LEMAY AVENUE HEALTH AND REHAB LLC

A licensure survey was completed on 11/13/23 to 11/16/23. No deficiency was cited.

Based on record review and interviews the facility failed to ensure one (#89) of five residents reviewed for nutritional status out of 36 total sample residents maintained acceptable parameters of nutritional status such as usual body weight or desirable body weight. Specifically, the facility failed to initiate food supplements when significant weight loss was identified. Resident #89 was admitted to the facility on 8/3/23 after a hip fracture. Her admission weight was 123 pounds (lbs). On 9/7/23 the resident's weight was 109.7 lbs, indicating a significant weight loss of 10.8 percent over the period of one month. Resident #89 was assessed by a registered dietitian (RD), however nutritional supplements were not initiated. Resident #89's weight continued to fluctuate for the next month and she never returned to her admitting weight. In addition, the facility failed to provide cuing and encouragement to Resident #89 during meals. Findings include:I. Facility policy and procedureThe Obtaining and Monitoring weights policy, revised November 2023, was provided by the assistant director of nursing (ADON) on 11/16/23 at 3:51 p.m. It revealed in pertinent part, "Weights will be obtained and monitored throughout the course of a resident's stay, unless otherwise noted in the resident's care plan."Weight loss procedure, the RD or nursing staff will open a Nutrition Event in MatrixCare if a significant weight loss is noted. The provider and responsible party will be notified regarding the weight loss. Planned weight loss (e.g. use of diuretics) does not constitute the need for an event."The RD and/or IDT will review circumstances and possible contributing factors for the weight loss and implement additional interventions as deemed appropriate."The plan of care will be updated to reflect the interventions with involvement of the resident and/or the resident's representative to ensure the resident's needs, preferences and goals are met."Continuing weight loss despite reasonable efforts to improve caloric and nutrient intake may indicate the resident is in multi-system failure or an end-stage or end-of-life condition warranting an additional assessment of the resident's overall condition."II. Resident #89A. Resident statusResident #89, age 89, was admitted on 2/7/23. According to the November 2023 computerized physician orders (CPO), diagnoses included acute left minimally displaced intertrochanteric proximal femur fracture, Alzheimer's disease with early onset, and advanced dementia. A comprehensive assessment completed on 8/9/23 revealed the resident had severe cognitive impairment. She required substantial/maximal assistance, of self care one/two person for more than half the effort with most activities of daily living (ADLs). She required supervision or touching assistance, verbal cues for eating. B. ObservationsDuring a continuous observation on 11/14/23 beginning at 12:09 p.m. and ending at 3:53 p.m. the following was observed:-At 12:09 p.m. the resident was sitting in the dining room eating her lunch. The resident independently ate her lunch which was cajun pot roast, hash brown casserole, green beans, and spice cake with frosting for dessert. She ate 50 percent of her entire meal. -At 12:34 p.m. the resident was sitting at the table with her food in front of her, and she was sleeping.-At 12:36 p.m. the resident was awake and took a bite of cajun pot roast.-At 12:47 p.m. the resident finished eating lunch, she ate 50 percent of her lunch.-At 12:55 p.m. the resident was sitting at the dining room table in a chair and she was sleeping.-At 2:43 p.m. the resident was walking with her walker around the dining room area and was assisted by an unidentified staff member who guided the resident back to the dining room table to sit down in the chair for a snack. Resident #89 was offered yogurt and orange juice to drink.-At 2:46 p.m. an unidentified staff member brought the resident a small bag of chips to eat along with the yogurt and orange juice to drink.-At 3:21 p.m. the resident had eaten all of her yogurt and chips. During a continuous observation on 11/15/23 beginning at 9:37 a.m. and ending at 12:40 p.m. the following was observed:-At 10:08 a.m. morning snacks were not offered and the resident was up off the couch and walking around down the hallway. An unidentified staff member followed the resident around the unit and the resident walked back to the couch and sat down.-At 10:49 a.m. until 11:23 a.m. resident laid on the couch asleep.-At 11:39 a.m. resident was awake and an unidentified staff member gave the resident a cup of cranberry juice. The resident drank all the cranberry juice, the unidentified staff member went and got the resident another cup of cranberry juice and placed it on the dining room table. Next to her.-At 11:50 a.m. lunch was being served and an unidentified staff member attempted to wake the resident to come to the dining room table to eat her lunch. The resident refused to get up and continued to lay down on the couch. An unidentified staff member took the resident's tray and placed it in the kitchen in the fridge for her to eat later.-At 12:40 p.m. lunch ended and the resident continued to be sound asleep on the couch. C. Record reviewThe nutritional care plan, revised on 11/14/23, documented that the resident had potential for weight decline related to decrease in oral intake as evidenced by less than 25 percent of meals eaten. The resident needed encouragement to self-dine, the family requested diet liberalization to regular finger foods to improve oral intake. Family members stated the resident ate meals with her "fingers" limited utensil usage at this time. On 9/6/23 the care plan was updated that the resident had a significant weight decline, change in appetite as evidenced by urinary tract infection (UTI). The interventions included being able to consistently consume more than 50 percent of food and fluids provided, monitoring weekly weights as ordered and providing a regular finger foods oral diet as ordered. According to the August 2023 medication administration record (MAR), the resident was not receiving any nutritional supplements. The nutrition progress note dated 8/8/23 care conference note documented in pertinent part. "Potential for decrease in intake, decrease in dinner intake. Weight stable at this time at 121.8 lbs (8/7/23). Readmit nutritional assessment and care plan in place at this time."The nutrition progress note dated 9/6/23 documented "Nutritional event opened related to significant weight decline over the past month. Antibiotics in place for urinary tract infection (UTI). Current body weight 110.3 (8/31/23) lbs, weight down 13 lbs over the past month."-No new interventions were initiated at this time for weight loss. -Resident #89 was not put on nutritional supplements or fortified foods. The nutrition progress note dated 9/14/23 documented the resident's current body weight was 111.2 lbs (9/11/23)with a weight gain of one pound over the past week. Staff encouraged fluids when solid meal items had been denied.-No new interventions were initiated at this time for weight loss. -Resident #89 was not put on nutritional supplements or fortified foods. The nutrition progress note dated 9/29/23 documented body weight 109 pounds (9/25/23). "Weight stable over the past month. Nutritional event discontinued."-No new interventions were initiated at this time for weight loss. -Resident #89 was not put on nutritional supplements or fortified foods. -The resident did not return to her admission weight of 123 lbs as documented on 8/3/23. -There was no nutritional progress note for the month of October 2023. The nutrition progress note dated 11/14/23 documented, "The family requested if finger foods could be removed from the regular diet to increase food intake as evidenced by the resident receiving an increase in meal assistance. Intake trends 25-50%, corrected body weight 108.2 lbs (11/6/23), weight stable over past month with weight down 11 lbs/9.5% over the past quarter. Weight decline related to left hip fracture and UTI. Registered dietitian will follow up with adding a donut at breakfast to assist with oral intake and variety."The resident's electronic medical record (EMR) documented the following weights: -On 7/31/23 the resident was hospitalized for a left hip fracture. She returned back to the facility on 8/3/23. Her weight on admission was 123.8 lbs.-On 8/3/23, the resident weighed 120.6 lbs;-On 9/21/23, the resident weighed 106.6 lbs, with a weight loss of 14.0 lbs (11.66%) in one month;-On 10/16/23, the resident weighed 107.5 lbs, with a weight gain of 0.9 lbs; and,-On 11/6/23, the resident weighed 108.2 lbs, with a weight gain of 0.7 lbs. III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 11/16/23 at 1:59 p.m. He said the resident ate independently and required cueing and prompting once in a while. He said the resident required prompting for one out of three meals provided. He said residents were provided with morning, afternoon and evening snacks. He said the kitchen staff rotated snacks as the residents would receive either tuna sandwiches or peanut butter and jelly sandwiches. He said Resident #89 would receive an occasional Boost (a nutritional supplement drink) if she had a low breakfast intake. He said the resident would be offered a Boost between breakfast and lunch and the Boost was ordered as needed. He said the resident usually ate more during lunch as she really enjoyed grilled cheese sandwiches. He said if the resident did not eat the majority of her lunch then staff would call the kitchen and ask for an alternative. He said the resident was verbal when she wanted to talk. He said the resident was able to verbalize what she did not like but was not able to verbalize what she did like. Registered nurse (RN) #1 was interviewed on 11/16/23 at 4:11 p.m. She said when Resident #89 came back from the hospital in August 2023, after a hip surgery, she was working with therapy and had some weight loss. She said the resident's family was going back and forth with placing the resident on hospice and decided they wanted to continue therapy instead. She said therapy helped the resident and now she was back to baseline. She said the resident's appetite decreased when she was recovering and was not transferring as much due to being in pain. She said the family was focused on comfort and wanted to get the resident back to her baseline. She said the resident's family came in frequently to check in on the resident. She said the family had not brought up any concerns regarding the resident's weight. She said if there were any concerns with any of the residents they would discuss it in morning meetings with the interdisciplinary team which consisted of the nurse manager, dietary, social worker, therapist, doctor/nurse practitioner, assistant director of nursing, director of nursing, nursing home administrator and activities. She said the resident lost some weight but it was due to her not feeling well. She said even though the resident was recovering, she would still come out and eat all her meals in the dining room. She said the resident had started on oxycodone to see if that would help with the pain. She said the pain got better so the family felt that regular food would be better for the resident. She said the resident sat at the assisted table so that the CNAs could monitor her. She said if the resident did not eat her meals the staff would save her tray and make sure she ate when she woke up. She said the resident's diet was changed from a regular diet to finger foods on 8/4/23. She said the resident did better with the sandwiches as she preferred to eat grilled cheese sandwiches and the family thought the finger foods would help. She said the resident's intake had been stable since 8/16/23. She said the resident's best meal intake was breakfast. She said the resident ate about 50 percent of her meals. The registered dietitian (RD) was interviewed on 11/16/23 at 2:29 p.m. She said the resident had her care conference on Tuesday 11/14/23 and the resident was not eating a lot of the finger foods offered, so the family wanted the finger foods discontinued and placed back on regular food for variety and more assistance. She said the resident was needing more assistance such as cueing with her meals as she was not self-initiating during dining. She said when the resident got a urinary tract infection and was recovering from her hip surgery she had a decrease in intake. The RD said on 9/6/23 the resident was not put on a supplement because she figured the resident's weight would come up. She said on 9/14/23 the resident's weight had gone up. She said on 9/29/23 she made no changes in interventions because the resident's weight had stabilized in that month. She said the resident's weight loss had ceased and no additional interventions were needed. She said the resident's body mass indeed (BMI) was considered underweight for her age and weight. She said she could not answer if supplements or fortified food would bring the resident's weight back to normal. She said she would be monitoring the resident since her diet changed to regular food before adding any supplements. The primary care provider was interviewed on 11/20/23 at 2:33 p.m. She said the resident's weight had been stable from spring to summer. She said unfortunately the resident had a fall in July 2023 and when she came back from the hospital she weighed 123 lbs. She said the weight gain was due to the resident receiving fluids after surgery. She said she did not think that the resident's weight gain was due to her eating more food. She said rapid weight gain was from the fluids she had received while in the hospital. She said that within two weeks the resident had dropped back down to 110 lbs. She said the dietician saw the resident frequently after her hospital stay and opened up an event when she noticed the resident's weight had changed. She said that the dietitian was keeping a close eye on the resident's weight. The physician said she saw no concern with the resident's weight and said the resident's weight was stabilized now. She said she did not think that the resident needed supplements at this time as the resident was at her baseline weight and supplements were not appropriate at this time. She said she did not know what the resident's weight was prior to being admitted to the facility. She said the resident's family said the resident had always been a "tiny gal."She said during meal times the unit had two aids on the unit to supervise and assist the residents. She said the resident was independent and does not need assistance or supervision while eating her meals. She said the resident had always been able to feed herself. She said any time there was a weight fluctuation or change in status with any resident, she was part of the daily morning meeting. She said she was part of daily occurrences and any events that opened up for residents. She said interventions were implemented at the time she returned from the hospital but said the resident did not need any updated interventions regarding weight at that time. She said she had no nutritional concerns when the resident had a urinary tract infection. She said the staff was monitoring her closely for what she was eating and the resident would eat well. She said that due to the resident eating well that she saw no concerns or additional concerns regarding increase for nutritional intake. IV. Facility follow upOn 11/17/23 NHA submitted additional information. Specifically, the physician documented the resident had some decline in the month of August 2023 related to recent surgery, hip pain, and overall changes, however, the resident's weight had returned to her baseline. She said the resident had remained around 110 lbs since March 2023. She said the resident had a hip fracture at the end of July 2023 and returned on 8/3/23 with an initial weight of 123.8 lbs. She said the resident resumed back to her base weight of 110 lbs. She said the rapid increase in weight over three days could not be explained by calories and was likely related to the resident receiving several liters of intravenous fluids (IV) while in the hospital. She said the resident's rapid decline and stabilization upon returning to the facility suggested the weight change was due to fluids. She said the resident's weight continued to be around 110 lbs.

