Every finding on record at Crestpark Stuttgart, LLC

Based on record review and interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS) assessments within 14 days of the completion date for 13 (Resident #8, #12, #22, #24, #26, #29, #30, #31, #33, #34, #35, #40, and #46) of 13 residents reviewed for resident assessments.The findings include:Resident #8A review of the admission Record, indicated the facility admitted Resident #8 on 07/19/2019 with diagnoses that included stroke, colostomy, kidney failure, bipolar, hypoglycemia, physical debility, vascular disease, and schizoaffective disorder.A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/11/2026, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The MDS also indicated Resident #8 had an ostomy and was not on any high-risk medications.Resident #12A review of the admission Record, indicated the facility admitted Resident #12 on 01/21/2016 with diagnoses that included Parkinsons's disease, cognitive communication deficit, osteoarthrosis of the hips, degenerative disease of the nervous system, atrial heart flutters, and high blood pressure.A review of the quarterly MDS, with an ARD of 06/04/2026, revealed Resident #12 had a BIMS score of 12 which indicated the resident was cognitively intact. The MDS also indicated Resident #12 had no impairment to arm or leg movement, used a mobility device and required substantial/maximal assistance in selfcare and mobility, used high risk medication such as anticoagulants and was on hospice care. Resident #22A review of the admission Record, indicated the facility admitted Resident #22 on 03/06/2012 with diagnoses that included cognitive communication deficit, mood disorder, Alzheimer's disease, psychiatric disorder, convulsions, congestive heart failure, malnutrition, depression, bipolar and dementia.A review of the quarterly MDS, with an ARD of 06/04/2026, revealed Resident #22 had a BIMS score of 00 which indicated Resident #22 had severe cognitive impairment. The MDS for Resident #22 also indicated mobility and self-care ranged from dependent to partial/moderate assistance, weight loss, and high-risk medications such as diuretics.Resident #24A review of the admission Record, indicated the facility admitted Resident #24 on 11/27/2019 with diagnoses that included sepsis, fracture to left hip, stroke, fibromyalgia, weakness, osteoarthrosis, hypotension, type-2 diabetes, depression, insomnia, anxiety, aneurysm [ excessive enlargement of an artery caused by weakening of the artery wall], difficulty in walking and unsteadiness on feet.A review of the quarterly MDS, with an ARD of 06/04/2026, revealed Resident #24 had a BIMS score of 2 which indicated the resident had severe cognitive impairment. The MDS also indicated Resident #24 was dependent and required substantial/maximal assistance with self-care and mobility, weight gain indicated and was not on high-risk medications.Resident #26A review of the admission Record, indicated the facility admitted Resident #26 on 07/26/2016 with diagnoses that included hypertension, anxiety, cognitive communication deficit, Alzheimer's disease, osteoarthritis, depression, and morbid obesity.A review of the quarterly MDS, with an ARD of 07/02/2026, revealed Resident #26 had a BIMS score of 8 which indicated the resident had moderate cognitive impairment. Resident #26's MDS indicated mobility to be partial/moderate assistance, and high-risk medications such as opioids, diuretics and anticonvulsants.Resident # 29A review of the admission Record, indicated the facility admitted Resident #29 on 08/21/2025 with diagnoses that included hypertension, depression, insomnia, dementia, congestive heart failure, gout and coronary artery disease.A review of the quarterly MDS, with an ARD of 06/04/20263, revealed Resident #29 had a BIMS score of 15 which indicated the resident was cognitively intact. The MDS also indicated Resident #29's mobility and selfcare ranged from independent to supervision/touch assistance and that Resident #29 used high-risk medications such as antidepressants and diuretics.Resident #30A review of the admission Record, indicated the facility admitted Resident #30 on 11/25/2025 with diagnoses that included altered mental status, acute kidney failure with tubular necrosis, hypertension, depression, traumatic brain injury, headaches, osteoarthritis, mild cognitive impairment and type-2 diabetes.A review of the quarterly MDS, with an ARD of 06/11/2026, revealed Resident #30 had a BIMS score of 15 which indicated the resident was cognitively intact. The MDS also indicated Resident #30's selfcare and mobility ranged from dependent to partial/moderate assistance, and high-risk medications such as antidepressants and anticoagulants.Resident #31A review of the admission Record, indicated the facility admitted Resident #31 on 08/19/2025 with diagnoses that included atrial fibrillation, osteoarthritis, congestive heart failure, hypertension, dementia, weight loss, and long-term anticoagulant use.A review of the quarterly MDS, with an ARD of 06/04/2026, revealed Resident #31 had a BIMS score of 11 which indicated the resident had moderate cognitive impairment. The MDS also indicated Resident #31was independent in selfcare and mobility, always continent of bowel and bladder, had no weight gain or weight loss was indicated, and was taking high risk medications such as diuretics and anticoagulants.Resident #33A review of the admission Record, indicated the facility admitted Resident #33 on 12/03/2025 with diagnoses that included stroke, weakness, cognitive communication deficit, acute kidney failure, hypertension, cancer of the tongue, and peripheral vascular disease.A review of the quarterly MDS, with an ARD of 06/04/2026, revealed Resident #33 had a BIMS score of 15 which indicated the resident was cognitively intact. The MDS also indicated Resident #33's selfcare and mobility ranged from dependent to substantial/maximal assistance, except for eating and oral hygiene, had impairment to one arm and leg, and was not on high-risk medications and had no special treatments.Resident #34A review of the admission Record, indicated the facility admitted Resident #34 on 12/11/2023 with diagnoses that included dementia, type 2 diabetes, unsteadiness on feet, hypertension, cognitive communication deficit, insomnia, stroke, and fatty liver.A review of the quarterly MDS, with an ARD of 06/11/2026, revealed Resident #34 had a BIMS score of 3 which indicated the resident had severe cognitive impairment. The MDS also indicated Resident #34's selfcare and mobility ranged from supervised touch assistance to set up or clean up assistance, and that Resident #34 used high risk medications such as a hypoglycemic. Resident #35A review of the admission Record, indicated the facility admitted Resident #34 on 11/17/2025 with diagnoses that included spinal cord injury, quadriplegia, hypertension, chronic kidney diseases, heart failure, sleep apnea, and convulsions.A review of the quarterly MDS, with an ARD of 06/04/2026, revealed Resident #34 had a BIMS score of 15 which indicated the resident was cognitively intact. The MDS indicated Resident #35 had impairment to both arms and used high-risk medications such as an anticoagulant and diuretics.Resident #40A review of the admission Record, indicated the facility admitted Resident #40 on 08/18/2025, with diagnoses that included acute kidney failure, cognitive communication deficit, chronic kidney disease, morbid obesity, hypertension, and insomnia.A review of the quarterly MDS, with an ARD of 06/25/2026, revealed Resident #40 was widowed and 62 inches tall. The remainder of this MDS was not complete. There was no assessment coordinator Registered Nurse (RN) signature to indicate completion. Resident #46A review of the admission Record, indicated the facility admitted Resident #46 with diagnoses that included Alzheimer's disease, heart failure, diabetes type 2, chronic kidney disease, dilated cardiomyopathy, hypertension, fibromyalgia and autoimmune thyroiditis.The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/11/2026, revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had moderate cognitive impairment. The MDS indicated no impairment to arms or legs, selfcare and mobility was independent, and used high-risk medications such as hypoglycemics and anticonvulsants.Review of a MDS 3.0 Completion Date report for the facility dated 04/01/2025-08/18/2026 indicated the following assessment completion and submission dates:- For Resident #8 a quarterly assessment was completed on 06/12/2026, and was submitted 07/26/2026, more than 14 days after completion. -For Resident #12, a quarterly assessment was completed on 06/05/2026, and was submitted 07/26/2026, more than 14 days after completion.-For Resident #22, a quarterly assessment was completed on 06/05/2026, and was submitted 07/26/2026, more than 14 days after completion.-For Resident #24, a quarterly assessment was completed on 06/05/2026, and was submitted 07/26/2026, more than 14 days after completion.-For Resident #26, an quarterly assessment was completed on 07/03/2026, and had no submission date listed. -For Resident #29, an quarterly assessment was completed on 06/05/2026, and was submitted 07/18/2025, more than 14 days after completion.-For Resident #30, a quarterly assessment was completed on 06/12/2026, and was submitted 07/26/2026, more than 14 days after completion.-For Resident #31, a quarterly assessment was completed on 06/05/2026, and was submitted 07/18/2026, more than 14 days after completion.-For Resident #33, a quarterly assessment was completed on 06/12/2026, and was submitted 07/26/2026, more than 14 days after completion.-For Resident #34, a quarterly assessment was completed on 06/12/2026, and was submitted 07/26/2026, more than 14 days after completion.-For Resident #35, a quarterly assessment was completed on 06/05/2026, and was submitted 07/26/2026, more than 14 days after completion.-For Resident #40, there was no assessment completion date or submittal date for the MDS with an ARD of 06/25/2026. -For Resident #46 a quarterly assessment was completed on 06/12/2026, and was submitted 07/26/2026, more than 14 days after completion.During an interview on 08/19/2026 at 11:18 AM, the Administrator stated the MDS coordinator was part-time and came in on her own time to do MDSs. The Administrator stated that the MDS coordinator had a schedule of residents that were due a MDS and when completed she marked that resident off. The Administrator stated that no one goes behind the MDS coordinator to make sure that MDSs were completed and submitted. The Administrator stated she was not aware that MDSs were being submitted late. The Administrator called the MDS coordinator for this surveyor to interview her without an answer. The Administrator left a message for MDS coordinator to call back and sent a text message as well. No call back from the MDS coordinator was received by this surveyor. On 08/19/2026 the Administrator provided a letter stating there was not a policy on care plans or MDSs. The letter also stated the RAI manual guidelines for coding and timeframe for submissions was used [to complete MDSs].

