and doctor. Findings include: Resident #12's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #12 required extensive assistance from 2 persons for bed mobility, dressing, and toilet use. In addition, he required total assistance with transfers. The MDS included diagnoses of heart failure, renal insufficiency (poor functioning kidneys), diabetes, morbid (severe) obesity. The Care Plan updated 6/23/23 included the following: a. Resident #12 received hospice level of care. b. Resident #12 needed assistance with care due to his physical decline. The Interventions indicated the following: - He used a bariatric bed with a foot extender - The staff lifted his recliner to accommodate his height. - He preferred to sleep in his recliner rather than the bed. c. Resident #12 used high risk medication for heart failure, atrial fibrillation, chronic kidney disease and diabetes. He chose to stop his medications and go on hospice services. d. Resident #12 had chronic pain related to joint replacements, morbid obesity, arthritis and diabetic polyneuropathy (damage to multiple peripheral nerves by diabetes). e. Resident #12 had an ADL self-care deficit. The Intervention instructed he didn't walk and he required a full-body mechanical lift for transfers. The Nurses Note dated 7/2/23 at 10:10 AM reflected Staff L, Registered Nurse (RN), Staff K, Licensed Practical Nurse (LPN), and Staff M, RN, had Resident #12 in the full-body mechanical lift to transfer him from the bed to his recliner. Staff M positioned herself behind recliner to help guide him into the chair and to assist with getting his hips pulled back. Staff K used the lift to get Resident #12 up in air so he could be moved. As Staff K pulled the lift back with the legs open, Staff L had Resident #12's feet and was turning him to align him with the lift, the legs on lift started to close. As this occurred the lift tipped over falling to the south. Staff M moved the recliner quickly so Resident #12 landed in recliner from the waist up, with his feet on the floor still hooked to the lift. The base of the lift came up to the north side hitting Staff L in both shins. While the upper lift landed on Staff K's left side of her back. Both filled out employee incident reports. They removed Resident #12 from the lift, so they could remove the lift off Staff K and assess their injuries. Staff M called additional staff to the room. The staff reconnected Resident #12 back up to the lift, while 1 staff member stood on each lift leg, they lifted Resident #12 in the air. With the legs to the life open and on each side of the recliner, the staff stepped off the lift and pushed the lift back further to get Resident #12 back in his recliner. The staff repositioned Resident #12 in his recliner in good position, and then the staff unhooked the lift. Resident #12 didn't have complaints of pain or discomfort. Staff M notified the DON immediately of the incident. On 3/21/24 at 10:25 AM, the Administrator said they didn't complete an incident report after Resident #12 fell from the lift because he didn't get hurt. The two staff who got hurt completed incident reports because they took the brunt of the machine. She said they didn't call Resident #12's family because he was his own person and made his own decisions. In addition, they didn't call the doctor since Resident #12 didn't get hurt. The Incident and Investigation Charting policy revised 8/22/17 directed a nurse should contact the physician and document means of contact. The nurse should contact the family and inform them of the events. If the fall occurred between 9 PM and 7 AM, without injury the call can happen at 7 AM the following morning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and employee file review the facility failed to protect residents from unnecessary punishment and abuse for 1 of 3 residents reviewed (Resident #2). On 1/26/24, Staff G, Certified Nurse Aide (CNA), reported that while she and Staff F, CNA, helped Resident #2 to the toilet, Resident #2 kicked, slapped, and spit at them. Staff G said that Staff F slapped Resident #2 on the face, stepped on her foot, and manhandled her into the wheelchair. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE], listed an admission date of 12/7/23. The MDS identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive deficits. Resident #2 required total staff assistance for toilet use, showering and dressing. She required partial assistance with toilet transfers. The MDS described Resident #2 as frequently incontinent of urine and bowel. The MDS included diagnoses of Alzheimer's disease, vascular dementia (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain), malnutrition (inadequate intake of nutrients) and anxiety disorder. The Care Plan included the following Focuses: a. Revised 3/3/24: Resident #2 needed assistance with activities of daily living (ADLs) and had a history of falls. The Interventions indicated the following. - Resident #2 had anti roll back brakes on her wheelchair - She could pivot transfer with the assistance of one. - The staff used a pull alarm attached to the wheelchair and to her clothing to alert them when she tried to self transfer. b. Revised 1/31/24: Resident #2 cognitive decline made it difficult at times for the staff to manage her behaviors or health condition. The Interventions indicated the staff would assist her family to find a specialized memory unit for placement. c. Revised 2/3/24: Resident #2 had a behavioral problem related to her Alzheimer's dementia, mood disturbance, and agitation. The Interventions reflected - Resident #2 had a Wander Guard alarm for safety due to history of exit seeking. - Monitor Resident #2's behavior episodes and attempt to determine the underlying causes such as location, time of day, persons involved and situations. On 3/19/24 at 1:51 PM, observed Resident #2 in her wheelchair in the dining room area. She appeared calm but did occasionally attempt to get out of her chair. The observation revealed an alarm clipped to her shirt and hanging from her wheelchair. At 3:36 PM witnessed her sleeping in her wheelchair and at 4:00 she still appeared calm while sitting in her wheelchair in dining area. The Facility Investigation dated 1/26/24 reflected Staff G, CNA, voiced concerns to Staff T, RN DON, regarding the occurrences during the overnight shift. Staff G talked further with administration regarding her concerns. During discussion Staff G stated Resident #2 sat in the living area in the front of the facility. Staff G and Staff F tried different interventions to help Resident #2 calm down. Staff G expressed Resident #2 stated she would go to the bathroom, so they assisted her to the bathhouse. While in the bathhouse Staff G expressed Resident #2 went to spit on her and Staff F. Staff G stepped back. Resident #2 continued to hit and kick at them. At this time Staff F bent down to Resident #2's level and sternly asked her not to spit. Staff F then raised his hand and tapped Resident #2 on her left cheek. When asked to further explain, Staff G expressed, she wasn't sure if she should call it a tap or a smack or what. She was sure that his hand contacted Resident #2's face. Staff G felt like Staff F may have stepped on Resident #2's foot, but with her hitting and kicking, it was hard to explain everything that happened. The nursing staff completed a skin assessment on 1/26/24, that revealed no new skin areas on Resident #2's left cheek/and or face with no indication of injury to Resident #2's left cheek. When Resident #2 visited with the Administration the morning of 1/26/24, she explained she had a good night and described all the helpers as so nice. Resident #2 worked on a puzzle during that time but couldn't record any specific details of the night when asked. When interviewing Staff F, CNA, he validated he worked the night before. Staff F verbalized that Resident #2, spit, hit, and screamed at the staff. He expressed they had tried the interventions from her activity book, bathroom, snack, 1 on ls, but Resident #2 wouldn't calm down. Staff F stated he attempted to hold Resident #2's hands, when she expressed she would kick him. Staff F stated when asked, Yes, I tapped her (Resident #2) on the face and said to her, can you please stop? Staff F described the tap as very soft with no power behind it. Discussion throughout the conversation included utilizing his walkie for the charge nurse at the time, and Staff F verbalized understanding. At the end of the conversation Staff F stated, I'm sorry - I wasn't trying to hurt her. Staff U, RN DON, and Staff T expressed they didn't have any specific resident concerns with Staff F. Staff U expressed that Staff F continued to need education regarding skills at times. The Police Report interview conducted on 1/31/24 between Staff F and the police officer, Staff F reported Resident #2 had dementia and often caused problems for the workers. The night of the incident, Resident #2 yelled and screamed, he knew that she would get better when people were around her and could bring her back to reality He told the officer that he saw Staff G having trouble with Resident #2. As Resident #2 hit and screamed at Staff G, so he decided to go in and help Staff G. While Resident #2 sat on the toilet, he got down to her eye level and tapped on her cheek to bring her back to reality. Resident #2 got more upset and threatened to kick him in the genital area. At that time, Staff F took his foot and placed it on top of Resident #2's foot to prevent her from kicking him. On 3/21 at 3:52 PM. Staff G said the incident with Staff F and Resident #2 happened so fast. Resident #2 was being difficult, hitting, and spitting which was not unusual for her. Staff G took her to the bathhouse to toilet her and she asked Staff F to assist. As Resident #2 sat on the toilet, she went to spit on Staff F. He got down to eye level with her and said we do not spit. The resident told him to go to hell. He went back to eye level with the resident again, said fuck it, and slapped her on the check. When Resident #2 tried to kick him in the genitals, Staff F stepped on one of her feet to keep her from kicking him. Staff G got between the two of them and Resident #2 said I'd rather deal with you, because I don't want to be black and blue. Staff G got Resident #2 up from the toilet, pulled her pants up, Staff F then grabbed the back of Resident #2's pants, whipped her around, and swung her into the wheelchair. The chair tipped back and if it hadn't had the anti tip bar on the back, she could have fell backwards in her chair. Staff G said she got Resident #2 to the dining room and tended to her the rest of the night. About an hour after the