Every finding on record at Chateau D'Ville Rehab and Retirement

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. A dish towel used for cleaning was contained in sanitation solution when not in use to prevent the risk of cross contamination; 2. The food preparation area was clean and sanitary; 3. Foods were stored in a sanitary manner and in accordance with professional standard of food service safety; 4. A chemical used for cleaning was not stored above items meant for resident consumption; and,5. The drainage pipe of the three-compartment sink was functioning in a sanitary manner. Findings: In an interview on 07/07/2026 at 8:20AM, S2Dietary Manager (DM) indicated the facility's kitchen was currently under renovation. S2DM further indicated the facility's dietary staff began utilizing a mobile kitchen to prepare all of the residents' meals approximately 1 month ago due to the facility's kitchen renovation.1.Observation in the mobile kitchen on 07/07/2026 at 10:20AM revealed a white dish towel with a black substance was on the counter top. Further observation revealed there were no sanitization buckets for dish towels in the mobile kitchen. In an interview on 07/07/2026 at 10:30AM, S2DM indicated the food preparation area in mobile kitchen was not kept in a clean and sanitary manner. 2. Observation of the mobile kitchen used for the preparation of residents' meals on 07/07/2026 at 10:20AM revealed:- The pots and pans stored on the shelf in the mobile kitchen had a buildup of debris and dust; and,- Small crawling insects were observed crawling on the counter near the food storage containers. In an interview on 07/07/2026 at 10:30AM, S2DM indicated the food preparation area in mobile kitchen was not kept in a clean and sanitary manner. Observation of the mobile kitchen used for the preparation of residents' meals on 07/07/2026 at 1:01PM revealed:-A fan located near the mobile kitchen's three-compartment sink was blowing over the food preparation and cooking areas in the direction of the stove; and,-A fan was blowing over the food preparation area where a dietary staff member prepared sandwiches for resident consumption. In an interview on 07/08/2026 at 11:27AM, S1Administrator acknowledged above mentioned the fans should not have been blowing over food preparation areas. 3. Observation of the mobile kitchen used for the preparation of residents' meals on 07/07/2026 at 8:20AM revealed defrosted and uncovered pork chops were sitting on an aluminum pan on the mobile kitchen's counter. In an interview on 07/07/2026 at 8:20AM, S2DM indicated the pork chops were stored in the aluminum pan and were waiting to be washed. S2DM further indicated the pork chops would be washed in the three-compartment sink but could not be washed until the dietary staff finished washing the pots and pans. Observation of the mobile kitchen used for the preparation of the residents' meals on 07/07/2026 at 10:20AM revealed:- Four food storage containers with a sticky build up with a black substance observed on the outside surface of each container;-A storage container of grits had a small crawling insect in the grits; and, -Two pans of unbaked and uncovered cherry cobbler were on the counter in the mobile kitchen. In an interview on 07/07/2026 at 10:30AM, S2DM indicated the pork chops, grits and cherry cobbler were not stored properly. 4.Observation of the mobile kitchen used for the preparation of residents' meals on 07/07/2026 at 1:01PM revealed:-A labeled spray bottle of cleaner & degreaser was present on a wire rack above an open cardboard box which contained paper packets of a food condiment/seasoning. In an interview on 07/08/2026 at 11:27AM, S1Administrator indicated the above mentioned cleaner & degreaser spray bottle should not have been stored above the residents' paper packets of food condiment/seasoning. 5.Observation on 07/08/2026 at 9:03AM revealed S2DM removed the drain plug on the sanitization compartment of the three-compartment sink to drain the liquid inside. Further observation at 9:05AM revealed an unknown liquid with brown and tan particles floating in it was present on the floor of the mobile kitchen between the handwashing sink and the three-compartment sink. Further observation revealed the above mentioned unknown liquid with the brown and tan particles was draining from the cabinets underneath the three-compartment sink and the handwashing sink whenever someone would move in the mobile kitchen. In an interview on 07/08/2026 at 9:06AM, S2DM indicated the above mentioned unknown liquid with brown and tan particles that was draining from underneath the three-compartment and handwashing sinks, was the liquid she just drained from the sanitization compartment of the three-compartment sink. S2DM further indicated the pipe that created the air gap between the three-compartment sink's drainage pipe and the floor drain were not aligned correctly which caused the water to leak onto the floor of the mobile kitchen. S2DM further indicated the above mentioned had occurred previously. In an interview on 07/08/2026 at 11:27AM, S1Administrator acknowledged the above mentioned unknown liquid with brown and tan particles floating in it should not have drained onto the floor from the drainage pipe under the three-compartment sink.

Based on interviews, and record reviews the facility failed to report an allegation of abuse to the State Survey Agency for 1 (Resident #84) of 1 sampled resident investigated for incident and accident documentation and reporting. Findings:Review of the facility's policy and procedure titled, Abuse and Neglect-Clinical Protocol dated 10/15/2022 revealed, in part, the facility would report suspected or identified abuse to the appropriate agencies timely. Review of Resident #84's Quarterly Minimum Data Set Assessment with a reference date of 12/03/2025 revealed, in part, Resident #84 was cognitively intact with a Brief Interview for Mental Status score of 15. Review of Resident #91's electronic medical record revealed, in part, Resident #91 had diagnoses of Dementia, Cognitive Communication Deficit, and social or emotional deficit following a stroke. Review of Resident #91's Quarterly Minimum Data Set Assessment with a reference date of 11/20/2025 revealed, in part, Resident #91's cognition was severely impaired with a Brief Interview for Mental Status score of 6. Review of the facility's Incident Description dated 11/27/2025 at 3:04PM prepared by S4Licensed Practical Nurse revealed, in part, Resident #84 approached the nurse at nurse's station with blood dripping from the top of Resident #84's right hand. Further review revealed Resident #84 reported to her that Resident #91 came up to Resident #84 and hit Resident #84 with her cane. Further review revealed there was a bruise to Resident #84's right upper arm and a skin tear to the back of Resident #84's right hand. Review of Resident #84's Nurse's Note dated 11/27/2025 at 3:01PM written by S3Registered Nurse revealed, in part, Resident #84 came up to S3Registered Nurse with a skin tear to the right hand and a bruise to the right middle arm. Further review revealed Resident #84 stated another resident hit her with a cane. Review of Resident #91's Nurse's Note dated 11/27/2025 at 3:59PM written by S3Registered Nurse revealed, in part, Resident #91 got into an altercation with Resident #84. Further review revealed Resident #84 stated Resident #91 hit Resident #84 on the hand, the head, and the right arm with Resident #91's cane. In an interview on 02/25/2026 at 9:23AM S2Director of Nursing indicated if there was an allegation of abuse at the facility, she knew she would have to report the situation to the State Survey Agency. In an interview on 02/25/2026 at 9:40AM Resident #84 indicated that Resident #91 hit Resident #84 with Resident #91's cane on 11/27/2025. Resident #84 further indicated she reported the incident to the facility when it happened. In an interview on 02/25/2026 at 10:06AM S2Director of Nursing indicated the incident on 11/27/2025 between Resident #84 and Resident #91 was not reported by the facility to the State Survey Agency. In an interview on 02/25/2026 at 11:05AM S1Administrator indicated he was responsible for reporting any allegations of abuse at the facility to the State Survey Agency. S1Administrator further indicated he did not report the above to the State Survey Agency.

Based on observations and interviews, the facility failed to: 1. Ensure staff performed hand hygiene while passing ice for 1 (S6Certified Nursing Assistant[CNA]) of 1 (S6CNA) CNAs observed passing ice; and, 2. Ensure hallway linen carts were kept covered for 2 Linen Carts (g, linen cart h) of 3 (linen cart b, linen cart h, linen cart i) linen carts observed. Findings: 1 Review of the facility's Handwashing-Hand Hygiene policy and procedures dated 01/22/2023 and reviewed on 1/28/2025 revealed, in part, personnel shall use alcohol-based hand rub or soap and water after contact with objects near the resident. Observation on 02/10/2025 at 10:20AM revealed S6CNA went into Room a, grabbed Resident #33's pitcher with ungloved hand, filled the pitcher with ice, returned the pitcher to Resident #33'a room, and exited Room a without performing hand hygiene. Observation on 02/10/2025 at 10:21AM revealed S6CNA went into Room b, grabbed Resident #32's pitcher with ungloved hand, filled the pitcher with ice, returned the pitcher to Resident 32's room, and exited Room b without performing hand hygiene. Observation on 02/10/2025 at 10:22AM revealed S6CNA went into Room c, grabbed Resident #16 and Resident #60's pitchers with ungloved hand, filled the pitchers with ice, returned the pitchers to Resident #16 and Resident #60's room, and exited Room c without performing hand hygiene. Observation on 02/10/2025 at 10:23AM revealed S6CNA went into Room d, grabbed Resident #78's pitcher with ungloved hand, filled the pitcher with ice, returned Resident 78's pitcher, and exited Room d without performing hand hygiene. Observation on 02/10/2025 at 10:24AM revealed S6CNA went into Room e, grabbed Resident #27's pitcher with ungloved hand, filled the pitcher with ice, returned Resident #27's pitcher, and exited Room e without performing hand hygiene. Observation on 02/10/2025 at 10:25AM revealed S6CNA went into Room f, grabbed Resident #38's pitcher with an ungloved hand, filled the pitcher with ice, returned Resident #38's pitcher, and exited the Room f without performing hand hygiene. In an interview on 02/10/2025 at 10:26AM, S6CNA confirmed she did not perform hand hygiene between residents' rooms while passing ice and should have. In an interview on 02/11/2025 at 12:21PM, S2Director of Nursing (DON) confirmed staff should perform hand hygiene between rooms when passing ice. 2. Observation on 02/10/2025 at 1:05PM revealed Linen Cart g was left uncovered, and clean linens were exposed to the surrounding environment. Observation on 02/10/2025 at 1:08PM revealed Linen Cart h was left uncovered, and clean linens were exposed to the surrounding environment. In an interview on 02/11/2025 at 12:21PM, S2DON indicated the linen carts should have been covered.

Based on observation, interviews and record review, observation, and interviews, the facility failed to ensure an expired medication was not available for resident use for 1 (Treatment Cart A) of 2 (Treatment Cart A, Medication Cart B) medication carts observed for expired medications. Findings: Review of the facility's policy titled, Storage of Medication dated 2001 and revised in April 2019, revealed, in part, expired drugs or biologicals should be returned to the dispensing pharmacy or destroyed. Observation of Treatment Cart A on 02/12/2025 at 11:50AM revealed one bottle of New Skin liquid bandage (a liquid that creates a thin transparent barrier on a wound) with an expiration date of 06/2024. Further observation revealed two tubes of Thera Honey gel (a gel used for wound treatment) both with an expiration date of 08/11/2024. In an interview on 02/12/2025 at 11:53AM, S7Treatment Nurse confirmed the bottle of New Skin liquid bandage and the tubes of Thera Honey gel found stored on Treatment Cart A was expired and available for resident use, and should not have been. In an interview on 02/12/2025 at 1:50PM, S2Director of Nursing confirmed the expired bottle of New Skin liquid bandage and two tubes of expired Thera Honey gel should not have been stored in Treatment Cart A and available for resident use.

Based on observation, interview, and record review, the facility failed to: 1. Promptly repair the loose toilet fixture (Resident #62); and, 2. Prevent discarded waste and personal protective equipment (PPE) from accumulating in the facility's parking lot. This deficient practice was identified for 1(Resident #62) of 25 (Resident #1, Resident #3, Resident #10, Resident #12, Resident #13, Resident #16, Resident #17, Resident #20, Resident #21, Resident #22, Resident #26, Resident #27, Resident #28, Resident #33, Resident #34, Resident #45, Resident #47, Resident #54, Resident #60, Resident #62, Resident #62, Resident #63, Resident #78, Resident #236, Resident #386) sampled residents observed for environment. Findings: 1. In an interview on 02/10/2025 at 10:10AM, Resident #62 indicated the bathroom toilet had been loose for some time and she had reported it to S4Maintenance Director. Observation on 02/10/2025 at 10:11AM revealed Resident #62's bathroom toilet was loose. Further observation revealed the base of the bathroom toilet was not adequately secured to the floor and could easily be moved when touched. Observation on 02/11/2025 at 8:40AM revealed Resident #62's bathroom toilet was loose. Further observation revealed the base of the bathroom toilet was not adequately secured to the floor and could easily be moved when touched. Observation on 02/12/2025 at 7:55AM revealed Resident #62's bathroom toilet was loose. Further observation revealed the base of the bathroom toilet was not adequately secured to the floor and could easily be moved when touched. In an interview on 02/12/2025 at 7:57AM, S4Maintenance Director indicated Resident #62's bathroom toilet base was loose and needed to be fixed. In an interview on 02/12/2025 at 8:00AM, S5Regional Administrator indicated Resident #62's bathroom toilet needed to be repaired. 2. Observation on 02/10/2024 at 9:21AM revealed the facility's back parking lot was littered with multiple discarded PPE gloves. Observation on 02/11/2025 at 8:15AM revealed the facility's back parking lot was littered with multiple discarded PPE gloves. In an interview on 02/11/2025 at 8:15AM, S1Administrator confirmed the above findings and indicated the facility's parking lot should be free of discard PPE gloves and general trash or debris. 49259

Based on interviews and record reviews, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form from Centers for Medicare and Medicaid Services CMS-10055 were given, explained, and/or signed by residents and/or a resident's responsible party prior to the discontinuation of Medicare Part A services (short term skilled nursing care and/or rehabilitation) for 3 (Resident #15, Resident #57, Resident #83) of 3 (Resident #15, Resident #57, Resident #83) sampled residents reviewed for termination of Medicare Part A services. Findings: Resident #15 Review of Resident #15's medical record revealed, in part, Resident #15's last day to receive Medicare Part A services was 01/16/2025. Further review revealed Resident #15 had 40 days of available therapy services available and remained living in the facility. Review of Resident #15's record revealed, in part, no documented evidence, and the facility was unable to present any documented evidence, Resident #15 and/or Resident #15's responsible party received a copy, was explained, and/or signed the CMS-10055 Form prior to Medicare Part A services being terminated by the facility on 01/16/2025. Resident #57 Review of Resident #57's medical record revealed, in part, Resident #57's last day to receive Medicare Part A services was 01/23/2025. Further review revealed Resident #57 had 50 days of available therapy services available and remained living in the facility. Review of Resident #57's record revealed, in part, no documented evidence, and the facility was unable to present any documented evidence, Resident #57 and/or Resident #57's responsible party received a copy, was explained, and/or signed the CMS-10055 Form prior to Medicare Part A services being terminated by the facility on 01/23/2025. Resident #83 Review of Resident #83's medical record revealed, in part, Resident #83's last day to receive Medicare Part A services was 01/17/2025. Further review revealed Resident #83 had 60 days of available therapy services available and remained living in the facility. Review of Resident #83's medical record revealed, in part, no documented evidence, and the facility was unable to present any documented evidence, Resident #83 and/or Resident #83's responsible part received a copy, was explained, and/or signed CMS-100055 Form prior to Medicare Part A services being terminated by the facility on 01/17/2025. In an interview on 02/12/2025 at 9:18AM, S3Regional Administrator indicated the facility should have had the CMS-10055 form signed by Resident #15, Resident #57, Resident #83 and/or their responsibly party prior to Medicare Part A services being terminated.

Based on observation and interview, the facility failed to prevent discarded waste and personal protective equipment (PPE) from accumulating around the facility's dumpster for 1 (Dumpster C) of 1 (Dumpster C) dumpsters observed for garbage disposal. Findings: Observation on 02/10/2025 at 9:22AM revealed the area surrounding Dumpster C contained paper waste, plastic debris and multiple discarded PPE gloves scattered on the ground. Further observation revealed a pile of general trash, including paper waste, plastic debris and discarded PPE gloves, behind the Dumpster C. Observation on 02/11/2025 at 8:16AM revealed the area surrounding Dumpster C contained paper waste, plastic debris and multiple discarded PPE gloves scattered on the ground. Further observation revealed a pile of general trash, including paper waste, plastic debris and discarded PPE gloves behind Dumpster C. In an interview on 02/11/2025 at 8:15AM, S1Administrator confirmed the above findings and indicated the area around Dumpster C should be free of discarded PPE gloves and general trash and/or debris.