Based on interviews, record review and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for two (Resident #35 and Resident #5) of two residents reviewed. The findings include:On 08/20/2026 at 2:30 PM, the Administrator stated the facility did not have a policy for care plans. Resident #35A review of the admission Record, indicated the facility admitted Resident #35 on 11/17/2025 with diagnoses that included atrial fibrillation, spinal cord injury, quadriplegia, hypertension, chronic kidney disease neurogenic bladder, heart failure, convulsions, and reduced mobility.A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2026, revealed Resident #35 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The MDS also indicated Resident #35 was on high-risk medications such as anticoagulants and diuretics. A review of Resident #35's Care Plan, updated on 06/04/2026, revealed the resident had an activities of daily living (ADL) deficit, was prescribed anticoagulants, had no plan to discharge from the facility, was a fall risk, incontinent of bowel and bladder, and at risk for the following: nutritional, pressure ulcers, and transfer safety. Interventions included the use of restorative programs to help maintain ADLs, administer medication as prescribed, monitor and report any abnormal bleeding, practice a routine toileting program, monitor weight, and indicated the resident required a mechanical lift. There were no interventions related to diuretic use mentioned on the care plan. A review of Physician Orders, revealed Resident #35 had an order for an anticoagulant 5mg orally two times daily, an antidiuretic 40mg orally at 5 AM for the diagnosis of chronic kidney failure, stage three and a blood pressure medication 10mg orally once daily. A review of Medication Administration Record, (MAR) revealed Resident #35 had multiple changes made to the diuretic medication. Originally the diuretic given was 20 mg daily, on 07/16/2026 the diuretic was increased to 40 mg daily. Resident #5A review of the admission Record indicated the facility admitted Resident #5 on 10/30/2020 with diagnoses that included other intestinal obstruction, blood clots of the arteries, cognitive communication deficit, transient cerebral ischemic attack, Alzheimer's disease, dysphagia, blockage and narrowing of both carotid arteries, gastroesophageal reflux disease, excess of salivary secretion.A review of the quarterly MDS, with an ARD of 07/07/2026, revealed Resident #5 had a BIMS score of 0 which indicated the resident had severe cognitive impairment. A review of Resident #5's Nurse's note, dated on 07/09/2026, revealed the resident had a percutaneous enteral gastric (PEG) tube placement on 07/9/2026 and documentation of orders for tube feeding. A review of Physician Orders, dated 07/14/2026, revealed Resident #5 had orders for PEG tube feedings and care: PEG tube per tube check for PEG tube placement with 10-30 cubic centimeters (CC) air via auscultation before medication and bolus feeds. PEG tube flush with 30 milliliters (ML) warm water before and after medication administration, and 95 ML before and after bolus feedings. Bolus tube feedings 240 ML five times a day.Review of Resident #5's Care Plan revised on 06/04/2026 revealed no identification for PEG tube care, medication administration, or bolus feedings, water flushes, or interventions for resident precautions to elevate head of bed at all times.During an interview on 08/18/2026 at 5:00 PM the Administrator called the Minimum Data Set (MDS) registered nurse on her cell phone. The Administrator indicated the MDS Nurse was part time and came in on nights and weekends. The Administrator stated the MDS nurse was responsible for updating the care plan with the MDS updates. During an interview on 08/20/2026 at 2:20 PM, the Director of Nursing (DON) indicated any changes or interventions should be listed in the care plan. Information that should be included in the care plan included meals, medications, showers, skin issues and medical diagnoses such as hypertension and diabetes. The DON stated, diuretics should be on there to look at weights, input, output and edema. The DON stated, A care plan is for the staff to know how to take care of the resident.During a second interview on 08/20/2026 at 2:30 PM, the Administrator indicated care plans were to be resident specific and individualized based on the resident. The Administrator indicated that certain high-risk medications such as antipsychotics and medical diagnoses were to be entered into the care plan. The Administrator stated the MDS triggers an indicator on what to include in the care plan. The Administrator indicated she has called and texted the MDS Nurse multiple times for an interview with the surveyor but had not received a reply or a returned call.

Based on observations and interviews, the facility failed to ensure staff performed proper hand hygiene when feeding residents, affecting 4 (Resident #18, #34, #36, #39) of 4 residents observed that required assistance with dining. The findings include: On 03/24/25 at 12:07 PM, Certified Nursing Assistant (CNA) #4 wiped her face with her right hand and did not perform hand hygiene before feeding Resident #18. CNA #4 then touched straws, drinks, and a geriatric chair without sanitizing or washing her hands before continuing to feed Resident #18. On 03/24/25 at 12:11 PM, CNA #4 touched the ice machine door, the handle of the ice scoop, drinking glasses, and poured tea without sanitizing or washing her hands at any time. She then returned to feed Resident #18. On 03/24/25 at 12:12 PM, CNA #2 did not perform hand hygiene between feeding Resident #34 and Resident #39. On 03/24/25 at 12:24 PM, CNA #2 took a phone out of her pocket and returned the phone to her pocket. She then resumed feeding Resident #39 without sanitizing or washing her hands. On 03/24/25 at 12:35 PM, CNA #2 pushed a cart of returned lunch trays and then returned to feed a resident without sanitizing or washing her hands. CNA #2 touched several of Resident #34's food containers, went to Resident #8 and touched the tray and Resident #8's skin and clothing, then went back to Resident #34 without sanitizing or washing her hands. On 03/24/25 at 12:39 PM, CNA #2 used her hands to open the door in the dining room which led outside. CNA #2 came back in from outside and went to Resident #34's table, touching the tray and fork without performing hand hygiene. On 03/24/25 at 12:42 PM, CNA #5 failed to sanitize or wash her hands between feeding two residents sitting at the same table. On 03/24/25 at 12:44 PM, CNA #5 threw a used cup and lid away, pushed a food cart, and then picked up a clean glass, scooped ice out of ice chest using ice scoop, obtained a clean lid, opened and placed a straw in the cup, all without performing hand hygiene at any time. She then delivered the cup to a resident. On 03/25/25 at 07:42 AM, during dining observation, CNA #6 did not perform hand hygiene between feeding Resident #36 and Resident #34. CNA #6 was drinking from a personal cup while feeding Resident #36 and Resident #34 without performing hand hygiene. On 03/26/25 at 07:40 AM, CNA #6 did not perform hand hygiene between feeding Resident #18 and Resident #26. On 03/26/25 at 07:48 AM, CNA #6 wore gloves and picked up used cloths from the tables and put them in a dirty cloth bin. Without removing the old gloves, CNA #6 went to table to feed Resident #1. Still without changing gloves or performing hand hygiene, CNA #6 went to other tables to pick up additional used cloths and took them to the dirty cloth bin. Using the same dirty gloves, CNA #6 touched geriatric chair handles, a resident's straw and eating utensils, and opened a canned drink for a different resident. CNA #6 returned to Resident #1 to continue feeding. No hand hygiene was performed during any part of this observation. On 03/27/25 at 08:38 AM, during an interview, Dietary Manager (DM) #11 stated staff should wash hands between residents when feeding residents and staff should not have cell phones nor personal drinks at the resident's table when feeding a resident. On 03/27/25 at 09:07 AM, during an interview with the Director of Nursing (DON), the DON stated staff should not have a personal beverage and/or drink a beverage at the resident's table while feeding the residents. She also stated staff should not take a cell phone from their pocket or even have a cell phone while feeding the residents. The DON verified staff should wash their hands between resident contact.

