BROOKDALE SKYLINE

A complaint survey prompted by #CO2671478, #CO2689634, Incident #2631191, Incident #2708479 and Incident #2709283 was completed on 1/5/26. No deficiencies were cited.

A licensure complaint survey prompted by #CO2689635 was completed on 1/5/26. No deficiencies were cited.

A survey for Incident #2648817 was conducted on 10/27/25 to 12/10/25. One deficiency was cited. The actual survey exit date was 10/28/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider, on 12/10/25.

Based on record review and interviews, the facility failed to ensure supervision and monitor assistive devices to prevent accidents for one (#2) of five residents reviewed for accidents out of seven sample residents. The facility failed to ensure staff transferred Resident #2 appropriately with a mechanical lift which resulted in a fall with major injury for the resident. Resident #2 was admitted to the facility for rehabilitation services on 10/7/25. The resident’s care plan directed staff to utilize a mechanical lift (a sit to stand lift) for transfers. On 10/11/25 certified nurse aide (CNA) #1 and CNA #2 used a gait belt (a belt that fastens around the waist, used for someone with mobility issues) to transfer Resident #2 from the toilet to her wheelchair. Resident #2 stood, and then lost the ability to bear weight in one of her legs and fell to the floor. Immediately after the incident, Resident #2 complained of right knee pain. The pain worsened and the resident was transported to the hospital on 10/12/25 where it was revealed that the resident had sustained a fracture to her right femur. Resident #2 discharged from the hospital and returned to the facility on 10/18/25. The facility investigation after the incident revealed CNA #1 and CNA #2 attempted to transfer Resident #2 using a gait belt instead of the mechanical lift. Due to the facility’s failure to adequately supervise and use a mechanical lift, Resident #2 fell and sustained a fracture to her right femur. Findings include:Record review, observations and interviews confirmed the facility corrected the deficient practice related to Resident #2’s fall prior to the onsite investigation on 10/27/25 to 10/28/25. The deficiency was cited as past non-compliance with a correction date of 10/17/25. I. Incident on 10/11/25The nursing home administrator (NHA) provided an investigation on 10/27/25 at 4:31 p.m. regarding Resident #2’s fall incident on 10/11/25 while being transferred by CNA #1 and CNA #2. The investigation documented that on 10/11/25 Resident #2 sustained a fall while being transferred from the toilet to the wheelchair. It documented Resident #2 was sent to the hospital on 10/12/25 after an Xray was done at the facility for Resident #2’s report of increased right knee pain. The hospital found Resident #2’s injury included a fracture of the right femur. The investigation included a statement by CNA #1 on 10/13/25. It documented CNA #1 said the night before the incident, Resident #2 had complained of discomfort with use of the mechanical lift. It documented on the night of the incident, CNA #1 said she and CNA #2 used the mechanical lift to transfer the resident from the bed to wheelchair, but then used a gait belt to assist the resident onto the toilet. The statement documented when the resident stood up from the toilet, she began to fall and CNA #1 and CNA #2 assisted Resident #2 to the floor. It documented Resident #2’s leg was bent when it reached the floor.-The statement revealed CNA #1 and CNA #2 had transferred the resident without the use of the mechanical lift. The investigation included a statement by CNA #2 on 10/14/25. It documented CNA #2 said she was in orientation and in training, She said CNA #1 was training her. It documented CNA #1 was apprehensive to use the mechanical lift due to Resident #2’s discomfort with previous use of the mechanical lift. The statement documented CNA #2 suggested they use a gait belt for a two person transfer. It documented CNA #1 and CNA #2 proceeded with transferring the resident using the gait belt. It documented when the resident stood from the toilet she began to fall and her right leg bent inward while being assisted to the ground. The investigation included a statement by licensed practical nurse (LPN) #1 on 10/14 25. It documented CNA #1 notified LPN #1 that Resident #2 had fallen in her bathroom. It documented LPN #1 found Resident #2 on the floor in the bathroom with a gait belt on. The statement documented CNA #1 told LPN #1 that she was upset because she should have used the mechanical lift for the transfer. The investigation documented nine interviews with residents at the facility and revealed no concerns with transfer assistance. The investigation documented that Resident #2’s fall resulted in a right femur fracture. II. Facility plan of correctionA. Immediate action to correct the deficient practice for Resident #2The facility provided documentation of staff education completed after the incident which included the following:A document titled Safe Patient Transfers and Kardex (staff directive tool) inservice, documented as an in person inservice provided by CNA #4 on 10/16/25. The document included 26 CNA, six LPN and four registered nurse (RN) signatures. The document included resident transfer education was reviewed during the meeting. It also included the importance of not transferring the resident without knowing their care plan status (not relying on information provided by others verbally), notification of the nurse if any concerns with transferring a resident including if the resident required reassessment and following the care plan regardless of the type of transfer the therapist was working on with a resident. A document titled Use of Therapy to Nursing Communication Form, dated 10/17/25, documented the director of rehabilitation services (DOR) would use the form to report resident functional changes to include transfer status, diet changes, bed mobility apparatus and therapy frequency. It documented the DOR would give the form to the DON and MDS coordinator after every resident evaluation or status change. It documented the MDS coordinator would update the resident care plan and Kardex. A document titled Use of Therapy to Nursing Form Review, documented an inservice provided by the DOR on 10/17/25. The document included 11 therapy department and nurse signatures. The inservice included when to use the therapy to nursing form, reporting patient functional changes but not limited to transfer status, diet changes, bed mobility apparatus, therapy frequency. The inservice also included completion of the form for every evaluation and status change and requirement for the form to be given to DON and the MDS to input in the resident’s care plan/Kardex. Documents titled CNA Skills Checklist and User Training were provided by the NHA on 10/27/25 at 6:06 p.m. The documents revealed CNA #1 demonstrated performance of resident transfers and completed online education by 4/17/25 and CNA #2 demonstrated performance and completed education of transfers by 9/22/25. B. Identification of other residentsA document titled Transfer Status was provided by the NHA on 10/27/25 at 6:06 p.m. The document, dated 10/13/25, revealed an audit of the transfer status for 48 residents who required transfer assistance at the facility and included the type of transfer required and confirmation that the care plan reflected the type of transfer required. C. Systematic changesAll nursing staff were re-educated on resident transfers using mechanical lift procedures. This was completed by 10/16/25. D. MonitoringAn audit tool titled ADLs for Dependent Residents/Transfers was provided by the NHA on 10/2/25 at 6:06 p.m. The document included instruction to complete three observations weekly for 12 weeks. The audit tool included documentation for four resident transfer observations on 10/21/25 and four observations on 10/27/25 completed by the DON, and included the type of resident transfer observed and confirmed that the care plan and Kardex had been updated. Interviews and record review during the investigation revealed corrective actions to identify the resident and other residents who had the potential to be affected by the deficient practice, systematic changes to prevent its recurrence and monitoring to ensure sustained corrections were in place. III. Facility policy and procedureThe Mechanical/Assistive Lifts policy, revised September 2017, was provided by the NHA on 10/28/25 at 4:57 p.m. It read in pertinent part, “For residents that require the use of mechanical or assistive lifts, a therapy order is requested from the health care provider for evaluation and treatment care recommendations.