Based on observations, interviews, and record review the facility failed to prepare food in a manner to prevent food borne illnesses by failing to discard improperly thawed chicken, preparing the chicken thighs, and placing them in the oven to cook for 76 out of 80 residents who are served/eat food prepared by the facility's kitchen. This deficient practice resulted in an Immediate Jeopardy situation on 02/28/2024 at 8:30 a.m. when an observation revealed multiple chicken thighs were being thawed without the use of running water in the sanitization compartment of the facility's three compartment sink. The Immediate Jeopardy situation continued when an observation on 02/28/2024 at 9:59 a.m. revealed the above mentioned improperly thawed chicken thighs were being baked in the facility's oven to be served to the residents for lunch. S1Administrator was notified of the Immediate Jeopardy on 02/28/2024 at 2:33 p.m. The Immediate Jeopardy was removed on 02/29/2024 at 10:47 a.m., after it was verified through observations, interviews, and record reviews, the facility implemented an acceptable Plan of Removal, prior to the survey exit. This deficient practice had the likelihood to cause more than minimum harm to the 76 residents who eat food prepared by the facility's kitchen. Findings: Review of facility's lunch menu for 02/28/2024 revealed, in part baked chicken was on the menu to be served for lunch. Review of facility's Food Preparation and Handling Policy with a revised date of 06/01/2019 revealed, in part to ensure all food served is of good quality and safe for consumption, all food will be prepared and handled according to the state, United State Food Codes, and Hazard Analysis and Critical Control Point (HACCP) guidelines. Further review of facility's policy for Food Preparation and Handling revealed, in part thaw poultry completely submerged under running water at a temperature of seventy degrees Fahrenheit or below with sufficient water velocity to agitate and float off loosened food particles into the overflow. Further review, revealed, in part thaw poultry for a period of time that does not allow thawed portions of ready-to-eat food to rise above forty one degrees Fahrenheit; or thaw poultry for a period of time that does not allow thawed portions of raw animal food requiring cooking to be above forty one degrees Fahrenheit for more than four hours including the time the food is exposed to the running water and the time needed for preparation for cooking. Review of Hazard Analysis and Critical Control Point (HACCP) guidelines dated 03/05/2024 revealed, in part, hazard analysis identifies potential hazards associated with food products which has the potential to produce organisms such as viruses and parasites. Further review revealed, potential food handling hazards has the potential to affect adults, seniors, and the immunocompromised. Observation on 02/28/2024 at 8:30 a.m., revealed multiple chicken thighs uncontained were thawing in the sanitization compartment of the facility's three compartment sink. Further observation revealed that no water was running over the thawing chicken thighs. In an interview on 02/28/2024 at 8:31 a.m., S4Dietary Manager confirmed the above mentioned chicken thighs were being thawed improperly. In an interview on 02/28/2024 at 9:59 a.m., S4Dietary Manager confirmed the chicken thighs should have been in a container and thawed under running water and not in the sanitization compartment of the facility's three compartment sink. Observation on 02/28/2024 at 9:59 a.m., revealed the same multiple chicken thighs were being baked in the facility's oven. In an interview on 02/28/2024 at 10:00 a.m., S4Dietary Manager confirmed the chicken thighs that were baking in the facility's oven were the same chicken thighs that were observed being thawed improperly in the sanitization compartment of the facility's three compartment sink. S4Dietary Manager further stated the chicken thighs that were in the facility's oven baking were going to be served to the facility's residents for lunch In an interview on 02/28/2024 a 10:40 a.m., S1Administrator stated the chicken thighs should have been thawed under running water and S1Administrator further stated the improperly thawed chicken thighs should have been discarded and not prepared to be served to facility residents. S1Administrator further indicated serving improperly thawed chicken thighs to the facility's residents could put the residents at risk for infection. In a phone interview on 02/28/2024 at 11:07 a.m., S6Registered Dietician stated the improperly thawed chicken thighs should not have been prepared to be served to facility residents.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received the appropriate interventions to decrease the risk of falls for 2 (Resident #46 and Resident #79) of the 3 sampled residents (Resident #46, Resident #61, and Resident #79) residents reviewed for falls. Findings: Resident #46 Review of Resident #46's Electronic Medical Record (EMR) revealed, in part Resident #46 had a diagnosis of hemiplegia and abnormal posture. Review of Resident# 46's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/2023 revealed, in part, Resident #46 had a Brief Interview Mental Status (BIMS) score of 11, which indicated Resident #46 moderately cognitive impaired. Further review revealed, Resident #46 was dependent and needed substantial to maximum assistance with transfers. Review of Resident #46's Physician Orders dated 10/13/2023 revealed, in part, the following: Resident #46 was at risk for falls. Review of the facility's incident documentation for November 2023, December 2023, and January 2024 revealed, in part, Resident #46 had unwitnessed falls on 08/23/2024, 11/11/2023, 01/26/2024, 01/28/2024, and 01/30/2024. Review of Resident #46's Fall Risk Screening dated 01/30/2024 revealed, in part, Resident #46 was assessed as being at moderate risk for falls and impaired mobility and gait. Review of Resident #46's Comprehensive Care Plan with a start date of 11/14/2023 revealed, in part, Resident #46 was at high risk for falls related to left sided hemiplegia. Further review revealed an intervention included to place frequently used items within Resident #46's reach. Observation on 02/27/2024 at 9:38 a.m., revealed Resident #46 was siting in wheelchair in his room. Further observation revealed, Resident #46's call bell and frequently used items out of Resident #46's reach. Observation on 02/29/2024 at 1:30 p.m. revealed, Resident #46 was lying in bed. Further observation revealed, Resident 46's frequently used items out of Resident #46's reach. In an interview on 02/29/2024 at 1:42 p.m. S2Director of Nursing stated Resident 46's frequently used items should be within Resident #46's reach. Resident #79 Review of Resident #79's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/29/2024 revealed, in part, Resident #79's Brief Interview for Mental Status (BIMS) score was 15, which indicated Resident #79 was cognitively intact. Review of the facility's incident documentation for January 2024 and February 2024 revealed, in part, Resident #79 had unwitnessed falls on 01/31/2024, 02/05/2024, 02/06/2024 at 7:30 p.m., 02/06/2024 at 11:00 p.m., 02/09/2024, 02/12/2024, and 02/17/2024. Review of Resident #79's fall risk screening dated 01/23/2024 revealed, in part, Resident #79 had a fall risk score of 13, which indicated Resident #79 was at high risk for falls. Review of Resident #79's Comprehensive Care Plan with a start date of 02/12/2024 revealed, in part, a plan of care was developed for Resident #79 for being at high risk for falls with interventions to include the use of a chair alarm when in the wheelchair and bed alarm when in bed. Review of Resident #79's February 2024 Physician Order Summary Report revealed an order to ensure a bed alarm is in place while Resident #79 was in bed and ensure a chair alarm was in place while Resident #79 was in the wheelchair. Observation on 02/28/2024 at 9:20 a.m. revealed Resident #79 was sitting in her wheelchair with no chair alarm. Observation on 02/29/2024 at 9:50 a.m. revealed Resident #79 was sitting in her wheelchair with no chair alarm. In an interview on 02/29/2024 at 9:50 a.m. Resident #79 stated she did not have a chair alarm on her chair, and further stated she did not have a bed alarm or chair alarm yesterday or last night. In an interview on 02/29/2024 at 10:00 a.m. S17Licensed Practical Nurse (LPN) stated Resident #79 had a history of falling and required a bed alarm. S17LPN stated Resident #79 did not require a chair alarm. In an interview on 02/29/2024 at 10:10 a.m. S16Certified Nurse Aide (CNA) stated Resident #79 had a history of falls and required a bed alarm and a chair alarm. S16CNA stated she did not put Resident #79's chair alarm on this morning. In an interview on 02/29/2024 at 10:15 a.m. S12Minimum Data Set (MDS) Nurse stated Resident #79 had a history of falls. S12MDS Nurse further stated Resident #79 required a bed alarm while in the bed and a chair alarm while in the wheelchair to decrease Resident #79's risk of falls and injury. Observation with S12MDS Nurse on 02/29/2024 at 10:18 a.m., revealed Resident #79 did not have on a chair alarm. In an interview on 02/29/2024 at 10:18 a.m., S12MDS Nurse confirmed Resident #79 did not currently have on a chair alarm and stated a chair alarm should have been placed on Resident #79's chair when Resident #79 was put in her chair. In an interview on 02/29/2024 at 11:59 a.m., S1Director of Nursing confirmed Resident #79 should have had a chair alarm on her wheelchair and a bed alarm per interventions on Resident #79's care plan. 48855

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program by: 1.) failed to perform hand hygiene while feeding residents for 4 (Resident #8, Resident #16, Resident #52, and Resident #57) of 6 (Resident #8, Resident #16, Resident #47, Resident #52, Resident #57, and Resident #74) sampled residents observed for dining; 2.) administering crushed medication from an open medication pill crusher pouch that fell on the floor. This practice was observed for 1 (S20Licensed Practical Nurse [LPN]) of 6 (S15LPN, S17LPN, S20LPN, S21LPN, S22LPN, and S23LPN) Licensed Practical Nurses observed during medication administration; 3.) failed to perform proper hand hygiene during urinary catheter care for 1 (Resident #78) of 1 (Resident #78) sampled resident observed for catheter care; and 4.) failed to perform proper hand hygiene during wound care for 1 (Resident #54) of 2 (Resident #54 and Resident #78) sampled residents observed for wound care. Findings: 1. Observation on 02/26/2024 at 12:08 p.m. revealed S7Cerified Nurse Aide (CNA) fed Resident #8, wiped his mouth with a napkin, and then fed Resident #16 without performing hand hygiene. Further observation revealed, S7CNA finished feeding Resident #16 and then fed Resident #8 without performing hand hygiene. S7CNA was then observed feeding Resident #16 two bites of food then fed Resident #8 three bites of food, then fed Resident #16 two bites of food without performing hand hygiene. Further observation revealed, after feeding Resident #8 a bite of food, S7CNA fed Resident #16 two more bites of food without performing hand hygiene. In an interview on 02/26/2024 at 12:11 p.m., S7CNA confirmed she did not perform hand hygiene between feeding residents and she should have. In an interview on 02/26/2024 at 12:15 p.m., S3Assistant Director of Nursing (ADON) stated S7CNA should have performed hand hygiene between feeding residents bites of food. Observation on 02/27/2024 at 11:48 a.m., revealed S9CNA fed Resident #57 a bite of food, and then picked up Resident #52's spoon from his tray to feed him. Further observation revealed Resident #52 was not ready for a bite of food and S9CNA placed Resident #52's spoon back onto his plate and began to feed Resident #57 without performing hand hygiene. In an interview on 02/26/2024 at 12:11 p.m., S9CNA confirmed she did not perform hand when she started to feed Resident #52 and Resident #57. S9CNA further stated she should have performed hand hygiene between touching resident's spoons. In an interview on 02/27/2024 at 12:57 p.m., S2Director of Nursing (DON) stated S7CNA and S9CNA should have performed hand hygiene between feeding residents. 2. Observation on 02/28/2024 at 1:37 p.m. revealed S20LPN crushed Gabapentin 600 milligrams (a medication use for nerve pain) in a clear open medication pill crusher pouch. Further observation revealed S20LPN dropped the clear open medication pill crusher pouch with the crushed medication in it on the floor. Further observation revealed S20LPN pick up the clear open medication pill crusher pouch with her hands and proceeded to Resident #33's room. Further observation revealed S20LPN put on gloves without washing her hands with soap and water or without hand sanitizer. Further review revealed S20LPN poured the medication from the clear open medication pill crusher pouch into a one ounce medication cup and diluted with water. Further observation revealed S20LPN administered the diluted medication into Resident #33's peg tube. In an interview on 02/28/2024 at 2:05 p.m,. S20LPN stated she did not think the clear open medication pill crusher pouch with medication was contaminated. S20LPN further stated she did not wash her hands after picking the clear open medication pill crusher pouch up off of the floor and she should have. In an interview on 02/29/2024 at 4:10 p.m., S2Director of Nursing (DON) stated S20LPN should have disposed of the dropped clear open medication pill crusher pouch and should have performed hand hygiene before performing peg tube medication administration. 3. Observation on 02/29/2024 at 11:01 p.m. revealed S18CNA put on gloves without first performing hand hygiene and performed Resident #78's catheter care. Further observation revealed S18CNA opened Resident #78's drawer and pulled out a pack of wipes without removing her gloves or performing hand hygiene. Further observation revealed, after wiping stool off of Resident #78's buttocks with a wipe and wet towel, S18CNA removed her gloves, did not perform hand hygiene, and reached into another assisting CNA's pocket to grab another pair of gloves. In an interview on 02/29/2024 at 11:16 a.m., S18CNA confirmed she did not perform hand hygiene before starting Resident #78's catheter care and should have. S18CNA stated she had not removed her gloves or performed hand hygiene before opening Resident #78's drawer and pulling out Resident #78's wipes and should have. S18CNA further confirmed she did not perform hand hygiene after cleaning stool from Resident #78's buttocks and removing her gloves, before reaching into the other CNA's pocket and should have. In an interview on 02/29/2024 at 11:20 a.m., S2DON stated S18CNA should have performed hand hygiene before starting catheter care, when removing her gloves, before putting new gloves on, and before reaching into another staff member's pocket. 4. Review of the policy and procedure titled, Wound Care and most recently revised in November 2017 revealed, in part, after removing a dressing staff should remove their gloves and wash and dry their hands before proceeding with wound care. Observation of wound care performed on 02/28/2024 at 10:45 a.m. revealed S14Treatment Nurse removed the dressing from Resident #54's sacral wound. Further observation revealed S14Treatment Nurse cleaned, packed, and redressed Resident #54's sacral wound without changing gloves or performing hand hygiene. In an interview on 02/28/2024 at 11:00 a.m., S14Treatment Nurse stated she should have performed hand hygiene and changed gloves while performing wound care to Resident #54's sacral wound. 47487 49562

Based on observation and interviews, the facility failed to ensure residents were treated with respect and dignity during dining for 2 (Resident #47 and Resident #74) of 6 (Resident #8, Resident #16, Resident #47, Resident #52, Resident #57, and Resident #74) residents observed for dining. Findings: Resident #47 Observation on 02/26/2024 at 11:55 a.m., revealed lunch trays were being served to the residents in Dining Room B. Observation on 02/26/2024 at 12:14 p.m., revealed all residents, except for Resident #47, were served their lunch trays in Dining Room B. Further observation revealed, some of the residents in Dining Room B had finished their meals, and staff were no longer passing lunch trays and were feeding residents. Resident #47 was observed looking around the dining room at other residents eating. In an interview on 02/16/2024 at 12:15 p.m., Resident #47 stated he had not yet received a lunch tray and wanted to eat. In an interview on 02/26/2024 at 12:15 p.m., S3Assistant Director of Nursing (ADON) stated Resident #47 should have been served a lunch tray. In an interview on 02/27/2024 at 12:57 p.m., S1Director of Nursing (DON) stated Resident #47 should have been served a lunch tray when the rest of the residents were served. Resident #74 Observation on 02/26/2024 at 12:00 p.m., revealed a peppershaker was being passed around by the residents in Dining Room B. Observation on 02/26/2024 at 12:05 p.m., revealed Resident #74, who was eating in Dining Room B, requested pepper for his meal from S8Certified Nurse Aide (CNA).Further observation revealed S8CNA responded to Resident #74 that he could not have pepper because the facility was out of pepper, and she could not get him any. In an interview on 02/26/2024 at 12:15 p.m., S3ADON stated if Resident #74 had requested pepper from S8CNA, S8CNA should have provided Resident #74 with pepper, unless it was contraindicated by his diet order. There was no evidence, and the facility did not present any evidence, Resident #74 could not have pepper with his diet. In an interview on 02/27/2024 at 12:57 p.m., S2DON stated if Resident #74 had requested pepper, S8CNA should have provided him with pepper.

Based on interview and record review, the facility failed to ensure a resident with a new diagnosis of Major Depressive Disorder was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #55) of 5 (Resident #3, Resident #15, Resident #40, Resident #55, and Resident #78) sampled residents reviewed for PASARR. Findings: Review of Resident #55's Electronic Medical Record (EMR) revealed, in part, Resident #55 had a diagnosis of Major Depressive Disorder on 01/25/2022. Review of Resident #55's Level I determination dated 05/27/2019 revealed, in part, only Resident #55's diagnosis of Schizophrenia was listed under his mental illnesses. There was no documented evidence and the facility did not present any documented evidence of completing a Level II PASARR evaluation as required for Resident #55. In an interview on 02/29/2024 at 1:48 p.m., S6Social Services stated Resident #55's mental illness of Major Depressive Disorder was not addressed on his Level I screening. S6Social Services further stated Resident #55's record should have been submitted to the appropriate state agency for review when he had a new diagnosis of Major Depressive Disorder.