A recertification survey with complaint #CO34159 was completed on 11/13/23-11/16/23. One deficiency was cited.

An Emergency Preparedness survey was conducted from 11/13/23 to 11/16/23. No deficiencies were cited.

Based on record review and interviews the facility failed to ensure one (#89) of five residents reviewed for nutritional status out of 36 total sample residents maintained acceptable parameters of nutritional status such as usual body weight or desirable body weight. Specifically, the facility failed to initiate food supplements when significant weight loss was identified. Resident #89 was admitted to the facility on 8/3/23 after a hip fracture. Her admission weight was 123 pounds (lbs). On 9/7/23 the resident's weight was 109.7 lbs, indicating a significant weight loss of 10.8 percent over the period of one month. Resident #89 was assessed by a registered dietitian (RD), however nutritional supplements were not initiated. Resident #89's weight continued to fluctuate for the next month and she never returned to her admitting weight. In addition, the facility failed to provide cuing and encouragement to Resident #89 during meals. Findings include:I. Facility policy and procedureThe Obtaining and Monitoring weights policy, revised November 2023, was provided by the assistant director of nursing (ADON) on 11/16/23 at 3:51 p.m. It revealed in pertinent part, "Weights will be obtained and monitored throughout the course of a resident's stay, unless otherwise noted in the resident's care plan."Weight loss procedure, the RD or nursing staff will open a Nutrition Event in MatrixCare if a significant weight loss is noted. The provider and responsible party will be notified regarding the weight loss. Planned weight loss (e.g. use of diuretics) does not constitute the need for an event."The RD and/or IDT will review circumstances and possible contributing factors for the weight loss and implement additional interventions as deemed appropriate."The plan of care will be updated to reflect the interventions with involvement of the resident and/or the resident's representative to ensure the resident's needs, preferences and goals are met."Continuing weight loss despite reasonable efforts to improve caloric and nutrient intake may indicate the resident is in multi-system failure or an end-stage or end-of-life condition warranting an additional assessment of the resident's overall condition."II. Resident #89A. Resident statusResident #89, age 89, was admitted on 2/7/23. According to the November 2023 computerized physician orders (CPO), diagnoses included acute left minimally displaced intertrochanteric proximal femur fracture, Alzheimer's disease with early onset, and advanced dementia. The 8/9/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment. Interview for mental status score was not conducted. She required substantial/maximal assistance, of self care one/two person for more than half the effort with most activities of daily living (ADLs). She required supervision or touching assistance, verbal cues for eating. B. ObservationsDuring a continuous observation on 11/14/23 beginning at 12:09 p.m. and ending at 3:53 p.m. the following was observed:-At 12:09 p.m. the resident was sitting in the dining room eating her lunch. The resident independently ate her lunch which was cajun pot roast, hash brown casserole, green beans, and spice cake with frosting for dessert. She ate 50 percent of her entire meal. -At 12:34 p.m. the resident was sitting at the table with her food in front of her, and she was sleeping.-At 12:36 p.m. the resident was awake and took a bite of cajun pot roast.-At 12:47 p.m. the resident finished eating lunch, she ate 50 percent of her lunch.-At 12:55 p.m. the resident was sitting at the dining room table in a chair and she was sleeping.-At 2:43 p.m. the resident was walking with her walker around the dining room area and was assisted by an unidentified staff member who guided the resident back to the dining room table to sit down in the chair for a snack. Resident #89 was offered yogurt and orange juice to drink.-At 2:46 p.m. an unidentified staff member brought the resident a small bag of chips to eat along with the yogurt and orange juice to drink.-At 3:21 p.m. the resident had eaten all of her yogurt and chips. During a continuous observation on 11/15/23 beginning at 9:37 a.m. and ending at 12:40 p.m. the following was observed:-At 10:08 a.m. morning snacks were not offered and the resident was up off the couch and walking around down the hallway. An unidentified staff member followed the resident around the unit and the resident walked back to the couch and sat down.-At 10:49 a.m. until 11:23 a.m. resident laid on the couch asleep.-At 11:39 a.m. resident was awake and an unidentified staff member gave the resident a cup of cranberry juice. The resident drank all the cranberry juice, the unidentified staff member went and got the resident another cup of cranberry juice and placed it on the dining room table. Next to her.-At 11:50 a.m. lunch was being served and an unidentified staff member attempted to wake the resident to come to the dining room table to eat her lunch. The resident refused to get up and continued to lay down on the couch. An unidentified staff member took the resident's tray and placed it in the kitchen in the fridge for her to eat later.-At 12:40 p.m. lunch ended and the resident continued to be sound asleep on the couch. C. Record reviewThe nutritional care plan, revised on 11/14/23, documented that the resident had potential for weight decline related to decrease in oral intake as evidenced by less than 25 percent of meals eaten. The resident needed encouragement to self-dine, the family requested diet liberalization to regular finger foods to improve oral intake. Family members stated the resident ate meals with her "fingers" limited utensil usage at this time. On 9/6/23 the care plan was updated that the resident had a significant weight decline, change in appetite as evidenced by urinary tract infection (UTI). The interventions included being able to consistently consume more than 50 percent of food and fluids provided, monitoring weekly weights as ordered and providing a regular finger foods oral diet as ordered. According to the August 2023 medication administration record (MAR), the resident was not receiving any nutritional supplements. The nutrition progress note dated 8/8/23 care conference note documented in pertinent part. "Potential for decrease in intake, decrease in dinner intake. Weight stable at this time at 121.8 lbs (8/7/23). Readmit nutritional assessment and care plan in place at this time."The nutrition progress note dated 9/6/23 documented "Nutritional event opened related to significant weight decline over the past month. Antibiotics in place for urinary tract infection (UTI). Current body weight 110.3 (8/31/23) lbs, weight down 13 lbs over the past month."-No new interventions were initiated at this time for weight loss. -Resident #89 was not put on nutritional supplements or fortified foods. The nutrition progress note dated 9/14/23 documented the resident's current body weight was 111.2 lbs (9/11/23)with a weight gain of one pound over the past week. Staff encouraged fluids when solid meal items had been denied.-No new interventions were initiated at this time for weight loss. -Resident #89 was not put on nutritional supplements or fortified foods. The nutrition progress note dated 9/29/23 documented body weight 109 pounds (9/25/23). "Weight stable over the past month. Nutritional event discontinued."-No new interventions were initiated at this time for weight loss. -Resident #89 was not put on nutritional supplements or fortified foods. -The resident did not return to her admission weight of 123 lbs as documented on 8/3/23. -There was no nutritional progress note for the month of October 2023. The nutrition progress note dated 11/14/23 documented, "The family requested if finger foods could be removed from the regular diet to increase food intake as evidenced by the resident receiving an increase in meal assistance. Intake trends 25-50%, corrected body weight 108.2 lbs (11/6/23), weight stable over past month with weight down 11 lbs/9.5% over the past quarter. Weight decline related to left hip fracture and UTI. Registered dietitian will follow up with adding a donut at breakfast to assist with oral intake and variety."The resident's electronic medical record (EMR) documented the following weights: -On 7/31/23 the resident was hospitalized for a left hip fracture. She returned back to the facility on 8/3/23. Her weight on admission was 123.8 lbs.-On 8/3/23, the resident weighed 120.6 lbs;-On 9/21/23, the resident weighed 106.6 lbs, with a weight loss of 14.0 lbs (11.66%) in one month;-On 10/16/23, the resident weighed 107.5 lbs, with a weight gain of 0.9 lbs; and,-On 11/6/23, the resident weighed 108.2 lbs, with a weight gain of 0.7 lbs. III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 11/16/23 at 1:59 p.m. He said the resident ate independently and required cueing and prompting once in a while. He said the resident required prompting for one out of three meals provided. He said residents were provided with morning, afternoon and evening snacks. He said the kitchen staff rotated snacks as the residents would receive either tuna sandwiches or peanut butter and jelly sandwiches. He said Resident #89 would receive an occasional Boost (a nutritional supplement drink) if she had a low breakfast intake. He said the resident would be offered a Boost between breakfast and lunch and the Boost was ordered as needed. He said the resident usually ate more during lunch as she really enjoyed grilled cheese sandwiches. He said if the resident did not eat the majority of her lunch then staff would call the kitchen and ask for an alternative. He said the resident was verbal when she wanted to talk. He said the resident was able to verbalize what she did not like but was not able to verbalize what she did like. Registered nurse (RN) #1 was interviewed on 11/16/23 at 4:11 p.m. She said when Resident #89 came back from the hospital in August 2023, after a hip surgery, she was working with therapy and had some weight loss. She said the resident's family was going back and forth with placing the resident on hospice and decided they wanted to continue therapy instead. She said therapy helped the resident and now she was back to baseline. She said the resident's appetite decreased when she was recovering and was not transferring as much due to being in pain. She said the family was focused on comfort and wanted to get the resident back to her baseline. She said the resident's family came in frequently to check in on the resident. She said the family had not brought up any concerns regarding the resident's weight. She said if there were any concerns with any of the residents they would discuss it in morning meetings with the interdisciplinary team which consisted of the nurse manager, dietary, social worker, therapist, doctor/nurse practitioner, assistant director of nursing, director of nursing, nursing home administrator and activities. She said the resident lost some weight but it was due to her not feeling well. She said even though the resident was recovering, she would still come out and eat all her meals in the dining room. She said the resident had started on oxycodone to see if that would help with the pain. She said the pain got better so the family felt that regular food would be better for the resident. She said the resident sat at the assisted table so that the CNAs could monitor her. She said if the resident did not eat her meals the staff would save her tray and make sure she ate when she woke up. She said the resident's diet was changed from a regular diet to finger foods on 8/4/23. She said the resident did better with the sandwiches as she preferred to eat grilled cheese sandwiches and the family thought the finger foods would help. She said the resident's intake had been stable since 8/16/23. She said the resident's best meal intake was breakfast. She said the resident ate about 50 percent of her meals. The registered dietitian (RD) was interviewed on 11/16/23 at 2:29 p.m. She said the resident had her care conference on Tuesday 11/14/23 and the resident was not eating a lot of the finger foods offered, so the family wanted the