“Mechanical/assistive lifting equipment is considered as a “full body” or “sit to stand” lift that aids the associate and the resident in transfer and/or care procedures.“It is recommended that mechanical/assistive lifting equipment is used for those residents who have been evaluated for the use of this equipment. Education should be provided on the proper use of the assistive mechanical lifting equipment prior to its use.”IV. Resident #2A. Resident statusResident #2, age 87, was admitted on 10/7/25. According to the October 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD, a lung disease), cirrhosis (disease of the liver), duodenal ulcer, chronic respiratory failure and low back pain .The 10/23/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #2 required set up assistance with eating and was dependent on staff for toileting, showering, dressing and transfers, including from the bed to chair and from a sit to stand position. B. Resident interviewResident #2 was interviewed on 10/27/25 at 11:20 a.m. Resident #2 said on the night she fell, the CNAs used a gait belt to transfer her to and from the toilet. Resident #2 said when she was standing her right leg gave out and her right leg twisted around the toilet while she slid to the floor. Resident #2 said the right knee pain developed overnight and she told staff the next day that it was getting worse. C. Record reviewThe activities of daily living (ADL) care plan, initiated 10/7/25, revealed Resident #2 had a self-care performance deficit and was dependent on staff for ADLs (bathing, dressing, toileting and mobility). The fall care plan, initiated 10/7/25, revealed Resident #2 was at high risk for falls and required a physical and occupational therapy evaluation. The Kardex (staff directive tool), revised 10/9/25, was provided by the NHA on 10/28/25 at 11:41 a.m. It revealed Resident #2 required a sit to stand mechanical lift for transfers. A nursing progress note, dated 10/12/25 at 1:04 a.m., documented Resident #2 was evaluated for a change of condition due to a fall. It documented Resident #2 had pain and the on-call physician was notified. The note documented the physician recommendation to continue to monitor for injuries. A nursing progress note, dated 10/12/25 at 4:00 p.m., documented Resident #2 had increased pain and swelling of her right knee. It documented the physician was contacted and a physician order was received for an Xray and pain medication (oxycodone) was provided to Resident #2. Resident #2’s hospital history and physical record, dated 10/12/25 at 9:30 p.m., documented Resident #2 had an admission diagnosis of a closed fracture of the right femur. An interdisciplinary team (IDT) post-event analysis form, dated 10/15/25 at 10:55 a.m., documented Resident #2 required a sit to stand mechanical lift. It documented on 10/11/25, CNA #1 and CNA #2 used a gait belt for transfer and Resident #2 fell while standing up after using the toilet. It documented Resident #2 was later transferred to the hospital for a possible fracture. V. Staff interviewsRN #1 was interviewed on 10/27/25 at 11:45 a.m. RN #1 said Resident #2’s knee would sometimes “give out” and for this reason she required a sit to stand lift prior to the fall. RN #1 said upon return from the hospital, Resident #2 required a full body mechanical lift. CNA #10 was interviewed on 10/27/25 at 11:53 a.m. CNA #10 said she took care of Resident #2 the day after she fell. CNA #10 said Resident #2 began to have more pain with movement and her right leg was swollen. She said Resident #2 could no longer use the sit to stand liftand she required the full body mechanical lift after the fall. CNA #1 was interviewed on 10/27/25 at 4:55 p.m. CNA #1 said she was training CNA #2 on the night of 10/11/25. CNA #1 said she was told that Resident #2 wanted to use the bathroom. CNA #1 said she and CNA #2 used the sit to stand mechanical lift to transfer the resident from the bed to the wheelchair. She said Resident #2 did not refuse to use the sit to stand lift, however, CNA #1 said she remembered the night before, Resident #2 complained that the sit to stand “bothered” her under her arms. CNA #1 said she and CNA #2 were also having difficulty maneuvering equipment in Resident #2’s bathroom and CNA #1 was concerned she did not have the room for the sit to stand lift. CNA #1 said she obtained a gait belt to transfer the resident and she and CNA #2 used the gait belt to transfer Resident #2 onto the toilet. CNA #1 said Resident #2 could not maintain a standing position after using the toilet and she began to fall to the floor. CNA #1 said she and CNA #2 assisted the resident to slide to the floor. CNA #1 said she then notified LPN #1 and the LPN also had an RN come to the room for assessment. CNA #1 said a full body lift was used to lift Resident #2 and return her to her bed. CNA #1 said Resident #2 should have been transferred with the sit to stand mechanical lift. She said if the sit to stand lift had been used, Resident #2 likely would not have slid down onto the floor. CNA #1 said she had previous training for transferring residents and the use of mechanical lifts, including the sit to stand lift. CNA #1 said after Resident #2’s fall incident, she received additional education from the facility’s resident transfer and mechanical lift trainer, CNA #4. CNA #1 said CNA #4 provided demonstrations and CNA #1 returned demonstrations for how to use the sit to stand mechanical lift in a resident restroom. CNA #2 was interviewed on 10/27/25 at 5:16 p.m. CNA #2 said she was on orientation on the night Resident #2 fell, and she and was being trained by CNA #1. CNA #1 said the day shift CNA had reported that the physical therapist was working with the resident on stand and pivot transfers. CNA #2 said Resident #1 had reported pain under her arms when using the sit to stand mechanical lift the previous night. CNA #1 said Resident #2 did not refuse to use the sit to stand lift at any time. CNA #1 said when the resident wanted to use the restroom, CNA #1 and CNA #2 used the sit to stand mechanical lift to transfer the resident from the bed to the wheelchair. CNA #1 said the previous day, the CNAs had used the sit to stand lift for Resident #2 in the bathroom, but had a lot of difficulty maneuvering the equipment, so she and CNA #1 proceeded to transfer Resident #2 onto the toilet using a gait belt instead of the sit to stand lift. CNA #1 said when they stood Resident #2 up with use of the gait belt, Resident #2’s right leg gave out, and she was lowered to the ground by the CNAs. CNA #1 said one of Resident #2’s legs crossed inward beneath the other as she was lowered to the floor. CNA #2 said she had training training prior to Resident #2’s fall regarding transferring residents with use of mechanical lifts. CNA #1 said she was provided extensive reeducation after Resident #2’s fall which included the use of the sit to stand mechanical lift, full body mechanical lift and slide board. She said the education also included the importance of adhering to what the resident’s care plan kardex designated for method of transfer and never rely on what another CNA thought could be done. CNA #2 said she learned it was important to never use a less supportive means to transfer a resident than what the