Based on observations and interviews, the facility: 1. failed to handle a resident's catheter bag in a manner to prevent urinary tract infections (Resident #78); and 2. failed to ensure staff provided catheter care in a manner to prevent urinary tract infections (Resident #78). This deficient practice was identified for 1 (Resident #78) of 1 sampled residents observed for catheter care. Findings: Observation of Resident #78 during personal care on 02/29/2024 at 11:01 a.m. revealed, while S18Certified Nurse Aide (CNA) was attempting to get a dried brown substance off Resident #78's Foley catheter, S18CNA used a towel to wipe the dried brown substance up Resident #78's Foley catheter towards his catheter insertion site three times. After personal care was completed S18CNA was observed lifting Resident #78 with a lift to put him in a wheelchair. Further observation revealed, S18CNA hung Resident #78's catheter bag on the arm of the lift. Further observation revealed, the urine and sediment in Resident #78's catheter bag flowed down the tubing of the catheter bag and back towards Resident #78's bladder after it was hung on the lift's arm. Further observation revealed, after Resident #78 was placed in wheelchair, S18CNA placed Resident #78's catheter bag on the floor. In an interview on 02/29/2024 at 11:16 a.m., S18CNA confirmed she had wiped from the end of Resident #78's Foley catheter towards Resident #78's catheter insertion site and should not have. S18CNA further stated she should not have hung Resident #78's Foley catheter bag, above his bladder, on the lift's arm. S18CNA further stated she should not have placed Resident #78's catheter bag on the floor. In an interview on 02/29/2024 at 11:20 a.m., S2Director of Nursing (DON) stated S18CNA should not have been wiping Resident #78's Foley catheter towards the catheter insertion site. S2DON further stated the resident's catheter bag should not have been hung above his bladder or placed on the floor.

Based on observation, interviews and record reviews, the facility failed to protect the resident's right to be free from resident to resident physical abuse for 3 (Resident #1, Resident #2, and Resident #3) of 3 (Resident #1, Resident #2, Resident #3) sampled residents investigated for abuse. Findings: Review of the facility's Abuse Prevention Program policy revealed, in part, the facility's residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Physical abuse included, but was not limited to hitting, slapping, pinching, and kicking. Resident #1 and Resident #4: Review of Resident #1's Admission Record revealed, in part, Resident #1 had diagnoses of anxiety disorder and schizoaffective disorder. Review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/24/2023 revealed, in part, Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Further review revealed Resident #1 had no behaviors directed towards others documented. Review of Resident #4's Admission Record revealed, in part, Resident #4 had diagnoses including Alzheimer's disease, anxiety disorder, and schizoaffective disorder. Review of Resident #4's MDS with an ARD of 08/28/2023 revealed, in part, Resident #4 had a BIMS score of 99, which indicated Resident #4 was unable to complete the interview. Further review revealed Resident #4 was documented to be moderately impaired in daily decision making. Review of the facility's Incident and Accident log revealed, in part, Resident #1 and Resident #4 had an incident on 09/18/2023 at 3:30 p.m. Review of Resident #1's Physician Progress Notes, signed by the physician on 09/19/2023, revealed, in part, Resident #1's physician, S10Medical Director, documented patient was struck by her roommate yesterday. Further review revealed S10Medical Director included the diagnosis of assault in unarmed fight in Resident #1's progress note. In an interview on 11/13/2023 at 3:01 p.m., Resident #1 stated Resident #4 deliberately hit her behind her head with an open hand on 09/18/2023 as they were passing one other in the hallway. Resident #1 stated Resident #R5 and Resident #R6 witnessed the incident between Resident #1 and Resident #4. Review of Resident #R5's MDS with an ARD of 08/23/2023 revealed, in part, Resident #R5 was diagnosed with aphasia (an inability to formulate language because of damage to specific area of the brain). Observation on 11/13/2023 at 3:11 p.m. revealed Resident #R5 demonstrated the above mentioned incident by taking his hand and hitting himself behind his head. Resident #R5 nodded yes when asked if that was how Resident #4 hit Resident #1 on 09/18/2023. In an interview on 11/14/2023 at 9:40 a.m., S9Maintenance stated he heard Resident #1 say, don't f*cking hit me, as Resident #4 was passing by Resident #1 in the hallway. S9Maintenance stated he did not witness Resident #4 hit Resident #1, but S9Maintenance did witness a vulgar verbal altercation between Resident #1 and Resident #4. S9Maintenance stated he informed S1Administrator regarding the incident between Resident #1 and Resident #4. In an interview on 11/14/2023 at 12:07 p.m., Resident #R6 stated he witnessed Resident #4 hit Resident #1 behind the head for no reason. Resident #R6 stated he was ambulating down the hall with Resident #4 walking on side of him. Resident #R6 further indicated Resident #4 hit Resident #1, and then Resident #1 cussed out Resident #4. In an interview on 11/14/2023 at 12:43 p.m., S2DON confirmed Resident #R6 was cognitive and reliable. In an interview on 11/14/2023 at 10:15 a.m., S4Social Services confirmed Resident #R5 was a reliable source of information, but Resident #R5 was nonverbal due to a previous stroke. S4Social Services additionally stated Resident #R5 was capable of acting out what happened during the 09/18/2023 incident between Resident #1 and Resident #4. In an interview on 11/14/2023 at 11:05 a.m., S1Administrator stated physical abuse between Resident #1 and Resident #4 could not be substantiated despite witness statements. S1Adminisrtator was unable to provide any explanation as to why he was unable to substantiate physical abuse between Resident #1 and Resident #4. In an interview on 11/14/2023 at 11:06 a.m., S2Director of Nursing (DON) stated physical abuse between Resident #1 and Resident #4 could not be substantiated despite witness statements. S2DON was unable to provide any explanation as to why she was unable to substantiate physical abuse between Resident #1 and Resident #4. In an interview on 11/14/2023 at 11:07 a.m., S4Social Services denied physical abuse between Resident #1 and Resident #4 could be substantiated despite witness statements. S4Social Services was unable to provide any explanation as to why she was unable to substantiate physical abuse between Resident #1 and Resident #4. Resident #1 and Resident #2: Review of Resident #1's Admission Record revealed, in part, Resident #1 had diagnoses of anxiety disorder and schizoaffective disorder. Review of Resident #1's MDS with an ARD of 10/24/2023 revealed, in part, Resident #1 had a BIMS score of 15, which indicated Resident #1 was cognitively intact. Further review revealed Resident #1 had no documented behaviors directed towards others. Review of Resident #2's Admission Record revealed, in part, Resident #2 had diagnoses of schizoaffective disorder, anxiety disorder, and impulse disorder. Review of Resident #2's MDS with an ARD of 08/22/2023 revealed, in part, Resident #2 had a BIMS score of 3, which indicated Resident #2 had severe cognitive impairment. Further review revealed Resident #2 had physical behavior symptoms directed toward others, which occurred 1 to 3 days within the 7-day look back period. Review of Resident #1's nurse's note written by S5Weekend Supervisor on 10/28/2023 at 3:40 p.m. revealed, in part, Resident #1 reported that Resident #2 hit her in her left breast. Review of Resident #1's Incident Note on 10/28/2023 3:33 p.m. revealed, in part, S5Weekend Supervisor observed Resident #1 who appeared tearful or saddened. Further review revealed Resident #1 reported to S5Weekend Supervisor that Resident #2 hit her. Review of Resident #2's Behavioral Note on 10/28/2023 at 3:00 p.m. revealed, in part, Resident #2 was accused of hitting Resident #1 in her chest. Review of S8Certified Nursing Assistant's (CNA) written statement signed and dated on 10/28/2023 revealed, in part, S8CNA witnessed Resident #1 and Resident #2 passing punches and fussing and cussing. Review of Resident #3's MDS with an ARD of 09/12/2023 revealed, in part, Resident #3 had a BIMS score of 15, which indicated Resident #3 was cognitively intact. Review of Resident #3's verbal statement transcribed by S5Weekend Supervisor revealed, in part, on 10/28/2023, Resident #3 witnessed Resident #2 punch Resident #1 in her chest. Review of Resident #1's Physician Progress Notes signed by the physician on 10/31/2023 revealed, in part, over the weekend there was an altercation with another resident. Further review revealed another resident hit her in the chest and it does appear that she struck the resident also. Review also revealed a diagnosis of injury due to altercation. In an interview on 11/13/2023 at 3:01pm, Resident #1 stated as she was coming back from the dining room on 10/28/2023, and Resident #2 punched her in her left breast with a closed fist. She stated at that time, she lifted her arms to stop Resident #2 from hitting her again, and Resident #2 attempted to bite her arm. Resident #1 stated Resident #R5 witnessed the incident. Observation on 11/13/2023 at 3:11 p.m. revealed when Resident #R5 was asked if Resident #2 hit Resident #1 in the chest, Resident #R5 nodded his head yes. Observation further revealed Resident #R5 demonstrated how Resident #2 hit Resident #1 by punching the left side of his own chest with a closed fist. In an interview on 11/14/2023 at 8:56 a.m., S8CNA, stated she witnessed Resident #1 and Resident #2 cursing at each other and hitting each other in the hallway coming from the dining room on 10/28/2023. S8CNA confirmed the incident between Resident #1 and Resident #2 was an incident of resident to resident verbal and physical abuse. In an interview on 11/14/2023 at 11:05 a.m., S1Administrator stated the abuse allegation of resident to resident physical abuse between Resident #1 and Resident #2 was unsubstantiated despite S8CNA's written statement which detailed Resident #1 and Resident #2 passing punches. In an interview on 11/14/2023 at 11:06 a.m., S2DON stated the abuse allegation of resident to resident physical abuse between Resident #1 and Resident #2 was unsubstantiated despite S8CNA's written statement which detailed Resident #1 and Resident #2 passing punches. In an interview on 11/14/2023 at 11:07 a.m., S4Social Services stated the abuse allegation of resident to resident physical abuse between Resident #1 and Resident #2 was unsubstantiated despite S8CNA's written statement which detailed Resident #1 and Resident #2 passing punches. In an interview on 11/14/2023 at 12:16 p.m., Resident #3 stated as residents were leaving the dining room on 10/28/2023, Resident #2 was harassing Resident #1. Resident #3 then stated he witnessed Resident #2 punch Resident #1 in her breast. In an interview on 11/14/2023 at 12:45 p.m., S2DON stated she came up with the scenario that was included in the SIMS report where Resident #1 was accidentally hit by Resident #2's arms after he threw them in the air due to his impulse control diagnosis. S2DON confirmed no witness statements aligned with her scenario. S2DON stated Resident #2 was sweet and had a diagnosis of intellectual disability, so S2DON felt Resident #2 was not capable to willfully hit Resident #1. S2DON further stated Resident #1 had a history of fabricating stories and prior abuse allegations. S2DON stated, I know how [Resident #2] is. S2DON also stated Resident #2 had psychiatric diagnoses which made it impossible for Resident #2 to have willful intent to physically abuse another resident. S2DON proceeded to state Resident #1 also had psychiatric diagnoses, but Resident #1 was capable to willfully hit Resident #1. In an interview on 11/14/2023 at 1:00 p.m., S1Administrator confirmed that despite a resident's diagnosis, all residents had a right to be free from abuse. In an interview on 11/14/2023 at 1:01 p.m., S2DON confirmed that despite a resident's diagnosis, all residents had a right to be free from abuse. Resident #2 & Resident #3: Review of the facility's incident report entered on 10/30/2023 at 1:55 p.m. revealed, in part a physical altercation had occurred between Resident #2 and Resident #3. Further review revealed, during the incident investigation that Resident #3 was interviewed on 10/30/2023 at 9:00 a.m. and stated his interaction with Resident #2 became physical. Review of Resident #2's medical record revealed he was admitted to the facility on [DATE] with a diagnoses of Impulse Disorder, Schizophrenia, and Cognitive Communication Deficit. Review of Resident #2's MDS with an ARD of 08/22/2023 revealed, in part, Resident #2 had a Brief Interview for Mental Status score of 3, which indicated Resident #2 was severely cognitively impaired. Review of Resident #3's medical record revealed he was admitted to the facility on [DATE] with a diagnoses of Anxiety and Major Depressive Disorder. Review of Resident #3's Minimum Data Set with an Assessment Reference Date of 09/12/2023 revealed, in part, Resident #3 had a Brief Interview for Mental Status score of 15, which indicated Resident #3 was cognitively intact. Review of Resident #3's verbal statement transcribed by S5Weekend Supervisor on 10/28/2023 revealed Resident #2 swung and hit Resident #3, and Resident #3 swung back at Resident #2. Review of Resident #3's progress note written by S4Social Services on 10/30/2023 at 10:35 a.m. revealed, in part, upon review of a previous incident that occurred over the weekend, it was revealed that Resident #3 taunted and hit another resident. Further review revealed, S4Social Services interviewed Resident #3 on what caused the altercation with Resident #3 and Resident #3 stated Resident #2 said something about his mother. In an interview on 11/14/2023 at 12:16 p.m., Resident #3 stated Resident #2 made derogatory remarks about Resident #3's family member. Resident #3 stated Resident #2 swung his arm with a closed fist and hit Resident #3. Resident #3 further stated, he swung his arm with a closed fist and hit Resident #2 back. Resident #3 further stated following the incident he informed S5Weekend Supervisor, Resident #2 and himself got into a verbal and physical altercation. In an interview on 11/15/2023 at 2:45 p.m., S5Social Services stated she was notified by S1Adminsitrator on 10/30/2023 around 9:30 a.m. that Resident #2 and Resident #3 had been in a physical altercation and Resident #3 hit Resident #2. S5Social Services further stated Resident #3 stated Resident #2 hit him and made derogatory remarks about Resident #3's mother. In an interview on 11/15/2023 at 3:00 p.m., S2Director of Nursing (DON) stated it is the facility and staff's responsibility to keep the residents safe and free from abuse. S2DON confirmed the above mentioned incident between Resident #2 and Resident #3 was considered verbal and physical abuse. In an interview on 05/31/2023 at 9:21 a.m., S1Administrator confirmed the above mentioned incident between Resident #2 and Resident #3 was considered verbal and physical abuse. 46683

Based on record reviews and interviews, the facility failed to immediately notify a resident's physician following incidents of resident to resident physical abuse for 3 (Resident #1, Resident #2, and Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents investigated for abuse. Findings: Review of the facility's Change in a Resident's Condition or Status policy and procedure revealed, in part, the nurse will notify the resident's Attending Physician, Nurse Practitioner or physician on call when there has been a(n): accident or incident involving the resident and a significant change in the resident's physical/emotional/mental condition. Resident #1 Review of Resident #1's Admission Record revealed, in part, Resident #1's primary physician was S10Medical Director. Review of Resident #1's nurse's note completed by S5Weekend Supervisor on 10/28/2023 at 3:40 p.m. revealed, in part, Resident #1 reported Resident #2 hit her in her left breast. Further review revealed documentation Resident #1's physician's office was notified of the incident via fax. There was no documented evidence and the facility was unable to present any documented evidence S10Medical Director was notified of Resident #1's above mentioned incident of resident to resident physical abuse immediately upon discovery. Resident #2 Review of Resident #2's Admission Record revealed, in part, Resident #2's primary physician was S10Medical Director. Review of Resident #2's nurse's note completed by S6Licensed Practical Nurse (LPN) on 10/28/2023 at 3:20 p.m. revealed, in part, Resident #2 and Resident #3 were observed swinging and cursing at one another. Review of the facility's Fax Form for Non-Emergency Communication document sent to S10Medical Director's office on 10/29/2023 (Sunday) at 11:27 a.m. revealed, in part, Resident #2 was documented to have been in 2 physical altercations with 2 different residents. Further review revealed S10Medical Director signed and dated his response on 10/30/2023 along with a written note that in the future the on call physician was to be notified of incidents. In an interview on 11/15/2023 at 11:39 a.m., S2Director of Nursing (DON) confirmed a fax was sent to S10Medical Director's closed office on 10/29/2023 (Sunday) which documented Resident #2 was involved in 2 physical altercations that occurred on 10/28/2023. S2DON confirmed Resident #2's physician or the on call physician should have been notified of the incident on 10/28/2023. In a telephone interview 11/15/2023 at 2:49 p.m., S6LPN stated she sent a fax to S10Medical Director's closed office regarding Resident #2's 2 physical altercations with residents, but the facility did not receive a fax or any form of communication back from S10Medical Director. In an interview on 11/15/2023 at 2:25 p.m., S2DON stated S10Medical Director did not want to be notified of incidents involving his residents via fax. S2DON additionally stated S10Medical Director was upset that he was not called immediately after the incident. S2DON confirmed sending a fax to a physician's office on a weekend without an immediate confirmation of the fax did not ensure the physician was made aware of an incident and/or change in condition. Resident #3 Review of Resident #3's verbal statement obtained and written by S5Weekend Supervisor on 10/28/2023 revealed Resident #2 swung and hit Resident #3, and Resident #3 swung back at Resident #2. In an interview on 11/14/2023 at 12:16 p.m., Resident #3 stated he swung his arm with a closed fist and hit Resident #2. Resident #3 further stated following the incident he informed S5Weekend Supervisor, he hit Resident #2. Review of Resident #3's nurse's note completed by S7Charge Nurse on 10/30/2023 at 9:25 a.m. revealed, in part, Resident #3's primary care physician was made aware of the above stated incident. In an interview on 11/15/2023 at 12:56 p.m., Resident #3's physician stated she was notified on 10/30/2023 of the incident that occurred between Resident #2 and Resident #3 by S7Charge Nurse when Resident #3 requested to discharge from the facility. In an interview on 11/15/2023 at 2:27 p.m., S5Weekend Supervisor stated she did not contact Resident #3's physician regarding the incident that occurred on 10/28/2023 between Resident #2 and Resident #3. In an interview on 11/15/2023 at 2:40 p.m., S7Charge Nurse stated S4Social Services informed her on 10/30/2023 that Resident #3 hit Resident #2 and Resident #3's physician needed to be notified. S7Charge Nurse stated she notified Resident #3's physician of the incident on 10/30/2023. S7Charge Nurse further stated prior to this date Resident #3's physician had not been notified of the above stated incident. In an interview on 11/15/2023 at 3:20 p.m., S2DON stated Resident #3's physician should have been notified immediately after Resident #3 hit Resident #2. 46683