incident, Resident #2 went to sleep in her room. Staff G said that hours went by before she saw the nurse. Staff F followed Staff G around throughout the rest of their shift and asked; are you going to tell on me? Staff G said she didn't get a chance to say anything to the nurse with Staff F always behind her. Staff G said the slap was not hard enough to leave a bruise, but it did leave a red mark on Resident #2's check that disappeared by morning. Staff G said she witnessed Staff F lose his temper at residents, as he would yell at them. She being afraid of Staff F that she could be retaliated against for reporting the incident. On 3/20/24 at 12:40 PM, Staff F said that Resident #2 was agitated the majority of the time. He said that on the overnight shift from 1/25/24 1/26/24, he asked the nurse if she could give her some medication to help her calm down and the nurse responded she already gave her an Ativan (antianxiety medication) earlier in the evening and couldn't give her any more. Staff F said he went to help Staff G because she let Resident #2 hit and kick her. He told her to get out of the way and let him take over. Resident #2 spit in his face, clawed at him, and flailed her arms. While Resident #2 sat on the toilet, she threatened to kick him between the legs, so he put his foot on top of her foot and placed it down. She started to claw more and spit in his face so he tried to talk to her because she can understand. Staff F said he tapped her on the face real soft, but it didn't work, so he told Staff G to take over. He said they put Resident #2 back into her wheelchair and wheeled her out to the nurse's station in front of the nurse. Staff F remembered being upset with the nurse because she didn't help them with Resident #2. He said the nurse saw them both scratched up pretty good, but the scratches happened when they cared for a different agitated resident earlier that evening. Staff F described Staff G as quiet and withdrawn, she just let Resident #2 beat her up and that's why he decided to take over, he said they shouldn't just stand there letting residents hit and kick them. Staff F said he grabbed Resident #2's hands and held them down to get her to stop hitting but she didn't care. Staff F said the nurse took Resident #2 back to her room until she went to sleep while he and Staff G answered call lights the rest of the night. On 3/20/24 at 2:59 PM, Staff I, Registered Nurse (RN), acknowledged she worked the overnight shift on 1/25/24 1/26/24, but denied knowing about the incident between Resident #2 and Staff F that night. She explained she found out 3 days later when the Administrator asked her about it. She did remember Resident #2 being agitated that night while in the dining room area, but she couldn't really describe what she was exactly doing. Staff I said Resident #2 had many issues, mostly she tried to get out of her wheelchair on her own. Staff I said sometimes when she sat with Resident #2, she talked about working at the bank and that helped. Resident #2 could get feisty, and sometimes, the as needed (PRN) medications helped calm her. When asked if she had any concerns with Staff F, she described him as a loner, who usually worked by himself and didn't want help. Staff I said she didn't assess Resident #2 after the incident because the aides didn't ask for help and she didn't know anything about it until days later. On 3/27/24 at 3:34 Resident #2's family member (RR#2) said they just transferred Resident #2 to a locked memory care unit and she did well. RR#2 explained the staff had better training to deal with her in that new environment. He said they did get a call about the incident on 1/26/24 and he understood that she was slapping around and he slapped her back. The family acknowledged that they understand it's frustrating for staff to deal with dementia residents. On 3/27/24 at 5:50 PM, Staff P, RN, said that she worked the 6p 6a shift and she worked with Staff F. She didn't personally hear Staff F raise his voice or get angry at residents, but heard from other staff that he would get in their face. She said one night, Staff F came to her and told her that he may have tapped a little hard on a resident's shoulder. He told her as he tried to get a resident changed for the night, she swung at him. He said he tried to distract her to get her attention and tapped her shoulder. Staff P immediately assessed the resident's shoulder and didn't see any marks. She said he got frustrated sometimes and she would separate him from the residents. She didn't remember a date but thought it happened within the past 3 months and with Resident #15. On 4/1/24 at 10:04 AM the Administrator said Staff G should have reported the alleged abuse immediately. She added how she addressed the concern as soon as she learned about it on the morning of 1/26/24. She educated all the staff that day that they must report alleged abuse immediately so the alleged abuser could be separated from the residents. She said that she had no knowledge of anger issues with Staff F towards residents. She said she didn't know of any incident between Resident #15 and Staff F. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy revised October 2023, directed all residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record, and policy review the facility failed to update a Care Plan with resident specific goals and interventions. In addition, the facility failed to follow the interventions established in the Care Plan for 1 of 3 residents reviewed (Resident #17). The staff reported Resident #17 often hit and scratched them during care. In addition, the staff failed to monitor episodes to determine underlying causes as the plan of care directed. Findings include: Resident #17's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. The MDS indicated Resident #17 didn't have physical behavioral symptoms directed toward others, such as hitting, kicking, pushing, scratching. In addition, she didn't exhibit rejection of care behavior. She required partial to moderate assistance with showers and upper body dressing. In addition, she required total assistance for toileting hygiene and putting on footwear. The MDS included diagnoses of unspecified dementia, without behavioral/psychiatric mood, anemia (low blood iron) and depression. The Care Plan included the following Focuses: a. 11/3/23: Resident #17 had impaired cognitive function and impaired thought processes related to dementia, but could verbalize her needs. b. 9/8/23: Resident #17 had a risk for behaviors related to dementia and would have daily incidents of refusing cares, not cooperating with staff, yelling or hitting at staff. The Interventions last updated 6/14/23, directed the staff to monitor behavior episodes and attempt to determine underlying causes, considering location, time of day, persons involved, and situations, then document behavior and potential causes. In a confidential interview, Staff F, Certified Nurse Aide (CNA), said Resident #17 often hit and scratched staff. They didn't feel the nurses and Administration did much to find solutions to these behaviors. In a confidential interview, Staff S, CNA, displayed fresh marks and scratches on the inside and outside of her lower arms. She said that she sustained these injuries from Resident #17 while providing care. She said that the resident would become agitated, and along with other CNA's, Staff S felt that they needed to come up with some better plans for assisting the resident with her agitation while protecting staff. A review of the nursing notes showed that since 1/1/24, the following progress notes contained incidents where Residents #17 became combative and scratched staff: a. 1/2/24 at 2:00 AM b. 1/4/24 at 9:23 PM c. 1/10/24 at 1:43 PM d. 1/15/24 at 9:48 PM e. 1/29/24 at 4:48 PM f. 1/31/24 at 1:02 AM g. 2/6/24 at 8:33 PM h. 2/20/24 at 2:03 PM i. 2/25/24 at 2:17 PM j. 2/26/24 at 5:10 PM k. 3/9/24 at 2:54 PM l. 3/13/24 at 9:58 PM m. 3/24/24 at 8:57 PM On 4/1/24 at 11:00 AM, Staff U, Registered Nurse (RN, Director of Nursing, DON), said when they had an incident with Resident #17 and the staff, they talked about it at the time of the event to determine the cause. If staff got scratched or hurt, they directed them to fill out an incident report and Administration would investigate the details. She acknowledged that they didn't use resident incident reporting to track and monitor the events. She said that they did not have any staff reports of getting scratched for a long time. On 4/1/24 at 11:40 AM, the Administrator said she thought Resident #17's behaviors got better because the staff didn't say anything to her about getting hit or scratched for sometime. When asked about team meetings to discuss, plan interventions and monitor progress, she said that they didn't use incident reports to track the episode, but they use different care pathways that triggered Care Plan goals. On 4/2/24 at 8:40 AM, Staff T, (RN, DON) said they would look back a week before to determine the MDS areas of concern. She acknowledged Resident #17's MDS dated 1/23, should include the incidents of behavioral concerns the prior week. When asked about the Care Plan intervention to monitor episodes and attempt to determine underlying cause, document behavior and potential causes. She replied they usually had those conversations and planning at the Care Conferences, then document it in the meeting notes. The Care Conference Notes dated 1/18/24 at 10:15 AM, listed the attendance as only Staff T and the Social Worker. The Problems/Needs area of the report showed a concern that the resident gets irritated with staff at times. The Resident/family concerns section showed no concerns at this time other than the resident scratching the staff at times. The document didn't include solutions or ideas for interventions that worked and/or didn't work. The Care Plan Development policy dated March 2017, directed the facility to develop a comprehensive plan of care. The plan of care would be reviewed periodically for the need for updating, modifying or additions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide timely assessments and interventions to 2 of 5 residents reviewed (Resident #12 and #17). Resident #12 fell when the mechanical lift tipped over, the nurses failed to provide follow up assessments. Resident #17 had a pattern of aggressive/combative behaviors and the staff failed to monitor for effective and ineffective interventions, in order to determine the best responses to keep her and the staff safe. Finding include: 1. Resident #12's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #12 required extensive assistance from 2 persons for bed mobility, dressing, and