Resident’s kardex demonstrated, and the gait belt with two person assist was less supportive than the sit to stand mechanical lift. LPN #2 was interviewed on 10/28/25 at 8:28 p.m. LPN #2 said she had received education about transferring residents several times this year, most recently within the past two weeks. LPN #2 said most recent training included a review and demonstration of mechanical lift equipment. CNA #8 was interviewed on 10/28/25 at 8:31 a.m. CNA #8 said she had previous mechanical lift training at the facility and had additional training within the past week. CNA #8 said the mechanical lift training included a return demonstration of the equipment. CNA #7 was interviewed on 10/28/25 at 8:48 a.m. CNA #7 said she had received education about transferring residents, including mechanical lift training during her orientation and again within the past two weeks. CNA #7 said the sit to stand mechanical lift and full body mechanical lifts were reviewed and she completed return demonstrations of the equipment. CNA #7 said it was important to follow the resident’s care plan and Kardex for resident transferring instructions, as it was always the accurate way to transfer a resident. CNA #6 was interviewed on 10/28/25 at 8:52 a.m. CNA #6 said she needed to check the resident’s Kardex each time prior to transferring a resident, as it had the correct information regarding how to transfer the resident. CNA #6 said she was on orientation, and had recently received a four hour inservice regarding resident transfers with mechanical lift demonstrations included. CNA #6 said if a resident could not or did not want to transfer as per the kardex, she would notify the nurse prior to transferring the resident. LPN #3 was interviewed on 10/28/25 at 8:55 a.m. LPN #3 said when transferring residents, she reviewed the resident’s care plan and Kardex prior to transferring a resident, as it revealed the safest way for the resident to transfer. LPN #3 said if she did not think the method of transfer was safe enough for a resident at a particular time, she would transfer using additional support, or upgrade to a full body lift. LPN #3 said a resident could not be provided less assistance than what the care plan and Kardex noted. LPN #3 said she had previous education at the facility about transferring residents with mechanical lifts and received additional education within the past two weeks. CNA #4 was interviewed on 10/28/25 at 9:24 a.m. CNA #4 said she had been a CNA, restorative aide and trainer for the facility. CNA #4 said she provided education to all nursing staff regarding transferring residents. CNA #4 said the CNAs initially had online education and then their competencies for transferring residents were checked off during their orientation. CNA #4 said in addition to shadowing another CNA during training, all new CNAs completed a resident transfer training session with CNA #4. CNA #4 said both CNA #1 and CNA #2 had received scheduled competency training, including resident transfers a week prior to Resident #2’s fall. She said the competency training included the need to review the care plan and kardex prior to transferring a resident, and that a resident could not be transferred with less support than what was directed per the kardex. CNA #4 said the sit to stand lift was helpful for those residents who were unable to stand and turn. CNA #4 said after Resident #2’s fall she provided reeducation to both CNA #1 and CNA #2 on 10/21/25, including having the CNAs return demonstrations for use of sit to stand mechanical lift and full body mechanical lift from both the bed to wheelchair and wheelchair to the toilet. The DOR was interviewed on 10/28/25 at 10:10 a.m. The DOR said prior to Resident #2’s fall, she was designated as a maximum assist with two transfer status, which automatically meant the CNAs needed to use a mechanical lift to move Resident #2. The DOR said Resident #2’s Kardex indicated she required a sit to stand mechanical lift. The DOR said Resident #2 should not have been transferred using a two person assist with a gait belt at any time. The DOR said even if the physical therapist was working on transfers with a gait belt, it does not mean the CNAs can change the status of the required mode for transferring the resident. The DOR said the process for changing a resident’s mode of transfer included an evaluation by the therapist who then reported to the DOR, the DOR brought to the interdisciplinary team, the MDS coordinator was notified and then the transfer status could be changed. The DOR said a resident could be full weight bearing, yet not have the strength or tolerance to do it for any length of time. The DOR said the CNAs must follow the care plan and Kardex for transferring a resident. The DOR said Resident #2 required a full body mechanical lift after she returned from the hospital. The MDS coordinator (MDS) was interviewed on 10/28/25 at 10:45 a.m. The MDS said Resident #2 was at high risk of falls and required a sit to stand mechanical lift for transfer on 10/9/25. The MDS said she would not have expected CNAs to use a gait belt with two person assist to transfer the resident at any time. LPN #1 was interviewed on 10/28/25 at 11:03 a.m. LPN #1 said the night of 10/11/25, CNA #1 came to her and said that Resident #2 fell in the bathroom. LPN #1 said she found the resident on the floor in her bathroom sitting with a gait belt around her waist. LPN #1 said she informed RN #2 who came to Resident #2’s bathroom and assessed the resident’s condition. LPN #1 said Resident #2 was transferred back to her bed with the use of a full body mechanical lift. LPN #1 said Resident #2 should have been transferred using the sit to stand mechanical lift per her kardex. LPN #1 said CNA #1 should have contacted her if the resident could not be transferred as directed by the resident’s kardex. LPN #1 said it was important to follow the recommendations of the therapy department, and if the recommendations were not followed, residents could be injured or fall. The DON was interviewed on 10/28/25 at 11:45 a.m. The DON said the CNAs used a gait belt to do perineal hygiene care and to stand Resident #2 from the toilet. The DON said CNA #1 and CNA #2 should have used the sit to stand mechanical lift because the Resident’s care plan indicated it was required and therapy evaluation revealed the resident required use of the mechanical lift. The DON said if the care plan was not followed, residents or staff could get injured. The DON said CNA #4 had completed reeducation for all CNAs regarding transferring residents. The DON said the education began on 10/16/25 and was completed by 10/21/25. The DON said she had been conducting audits since Resident #2’s fall, and the plan was to conduct at least three observations of resident transfers per week for 12 weeks. The DON said the audits were reviewed at the facility’s quality assurance performance improvement (QAPI) meeting on 10/24/25, and would continue to be reviewed monthly. The nurse practitioner (NP) was interviewed on 10/28/25 at 12:24 p.m. The NP said CNA #1 and CNA #2 should have checked with the nurse prior to changing the mode of transfer for Resident #2. The NP said even if the physical therapist was working with the resident on stand and pivot transfers, her transfer status would be what was written on the Kardex. CNA #9 was interviewed on 10/28/25 at 2:15 p.m. CNA #9 said she had received education about mechanical lifts and transferring residents when she began working at the facility. CNA #9 said within the past two weeks the facility again reviewed transferring residents. CNA #9 said it was important to check the resident’s kardex and confirm the status of the equipment used for resident transfers. CNA #9 said if a resident did not like or want to transfer with certain equipment she would explain to the resident why it had been determined to be the safest method for transferring and she would contact the nurse for any resident concerns.