Based on observations, interview and record review the facility failed to keep heating and air ventilation clean to prevent potential airborne sickness for all 47 residents who reside in the facility. The findings are: On 08/15/2024 between 9:40 AM, and 10:40 AM, during rounds, this surveyor observed air vents with a dark black substance coating much of the outside in resident rooms: 16, 25, 28, 30, 31, 32, 33, 34, 35, 36, 38, and in the men and women's bathrooms on the east and west halls. In addition, a dark black substance, approximately 5 inches by 3 inches, was noted on the ceiling tile directly above the vent in room [ROOM NUMBER]. On 08/15/2024 at 10:45 AM, when the Housekeeping Supervisor was asked to describe the black substance on the vents in the resident's rooms, she said it may be smoke from some wires that melted and smoked after a water pipe burst in the ceiling last December (2023). When the Housekeeping Supervisor accompanied this surveyor to the women's bathroom on the east hall and was asked to describe the vent in the center of the bathroom ceiling. She commented that it looked like dust and mold from the ceiling being wet after the leak and then. She stated it was maintenance's responsibility to clean the vents. On 08/15/2024 at 11:11 AM, the Maintenance Director accompanied this surveyor to the women's bathroom on the east hall and when asked to describe the vent, he confirmed it was mold, then commented if he cleaned it, it would just come back. He stated he could get the company that fixed the roof to come and check up in the ceiling for water. He confirmed that the Administrator was aware of the mold. On 08/15/2024 at 11:40 AM, the Administrator accompanied this surveyor to the Rooms 33, 35, and the women's bathroom on the east hall. She denied knowing about the black substance on the vents in the bathrooms and in the resident rooms. She stated she would get it taken care of right away. On 08/16/2024 at 10:30 AM, the Administrator was asked for a policy on cleaning vents. She stated they did not have one.

Based on observation, interview, and record review, the facility failed to ensure the call light was placed within reach of 3 (Residents #3, #4 and #5) of five sampled residents to enable them to call for assistance when needed. The findings are: 1. Review of the Physician's Orders for August 2024 noted Resident #3 had a diagnosis of dementia. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/30/2024 with a Brief Interview for Mental Status (BIMS) of 7 (7-12 indicates moderate cognitive impairment) noted Resident #3 ambulated in a wheelchair and required maximal assistance with toileting and supervision/touch assistance with transfers. On 08/14/2024 at 9:58 AM, Resident #3 was observed lying in bed, there was a wheelchair on the left side of the bed and the right side of bed was against the wall. The resident's call light was hanging down from wall, lying on the floor on the left side of the bedside table, out of the resident's reach. When this surveyor entered the room, Resident #3 requested to be assisted up in a wheelchair. Review of Resident #3's Care Plan with a revision date of 05/30/2024 noted the resident needed assistance with transfers and toileting and was at risk for falls with an intervention to keep the call light in reach. 2. Review of Resident #4's August 2024 Physician's Orders noted the resident had diagnoses of complete traumatic amputation of lower extremity, and unspecified weakness. Review of Resident #4's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/2024 noted a Brief Interview for Mental Status (BIMS) of 12 (8-12 indicates moderate cognitive impairment), and the resident ambulated in a wheelchair, had bilateral impairment to the lower extremities, and was dependent for transfers, turning and toileting. On 08/14/2024 at 10:00 am, Resident #4 was observed lying in bed, the call light was not attached to the bed, but was lying on the floor not in the resident's reach. Review of Resident #4's Care Plan with a revision date of 06/27/2024 noted the resident was at risk for falls and to keep call light in reach. 3. Review of Resident #5's August 2024 Physician's Orders noted the resident had a diagnosis of Congestive Heart Failure. Review of Resident #5's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/18/2024 noted a Brief Interview for Mental Status (BIMS) of 13 (13-15 indicates cognitively intact), and the resident ambulated via wheelchair and was dependent for toileting and transfers. Review of Resident #5's Care Plan with a revision date of 07/18/2024 noted the resident was to keep the call light in reach due to resident's need for assistance, risk of falls and need for incontinent care. On 08/14/2024 at 10:05 AM, Resident #5 was lying in bed. The resident ' s call light was lying on the floor and another call light was attached to a privacy curtain at the foot of the resident's bed. Neither call light was in reach of the resident. On 08/14/2024 at 3:10 PM, Certified Nursing Assistant (CNA) #1 was interviewed and confirmed it is important for the call lights to be in reach of residents so they can call for assistance when needed. On 08/14/2024 at 3:22 PM, during an interview, CNA #2 stated it was important to ensure the call light is in the resident's reach in case the resident has an emergency. On 08/15/2024 at 11:14 PM, when the Director of Nursing (DON) was asked if they had a policy or in-service for the call lights, she replied call lights are basic nursing and they did not have an in-service or specific policy on them.