finger foods discontinued and placed back on regular food for variety and more assistance. She said the resident was needing more assistance such as cueing with her meals as she was not self-initiating during dining. She said when the resident got a urinary tract infection and was recovering from her hip surgery she had a decrease in intake. The RD said on 9/6/23 the resident was not put on a supplement because she figured the resident's weight would come up. She said on 9/14/23 the resident's weight had gone up. She said on 9/29/23 she made no changes in interventions because the resident's weight had stabilized in that month. She said the resident's weight loss had ceased and no additional interventions were needed. She said the resident's body mass indeed (BMI) was considered underweight for her age and weight. She said she could not answer if supplements or fortified food would bring the resident's weight back to normal. She said she would be monitoring the resident since her diet changed to regular food before adding any supplements. The primary care provider was interviewed on 11/20/23 at 2:33 p.m. She said the resident's weight had been stable from spring to summer. She said unfortunately the resident had a fall in July 2023 and when she came back from the hospital she weighed 123 lbs. She said the weight gain was due to the resident receiving fluids after surgery. She said she did not think that the resident's weight gain was due to her eating more food. She said rapid weight gain was from the fluids she had received while in the hospital. She said that within two weeks the resident had dropped back down to 110 lbs. She said the dietician saw the resident frequently after her hospital stay and opened up an event when she noticed the resident's weight had changed. She said that the dietitian was keeping a close eye on the resident's weight. The physician said she saw no concern with the resident's weight and said the resident's weight was stabilized now. She said she did not think that the resident needed supplements at this time as the resident was at her baseline weight and supplements were not appropriate at this time. She said she did not know what the resident's weight was prior to being admitted to the facility. She said the resident's family said the resident had always been a "tiny gal."She said during meal times the unit had two aids on the unit to supervise and assist the residents. She said the resident was independent and does not need assistance or supervision while eating her meals. She said the resident had always been able to feed herself. She said any time there was a weight fluctuation or change in status with any resident, she was part of the daily morning meeting. She said she was part of daily occurrences and any events that opened up for residents. She said interventions were implemented at the time she returned from the hospital but said the resident did not need any updated interventions regarding weight at that time. She said she had no nutritional concerns when the resident had a urinary tract infection. She said the staff was monitoring her closely for what she was eating and the resident would eat well. She said that due to the resident eating well that she saw no concerns or additional concerns regarding increase for nutritional intake. IV. Facility follow upOn 11/17/23 NHA submitted additional information. Specifically, the physician documented the resident had some decline in the month of August 2023 related to recent surgery, hip pain, and overall changes, however, the resident's weight had returned to her baseline. She said the resident had remained around 110 lbs since March 2023. She said the resident had a hip fracture at the endof July 2023 and returned on 8/3/23 with an initial weight of 123.8 lbs. She said the resident resumed back to her base weight of 110 lbs. She said the rapid increase in weight over three days could not be explained by calories and was likely related to the resident receiving several liters of intravenous fluids (IV) while in the hospital. She said the resident's rapid decline and stabilization upon returning to the facility suggested the weight change was due to fluids. She said the resident's weight continued to be around 110 lbs.

Based on observations, record review and staff interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to:-Demonstrate proper hand hygiene while assisting a residents with their meals; -Ensure control measures for monitoring and preventing Legionella and waterborne pathogens growth were included in the facility's water management plan; and,-Pass medications in a sanitary manner. Findings include:I. Proper hand hygieneA. Professional referenceThe Colorado Retail Food Regulations, effective 1/1/19 and retrieved 11/20/23 from https://cdphe.colorado.gov/environment/food-regulations revealed in pertinent part, "Cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food and lip-contact surfaces is prevented."B. Facility policy and procedureThe Standard Precautions policy and procedure, revised November 2023, was provided by the nursing home administrator (NHA) on 11/16/23 at 2:00 p.m. It revealed in pertinent part, "Health care workers must perform hand hygiene (even if gloves are used): Before and after direct contact with a resident, before performing an aseptic (minimizing contamination) task, after contact with inanimate objects in the residents room especially those in the immediate vicinity of the resident and before and after meals."C. Observations Staff were observed touching the mouthpiece of residents ' drink glasses during meal service after using frequently touched items at the drink station such as drink pitchers and a pump container of thickening agent. The staff failed to perform hand hygiene before touching the mouthpiece of drink glasses and carried glasses and cups using the handle or base of the glass. The staff also failed to perform hand hygiene before utilizing a resident's silverware to assist in cutting her food. Dining room observations were made on 11/13/23 from 11:40 a.m. to 12:30 p.m. At 11:57 a.m. certified nurse aide (CNA) #2 picked up a pitcher from a drink station and filled two drink glasses. CNA #2 then used her hand to pump a gel thickener into each glass and used a spoon to stir the drinks. CNA #2 then carried the two full drink glasses with her bare hands around the mouthpiece of the glass and sat them in front of a resident at a dining table. At 11:59 a.m. CNA #2 poured a can of soda into a drink glass and then used her hand to pump a gel thickener into the glass. CNA #2 held the mouthpiece of the glass with one hand and used a spoon to stir the drink with her other hand. CNA #2 then carried the drink glass and set the drink on the table in front of a resident who then took a drink from the glass. At 12:03 p.m. CNA #2 placed two drinking glasses on the counter. CNA #2 then grabbed a drink pitcher and poured a red colored beverage into one glass, grabbed a second pitcher and poured water into the second glass. CNA #2 then carried the two drink glasses to the dining room with a finger around the mouthpiece of the glasses and placed the glass of water at one table and then glass of red drink at another table. At 12:05 p.m. CNA #2 pushed her hair behind her ear with her fingers, then stirred a drink on the table with a spoon, removed a straw from the wrapper, put the straw in the glass she just stirred and offered a resident a drink from the same glass. The resident took a drink. -CNA #2 failed to perform hand hygiene after touching her hair and then stirring a resident's beverage and placing a straw inside the glass. At 12:11 p.m. CNA #2 poured hot water from a pitcher into a coffee cup and placed a tea bag in the hot water. CNA #2 carried the coffee cup to a dining table with her hand around the mouthpiece of the coffee cup, and set the cup in front of a resident. The resident drank from the coffee cup during the meal. At 12:12 p.m. CNA #2 placed a drinking glass on the counter, picked up a water pitcher and filled the glass with water while her fingers held the mouthpiece of the glass. CNA #2 then carried the drinking glass while still touching the mouthpiece and set it in front of a resident at a dining table. Dining room observations were made on 11/15/23 from 12:00 p.m. to 12:40 p.m. At 12:12 p.m. an unidentified staff member poured coffee from a pitcher into a coffee cup, then carried the coffee cup with his fingers around the mouthpiece of the cup and set the cup on a dining table in front of a resident. The resident drank from the coffee cup. At 12:13 p.m. CNA #2 placed two glasses on the counter and filled the first glass with water from a pitcher. CNA #2 then opened a can of soda and filled the second glass. CNA #2 then brought both drinks to a resident at a dining table. At 12:15 p.m. CNA #2 offered a resident sitting at a table to heat up his cup of coffee. CNA #2 took the coffee cup and walked to the microwave, opened the microwave and placed the coffee cup inside the microwave to heat up the coffee. CNA #2 then removed the coffee cup from the microwave and returned to the resident's table carrying his coffee cup with her fingers around the mouthpiece. CNA #2 then set the coffee cup on the table in front of the resident. The resident then drank out of the coffee cup. At 12:19 p.m. CNA #2 carried a coffee cup to the table by the handle and set it down on the table. CNA #2 then removed her hand from the handle of the coffee cup and grabbed the mouthpiece of the coffee cup to turn the cup so the resident was able to reach the handle of the coffee cup. At 12:37 p.m. an unidentified staff member delivered a meal tray to a resident's table and set the tray on the table. The unidentified staff member then removed the resident's meal plate from the tray and set the plate in front of the resident. The staff member did not perform hand hygiene, then unrolled the resident's silverware from the clean linen napkin and used the resident's silverware to cut the residence food and then handed the silverware to the resident.-The meal trays used to deliver meals were not sanitized in between each meal delivery and staff set the meal trays on the residents ' dining tables during meal times. After a meal was dropped off at a resident's table, the tray was returned to the bottom of a stack of trays to be used for additional meal deliveries during the same meal service. D. Staff interviews The assistant director of nursing was interviewed (ADON) on 11/16/23 at 10:00 a.m. The ADON said she had concerns about handwashing, and handwashing was something the facility always continued to improve on and the facility did hand washing audits monthly. The facility completed the hand washing audits observing staff in resident rooms and in the dining rooms. The infection preventionist (IP) was interviewed on 11/16/23 at 10:00 a.m. The IP and ADON said handling of the cups in the dining room would be observed more going forward. The ADON was interviewed on 11/16/23 at 12:40 p.m. The ADON said she provided facility staff with training to not touch the mouthpiece of the drinking glasses. The ADON said staff stated to her during the training the mouthpiece of the drinking cups were touched in the dining room. The ADON was interviewed on 11/16/23 at 2:05 p.m. The ADON said when she provide education to CNA #2 about hand hygiene in the dining room, CNA #2 acknowledged that she did carry resident beverage cups and glasses by the mouthpiece. E. Facility follow upThe ADON provided follow up education presented to CNA #2 on 11/16/23 at 2:05 p.m. The topics the CNA was educated on included: not touching the top of resident cups while serving beverages, using handles on mugs to deliver and education on hand sanitizing before cutting up resident food to prevent cross contamination. The ADON provided a Sanitary Serving in-service documentation on 11/16/23 at 2:05 p.m. The inservice was given on 11/16/23 and previously in April 2023 to facility staff members. Pertinent information in the inservice included: "Never pick up drinking glasses from the rim, always pick them up from the bottom, hand hygiene should be performed after touching dirty dishes and between each tray passed."II. Monitoring legionellaA. Professional referenceThe Center for Disease Control and Prevention (CDC) recommendations for Legionella, last