A complaint survey, prompted by #CO2620379 was conducted on 9/18/25. No deficiencies were cited.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

A revisit survey was completed on 8/11/25 for all previous deficiencies cited on 6/11/25. The facility is in compliance with all regulations surveyed.

A complaint survey, prompted by #CO40297 was conducted on 6/10/25 to 6/11/25. One deficiency was cited.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper personal hygiene for three (#6, #8 and #9) of seven residents reviewed for ADLs out of 13 sample residents. Specifically, the facility failed to:-Ensure staff used a gait belt when transferring Resident #6 from a recliner to the wheelchair while taking the resident to his room to provide incontinence care;-Ensure staff properly used a Hoyer lift (mechanical lift) when transferring Resident #8 to her bed to provide incontinence care; and,-Ensure Resident #8 and Resident #9 were provided with timely incontinence care. Findings include:I. Professional reference According to the Joerns Hoyer manufacturer guidelines, 2021, retrieved on 6/16/25, from https://www.https://www.joerns.com/product/hoyer-pro-slings/,"A sling is an item of moving and handling equipment that is used with a mechanical lift in order to facilitate the transfer of a patient. It comprises a specially designed and constructed piece of fabric that is placed under and/or around a patient before being attached to the spreader bar/cradle of a lift to raise, transfer and lower the patient. When selected and used correctly, a sling and lift combination will achieve a safer transfer and reduce the risks associated with manual handling."Cross over leg straps, pass one leg strap through the other and attach to the hoist on the front hooks."II. Facility policy and procedureThe Supporting the Activities of Daily Living policy, revised February 2024, was provided by the assistant director of nursing (ADON) on 6/11/25 at 5:10 p.m. It read in pertinent part, "Residents who are unable to carry out activities of daily living independently should receive theservices necessary to maintain good nutrition, grooming, personal and oral hygiene."Appropriate care and services should be provided for residents who are unable to carry outADLs independently, with the consent of the resident and/or resident representative and inaccordance with the plan of care, including appropriate support and assistance with:-Hygiene (bathing, dressing, grooming, and oral care);-Mobility (transfer and ambulation, including walking);-Elimination (toileting);-Dining (meals and snacks); and,-Communication (speech, language, and any functional communication systems)."The Gait/Transfer/Walking Belts policy, revised May 2022, was provided by the ADON on 6/11/25 at 5:10 p.m. It read in pertinent part, "Gait/transfer/walking belts are safety devices used for assisting a resident with transfer and/orambulation with mobility needs. These devices are used with residents who may have an unsteady gait, are at risk for falls, or other health conditions that affect ambulation."Staff providing resident care should have access to gait/transfer belts and receive training in proper body mechanics. Gait/transfer belts should be used when needed, while providing care, assisting with ambulation, or transferring a resident. The Mechanical/Assistive Lifts policy, revised September 2017, was provided by the ADON on 6/11/25 at 5:10 p.m. It read in pertinent part,"The use of all mechanical/assistive lift equipment should be according to manufacturer'srecommendations."Staff should be educated on proper use of the equipment."Education should be provided on the proper use of the assistive mechanical liftingequipment prior to its use."The Perineal Care procedure, issued October 2016, was provided by the ADON on 6/11/25 at 5:10 p.m. It read in pertinent part,"The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition."Use a washcloth with warm water and soap or a disposable moist cloth. Wash perineal area, wiping from front to back."Wash the rectal area thoroughly, wiping from the base of the labia towards and extendingover the buttocks. Do not reuse the same washcloth/water or moist disposable cloth to cleanthe labia."Discard disposable items into designated containers. Remove gloves and discard into designated containers. Wash and dry your hands thoroughly."III. Failure to transfer Resident #6 appropriately using a gait beltA. Resident #61. Resident #6, age greater than 65, was admitted on 2/7/25. According to the June 2025 computerized physician orders (CPO), diagnoses included dementia, history of falling, unspecified lack of coordination, abnormal gait and mobility. The 5/9/25 minimum data set (MDS) assessment revealed Resident #6 had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. Resident #6 required assistance for transfers, toileting and personal hygiene. The MDS assessment documented Resident #6 was frequently incontinent of urine and occasionally incontinent of bowel. 2. ObservationsOn 6/11/25 at 10:41 a.m. Resident #6 was assisted by certified nurse aide (CNA) #3 to transfer from a recliner to his wheelchair in order to go to the resident's room to provide incontinence care. Resident #6 was slow to respond to questions and did not open his eyes during the transfer. -CNA #3 did not use a gait belt while providing a stand pivot transfer from the recliner to the wheelchair. After Resident #6's incontinence care was finished, CNA #3 applied the resident's gait belt and requested assistance from CNA #5 in order to transfer Resident #6 back to the recliner. CNA #3 and CNA #5 commented on how tired Resident #6 appeared to be this morning. -Despite the placement of the gait belt to transfer Resident #6, CNA #3 did not hold onto the gait belt to transfer the resident, instead placing her arms under Resident #6's armpits and lifting the resident by the shoulders during the transfer. 3. Record reviewThe comprehensive care plan, updated 6/3/25, documented Resident #6 required assistance from staff for transfers, toileting, bathing and personal hygiene. Interventions included the use of appropriate assistive devices and for staff to provide frequent cues to the resident when ambulating to reduce the risk of falls. 4. Staff interviewsThe director of rehabilitation (DOR) was interviewed on 6/11/25 at 3:38 p.m. The DOR said she provided hands-on training on the use of gait belts and assistive devices for the nurses and CNAs. The DOR said she instructed the staff to use a gait belt with any ambulation or stand-pivot transfers for the safety of the staff and the residents. The DOR said holding the resident under the shoulders could dislocate the resident's shoulder if the resident started to fall. IV. Failures with Resident #8 and Resident #9A. Resident #81. Resident #8, age greater than 65, was admitted on 10/9/23. According to the June 2025 CPO, diagnoses included Alzheimer's dementia and heart failure. The 4/3/25 MDS assessment revealed Resident #8 had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Resident #8 was dependent on staff assistance for dressing, bathing, toileting, repositioning and personal hygiene. The MDS assessment documented Resident #8 was always incontinent of urine and always incontinent of bowel. 2. ObservationsDuring a continuous observation of Resident #8 in the dining room and common area on 6/11/25, beginning at 8:50 a.m. and ending at 12:45 p.m., the following was observed:At 8:50 a.m. Resident #8 was being assisted with eating breakfast by an unidentified CNA in the dining room. Resident #8 was seated in her wheelchair with her Hoyer lift sling underneath her. At 8:59 a.m., after the meal was complete, an unidentified CNA wheeled Resident #8 in her wheelchair to sit in front of the television (TV) in the common area. From 8:59 a.m. until 12:45 p.m. Resident #8 remained in her wheelchair in the common area. During this time Resident #8 was not checked for incontinence by staff. -Resident #8 was not offered or providedwith incontinence care between 8:50 a.m. and 12:45 p.m., a period of three hours and 55 minutes. On 6/11/25 at 12:57 p.m. CNA # 1 and CNA #2 transferred Resident #8 from her wheelchair to her bed using a Hoyer lift. During the transfer, the lower straps of the Hoyer lift sling were not crossed over each other to secure the resident per the manufacturer's guidelines (see manufacturer's guidelines above). After transferring Resident #8 to her bed, CNA #1 and CNA #2 proceeded to provide the resident with incontinence care. When CNA #1 removed the resident's brief, the brief was heavily saturated with urine in the front and back of the brief. -While providing incontinence care to Resident #8, CNA #1 used the same disposable moist cloth for multiple wipes on Resident #8's backside without folding the cloth to expose a new clean area of the cloth for each wipe. After Resident #8's brief was changed, CNA #1 and CNA #2 repositioned Resident #8 in bed.-CNA #1 and CNA #2 did not remove their soiled gloves and perform hand hygiene prior to repositioning the resident. 3. Record reviewThe care plan, updated 4/4/25, identified Resident #8 was incontinent of both bowel and bladder. Interventions included checking Resident #8 for incontinence, assisting Resident #8 with toileting as needed, providing incontinence care and applying barrier cream after each incontinence episode. B. Resident #91. Resident statusResident #9, age greater than 65, was admitted on 3/19/25. According to the June 2025 CPO, diagnoses included dementia, altered mental status and urinary tract infection. The 4/28/25 MDS assessment revealed Resident #9 had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. Resident #9 required substantial assistance for transfers, toileting, dressing and personal hygiene. The MDS assessment documented Resident #9 was always incontinent of bowel and bladder. 2. ObservationsDuring a continuous observation of Resident #9 in the dining room and common area on 6/11/25, beginning at 8:50 a.m. and ending at 12:45 p.m., the following was observed:At 8:55 a.m. Resident #9 wheeled herself in front of an open window. From 8:55 a.m. until 11:41 a.m. no staff approached Resident #9 to offer incontinence care to the resident. At 11:41 a.m. CNA #1 assisted Resident #9 in her wheelchair to the dining room CNA #1 and LPN #1 repositioned Resident #9 in her wheelchair in the dining room. CNA #1 and LPN #1 hooked their arms underneath Resident #9's armpits to pull her up in the wheelchair. At 12:30 p.m. CNA #4 began providing eating assistance to Resident #9. Resident #9 was not offered or provided with incontinence care between 8:50 a.m. and 12:45 p.m., a period of three hours and 55 minutes.-At 12:45 p.m., upon prompting, staff attempted to check Resident #9 for incontinence, however, Resident #9 refused. 3. Record review The care plan, updated 3/19/25, identified Resident #9 was incontinent of both bowel and bladder. Interventions included checking Resident #9 for incontinence, assisting Resident #9 with toileting as needed, providing incontinence care and changing the resident's clothing after each incontinence episode. C. Staff interviewsLPN #1 was interviewed on 6/11/25 at 12:45 p.m. LPN #1 said Resident #8 was incontinent of both bowel and bladder and required staff to check and change her because Resident #8 was at risk for pressure injuries. LPN #1 said the last time Resident #8 was provided with incontinence care (on 6/11/25) was before breakfast. LPN #1 said Resident #9 was incontinent and changed by staff before breakfast (on 6/11/25). LPN #1 said Resident #9 became agitated easily and often refused care. LPN #1 said when Resident #9 refused care, LPN #1 or another staff member would offer the care again a few minutes later. CNA #1 was interviewed on 6/11/25 at 2:54 p.m. CNA #1 said Resident #8 was changed for the first time on her shift before breakfast, usually between 7:30 a.m. and 8:30 a.m. CNA #1 said she typically checked and changed all of the residents three times a shift; once before breakfast, once after lunch and once at the end of the shift. The DOR was interviewed on 6/11/25 at 3:38 p.m. The DOR said she provided hands-on training to staff on how to use assistive devices and lifts, but she had not provided an in person all-staff education on safe Hoyer lift use since starting as the DOR for the facility a few months prior. The DOR said she was not sure if the previous DOR provided in-person education on safe Hoyer lift use. The DOR said the only time staff should not cross the lower straps of the transfer sling when using a Hoyer lift was if the resident had a full body sling with a seat. The DOR said she was not sure what type of sling was being used for Resident #8. The DOR said staff should not pull up Resident #9 by hooking their arms under Resident #9's shoulders. She said one staff member should hold the resident under the legs and push the resident up in the wheelchair while another staff bear hugged the resident from behind to safely reposition the resident in the wheelchair.-After the interview, the DOR confirmed that Resident #8 was in a normal Hoyer lift sling and staff should have crossed the lower straps of the sling, as was recommended by the manufacturer. The ADON and the clinical consultant (CC) were interviewed together on 6/11/25 at 4:20 p.m. The ADON said residents who were unable to inform staff when they needed incontinence care should be checked every two hours. The ADON said untimely incontinence care increased the residents' risk for skin breakdown or urinary tract infections (UTI). The ADON said she was not aware of any in-person training provided to staff on incontinence care since starting as the ADON for the facility a few months prior. She said professional standards for cleaning residents after an incontinence episode included using a new clean disposable moist cloth with each wipe, or folding the cloth to a clean side between each wipe. The ADON said staff should only clean in one direction, from front to back, when providing incontinence care on female residents. The CC said training modules on staff expectations for incontinence care and the use of assistive devices and lifts were completed during new employee orientation.