Based on record review and interview, the facility failed to ensure a resident remained free of involuntary seclusion by staff and to ensure all other residents were protected from further involuntary seclusion for 1 of 1 (Resident #34) sampled residents who had been involuntary secluded. The Administrator was informed of the Immediate Jeopardy on 01/09/24 at 3:07 PM The failed practice had the potential to affect all 45 residents currently in the facility. The findings are: On 01/08/24 at 3:59 PM, Surveyor notified the family member by phone for a family interview. During the interview the daughter said last week on Wednesday it was reported a staff member locked him (Resident #34) in his room. The staff member was fired, and an investigation is under way. She said she has a meeting with the administrator tomorrow 1/9/24. The facility's policy titled Policy and Procedure Regarding investigation and reporting of alleged violations of federal or state laws involving mistreatment, neglect, abuse, injuries of unknown source and misappropriation of residents property provided by Administrator on 1/08/24 at 11:40 AM., showed the following: It is the policy of this facility {named} to prevent the occurrence of abuse ( verbal, mental, physical, sexual ,involuntary seclusion) . Mental Abuse: isolating a resident from social interaction . INVOLUNTARY SECLUSION is defined as separation of a resident from other residents .confinement to her/his room against the residents will . staff hold a door shut, from the opposite side of the door in order to prevent egress. A Reportable to The Office of Long-Term Care dated 12/29/24 at 3:00 PM documented, .This Staff member reported that (Certified Nursing Assistant) CNA # 2 had pushed resident to his room and held the door closed so the resident could not leave room . Cameras were reviewed by facility Registered Nurse (RN) at approximately l8:14, 6:14 PM, CNA was observed pushing resident into his room. CNA then walked away from the door. CNA was observed pushing the resident into his room and closing the door. CNA stood at the door until 18:16:19 (6:16 PM and 19 seconds). CNA then walked away from the door . At 20:53:20 (8:53 PM and 20 seconds), CNA was observed on camera pushing resident to room again and closing the door on the resident. Based upon posture and hand placement CNA was holding the door shut. CNA moved away from the door at approximately 20:53:46 (8:53 PM and 46 seconds). At approximately 20:53:56 (8:53 PM and 56 seconds), CNA is seen running across the hall to the resident's room. Pushed resident back into room and holds the door closed from 20:54:1 I TO 20:54:39 (8:54 PM and 1 second to 8:54 PM and 39 seconds). The employee was terminated. The Plan of Care dated 12/07/15 documented, .Cognitive Resident has impaired cognitive skills .short term memory problem, decision making problem. Resident #34 had diagnoses of Alzheimer's disease, Dementia, and Encephalopathy. On 1/9/2024 at 9:47 AM, interview with Resident #7. She has been a resident here for 9 years. No issues with staff. She stated, One resident will wander into this resident's room. Resident #7 said, I punch my call light and they come get her. Resident #7 said that she feels the resident wants to stay around and that she feels sorry for her. On 1/9/2024 at 9:30 AM, CNA #3 was asked if she had any knowledge of the alleged abuse of Resident #34, CNA #3 said no. The Surveyor asked what actions, if any, did you take in response to the allegation. CNA #3 stated, Report it to the charge nurse. CNA #3 was asked If she was familiar with the alleged victim and if she has noticed any changes in the alleged victim's behavior as a result of the alleged abuse. If so, describe. CNA #3 stated, I know him but never worked with him. I did hear about [named employee]. I wasn't there but they said she pulled a chair from under him, and he hit the floor. I'm not aware of any harm because I do not work down there. They turned it into the OLTC, and she got fired. No knowledge of any other abuse by this CNA. CNA #3 was asked if she had received training on abuse identification, prevention, and reporting requirements. CNA #3 said, not recently, but had received some training on abuse and aggression, but she did not know when. On 1/9/24 at 10:09 AM, (Licensed Practical Nurse) LPN#3 was asked if she had any knowledge of any alleged abuse If so, describe. LPN #3 stated, Yes, recently he asked the nurse for assistance he was at the edge of the chair. Before they moved the wheelchair, she (named x-employee) pulled the chair out and he hit the floor. He is Resident #34. They investigated where the CNA held the door, and it was on camera. Assistant Director of Nursing (ADON) does admissions and investigations and she had to talk to her, (named x employee), in the investigation. and (named X-employee) was fired. The Surveyor asked did the alleged perpetrator and/or victim exhibit any behaviors that would provoke one another? LPN #3 said it is all the hollering. It is the way she approached them. LPN #3 was asked if she had received training on abuse identification, prevention, and reporting requirements. LPN #3 stated Yes, most of the time I do it on my [Continuing Education Units] CEUs. Here we get print outs; we haven't had any together trainings since COVID. We used to have them once a month. Nurses will go in with [named employee] and do return demonstration. I do not recall any recent retraining's on aggressive residents. On 1/9/24 at 10:14 AM, CNA #4, was asked if she had any knowledge of Resident #34 being held in his room against his will? CNA stated, No. CNA #4 was asked what action she would you take if a resident reports an allegation of abuse by another resident. CNA #4 stated, I would report it to the charge nurse. CNA #4 was asked what action she would take if a resident reported an allegation of abuse by a staff member to her. CNA#4 stated, I would report it to the charge nurse. CNA #4 was asked if she had received any abuse training. CNA stated, When we get our checks, we get a packet that we read. Before COVID we would have meetings. Different pay periods, we have different packets, such as one on abuse, one on fires, one on storms. CNA #4 was asked if she could recall, when was the last training she had on abuse, and stated I'm not good with dates so I don't remember. On 1/9/24 at 10:24 AM, CNA #5 was asked if she had any knowledge of Resident #34 being held in his room against his will. CNA stated, no. CAN #5 asked what action she would take if a resident reports an allegation of abuse by a staff member to you. CNA #5 stated, I would take the concern up with the charge nurse and we will ' talk to the Administrator. CNA #5 was asked if she had received any abuse training. CNA #5 stated, yes. , CNA #5 was asked if she could remember when she received her last abuse training. CNA#5 stated, I had it when I finished my CNA classes in September 2023. The resident was asked if she had ever been in room and staff would not allow you to leave. Resident stated, no. The resident was asked if she felt comfortable reporting concerns to staff. The resident stated, No, you have to keep your mouth shut. Do you have any concerns about how they would treat you? Resident #28 said, you are asking me some hard questions and I don't know what to say. On 1/9/24 at 8:40 AM, (LPN #1) was asked if she was aware of an incident involving Resident #34. LPN stated I heard one of the CNAs pulled the door shut and held it for about 5 minutes. I heard he was banging on the door to get out. I also heard it was caught on camera and that just wasn't right. LPN #1 was asked who she heard it from, and she stated, I don't really remember; I hate to say the wrong person. LPN #1 was asked if she reported this to anyone. LPN #1 stated, I did not report it because the Administrator was already working on it so I knew she knew. On 1/9/24 at 8:48 AM, Resident # 6 was asked if the staff treated him with dignity, respect, and kindness. Resident stated, I feel an aide [named x-employee] was mean to me because she took my wheelchair and refused to give it back; I feel that was very wrong. The Resident was asked if he reported the incident to anyone and he stated, The Administrator {named}. On 1/9/24 at 9:01 AM, Resident #24, was asked if the staff treated her with dignity, respect, and kindness. Resident stated, Absolutely, I chose to live here. If they were mean, I would leave. On 1/9/24 at 9:15 AM, the CNA #1 was asked if she was aware of an incident that involved Resident #34. The CNA stated, Yes, I have. I heard [named x-employee] took him to his room and held the door. He was banging on the door, then went to the bathroom door and was banging on it. Did you report this to anyone? CNA #1 stated, No they were investigating it already. How often are you trained on abuse and neglect. CNA#1 stated, on hire. On 1/9/24 at 10:15 AM, the Administrator was asked if she was aware of an incident that involved Resident #34. The Administrator stated, yes. The Administrator was asked if she could tell me what occurred. She stated, Yes, I came in to work and the social worker told me they were watching the videos because it had been reported to her that the [named x employee] had held a door closed so a Resident could not get out of his room. I watched the videos then had the ADON watch them. I called the [named x-employee] in and got her statement. I told her what she had done was involuntary seclusion and that she was terminated and that it would be reported to