reviewed on 3/25/21, was retrieved on 11/20//23 at https://www.cdc.gov/legionella/wmp/healthcare-facilities/healthcare-wmp-faq.html under Healthcare Water Management read in pertinent part: "Healthcare facilities, such as hospitals and nursing homes, usually serve the populations at highest risk for Legionnaires' disease. These include older people and those who have certain risk factors, such as being a current or former smoker, having a chronic disease, or having a weakened immune system. Also, healthcare facilities can have large complex water systems that promote Legionella (the bacterium that causes legionnaires' disease) growth if not properly maintained. For these reasons, the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) consider it essential that hospitals and nursing homes have a water management program that is effective in limiting legionella and other opportunistic pathogens of premise plumbing (waterborne pathogens, for short) from growing and spreading in their facility."Water management programs identify hazardous conditions and take steps to minimize the growth and spread of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key activities are routinely performed in a Legionella water management program: Establish a water management program team; describe the building water systems using flow diagrams and a written description; identify areas where Legionella could grow and spread; decide where control measures should be applied and how to monitor them; establish ways to intervene when control limits are not met; make sure the program is running as designed (verification) and is effective (validation); document and communicate all the activities."Members of a building water management program team work together to: Identify ways to minimize growth and spread of legionella and other waterborne pathogens, conduct routine checks of control measures to monitor areas at risk, and take corrective action if a problem is found."Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions. Programs should include predetermined responses to correct hazardous conditions if the team detects them."B. Facility policy and procedureThe Legionella policy and procedure, revised December 2022, was provided by the assistant director of nursing (ADON) on 11/14/23 at 10:42 p.m. It revealed in pertinent part, "In man made settings, Legionella can grow if water is not properly maintained and then small drops of water that contain the bacteria get into the air and people breath them in. Those at highest risk for Legionnaires' disease are persons with weakened immune systems, chronic lung diseases and certain comorbidities. The most likely sources of infection include water used for showering, cooling towers used in large air cooling systems, hot water tanks and heaters, large plumbing systems, decorative fountains and hot tubs."C. Record reviewThe Water Management Plan, dated April 2023, was provided by the NHA on 11/14/23 at 3:00 p.m. The Water Management Plan documented protocols for vacant or unoccupied rooms and staff responsible for the protocol were housekeeping staff. Protocols revealed the maximum number of days a room was allowed to be vacant without action was three days. Protocols for rooms recently vacated were to open every plumbing fixture in the room on maximum hot setting for approximately one minute, open every plumbing fixture in the room on cold setting for approximately one minute, flush the toilet one time, and clean and disinfect the room. Protocols for rooms vacant more than three days were to open every plumbing fixture in the room on maximum hot setting for one minute and open every plumbing fixture in the room on maximum cold setting for one minute and flush the toilet. The potable system monitoring frequency revealed empty rooms were to be flushed daily. The Water Management Plan revealed internal measures and corrective actions were put in place for areas that had potential for Legionella colonization and growth or other organizations in the facility ice machines. The ice machines were to be cleaned according to the manufacturer's instructions.-The facility was unable to provide documentation of monitoring or control measures for recently vacated rooms, rooms vacant more than three days or facility ice machines as required by the facility Water Management Plan. D. Staff interviewsThe NHA was interviewed on 11/16/23 at 12:30 p.m. The NHA said housekeeping staff cleaned resident rooms daily when the rooms were empty. The housekeeping department kept track of empty resident rooms and room turnover. The NHA said the facility changed that the housekeeping will monitor the vacant room flushes in the future. The NHA said she was unable to find the ice machine cleaning records because the records were previously electronic records and not saved, and the facility did not have any additional written records of the ice machine cleaning. III. Failure to follow infection control practices during medication passA. ObservationsRN #3 was observed on 11/14/23 at 11:54 a.m. during medication administration. On three occasions she was observed passing medication to the residents in the dining room. RN #3 she disposed of the plastic medication cups into the trash by pushing the trash lid with the side of her hand. -She did not sanitize her hands prior to passing medications to the next resident. B. Staff interviewThe assistant ADON was interviewed on 11/16/23 at 4:30 p.m. She said all staff were expected to clean or sanitize their hands after touching the lid on the trash. She said the plan was to educate the staff on proper hand hygiene and to replace the trash bin with a different one where the lid was operated by the foot pedal.

A revisit survey was completed on 9/20/23 for all previous deficiencies cited on 7/26/2023. The facility is in compliance with all regulations surveyed.

A revisit survey was completed on 9/20/2023 for all previous deficiencies cited on 7/26/2023. The facility is in compliance with all regulations surveyed.

A survey prompted by complaint #CO33237 was completed 7/12/23 to 7/26/23. One deficiency was cited.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of four sample residents received adequate supervision and services to prevent an accident/hazard. Resident #1 had diagnoses of dementia, bilateral knee contractures and chronic pain. She required extensive assistance with a mechanical lift to transfer. The facility had mechanical ceiling lifts in resident rooms and tub rooms. Resident #1 had a brain injury due to a fall from a ceiling lift on 5/27/23 at approximately 11:00 a.m. According to the facility investigation, Resident #1 had fractures of the right and left femur (thigh bone), C1 and C2 fractures (neck), right clavicle fracture and a subdural hematoma (bleeding in head between brain and outermost covering) due to the fall. She passed away at the hospital. The facility investigation documented the resident was a two person transfer with a ceiling lift, and the nurse aide was transferring the resident with the ceiling lift by herself. The investigation revealed one of the sling loops came off the lift hook causing the resident to fall. Findings include: I. Facility policy and procedureThe Transferring, Lifting, Repositioning policy, revised 5/31/23, was received from the director of nursing (DON) on 7/13/23 at 12:07 p.m. The policy documented in pertinent part, "Upon admission or change of condition, residents will be evaluated for their ability to transfer safely. Mechanical lift transfers may be completed by one or two staff in accordance with facility protocol. No staff member is to use a mechanical lift device until properly educated on its use. Utilize the Mechanical Lift (sling) for: Anyone requiring maximum assistance of one person for lifting or transfers; Anyone requiring 2 people to transfer or lift; Anyone unable to bear weight for at least 4 seconds (so they can't safely stand/pivot); Anyone who is unpredictable with the amount of assistance they require (if their knees tend to 'give out' , if they resist when trying to transfer or lift, or if they are uncooperative at times); Any situation where it is unclear if the resident can be transferred safely with the assistance of one person; or anytime a resident is on the floor and needs to be lifted to a chair or bed. Residents will be re-evaluated throughout their stay for any possible changes to their transfer status, which will be communicated to nursing and therapy staff. See sling color chart for (lift manufacturer) slings."II. Resident statusResident #1, over 65 years old, was admitted on 8/27/18 and readmitted on 11/12/18 and discharged to the hospital 5/27/23. According to the July 2023 computerized physician orders (CPO) diagnoses included right and left knee contractures, dorsalgia (back pain) and osteoarthritis. The 5/19/23 facility assessment revealed the resident was severely cognitively impaired and unable to complete a brief interview for mental status score (BIMS). She had short term memory loss and moderate difficulty making daily life decisions. She required extensive two person assistance with transfers, and extensive one person assistance with bed mobility, toileting, dressing, and personal hygiene. She had not had any falls since her last assessment. III. Facility investigationThe facility investigation was received on 7/12/23 at 12:10 p.m. from the nursing home administrator (NHA). The investigation documented:A form titled Occurrence summary, dated 5/27/23, in the investigation file documented Resident #1 was being transferred from bed to wheelchair with the ceiling lift by nurse aide (NA) #1 who was working as the bath aide. The resident sustained a fall to the floor with neurological changes and complaints of left leg pain. The resident landed on the floor mat with her upper body on the floor. The resident was sent to the hospital and diagnosed with fractures to both femurs, C1 and C2 vertebrae of the neck, right clavicle fracture and subdural hematoma. NA #1 reported that she had been using two hands to operate the ceiling lift remote, as it was not functioning properly. A loop on the sling slipped off the lift and the resident fell out of the sling. The investigation documented the NA transferred the resident without two people using the ceiling lift, and the resident's care plan said she was a two person transfer. The charge nurse, registered nurse (RN) #2, contacted the on-call nurse manager, the staff development coordinator (SDC). The SDC came into the facility at 11:53 a.m. and began interviewing the staff involved. The investigation documented the director of nursing (DON) and nursing home administrator (NHA) were notified on 5/27/23, and the SDC finished the investigation on 5/27/23 at 5:00 p.m. Interviews in the investigation file documented the following:Nurse aide (NA) #1 documented she had just finished Resident #1's bath. She said in the tub room she had to hold the wire at the base of the remote for the ceiling lift to work. She took the resident to her room. She used the ceiling lift in the resident's room to transfer the resident. NA #1 said she had to hold the cord at the base of the remote in a certain way for the buttons to function on the ceiling lift. She connected the loops of the sling to the bar of the lift. She began to lift the resident but the right lower loop was not connected. She lowered the resident back down and reconnected the right lower loop. The NA said after reconnecting the loop she started the lift again and stated she started struggling with the remote control. She said the cord appeared to be not connected to the remote. The NA said she was focused on holding the remote correctly at the top so the buttons would work on the lift's remote. She said both hands were on the remote in order for the lift to work correctly. Resident #1 was suspended over the floor mat which was still in place adjacent to her bed. NA #1 said it appeared the right lower loop on the sling disconnected again from the lift hook. The resident fell, landing on her bedside mat diagonally, with her head on the floor, both legs were under the bed and the right knee hit the vertical post under the bed and the left leg followed. She said she did not have her resident information sheet (RIS). She knelt next to the resident, held the resident's head and tried to find a