A revisit survey was completed on 6/5/25 for all previous deficiencies cited on 4/17/25. The facility is in compliance with all regulations surveyed.

A recertification survey with complaints #CO34869 and #CO38476 was completed on 4/15/25 to 4/17/25. Five deficiencies were cited.

An Emergency Preparedness survey was conducted from 4/15/25 to 4/17/25. Two deficiencies were cited.

Based on observation, record review and staff interviews, the facility failed to develop and implement policies and procedures to provide for the safe evacuation from the facility in the event of an emergency. Specifically, the facility failed to develop a safe evacuation plan in the event the elevators were not usable for the third, fourth and fifth floors, which included consideration of care and treatment needs of the evacuees and staff responsibilities. Findings include:I. Facility policy and procedureThe Emergency Preparedness-Planning for Evacuation policy, revised October 2023, was provided by the nursing home administrator (NHA) on 4/15/25 at 3:43 p.m. It read in pertinent part, "This community prepares for evacuations well in advance of a crisis or disaster situation requiring partial or complete evacuation, regardless of whether the evacuation is planned or spontaneous. The community understands that if a community-wide and regional disaster is occurring, the community has to be prepared to be self-sufficient, as response times of Emergency Medical Services and other transportation providers may be delayed. Evacuation Routes: The community shall determine the primary evacuation routes and alternate evacuation routes in advance of a crisis or disaster scenario; Evacuation routes and alternate routes shall be designated in accordance with the local Emergency Management Plan."-The policy and procedure was reviewed in its entirety and there was no facility evacuation plan which addressed evacuation from the third, fourth, and fifth floors via the stairs in the event the elevator was not usable and the corresponding staff responsibilities. II. ObservationsAn observation of the facility which was located on the third, fourth and fifth floors of the building was conducted on 4/15/25 at 2:40 p.m. The NHA and the maintenance director (MTD) were in attendance. Evacuation routes were not observed to be posted at the facility in order to direct staff and residents how to safely evacuate in the case of an emergency. There was an exit sign outside of the two stairwells on each of the third, fourth and fifth floors. Inside the stairwell were cement stairs, there were no assistive devices and/or sleds for those residents who were unable to ascend stairs and/or used a wheelchair and/or were non ambulatory. On the second floor, in a storage room there was a cardboard box, which contained five bariatric evacuation sleds. III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 4/15/25 at 10:54 a.m. on the fifth floor. RN #1 said she did not know how to evacuate residents if the elevators were not working. She said she did not recall receiving any training on how to evacuate residents from the fifth floor. Licensed practical nurse (LPN) #1 was interviewed on 4/15/25 at 10:56 a.m. on the third floor. LPN #1 said she thought the staff would evacuate residents with two staff members with a wheelchair down the stairs in the case of an emergency. LPN #1 said she did not recall if she had received training on evacuating the residents from the third floor. The NHA and the MTD were interviewed together on 4/15/25 at 2:50 p.m. The MTD said he would defend in place during an emergency and per the direction from the fire department. He said if evacuation was needed he had evacuation sleds. He said the sleds had not been implemented yet and the staff had not been trained on how to use them. The MTD said he would conduct the training soon. The NHA and MTD said if they had to evacuate it would be a resident by resident situation and they would carry them down the stairs. The NHA and the MTD said they planned to put two sleds on each floor.

Based on record review and interviews, the facility failed to conduct two exercises annually to test the facility's emergency plan and maintain documentation of the facility's response to all drills, tabletop exercises, and emergency events, and then revise the facility's emergency plan, as needed. Specifically, the facility failed to:-Participate in a community-based or facility based-full scale exercise and/or actual emergency in the previous 12- month cycle; and,-Participate in a second community-based or facility-based full scale exercise, mock disaster drill or facilitated table top exercise or workshop in the previous 12-month cycle. Findings include:I. Testing participationThe facility's Emergency Preparedness Planning and Resource Manual (EPPRM), updated 10/12/24, was provided by the nursing home administrator (NHA) on 4/17/25 at 10:42 a.m.-Review of the EPPRM revealed the facility's emergency preparedness plan failed to reveal documentation that the facility had participated in one community based functional/full scale exercise and an additional exercise had been conducted in the last year (12-month cycle). On 4/17/25 at 4:27 p.m. the NHA provided documentation that the facility conducted a mock elopement drill on 6/28/24 that included procedures for the drill, an undated and unlabeled sign in sheet with nine staff members.-However, there was no documentation of the facility's response to the drill. II. Staff interviewThe NHA was interviewed on 4/17/25 at 10:42 a.m. The NHA said he could not find documentation that the facility had conducted two exercises annually to test the facility's emergency plan. The NHA said himself and the maintenance director were unable to find relevant and completed documentation to meet regulatory compliance requirements. The NHA was interviewed again 4/17/25 at 3:46 p.m. He said it was important to conduct the full scale exercises and actual practice yearly so the staff know what to do in an actual emergency. The NHA said after an exercise or emergency he would have the staff talk about it to see if we were following our policy and procedures and if we called the right emergency departments and triaged correctly. The NHA said the whole point of testing was to keep everyone safe.

Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care was provided such care, consistent with professional standards of practice for one (#1) of two residents reviewed for the use of supplemental oxygen of 27 sample residents. Specifically, the facility failed to ensure Resident #1's oxygen was consistently administered according to physician's orders. Findings include: I. Facility policy and procedureThe Oxygen Administration policy, revised April 2024, was provided by the nursing home administrator (NHA) on 4/17/2025 at 3:03 p.m. It read in pertinent part, "The nurse should monitor oxygen administration and record the resident's response to oxygen therapy in the medical record. Verify that there is a physician's order for the procedure. Review the healthcare provider's orders or community protocol for oxygen administration." II. Resident #1 A. Resident status Resident #1, age 65, was admitted on 1/8/25. According to the April 2025 computerized physicians orders (CPO), diagnoses included chronic respiratory failure with hypercapnia and hypoxia (a condition where there is an excess of carbon dioxide in the blood and low levels of oxygen in body tissue), chronic obstructive pulmonary disease (COPD), muscle weakness, cognitive communication deficit, phocomelia of the limbs (a rare congenital anomaly with the proximal aspect of an extremity is absent with the hand or foot) anxiety disorder, altered mental status and pneumonitis due to inhalation of food and vomit. The 1/14/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The assessment indicated the resident did not have any behaviors or rejections of care during the assessment period. She was dependent on staff due to upper and lower impairment on both sides and required extensive to maximum assistance with care. The MDS assessment indicated the resident required continuous oxygen. B. Record review The oxygen care plan, initiated 1/14/25, revealed Resident #1 received oxygen therapy related to COPD, chronic respiratory failure. Pertinent interventions included providing oxygen via nasal canal between two to four liters per minute (LPM) during the day at a continuous flow per physician's orders. The April 2025 CPO included:-Oxygen at two to four LPM continuously via nasal cannula, ordered 4/7/25. C. Observations and interviews On 4/15/25 at 10:45 a.m. Resident #1 was in her room. There was an oxygen concentrator in her room, but the nasal canula was not in place via nasal canula. There was a portable oxygen tank on the back of the resident's wheelchair. However, the portable oxygen concentrator was empty. The personal care provider alerted the facility staff about the resident's oxygen tank being empty. Certified nursing assistant (CNA) #5 said the oxygen tank was empty. The resident was having difficulty understanding her personal care provider, who was visiting her. On 4/16/25 at 2:45 p.m., Resident #1 was in her room. She was talking on the phone. The resident repeatedly asked the individual she was speaking to on the phone if she was coming to get her. Resident #1 asked licensed practical nurse (LPN) #1 if her oxygen tank was working. The LPN checked the resident's portable oxygen tank and said she was replacing it for the resident. LPN #1 took the portable tank with her, leaving the resident with no oxygen for approximately two minutes. She returned with a full tank for the resident. D. Staff interviews Certified nursing aide (CNA) #5 was interviewed on 4/16/25 at 4:05 p.m. CNA #5 said Resident #1's portable oxygen tank was refilled by the night shift and the CNA's ensured that the resident had her oxygen on at all times. CNA #5 said the resident was receptive to having staff assist her with wearing her nasal cannula and would not resist or decline the oxygen use. CNA #5 said Resident #1 would get short of breath and display other medical complications if she was not receiving continuous oxygen. CNA #5 said she tried to keep an eye on all the portable oxygen tanks but sometimes they ran out without her noticing.. CNA #5 said Resident #1's portable oxygen tank was usually set between 2 to 4 LPM. Licensed practical nurse (LPN) #1 was interviewed on 4/16/25 at 4:25 p.m. LPN #1 said Resident #1 had a physician's order for 2 to 4 liters of continuous oxygen (LPM). She said all staff nursing members were responsible to check the portable tanks to ensure they were not empty. LPN #1 said oxygen was considered a medication and a physician's order for a resident to receive oxygen should be followed accordingly. She said the resident could suffer medical complications such as shortness of breath. The director of nursing (DON) was interviewed on 4/16/25 at 4:56 p.m. The DON said it was important for physician's orders to be followed. She said all of the CNA's and nurses were responsible for monitoring the portable oxygen tanks to ensure they were not empty. The DON said if Resident #1 was having difficulty and appeared agitated, the staff should have checked her oxygen tank. She said the nursing staff should have ensured that Resident #1 received continuous oxygen as prescribed by the physician. The DON said she had updated the medication administration record (MAR) for the nursing staff to check all portable tanks more frequently. She said she would immediately provide education to the nursing staff about the importance of oxygen administration and the proper monitoring of oxygen use.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12-months and provide regular in-service education based on the outcome of these reviews for two of two certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews and provide regular in-service education based on the outcome of the reviews for CNA #2 and CNA #3. Findings include:I. Facility policy and procedureThe Annual Performance Planning Guide, undated, was provided by the nursing home administrator (NHA) on 4/17/25 at 4:47 p.m. It read in pertinent part, "Performance planning is a critical part of the performance management process. While annual reviews are a look back, performance plans are a look forward. A collaborative process between associate and supervisor, they set the foundation for performance management by establishing clear and defined individual performance and development goals for the year. Revisit the performance plan throughout the year to measure progress, discuss obstacles, give feedback, and coach to success. At annual review time, measure performance against the goals set in the performance plan. Performance planning is a process conducted by a supervisor and their direct reports in which together they plan the performance goals for the upcoming year and discuss developmental goals."II. Record reviewAnnual performance reviews were requested on 4/16/25 at 10:35 a.m. The facility was unable to provide annual performance evaluations for CNA #2 (hired 2/17/2020) and CNA #3 (hired 7/8/08).-CNA #2 and CNA #3 did not have an annual performance review completed and did not have an in-service education plan based on the outcome of the review. III. Staff interviewsThe director of nursing (DON) was interviewed on 4/17/25 at 3:21 p.m. The DON said the facility should complete a performance review of the CNAs at least once every 12 months and provide regular in-service education based on the outcome of the review. The DON said the facility had not completed it yet but their policy said it should be done. The DON said she could not locate the reviews for CNA #2 and CNA #3. The DON said the purpose of completing the performance review was to see how the CNAs were doing, what they needed help with and to give feedback and set expectations. The DON said she would be doing a skills fair and regular in-service education based on the outcomes of the review. The DON said the plan now was to do the annual reviews and skills fair. She said she would start that within the next quarter to get everyone reviewed.