Based on record reviews and interviews, the facility failed to implement their written policies and procedures for abuse by failing to ensure residents were protected after an allegation of physical abuse for 1 (Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Prevention Program policy revealed, in part the facility was to protect residents during abuse investigations. Review of the facility's Abuse Investigation and Reporting policy revealed, in part in the case of resident-to-resident suspected abuse, the parties will remain separated from one another until the investigation has been completed. Review of the facility's Abuse and Neglect- Clinical Protocol policy revealed, in part, if the facility staff did not provide immediate interventions to assure the safety of residents, the facility did not provide sufficient protection to prevent resident to resident abuse. Review of Resident #3's statement obtained and written by S5Weekend Supervisor on 10/28/2023 revealed Resident #2 swung and hit Resident #3, and Resident #3 swung back at Resident #2. Review of the facility's monitoring tool for Resident #3 revealed no documentation for 10/29/2023 from 6:00 p.m.- 12:00 a.m. and 10/30/2023 from 12:00 a.m.- 10:00 a.m. In an interview on 11/14/2023 at 12:16 p.m., Resident #3 stated he swung his arm with a closed fist and hit Resident #2. Resident #3 further stated following the incident he informed S5Weekend Supervisor, he hit Resident #2. In an interview on 11/13/2023 at 2:33 p.m., S6Licensed Practical Nurse (LPN) confirmed she was the nurse assigned to Resident #3 on 10/28/2023. S6LPN further stated no action such as an in increase in supervision and/or one on one monitoring of Resident #3 was taken on 10/28/2023 or 10/29/2023. In an interview on 11/14/2023 at 12:45 p.m., S5Weekend Supervisor stated the facility's process following resident to resident physical altercations, was to place the residents involved on one on one monitoring until the resident could be removed from the facility to ensure all the residents in the facility were safe. S5Weekend Supervisor confirmed she did not place Resident #3 on one on one monitoring because Resident #3 did not have any psychiatric diagnosis. S5Weekend Supervisor further stated Resident #3 stated he was calm; therefore, she did not feel he was a danger to other residents in the facility. In an interview on 11/14/2023 at 1:03 p.m., S2Director of Nursing (DON) confirmed the facility's process following resident to resident physical altercations, was to place the residents involved in the physical altercation on one on one monitoring, regardless of the residents diagnosis, until the resident could be removed from the facility to ensure all the residents in the facility were safe. S2DON further stated Resident #3 should have been placed on one on one monitoring immediately following Resident #3 hitting Resident #2 to ensure the protection of all of the residents in the facility.

Based on record review and interviews, the facility failed to ensure an alleged violation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 3 (Resident #1, Resident #2, and Resident #3) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents reviewed for abuse. Findings: Review of the facility's Abuse Investigation and Reporting policy revealed, in part an alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than two house if the alleged violations involves abuse. Resident #1 and Resident #2: Review of the facility's incident report entered on 10/28/2023 at 7:06 p.m. revealed, in part, S5Weekend Supervisor was notified by Resident #1 of an allegation of resident to resident physical abuse involving Resident #2 on 10/28/2023 at approximately 3:15 p.m. Review of Resident #1's nurse's note written by S5Weekend Supervisor on 10/28/2023 at 3:40 p.m. revealed, in part, Resident #1 reported that Resident #2 hit her in her left breast. In an interview on 11/15/2023 at 3:01 p.m., S5Weekend Supervisor confirmed 3:15 p.m. was the time she discovered Resident #1 and Resident #2's alleged resident to resident physical abuse incident. S5Weekend Supervisor stated she did not immediately notify S2Director of Nursing (DON) following the discovery of the alleged resident to resident abuse incident. In an interview on 11/15/2023 at 3:04 p.m., S2DON confirmed S5Weekend Supervisor did not immediately notify S2DON upon the discovery of Resident #1's allegations of resident to resident physical abuse. S2DON confirmed the SIMS report was entered on 10/28/2023 at 7:06 p.m., which was greater than 2 hours after the discovery of the above mentioned alleged resident to resident physical abuse. Resident #2 and Resident #3: Review of a incident report entered on 10/30/2023 at 1:55 p.m. revealed, in part an incident of verbal and physical abuse had occurred between Resident #2 and Resident #3. Further review revealed an allegation of verbal abuse with a discovered date of 10/30/2023 at 12:30 p.m. Further review revealed, during the incident investigation Resident #3 was interviewed on 10/30/2023 at 9:00 a.m. and stated his interaction with Resident #2 became physical. Review of Resident #3's verbal statement transcribed by S5Weekend Supervisor on 10/28/2023 revealed Resident #2 swung and hit Resident #3, and Resident #3 swung back at Resident #2. Review of Resident #3's progress note written by S6Licensed Practical Nurse (LPN) on 10/28/2023 at 9:30 p.m. revealed, in part Resident #3 denied discomfort related to the incident involving Resident #2. Review of Resident #3's progress note written by S7Charge Nurse with an effective date of 10/30/2023 at 9:25 a.m. revealed, in part Resident #3's Primary care physician was made aware of the incident. Review of Resident #3's progress note written by S4Social Services on 10/30/2023 at 10:35 a.m. revealed, in part upon review of a previous incident that occurred over the weekend, it was revealed that Resident #3 taunted and hit another resident. In an interview on 11/15/2023 at 2:45 p.m., S5Social Services stated she was notified by S1Adminsitrator on 10/30/2023 around 9:30 a.m. that Resident #2 and Resident #3 had been in a physical altercation. In an interview on 11/15/2023 at 3:10 p.m., S1Administrator stated despite S5Weekend Supervisor being made aware of the physical abuse incident between Resident #2 and Resident #3 on 10/28/2023 and Resident #3 confirmed on 10/30/2023 with S4Social Worker that he hit Resident #2 on 10/28/2023, S1Administrator still felt the discovered time of the incident on 10/30/2023 at 12:30 p.m. was the time the facility had concluded their investigation and could initiate a SIMS report. In an interview on 11/15/2023 at 3:20 p.m., S2DON stated she was made aware Resident #2 and Resident #3 verbally and physically abusing each other on 10/30/2023 at approximately 9:00 a.m. when she arrived to the facility. S2DON further stated Resident #2 and Resident #3's incident was discovered prior to the listed discovered date and time of 10/30/2023 at 12:30 p.m. S2DON further stated the SIMS report should have been entered within 2 hours after the initial discovery of the incident and it was not. 46683

Based on record reviews and interviews, the facility failed to obtain a physician's order prior to transferring a resident to an inpatient psychiatric hospital for 1 (Resident #2) of 4 (Resident #1, Resident #2, Resident #3, Resident #4) sampled residents investigated for abuse. Findings: Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standards, Part XLVII Nurses: Practical Nurses and Registered Nurses, Subpart 2 Registered Nurses, Chapter 37 Nursing Practice revealed, in part, a standard of nursing practice included executing health care regimes as prescribed by a licensed physician, or authorized prescriber. Review of Resident #2's Admission Record revealed, in part, Resident #2's primary physician was S10Medical Director. Review of Resident #2's nurse's note completed by S2Director of Nursing (DON) on 10/28/2023 at 9:31 p.m. revealed, in part, an inpatient behavioral hospital was contacted to complete evaluation and treatment for Resident #2. Review of Resident #2's nurse's note completed by S6LPN on 10/29/2023 at 1:10 p.m. revealed, in part, Resident #2 was transported and admitted to an inpatient psychiatric hospital. On 11/15/2023 at 12:10 p.m. Resident #2's electronic medical record revealed no documented evidence of a physician's order from S10Medical Director to transfer and admit Resident #2 to an inpatient psychiatric hospital. Review of Resident #2's physical chart revealed no documented telephone orders from S10Medical Director to send Resident #2 to the inpatient psychiatric hospital on 10/29/2023. There was no documented evidence and the facility did not present any documented evidence a physician's order obtained for Resident #2 to be transferred and admitted to a psychiatric hospital on 10/29/2023. In an interview on 11/15/2023 at 1:39 p.m., S2DON confirmed she reviewed Resident #2's physical chart and there was no documentation that S10Medical Director was contacted on 10/28/2023 or 10/29/2023 to obtain an order to send Resident #2 to an inpatient psychiatric hospital. In an interview on 11/15/2023 at 2:19 p.m., S5Weekend Supervisor stated following Resident #2's alleged physical altercations with two residents, she called an inpatient psychiatric hospital to set up placement for Resident #2. S5Weekend Supervisor denied speaking with S10Medical Director to obtain an order prior to sending Resident #2 to the inpatient psychiatric hospital. In an interview on 11/15/2023 at 2:25 p.m., S2DON confirmed it was out of a nurse's scope of practice to transfer a resident and have the resident admitted to an inpatient psychiatric hospital without a physician's order. In a telephone interview 11/15/2023 at 2:49 p.m., S6LPN stated she did not get a telephone order or verbal order on 10/28/2023 or on 10/29/2023 from S10Medical Director to send Resident #2 to an inpatient psychiatric hospital. S6LPN stated she sent a fax to S10Medical Director's office on 10/29/2023 (Sunday), which indicated Resident #2 was being transferred to an inpatient psychiatric hospital. S6LPN further indicated she had not received a fax or any form of communication back from S10Medical Director with an order to send Resident #2 to the psychiatric hospital prior to doing so.

Based on record reviews and interviews, the facility failed to ensure staff did not transcribe an order that was not obtained from a physician for 1 (Resident #2) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) sampled residents investigated for abuse. Findings: Review of Resident #2's Admission Record revealed, in part, Resident #2's primary physician was S10Medical Director. Review of Resident #2's nurse's note completed by S6Licensed Practical Nurse(LPN) on 10/29/2023 at 1:10 p.m. revealed, in part, Resident #2 was transported and admitted to an inpatient psychiatric hospital. Review of Resident #2's physical chart revealed no documented telephone orders from S10Medical Director to send Resident #2 to the inpatient psychiatric hospital on 10/29/2023. On 11/15/2023 at 12:10 p.m., Resident #2's electronic medical record revealed no documented evidence of a physician's order from S10Medical Director to transfer and admit Resident #2 to an inpatient psychiatric hospital. On 11/15/2023 at 1:24 p.m., Resident #2's electronic medical record revealed, in part, a telephone order was given by S10Medical Director to S5Weekend Supervisor on 10/29/2023 at 11:00 a.m. to send to Resident #2 to an inpatient psychiatric hospital. Further review of the order details revealed the order was created by S5Weekend Supervisor on 11/15/2023 at 1:14 p.m. and signed by S10Medical Director on 11/15/2023 at 1:20 p.m. In an interview on 11/15/2023 at 1:39 p.m., S2DON confirmed the physician's order to send Resident #2 to the inpatient psychiatric hospital was created on 11/15/2023 at 1:14 p.m. S2DON confirmed S5Weekend Supervisor should not have back dated the above mentioned physician's order. In an interview on 11/15/2023 at 2:19 p.m., S5Weekend Supervisor denied obtaining a telephone order from S10Medical Director on 10/29/2023 to send Resident #2 to an inpatient psychiatric hospital. S5Weekend Supervisor stated she was instructed by her team on 11/15/2023 to enter the above mentioned telephone order from S10Medical Director dated 10/29/2023 to send Resident #2 to an inpatient psychiatric hospital. In an interview on 11/15/2023 at 2:25 p.m., S2DON confirmed she, S3Assistant Director of Nursing, and S1Administrator instructed S5Weekend Supervisor to enter an order from S10Medical Director on 10/29/2023 to send Resident #2 to an inpatient psychiatric hospital today (11/15/2023). S2DON stated when the surveyor asked to see Resident #2's physician's orders, S2DON noticed Resident #2 did not have an physician's order to be sent to the inpatient psychiatric hospital on 10/29/2023. S2DON stated she then directed S5Weekend Supervisor to enter a physician's order S5Weekend Supervisor did not obtain. In an interview on 11/15/2023 at 2:45 p.m., S5Weekend Supervisor confirmed she did not speak with S10Medical Director on 10/29/2023 to obtain a physician's order to send Resident #2 to an inpatient psychiatric hospital.