toilet use. In addition, he required total assistance with transfers. The MDS included diagnoses of heart failure, renal insufficiency (poor functioning kidneys), diabetes, morbid (severe) obesity. The Care Plan updated 6/23/23 included the following: a. Resident #12 received hospice level of care. b. Resident #12 needed assistance with care due to his physical decline. The Interventions indicated the following: - He used a bariatric bed with a foot extender - The staff lifted his recliner to accommodate his height. - He preferred to sleep in his recliner rather than the bed. c. Resident #12 used high risk medication for heart failure, atrial fibrillation, chronic kidney disease and diabetes. He chose to stop his medications and go on hospice services. d. Resident #12 had chronic pain related to joint replacements, morbid obesity, arthritis and diabetic polyneuropathy (damage to multiple peripheral nerves by diabetes). e. Resident #12 had an ADL self-care deficit. The Intervention instructed he didn't walk and he required a full-body mechanical lift for transfers. The Nurses Note dated 7/2/23 at 10:10 AM reflected Staff L, Registered Nurse (RN), Staff K, Licensed Practical Nurse (LPN), and Staff M, RN, had Resident #12 in the full-body mechanical lift to transfer him from the bed to his recliner. Staff M positioned herself behind recliner to help guide him into the chair and to assist with getting his hips pulled back. Staff K used the lift to get Resident #12 up in air so he could be moved. As Staff K pulled the lift back with the legs open, Staff L had Resident #12's feet and was turning him to align him with the lift, the legs on lift started to close. As this occurred the lift tipped over falling to the south. Staff M moved the recliner quickly so Resident #12 landed in recliner from the waist up, with his feet on the floor still hooked to the lift. The base of the lift came up to the north side hitting Staff L in both shins. While the upper lift landed on Staff K's left side of her back. Both filled out employee incident reports. They removed Resident #12 from the lift, so they could remove the lift off Staff K and assess their injuries. Staff M called additional staff to the room. The staff reconnected Resident #12 back up to the lift, while 1 staff member stood on each lift leg, they lifted Resident #12 in the air. With the legs to the life open and on each side of the recliner, the staff stepped off the lift and pushed the lift back further to get Resident #12 back in his recliner. The staff repositioned Resident #12 in his recliner in good position, and then the staff unhooked the lift. Resident #12 didn't have complaints of pain or discomfort. Staff M notified the DON immediately of the incident. On 3/21/24 at 10:58 AM Staff M said she helped two other nurses transfer Resident #12 in the lift when it tipped over. She said Resident #12 landed in the recliner with his feet on the floor. She said that didn't complain of any pain and she didn't see any scratches. She didn't know if anyone completed a full nursing assessment. On 3/26/24 at 10:00 AM, when asked if the nurses completed a full assessment on Resident #12 after the fall, the Administrator said she didn't know for sure, and added Resident #12 would let them know if he had any pain or concerns. 2. Resident #17's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. The MDS indicated Resident #17 didn't have physical behavioral symptoms directed toward others, such as hitting, kicking, pushing, scratching. In addition, she didn't exhibit rejection of care behavior. She required partial to moderate assistance with showers and upper body dressing. In addition, she required total assistance for toileting hygiene and putting on footwear. The MDS included diagnoses of unspecified dementia, without behavioral/psychiatric mood, anemia (low blood iron) and depression. The Care Plan included the following Focuses: a. 11/3/23: Resident #17 had impaired cognitive function and impaired thought processes related to dementia, but could verbalize her needs. c. 9/8/23: Resident #17 had a risk for behaviors related to dementia and would have daily incidents of refusing cares, not cooperating with staff, yelling or hitting at staff. The Interventions last updated 6/14/23, directed the staff to monitor behavior episodes and attempt to determine underlying causes, considering location, time of day, persons involved, and situations, then document behavior and potential causes. In a confidential interview, Staff F, Certified Nurse Aide (CNA), said Resident #17 often hit and scratched staff. They didn't feel the nurses and Administration did much to find solutions to these behaviors. In a confidential interview, Staff S, CNA, displayed fresh marks and scratches on the inside and outside of her lower arms. She said that she sustained these injuries from Resident #17 while providing care. She said that the resident would become agitated, and along with other CNA's, Staff S felt that they needed to come up with some better plans for assisting the resident with her agitation while protecting staff. On 4/1/24 at 11:00 AM, Staff U, Registered Nurse (RN, Director of Nursing, DON), said that when they have an incident with Resident #17 being combative, they talk about it at the time of the event to determine cause. She reported they didn't have a formal Interdisciplinary Team Meeting (IDT) to talk about root causes or possible solutions. On 4/1/24 at 11:40 AM, the Administrator said she thought Resident #17's behaviors got better because the staff didn't say anything to her about getting hit or scratched for some time. When asked about team meetings to discuss, plan interventions and monitor progress, she said that they didn't use incident reports to track the episode, but they use different care pathways that triggered Care Plan goals. On 4/2/24 at 8:40 AM, Staff T, (RN, DON) said they would look back a week before to determine the MDS areas of concern. She acknowledged Resident #17's MDS dated 1/23, should include the incidents of behavioral concerns the prior week. When asked about the Care Plan intervention to monitor episodes and attempt to determine underlying cause, document behavior and potential causes. She replied they usually had those conversations and planning at the Care Conferences, then document it in the meeting notes. The Care Conference Notes dated 1/18/24 at 10:15 AM, listed the attendance as only Staff T and the Social Worker. The Problems/Needs area of the report showed a concern that the resident gets irritated with staff at times. The Resident/family concerns section showed no concerns at this time other than the resident scratching the staff at times. The document didn't include solutions or ideas for interventions that worked and/or didn't work. The Care Plan Development policy dated March 2017, directed the facility to develop a comprehensive plan of care. The facility would review the plan of care periodically for the need for updating, modifying or additions. The undated Fall Protocol policy, instructed immediately after a fall, the nurse would; assess the resident's physical condition before moving, continue to monitor the residents physical and mental status every shift for a minimum of 24 hours and document in the nurse's notes. According to a facility policy titled: QAPI Quality Assurance Performance Improvement, dated 10/5/17, reflected the facility strived to provide excellent quality resident/patient care and services. The policy defined Quality as meeting or exceeding the needs, expectations, and requirements of the patients cost effectively while maintaining good resident/patient outcomes and perceptions of patient care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to implement incident and/or unusual occurrence reports for 3 of 3 residents reviewed (Residents #1, #12, and #17). The mechanical lift tipped over while transferring Resident #12, the facility failed to follow up with an incident report or investigation into the failure. Resident #1 sustained a skin tear on her arm and the facility failed to investigate the cause. Staff discovered that Resident #17 had scratches on her arms, the chart lacked an incident report or investigation into the cause. Findings include: 1. Resident #12's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #12 required extensive assistance from 2 persons for bed mobility, dressing, and toilet use. In addition, he required total assistance with transfers. The MDS included diagnoses of heart failure, renal insufficiency (poor functioning kidneys), diabetes, morbid (severe) obesity. The Care Plan updated 6/23/23 included the following: a. Resident #12 received hospice level of care. b. Resident #12 needed assistance with care due to his physical decline. The Interventions indicated the following: - He used a bariatric bed with a foot extender - The staff lifted his recliner to accommodate his height. - He preferred to sleep in his recliner rather than the bed. c. Resident #12 used high risk medication for heart failure, atrial fibrillation, chronic kidney disease and diabetes. He chose to stop his medications and go on hospice services. d. Resident #12 had chronic pain related to joint replacements, morbid obesity, arthritis and diabetic polyneuropathy (damage to multiple peripheral nerves by diabetes). e. Resident #12 had an ADL self-care deficit. The Intervention instructed he didn't walk and he required a full-body mechanical lift for transfers. A nursing note dated 7/2/23 at 10:10 AM showed that three nurses went to transfer the Resident #12 from the bed to recliner and the mechanical lift tipped over. The resident fell into the recliner and had no injuries, however, two of the staff sustained injuries from the machine falling. On 3/25/24 at 12:23 PM Staff L, RN, remembered controlling the mechanical lift on 7/2/23 when it tipped over with Resident #12. She said she had the legs open when she lifted him from the bed and pulled it backwards. As she stepped to the side, she helped reposition the resident in the sling. Once she started to help turn Resident #12, one of the legs on the machine started to close, causing the machine to tip to the side. The base of the machine scraped up her leg. Staff M pushed the recliner under Resident #12, while Staff K got between Resident #12 and the machine to help position him. As the machine tipped, the top handles, where the sling hooks onto, fell down on top of Staff K. Staff L said that she didn't hear any clunking, but the legs just closed. She explained that had happened several times before with that machine, when she transferred residents. She reported it to the office on more