the Office of Long-term care. We felt we had a finding. The Surveyor asked if she had done an in-service since the incident. The Administrator stated, no. On 1/9/24 at 10:35 AM, the social worker was asked if she was aware of an incident that involved Resident #34. She stated, Yes, [named CNA ' s]came to my office because they were upset over [named x-employee] locking Resident #34 in his room and not letting him out. I heard he was hollering and banging on the door. I told my Administrator. The Social worker was asked how often she was trained on abuse and neglect, and she stated, On hire and during some in-services. The Surveyor asked what was the Administrators response? The social worker stated, she watched the cameras and fired [named x-employee]. On 1/9/24 at 10:45 AM, the Director of Nurses (DON) was asked if she was aware of an incident that involved Resident #34. She stated, Yes, as soon as I arrived at work the Administrator told me. What do you know about the investigation? The DON stated, I know the cameras were watched and she called [named x-employee] in, and they terminated her. They did a reportable. The DON was asked how often staff were trained concerning abuse and neglect. The DON stated, yearly. The DON was asked if she had done an in-service since the incident. The DON stated, no. The following Plan of removal was accepted on 01/10/2024 at 9:10 AM. 1. Corrective Action: Certified Nursing Aide was terminated on 12/29/2023 for involuntary seclusion. 2. Identify: All residents in the facility were checked on 12/29/2023 by designated nurse with no negative findings. 3. Systemic Changes: All staff present were in-serviced on 01/09/2024 by a designated LPN. All incoming staff will be in-serviced by a designated LPN upon arriving at work on involuntary seclusion. 4. Monitor: Cameras will be reviewed 5 times per week by a designated staff to ensure no staff are holding a resident room door shut. Negative findings will be brought to the Administrator immediately. QA will follow up on findings. weekly. 5. Completion Date: 0l/09/2024

Based on observation, record review and interview, the facility failed to ensure an effective fall prevention program that included adequate supervision and a system for residents who were at risk for falls was developed and consistently implemented, as evidenced by:failure to ensure anti-rollbacks were consistently monitored to ensure they were in working condition to prevent falls to the extent possible and reduce the potential for further injury from falls that did occur for 1 (Resident #148) of 1 (Resident #148) sampled Resident who sustained a fracture; failed to ensure falls were thoroughly investigated for causative factors and interventions were developed and implemented based on those causative factors to decrease the potential for further falls / injuries for 2 (Residents #18 and #34) of 5 (Residents #18, #23, #34, #40 and #148) sampled residents who had falls in the past 3 months. The failed practices resulted in an Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #148, who experienced falls that resulted in a fracture and Residents #18 and #34, who experienced multiple falls, and had the potential to cause more than minimal harm to 5 residents who experienced falls in the past 3 months. The Administrator was informed of the Immediate Jeopardy on 01/10/2024 at 3:50 PM The findings are: Resident #148 had diagnoses of Osteoarthritis, muscle weakness (generalized), difficulty in walking, unsteadiness on feet and other abnormalities of gait and mobility. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/30/23 documented the Resident scored a 00 (00-07 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), used a wheelchair (w/c) for mobility, and required partial / moderate assistance with personal hygiene and with sit to stand, had two falls since admit / prior assessment with no injury and one fall since admit / prior assessment with a major injury. A Care Plan (CP) with a review date of 12/05/23 documented the resident was at risk for fall related injury evidenced by a previous fall. Resident #148 fell on [DATE] and sustained a left (L) hip fracture (fx). The CP was not updated to reflect interventions for monitoring / caring for a resident with a sustained fx from a fall. Resident #148 ' s Incident and Accident (I&As) Reports were reviewed and the following information was noted: On 10/07/23 at 5:10 PM, [Resident #148] was found on the floor in front of wheelchair. Intervention: OT (Occupational Therapy) will work on core strengthening. Cause of fall: may have been sitting on the edge of wheelchair. On 10/10/23 at 12:50 PM, [Resident #148] was found on floor sitting on buttocks with back against wheelchair. Intervention: OT will work on transfers. Cause of fall: blank. On 11/05/23 at 4:00 PM, [Resident #148] was found sitting upright in front of her wheelchair with a small laceration to left side of forehead. Intervention: PT [Physical Therapy] will eval. (evaluate) and treat. Cause of fall: Resident transfers self to/from bed. Obtain UA (urinalysis). Fall occurred on 11/05/23, referred to therapy on 11/06/23. PT to eval on 11/07/23. 11/8/23 orders to obtain a UA & (and) C&S (culture and sensitivity) on 11/10/23. PT orders were recommended for PT treatment 2-4 (two to four) X ' s (times) a week for up to 8 weeks. On 11/16/23 at 15:35 (3:35) PM, witnessed by hall nurse attempting to transfer from wheelchair to straight back chair. The brakes of the wheelchair were not locked, and it rolled out from under her, and she fell on the floor. Intervention: PT will work on wheelchair safety. On 11/26/23 at 1:50 AM, found sitting on the floor by the wheelchair. Intervention: Because PT and OT benefits were exhausted. Restorative will work on transfers. Cause of fall: Transferring without assistance. On 11/29/23 at 2054 [8:54] P.M., found lying on the floor. The wheelchair brakes were unlocked. Intervention: ordered x-ray of hip. (Resulted in a fracture.) Installed antiroll backs on wheelchair. Cause of fall: resident transfers self to wheelchair and the brakes are never locked. PT started treatment on 12/13/23. On 1/3/24 at 12:48 PM, found on the floor. Intervention: PT will educate on transfer safety. Cause of fall: blank. On 1/9/24 at 2:00 PM, the Director of Rehab (DOR) was asked if she felt the repetitious interventions had been effective and she stated, no. She was asked if a Resident #148 with a BIM of 00 had the ability to be educated per therapy treatment and she stated, She can respond immediately sometimes but can ' t retain 30 minutes later. On 01/09/24 at 3:29 PM Resident #148 was propelling self-down the hall. The bar to the antiroll backs on the right side was upside down causing the antiroll backs to improperly function. Licensed Practical Nurse (LPN) #1 reached down to straighten up the bar and it fell out when she pulled on it. LPN #1 and the Housekeeping Supervisor attempted to reinsert the bar but couldn't. On 1/10/24 at 9:25 AM, Certified Nursing Assistant (CNA) #2 was asked if she was familiar with the device (anti roll backs) on the wheelchair. She stated, It ' s an anti-rollback. CAN #2 was asked what the purpose of anti-roll backs were for and stated, So it doesn ' t roll back when the resident gets in or out of it. She was asked if she ever checked them for proper functioning and stated, Every day, before putting them in the wheelchair. She was asked to explain the functioning verses non-functioning and stated, If it isn't working properly, a person can fall and break something. She was asked if she had ever had an in-service on anti-roll backs and she stated, yes. On 1/10/24 at 9:35 AM, CNA #6 was asked if she was familiar with the device (anti roll backs) on the wheelchair and she stated, No, maybe can' t roll the chair backwards. CNA #6 was asked what is the purpose of an anti-roll back, and she stated, I've never had one. She was asked if she ever checked them for proper functioning and she stated, no. CAN #6 was asked to explain the functioning verses non-functioning and she stated, The resident can fall out and possibly be injured. She was asked if she'd ever had an in-service on anti-roll backs and she stated, I can't remember. On 1/10/24 at 9:40 AM, Maintenance pulled the wheelchair backwards and stated, It's still not working. Resident #18 has diagnoses of Vascular Dementia without Behavioral Disturbances, Altered Mental Status and Sciatica Right Side The Quarterly MDS with an ARD of 11/09/23 of Resident #18 documented the Resident had a BIMS of 7 (00-07 indicates severely impaired). A Care Plan with a review date of 11/14/23 documented problem of falls with the following approaches: Provide w/c for mobility, Provide Restorative Therapy to prevent decline, 09/03/23-PT will eval and tx, 09/25/23-OT to eval and tx, 10/08/23-PT will work on strengthening, 10/28/23-Vitamin D level drawn, 11/04/23- PT/OT to eval and tx as indicated, 11/06/23-Obtain UA [urinalysis] to r/o [rule out] UTI [Urinary Tract Infection], 11/21/23- OT to work on transfer safety, 11/25/23-OT to work on using urinal; Problem- Safety 11/10/23- Approaches: CNA information sheet will reflect that resident transfers self. On 01/08/24 at 10:45 AM, Resident #18 was in bed and both of his arms were purple and he complained of back pain. There was a dressing to the left arm. The Resident stated, I fell . The following Incident and Accident (I & A)'s reports regarding falls were documented for Resident #18: 09/3/23 at 0100 [1:00] AM, Resident (Res) turned on emergency call and CNA found res (Resident) sitting up against the wall, soaked in urine and bleeding on the (left) (L) side of face. Res stated legs gave out on him. Immediate Action: R [Resident] was cleaned up, [adhesive strips] applied to area cut above (L) eyebrow. Fall investigation completed and PT notified at 09/25/23 at 10 AM. Interventions: P/T will eval & [and] treat. 