pulse. She began yelling for help and pushed the call light. Two certified nurse aides (CNAs) came within two minutes and ran for the nurse. She said RN #3 and RN #1 responded within five minutes. RN #1 documented a CNA came and told her she needed a nurse. RN #1 said she and RN #3 ran to the room and observed Resident #1 lying diagonally on the floor mat. NA #1 was holding the resident's head. NA #1 told RN #1 that she was transferring the resident when one of the loops came off. The NA said she tried to protect the resident's head as she fell. RN #1 said she could only hear a faint heartbeat at her chest. She said RN #3 obtained a pulse in the 50s on the resident's wrist (normal pulse for this resident was 54 to 72 beats per minute). RN #1 said she did not see any lumps or bumps on the resident's head but the resident's pupils were sluggish to react and unequal. She was unsure if this was the resident's normal baseline. RN #1 said she called for the charge nurse. The charge nurse, RN #2, arrived at the room. RN #1 documented she focused on stabilizing the cervical (neck) spine while RN #2 inspected the resident's lower extremities for passive range of motion. RN #1 said Resident #1 was not initially responsive to verbal or tactile stimulation, but her eyes were open. Resident #1 became more alert with the exam of her lower extremities. RN #2 left the room to call the family. RN #2 returned and said the family wanted to discuss with each other whether to send the resident to the hospital. RN #1 said that RN #2 observed the resident's left foot was rotated inward. The right leg appeared normal. RN #2 left the room again to inform the family of a possible fracture to the left leg. RN #1 said the resident's power of attorney (POA) arrived and asked the resident how she was doing, the resident responded she was not doing well. The resident said her left leg hurt. RN #1 said emergency medical services (EMS) arrived a few minutes later and the resident was transferred to the hospital. RN #3 documented at approximately 10:50 a.m. she heard a CNA yelling down the hall they needed a nurse. She said she and RN #1 ran to Resident #1's room. The resident was lying on the floor on her fall mat on her right side. Her legs were hitting the bottom of the bed. The bath aide (NA) #1 was with the resident. NA #1 said she was transferring the resident with the ceiling lift from the bed to the wheelchair, had trouble with the remote and one of the straps on the sling came undone from the lift. RN #3 said Resident #1 appeared to be having a hard time breathing and was not responding, just staring off into space. RN #3 said she did not know if the resident hit her head on the floor or the fall mat next to her bed. She said she ran to get the vital sign equipment, RN #1 stayed with the resident and RN #2 went to call the family. RN #3 said Resident #1's blood pressure and respiratory rate were elevated. She said RN #1 listened to the resident's chest, but had a hard time hearing her heartbeat. RN #3 said she was able to locate a pulse on the resident's wrist and it was in the 50s. RN #3 said RN #2 arrived. RN #3 said she turned the resident's oxygen up from one liter per minute (LPM) to four liters per minute to keep the resident's oxygen saturation above 90%. She said RN #2 assessed the resident's eyes and said her pupils were sluggish and the right more dilated than the left. RN #3 said the resident continued to appear to have difficulty breathing. She said RN #2 left to call the family and she monitored the vital signs while RN #1 stabilized the resident's neck. RN #3 said the resident became more alert and started to answer questions but not at her baseline. She said the resident was still staring off in space. RN #3 said RN #2 had spoken to the family and they would discuss what they wanted to do. RN #3 said she, RN #2, RN #1 and NA #1 transferred the resident to the bed to be more comfortable. RN #3 said the resident was more comfortable in bed and appeared to be breathing easier and began to answer questions. RN #3 said the distal end of the left thigh area appeared deformed. RN #2 left to call the family again. RN #3 said the family arrived and the resident told them she was not doing well and had pain in her left leg. The resident was transported to the hospital via EMS per the family's request. RN #2 documented the resident had fallen from the ceiling lift. She was lying diagonally on the floor mat with her legs under the bed. She had a pillow under her head. RN #2 said Resident #1 was diaphoretic (sweating heavily). She was less alert than her baseline. RN #2 said her oxygen saturation level was low and it had been difficult to obtain vital signs. She said her legs appeared bent, without obvious injuries. She said her right pupil was larger than the left and she had a change in cognition. RN #2 said she had no bumps on her head. RN #2 said Resident #1 said "ouch" a few times during the assessment but could not state the location of her pain. RN #2 said she left to call the family due to the advance directive medical orders for scope of treatment (MOST) form documenting comfort care was desired. She said the family would discuss what they wanted to do. RN #2 said upon further assessment of Resident #1, the left thigh area had a bump and was visibly deformed. She left to call the family again. RN #2 said the family came to the facility. The resident was sent to the hospital. The investigation documented the resident passed away on 5/28/23 at 1:40 a.m. in the hospital. It further documented the hospital records listed the immediate cause of death was heart block; other significant conditions which contributed to the death included C1 and C2 fracture, right and left femur fractures. The facility findings in the investigation documented:The resident fell while using a mechanical lift and sustained an injury. Safety interventions and facility's policies and procedures were not followed. The fall was due to human error but may be secondarily due to equipment malfunction. Resident #1 required two people to transfer with the lift due to pain. The resident was transferred with one person and the nurse aide did not have a RIS with her to indicate how the resident transferred. NA #1 was working as the bath aide that day and the bath sheet did not contain the resident's transfer status. The facility documented they changed the policy after this to print out an RIS for the bath aide each day for all the halls. The maintenance department was notified of the issue with the ceiling lift in Resident #1's room and in the tub room. NA #1 was suspended on 5/27/23 and the facility terminated her employment on 6/1/23. The facility documented NA #1 had not followed facility policy, she did not have a second person with her for a ceiling transfer, and the resident was not secured properly in the lift. NA #1 reported that she had trouble with the lift remote, however this had not been reported to the charge nurse or maintenance. The termination further documented the NA had transferred the resident three previous times without seeking assistance. The SDC documented she tested the ceiling lift in the tub room and in Resident #1's room that morning and the lifts only worked intermittently. The lift in the resident's room appeared to have a connection issue at the cord and remote which was what NA #1 had described. The lift in the tub room and the buttons on the controls failed intermittently with weight to the sling. She documented the ceiling lift belt that extended down to the bar which held the sling was observed to be frayed. The facility documented their plan was to provide education both verbal and written to NA #1. The NA was suspended and sent home pending the investigation. It documented the NA did not follow proper transfer techniques and did not tag out faulty equipment. The facility documented it intended to conduct education for all staff on ceiling lifts and education on maintenance. The investigation documented immediate transfer training was started 5/27/23, with education on not using equipment that was not functioning properly and notifying the maintenance department. On 5/27/23 the education, titled Transfer Safety Education, was based on the previous facility policy that allowed ceiling lift transfers to be done by one or two people. The education included steps for a safe transfer with a one or two person assist, including proper sling placement and ensuring the sling straps were secured properly and evenly. The education documented to never use a piece of equipment that was not functioning properly. Notify the maintenance department via a maintenance request that a repair was required as soon as possible. Always transfer resident as indicated on the RIS. The RIS should be carried by all CNAs each shift. On 5/28/23, the education titled Transfer Safety Education was revised. It documented two people were needed to assist a resident with a ceiling lift transfer. The first person would operate the lift controls and assist with resident positioning. The second person would manage the resident's extremities for safety, manage oxygen or catheter tubing as needed and assist with positioning. On 5/30/23 a Transfer Training inservice reviewed safety and the current lift transfer policy. Nurse managers would complete routine audits to observe staff transfer residents with ceiling for lifts, daily for two weeks, weekly for four weeks, monthly for three months and quarterly for four quarters. The investigation documented the evening charge nurse on 5/28/23 completed an audit of the facility ceiling lifts. The investigation documented the maintenance department assessed the lift in the affected resident's room on 5/30/23. The only issue noted was an issue with the battery that did not interfere with safety. A ceiling audit lift done by maintenance on 5/31/23 indicated the lift in Resident #1's room was no longer in use. Additionally, 56 other lifts were removed or tagged out to not use due to, for example, issues with the emergency stop switches, hand controls or remotes not working properly, cracks in chassis (load bearing portion of lift) and wheels, worn straps and battery issues (see below).-Although 56 lifts were removed or tagged, six residents who required the ceiling lifts were changed to a mechanical hoyer lift. The facility investigation documented they had updated their Transfer and Lift policy on 5/28/23, from one to two person assist with lifts based on the resident status to two person assist with all lifts. The facility charge nurses and nurse managers completed random audits of staff transferring residents with a mechanical lift. The random audits by the nurse managers and charge nurses were reviewed. The facility had completed 47 random observations of lift transfers with the nursing staff since the fall on 5/27/23. One person required more education, which was immediately completed. The facility investigation concluded the cause of the fall from the lift was due to the NA not having second person with her for the transfer, not carrying the resident information sheet with her, verifying placement of the sling loops on the ceiling lift, the ceiling lift remote not functioning and the ceiling lift not being tagged and removed from service when the NA first noticed the issue with the remote. IV. Observations and interviewsCNAs #1 and #3 were interviewed on 7/12/23 at 10:40 a.m. during an observation of transferring Resident #2 with a ceiling lift. CNA #1 said she heard Resident #1 fell during a ceiling lift transfer due to the sling not being properly connected and the remote was not working correctly. CNA #1 and CNA #3 said in the past the CNAs could use the ceiling lift with one or two people to transfer. They said after the resident had the fall from the lift, the staff had to use two people. CNA #3 said they were in-serviced about a month ago to use two people for the lifts. The two CNAs began to roll Resident #2 and place a sling under Resident #2 to transfer him with the ceiling lift. The resident was then lifted by the ceiling lift with CNA #1 controlling the lift and CNA #3 guiding the resident from the bed to the wheelchair. CNA #1 said a resident's transfer status was listed on the RIS (resident information sheet) the CNAs carried in their pockets. She said the charge nurse updated them with a new admission or