than one occasion. She said all of the staff knew the mechanical lift didn't function properly. She didn't have any knowledge of any other residents falling from the machine, but it particularly worried the staff about transferring very large residents. She said she didn't fill out a maintenance sheet, because she assumed that since so many people knew about it, someone already did that. On 3/21/24 at 10:25 AM, the Administrator said they didn't complete an incident report after Resident #12 fell from the lift because he didn't get hurt. The two staff who got hurt completed incident reports because they took the brunt of the machine. On 3/26/24 at 10:00 AM, the Administrator said because Resident #12 didn't get hurt, the nurses put details in their notes, they addressed the concerns, she didn't see a need for an incident report when the lift tipped over. 2. Resident #1's MDS assessment dated [DATE], identified a BIMS score of 4, indicating severe cognitive deficits. She hallucinated and had delusions. She required set up and clean up for meals and was totally dependent on staff for hygiene, toileting and bathing. The resident was frequently incontinent of bladder and bowel. The MDS included diagnoses of anemia (low blood iron), renal insufficiency, Alzheimer's disease and borderline personality disorder (impulsive mental health behaviors). The Care Plan Focus revised 7/17/23 indicated Resident #1 needed assistance with care and mobility due to her weakness, poor balance, and decreased mobility. The Interventions directed Resident #1 required an assist of 2 with transfers and ambulation with a gait belt and walker. The Care Plan Focus revised 2/16/24 reflected Resident #1 had a history of altered skin integrity. The Intervention directed to complete a wound assessment per skin integrity flow sheet. According to the Skin Condition Report dated 3/20/24, Resident #1 had a V shaped skin tear on left arm 2 centimeter (cm) x 0 cm. The section labeled cause of bruise or skin tear remained incomplete. The Nurses Note dated 3/20/24 at 1:53 PM indicated Resident #1 sustained a skin tear on her left forearm after coming back from the bathroom and lying down in bed after lunch. The area looked bruised and measured 2 cm x 2 cm. The note lacked the cause of the injury. On 3/21/24 at 12:25 PM, Staff A, Certified Nurse Aide (CNA), said when she and another aide transferred Resident #1 to the bathroom, they didn't notice the skin tear or any blood. When they got her off the toilet to go to her bed, they noticed the skin tear on her right arm, with dried blood around on the arm. The resident couldn't say what happened. The chart lacked an incident report or investigation into the cause of the skin tear and bruising. 3. Resident #17's MDS assessment dated [DATE], identified a BIMS score of 5, indicating severely impaired cognition. She required partial to moderate assistance with showers and upper body dressing. In addition, she required total assistance for toileting hygiene and putting on footwear. The MDS included diagnoses of unspecified dementia, without behavioral/psychiatric mood, anemia (low blood iron) and depression. The Care Plan included the following Focuses: a. 11/3/23: Resident #17 had impaired cognitive function and impaired thought processes related to dementia, but could verbalize her needs. c. 9/8/23: Resident #17 had a risk for behaviors related to dementia and would have daily incidents of refusing cares, not cooperating with staff, yelling or hitting at staff. The Interventions last updated 6/14/23, directed the staff to monitor behavior episodes and attempt to determine underlying causes, considering location, time of day, persons involved, and situations, then document behavior and potential causes. In a confidential interview, Staff F, Certified Nurse Aide (CNA), said Resident #17 often hit and scratched staff. They didn't feel the nurses and Administration did much to find solutions to these behaviors. In a confidential interview, Staff S, CNA, displayed fresh marks and scratches on the inside and outside of her lower arms. She said that she sustained these injuries from Resident #17 while providing care. She said that the resident would become agitated, and along with other CNA's, Staff S felt that they needed to come up with some better plans for assisting the resident with her agitation while protecting staff. A Skin Condition Report dated 12/31/23 reflected Resident #17 had 3 scratches on her left lower arm, surrounded by purple bruising. The report listed the cause Resident #17 scratched herself during cares. The document lacked an explanation for the bruising. Resident #17's clinical record lacked an incident report or investigation related to her skin concerns. On 4/1/24 at 11:00 AM, Staff U, Registered Nurse (RN, Director of Nursing, DON), said that when they have an incident with Resident #17 being combative, they talk about it at the time of the event to determine cause. She reported they didn't have a formal Interdisciplinary Team Meeting (IDT) to talk about root causes or possible solutions. On 4/1/24 at 11:40 AM, the Administrator said she thought Resident #17's behaviors got better because the staff didn't say anything to her about getting hit or scratched for some time. When asked about team meetings to discuss, plan interventions and monitor progress, she said that they didn't use incident reports to track the episode, but they use different care pathways that triggered Care Plan goals. On 3/25/24 at 12:10 PM, the Administrator said they don't do incident reports on everything that happened at the facility, as they would be doing reports all day long. She said that with the lift fall, they followed up, and got a different one. They did all the steps included in the incident report anyway. The Incident and Investigation Charting policy dated 12/1/16, described the purpose as to record the fact about the incident to notify the Administration that an incident occurred and to provide data for trending and tracking incidents. To use a systematic effort to determine what happened, how it happened, why it happened and whom it happened to. The Incident investigation was an important part of the Quality Assurance Program. The charge nurse completes an incident report and the investigation report. The resident would be placed on the facility hot chart which required a reassessment at least once per shift for 24 hours. The DON should review each report, sign, and date the form. The DON should forward the report to the Administrator for review. In addition, the DON shall review all incident reports with the Medical Director on a monthly basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to treat residents with dignity and respect for 3 of 14 residents reviewed (Residents #11, #8, #10). On 3/20/24, observed Residents #11 and #8 sit at the breakfast table waiting for breakfast for over an hour after other residents finished their meals. When Resident #8 attempted to drink her chocolate drink, she spilled it on her blouse, and on the floor. Resident #10 reported during the evening meals, many of the residents who require assistance with transfers, wait until after 8:00 PM for the staff to assist them. In addition, Resident #10 also reported that a staff member was rude to her and embarrassed her while educating her about her medication. Findings include: 1. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive deficits. He required maximum assistance with eating and dressing. He required total assistance with hygiene and transfers. The MDS included diagnoses of Down Syndrome, chronic kidney disease, obstructive and reflux uropathy (troubles with urination). Resident #11 required a mechanically altered diet while a resident. The Clinical Physician's Orders reviewed 3/21/24 listed an order dated 7/21/23 for a general diet with pureed texture. The Care Plan Focuses reflected the following: a. Revised 6/29/23: Resident #11 didn't have natural teeth and he choose to not wear dentures. The Interventions directed the staff to assist Resident #11 to eat with set-up assistance and verbal cues. b. Revised 12/12/23: Resident #11 had a risk for a weight change related to altered nutrition intake, needed for mechanically altered diet, and difficulty with communication. 2. Resident #8's MDS assessment dated [DATE] identified a BIMS score of 1, indicating severely impaired cognition. She required supervision and assistance with eating. In addition, she required total assistance with hygiene and transfers. The MDS included diagnoses of anemia, renal insufficiency (poor kidney function), diabetes mellitus, and Alzheimer's Disease. Resident #8 required a mechanically altered diet while a resident at the facility. The Care Plan Focuses indicated the following: a. Revised 9/12/23: Resident #8 needed assistance with activities of daily living (ADLs) related to weakness and impaired vision. She liked to eat food with fingers. b. Revised 11/13/23: Resident #8 had a risk for a weight change related to altered nutrition intake secondary to diabetes and anemia. The Interventions directed the staff to offer a pureed food diet, encourage good oral intake at meals, monitor for chewing and swallowing issues On 3/20/24 observed the following: a. At 8:10 AM #8 and #11 sat at the breakfast table waiting for food while other residents finished eating. b. At 8:34 AM Residents #8 and #11 still didn't have their food and waited for assistance to eat. c. At 9:00 AM Residents #8 and #11 still haven't ate and continued to sit waiting at the table. d. At 9:19 AM Residents #8 and #11 haven't ate and didn't have food in front of them yet, and the dining room didn't have other residents at the tables. e. At 9:26 AM when asked why Resident #8 and #11 didn't eat yet, Staff X, Dietary Aide, said they couldn't serve the residents with pureed food orders until they had an aide that could assist them with their meal. f. At 9:30 AM while Resident #8 drank a chocolate drink and it spilled down her blouse and onto the floor. g. At 9:31 AM witnessed the Director of Nursing (DON) sit with Resident #11 and assisted him with his meal. On 4/2/24 at 8:40 AM, the DON said she expected the kitchen staff to page an aide when they were ready for residents to eat. 3. Resident #10's MDS assessment dated [DATE], identified a BIMS score of 15, indicating intact cognition. The MDS listed her as independent with eating, hygiene, dressing, and toilet use. On 3/20/24 at 10:56 AM, Resident #10 said she noticed some residents stayed in the dining room for hours after the end of the evening meal. She said one night, the residents had to wait until after 8:00 PM before the staff started transferring