Based on record review and interview, the facility failed to: 1.Ensure a thorough investigation was conducted when an injury of unknown origin was discovered for 1 (Resident #286) of 4 (Resident #35, Resident #42, Resident #286, Resident #287) sampled residents reviewed for accidents. 2. Ensure in-services were conducted in a timely manner with all staff to prevent any further incidents for 1 (Resident #286) of 4 (Resident #35, Resident #42, Resident #286, Resident #287) sampled residents reviewed for accidents Findings: Review of the facility's Protocols for Reporting Abuse, Neglect, Mistreatment, Misappropriation of Resident Property, or Exploitation Policy revealed, in part, an injury of unknown origin is defined when the source of the injury was not observed by any person, the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury. Review revealed, in part, the facility will provide different or new interventions once the allegation is reported, that will ensure the protection of all other residents in the facility. Further review, revealed, in part, the investigation will follow up with documented proof of resident and staff interviews. Review of Resident #268's record revealed, in part, Resident #286 was admitted to the facility on [DATE] with a readmitted [DATE] with a diagnosis Vitamin D deficiency. Review of Resident #286's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/16/2022 revealed, in part, Resident #286 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the BIMS due to cognitive impairment. Further review revealed, Resident #286 required extensive assistance from one person with bed mobility and toileting, required extensive assistance from two persons with transfers, and had impaired mobility on one side to his upper and lower extremities. Review of Facility Incident Report with an incident date and time of 09/29/2022 at 7:00 p.m. for Resident #286 revealed, S8LicensedPracticalNurse(LPN) was called to Resident #286's room by S9Certified Nursing Assistant(CNA) who stated Resident #286 yelled with pain to his right leg when she attempted to turn and change him. Review of the facility's Statewide Incident Management System (SIMS) revealed an incident was discovered at 10:00 p.m. on September 29, 2023 for Resident #286. Review revealed the facility documented bone demineralization was noted on the x-ray interpretation. Review revealed the facility reported having interviewed cognitive residents on Resident #286's hall and no concerns were identified. Further review revealed facility documented having assessed Resident #286 for an injury of unknown origin, but no concerns were identified due to, the facility determined the probable cause of the injury was Bone Demineralization and Vitamin D Deficiency causing an increased risk of fracture. Review of Resident #286's right hip x-ray results dated 09/29/2022 at 8:45 p.m. revealed, in part, a one-half shaft with superior displaced subcapital( top) right femoral neck fracture with soft tissue edema(the right upper hip was broken). Further review revealed no documented evidence of the radiologist having noted any area of osteopenia or bone demineralization near the area of Resident #286's noted fracture. Review of Resident #286's Orthopedic Consult Physician's note dated 10/05/2022 revealed, in part, upon physical examination Resident #286 had tenderness to touch over the right greater trochanter (top part of the femur) with compression as well. Review revealed Resident #286 requires assistance with turning in bed from his nursing assistance staff, has secondary joint contractures of the lower extremities, and his pain started a few days ago. Review revealed the nursing assistant stated that he does not walk or stand, but he does pivot for transfers. Further review of imaging revealed, the findings appeared acute. Further review of Resident #286's Orthopedic Consult Physician's note revealed no documented evidence of Resident #286's fracture having been contributed to osteopenia or bone demineralization. In an interview on 02/26/2023 at 12:30 p.m., S2Director Of Nursing (DON) stated she did not have documented evidence of interviews she conducted with other residents regarding Resident #286's incident nor regarding the care S9CNA provided. In an interview on 02/27/2023 at 1:47 p.m., S9CNA stated she stated she was never asked to provide a demonstration of how she turned Resident #286 on 9/29/2022. S9CNA further stated she was in-serviced but it was later in the week, but she does not recall the exact date. In an interview on 02/27/2023 at 3:47 p.m., S11SocialServicesDirector (SSD) stated she did not interview Resident #18, Resident #286's roommate, or surrounding residents about Resident #286's injury of unknown origin. S11SSD stated she did not interview S9CNA because it was not her job to investigate an incident. In an interview on 02/28/2023 at 8:35 a.m., S2DON stated the investigation for Resident #286's was focused on pain. She stated abuse, neglect, or mistreatment was not suspected due and the fracture was related to Resident #286 being so frail in condition. She stated the in-services and education were started on 10/08/2022 and they should have been initiated immediately following the incident on 09/29/2022. She stated she did not observe or evaluate S9CNA on turning and transfers following the incident. She further stated they should have included 100 percent of staff compliance on the in-services and they did not. In an interview on 02/28/2023 at 10:35 a.m. S6Corporate Nurse stated she contacted the xray company and asked the radiologist to re-read the xrays. Review of Resident #286's xray with an original date 09/29/2023 with an addendum date of 02/28/2023 revealed a medical director review that stated the right hip demonstrated an acute fracture involving the subcapital (top) femoral neck and that osteopenia was present. Review of the facility's In-service Training with topic of transferring a resident make sure to keep in mind of where body parts are placed and if a resident has an injury make sure a nurse is notified dated 10/08/2022 revealed only 17 CNAs of the 32 total CNAs employed had been in-serviced Review of facility's In-service Training with a topic of resident abuse and neglect, reporting, and fall prevention dated 10/10/2022 revealed, only 5 CNAs of the 32 total CNAs employed and 8 LPNs of the 20 LPNS employed had been in-serviced Review of facility's In-service Training with a topic of turning, hoyer lifts, transporting residents, and change in condition dated 10/24/2022 revealed, only 13 CNAs of the 32 CNAs employed were in-serviced. In an interview on 02/28/2023 at 1:21p.m., S12LPN stated she was not immediately in-serviced on abuse and neglect after the incident. In an interview on 02/28/2023 at 8:30 a.m., S6CorporateNurse stated the investigation for Resident #286 did not have adequate documentation to support a thorough investigation for an injury of unknown origin. S6CorporateNurse stated the original x-ray did not reflect Resident #286 had bone demineralization and the facility had no documented evidence Resident #286 had osteopenia or bone demineralization prior to 02/28/2023. In an interview on 02/28/2023 at 8:40 a.m., S1Administrator stated the investigation was focused on Resident #286's pain and it should have included and ruled out any incident that could have occurred or caused Resident #286's injury of unknown origin. He stated the in-services and education should have been initiated immediately following the incident on 09/29/2023 and not on 10/08/2022. He further stated they should have included 100 percent of staff compliance and they did not. In an interview on 02/28/2023 at 3:40 p.m., S13RegionalAdministrator stated the facility should have investigated Resident #286 as an injury of unknown origin, ruled out any causes of the injury such as abuse or neglect, and education and in-servicing for all staff should have begun immediately.

Based on observation, record review, and interview the facility failed to ensure each resident received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #3) of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for accident hazards in a total sample of 5. The facility identified 82 residents (All residents in the facility except Resident #6 and Resident #7) which use the facility's vehicles for transportation out into the community. The facility failed to: 1. Have a system in place which ensured all transportation staff was in-serviced on the vehicle's lift system according to the manufacturer's recommendations; 2. Ensure a resident was not injured due to malfunctioning rollstop gate on the van ' s wheelchair lift; 3. Ensure the facility's vehicle was inspected and resident's injury investigated prior to sending the vehicle and transportation driver to pick up another resident after a resident was injured. An Immediate Jeopardy situation began on 11/16/13 at 2:11pm for Resident #3 when the resident was placed on the facility's van wheelchair lift, in his wheelchair, in the improper position, with the wheelchair brakes not applied, and with the automatic front roll stop (gate) not engaged and in the locked position. The resident fell from the facility's wheelchair lift and sustained a right olecranon fracture (elbow fracture), an incomplete or insufficiency fracture at the right femoral head neck junction. In interview on 11/27/13 at 9:26am S7/CNA (Certified Nursing Assistant) stated Resident #3 was able to feed himself, was able to assist with his bed mobility, would walk with the restorative aide with a walker, he could propel himself with his feet and would use his arms to pull himself on the rails to propel the wheelchair, and the resident was able to stand and assist with transfers before his recent falls. S7/CNA further stated since the fall he is unable to feed himself, unable to assist with bed mobility, has not walked with the restorative aide since his fall, the resident was unable to get around in his wheelchair, and did not assist with transfers since his fall. S7/CNA further stated she was working with Resident #3 today 11/27/13 and she had to do everything for him. In interview on 11/27/13 at 9:33am S8/LPN (Licensed Practical Nurse) stated before Resident #3's fall he was alert with a good appetite, would ambulate in the halls with a wheelchair, would stay to himself, walked by himself when he wanted and would walk with the restorative aide, was able to assist with toileting. S8/LPN further stated since Resident #3's fall we have to feed him and do most things for him. Resident #3 has become totally dependent and has a sad affect now. Staff now has to remind him to even open his mouth to eat and encourage him to participate for all activities of daily living. S8/LPN further stated Resident #3's shunt had to be moved higher on his right arm due to the location of the shunt by the broken bone. The Immediate Jeopardy continued until 11/27/13 for the other 82 residents identified by the facility as using the facility's vehicles for transportation into the community after Resident #3 was injured after attempting to offload the resident from the facility's van and the facility did not put a system in place to avoid further injury to any resident who used the van. The Administrator was notified the Immediate Jeopardy situation was removed on 11/27/13 at 12:45pm, when an acceptable plan of removal was presented. The facility's plan revealed an in-service was held to educate staff listed on the facility's insured driver's list of the Lift Operations Manual's Operating Instructions held by the administrator. The facility's plan of removal also included an in-service on procedure for operation of the roll stop while the spring mechanism is not operational. Review revealed safety checks would be performed by the transportation aides on the days the vehicles are utilized. Review revealed the administrator should be notified immediately of any lift or safety concerns with the vehicle identified. Further review of the facility's plan of removal revealed future transportation staff will receive vehicle training and lift operation instruction by the administrator upon hire and/or prior to being allowed to transport residents to ensure staff maintains resident safety. The Administrator will give quarterly in-services to transportation drivers to ensure safety protocols are being followed, and transportation drivers will ensure safety by completing safety checklists each day before transporting residents. Further review of the facility's plan of removal revealed the administrator will monitor transportation aides operate the lift with a resident three times weekly for 30 days and then once weekly for another 30 days to ensure compliance. Transportation aides will turn safety checks in to the administrator daily when completed and prior to transport. Any non-compliance will be reported to the QI (Quality Improvement) committee for interventions as indicated. Completion date is 11/27/13. Attached to the facility's plan of removal was the facility's vehicle lift operation monitoring tool, vehicle safety check list, and in-service training (conducted on 11/27/13 at 10:30am) for proper usage of lift system per the lift's operators manual with return demonstration for all 5 staff members approved by the facility to transport facility residents. There were 82 residents identified by the facility as using the facility's vehicles for transportation into the community with a total facility census of 84 per the facility's Resident Census and Conditions of Residents dated 11/26/13. The deficient practice remains at a Scope/Severity of Level 3 (G), Actual Harm. Findings: Review of Resident #3's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/15/13 revealed BIMS (Brief Interview for Mental Status) of 3 (00-07 equals severe impairment in cognitive status). Further review revealed Resident #3 required limited assistance of one person physical assistance for transfers, walking in room and corridor and locomotion on unit; and required extensive assistance of one person physical assistance for locomotion off unit and dressing and toileting. Further review revealed, Resident #3 needed supervision with set up assistance for eating. Review of Resident #3's Discharging Hospital's Patient Discharge Summary dated 11/22/13 revealed Resident #3 was discharged from the hospital with a closed fracture of right ulna. Further review of Resident #3's Discharging Hospital's Surgical/Invasive Procedure Progress Note dated 11/21/13 revealed Resident #3 required surgical intervention for a malfunctioned access to his right [MEDICAL TREATMENT] access. Review of the CT (Computerized Tomography) of the Pelvis Report dated 11/25/13 revealed Resident #3 was also noted with findings of an incomplete or insufficiency fracture at the right femoral head neck junction. In interview on 11/27/13 at 9:26am S7/CNA (Certified Nursing Assistant) stated Resident #3 was able to feed himself, was able to assist with his bed mobility, would walk with the restorative aide with a walker, he could propel himself with his feet and would use his arms to pull himself on the rails to propel the wheelchair, and the resident was able to stand and assist with transfers before his recent falls. S7/CNA further stated since the fall he is unable to feed himself, unable to assist with bed mobility, has not walked with the restorative aide since his fall, the resident was unable to get around in his wheelchair, and did not assist with transfers since his fall. S7/CNA further stated she was working with Resident #3 today 11/27/13 and she had to do everything for him. In interview on 11/27/13 at 9:33am S8/LPN (Licensed Practical Nurse) stated before Resident #3's fall he was alert with a good appetite, would ambulate in the halls with a wheelchair, would stay to himself, walked by himself when he wanted and would walk with the restorative aide, was able to assist with toileting. S8/LPN further stated since Resident #3's fall we have to feed him and do most things for him. Resident #3 has become totally dependent and has a sad affect now. Staff now has to remind him to even open his mouth to eat and encourage him to participate for all activities of daily living. S8/LPN further stated Resident #3's shunt had to be moved higher on his right arm due to the location of the shunt by the broken bone. Review of resident's Nurse's Notes dated 11/22/13 through 11/26/13 revealed Resident #3 requires extensive assistance for bed mobility and eating by one person physical assistance and is totally dependent for transfers and toileting requiring one person physical assistance. Review of Nurses Notes dated 11/25/13 revealed resident started complaining of pain to right leg and back. Review of the CT (Computerized Tomography) of the Pelvis Report dated 11/25/13 revealed Resident #3 noted with findings of an incomplete or insufficiency fracture at the right femoral head neck junction. Review of the facility's OTIS (Online Tracking and Incident System) for the incident involving Resident #3 revealed on 11/16/13 at 2:11pm Resident #3 was returning from [MEDICAL TREATMENT] and was injured while being unloaded from the vehicle using the wheelchair lift. Review of documentation of S5/CNA's Statement dated 11/16/13 revealed S5/CNA was attempting to unload Resident #3 from the facility's van when she released the lift into position she assisted the resident onto the lift upon doing so the left wheel got stuck and as she assisted him to free his wheelchair Resident #3 began rolling back and he rolled completely off the ramp. S5/CNA further documented the gate to the lift was not locked. Review of the resident's Nurses Notes dated 11/16/13 revealed the nurse was informed Resident #3 had fallen from the facility's van's ramp to the concrete outside, upon entering the scene the nurse noted the ramp was in the air and the safety flap which must be up in order to keep the resident from rolling off while in air was down and even with the ramp. Review of the facility's documentation of incident investigation performed by S2/DON (Director of Nursing) revealed S5/CNA (Certified Nursing Assistant) failed to keep Resident #3 safe while in her care. Further review revealed S5/CNA was asked on 11/18/13 to demonstrate the procedure used when assisting the resident off of the facility transportation van. Review revealed S2/DON observed and noted S5/CNA failed to lock resident wheelchair prior to transfer, S5/CNA failed to check equipment (lift gate) prior to transfer, which caused Resident #3's wheelchair to roll backward and to fall onto the cement causing the resident injury. Review of S5/CNA's CNA Performance and Skills Evaluation dated 11/21/12 revealed S5/CNA date of hire was 09/12/12 with no evidence of competency evaluation for transportation duties. Review of S1/Administrator's, S4/Maintenance Director's, and S6/Transportation Aide's Company Owned Vehicle Driver In-service Checklists revealed no evidence of the staff having been trained on lift operation. In interview on 11/26/13 at 2:15pm S1/Administrator stated he did not have any transportation competency evaluations for S2/DON, S3/DON, and S5/CNA. S1/Administrator further stated S5/CNA did have an in-service on 10/09/13 which primarily focused on securing of the wheelchair inside of the facility's vehicles. Review of In-Service Training dated 10/09/13 revealed S5/CNA and S6/Transportation Aide were the only staff in-serviced on 10/09/13 regarding "van-proper securing of wheelchairs". Further review revealed method delivery was demonstration, return demonstration, and handout of policy. Attached to the In-Service for 10/09/13 revealed Monitoring Tool for Transferring and Securing in Residents on Van with dates of 11/18/13 and 11/26/13 monitoring transferred correctly and secured in correctly. Review of the facility's Policies for Company Owned Vehicle revealed policies for the vehicle being for business purposes only, seatbelts, traffic laws, alcohol/illegal substances, cell phone use, radio stations, vehicle safety/emergency issues, medical emergency, and smoking, food and beverages. Further review of the facility's Policies for Company Owned Vehicle revealed no evidence of a facility policy for proper use of the vehicle's van lift. Review of the Export Use Wheelchair and Standee Lift and Folding Platform Operator Manual revealed in part: the manual is to be read and thoroughly understand the operating instructions before attempting to operate the lift; inspect product before each use, if unsafe conditions unusual noises or movements do not operate the lift until the problem is corrected; the product should be maintained at the highest level of performance. Further review revealed front roll stop is a front barrier that prevents wheelchair from inadvertently rolling off of platform during platform movement. Further review of Operators Manual and Figure 2-2 revealed wheelchair occupant should preferably face outward on platform when entering or exiting vehicle to minimize the possibility of the large rear wheels rolling up and over the front roll stop. Review revealed it is never safe for a wheelchair occupant to exit a vehicle backwards, it is not safe to rely on a threshold warning device audible or other to confirm that it is safe for a passenger to exit backwards. The device may be inoperative or unheard and they might exit backwards when the platform is on the ground. When exiting vehicle verify that platform is at same height as floor and front roll stop is up and locked. The raised front roll stop prevents slow and unintentional rolling off of the platform. Further review revealed in part: do not allow an untrained person to operate the lift. Observation on 11/26/13 at 11:10am of S6/Transportation Aide demonstrating use of lift on an empty wheelchair revealed the bus in the park position. S6/Transportation Aide then proceeded to turn on the power button to the lift and then used the attached remote to lower the lift then she lowered the ramp even with the ground. S6/Transportation Aide then placed the wheelchair on the lift facing the vehicle and then locked the brakes to the wheelchair and then used her foot to lift the roll stop into place and nudged it with her foot to ensure it was locked into place. In interview on 11/26/13 at 11:10am S6/Transportation Aide stated the van had issues in the past such as the bolts securing the straps to the floor were really loose and the lift flap was staying down and had to pick up with her foot to secure. S6/Transportation Aide further stated once the lift flap was up it would lock into place. S6/Transportation Aide further stated the van was currently in the shop at a local repair shop. Observation on 11/26/13 at 12:31pm the facility's van was observed at the repair shop the lift was lowered by S1/Administrator, the lift was locked into place and did not open until it hits the ground; further observation revealed the roll stop was latched into place and was unable to be opened, but the roll stop did not automatically latch when the lift gate was latched into place. Review of Resident #1's Nurses Note dated 11/16/13 revealed Resident #1 was picked up from the local hospital on [DATE] after the incident with Resident #3. In interview on 11/26/13 at 1:15pm S1/Administrator stated no inspection or maintenance was performed of the vehicle on 11/16/13 after the incident with Resident #3 due to his knowledge the vehicle was not scheduled to be used until the Monday, 11/18/13. S1/Administrator further stated he did not tell anyone at the facility to put the van out of operation due to from the phone conversation on 11/16/13 with the nurse he did not feel as though the lift gate was a safety issue due to the flap can manually be lifted and locked into place. He further stated the video and investigation was not begun until the Monday 11/18/13. He further stated even if he knew the vehicle was needed to pick up Resident #1 he would have allowed it to go out because he did not feel like it was a safety issue. In interview on 11/26/13 at 3:05pm S1/Administrator stated he did not have any manuals for the lift on the van and/or bus. S1/Administrator stated on 10/09/13 he had an in-service for transportation drivers performed by him (S1) and S3/ADON regarding transportation primarily focusing on latching in the wheelchair, but did provide demonstration and return demonstration from putting on lift to latching the wheelchair in and he (S1) sat in the chair for the return demonstration. He was then asked how he was able to verify if the lift and van was being used properly and he indicated "common sense". He further stated the company got the vans and lifts with the change of ownership and had never seen a manual for either of the lifts. He further stated he had no in-service prior to 11/27/13 which instructed transportation staff of what safety precautions needed to be in place if the roll stop did not engage. Observation on 11/27/13 at 10:14am revealed S2/DON, S3/ADON, S4/Maintenance Director, and S6/Transportation Aide outside next to the facility bus in an in-service being performed by S1/Administrator. Observation further revealed every member present was given an Operators manual for the vehicle and S1/Administrator clarified all residents should be loaded and unloaded from the lift facing away from the vehicle per the Operators Manual. S1/Administrator then read out loud the Operators Manual. S1/Administrator further instructed if the roll stop does not automatically come up then the vehicle operator should engage the roll stop and check to ensure the roll stop is locked. He further stated the driver will have a daily check off to fill out prior to leaving with a client and will be turned in daily to him. He stated he should be notified immediately of any issues with the lift, vehicle, and/or safety devices. He then stated to the surveyor that the vehicle staff transporters list has been amended to include S1/Administrator, S2/DON, S3/ADON, S4/Maintenance Director, and S6/Transportation Driver as the only persons allowed to transport residents until new transportation driver is hired and training provided. In interview on 11/27/13 at 10:31am S4/Maintenance Director stated he has had to check lift gate before but does not work on the lifts because only qualified facilities can work on the lifts. He further stated he knew about the lift gate not working properly for a few weeks but unsure of date he was notified. S4/Maintenance Director further stated the administrator also was aware of the life gate not automatically latching. S4/Maintenance Director further stated until today he was under the understanding the residents were loaded and unloaded facing the vehicle and had never received or reviewed the Lift's Operators Manual prior today 11/27/13. In interview on 11/27/13 at 10:37am S6/Transportation Aide stated prior to today 11/27/13 she had never seen the Lift's Operation Manual or been instructed and/or educated on the Operation Manual's Manufacturer's recommendations. S6/Transportation Aide stated she has had to manually engage the lift gate for a couple of weeks. S6/Transportation Aide also stated she had notified S1/Administrator of this weeks ago but when she went to show him the problem the lift gate had worked at which time he told her just to notify him if the issue would happen again. S6/Transportation Aide further stated until today when the in-service took place on 11/27/13 she was facing the resident toward the vehicle when loading and unloading the resident on the wheelchair lift.