09/25/23 at 5:45 AM, Incident: Res attempted self-transfer and stood up to see who was at door and legs gave out. Immediate Action: No due to no injury Interventions: Fall investigation completed and PT notified 09/25/23 at 10 AM and res reminded to hit CL [call light] for assistance getting oob [out of bed] and walking. O/T will eval & treat. 10/08/23 at 1:40 PM, Incident: Another Res yelled that res was trying to turn w/c around and he got tangled in it and fell on (L) arm. Sustained an abrasion to (L)arm and skin tear to (L) arm. Immediate Action: w/c, xerofoam, drsg [dressing].(exactly how I&A documented). Interventions: Fall Investigation completed, and PT notified 10/08/23 at 1:40 PM. P/T will work on strengthening. 10/28/23 at 8 PM, Incident: LPN [Licensed Practical Nurse] noted dried blood on bed linen. Res assessed and skin tear to [right] elbow. Res informed LPN he fell earlier in bathroom. Injury documented laceration. Immediate Action: Tx [treatment] applied per protocol and ROM [range of motion] to extremities Interventions: No noted. 11/04/23 at 23:15 (11:15) PM, Incident: Resident fell exiting bathroom Immediate Action: N/A (Injury section blank) Interventions: Fall Investigation completed and PT notified 11/6/23 at 10 AM. P/T & O/T will eval and treat. 11/06/23 at 5:25 AM, Incident: staff called to Resident room and Resident stated he fell and hit (L) arm on doorway. Denied hitting head. Injury documented other and diagram shows skin tear, bruise to (L) arm and skin tear to (L) hand. Immediate Action: First aid but no documentation as to what it was. Interventions: Fall Investigation completed, and PT notified 11/06/23 at 10 AM. U/A [urinalysis] & [and] C/S [culture and sensitivity]. 11/21/23 at 20:15 [8:15] PM, Incident: Resident observed sitting in floor in hallway behind w/c by nurse. Injury section blank but diagram shows skin tear to right arm. Immediate Action: nothing documented, and first aid box not checked. Interventions: Investigation F/U (follow up) has no date when completed but noted O/T will work on transfer safety. 11/25/23 at 7:15 AM, Incident: CNA yelled for LPN noting resident on floor, lying behind w/c, adult brief partially down and urine on floor. Bleeding noted (L) arm. Injury-laceration. Immediate Action: Tx per protocol. Interventions: Fall Investigation completed, and PT notified 11/27/23 at 1:46 PM. O/T will work on using urinal. 12/05/23 at 4:35 AM, Incident: staff member knocked on resident door, called resident ' s name and resident rolled out of bed and hit back of head on dresser. Injury noted redness and small bruise to back of head. Immediate Action: N/A (Non-Available) Interventions: Fall Investigation completed, and PT notified 12/5/23 at 10 AM. O/T to work on bed mobility. 12/29/23 at 4:55 AM, Incident: CNA called nurse to room and stated pt. [patient] on floor. Pt. on buttocks and with skin tear to (L) elbow as injury. Immediate Action: No first aid needed for form. Interventions: Fall Investigation completed, and PT notified 12/29/23 and Melatonin 3 mg [milligrams]1 tab [tablet] PO [by mouth] q [every] HS [bedtime]. 01/02/24 at 11:45 AM, Incident: Resident stood out of w/c and fell on buttock. Hit back of door. Injury: section blank but diagram documents old skin tears to right arm. Immediate Action: First aid but not documented what it was. Interventions: Fall Investigation completed, and PT notified 01/03/24 at 10:30 am and P/T will eval and treat. 1/10/24 at 9:50 AM, LPN #3 was asked, How do you know what residents risk factors are for having an accident? LPN #3 said when they come in, they do a head-to-toe assessment. I know from dealing with residents every day what their risk factors are. If they have one coming in from another facility, they make it known to us what those are. She was asked, A resident with risk factors for falls, how often are they assessed and where is it documented? LPN #3 stated Every day they are assessed. I just put mine on shift report if anything changes. If there are no changes, I don't put it anywhere, just follow up as needed. She was asked, how do you know what interventions or assistance is needed to prevent falls? and she stated, We have a CNA book that has what the resident can do regarding ADLs. I refer to the resident ' s care plan and we have shift report regarding any change and sometimes it's just verbally told to me by the nurse. She was asked, if a resident has a fall and you witness this, what do you do? LPN #3 stated, I assess the resident before I move them and if assistance is needed I will help to get them either to the bed or restroom or wherever they need to go. She was asked, what do you do if a resident refuses the intervention in place? and she stated, I would tell the doctor and make a note on the Progress Note or shift report. She was asked, how did you identify that the interventions were suitable for this resident? She stated, By working with them every day, and there to assess them every day. Just knowing their diagnosis and what they are capable of doing. On 1/10/24 at 9:41 AM, CNA #3 was asked, How do you know what care a resident need? and she stated, If something is going on with resident, the CNA will tell me or the nurse. She was asked, How do you know if a resident has had a fall or other incident? and she stated, If it happens on another shift, the nurse will tell me when I come in. She was asked, How do you know what interventions are in place for a resident that may have fallen? and she stated, It will be in their charts, in their care plan. If they fall on us, the paper will say what your interventions will be, so we have to write something. She was asked, If a resident has a fall or other injury and you witness this, what do you do? and she stated, Come and report it to the charge nurse and then we fill out the witness statement and give it to the charge nurse. She was asked, What do you do if a resident refuses the intervention in place? and she stated, I would go and let the charge nurse know. Resident #34 had diagnoses of Alzheimer's Disease, and Dementia. A 5-Day MDS with an ARD of 12/06/23 documented Resident #34 had a BIMS of 01 (00-07 indicates severely impaired), used a walker and w/c for mobility, dependent for toileting, and required substantial / maximal assist for sit to stand. A Progress Note Report for Sat [Saturday], Sep [September] 30, 2023 Thru [through] Wed [Wednesday], Dec [December] 06 2023 documented, . 12/06/2023 1200 Nursing Staff Admission admitted to facility from hospital with left femur fracture . Fall on 12/1/23 no injury . Fall on 12/02/23 no injury. Fall on 12/06/23 with minor injury-red area to top of head. Another fall on 12/06/23 with minor injury-abrasion . transferred to ER [emergency room ] due to pain in my left hip. X RAYS were negative . A Medicare Nurse's Notes dated 11/20/23 documented, Admit to [Named Facility] from [Local Hospital] . PT /OT to eval. DX [Diagnosis]: (L) [Left] femur fx [fracture] . Other dx (diagnosis): Alzheimer's dementia . An Activities of Daily Living (ADL) sheet for Resident #34, dated 12/6/23, documented the resident was independent for bed mobility, but required supervision for transfers and toilet use. A Care Plan with no review date documented falls with a problem date of 12/07/23 as evidenced by reason for prior hospital stay and recent falls at facility. The approaches where a. observe for side effects of any drugs that can cause, but there were no side effects listed; b. Provide environmental adaptations, but none were listed and c. Safety measures to reduce fall risk, but none were listed. The resident fell on ce on 12/1 and twice on 12/6 and neither fall was care planned. The following Incident / Accident Reports are regarding Resident #34's falls: 12/1/23 at 8:40 AM, Resident sitting upright on side of bed on floor. Type of Injury: None apparent. Investigation Follow-Up dated 12/1/23 documented Recommendations / New Interventions P/T [Physical therapy] to work on strengthening. Fall Investigation dated 12/1/23 documented Physical Therapy notified of fall 12/4/23 and cause of fall was[resident] got up [without] assistance. 12/6/23 at 5:30 AM, [resident] Rt [right] side was between chair back [and] arm (chair back broken) Rt side neck against chair leg [and] throat against bottom rail of chair . Type of Injury Abrasion. Investigation Follow-Up dated 12/6/23 documented Recommendations / New Interventions Remove chair or have fixed son stated he would bring out new chair. Fall Investigation documented Physical Therapy notified of fall 12/7/23 and cause of fall was the chair back broke. 12/6/23 at 1515 [3:15] PM, resident tried to transfer himself. Landed on the left side. Abrasion on (L) temple Guarding (L) hip. Complaining of pain. Unable to do ROM [range of motion]. Type of Injury-blank. Resident was sent to hospital by EMS [Emergency Medical Services]. Investigation Follow-Up dated 12/6/23 documented Recommendations / New Interventions P/T will work on transfers. Fall Investigation dated 12/6/23 documented Physical Therapy notified of fall 12/8/23 and cause of fall was transferring without assistance. 