them back to their rooms. Resident #10 explained she felt so sorry for them. She added that she noticed the residents who needed help with eating, waited for a long time after everyone else had their meals to get help with their meals. In addition, Resident #10 reported she had one nurse embarrass her. When she questioned Staff Y, Registered Nurse (RN), about her medications, the nurse snapped at her in front of her roommate. She told her that she told about those medications that morning. She added she should have taken her to the emergency room when she hit her head, because she was getting goofy. Resident #10 said it embarrassed her and she felt degraded. The Resident Rights policy revised November 2016 instructed the facility must treat each resident with respect and dignity. In addition, they should care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to ensure residents had assistance with Activities of Daily Living (ADL) for 5 of 14 residents reviewed (Residents #1, #8, #11, #13, and #14). During an observation of meals, Residents #14, #11, and #8 required assistance with eating had to wait over an hour after other residents finished their breakfast, to be able to eat their meal. In addition, the facility failed to provide baths for Residents #1 and #13 as directed by their plan of care. In a 30 day timeframe Resident #1 only had 3 showers and Resident #13 had only 2 showers. Findings include: 1. Resident #14's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status score (BIMS) score of 0, indicating severely impaired cognition. The MDS indicated Resident #14 wandered. She required supervision and assistance with meals. The MDS included diagnoses of renal insufficiency (poor kidney function), non Alzheimer's dementia, malnutrition (inadequate intake of nutrients) and anxiety. A nutrition assessment on 2/16/24 at 3:58 PM, showed that Resident #14 was admitted to the facility with malnourishment due to dementia diagnosis, and her weight was down 2 pounds since admission. The Mini Nutrition dated 2/16/24 at 2:37 PM listed Resident #14's weight at 133.4 pounds (lbs.) on 2/12/24. Resident #14 had a moderate decrease in food intake in the last 3 months. The Mini Nutrition Score reflected a 5.0, indicating malnourished. The Nutrition Admission/Annual/Sig Change assessment dated [DATE] at 3:58 PM indicated Resident #14 had a slight weight loss since her admission. She ate an average of 49% by herself with staff cueing. The assessment described Resident #14 as malnourished due to a dementia diagnosis. She had a moderate decrease in oral intake with a decrease in weight of 2.1 lbs. from admission. The Alert Note dated 3/20 at 5:10 PM reflected Resident #14 ate 50% or less for 2 or more meals that day. The note indicated she did feed herself with staff supervision. The staff attempted to assist her, but she refused. The Care Plan Focus revised 2/19/24 identified Resident #14 needed assistance with ADLs related to her hip fracture. The Intervention instructed to assist her with eating by providing verbal cues to physical assistance. The Care Plan Focus revised 2/20/24 indicated Resident #14 had a risk for weight changes related to altered nutrition intake secondary to diagnosis of dementia, anxiety, severe protein-calorie malnutrition, depression, left greater than 25% of her meals uneaten, and hospice. 2. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive deficits. He required maximum assistance with eating and dressing. He required total assistance with hygiene and transfers. The MDS included diagnoses of Down Syndrome, chronic kidney disease, obstructive and reflux uropathy (troubles with urination). Resident #11 required a mechanically altered diet while a resident. The Clinical Physician's Orders reviewed 3/21/24 listed an order dated 7/21/23 for a general diet with pureed texture. The Care Plan Focuses reflected the following: a. Revised 6/29/23: Resident #11 didn't have natural teeth and he choose to not wear dentures. The Interventions directed the staff to assist Resident #11 to eat with set-up assistance and verbal cues. b. Revised 12/12/23: Resident #11 had a risk for a weight change related to altered nutrition intake, needed for mechanically altered diet, and difficulty with communication. 3. Resident #8's MDS assessment dated [DATE] identified a BIMS score of 1, indicating severely impaired cognition. She required supervision and assistance with eating. In addition, she required total assistance with hygiene and transfers. The MDS included diagnoses of anemia, renal insufficiency (poor kidney function), diabetes mellitus, and Alzheimer's Disease. Resident #8 required a mechanically altered diet while a resident at the facility. The Care Plan Focuses indicated the following: a. Revised 9/12/23: Resident #8 needed assistance with activities of daily living (ADLs) related to weakness and impaired vision. She liked to eat food with fingers. b. Revised 11/13/23: Resident #8 had a risk for a weight change related to altered nutrition intake secondary to diabetes and anemia. The Interventions directed the staff to offer a pureed food diet, encourage good oral intake at meals, monitor for chewing and swallowing issues On 3/20/24 observed the following: a. At 8:10 AM #8 and #11 sat at the breakfast table waiting for food while other residents finished eating. b. At 8:34 AM - Residents #8 and #11 still didn't have their food and waited for assistance to eat. - Resident #14 had two family members come to gather her belongings. When her family discovered she didn't eat yet, her husband sat down next to her and helped her eat. c. At 9:00 AM Residents #8 and #11 still haven't ate and continued to sit waiting at the table. d. At 9:19 AM Residents #8 and #11 haven't ate and didn't have food in front of them yet, and the dining room didn't have other residents at the tables. e. At 9:26 AM when asked why Resident #8 and #11 didn't eat yet, Staff X, Dietary Aide, said they couldn't serve the residents with pureed food orders until they had an aide that could assist them with their meal. f. At 9:30 AM while Resident #8 drank a chocolate drink and it spilled down her blouse and onto the floor. g. At 9:31 AM witnessed the Director of Nursing (DON) sit with Resident #11 and assisted him with his meal. 4. Resident #1's MDS assessment dated [DATE], identified a BIMS score of 4, indicating severe cognitive deficits. She hallucinated and had delusions. She required set up and clean up for meals. Resident #1 required total assistance with hygiene, toilet use, and bathing. The resident was frequently incontinent of bladder and bowel. The MDS included diagnoses of anemia (low blood iron), renal insufficiency, Alzheimer's disease and borderline personality disorder (impulsive mental health behaviors). The Care Plan Focus revised 7/17/23 indicated Resident #1 needed assistance with care and mobility due to her weakness, poor balance, and decreased mobility. The Interventions directed she required the assistance of 2 staff with transfers in and out of the shower with an assist of one during bath. She preferred to have a bath once a week, on Tuesdays. The Care Plan Focus revised 2/16/24 reflected Resident #1 had a history of altered skin integrity. The Interventions instructed the staff report any new areas of skin concern noted with daily cares to nurse. The Nurses Note dated 3/19/24 at 6:04 PM reflected Resident #1 didn't get a shower or bath that day because the bath aide left at 4:30 PM. The POC Response History related to showers/baths reviewed on 3/20/24 for the previous 30 days indicated Resident #1 had a bath on 2/20/24, 3/6/24, and 3/12/24. The dates of 2/27/24 and 3/3/24 listed not applicable. 5. Resident #13's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. He required partial assistance with baths and showers. In addition, he required substantial assistance with toilet use and dressing. The MDS included diagnoses of anemia, hemiplegia or hemiparesis. The Care Plan Focus revised 9/15/23 reflected Resident #13 needed assistance with ADL's related to a stroke with left sided weakness and limited balance. He preferred to bathe once a week as he didn't do too much to get dirty, so he preferred to bathe on Tuesdays. The Nurses Note dated 3/19/24 at 6:03 PM, indicated Resident #13 didn't get a bath that day because the bath aide left at 4:30 PM. On 3/21/24 at 12:22 PM, Resident #13 said he didn't get his bath Tuesday for some reason. He said that he was okay with just one a week, but at the time of the interview, no one offered him another opportunity. On 3/25/24 at 4:25 PM Resident #13 said no one offered him another opportunity to have a bath or shower. He added the next day is Tuesday, so maybe he'll get one if nothing else breaks down. The POC Response History related to showers or baths reviewed on 3/21/24 for the previous 30 days listed Resident #13 received a bath on 3/6/24 and 3/12/24. The documentation listed not applicable for 2/23/24, 2/27/24, 3/1/24, and 3/8/24. On 4/2/24 at 8:40 AM, Staff T, RN DON, said she expected the kitchen staff to page for an aide when they were ready for residents to eat. She said that the bath aides try to get through the bath list if they are unable to, the residents should be offered a bath the next day if they didn't get one on their scheduled day. On 3/20/24 at 2:35, Staff J, CNA, said that getting through the entire list of residents on their bath days is challenging sometimes. There are days when 2 3 residents don't get the bath because she just can't get to them. On 3/25/24 at 12:10 PM, the Administrator said that they did not have a policy related to feeding assistance and they follow the individualized Care Plans for the resident needs. She said they didn't have a specific policy on offering baths and showers, adding the Care Plans detailed their preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, the facility failed to ensure that residents were safe from accidents related to mechanical lift transfers for 3 of 5 residents reviewed (Residents #5, #9, and #12). A mechanical full body lift machine tipped over during a transfer with Resident #12 and the resident landed in a recliner without injury. In addition, the staff failed to tighten the sling for a sit-to-stand transfer machine for observed transfers of Resident #5 and Resident #9. Findings include: 1. Resident #12's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #12 required extensive assistance from 2 persons for bed mobility, dressing, and toilet use. In addition, he required total assistance with transfers. The MDS included diagnoses of heart failure, renal insufficiency (poor functioning kidneys), diabetes, morbid (severe) obesity. The Care Plan updated 6/23/23 included the following: a. Resident #12 received hospice level of care. b. Resident #12 needed assistance with care due to his physical decline. The Interventions indicated the following: - He used a bariatric bed with a foot extender - The staff lifted his recliner to accommodate his height. - He preferred to sleep in his recliner rather than the bed. c. Resident #12 used high risk medication for heart failure, atrial fibrillation, chronic kidney disease and diabetes. He chose to stop his medications and go on hospice services. d. Resident #12 had chronic pain related to joint replacements, morbid obesity, arthritis and diabetic polyneuropathy (damage to multiple peripheral nerves by diabetes). e. Resident #12 had an ADL self-care deficit. The Intervention instructed he didn't walk and he required a full-body mechanical lift for transfers. The Nurses Note dated 7/2/23 at 10:10 AM reflected Staff L, Registered Nurse (RN), Staff K, Licensed Practical Nurse (LPN), and Staff M, RN, had Resident #12 in the full-body mechanical lift to transfer him from the bed to his recliner. Staff M positioned herself behind recliner to help guide him into the chair and to assist with getting his hips pulled back. Staff K used the lift to get Resident #12 up in air so he could be moved. As Staff K pulled the lift back with the legs open, Staff L had Resident #12's feet and was turning him to align him with the lift, the legs on lift started to close. As this occurred the lift tipped over falling to the south. Staff M moved the recliner quickly so Resident #12 landed in recliner from the waist up, with his feet on the floor still hooked to the lift. The base of the lift came up to the north side hitting Staff L in both shins. While the upper lift landed on Staff K's left side of her back. Both filled out employee incident reports. They removed Resident #12 from the lift, so they could remove the lift off Staff K and assess their injuries. Staff M called additional staff to the room. The staff reconnected Resident #12 back up to the lift, while 1 staff member stood on each lift leg, they lifted Resident #12 in the air. With the legs to the life open and on each side of the recliner, the staff stepped off the lift and pushed the lift back further to get Resident #12 back in his recliner. The staff repositioned Resident #12 in his recliner in good position, and then the staff unhooked the lift. Resident #12 didn't have complaints of pain or discomfort. Staff M notified the DON immediately of the incident. On 3/21/24 at 10:25 AM, the Administrator said that the Maintenance department looked at the mechanical lift after it tipped and thought a bolt might have come loose and the handle didn't lock when the legs opened up. The Administrator said they took the machine out of commission, then she went out the next day and rented another machine. She reported Maintenance did regular checks on the lift before it happened. Even though the monthly checks included one checkmark, she said that she trusted the Maintenance man to do a thorough inspection of the machines. On 3/21/24 at 10:45 AM, Staff N, Maintenance, said the mechanical lift had a welded area around the bolt on the base of the lift. The bolt broke loose before or after the fall. The bolt connected the mechanism from the handle to open and close the legs of the machine. He said he did monthly checks on the lifts and didn't have any concerns. He added he wouldn't see any wear and tear on the weld before it broke. On 3/21/24 at 10:58 AM Staff M, RN, said she assisted transferring Resident #12 when the lift tipped. She described her position as behind the recliner so she could pull on the sling and guide Resident #12 into the recliner once he would get into position. The legs of the lift couldn't open under the bed, so once they lifted Resident #12 off the bed, the nurse backed the lift away from the bed. While she backed up and turned the machine, she started to widen the legs at the same time. She said that this cause Resident #12's weight to shift causing the lift to tip. When she saw the lift tipping, she pushed the recliner forward to catch Resident #12. One of the nurses got between Resident #12 and the lift to protect him, when the top of the machine fell on her. The other nurse got hit by the legs of the machine as it fell. Staff M said the legs of the lift didn't completely open and she didn't see anything break or hear a clunk. They had more staff come in and help move Resident #12 up further in the recliner with the use of the lift. They had a staff member stand on each one of the legs of the machine while they lifted him up further in the recliner. On 3/21/24 at 11:05 AM, Staff K, Licensed Practical Nurse (LPN), said that she helped two other staff members transfer Resident #12 from the bed to the recliner on 7/2/23. Staff L, Registered Nurse (RN), controlled the machine, while she and Staff M, RN, maneuvered the sling with Resident #12 inside. She said they had difficulties turning him because of his weight. When Staff L tried to turn the machine and open the legs on the lift, the handle used to pull the legs open, snapped. She said that she heard a clunk, and one of the legs closed, jolting Resident #12. Due to the jolt, the machine become off balanced, sending Resident #12 forward, over the recliner, and the machine tipped over to the side. The lift fell on top of her, causing some rib injuries. On 3/24/24 at 2:06 PM, Staff H, CNA, described Resident #12 as so large that when she needed to transfer him with the mechanical lift, she made sure she had 3 more people there to help. Staff H described the lift as unsteady before the fall, the legs felt rickety, they wouldn't open all the way, and the machine didn't steer very well. Sometimes, the legs closed on their own, and the staff knew that it didn't work correctly. Staff H said she told the Maintenance staff person that the machine rattled and had something loose, but it didn't get repaired. On 3/24/24 at 2:53 PM, Staff V, Certified Nurse Aide (CNA), remembered the total body mechanical lift malfunctioned before it tipped over with Resident #12 attached. She explained around 6 PM, she toileted a resident when she found a bolt on the floor under the machine. She and another aide tipped it over to see where it came from and put a sign on it to not use it. Maintenance worked on it then. The remote on the machine would cut in and out, and the lever would stick sometimes when they went to open and close the legs. She said the facility had a Maintenance book, for the staff to enter things that needed attention, but it took a long time to get things repaired. On 3/25/24 at 8:00 AM, Staff N denied remembering anyone coming to him about concerns of the mechanical lift not working properly before it broke. He did remember repairing a standing mechanical lift. Staff N went through the Maintenance request slips from May, June and July of 2023. He explained he didn't have concerns communicated regarding the lever/legs not functioning properly. On 3/25/24 at 12:23 PM Staff L, RN, remembered controlling the mechanical lift on 7/2/23 when it tipped over with Resident #12. She said she had the legs open when she lifted him from the bed and pulled it backwards. As she stepped to the side, she helped reposition the resident in the sling. Once she started to help turn Resident #12, one of the legs on the machine started to close, causing the machine to tip to the side. The base of the machine scraped up her leg. Staff M pushed the recliner under Resident #12, while Staff K got between Resident #12 and the machine to help position him. As the machine tipped, the top handles, where the sling hooks onto, fell down on top of Staff K. Staff L said that she didn't hear any clunking, but the legs just closed. She explained that had happened several times before with that machine, when she transferred residents. She reported it to the office on more than one occasion. She said all of the staff knew the mechanical lift didn't function properly. She didn't have any knowledge of any other residents falling from the machine, but it particularly worried the staff about transferring very large residents. She said she didn't fill out a Maintenance sheet, because she assumed that since so many people knew about it, someone already did that. On 3/25/24 at 3:30 PM, Staff A, CNA, said she knew the full body lift didn't function properly before Resident #12 fell. She said the lift had things loose and one leg automatically shut after it opened. Staff A said that she went directly to the Maintenance man and told him they had a problem with the lift. He told her to put it in the log book, but she felt it needed addressed right away because it wasn't safe. She said that it was a shame that it took an accident to get it addressed. During a follow-up interview on 3/26/24 at 1:39 PM, Staff N said he didn't know about the recommended, scheduled Maintenance on the lifts. It's basically just looking it over and he referred to the checklist he used with one checkmark per month. He said he looked at everything on the machines monthly and checked it off. When asked if the manufacturer had specific recommendations related to the scheduled Maintenance, he responded some of the manufacturers recommended greasing every so often. Staff N said the lift that broke was a Prolift brand, but he didn't have the manufacturers handbook. After the machine tipped and broke they disposed of the lift and the handbook. Staff N did not know when they purchased the Volaro lift they currently had or how old it may be. Observations revealed that the facility used a Valaro total body lift. According to the Valaro handbook, a maintenance schedule indicated that every 3 months: a. Pivot points should be lubed and the actuator greased with heavy duty #2 grease. b. Check the leg adjuster stop for signs of wear, check the movement of the lift, c. Check leg covers and replace if cracked, d. Check all external fittings tighten where needed, e. Remove padding and check hanger [NAME] and fittings. f. Hanger bolt must be repaired every three years g. Actuator bearing (ball screw nut) must be replaced when grinding wear was heard but not longer than 5 years. The manual included a recommended sample monthly inspection sheet and check off list. The Maintenance Repair Need sheet dated 6/12/23 indicated in the Ice Room the unnamed mechanical full-body lift battery charger sparked when a battery got plugged in. The date completed section listed the person couldn't make it spark. According to the Stand and Lift Monthly Checks in 2023, in July of 2023 Maintenance installed a new leg spreader