Based on observation, record review, and interview the facility failed to ensure that the resident environment remains as free of accident hazards as possible for 1 (Resident #3) of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for accident hazards in a total sample of 5. The facility identified 82 residents (All resident's in the facility except Resident #6 and Resident #7) which use the facility's vehicles for transportation out into the community. The facility failed to: 1. Have a system in place which ensured all transportation staff was in-serviced on the vehicle's lift system according to the manufacturer's recommendations. 2. Ensure a resident was not injured due to malfunctioning rollstop gate on the van ' s wheelchair lift; 3. Ensure the facility's vehicle was inspected and resident's injury investigated prior to sending the vehicle and transportation driver to pick up another resident after a resident was injured. An Immediate Jeopardy situation was identified which began on 11/16/13 at 2:11pm for Resident #3 when the resident was placed on the facility's van wheelchair lift in his wheelchair in the improper position, with the wheelchair brakes not applied, and with the automatic front roll stop (gate) not engaged and in the locked position. The resident fell from the facility's wheelchair lift and sustained a right olecranon fracture (elbow fracture) and an incomplete or insufficiency fracture at the right femoral head neck junction. The fall occurred after the resident was placed on the wheelchair lift in his wheelchair in the improper position, with the wheelchair brakes not applied, and with the automatic front roll stop (gate) not engaged and in the locked position. In interview on 11/27/13 at 9:26am S7/CNA indicated Resident #3 was able to feed himself, was able to assist with his bed mobility, would walk with the restorative aide with a walker, he could propel himself with his feet and would use his arms to pull himself on the rails to propel the wheelchair, and the resident was able to stand and assist with transfers before his recent falls. S7/CNA further stated since the fall he is unable to feed himself, unable to assist with bed mobility, has not walked with the restorative aide since his fall, the resident was unable to get around in his wheelchair, and did not assist with transfers since his fall. S7/CNA further indicated she was working with Resident #3 today 11/27/13 and she had to do everything for him. In interview on 11/27/13 at 9:33am S8/LPN (Licensed Practical Nurse) stated before Resident #3's fall he was alert with a good appetite, would ambulate in the halls with a wheelchair, would stay to himself, walked by himself when he wanted and would walk with the restorative aide, was able to assist with toileting. S8/LPN further stated since Resident #3's fall we have to feed him and do most things for him. Resident #3 has become totally dependent and has a sad affect now. Staff now has to remind him to even open his mouth to eat and encourage him to participate for all activities of daily living. S8/LPN further stated Resident #3's shunt had to be moved higher on his right arm due to the location of the shunt by the broken bone. The Immediate Jeopardy continued until 11/27/13 for the other 82 residents identified by the facility as using the facility's vehicles for transportation into the community after Resident #3 was injured after attempting to offload the resident from the facility's van and the facility did not put a system in place to avoid further injury to any resident who used the van. The Administrator was notified and Immediate Jeopardy situation was removed on 11/27/13 at 12:45pm, when an acceptable plan of removal was presented. The facility's plan revealed an in-service was held to educate staff listed on the facility's insured driver's list of the Lift Operations Manual's Operating Instructions held by the administrator. The facility's plan of removal also included an in-service on procedure for operation of the roll stop while the spring mechanism is not operational. Review revealed safety checks will be performed by the transportation aides on the days the vehicles are utilized. Review revealed the administrator should be notified immediately of any lift or safety concerns with the vehicle identified. Review of the facility's plan of removal revealed future transportation staff will receive vehicle training and lift operation instruction by the administrator upon hire and/or prior to being allowed to transport residents to ensure staff maintains resident safety. Administrator will give quarterly in-services to transportation drivers to ensure safety protocols are being followed, and transportation drivers will ensure safety by completing safety checklists each day before transporting residents. Further review of the facility's plan of removal revealed the administrator will monitor transportation aides operate the lift with a resident three times weekly for 30 days and then once weekly for another 30 days to ensure compliance. Transportation aides will turn safety checks in to the administrator daily when completed and prior to transport. Any non-compliance will be reported to the QI (Quality Improvement) committee for interventions as indicated. Completion date is 11/27/13. Attached to the facility's plan of removal was the facility's vehicle lift operation monitoring tool, vehicle safety check list, and in-service training (conducted on 11/27/13 at 10:30am) for proper usage of lift system per the lift's operators manual with return demonstration for all 5 staff members approved by the facility to transport facility residents. There were 82 residents identified by the facility as using the facility's vehicles for transportation into the community with a total facility census of 84 per the facility's Resident Census and Conditions of Residents dated 11/26/13. The deficient practice remains at a Scope/Severity of Level 3 (G), Actual Harm. Findings: Review of Resident #3's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/15/13 revealed BIMS (Brief Interview for Mental Status) of 3 (00-07 equals severe impairment in cognitive status). Further review revealed Resident #3 required limited assistance of one person physical assistance for transfers, walking in room and corridor and locomotion on unit; and required extensive assistance of one person physical assistance for locomotion off unit and dressing and toileting. Further review revealed Resident #3 needed supervision with set up assistance for eating. Review of Resident #3's Discharging Hospital's Patient Discharge Summary dated 11/22/13 revealed Resident #3 was discharged from the hospital with a closed fracture of right ulna. Further review of Resident #3's Discharging Hospital's Surgical/Invasive Procedure Progress Note dated 11/21/13 revealed Resident #3 required surgical intervention for a malfunctioned access to his right dialysis access . Review of the resident's CT (Computerized Tomography) of the Pelvis Report dated 11/25/13 revealed Resident #3 noted with findings of an incomplete or insufficiency fracture at the right femoral head neck junction. Review of the facility's OTIS (Online Tracking and Incident System) for the incident involving Resident #3 revealed on 11/16/13 at 2:11pm Resident #3 was returning from Dialysis and was injured while being unloaded from the vehicle using the wheelchair lift. Review of documentation of S5/CNA's Statement dated 11/16/13 revealed S5/CNA was attempting to unload Resident #3 from the facility's van when she released the lift into position she assisted the resident onto the lift upon doing so the left wheel got stuck and as she assisted him to free his wheelchair Resident #3 began rolling back and he rolled completely off the ramp. S5/CNA further documented the gate to the lift was not locked. Review of Nurses Notes dated 11/16/13 revealed the nurse was informed Resident #3 had fallen from the facility's van's ramp to the concrete outside, upon entering the scene the nurse noted the ramp was in the air and the safety flap which must be up in order to keep the resident from rolling off while in air was down and even with the ramp. Review of documentation of incident investigation performed by S2/DON (Director of Nursing) revealed S5/CNA (Certified Nursing Assistant) failed to keep the Resident #3 safe while in her care. Further review revealed S5/CNA was asked on 11/18/13 to demonstrate the procedure used when assisting the resident off of the facility transportation van. Review revealed S2/DON observed and noted S5/CNA failed to lock resident wheelchair prior to transfer, S5/CNA failed to check equipment (lift gate) prior to transfer, which caused Resident #3's wheelchair to roll backward and to fall onto the cement causing the resident injury. Review of S5/CNA's CNA Performance and Skills Evaluation dated 11/21/12 revealed S5/CNA date of hire was 09/12/12 with no evidence of competency evaluation for transportation duties. Review of S1/Administrator's, S4/Maintenance Director's, and S6/Transportation Aide's Company Owned Vehicle Driver In-service Checklists revealed no evidence of the staff having been trained on lift operation. In interview on 11/26/13 at 2:15pm S1/Administrator stated he did not have any transportation competency evaluations for S2/DON, S3/DON, and S5/CNA. S1/Administrator further stated S5/CNA did have an in-service on 10/09/13 which primarily focused on securing of the wheelchair inside of the facility's vehicles. Review of In-Service Training dated 10/09/13 revealed S5/CNA and S6/Transportation Aide was the only staff in-serviced on 10/09/13 regarding "van-proper securing of wheelchairs". Further review revealed method delivery was demonstration, return demonstration, and handout of policy. Attached to the In-Service for 10/09/13 revealed Monitoring Tool for Transferring and Securing in Residents on Van with dates of 11/18/13 and 11/26/13 monitoring transferred correctly and secured in correctly. Review of the facility's Policies for Company Owned Vehicle revealed policies for the vehicle being for business purposes only, seatbelts, traffic laws, alcohol/illegal substances, cell phone use, radio stations, vehicle safety/emergency issues, medical emergency, and smoking, food and beverages. Further review of the facility's Policies for Company Owned Vehicle revealed no evidence of a facility policy for proper use of the vehicle's van lift. Review of the Export Use Wheelchair and Standee Lift and Folding Platform Operator Manual revealed in part: the manual is to be read and thoroughly understand the operating instructions before attempting to operate the lift; inspect product before each use, if unsafe conditions unusual noises or movements do not operate the lift until the problem is corrected; the product should be maintained at the highest level of performance. Further review revealed front roll stop is a front barrier that prevents wheelchair from inadvertently rolling off of platform during platform movement. Further review of Operators Manual and Figure 2-2 revealed wheelchair occupant should preferably face outward on platform when entering or exiting vehicle to minimize the possibility of the large rear wheels rolling up and over the front roll stop. Review revealed it is never safe for a wheelchair occupant to exit a vehicle backwards, it is not safe to rely on a threshold warning device audible or other to confirm that it is safe for a passenger to exit backwards- the device may be inoperative or unheard and they might exit backwards when the platform is on the ground. When exiting vehicle verify that platform is at same height as floor and front roll stop is up and locked. The raised front roll stop prevents slow and unintentional rolling off of the platform. Further review revealed in part: do not allow an untrained person to operate the lift. Observation on 11/26/13 at 11:10am of S6/Transportation Aide demonstrating use of lift on an empty wheelchair revealed the bus in the park position. S6 then proceeded to turn on the power button to the lift and then used the attached remote to lower the lift then she lowered the ramp even with the ground. S6 then placed the wheelchair on the lift facing the vehicle and then locked the brakes to the wheelchair and then used her foot to lift the roll stop into place and nudged it with her foot to ensure it was locked into place. In interview on 11/26/13 at 11:10am S6/Transportation Aide stated the van had issues in the past such as the bolts securing the straps to the floor were really loose and the lift flap was staying down and had to pick up with her foot to secure. S6/Transportation Aide further stated once the lift flap was up it would lock into place. S6/Transportation Aide further stated the van was currently in the shop at a local repair shop. Observation on 11/26/13 at 12:31pm the facility's van was observed at the repair shop the lift was lowered by S1/Administrator the lift was locked into place and did not open until it hits the ground; further observation revealed the roll stop was latched into place and was unable to be opened- but the roll stop does not automatically latch when the lift gate is latched into place. Review of Resident #1's Nurses Note dated 11/16/13 revealed Resident #1 was picked up from the local hospital on [DATE] after the incident with Resident #3. In interview on 11/26/13 at 1:15pm S1/Administrator stated no inspection or maintenance was performed of the vehicle on 11/16/13 after the incident with Resident #3 due to his knowledge the vehicle was not scheduled to be used until the Monday, 11/18/13. S1/Administrator further stated he did not tell anyone at the facility to put the van out of operation due to from the phone conversation on 11/16/13 with the nurse he did not feel as though the lift gate was a safety issue due to the flap can manually be lifted and locked into place. He further stated the video and investigation was not begun until the Monday 11/18/13. He further stated even if he knew the vehicle was needed to pick up Resident #1 he would have allowed it to go out because he did not feel like it was a safety issue. In interview on 11/26/13 at 3:05pm S1/Administrator stated he did not have any manuals for the lift on the van and/or bus. S1/Administrator stated on 10/09/13 he had an in-service for transportation drivers by performed by him (S1) and S3/ADON regarding transportation primarily focusing on latching in the wheelchair but did provide demonstration and return demonstration from putting on lift to latching the wheelchair in and he (S1) sat in the chair for the return demonstration. He was then asked how he was able to verify if the lift and van was being used properly he stated "common sense". He further stated the company got the vans and lifts with the change of ownership and had never seen a manual for either of the lifts. He further stated he had no in-service prior to 11/27/13 which instructed transportation staff of what safety precautions needed to be in place if the roll stop did not engage. Observation on 11/27/13 at 10:14am revealed S2/DON, S3/ADON, S4/Maintenance Director, and S6/Transportation Aide outside next to the facility bus in an in-service being performed by S1/Administrator. Observation further revealed every member present was given an Operators manual for the vehicle and S1/Administrator clarified all residents should be loaded and unloaded from the lift facing away from the vehicle per the Operators Manual. S1/Administrator then read out loud the Operators Manual. S1/Administrator further instructed if the roll stop does not automatically come up then the vehicle operator should engage the roll stop and check to ensure the roll stop is locked. He further stated the driver will have a daily check off to fill out prior to leaving with a client and will be turned in daily to him. He stated he should be notified immediately of any issues with the lift, vehicle, and/or safety devices. He then stated to the surveyor that the vehicle staff transporters list has been amended to include S1/Administrator, S2/DON, S3/ADON, S4/Maintenance Director, and S6/Transportation Driver as the only persons allowed to transport residents until new transportation driver is hired and training provided. In interview on 11/27/13 at 10:31am S4/Maintenance Director stated he has had to check lift gate before but does not work on the lifts because only qualified facilities can work on the lifts. He further stated he knew about the lift gate not working properly for a few weeks but unsure of date he was notified. S4/Maintenance Director further stated the administrator also was aware of the life gate not automatically latching. S4/Maintenance Director further stated until today he was under the understanding the residents were loaded and unloaded facing the vehicle and had never received or reviewed the Lift's Operators Manual prior today 11/27/13. In interview on 11/27/13 at 10:37am S6/Transportation Aide stated prior to today 11/27/13 she had never seen the Lift's Operation Manual or been instructed and/or educated on the Operation Manual's Manufacturer's recommendations. S6/Transportation Aide stated she has had to manually engage the lift gate for a couple of weeks. S6/Transportation Aide also stated she had notified S1/Administrator of this weeks ago but when she went to show him the problem the lift gate had worked at which time he told her just to notify him if the issue would happen again. S6/Transportation Aide further stated until today when the in-service took place on 11/27/13 she was facing the resident toward the vehicle when loading and unloading the resident on the wheelchair lift. Review of Nurse's Notes dated 11/22/13 through 11/26/13 revealed Resident #3 requires extensive assistance for bed mobility and eating by one person physical assistance and is totally dependent for transfers and toileting requiring one person physical assistance. Review of Nurses Notes dated 11/25/13 revealed resident started complaining of pain to right leg and back. Review of the CT (Computerized Tomography) of the Pelvis Report dated 11/25/13 revealed Resident #3 noted with findings of an incomplete or insufficiency fracture at the right femoral head neck junction.