12/7/23 at 1932 [7:32] PM, Resident was observed by CNA [Certified Nursing Assistant] [Name] to be on the floor in his room in front of his recliner on his bottom. W/c was in the doorway . w/c brakes were not locked . Type of Injury nonapparent. Investigation follow-up dated 12/7/23 documented recommendations / New Interventions: Rocking recliner taken out of room. Fall Investigation dated 12/7/23 documented Physical Therapy notified of fall 12/11/23. 12/8/23 at 8:40 AM, Staff heard resident yell Help Noticed door closed d/t [due to] isolation precautions. Opened door observed [named Resident] lying on his back in front of his recliner. Recliner legs were reclined. C/O [complain of] pain (L) hip which is normal complaint prior this fall. Type of Injury-blank. Investigation Follow-Up dated 12/8/23 documented Recommendations / New Interventions Recliner replaced w/a [with a] love seat. Fall Investigation dated 12/8/23 documented Physical Therapy notified of fall 12/11/23 and no cause of fall listed. 12/28/23 at 2:30 PM, Pat [patient] had feet on other resident ' s bed. CNA was told resident would need pulled up before could be moved. She stated, It will be fine. and pulled wheelchair before pt was properly in wheelchair. Resident landed on butt. Type of Injury None apparent. Investigation Follow-Up documented Date of Incident 12/28/23 and Recommendations / New Interventions CNA terminated. Fall Investigation dated 12/28/23 documented Physical Therapy notified of fall 1/2/24 and cause of fall as improper transfer. On 1/10/24 at 10:00 AM, the Director of Nursing (DON) was interviewed and asked to explain the procedure for the Incidences and Accidents. She stated, Whoever sees it tells the nurse, obtains a witness statement. The nurse will do an I & A report, investigation follow-up and notify the MD [Medical Doctor] and family. Complete a body audit and assess the resident. Text the DON. She was asked if an intervention is in place and another fall occurs, what is the next step and she confirmed that you find a different intervention, specific for the situation. She confirmed an in-service on falls and interventions was performed May 2023 per her logs. She was asked if putting repetitive interventions in place was their policy and procedure and have, they been effective and she stated, Probably not. Resident could sustain an injury. On 1/10/24 at 10:05 AM, the Administrator stated, We use therapy a lot and we refer for different strengthening's. She was asked, You refer to Physical therapy, Occupational therapy and restorative for strengthening and alternate between OT & PT. Did that prevent the falls before an injury occurred? She stated, No, but we depend on therapy a lot for different kinds of strengthening. The Immediate Jeopardy was removed on 01/11/24 at 11:13 AM, when the following Plan of Removal was implemented by the facility 1. Corrective Actions: Residents #148's anti-rollbacks are in working order and her Florinef was added on 1/10/2024. Resident #34 was placed on a toileting program on 1/10/2024. Resident #18's Buspar was decreased 1/10/2024. All anti-rollbacks were checked on 1/11/2024 and repaired by maintenance if needed. 2. Identify: All residents who have had multiple falls over the past 30 days have been identified and interventions reviewed. All residents with anti-rollbacks have been identified by Maintenance. 3. Systemic Changes: Administrator, Director of Nursing and nurses were trained on 1/10/12024 on not having similar interventions that are not effective by designated LPN. All nurses were trained on effective fall interventions upon arrival to work. All CNA's were trained on how anti rollbacks work and to notify Maintenance of any not working correctly. Maintenance was in-serviced on 1/10/2024 by a designated nurse on checking anti-rollbacks. The Administrator was in-serviced on 1/11/2024 on anti-rollbacks and fall interventions by an RN who is a member of the governing body. 4. Monitor: All falls will be reviewed daily x [times] 5 by Director of Nursing and Administrator to ensure interventions chosen are not similar and effective and will correct negative findings immediately. Anti-rollbacks will be checked daily x 5 to ensure they are working properly and will correct negative findings immediately. Findings will be discussed weekly at QA [Quality Assurance] meeting for effectiveness. 5. Completion Date: 1/11/2024 On 01/11/2024 at 9:39 AM, the Maintenance was asked, Have you been checking and fixing anti-rollbacks this morning? Maintenance replied, Yes I have. The Surveyor asked, You have had to fix anti-rollbacks this morning and if so, how many have you fixed? He stated, Yes, the anti-rollbacks were not tight enough. I have had to fix 4 this morning, the 4th one is in activities and will be fixed after activities. He was asked, Have you had any training on anti-rollbacks? and he stated, I had training when I started on anti-rollbacks. Surveyor asked, Have you had to train any other staff on anti-rollbacks? and he stated, No I have not. On 01/11/2024 at 2:02 PM, LPN #3 was asked, When was the last time you were trained on anti-rollbacks and how they work and how to monitor if they are functioning properly? LPN #3 stated, I have been trained on that. I do not remember the last time. On 1/11/24 at 2:02 PM, CNA #3 was asked when she was last trained on antiroll backs and she stated, Today. They are to keep them from falling. You can't roll them if the resident is not sitting in the chair. On 1/11/24 at 2:07 P.M. LPN #4 was asked if she had been trained on anti-rollbacks, and she stated no. She was asked if she knew what they were for and if she would have any idea if they were functioning properly and she stated, no. At 2:15 PM, LPN #4 came to the room and stated, I didn ' t understand what you were asking. I do know what the antiroll back is, and I was in-serviced today. It ' s the metal bar to prevent falls. A Falls and Fall Risk, Managing form, provided by the Administrator on 1/12/24 at 12:27 P.M. documented, . Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . On 1/11/24 at 2:42 PM, the Administrator provided a copy of a form titled Complete In-Service Training Report with Personnel Attending, dated 1/10/24, and the subjects listed were I/A not having similar interventions that are not effective as previous I/A ' s, CNA to anti rollbacks work & notify Maintenance if any not working properly. Resident #2 placed on a toileting plan. Resident #3 Buspar was decreased, Resident #1 Florinef was added. It contained signatures with various titles, RNs, LPN, CNAs, and Maintenance. There was also a page of CNAs who were in-serviced by telephone. There was another form on In-Service Training Report and the subject was Antiroll backs- What it is, reason we use them which included . CNA names listed on it. The Administrator said these were completed after they reported to work at 2 PM.

Based on observation, interview and record review, the facility failed to ensure that meats were stored properly during the thawing process to prevent the potential for food borne illness for residents who received meal trays from 1 of 1 kitchen, the facility failed to ensure expired food items were promptly removed from the stock to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen, the facility failed to ensure dented food cans were promptly removed or discarded to prevent the growth of bacteria, The facility failed to ensure interventions were in place to prevent possible cross contamination during the meal preparation to prevent potential food borne illness for residents who received meal trays from 1 of 1 kitchen. These failed practices had the potential to affect 44 residents who received meals from the kitchen. The findings are: 1. On [DATE] at 10:54 AM, Surveyor observed with Dietary Manager Refrigerator #2 raw hamburger meat thawing in a pan on the shelf above a bag of raw potatoes, box of cabbage, box of cucumbers, and box of lettuce heads. Surveyor made observations of a bag of diced raw potatoes with an expiration date of [DATE], and (2) 5-pound containers of cottage cheese with an expiration date of [DATE]. 2. On [DATE] at 11:10 AM, Surveyor observed with Dietary Manager in the milk cooler a ,d+[DATE] gallon of buttermilk that had expired with an expiration date of [DATE]. 3. On [DATE] at 11:13 AM, one dented can was noted on a rack in the dry storage room. (1) One gallon can of cranberry sauce noted to be on the rack with other cans. 4. On [DATE] at 11:23 AM, raw chicken fried steak patties placed in deep fryer basket by Dietary Employee #1. 5. On [DATE] at 11:29 AM Dietary Employee #1 had red tongs in hand and reached to grab the cooked chicken fried steak patties with the contaminated tongs but was stopped by Surveyor. 6. On [DATE] at 11:29 AM, Surveyor asked the Dietary Manager, Why was DE #1 stopped at this time? Dietary Manager stated, Tongs were used to place raw chicken fried steak in the fryer and they attempted to remove them with the same tongs. 7. On [DATE] at 11:10 AM, Surveyor asked the Dietary Manager, How should raw meat be stored when in the refrigerator to thaw? Dietary Manager stated, Raw meat should be stored on the bottom not over other foods? Surveyor asked, Why should raw meat not be stored over other foods? Dietary Manager replied, Its cross contamination. 8. On [DATE] at 11:14 AM, the Dietary Manager was asked by the Surveyor, What is your process for dented cans? Dietary Manager stated, We set the dented cans off to the side and do not use the ones with a dent at the seam.