Based on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practical physical, mental, and psychosocial well-being for two (#29 and 42) of three residents reviewed for dementia care out of 27 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #29 and Resident #42 to provide the resident with their highest practicable quality of life and care. Findings include: I. Facility policy and procedureThe Dementia Care policy and procedure, revised February 2022, was received from the nursing home administrator (NHA) on 4/16/25 at 10:39 a.m.. It read in pertinent part, "Residents who have been diagnosed as having dementia should have a resident-centered care plan to maximize remaining abilities and quality of life." II. Resident #29 A. Resident status Resident #29, age 83, was admitted on 2/3/23. According to the April 2025 computerized physician orders (CPO), diagnoses included dementia, type 2 diabetes mellitus with other diabetic neurological diabetic neurological complications, scrotal varices (enlarged veins in the scrotum that can cause pain), urinary tract infections and hearing loss. The 1/10/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of five out of 15. He required total assistance with toileting, showering, personal hygiene and dressing and moderate assistance with oral hygiene. The assessment revealed the resident did not reject care and did not exhibit physical or verbal behaviors or wander. B. Resident #29 interview and observations Resident #29 was interviewed on 4/15/25 at 10:45 a.m. The resident was in his wheelchair on the left side of his bed in his room. He said "help me" and said he wanted to go to bed. At 10:59 a.m. certified nurse aide (CNA) #7 went into the resident's room. The resident said he wanted to go to bed. The CNA said it was almost time for lunch and assisted the resident to the dining area. At 11:20 a.m. Resident #29 was in his room. He said "help, help." CNA #6 went into his room. Resident #29 said he wanted to be in bed. CNA #6 said it was almost time for lunch and he could not go to bed. At 11:23 p.m. CNA #6 assisted Resident #29 out of the resident's room. At 11:26 a.m. Resident #29 went back in his room. He was on the left side of his bed, rolling back and forth in a repetitive motion. At 11:28 a.m. Resident #29 initiated his call light indicating he needed assistance. At 11:29 a.m. CNA #8 went into the resident's room. CNA #8 did not provide the resident with any care and left the room within the minute. At 11:30 a.m. Resident #29 initiated his call light. CNA #7 and CNA #8 went into Resident #29's room. Resident #29 said he wanted to go to bed. CNA #7 and CNA #8 said it was lunchtime and assisted the resident to the dining area. Between 11:30 a.m. and 11:35 a.m. Resident #29 assisted himself back to his room. At 11:35 a.m. Resident #29 was back in his room. An unidentified CNA was assisting another resident when they walked past Resident #29's room, Resident #29 was sitting in his doorway and attempted to reach for the unidentified CNA.-However, the staff did not offer any person-centered care when the resident requested to go to bed multiple times. During a continuous observation on 4/16/25, beginning at 11:12 a.m. and ending at 12:54 p.m., the following was observed: At 11:12 a.m. Resident #29 was in his wheelchair in his room on the left side of his bed with his head down. At 11:16 a.m.,Resident #29 left his room and looked at the newspaper that was on the counter in the common area. At 11:19 a.m. Resident #29 self-propelled back to his room and was on the left side of his bed. At 11:25 a.m. Resident #29 left his room, turned off his bedroom light and went back to the dining room. At 11:27 a.m. an unidentified CNA walked passed Resident #29, he said "help" and she said "one second." The unidentified CNA left the common area. Resident #29 went to his room, turned on his bedroom light and went to the left side of his bed. From 11:30 a.m. to 11:32 a.m. Resident #29 left his room, turned his bedroom light off and went to the farthest dining table from his room. He was sitting in his wheelchair in front of the dining table with no activities in front of him. At 11:38 a.m. Resident #29 returned to his room. He turned his bedroom light on. He went to the left side of his bed. He turned around and he was at his doorway and said "help nurse help." He turned off his bedroom light and went back to the dining table closest to his room. At 11:43 a.m. Resident #29 returned to his room, turned on his light, went to the left side of his bed and began rolling back and forth in a repetitive motion in his wheelchair. At 11:46 a.m. Resident #29 left his room, turned his bedroom light off and went to the dining table closest to his room. At 11:48 a.m. Resident #29 returned to his room, turned on his light, went to the left side of his bed and began rolling back and forth in a repetitive motion in his wheelchair. At 11:53 a.m. Resident #29 left his room, turned off his bedroom light, went to the dining table closest to his room and then self-propelled himself around the dining area. From 11:58 a.m. until 12:04 p.m. Resident #29 returned to his room, turned on his light, went to the left side of his bed and began rolling back and forth in a repetitive motion. At 12:05 p.m. Resident #29 was sitting in his doorway. He raised his hand when licensed practical nurse (LPN) #3 walked by. She told him he was first on the list for the scenic drive outing at 2:30 p.m. He looked at his watch and went to the dining table closest to his room. At 12:13 p.m. Resident #29 went to the dining table closest to his room. At 12:15 p.m. Resident #29 returned to his room, turned on his light, went to the left side of his bed and began rolling back and forth in a relative motion. At 12:26 p.m. Resident #29 left his room and went to the dining table farthest away from his room. At 12:33 p.m. an unidentified CNA walked by Resident #29. He told the CNA he had terrific pain in his scrotal area and needed a pain pill. The CNA said she would tell the nurse. At 12:35 p.m. Resident #29 went to his room and the CNA went to the nurse's station. At 12:37 p.m. LPN #3 went to Resident #29's room. At 12:42 p.m. Resident #29 left his room and went to the dining table farthest away from his room. At 12:46 p.m,. LPN #3 was with Resident #29 at the dining table farthest away from the resident's room. Resident #29 said his testicle hurt. LPN #3 offered incontinence care and Resident #29 declined. -During the observation, the staff failed to address the resident's request for help and provided person-centered interventions for the residents' behaviors. C. Record review Review of Resident #29's dementia care plan, initiated on 2/4/23 and revised on 3/15/23, revealed the resident had impaired cognitive function or impaired thought processes. Interventions included communicating with the resident, family and caregivers regarding the resident's capabilities and needs, encouraging the resident to take medications offered and asking yes or no questions to determine the resident's needs. -The care plan failed to include the resident's repetitive behavior of rolling back and forth, requests to go to bed before, asking for help or person-centered interventions to address the resident's behaviors. Review of Resident #29's activities care plan, revised on 9/22/24, revealed the resident benefited from associate support for resident programs. Interventions included establishing and recording the resident's prior level of activity involvement and interest with the resident, caregiver, and family on admission and as necessary, inviting the resident to programs of interest, preferred activities were reading the newspaper ,and family visiting. An additional intervention initiated on 4/17/25 (during the survey) included for the staff to assist the resident to bed per his preference when requested.-The care plan failed to include the request for a bed before the start of the survey (see staff interview below). III. Resident #42 A. Resident status Resident #42, age 85, was admitted on 2/26/25. According to the April 2025 CPO, diagnoses included dementia, Parkinson's disease (disease that causes tremors), hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction (stroke) affecting the right dominant side, insomnia (difficulty sleeping) and depression, The 3/4/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 11 out of 15. He required moderate assistance with oral hygiene, showering and moderate assistance He required substantial assistance with toileting. The assessment revealed the resident did not reject care, did not exhibit physical or verbal behaviors or wander. B. Additional resident interviews Resident #153 was interviewed on 4/15/25 at 11:10 a.m. He said Resident #42 wandered into his room once since he was admitted to the facility. He said he did not know what the facility was doing to prevent him from coming into his room. Resident #38 was interviewed on 4/15/25 at 3:07 p.m. She said Resident #42 sometimes would wander into her room in the evening. She said did not know what the facility was doing to prevent him from coming into her room. She was frustrated he wandered into her room because it took time away from the staff to redirect the resident out of her room. C. Observations During a continuous observation on 4/16/25, beginning at 11:12 a.m. and ending at 12:54 p.m., the following was observed:Resident #42 was observed in his bed lying on his right side with his eyes closed. D. Record review Review of Resident #42's wandering care plan, revised 3/23/25, revealed the resident was at risk for elopement and the resident wandered aimlessly. Interventions included discussing the risks, discussing safe discharge with the resident and responsible party, distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books, identifying patterns of wandering and intervening as appropriate, monitoring location throughout the shift and documenting wandering behaviors and attempting diversional interventions. . The care plan documented the resident prefers: (blank). -However, the care plan failed to identify the resident wandered into other resident's rooms, interventions to prevent wandering into other resident's rooms and did not specify the resident's preferences. The 3/5/25 nurse progress note revealed the resident made many attempts to wander into other resident's rooms. He was not easily redirected. The staff had to sit with the resident one-on-one at times to keep him from entering others' rooms. The 3/6/25 nurse progress note revealed the resident continued to wander around and sometimes in other resident's rooms. The 4/14/25 nurse progress note revealed the resident often exhibited increased wandering and agitation at this time of day due to disease process. The 4/16/25 nurse progress note revealed the resident was confused and wandered around the common area and attempted to go into another resident's room. He was not easily redirected. He was provided with snacks and games. -Review of the Resident #42's progress notes revealed there was not consistent documentation regarding what interventions were used and which interventions were effective when the resident's wandering was observed. The behavior monitoring and intervention task record was reviewed from 3/19/25 to 4/17/25. It revealed Resident #42 was known to have wandering on 3/22/25, 3/23/25, 3/28/25, 3/30/25, 4/4/25, 4/6/25, 4/7/25, 4/8/25, 4/11/25 and 4/16/25. -Review of the behavior monitoring and intervention task record revealed there was no documentation regarding what interventions were used and which interventions were effective when the resident's wandering was observed. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 4/15/25 at 8:55 a.m. RN #1 said she was familiar with Resident #42. At the time of the interview, she said he was sitting at a dining table near the kitchenette near his room. She said he often wandered and he moved very quickly. She said she had to keep her eyes on him because he was quick to stand up. During the interview, RN #1 directed CNA #6 to assist the resident as he was trying to stand up. LPN #3 was interviewed on 4/17/25 at 3:44 p.m. LPN #3 said if a resident had dementia and they asked to go to bed, the nursing staff should help the resident go to bed. She said if a resident was consistently doing the same behavior, there should be interventions to redirect the resident. She said she needed to document behaviors she observed during her shift. She said she needed to do a better job of documenting the behaviors residents exhibited, what interventions she used and if the interventions were effective. LPN #3 said Resident #29 had dementia. LPN #3 said he asked to go to bed, he would go in and out of his room and roll back and forth on the left side of his bed daily. She said she did not know what interventions to redirect the resident to meaningful activities that were person-centered worked for him. She said she knew he liked participating in activities that were outside of the facility. She said Resident #39 went on an outing yesterday (4/16/25). LPN #3 said Resident #42 wandered and had dementia. LPN #3 said he wandered most recently on Friday and Saturday. She said he slept during the day because his sleep schedule was off. LPN #3 said he experienced sundowners (confusion and agitation occurring in the late afternoon or early evening). She said the physician adjusted his medications to try to help with his sleep pattern but she said she has not seen a change in his sleep. She said she needed to be better at documenting when he wandered, what interventions she used and if the interventions were effective. The director of nursing (DON) was interviewed on 4/17/25 at 4:06 p.m. She said if a resident had dementia and they asked to go to bed, the nursing staff should not say it was almost time for lunch. The DON said the nursing staff could do better in offering personalized interventions for dementia residents. She said if the resident was asking for help or the same behavior, there should be personalized interventions in place to help redirect the resident. The DON said she knew Resident #29 asked to go to bed frequently. She said effective interventions to prevent the resident from going to bed before meal time were offering a newspaper or a banana.