handle kit that month on the Valaro lift. On 3/27/24 at 7:30 AM, the Administrator said the Maintenance Man looked at the three mechanical lifts that morning and he tightened a bolt on the Sit to Stand lift. He told her they could only tightened the bolts so many times until the threading strips. When asked about the replacement leg spreader handle kit done in July 2023, she thought it had a bolt issue that got tightened too many times. He called the company and asked what he needed to do, they recommended replacing it. 2. Resident #5's MDS assessment dated [DATE] identified a BIMS of 12 (moderate cognitive deficit). He required total assistance from staff for sitting to standing, toilet transfers, and bed mobility. The MDS indicated Resident #5 had frequent incontinence of bowel and bladder. The MDS included diagnoses of obstructive uropathy (difficulty urinating), epilepsy (seizure disorder), anxiety disorder, psychotic disorder and lack of coordination. The Care Plan Focus revised 8/23/23 indicated Resident #5 couldn't walk anymore and required a mechanical assist to stand safely. On 3/19/24 at 3:27 PM, watched Staff C, CNA, and Staff D, CNA, assist Resident #5 with the Sit to Stand (standing) mechanical lift. As they positioned him with the standing mechanical lift, he wore boots and had his feet on the platform. The observation revealed the standing mechanical lift didn't have leg straps. The staff hooked up the sling and lifted him to a standing position. As he stood, the staff failed to tighten the belt around his torso. The sling was mostly in his armpits with his arms parallel to the floor. Resident #5 had his knees locked straight, with his bottom out, and his shins away from the shin guards. They took him to the bathroom and lowered him on the toilet. On 3/26/24 at 8:15 AM, witnessed two unidentified CNA's transferred Resident #5 using the standing mechanical lift while Staff U, RN DON, observed. As they transferred Resident #5 the sling raised up to his armpits. Staff U acknowledged most of the sling rested in the armpits and looked as if he supported most of his weight by his arms. She added as the sling had padding it made it easier on the armpit. She agreed it wasn't ideal, but she taught her staff not to chicken wing (arms above head) the residents with transfers. 3. Resident #9's MDS assessment dated [DATE] identified a BIMS score of 6, indicating severely impaired cognition. Resident #9 required total staff assistance from staff for sit to stand, chair to bed transfer, and toilet transfers. The MDS described her as frequently incontinent of bowel and bladder. The MDS included diagnoses of Alzheimer's disease, anxiety disorder, psychotic disorder, and polyneuropathy (Damage to multiple peripheral nerves). The MDS indicated she had occasional pain and transferred with the use of a mechanical lift. The Care Plan Focus revised 8/5/23, identified Resident #9 needed assistance with activities of daily living (ADLs) due to a history of falls and weakness. On 3/20 at 7:37 AM witnessed Resident #9 sitting on the toilet with the standing mechanical lift in front of her. Staff E, CNA, adjusted the sling to the lowest hook and then lifted her from the toilet with the standing mechanical lift. As the machine raised Resident #9 into a standing position, the sling slid up to her armpits with no support to her back, Staff A stood nearby encouraging her to stand straight and to use her legs. Once Resident #9 stood in the upright position, they failed to tighten the belt, and it hung loosely to her waist. As she hanged with her arms parallel to the floor, the sling held a majority of her weight, the staff wiped Resident #9's bottom. At 7:41 Resident #9 said I have to sit down, the staff encouraged her to use her legs and stand tall as they put on a clean brief. Resident #9 said let me sit down. When they finished applying her brief, they lowered her to the wheelchair. On 3/21/24 at 7:45 AM Staff T, RN DON, and Staff W, Certified Medication Aide (CMA), stayed in the room with Resident #9 while she sat on the toilet. When she finished on the toilet, they raised Resident #9 up with the standing mechanical lift. Resident #9 gasped and struggled to breath. When she stood in the machine, they failed to tighten the belt, and it hung loosely down the front. Resident #9 held onto the handles but struggled as her arms remained parallel to the floor with her knees bent. They cleaned up her bottom and applied a clean brief. Resident #9 said her arms hurt and Staff T encouraged her to stand up straight and said your chicken winged. Again, Resident #9 reported her arms hurt. When they lowered her into the wheelchair, Staff T asked Resident #9 where it hurt and she pointed to her right arm pit. The observations of the slings used for the 3 Residents with the Sit to Stand transfers, revealed the facility used slings (Volaro) different from the manufacturer/company as the Sit to Stand mechanical lift (Invacare). On 3/21/24 at 1:40 PM a representative from the sling manufacturer said the manufacturers would say that if they didn't test a sling on their machine, they wouldn't recommend using it on a machine from another company. On 3/21/24 at 1:30, a representative from Invacare (maker of the Sit to Stand) said that if they didn't test a sling on their machines they wouldn't recommend using it for patient transfers. On 3/21/24 at 2:53 PM, the Administrator said she talked to a representative from the Invacare company and asked about what slings could be used. His response was that they can use Invacare approved slings. She asked him what that means, how are they approved, and he told her any sling that matches the hooks on the machine and fits properly. In an email correspondence on 3/25/24 at 9:14 AM, the Invacare Product Manager said Invacare patient lifts are specifically designed and manufactured for use in conjunction with Invacare slings. Slings designed by other manufacturers have not been tested by Invacare and we cannot recommend them for use with Invacare lifts. The use of non Invacare slings on Invacare lifts would be at the sole discretion of the facility. On 3/25/24 at 12:10 PM the Administrator agreed that the sling waist belt around a resident on the Sit to Stand lift should have been snug when the residents stood in the machine. When asked about sling choices, she referenced the email, where the representative said use of non Invacare slings on Invacare lifts would be at the sole discretion of the facility. She said that they found for Invacare slings looked just like the ones they used. The undated Stand Up Patient Lift User Manual, instructed Invacare products were specifically designed and manufactured for use in conjunction with Invacare accessories. Invacare hasn't tested accessories designed by other manufactures and don't recommend them for use with Invacare products. A warning label on the side of the Invacare machine showed that staff should only use Invacare slings and lift accessories. The Invacare manual, Page 8 section I general Guidelines indicated that the belt must be snug, otherwise the patient can slide out of the sling during transfer, possibly causing injury The undated Sit to Stand Policy and Procedure directed the staff to position the top of the harness around the upper body of the resident, 4- 5 inches under the arms, then secure the safety strap around the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record, and staff interview, the facility failed to update a Care Plans following a fall with new interventions for 1 of 6 residents reviewed (Resident #11). Findings include: Resident #11's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. The MDS indicated that Resident #11 required extensive assistance of two persons for bed mobility, dressing, toilet use, and personal hygiene. In addition, the MDS listed Resident #11 as totally dependent on 2 persons for transfers. The MDS described Resident #11 as non-ambulatory. The MDS included diagnoses of non-traumatic brain dysfunction (a brain injury not caused by an outside force, such as a blow to the head) and down syndrome (genetic growth disorder caused by an extra chromosome). The COMS (R) Post Fall Evaluation dated 5/19/23 at 4:45 PM listed that Resident #11 had an unwitnessed fall at his bed side. The nurse did not find a reason for his fall, observed Resident #11 lying half on and half off his floor mat from his should blades up. Resident #11 could not say what he was doing at the time of his fall, but denied rolling out of bed. Resident #11 said that he fell. The Nurses Note dated 5/19/23 at 5:14 PM after hearing Resident #11 call for help, staff found him half on and half off the fall mat next to his bed. Resident #11 said that he fell out of bed. Resident #11 had a history of rolling out of bed and crawling on the floor. The Care Plan Focus revised 6/29/23 reflected that Resident #11 required assistance with activities of daily living (ADLs) due to his history of weakness, poor balance, and history of falls that placed him at a higher risk for falls and injury. Resident #11 did not always use his call light for assistance to get out of bed, he will roll out on to the floor mat from his high low bed when in the low position if he is ready to get up or if he did not want to go to bed. Resident #11 also will roll out of bed and play with his cards and/or magazines on the floor. The Intervention revised on 3/24/17 indicated that Resident #11 could roll out of his bed, sit on his mat, and play with his cards and/or magazines. The Care Plan lacked an intervention following the incident on 5/19/23 when Resident #11 reported to the nurse that he fell when staff discovered him on the floor. The facility did not have policies regarding falls or updating Care Plans. On 8/10/23 at 10:20 AM, the Administrator acknowledged that the staff should have updated the Care Plan with fall information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews the facility failed to ensure the code status matched the electronic and paper health record for one of 16 residents (Resident #5) reviewed. The facility reported a census of 32. Findings include: Resident #5's electronic health record revealed a physician's order for Cardiopulmonary Resuscitation (CPR) dated [DATE]. Resident 5's paper health record documented an Iowa Physician Orders for Scope of Treatment (IPOST) marked DNR (Do Not Attempt Resuscitation) signed by the resident and the physician on [DATE]. During an interview on [DATE] at 7:44 AM Staff A, Registered Nurse (RN), reported that she would look in a resident's electronic health record for their code status. Staff A said that she could also look in the paper chart but she would look in the electronic health record. Staff A stated the residents' doors also have dots, with red dot for DNR and not sure what other dot color is for CPR. On [DATE] at 7:50 AM, noted Resident #5's door/nametag did not have a dot and their chart had a blue dot. On [DATE] at 7:59 AM, the Director of Nursing (DON) explained to verify a resident's code status, she would first look at the dots on the resident's door, A red dot meant DNR and a green dot meant CPR, and then she would look at the electronic health record. The DON confirmed that the electronic health record documented CPR and the paper chart documented the most current code status of DNR. The DON stated she expected the Advanced Directives to be updated and correct in the electronic health record. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment within 14 days of a change in status for a resident with a decline in activities of daily living (ADL) and a Stage 2 pressure ulcer for one (Resident # 21) of twelve residents' reviewed. The facility reported a census of 32 residents. Findings include: Resident #21's Minimum Data Set (MDS) annual assessment dated [DATE] included diagnoses of Alzheimer's disease, psychotic disorder, and anxiety disorder. The MDS identified Resident #21 needed supervision of one person with bed mobility, transfer, walking in room, and limited assistance of one person with toilet use. The MDS documented that Resident #21 had a stage one pressure ulcer. The MDS identified a Brief Interview for Mental Status (BIMS) score of 14, indicating mild cognitive impairment for decision-making. Resident #21's MDS quarterly assessment dated [DATE] identified they required an extensive assist of two people for bed mobility, transfers, walking in their room, and toilet use. The MDS documented Resident #21 had a Stage two pressure ulcer. On 7/13/22 at 8:00 AM, observed Staff C, Certified Nurse's Aide (CNA), and Staff D, CNA, in Resident #21's room with herstanding with a walker in front of the recliner. Staff D asked to change resident's dress, resident did not respond, and staff changed her dress without resistance or help from Resident #21. Staff C and Staff D assisted Resident #21 to sit in her wheelchair. On 7/13/22 at 10:23 AM Staff E, CNA, explained that Resident #21 required increased assistance for the past two months. Staff E explained that Resident #21 needs two staff to get her out of her chair (as she did not sleep in bed), transfer to toilet and wheelchair, walk in her room, and provide toilet use hygiene. On 7/14/22 at 2:20 PM, the Director of Nursing stated she expected a significant change MDS to be completed with the noted resident's decline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, and staff interviews, the facility failed to update the comprehensive care plan with a new diagnosis that required daily weight monitoring, oxygen usage, a significant decline in activities of daily living (ADLs), and a stage two pressure ulcer for two of twelve residents (Residents #5 and #21) reviewed. The facility reported a census of 32 residents. Findings include: 1. Resident #5's Minimum data set (MDS) assessment dated [DATE] included diagnoses of diabetes mellitus and hypertension, high blood pressure. Resident #5's MDS identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impaired cognition. Resident #5's electronic health record (EHR) documented a new diagnosis of acute on chronic systolic (congestive) heart failure, failure of the heart to pump blood efficiently, on 6/27/22. The Nurses Note dated 6/25/22 at 5:06 PM indicated that the nurse called the hospital and got notified that Resident #5 got admitted for observation at least for an overnight. Resident #5 got intravenous (IV) lasix, medication used to reduce fluid overload, and other diuretics. Resident #5 used 2 Liters (L) of oxygen with oxygen saturations of the low 90's. The hospital nurse stated that Resident #5 remained tired and fell asleep as soon as the staff finished talking to her. Resident #5's July 2022 Medication Administration Record (MAR) documented an order started 7/1/22 of Lasix tablet 40 milligrams (MG) to give one tablet by mouth twice a day related to acute chronic systolic (congestive) heart failure. Get a daily weight before breakfast and if an increase of two pounds in one day, give Resident #5 one extra Lasix and notify her physician. Resident #5's Care Plan with a target date of 7/29/22 lacked documentation of her diagnosis of congestive heart failure and daily monitoring of weights. 2. Resident #21's Minimum Data Set (MDS) annual assessment dated [DATE] included diagnoses of Alzheimer's disease, psychotic disorder, and anxiety disorder. The MDS identified Resident #21 needed supervision of one person with bed mobility, transfer, walking in room, and limited assistance of one person with toilet use. The MDS documented that Resident #21 had a stage one pressure ulcer. The MDS identified a Brief Interview for Mental Status (BIMS) score of 14, indicating mild cognitive impairment for decision-making. Resident #21's MDS quarterly assessment dated [DATE] identified they required an extensive assist of two people for bed mobility, transfers, walking in their room, and toilet use. The MDS documented Resident #21 had a Stage two pressure ulcer. Resident #21's Care Plan Focus revised 11/23/21 indicated that she needed assistance with ADL's at times if she struggled as it placed her at risk for falls or injury. When staff attempt to help Resident #5, she made statements about taking away her independence or that she had to give up her coloring to get that done on a regular schedule with the staff. Resident #21 became unhappy about needing additional care. Due to this, Resident #21 could become rude and disrespectful to the staff and her family when talk of additional support got suggested. The included interventions documented that Resident #21 a. Revised 1/18/22: Required only an assist of one person with dressing b. Revised 3/14/22: Could move around her room with her walker independently. On 7/13/22 at 8:00 AM, observed Staff C, Certified Nurse Aide (CNA), and Staff D, CNA, helping Resident #21 stand up with her walker in front of her recliner. Staff D asked to change her dress, but Resident #21 did not respond. The staff did help change Resident #21's dress without resistance or help from her. Staff C and Staff D assisted the residents to sit in their wheelchairs. On 7/13/22 at 10:23 AM Staff E, CNA, said that Resident #21 required increased assistance for two months and needed two staff to get her out of her chair (as she didn't sleep in a bed), transfer to the toilet, transfer to the wheelchair, walk in her room, and provide assistance with toilet use. On 7/14/22 at 2:20 PM, the Director of Nursing stated that she expected for Care Plans to be updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, and staff interviews the facility failed to ensure each resident received the necessary respiratory care and services in accordance with professional standards of practice for one of one residents reviewed (Resident #5). The facility reported a census of 32 residents. Findings include: Resident #5's Minimum data set (MDS) assessment dated [DATE] included diagnoses of diabetes mellitus and hypertension, high blood pressure. Resident #5's MDS identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate impaired cognition. Resident #5 had shortness of breath with exertion, when sitting at rest, and when lying flat. Resident #5's MDS indicated that she used oxygen while a resident in the 14 day lookback period. Observations On 7/11/22 at 12:19 PM observed Resident #5 in the dining room (DR) wearing oxygen (O2) at two liters per (/) nasal cannula (L/NC). On 7/12/22 at 10:16 AM, observed Resident #5 in her room wearing O2 set to 1.5 L/NC. On 7/13/22 at 1:00 PM noted Resident #5 in the DR wearing O2 set to 3L/NC. On 7/14/22 at 1:55 PM, observed Resident #5 in her room wearing O2 at 1.5 L/NC. Resident #5's July 2022 Treatment Administration Record included a physician's order for O2 at 1.5 L/NC to keep oxygen saturations greater than (>) 90 percent (%), and titrate per facility protocol as needed for low O2. On 7/14/22 at 2:03 PM, the Director of Nursing (DON) stated protocol for titration of O2 would be to not go above the ordered 1.5 L/NC without notifying the physician but could go lower than 1.5 L/NC if they had an oxygen saturation of 90% or above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review the facility failed to ensure that the staff followed adequate infection control standards of practice to protect residents from potential infection by not wearing personal protective equipment (PPE) correctly. Observations showed staff performing testing without proper PPE, and not removing their gloves after incontinence care. The facility reported a census of 32 residents. Findings include: 1. On 7/11/22 at 10:35 AM, observed the Director of Nursing (DON), without wearing gloves, perform a nasal swab test for novel coronavirus 2019 (COVID-19) on the Dietary Manager. The [facility name], Required COVID-19 Testing policy revised 2/20/22, directed staff during a specimen collection, that they must maintain proper infection control and use recommended PPE, which included a N95 (non-oil mask that is 95% efficient), or a facemask if a respirator is not available, eye protection, gloves, and a gown, when collecting specimens. 2. On 7/11/22 starting at 12:12 PM, watched Staff B, Certified Nurse Aide (CNA), wearing his facemask below his nose, assist two residents to eat while touching his mask, then touching the residents' cups and silverware. Staff B continued to touch his facemask and then touch each residents' silverware and cups throughout the lunch meal. Observations On 7/11/22 at 1:25 PM, observed Staff B come out of resident room [ROOM NUMBER] wearing his facemask below his nose. On 7/11/22 at 2:02 PM, watched Staff B wearing his facemask below his nose and upper lip transfer a resident to the toilet with a lift. On 7/11/22 at 3:09 PM, noted Staff B wearing his face mask not covering nose or mouth while talking to a resident in their room. On 7/13/22 at 4:30 PM, the Director of Nursing (DON) confirmed 4 residents tested positive for COVID-19 on 7/13/22. On 7/11/22 at 2:12 PM, witnessed Staff B cleansed a resident's buttocks after helping them with going to the toilet. Without removing his gloves, Staff B touched the lift and bedside table. On 7/14/22 at 2:23 PM, the DON reported that she expected masks to cover the staff member's nose and mouth, to remove gloves, wash hands after providing cares, before touching other items, and to wear gloves with testing.