Based on observation, record review, and interview the facility failed to maintain all essential mechanical, electrical, and patient care equipment in safe and operating condition for 1 (Resident #3) of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for accident hazards in a total sample of 5 as evidenced by the facility failing to ensure the automatic roll stop (lift gate) was functioning properly before transporting residents. The facility identified 82 residents (All residents in the facility except Resident #6 and Resident #7) which use the facility's vehicles for transportation out into the community. An Immediate Jeopardy situation began on 11/16/13 at 2:11pm for Resident #3 when the resident was placed on the facility's van wheelchair lift in his wheelchair with the automatic front roll stop (gate) not engaged and in the locked position. The resident fell from the facility's wheelchair lift and sustained a right olecranon fracture (elbow fracture) and an incomplete or insufficiency fracture at the right femoral head neck junction. The fall occurred after the resident was placed on the wheelchair lift in his wheelchair with the automatic front roll stop (gate) not engaged and in the locked position. In interview on 11/27/13 at 9:26am S7/CNA (Certified Nursing Assistant) stated Resident #3 was able to feed himself, was able to assist with his bed mobility, would walk with the restorative aide with a walker, he could propel himself with his feet and would use his arms to pull himself on the rails to propel the wheelchair, and the resident was able to stand and assist with transfers before his recent falls. S7/CNA further stated since the fall he is unable to feed himself, unable to assist with bed mobility, has not walked with the restorative aide since his fall, the resident was unable to get around in his wheelchair, and did not assist with transfers since his fall. S7/CNA further stated she was working with Resident #3 today 11/27/13 and she had to do everything for him. In interview on 11/27/13 at 9:33am S8/LPN (Licensed Practical Nurse) stated before Resident #3's fall he was alert with a good appetite, would ambulate in the halls with a wheelchair, would stay to himself, walked by himself when he wanted and would walk with the restorative aide, was able to assist with toileting. S8/LPN further stated since Resident #3's fall we have to feed him and do most things for him. Resident #3 has become totally dependent and has a sad affect now. Staff now has to remind him to even open his mouth to eat and encourage him to participate for all activities of daily living. S8/LPN further stated Resident #3's shunt had to be moved higher on his right arm due to the location of the shunt by the broken bone. The Immediate Jeopardy continued until 11/27/13 for the other 82 residents identified by the facility as using the facility's vehicles for transportation into the community after Resident #3 was injured after attempting to offload the resident from the facility's van and the facility did not put a system in place to avoid further injury to any resident who used the van. The Administrator was notified and the Immediate Jeopardy situation was removed on 11/27/13 at 12:45pm, when an acceptable plan of removal was presented. The facility's plan revealed an in-service was held to educate staff (listed on the facility's insured driver's list) of the Lift Operations Manual's Operating Instructions held by the administrator. The facility's plan of removal also included an in-service on procedure for operation of the roll stop while the spring mechanism is not operational. Review revealed safety checks will be performed by the transportation aides on the days the vehicles are utilized. Review revealed the administrator should be notified immediately of any lift or safety concerns with the vehicle identified. Review of the facility's plan of removal revealed future transportation staff will receive vehicle training and lift operation instruction by the administrator upon hire and/or prior to being allowed to transport residents to ensure staff maintains resident safety. Administrator will give quarterly in-services to transportation drivers to ensure safety protocols are being followed, and transportation drivers will ensure safety by completing safety checklists each day before transporting residents. Further review of the facility's plan of removal revealed the administrator will monitor transportation aides operate the lift with a resident three times weekly for 30 days and then once weekly for another 30 days to ensure compliance. Transportation aides will turn safety checks in to the administrator daily when completed and prior to transport. Any non-compliance will be reported to the QI (Quality Improvement) committee for interventions as indicated. Completion date is 11/27/13. Attached to the facility's plan of removal was the facility's vehicle lift operation monitoring tool, vehicle safety check list, and in-service training (conducted on 11/27/13 at 10:30am) for proper usage of lift system per the lift's operators manual with return demonstration for all 5 staff members approved by the facility to transport facility residents. There were 82 residents identified by the facility as using the facility's vehicles for transportation into the community with a total facility census of 84 per the facility's Resident Census and Conditions of Residents dated 11/26/13. The deficient practice remains at a Scope/Severity of Level 3 (G), Actual Harm. Findings: Review of Resident #3's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/15/13 revealed BIMS (Brief Interview for Mental Status) of 3 (00-07 equals severe impairment in cognitive status). Further review revealed Resident #3 required limited assistance of one person physical assistance for transfers, walking in room and corridor and locomotion on unit; and required extensive assistance of one person physical assistance for locomotion off unit and dressing and toileting. Further review revealed Resident #3 needed supervision requiring set up assistance for eating. Review of Resident #3's Discharging Hospital's Patient Discharge Summary dated 11/22/13 revealed Resident #3 was discharged from the hospital with a closed fracture of right ulna. Further review of Resident #3's Discharging Hospital's Surgical/Invasive Procedure Progress Note dated 11/21/13 revealed Resident #3 required surgical intervention for a malfunctioned access to his right [MEDICAL TREATMENT] access. Review of the CT (Computerized Tomography) of the Pelvis Report dated 11/25/13 revealed Resident #3 noted with findings of an incomplete or insufficiency fracture at the right femoral head neck junction. Review of the facility's OTIS (Online Tracking and Incident System) for the incident involving Resident #3 revealed on 11/16/13 at 2:11pm Resident #3 was returning from [MEDICAL TREATMENT] and was injured while being unloaded from the vehicle using the wheelchair lift. Review of the facility's documentation of S5/CNA's Statement dated 11/16/13 revealed S5/CNA was attempting to unload Resident #3 from the facility's van when she released the lift into position she assisted the resident onto the lift upon doing so the left wheel got stuck and as she assisted him to free his wheelchair Resident #3 began rolling back and he rolled completely off the ramp. S5/CNA further documented the gate to the lift was not locked. Review of the resident's Nurses Notes dated 11/16/13 revealed the nurse was informed Resident #3 had fallen from the facility's van's ramp to the concrete outside, upon entering the scene the nurse noted the ramp was in the air and the safety flap which must be up in order to keep the resident from rolling off while in air was down and even with the ramp. Review of the facility's documentation of incident investigation performed by S2/DON (Director of Nursing) revealed S5/CNA (Certified Nursing Assistant) failed to keep the Resident #3 safe while in her care. Further review revealed S5/CNA was asked on 11/18/13 to demonstrate the procedure used when assisting the resident off of the facility transportation van. Review revealed S2/DON observed and noted S5/CNA failed to lock resident wheelchair prior to transfer, S5/CNA failed to check equipment (lift gate) prior to transfer, which caused Resident #3's wheelchair to roll backward and to fall onto the cement causing the resident injury. Review of the facility's Policies for Company Owned Vehicle revealed policies for the vehicle being for business purposes only, seatbelts, traffic laws, alcohol/illegal substances, cell phone use, radio stations, vehicle safety/emergency issues, medical emergency, and smoking, food and beverages. Further review of the facility's Policies for Company Owned Vehicle revealed no evidence of a facility policy for proper use of the vehicle's van lift. Review of the Export Use Wheelchair and Standee Lift and Folding Platform Operator Manual revealed in part: the manual is to be read and thoroughly understand the operating instructions before attempting to operate the lift; inspect product before each use, if unsafe conditions unusual noises or movements do not operate the lift until the problem is corrected; the product should be maintained at the highest level of performance. Further review revealed front roll stop is a front barrier that prevents wheelchair from inadvertently rolling off of platform during platform movement. When exiting vehicle verify that platform is at same height as floor and front roll stop is up and locked. The raised front roll stop prevents slow and unintentional rolling off of the platform. Observation on 11/26/13 at 11:10am of S6/Transportation Aide demonstrating use of lift on an empty wheelchair revealed S6/Transportation Aide then placed the wheelchair on the lift and then locked the brakes to the wheelchair and then used her foot to lift the roll stop into place and nudged it with her foot to ensure it was locked into place. In interview on 11/26/13 at 11:10am S6/Transportation Aide stated the van had issues in the past such as the bolts securing the straps to the floor were really loose and the lift flap was staying down and had to pick up with her foot to secure. S6/Transportation Aide further stated once the lift flap was up it would lock into place. S6/Transportation Aide further stated the van was currently in the shop at a local repair shop. Observation on 11/26/13 at 12:31pm the facility's van was observed at the repair shop the lift was lowered by S1/Administrator the lift was locked into place and did not open until it hits the ground; further observation revealed the roll stop was latched into place and was unable to be opened- but the roll stop does not automatically lift and latch into place when loading into the vehicle. Review of Resident #1's Nurses Note dated 11/16/13 revealed Resident #1 was picked up from the local hospital on [DATE] after the incident with Resident #3. In interview on 11/26/13 at 1:15pm S1/Administrator stated no inspection or maintenance was performed of the vehicle on 11/16/13 after the incident with Resident #3 due to his knowledge the vehicle was not scheduled to be used until the Monday, 11/18/13. S1/Administrator further stated he did not tell anyone at the facility to put the van out of operation due to from the phone conversation on 11/16/13 with the nurse he did not feel as though the lift gate was a safety issue due to the flap can manually be lifted and locked into place. He further stated the video and investigation was not begun until the Monday 11/18/13. He further stated even if he knew the vehicle was needed to pick up Resident #1 he would have allowed it to go out because he did not feel like it was a safety issue. In interview on 11/26/13 at 3:05pm S1/Administrator stated on 10/09/13 he had an in-service for transportation drivers by performed by him (S1) and S3/ADON regarding transportation primarily focusing on latching in the wheelchair but did provide demonstration and return demonstration from putting on lift to latching the wheelchair in the vehicle and he (S1) sat in the chair for the return demonstration. S1/Administrator further stated he had no in-service prior to 11/27/13 which instructed transportation staff of what safety precautions needed to be in place if the roll stop did not engage. Observation on 11/27/13 at 10:14am revealed S2/DON, S3/ADON, S4/Maintenance Director, and S6/Transportation Aide outside next to the facility bus in an in-service being performed by S1/Administrator. S1/Administrator instructed if the roll stop does not automatically come up then the vehicle operator should engage the roll stop and check to ensure the roll stop is locked. He further indicated the driver will have a daily check off to fill out prior to leaving with a client and will be turned in daily to him. He indicated he should be notified immediately of any issues with the lift, vehicle, and/or safety devices. In interview on 11/27/13 at 10:31am S4/Maintenance Director stated he has had to check lift gate before but does not work on the lifts because only qualified facilities can work on the lifts. He further stated he knew about the lift gate not working properly for a few weeks but unsure of date he was notified. S4/Maintenance Director further stated the administrator also was aware of the life gate not automatically latching. In interview on 11/27/13 at 10:37am S6/Transportation Aide stated she has had to manually engage the lift gate for a couple of weeks. S6/Transportation Aide also indicated she had notified S1/Administrator of the problem with the lift gate weeks ago but when she went to show him the problem the lift gate had worked at which time he told her just to notify him if the issue would happen again.