change in condition for a resident. CNA #1 said the RIS was a list of basic things the resident needed like how they transferred, whether to use a lift and how many staff were needed to assist the resident. CNA #2 was interviewed with CNA #3 on 7/12/23 at 10:51 a.m. while transferring Resident #3 with the ceiling lift from bed to wheelchair. CNA #4 entered the room after a few minutes and introduced herself as the CNA team lead. CNA #2 controlled the lift and CNA #3 guided the resident to the wheelchair. CNA #2 said she had training on the lifts about two months ago due to a resident who fell out of a sling from a lift. She said the training consisted of a demonstration of the lift and placement of sling loops. She said she did not have to demonstrate how to use the lift and there was no quiz or other follow up from the inservice. She said the staff were educated that all residents who used a lift required two staff members to assist. CNA #2 said in the past, some residents could be transferred with the lift and one staff member to assist. CNA #2 said the RIS sheet told the staff how to transfer the resident. She said each resident had their own sling in their room. CNA #2 said she checked the lifts to make sure there was no red warning light on. She said some of the other lifts had red lights on but those had not been used since Resident #1 fell. Resident rooms on the second floor were observed on 7/12/23 at 3:59 p.m. Rooms 2109, 2209, 2217, 2509 and 2409 had signs on the ceiling lift to not use them. Resident #1's room, the ceiling lift was removed. V. Record review and interviewsThe NHA was interviewed on 7/12/23 at 12:10 p.m. She said the maintenance supervisor (MS) was new and had started on 6/1/23. She said the regional maintenance director (RMD) had completed an audit of all ceiling lifts for any malfunctioning or repairs needed on 5/31/23. The NHA provided a copy of the maintenance audit of the ceiling lifts and personnel file for NA #1 on 7/12/23 at 3:43 p.m. The NHA said the maintenance audit was done on 5/31/23 by the RMD. She said the facility was built in 2007 and many of the ceiling lifts in resident rooms and tub rooms were installed at that time. She said some were installed later according to the audit done by the RMD and dates on the lifts. The untitled, undated, unsigned resident room ceiling lift audit completed on 5/31/23 by the RMD according to the NHA, revealed the following information:Twenty-nine rooms listed as room number "0." The lifts were dated 2004, 2005 and 2007. Repairs needed included one or more of the following for each lift: emergency stop switch issue, maintenance light was on, see damage report, cracked chassis, batteries and hand control issues, new strap needed on lift, new strap switch plate needed, new switch board and chassis needed. It was unclear where these lifts were located. Twenty-five rooms, with specific room numbers listed, dated 2004 and 2007, documented emergency stop switch issues, hand control issues, battery concerns, cracked chassis and maintenance lights that were on. Six of these rooms were highlighted in the audit. The audit did not indicate what the highlighting meant. These six rooms were observed during the survey with signs on the lifts to not use them (see above). The residents in these six rooms required a lift, and the hoyer lift was used. Resident #1's room number was not listed on the audit (the lift may have had one of the lifts listed as room "0.") Resident #2 and Resident #3's rooms were listed on the audit as no repairs needed. The RMD was interviewed with the NHA on 7/13/23 at 10:48 a.m. The RMD said he could not locate any previous maintenance records for the ceiling lifts. He said he had been in contact with the manufacturer and had signed a contract to have the manufacturer come out and inspect the lifts. He said it would be next month in August but he did not have a date yet. The NHA said the staff knew to let the maintenance supervisor know if there were any issues with the lifts. She said the facility had started a new process for maintenance requests. The NHA said she did not remember when, she thought maybe in June 2023. The new process involved having a maintenance book on each floor where the staff could write their concerns and the maintenance supervisor would review when he was in and sign off the request. The RMD said the rooms listed as "0" on the 5/31/23 ceiling lift audit were lifts he removed from rooms. He said he did not keep track of which ones were removed from which rooms. He said the highlighted rooms on the audit that had maintenance issues were six rooms where the resident needed a lift and the staff should use a portable mechanical lift and not the ceiling lift. He said a sign had been placed on the ceiling lift to prevent use. The RMD said the rest of the resident rooms with ceiling lift issues were residents who did not use the lifts. The NHA or RMD did not have a process to track if a resident's transfer status in those rooms changed and they needed to use the lift to ensure the staff did not use the ceiling lifts. The RMD said he had checked the lifts with his assistant on 5/31/23 for maintenance lights, issues with the switchesfor the emergency stops, cracked chassis housing, worn straps, hand control issues and battery issues. He said the lifts would be inspected again by him next quarter. The RMD said he assessed the four tub lifts on 5/31/23 and the lifts were working appropriately. The maintenance supervisor (MS) was interviewed with the NHA on 7/13/23 at 11:57 a.m. The MS said he had the position at the facility on 6/1/23. He was the only maintenance person for the facility but he could call the regional maintenance director (RMD) if he needed to. The MS said if the staff had a maintenance issue, they logged in a maintenance book on each floor. He said he checked the maintenance books when he came in each day. The MS said the staff had sometimes left him sticky notes on his door, sent him an email or called him if there was a maintenance issue rather than writing it in the maintenance book. He did not have a preferred method for the staff to communicate with him. The NHA said the facility had started the new process of writing maintenance requests in books on each floor a month or two ago, but she could not remember. She said she was unhappy with an outside company who the facility used for maintenance tracking and the facility had switched to this new process. The facility general orientation sheet documented NA #1 had been given information and facility's policies about resident handling, transfers and body mechanics. On 7/26/23 at 3:40 p.m., during the survey, the nurse consultant (NC) provided a computer printout that documented NA #1 had nursing orientation on 3/18/23 that included a skills assessment on mechanical lifts. The staff development coordinator (SDC) was interviewed on 7/13/23 at 11:40 a.m. She said she was the nurse manager on call on 5/27/23 and had come into the facility to investigate what happened on 5/27/23. She said the event with Resident #1 was an accident. She said she had spoken to the staff on 5/27/23 about being more intentional with their work by paying more attention to what they were doing. She said it was not the process of the transfer that failed but it was a safety issue. She said she called and spoke to the DON on 5/27/23 about changing the facility's policy on one to two person assistance with the lifts to always having two people to help avoid further risks of errors with transfers. The SDC said she began to inservice the staff at the facility on 5/27/23 on transfer safety education. She said she thought maintenance did some audits of the lifts on 5/28/23. The SDC said she posted on 5/28/23 mandatory transfer training scheduled for 5/30/23, 5/31/23 and 6/1/23 in 30 minute blocks. The SDC said it was not that NA #1 did not know how to transfer the resident. She was trained before she went on the floor. She said the staff all know how to transfer the residents with the lifts. She said they just needed to be more mindful and purposeful with their work. The SDC said on 5/30/23 the facility changed their policy to always having two people to transfer a resident using a lift. She said during a transfer with ceiling lift, the second person's job was to guide the resident's legs and body while the first person operated the remote and lift. The SDC said the education on 5/30/23 through 6/1/23 consisted of a demonstration on the ceiling lift and portable hoyer lift. The SDC said all staff were trained when hired on tagging equipment and removing it from use if it was malfunctioning. The SDC said she did not know if all nursing staff had been through the education yet. She said she thought it was about 98% of the nurses and 83% of the CNAs. The SDC said she thought the business office was tracking the staff that still needed to be educated. The SDC said it was not a training issue, it was human error. The DON was interviewed with the NHA on 7/13/23 at 2:35 p.m. She said the facility had begun immediate training with the nursing staff on 5/27/23 regarding lift safety. She said additional education was provided again when the facility changed their policy to having two persons assist with all lifts 5/30/23. Additionally, in person demonstration of lift training was done over the next few days and the charge nurses began random audits of lift transfers and were still doing random transfers according to the facility's follow up plan (see above). The DON said when a resident was admitted the admitting nurse got a report from the hospital. The admitting nurse updated the RIS with the resident's needs including how they transferred. If the transfer status was unknown the resident was transferred with two people until they were assessed by the therapy department. She said the staff would use the mechanical lift if the resident could not bear 50 percent of the weight. The RMD was interviewed again on 7/26/23 at 1:55 p.m. He said some of the lifts were left in resident rooms even though they had maintenance issues after his audit on 5/31/23. He said those lifts were stuck and he could not remove them. The RMD said those rooms had a tag placed on them that indicated not to use them. The RMD was interviewed again on 7/26/23 at 3:40 p.m. He said the ceiling lift manufacturer would be coming to the facility on 7/31/23 to assess all the ceiling lifts for any further issues or parts needed. CNA #1 was interviewed again on 7/26/23 at 2:05 p.m. She said she did not recall any concerns with the lift for Resident #1 prior to the fall. CNA #1 said the staff used to type the maintenance concern on a tablet for the maintenance person. She said last month the facility transitioned to a maintenance request book on each nurses station. CNA #4 as interviewed on 7/26/23 at 2:07 p.m. She said she did not remember any concerns with the lift in Resident #1's room. LPN #1 was interviewed on 7/26/23 at 2:17 p.m. She said she did not remember any issues with Resident #1's lift prior to her fall. The DON was interviewed on 7/26/23 at 2:30 p.m. She said she did not think there were any other resident falls from using the lifts. She said she had been at the facility since it opened in 2007. RN #4 was interviewed on 7/26/23 at 2:50 p.m. She said she was not here the day Resident #1 fell from the lift. She said she heard the fall was due to user error. She said she heard the clip on the lift hook was not closed allowing the sling loop to slip out. She said if there was a concern with a lift, she would put a sign on it to not use it and use a different lift. RN #4 said a request for the maintenance department to look at the lift should be written in the maintenance request book. The DON was interviewed again on 7/26/23 at 3:40 p.m. She said the facility currently had 26 residents that required a mechanical lift. She said 46 of the facility ceiling lifts were functioning properly, 34 lifts had been removed from resident rooms due to maintenance issues, 15 rooms still had lifts in them that did not work and were tagged not to use and four lifts in the tub rooms were working properly. The DON said seven residents were using a Hoyer lift (floor lift) due to the ceiling lift in their room not functioning properly.

A survey for Incident #32548 was conducted from 7/12/23 to 7/26/23. One deficiency was cited.