Based on observations, record review and interviews, the facility failed to ensure meals were served according to the resident's preferences for one (#103) of three residents out of 27 sample residents. Specifically, the facility failed to ensure Resident #103 received the meal items she ordered. Findings include: I. Resident #103 A. Resident status Resident #103, age greater than 65, was admitted on 4/9/25. According to the April 2025 CPO, diagnoses included dementia, depression and Parkinson's disease (a disease that causes tremors). B. Resident interview and observations Resident #103 was interviewed on 4/17/25 at 12:20 p.m. The resident said she had problems with her lunch meal. The resident's meal ticket did not indicate the resident's choice for the lunch meal on 4/17/25 as it was blank. Resident #103 said this happened all the time since she was admitted to the facility. The resident said her son helped her fill out her meal tickets but the meal ticket that was delivered with her lunch tray was blank. She said she did not know what happened to her meal ticket that was completed a few days ago with the help of her son. The resident said she did not order the food on her tray so she did not eat it. C. Observations and resident representative interviewDuring a continuous observation on 4/17/25, beginning at 12:25 p.m. and ending at 12:50 p.m. the following was observed: Resident #103's son arrived at the facility to visit his mother during lunch. The resident's son asked the registered dietitian (RD) the reason his mother's meal ticket was blank. He said he completed the meal ticket with a nurse on the phone and the meal his mother received was not what they had ordered. The (RD said she was not sure why the meal ticket was blank. The resident's son said it had been an issue since the resident was admitted to the facility and that's the reason he called to ensure that the ticket was completed. D. Record review The nutrition care plan, dated 4/10/25, revealed the resident was at nutritional risk as evidenced by her medical diagnosis. Interventions included providing the resident her diet as ordered and monitoring meal intake with each meal. II. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 4/17/25 at 1:05 p.m. CNA #4 said the nursing staff assisted the residents who needed assistance to complete their meal tickets. CNA #4 said Resident #104's son assisted the resident in completing her meal ticket. She said she did not know why her ticket came back blank. The RD was interviewed on 4/17/25 at 12:40 p.m. The RD said Resident #103's son had called her and requested to assist his mother to complete the meal ticket. She said she gave the blank meal tickets to the nursing staff and it was completed on the phone with the resident's son. The RD said she does not know what happened to that meal ticket. The RD said the dietary staff should review and ensure all meal tickets were completed, submitted and notify the nursing staff of any incomplete meal ticket. The RD said she did not know this was happening and she would consult with the dietary department to come up with a plan to prevent this from happening again. The dining service supervisor (DSS) was interviewed on 4/17/25 at 12:55 p.m. The DSS said sometimes the dietary department received blank meal tickets. The DSS said when this happened the dietary staff would serve the main dish for the residents whose meal tickets were not completed. She said the nursing staff were supposed to assist the residents in completing their meal tickets. She said she was not sure if that was happening, as they received several blank meal tickets. She said the dietary staff should be reviewing the meal tickets to ensure they were completed and calling the nursing staff to verify every incomplete ticket. The DSS said if the meal tickets were not reviewed and verified for any inconsistencies, residents would receive meals that they did not order or preferred to eat. The executive chef (EC) was interviewed on 4/17/25 at 1:10 p.m. The EC said the dining service staff should be reviewing the meal tickets and informing the nursing staff of all inconsistencies to ensure residents receive their food preferences. The EC said he would consult with the dietary team to review their meal ticket process and immediately offer education to the staff to prevent the issue from happening again.

Based on observations and interviews, the facility failed to ensure an infection prevention and control programs (IPCP) was maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of three units. Specifically, the facility failed to ensure staff wore the appropriate PPE when providing wound care for Resident #50 who was on enhanced barrier precautions (EBP) related to an abdominal wound. Findings include: I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of MDROs, retrieved on 4/22/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent parts,"EBP are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities."Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization."Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing. II. Facility policy and procedureThe Isolation Precautions policy, revised September 2022, and the Enhanced Barrier Precautions Policy, revised February 2025, was received from the director of nursing (DON) on 4/17/25 at 1:45 p.m. The policy read in pertinent part,"EBP should be used as an infection prevention and controlintervention to reduce the spread of MDROs to residents. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to associate hands and clothing. Gloves and gown may be applied prior to performing high-contact resident care activity. PPE is changed before caring for another resident."EBPs are indicated with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (Band-Aid) or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers."III. Observations On 4/15/25 at 11:25 a.m. there was a sign on Resident #50's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. On 4/16/25 10:43 a.m. registered nurse (RN) #2 was completing wound care for Resident #50, who had a. abdominal wound. RN #2 had gloves on. RN #2 failed to put on a gown. IV. Resident interviewResident #50 was interviewed on 4/16/25 at 2:36 p.m. Resident #50 said the nurses never put on gowns when changing his abdominal wound dressing or when changing his abdominal wound vacuum machine. Resident #50 said they only wore gloves. V. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 4/16/25 at 2:44 p.m. CNA #1 said when she was providing care for Resident #50, she put on gloves and a gown. She said if she was going to assist the resident transfers, using the bathroom or helping the nurse with wound care, she would put on a gown and gloves to ensure the resident would not get an infection. RN #2 was interviewed on 4/16/25 at 3:00 p.m. RN #2 said Resident #50 was on EBP. She said the staff should wear gloves and a gown when providing wound care or when providing any close contact activities to protect the resident from getting an infection. RN #2 said she forgot to put on a gown today when she was changing his abdominal wound dressing. RN #2 said staff should put on gloves and gowns before going into Resident #104's room because he had an infectious bacteria in his wound. She said wearing a gown and gloves helped prevent the resident's infection from transferring to staff or residents. The director of nursing (DON) was interviewed on 4/16/25 at 4:33 p.m. The DON said if a resident was on precautions, the facility's procedure was to ensure there was a sign on the door to inform the staff the precautions that needed to be followed. She said if the resident was on precautions, a cart with PPE was stored outside of the resident's room. She said the nursing staff was provided education so they knew how to correctly care for the residents and prevent the transmission of bacteria or cause an infection. The DON said it was the responsibility of the nursing staff to update the care plan so all of the staff knew how to address the care needs for the individual residents. The DON said the staff should put on gloves and a gown before entering Resident #104 room and remove the gloves and gown before exiting the room. The DON said staff should put on gloves and gown with any high contact care for Resident #50 such as wound care, bathing, dressing, transfers and assisting the resident to the bathroom. The infection preventionist (IP) was interviewed on 4/16/25 at 4:55 p.m. The IP said staff should put on gloves and a gown when providing wound care for Resident #50 to ensure the wound does not get infected. The IP said she did not think the staff had to wear a gown when transferring a resident that was on EBP.The IP said Resident #50 had physician's orders that indicated he was on EBP. The IP said she was responsible for training the nursing, dietary and rehabilitation staff regarding EBP and contact precautions procedure. She said she would conduct surveillance and audits in addition to giving all staff re-education on the different precaution procedures. The IP said if the nurses and the CNA's did not read the care plan, that could have been the reason precaution procedures were not followed.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.