Based on observation, record review, and interview the facility failed to be administered in manner that enabled it to effectively maintain the highest practicable wellbeing of its residents to ensure those residents were free from accident hazards for 1 (Resident #3) of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for accident hazards in a total sample of 5. The facility identified 82 residents (All residents in the facility except Resident #6 and Resident #7) which use the facility's vehicles for transportation out into the community. The facility failed to: 1. Have a system in place which ensured all transportation staff was in-serviced on the vehicle's lift system according to the manufacturer's recommendation; 2. Ensure a resident was not injured due to malfunctioning resident care equipment; 3. Ensure the facility's vehicle was inspected and resident's injury investigated prior to sending the vehicle and transportation driver to pick up another resident after a resident was injured. An Immediate Jeopardy situation began on 11/16/13 at 2:11pm for Resident #3 when the resident was placed on the facility's van wheelchair lift in his wheelchair in the improper position, with the wheelchair brakes not applied, and with the automatic front roll stop (gate) not engaged and in the locked position. The resident fell from the facility's wheelchair lift and sustained a right olecranon fracture (elbow fracture) and an incomplete or insufficiency fracture at the right femoral head neck junction. The fall occurred after the resident was placed on the wheelchair lift in his wheelchair in the improper position, with the wheelchair brakes not applied, and with the automatic front roll stop (gate) not engaged and in the locked position. In interview on 11/27/13 at 9:26am S7/CNA (Certified Nursing Assistant) stated Resident #3 was able to feed himself, was able to assist with his bed mobility, would walk with the restorative aide with a walker, he could propel himself with his feet and would use his arms to pull himself on the rails to propel the wheelchair, and the resident was able to stand and assist with transfers before his recent falls. S7/CNA further stated since the fall he is unable to feed himself, unable to assist with bed mobility, has not walked with the restorative aide since his fall, the resident was unable to get around in his wheelchair, and did not assist with transfers since his fall. S7/CNA further stated she was working with Resident #3 today 11/27/13 and she had to do everything for him. In interview on 11/27/13 at 9:33am S8/LPN (Licensed Practical Nurse) stated before Resident #3's fall he was alert with a good appetite, would ambulate in the halls with a wheelchair, would stay to himself, walked by himself when he wanted and would walk with the restorative aide, was able to assist with toileting. S8/LPN further stated since Resident #3's fall we have to feed him and do most things for him. Resident #3 has become totally dependent and has a sad affect now. Staff now has to remind him to even open his mouth to eat and encourage him to participate for all activities of daily living. S8/LPN further stated Resident #3's shunt had to be moved higher on his right arm due to the location of the shunt by the broken bone. The Immediate Jeopardy continued until 11/27/13 for the other 82 residents identified by the facility as using the facility's vehicles for transportation into the community after Resident #3 was injured after attempting to offload the resident from the facility's van and the facility did not put a system in place to avoid further injury to any resident who used the van. The Administrator was notified and the Immediate Jeopardy situation was removed on 11/27/13 at 12:45pm, when an acceptable plan of removal was presented. The facility's plan revealed an in-service was held to educate staff (listed on the facility's insured driver's list) of the Lift Operations Manual's Operating Instructions held by the administrator. The facility's plan of removal also included an in-service on procedure for operation of the roll stop while the spring mechanism is not operational. Review revealed safety checks will be performed by the transportation aides on the days the vehicles are utilized. Review revealed the administrator should be notified immediately of any lift or safety concerns with the vehicle identified. Review of the facility's plan of removal revealed future transportation staff will receive vehicle training and lift operation instruction by the administrator upon hire and/or prior to being allowed to transport residents to ensure staff maintains resident safety. Administrator will give quarterly in-services to transportation drivers to ensure safety protocols are being followed, and transportation drivers will ensure safety by completing safety checklists each day before transporting residents. Further review of the facility's plan of removal revealed the administrator will monitor transportation aides operate the lift with a resident three times weekly for 30 days and then once weekly for another 30 days to ensure compliance. Transportation aides will turn safety checks in to the administrator daily when completed and prior to transport. Any non-compliance will be reported to the QI (Quality Improvement) committee for interventions as indicated. Completion date is 11/27/13. Attached to the facility's plan of removal was the facility's vehicle lift operation monitoring tool, vehicle safety check list, and in-service training (conducted on 11/27/13 at 10:30am) for proper usage of lift system per the lift's operators manual with return demonstration for all 5 staff members approved by the facility to transport facility residents. There were 82 residents identified by the facility as using the facility's vehicles for transportation into the community with a total facility census of 84 per the facility's Resident Census and Conditions of Residents dated 11/26/13. The deficient practice remains at a Scope/Severity of Level 3 (G), Actual Harm. Findings: 1. Cross refer to finding at 309 2. Cross refer to finding at 323 3. Cross refer to finding at 456 4. Cross refer to finding at 498 In interview on 11/26/13 at 2:15pm S1/Administrator stated he did not have any transportation competency evaluations for S2/DON, S3/DON, and S5/CNA. S1/Administrator further stated S5/CNA did have an in-service on 10/09/13 which primarily focused on securing of the wheelchair inside of the facility's vehicles. Review of In-Service Training dated 10/09/13 revealed S5/CNA and S6/Transportation Aide was the only staff in-serviced on 10/09/13 regarding "van-proper securing of wheelchairs ". Further review revealed method delivery was demonstration, return demonstration, and handout of policy. Attached to the In-Service for 10/09/13 revealed Monitoring Tool for Transferring and Securing in Residents on Van with dates of 11/18/13 and 11/26/13 monitoring transferred correctly and secured in correctly. Review of the facility's Policies for Company Owned Vehicle revealed policies for the vehicle being for business purposes only, seatbelts, traffic laws, alcohol/illegal substances, cell phone use, radio stations, vehicle safety/emergency issues, medical emergency, and smoking, food and beverages. Further review of the facility's Policies for Company Owned Vehicle revealed no evidence of a facility policy for proper use of the vehicle's van lift. Review of the Export Use Wheelchair and Standee Lift and Folding Platform Operator Manual revealed in part: the manual is to be read and thoroughly understand the operating instructions before attempting to operate the lift; inspect product before each use, if unsafe conditions unusual noises or movements do not operate the lift until the problem is corrected; the product should be maintained at the highest level of performance. Further review revealed front roll stop is a front barrier that prevents wheelchair from inadvertently rolling off of platform during platform movement. Further review of Operators Manual and Figure 2-2 revealed wheelchair occupant should preferably face outward on platform when entering or exiting vehicle to minimize the possibility of the large rear wheels rolling up and over the front roll stop. Review revealed it is never safe for a wheelchair occupant to exit a vehicle backwards, it is not safe to rely on a threshold warning device audible or other to confirm that it is safe for a passenger to exit backwards- the device may be inoperative or unheard and they might exit backwards when the platform is on the ground. When exiting vehicle verify that platform is at same height as floor and front roll stop is up and locked. The raised front roll stop prevents slow and unintentional rolling off of the platform. Further review revealed in part: do not allow an untrained person to operate the lift. In interview on 11/26/13 at 1:15pm S1/Administrator stated no inspection or maintenance was performed of the vehicle on 11/16/13 after the incident with Resident #3 due to his knowledge the vehicle was not scheduled to be used until the Monday 11/18/13. S1/Administrator further stated he did not tell anyone at the facility to put the van out of operation due to from the phone conversation on 11/16/13 with the nurse he did not feel as though the lift gate was a safety issue due to the flap can manually be lifted and locked into place. He further stated the video and investigation was not begun until the Monday 11/18/13. He further stated even if he knew the vehicle was needed to pick up Resident #1 he would have allowed it to go out because he did not feel like it was a safety issue. In interview on 11/26/13 at 3:05pm S1/Administrator stated he did not have any manuals for the lift on the van and/or bus. S1/Administrator stated on 10/09/13 he had an in-service for transportation drivers by performed by him (S1) and S3/ADON regarding transportation primarily focusing on latching in the wheelchair but did provide demonstration and return demonstration from putting on lift to latching the wheelchair in and he (S1) sat in the chair for the return demonstration. He was then asked how he was able to verify if the lift and van was being used properly he stated "common sense". He further stated the company got the vans and lifts with the change of ownership and had never seen a manual for either of the lifts. He further stated he had no in-service prior to 11/27/13 which instructed transportation staff of what safety precautions needed to be in place if the roll stop did not engage. Observation on 11/27/13 at 10:14am revealed S2/DON, S3/ADON, S4/Maintenance Director, and S6/Transportation Aide outside next to the facility bus in an in-service being performed by S1/Administrator. Observation further revealed every member present was given an Operators manual for the vehicle and S1/Administrator clarified all residents should be loaded and unloaded from the lift facing away from the vehicle per the Operators Manual. S1/Administrator then read out loud the Operators Manual. S1/Administrator further instructed if the roll stop does not automatically come up then the vehicle operator should engage the roll stop and check to ensure the roll stop is locked. He further stated the driver will have a daily check off to fill out prior to leaving with a client and will be turned in daily to him. He stated he should be notified immediately of any issues with the lift, vehicle, and/or safety devices. He then stated to the surveyor that the vehicle staff transporters list has been amended to include S1/Administrator, S2/DON, S3/ADON, S4/Maintenance Director, and S6/Transportation Driver as the only persons allowed to transport residents until new transportation driver is hired and training provided. In interview on 11/27/13 at 10:37am S6/Transportation stated she has had to manually engage the lift gate for a couple of weeks. S6/Transportation Aide also stated she had notified S1/Administrator of this weeks ago but when she went to show him the problem the lift gate had worked at which time he told her just to notify him if the issue would happen again. S6/Transportation Aide further stated until today when the in-service took place on 11/27/13 she was facing the resident toward the vehicle when loading and unloading the resident on the wheelchair lift. Review of Nurse's Notes dated 11/22/13 through 11/26/13 revealed Resident #3 requires extensive assistance for bed mobility and eating by one person physical assistance and is totally dependent for transfers and toileting requiring one person physical assistance. Review of Nurses Notes dated 11/25/13 revealed resident started complaining of pain to right leg and back. Review of the CT (Computerized Tomography) of the Pelvis Report dated 11/25/13 revealed Resident #3 noted with findings of an incomplete or insufficiency fracture at the right femoral head neck junction.

Based on observation, record review, and interview the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 (Resident #3) of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for accident hazards in a total sample of 5 as evidenced by the facility failing to: 1. Have a system in place which ensured CNA (Certified Nursing Assistant) staff was properly trained on how to assist a wheelchair bound resident onto and off of the transportation vehicles; 2. In-serviced staff on the vehicles ' lifts system according to the manufacturer's recommendations (S5/CNA, Transportation Driver and S6/Transportation Aide); 3. Ensure a resident did not sustain injuries due to a CNA not properly locking the residents wheelchair in place and checking the lift system prior to assisting a resident onto the lift (S5/CNA, Transportation Driver). The facility identified 82 residents which use the facility's vehicles for transportation out into the community (All resident's in the facility except Resident #6 and Resident #7). An Immediate Jeopardy situation began on 11/16/13 at 2:11pm for Resident #3 when the resident was placed on the facility's van wheelchair lift in his wheelchair in the improper position, with the wheelchair brakes not applied, and with the automatic front roll stop (gate) not engaged and in the locked position. The resident fell from the facility's wheelchair lift and sustained a right olecranon fracture (elbow fracture) and an incomplete or insufficiency fracture at the right femoral head neck junction. The fall occurred after the resident was placed on the wheelchair lift in his wheelchair in the improper position, with the wheelchair brakes not applied, and with the automatic front roll stop (gate) not engaged and in the locked position. In interview on 11/27/13 at 9:26am S7/CNA (Certified Nursing Assistant) stated Resident #3 was able to feed himself, was able to assist with his bed mobility, would walk with the restorative aide with a walker, he could propel himself with his feet and would use his arms to pull himself on the rails to propel the wheelchair, and the resident was able to stand and assist with transfers before his recent falls. S7/CNA further stated since the fall he is unable to feed himself, unable to assist with bed mobility, has not walked with the restorative aide since his fall, the resident was unable to get around in his wheelchair, and did not assist with transfers since his fall. S7/CNA further stated she was working with Resident #3 today 11/27/13 and she had to do everything for him. In interview on 11/27/13 at 9:33am S8/LPN (Licensed Practical Nurse) stated before Resident #3's fall he was alert with a good appetite, would ambulate in the halls with a wheelchair, would stay to himself, walked by himself when he wanted and would walk with the restorative aide, was able to assist with toileting. S8/LPN further stated since Resident #3's fall we have to feed him and do most things for him. Resident #3 has become totally dependent and has a sad affect now. Staff now has to remind him to even open his mouth to eat and encourage him to participate for all activities of daily living. S8/LPN further stated Resident #3's shunt had to be moved higher on his right arm due to the location of the shunt by the broken bone. The Immediate Jeopardy continued until 11/27/13 for the other 82 residents identified by the facility as using the facility's vehicles for transportation into the community after Resident #3 was injured after attempting to offload the resident from the facility's van and the facility did not put a system in place to avoid further injury to any resident who used the van. The Administrator was notified and the Immediate Jeopardy was removed on 11/27/13 at 12:45pm, when an acceptable plan of removal was presented. The facility's plan revealed an in-service was held to educate staff listed on the facility's insured driver's list of the Lift Operations Manual's Operating Instructions held by the administrator. The facility's plan of removal also included an in-service on procedure for operation of the roll stop while the spring mechanism is not operational. Review revealed safety checks will be performed by the transportation aides on the days the vehicles are utilized. Review revealed the administrator should be notified immediately of any lift or safety concerns with the vehicle identified. Review of the facility's plan of removal revealed future transportation staff will receive vehicle training and lift operation instruction by the administrator upon hire and/or prior to being allowed to transport residents to ensure staff maintains resident safety. Administrator will give quarterly in-services to transportation drivers to ensure safety protocols are being followed, and transportation drivers will ensure safety by completing safety checklists each day before transporting residents. Further review of the facility's plan of removal revealed the administrator will monitor transportation aides operate the lift with a resident three times weekly for 30 days and then once weekly for another 30 days to ensure compliance. Transportation aides will turn safety checks in to the administrator daily when completed and prior to transport. Any non-compliance will be reported to the QI (Quality Improvement) committee for interventions as indicated. Completion date is 11/27/13. Attached to the facility's plan of removal was the facility's vehicle lift operation monitoring tool, vehicle safety check list, and in-service training (conducted on 11/27/13 at 10:30am) for proper usage of lift system per the lift's operators manual with return demonstration for all 5 staff members approved by the facility to transport facility residents. There were 82 residents identified by the facility as using the facility's vehicles for transportation into the community with a total facility census of 84 per the facility's Resident Census and Conditions of Residents dated 11/26/13. The deficient practice remains at a Scope/Severity of Level 3 (G), Actual Harm. Findings: Review of Resident #3's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/15/13 revealed BIMS (Brief Interview for Mental Status) of 3 (00-07 equals severe impairment in cognitive status). Further review revealed Resident #3 required limited assistance of one person physical assistance for transfers, walking in room and corridor and locomotion on unit; and required extensive assistance of one person physical assistance for locomotion off unit and dressing and toileting. Further review revealed Resident #3 supervision with set up assistance for eating. Review of Resident #3's Discharging Hospital's Patient Discharge Summary dated 11/22/13 revealed Resident #3 was discharged from the hospital with a closed fracture of right ulna. Further review of Resident #3's Discharging Hospital's Surgical/Invasive Procedure Progress Note dated 11/21/13 revealed Resident #3 required surgical intervention for a malfunctioned access to his right [MEDICAL TREATMENT] access. Review of the CT (Computerized Tomography) of the Pelvis Report dated 11/25/13 revealed Resident #3 noted with findings of an incomplete or insufficiency fracture at the right femoral head neck junction. Review of the facility's OTIS (Online Tracking and Incident System) for the incident involving Resident #3 revealed on 11/16/13 at 2:11pm Resident #3 was returning from [MEDICAL TREATMENT] and was injured while being unloaded from the vehicle using the wheelchair lift. Review of the facility's documentation of S5/CNA's (Certified Nursing Assistant), who also provides transportation to residents, Statement dated 11/16/13 revealed S5/CNA was attempting to unload Resident #3 from the facility's van when she released the lift into position she assisted the resident onto the lift upon doing so the left wheel got stuck and as she assisted him to free his wheelchair Resident #3 began rolling back and he rolled completely off the ramp. S5/CNA further documented the gate to the lift was not locked. Review of the resident's Nurses Notes dated 11/16/13 revealed the nurse was informed Resident #3 had fallen from the facility's van's ramp to the concrete outside, upon entering the scene the nurse noted the ramp was in the air and the safety flap which must be up in order to keep the resident from rolling off while in air was down and even with the ramp. Review of the facility's documentation of incident investigation performed by S2/DON (Director of Nursing) revealed S5/CNA (Certified Nursing Assistant) failed to keep the Resident #3 safe while in her care. Further review revealed S5/CNA was asked on 11/18/13 to demonstrate the procedure used when assisting the resident off of the facility transportation van. Review revealed S2/DON observed and noted S5/CNA failed to lock resident wheelchair prior to transfer, S5/CNA failed to check equipment (lift gate) prior to transfer, which caused Resident #3's wheelchair to roll backward and to fall onto the cement causing the resident injury. Review of S5/CNA's CNA Performance and Skills Evaluation dated 11/21/12 revealed S5/CNA date of hire was 09/12/12 with no evidence of competency evaluation for transportation duties. Review of S1/Administrator's, S4/Maintenance Director's, and S6/Transportation Aide's Company Owned Vehicle Driver In-service Checklists revealed no evidence of the staff having been trained on lift operation. In interview on 11/26/13 at 2:15pm S1/Administrator indicated he did not have any transportation competency evaluations for S2/DON, S3/DON, and S5/CNA. S1/Administrator further indicated S5/CNA did have an in-service on 10/09/13 which primarily focused on securing of the wheelchair inside of the facility's vehicles. Review of In-Service Training dated 10/09/13 revealed S5/CNA and S6/Transportation Aide was the only staff in-serviced on 10/09/13 regarding "van-proper securing of wheelchairs". Further review revealed method delivery was demonstration, return demonstration, and handout of policy. Review of the facility's Policies for Company Owned Vehicle revealed policies for the vehicle being for business purposes only, seatbelts, traffic laws, alcohol/illegal substances, cell phone use, radio stations, vehicle safety/emergency issues, medical emergency, and smoking, food and beverages. Further review of the facility's Policies for Company Owned Vehicle revealed no evidence of a facility policy for proper use of the vehicle's van lift. Review of the Export Use Wheelchair and Standee Lift and Folding Platform Operator Manual revealed in part: the manual is to be read and thoroughly understand the operating instructions before attempting to operate the lift; inspect product before each use, if unsafe conditions unusual noises or movements do not operate the lift until the problem is corrected; the product should be maintained at the highest level of performance. Further review revealed front roll stop is a front barrier that prevents wheelchair from inadvertently rolling off of platform during platform movement. Further review of Operators Manual and Figure 2-2 revealed wheelchair occupant should preferably face outward on platform when entering or exiting vehicle to minimize the possibility of the large rear wheels rolling up and over the front roll stop. Review revealed it is never safe for a wheelchair occupant to exit a vehicle backwards, it is not safe to rely on a threshold warning device audible or other to confirm that it is safe for a passenger to exit backwards- the device may be inoperative or unheard and they might exit backwards when the platform is on the ground. When exiting vehicle verify that platform is at same height as floor and front roll stop is up and locked. The raised front roll stop prevents slow and unintentional rolling off of the platform. Further review revealed in part: do not allow an untrained person to operate the lift. Observation on 11/26/13 at 11:10am of S6/Transportation Aide demonstrating use of lift on an empty wheelchair revealed the bus in the park position. S6 then proceeded to turn on the power button to the lift and then used the attached remote to lower the lift then she lowered the ramp even with the ground. S6 then placed the wheelchair on the lift facing the vehicle and then locked the brakes to the wheelchair and then used her foot to lift the roll stop into place and nudged it with her foot to ensure it was locked into place. In interview on 11/26/13 at 3:05pm S1/Administrator stated he did not have any manuals for the lift on the van and/or bus. S1/Administrator stated on 10/09/13 he had an in-service for transportation drivers by performed by him (S1) and S3/ADON regarding transportation primarily focusing on latching in the wheelchair but did provide demonstration and return demonstration from putting on lift to latching the wheelchair in and he (S1) sat in the chair for the return demonstration. He was then asked how he was able to verify if the lift and van was being used properly he stated "common sense". He further stated the company got the vans and lifts with the change of ownership and had never seen a manual for either of the lifts. He further stated he had no in-service prior to 11/27/13 which instructed transportation staff of what safety precautions needed to be in place if the roll stop did not engage. In interview on 11/27/13 at 10:37am S6/Transportation Aide stated prior to today 11/27/13 she had never seen the Lift's Operation Manual or been instructed and/or educated on the Operation Manual's Manufacturer's recommendations. S6/Transportation Aide stated she has had to manually engage the lift gate for a couple of weeks. S6/Transportation Aide further stated until today when the in-service took place on 11/27/13 she was facing the resident toward the vehicle when loading and unloading the resident on the wheelchair lift.