Based on interviews and record review, the facility failed to ensure one (#1) of three residents reviewed for accidents out of four sample residents received adequate supervision and services to prevent an accident/hazard. Resident #1 had diagnoses of dementia, bilateral knee contractures and chronic pain. She required extensive assistance with a mechanical lift to transfer. The facility had mechanical ceiling lifts in resident rooms and tub rooms. Resident #1 had a brain injury due to a fall from a ceiling lift on 5/27/23 at approximately 11:00 a.m. According to the facility investigation, Resident #1 had fractures of the right and left femur (thigh bone), C1 and C2 fractures (neck), right clavicle fracture and a subdural hematoma (bleeding in head between brain and outermost covering) due to the fall. She passed away at the hospital. The facility investigation documented the resident was a two person transfer with a ceiling lift, and the nurse aide was transferring the resident with the ceiling lift by herself. The investigation revealed one of the sling loops came off the lift hook causing the resident to fall. Findings include:I. Facility policy and procedureThe Transferring, Lifting, Repositioning policy, revised 5/31/23, was received from the director of nursing (DON) on 7/13/23 at 12:07 p.m. The policy documented in pertinent part, "Upon admission or change of condition, residents will be evaluated for their ability to transfer safely. Mechanical lift transfers may be completed by one or two staff in accordance with facility protocol. No staff member is to use a mechanical lift device until properly educated on its use. Utilize the Mechanical Lift (sling) for: Anyone requiring maximum assistance of one person for lifting or transfers; Anyone requiring 2 people to transfer or lift; Anyone unable to bear weight for at least 4 seconds (so they can't safely stand/pivot); Anyone who is unpredictable with the amount of assistance they require (if their knees tend to 'give out' , if they resist when trying to transfer or lift, or if they are uncooperative at times); Any situation where it is unclear if the resident can be transferred safely with the assistance of one person; or anytime a resident is on the floor and needs to be lifted to a chair or bed. Residents will be re-evaluated throughout their stay for any possible changes to their transfer status, which will be communicated to nursing and therapy staff. See sling color chart for (lift manufacturer) slings."II. Resident statusResident #1, over 65 years old, was admitted on 8/27/18 and readmitted on 11/12/18 and discharged to the hospital 5/27/23. According to the July 2023 computerized physician orders (CPO) diagnoses included right and left knee contractures, dorsalgia (back pain) and osteoarthritis. The 5/19/23 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired and unable to complete a brief interview for mental status score (BIMS). She had short term memory loss and moderate difficulty making daily life decisions. She required extensive two person assistance with transfers, and extensive one person assistance with bed mobility, toileting, dressing, and personal hygiene. She had not had any falls since her last assessment. III. Facility investigationThe facility investigation was received on 7/12/23 at 12:10 p.m. from the nursing home administrator (NHA). The investigation documented:A form titled Occurrence summary, dated 5/27/23, in the investigation file documented Resident #1 was being transferred from bed to wheelchair with the ceiling lift by nurse aide (NA) #1 who was working as the bath aide. The resident sustained a fall to the floor with neurological changes and complaints of left leg pain. The resident landed on the floor mat with her upper body on the floor. The resident was sent to the hospital and diagnosed with fractures to both femurs, C1 and C2 vertebrae of the neck, right clavicle fracture and subdural hematoma. NA #1 reported that she had been using two hands to operate the ceiling lift remote, as it was not functioning properly. A loop on the sling slipped off the lift and the resident fell out of the sling. The investigation documented the NA transferred the resident without two people using the ceiling lift, and the resident's care plan said she was a two person transfer. The charge nurse, registered nurse (RN) #2, contacted the on-call nurse manager, the staff development coordinator (SDC). The SDC came into the facility at 11:53 a.m. and began interviewing the staff involved. The investigation documented the director of nursing (DON) and nursing home administrator (NHA) were notified on 5/27/23, and the SDC finished the investigation on 5/27/23 at 5:00 p.m. Interviews in the investigation file documented the following:Nurse aide (NA) #1 documented she had just finished Resident #1's bath. She said in the tub room she had to hold the wire at the base of the remote for the ceiling lift to work. She took the resident to her room. She used the ceiling lift in the resident's room to transfer the resident. NA #1 said she had to hold the cord at the base of the remote in a certain way for the buttons to function on the ceiling lift. She connected the loops of the sling to the bar of the lift. She began to lift the resident but the right lower loop was not connected. She lowered the resident back down and reconnected the right lower loop. The NA said after reconnecting the loop she started the lift again and stated she started struggling with the remote control. She said the cord appeared to be not connected to the remote. The NA said she was focused on holding the remote correctly at the top so the buttons would work on the lift's remote. She said both hands were on the remote in order for the lift to work correctly. Resident #1 was suspended over the floor mat which was still in place adjacent to her bed. NA #1 said it appeared the right lower loop on the sling disconnected again from the lift hook. The resident fell, landing on her bedside mat diagonally, with her head on the floor, both legs were under the bed and the right knee hit the vertical post under the bed and the left leg followed. She said she did not have her resident information sheet (RIS). She knelt next to the resident, held the resident's head and tried to find a pulse. She began yelling for help and pushed the call light. Two certified nurse aides (CNAs) came within two minutes and ran for the nurse. She said RN #3 and RN #1 responded within five minutes. RN #1 documented a CNA came and told her she needed a nurse. RN #1 said she and RN #3 ran to the room and observed Resident #1 lying diagonally on the floor mat. NA #1 was holding the resident's head. NA #1 told RN #1 that she was transferring the resident when one of the loops came off. The NA said she tried to protect the resident's head as she fell. RN #1 said she could only hear a faint heartbeat at her chest. She said RN #3 obtained a pulse in the 50s on the resident's wrist (normal pulse for this resident was 54 to 72 beats per minute). RN #1 said she did not see any lumps or bumps on the resident's head but the resident's pupils were sluggish to react and unequal. She was unsure if this was the resident's normal baseline. RN #1 said she called for the charge nurse. The charge nurse, RN #2, arrived at the room. RN #1 documented she focused on stabilizing the cervical (neck) spine while RN #2 inspected the resident's lower extremities for passive range of motion. RN #1 said Resident #1 was not initially responsive to verbal or tactile stimulation, but her eyes were open. Resident #1 became more alert with the exam of her lower extremities. RN #2 left the room to call the family. RN #2 returned and said the family wanted to discuss with each other whether to send the resident to the hospital. RN #1 said that RN #2 observed the resident's left foot was rotated inward. The right leg appeared normal. RN #2 left the room again to inform the family of a possible fracture to the left leg. RN #1 said the resident's power of attorney (POA) arrived and asked the resident how she was doing, the resident responded she was not doing well. The resident said her left leg hurt. RN #1 said emergency medical services (EMS) arrived a few minutes later and the resident was transferred to the hospital. RN #3 documented at approximately 10:50 a.m. she heard a CNA yelling down the hall they needed a nurse. She said she and RN #1 ran to Resident #1's room. The resident was lying on the floor on her fall mat on her right side. Her legs were hitting the bottom of the bed. The bath aide (NA) #1 was with the resident. NA #1 said she was transferring the resident with the ceiling lift from the bed to the wheelchair, had trouble with the remote and one of the straps on the sling came undone from the lift. RN #3 said Resident #1 appeared to be having a hard time breathing and was not responding, just staring off into space. RN #3 said she did not know if the resident hit her head on the floor or the fall mat next to her bed. She said she ran to get the vital sign equipment, RN #1 stayed with the resident and RN #2 went to call the family. RN #3 said Resident #1's blood pressure and respiratory rate were elevated. She said RN #1 listened to the resident's chest, but had a hard time hearing her heartbeat. RN #3 said she was able to locate a pulse on the resident's wrist and it was in the 50s. RN #3 said RN #2 arrived. RN #3 said she turned the resident's oxygen up from one liter per minute (LPM) to four liters per minute to keep the resident's oxygen saturation above 90%. She said RN #2 assessed the resident's eyes and said her pupils were sluggish and the right more dilated than the left. RN #3 said the resident continued to appear to have difficulty breathing. She said RN #2 left to call the family and she monitored the vital signs while RN #1 stabilized the resident's neck. RN #3 said the resident became more alert and started to answer questions but not at her baseline. She said the resident was still staring off in space. RN #3 said RN #2 had spoken to the family and they would discuss what they wanted to do. RN #3 said she, RN #2, RN #1 and NA #1 transferred the resident to the bed to be more comfortable. RN #3 said the resident was more comfortable in bed and appeared to be breathing easier and began to answer questions. RN #3 said the distal end of the left thigh area appeared deformed. RN #2 left to call the family again. RN #3 said the family arrived and the resident told them she was not doing well and had pain in her left leg. The resident was transported to the hospital via EMS per the family's request. RN #2 documented the resident had fallen from the ceiling lift. She was lying diagonally on the floor mat with her legs under the bed. She had a pillow under her head. RN #2 said Resident #1 was diaphoretic (sweating heavily). She was less alert than her baseline. RN #2 said her oxygen saturation level was low and it had been difficult to obtain vital signs. She said her legs appeared bent, without obvious injuries. She said her right pupil was larger than the left and she had a change in cognition. RN #2 said she had no bumps on her head. RN #2 said Resident #1 said "ouch" a few times during the assessment but could not state the location of her pain. RN #2 said she left to call the family due to the advance directive medical orders for scope of treatment (MOST) form documenting comfort care was desired. She said the family would discuss what they wanted to do. RN #2 said upon further assessment of Resident #1, the left thigh area had a bump and was visibly deformed. She left to call the family again. RN #2 said the family came to the facility. The resident was sent to the hospital. The investigation documented the resident passed away on 5/28/23 at 1:40 a.m. in the hospital. It further documented the hospital records listed the immediate cause of death was heart block; other significant conditions which contributed to the death included C1 and C2 fracture, right and left femur fractures. The facility findings in the investigation documented:The resident fell while using a mechanical lift and sustained an injury. Safety interventions and facility's policies and procedures were not followed. The fall was due to human error but may be secondarily due to equipment malfunction. Resident #1 required two people to transfer with the lift due to pain. The resident was transferred with one person and the nurse aide did not have a RIS with her to indicate how the resident transferred. NA #1 was working as the bath aide that day and the bath sheet did not contain the resident's transfer status. The facility documented they changed the policy after this to print out an RIS for the bath aide each day for all the halls. The maintenance department was notified of the issue with the ceiling lift in Resident #1's room and in the tub room. NA #1 was suspended on 5/27/23 and the facility terminated her employment on 6/1/23. The facility documented NA #1 had not followed facility policy, she did not have a second person with her for a ceiling transfer, and the resident was not secured properly in the lift. NA #1 reported that she had trouble with the lift remote, however this had not been reported to the charge nurse or maintenance. The termination further documented the NA had transferred the resident three previous times without seeking assistance. The SDC documented she tested the ceiling lift in the tub room and in Resident #1's room that morning and the lifts only worked intermittently. The lift in the resident's room appeared to have a connection issue at the cord and remote which was what NA #1 had described. The lift in the tub room and the buttons on the controls failed intermittently with weight to the sling. She documented the ceiling lift belt that extended down to the bar which held the sling was observed to be frayed. The facility documented their plan was to provide education both verbal and written to NA #1. The NA was suspended and sent home pending the investigation. It documented the NA did not follow proper transfer techniques and did not tag out faulty equipment. The facility documented it intended to conduct education for all staff on ceiling lifts and education on maintenance. The investigation documented immediate transfer training was started 5/27/23, with education on not using equipment that was not functioning properly and notifying the maintenance department. On 5/27/23 the education, titled Transfer Safety Education, was based on the previous facility policy that allowed ceiling lift transfers to be done by one or two people. The education included steps for a safe transfer with a one or two person assist, including proper sling placement and ensuring the sling straps were secured properly and evenly. The education documented to never use a piece of equipment that was not functioning properly. Notify the maintenance department via a maintenance request that a repair was required as soon as possible. Always transfer resident as indicated on the RIS. The RIS should be carried by all CNAs each shift. On 5/28/23, the education titled Transfer Safety Education was revised. It documented two people were needed to assist a resident with a ceiling lift transfer. The first person would operate the lift controls and assist with resident positioning. The second person would manage the resident's extremities for safety, manage oxygen or catheter tubing as needed and assist with positioning. On 5/30/23 a Transfer Training inservice reviewed safety and the current lift transfer policy. Nurse managers would complete routine audits to observe staff transfer residents with ceiling for lifts, daily for two weeks, weekly for four weeks, monthly for three months and quarterly for four quarters. The investigation documented the evening charge nurse on 5/28/23 completed an audit of the facility ceiling lifts. The investigation documented the maintenance department assessed the lift in the affected resident's room on 5/30/23. The only issue noted was an issue with the battery that did not interfere with safety. A ceiling audit lift done by maintenance on 5/31/23 indicated the lift in Resident #1's room was no longer in use. Additionally, 56 other lifts were removed or tagged out to not use due to, for example, issues with the emergency stop switches, hand controls or remotes not working properly, cracks in chassis (load bearing portion of lift) and wheels, worn straps and battery issues (see below).-Although 56 lifts were removed or tagged, six residents who required the ceiling lifts were changed to a mechanical hoyer lift. The facility investigation documented they had updated their Transfer and Lift policy on 5/28/23, from one to two person assist with lifts based on the resident status to two person assist with all lifts. The facility charge nurses and nurse managers completed random audits of staff transferring residents with a mechanical lift. The random audits by the nurse managers and charge nurses were reviewed. The facility had completed 47 random observations of lift transfers with the nursing staff since the fall on 5/27/23. One person required more education, which was immediately completed. The facility investigation concluded the cause of the fall from the lift was due to the NA not having second person with her for the transfer, not carrying the resident information sheet with her, verifying placement of the sling loops on the ceiling lift, the ceiling lift remote not functioning and the ceiling lift not being tagged and removed from service when the NA first noticed the issue with the remote. IV. Observations and interviewsCNAs #1 and #3 were interviewed on 7/12/23 at 10:40 a.m. during an observation of transferring Resident #2 with a ceiling lift. CNA #1 said she heard Resident #1 fell during a ceiling lift transfer due to the sling not being properly connected and the remote was not working correctly. CNA #1 and CNA #3 said in the past the CNAs could use the ceiling lift with one or two people to transfer. They said after the resident had the fall from the lift, the staff had to use two people. CNA #3 said they were in-serviced about a month ago to use two people for the lifts. The two CNAs began to roll Resident #2 and place a sling under Resident #2 to transfer him with the ceiling lift. The resident was then lifted by the ceiling lift with CNA #1 controlling the lift and CNA #3 guiding the resident from the bed to the wheelchair. CNA #1 said a resident's transfer status was listed on the RIS (resident information sheet) the CNAs carried in their pockets. She said the charge nurse updated them with a new admission or change in condition for a resident. CNA #1 said the RIS was a list of basic things the resident needed like how they transferred, whether to use a lift and how many staff were needed to assist the resident. CNA #2 was interviewed with CNA #3 on 7/12/23 at 10:51 a.m. while transferring Resident #3 with the ceiling lift from bed to wheelchair. CNA #4 entered the room after a few minutes and introduced herself as the CNA team lead. CNA #2 controlled the lift and CNA #3 guided the resident to the wheelchair. CNA #2 said she had training on the lifts about two months ago due to a resident who fell out of a sling from a lift. She said the training consisted of a demonstration of the lift and placement of sling loops. She said she did not have to demonstrate how to use the lift and there was no quiz or other follow up from the inservice. She said the staff were educated that all residents who used a lift required two staff members to assist. CNA #2 said in the past, some residents could be transferred with the lift and one staff member to assist. CNA #2 said the RIS sheet told the staff how to transfer the resident. She said each resident had their own sling in their room. CNA #2 said she checked the lifts to make sure there was no red warning light on. She said some of the other lifts had red lights on but those had not been used since Resident #1 fell. Resident rooms on the second floor were observed on 7/12/23 at 3:59 p.m. Rooms 2109, 2209, 2217, 2509 and 2409 had signs on the ceiling lift to not use them. Resident #1's room, the ceiling lift was removed. V. Record review and interviewsThe NHA was interviewed on 7/12/23 at 12:10 p.m. She said the maintenance supervisor (MS) was new and had started on 6/1/23. She said the regional maintenance director (RMD) had completed an audit of all ceiling lifts for any malfunctioning or repairs needed on 5/31/23. The NHA provided a copy of the maintenance audit of the ceiling lifts and personnel file for NA #1 on 7/12/23 at 3:43 p.m. The NHA said the maintenance audit was done on 5/31/23 by the RMD. She said the facility was built in 2007 and many of the ceiling lifts in resident rooms and tub rooms were installed at that time. She said some were installed later according to the audit done by the RMD and dates on the lifts. The untitled, undated, unsigned resident room ceiling lift audit completed on 5/31/23 by the RMD according to the NHA, revealed the following information:Twenty-nine rooms listed as room number "0." The lifts were dated 2004, 2005 and 2007. Repairs needed included one or more of the following for each lift: emergency stop switch issue, maintenance light was on, see damage report, cracked chassis, batteries and hand control issues, new strap needed on lift, new strap switch plate needed, new switch board and chassis needed. It was unclear where these lifts were located. Twenty-five rooms, with specific room numbers listed, dated 2004 and 2007, documented emergency stop switch issues, hand control issues, battery concerns, cracked chassis and maintenance lights that were on. Six of these rooms were highlighted in the audit. The audit did not indicate what the highlighting meant. These six rooms were observed during the survey with signs on the lifts to not use them (see above). The residents in these six rooms required a lift, and the hoyer lift was used. Resident #1's room number was not listed on the audit (the lift may have had one of the lifts listed as room "0.") Resident #2 and Resident #3's rooms were listed on the audit as no repairs needed. The RMD was interviewed with the NHA on 7/13/23 at 10:48 a.m. The RMD said he could not locate any previous maintenance records for the ceiling lifts. He said he had been in contact with the manufacturer and had signed a contract to have the manufacturer come out and inspect the lifts. He said it would be next month in August but he did not have a date yet. The NHA said the staff knew to let the maintenance supervisor know if there were any issues with the lifts. She said the facility had started a new process for maintenance requests. The NHA said she did not remember when, she thought maybe in June 2023. The new process involved having a maintenance book on each floor where the staff could write their concerns and the maintenance supervisor would review when he was in and sign off the request. The RMD said the rooms listed as "0" on the 5/31/23 ceiling lift audit were lifts he removed from rooms. He said he did not keep track of which ones were removed from which rooms. He said the highlighted rooms on the audit that had maintenance issues were six rooms where the resident needed a lift and the staff should use a portable mechanical lift and not the ceiling lift. He said a sign had been placed on the ceiling lift to prevent use. The RMD said the rest of the resident rooms with ceiling lift issues were residents who did not use the lifts. The NHA or RMD did not have a process to track if a resident's transfer status in those rooms changed and they needed to use the lift to ensure the staff did not use the ceiling lifts. The RMD said he had checked the lifts with his assistant on 5/31/23 for maintenance lights, issues withthe switches for the emergency stops, cracked chassis housing, worn straps, hand control issues and battery issues. He said the lifts would be inspected again by him next quarter. The RMD said he assessed the four tub lifts on 5/31/23 and the lifts were working appropriately. The maintenance supervisor (MS) was interviewed with the NHA on 7/13/23 at 11:57 a.m. The MS said he had the position at the facility on 6/1/23. He was the only maintenance person for the facility but he could call the regional maintenance director (RMD) if he needed to. The MS said if the staff had a maintenance issue, they logged in a maintenance book on each floor. He said he checked the maintenance books when he came in each day. The MS said the staff had sometimes left him sticky notes on his door, sent him an email or called him if there was a maintenance issue rather than writing it in the maintenance book. He did not have a preferred method for the staff to communicate with him. The NHA said the facility had started the new process of writing maintenance requests in books on each floor a month or two ago, but she could not remember. She said she was unhappy with an outside company who the facility used for maintenance tracking and the facility had switched to this new process. The facility general orientation sheet documented NA #1 had been given information and facility's policies about resident handling, transfers and body mechanics. On 7/26/23 at 3:40 p.m., during the survey, the nurse consultant (NC) provided a computer printout that documented NA #1 had nursing orientation on 3/18/23 that included a skills assessment on mechanical lifts. The staff development coordinator (SDC) was interviewed on 7/13/23 at 11:40 a.m. She said she was the nurse manager on call on 5/27/23 and had come into the facility to investigate what happened on 5/27/23. She said the event with Resident #1 was an accident. She said she had spoken to the staff on 5/27/23 about being more intentional with their work by paying more attention to what they were doing. She said it was not the process of the transfer that failed but it was a safety issue. She said she called and spoke to the DON on 5/27/23 about changing the facility's policy on one to two person assistance with the lifts to always having two people to help avoid further risks of errors with transfers. The SDC said she began to inservice the staff at the facility on 5/27/23 on transfer safety education. She said she thought maintenance did some audits of the lifts on 5/28/23. The SDC said she posted on 5/28/23 mandatory transfer training scheduled for 5/30/23, 5/31/23 and 6/1/23 in 30 minute blocks. The SDC said it was not that NA #1 did not know how to transfer the resident. She was trained before she went on the floor. She said the staff all know how to transfer the residents with the lifts. She said they just needed to be more mindful and purposeful with their work. The SDC said on 5/30/23 the facility changed their policy to always having two people to transfer a resident using a lift. She said during a transfer with ceiling lift, the second person's job was to guide the resident's legs and body while the first person operated the remote and lift. The SDC said the education on 5/30/23 through 6/1/23 consisted of a demonstration on the ceiling lift and portable hoyer lift. The SDC said all staff were trained when hired on tagging equipment and removing it from use if it was malfunctioning. The SDC said she did not know if all nursing staff had been through the education yet. She said she thought it was about 98% of the nurses and 83% of the CNAs. The SDC said she thought the business office was tracking the staff that still needed to be educated. The SDC said it was not a training issue, it was human error. The DON was interviewed with the NHA on 7/13/23 at 2:35 p.m. She said the facility had begun immediate training with the nursing staff on 5/27/23 regarding lift safety. She said additional education was provided again when the facility changed their policy to having two persons assist with all lifts 5/30/23. Additionally, in person demonstration of lift training was done over the next few days and the charge nurses began random audits of lift transfers and were still doing random transfers according to the facility's follow up plan (see above). The DON said when a resident was admitted the admitting nurse got a report from the hospital. The admitting nurse updated the RIS with the resident's needs including how they transferred. If the transfer status was unknown the resident was transferred with two people until they were assessed by the therapy department. She said the staff would use the mechanical lift if the resident could not bear 50 percent of the weight. The RMD was interviewed again on 7/26/23 at 1:55 p.m. He said some of the lifts were left in resident rooms even though they had maintenance issues after his audit on 5/31/23. He said those lifts were stuck and he could not remove them. The RMD said those rooms had a tag placed on them that indicated not to use them. The RMD was interviewed again on 7/26/23 at 3:40 p.m. He said the ceiling lift manufacturer would be coming to the facility on 7/31/23 to assess all the ceiling lifts for any further issues or parts needed. CNA #1 was interviewed again on 7/26/23 at 2:05 p.m. She said she did not recall any concerns with the lift for Resident #1 prior to the fall. CNA #1 said the staff used to type the maintenance concern on a tablet for the maintenance person. She said last month the facility transitioned to a maintenance request book on each nurses station. CNA #4 as interviewed on 7/26/23 at 2:07 p.m. She said she did not remember any concerns with the lift in Resident #1's room. LPN #1 was interviewed on 7/26/23 at 2:17 p.m. She said she did not remember any issues with Resident #1's lift prior to her fall. The DON was interviewed on 7/26/23 at 2:30 p.m. She said she did not think there were any other resident falls from using the lifts. She said she had been at the facility since it opened in 2007. RN #4 was interviewed on 7/26/23 at 2:50 p.m. She said she was not here the day Resident #1 fell from the lift. She said she heard the fall was due to user error. She said she heard the clip on the lift hook was not closed allowing the sling loop to slip out. She said if there was a concern with a lift, she would put a sign on it to not use it and use a different lift. RN #4 said a request for the maintenance department to look at the lift should be written in the maintenance request book. The DON was interviewed again on 7/26/23 at 3:40 p.m. She said the facility currently had 26 residents that required a mechanical lift. She said 46 of the facility ceiling lifts were functioning properly, 34 lifts had been removed from resident rooms due to maintenance issues, 15 rooms still had lifts in them that did not work and were tagged not to use and four lifts in the tub rooms were working properly. The DON said seven residents were using a Hoyer lift (floor lift) due to the ceiling lift in their room not functioning properly.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/10/2023 and 07/16/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A survey for Incident #31931 was conducted on 5/17/23 to 5/18/23. No deficiencies were cited.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 03/13/2023 and 03/19/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.