Based on interview and record review, the facility failed to ensure the resident trust account received interest monthly based on the balance in the account. This failed practice affected 2 Residents (Resident #198 and #23) of selected residents for review. This failed practice had the potential to affect all 20 trust accounts in the facility. The findings are: 1. On 01/08/2024 at 3:05 PM, Surveyor reviewed selected accounts for interest allocation. Resident #198 and Resident #23 noted to have not received interest paid to account. 2. On 1/11/2024 at 9:40 AM, Surveyor reviewed a 6-month printout of the selected accounts. It was determined that Resident #198 had not received an interest payment since 09/29/2023 and Resident #23 has not received from the review time of 07/03/2023 to present. 3. On 01/08/2024 at 3:32 PM, Surveyor asked the Administrator if Residents #198 and #23 were receiving interest on their trust accounts? The Administrator confirmed that both Residents have not received interest applied to their accounts. 4. On 01/12/2024 at 3:48 PM Administrator stated, We have no personal fund/trust account policy.

Based on record review and interview, the facility failed to ensure care plans were reviewed and revised at least quarterly and / or when a resident ' s care needs changed, to include oxygen use for 1 Resident #23 of 4 (R #11, R #23, R #24, and R #28) sampled residents who had order for oxygen, failure to revise the plan of care to address the use of an antidepressant , an antipsychotic and falls to ensure staff were aware of the necessary care, assessments and services required for 1 sampled Resident #18 who had orders for an antidepressant and 1 Resident #20 sampled resident who had orders for an antipsychotic and 3 (Residents #18, #34 and #148) of 5 (Residents #18, #23, #34, #40 and #148) sampled residents who were at risk for falls. The findings are: 1. A Physician Order dated 10/30/22 for Resident #23 documented, .Oxygen PRN (whenever necessary) 2 LPM (liters per minute) per /nasal Cannula PRN sats(oxygen saturation ) . a. On 01/08/24 11:37 AM, Resident #23 was lying in the bed with oxygen in use at 2 liters per nasal cannula. There was no date on oxygen tubing or an Oxygen in Use sign on the door. b. On 01/08/24 4:50 PM, Resident #23 was lying in bed with oxygen in use at 2 liters per nasal cannula. There were no dates on the oxygen tubing or an Oxygen in Use sign on the door. c. On 01/09/24 8:41 AM, Resident #23 was lying in bed with oxygen in use at 2 liters per minute per nasal. There were no dates on the oxygen tubing or no an Oxygen in Use sign on the door. d. The Care Plan dated 11/10/23 with no revision date for Resident #23 had no documentation of oxygen on it. e. On 1/12/24 at 9:30 AM, MDS Coordinator (MDSC) was asked what a care plan is. The MDSC answered, The plan of care that involves the interdisciplinary team. We adjust it to make it patient centered. She was asked, how often should the care plan be reviewed and revised? She answered, With any change, or any time we add something, or if there is a change in condition or at least every quarter. She was asked to review Resident #23's care plan for oxygen. She stated, It ' s not on there, I missed it. The MDSC was asked if the oxygen should have been care planned. The MDSC stated, Yes mam. The MDSC was asked to explain the importance of oxygen being in the Care Plan. The MDSC stated, So the staff can see what all she needs to have done. So, they will know she might need oxygen. f. A Policy titled, Care Plans, Comprehensive which was provided by the Administrator on 01/12/24 at 12:27 A. M. documented, . An Individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents, medical, nursing, mental and psychological needs is developed for each resident. 46868

Surveyor: [NAME], [NAME] Based on observation of the medication pass on 01/10/24 at 12:00 noon and 01/11/24 at 8 AM, record review and interview, the facility failed to ensure the medication error rate was less than 5% to prevent complications. Physician's Orders were not followed for 2 residents (Resident #14, and #148) of 6 residents whose medications were observed with 2 errors in 28 opportunities, resulting in a medication error rate of 7.14 %. The failed practice had the potential to affect all residents who received medications from the Medication Cart. The findings are: 1. Resident #148 had a diagnosis of Hypotension. a. A physician's order dated 12/08/20 documented Midodrine 5 mg oral tablet per tube. b. On 01/10/24 at 12:22 PM, Licensed Practical Nurse (LPN) #1 prepared medication consisting of Midodrine 10 mg. The medication was crushed and diluted with water. After the medication was administered, the Surveyor asked the LPN#1 if she was finished. LPN #1 stated, yes as she gathered her dirty medication cups and stacked them. The Surveyor asked LPN #1 to explain what is in the bottom of the cup. LPN #1 stated, It's some of her Midodrine. LPN #1 did not add a little water and complete the dose. LPN #1 discarded the medication cups with the partial dose in it. 2. Resident #14 had a diagnosis of anemia. a. A physicians order dated 09/26/23 documented Ferrous Sulfate 325 mg oral tablet 1 tablet po TID (three times daily). b. On 1/11/24 at 8:06 AM, LPN #2 prepared medications for administration. LPN #2 was asked how many pills he had in the medication cup. LPN #2 stated, 6 There were 7 pills to be administered. LPN # 2 failed to give the Ferrous Sulfate. On 1/12/24 at 9:00 AM LPN 1 was asked why it was important to completely give all medications ordered by the physician. LPN #1 stated, Because if they don't get their medications then they can get sick and go to the hospital. On 01/12/24 at 9:11 AM, the Director of Nurses (DON) was asked if nurses were expected to follow the Physicians orders while administering medications. The DON stated, yes. On 1/12/24 at 12:27 PM, the Administrator provided a policy titled,: Administering Medications: Medications will be administered in a safe and timely manner, and as prescribed .12. The individual administering the medication must initial the residents MAR on the appropriate line after giving each medication .15. If a drug is withheld, refused, or given at a time other than the scheduled time,the individual administering the medication shall initial and circle the MAR space provided for that drug and dose .

Based on observation, record review and interview, the facility failed to ensure medications were not left in resident rooms for 1 of 1 (Resident #7) sampled residents who was observed with medication at the bedside, and failed to ensure the refrigerated narcotic medications in the medication storage room on the South Hall were stored in a permanently affixed compartment to prevent the potential of misappropriation of resident property. The findings are: 1. Resident #7 had a diagnosis of Gastroesophageal reflux disease. a. The January 2024 Physician's Orders documented, (CA. Carbonate) [Calcium Carbonate] .PO [by mouth] TID [three times a day] Give 2 tabs[tablets]= [equal] 1,000 MG [milligrams] . There is no order for self-administration of medication. b. A Care Plan with a review date of 11/07/23 had no problem or approaches listed for self-administration of medications for this Resident. c. On 01/08/24 at 11:24 AM, Resident #7 was sitting up in recliner, awake and the television (tv) was on. There was a pill cup with a pink and yellow tablet inside on the bedside table. The Resident was asked what those tablets were in the pill cup, and she said (named calcium carbonate) and she takes those for her stomach. d. On 01/10/24 at 5:17 PM, Resident #7 was sitting up in a wheelchair (w/c) with a bedside table in front of her and she was positioned in front of the television. She was eating supper and had a pill cup on the bedside table with a pink and yellow tablet in it. e. On 1/11/23 at 10:30 AM, review of Resident #7 ' s chart showed no self-administration of medication assessment. f. A Policy on Administering Medications, provided by the Administrator, on 1/12/24 at 12:27 PM, documented, . 18. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely . 2. On 01/11/24 at 3:15 PM, Licensed Practical Nurse (LPN) #3 and Surveyor were in the medication storage room on the South Hall. There was a refrigerator that had a lock on it. The nurse unlocked it and there was a black box sitting on the top shelf un-secured. The nurse was asked to unlock the box so the contents could be looked at and she picked the box up, removed it from the rack and sat it on the counter. She unlocked it and it contained the following meds: 1. Lorazepam 2 injectable syringes- 2 mg/1 ml (milliliter) in each vial for Resident #40 that was unopened. 2. Lorazepam 1 vial- 2 mg /ml unopened for Resident #26. 3. Stock Lorazepam 2 vials- 2 mg /1 ml, unopened and each in a clear plastic bag. a. On 1/12/24 at 5:24 PM, the Director of Nursing (DON) was interviewed, and she said the black box in the refrigerator was affixed, but the key was lost and they had to replace it and they assumed the other locks were sufficient. She then confirmed the narcotic box should've been permanently affixed in the medication storage room refrigerator because a resident could grab it. She also confirmed that the nurse should not leave medication at the resident's bedside unless it is ordered and to ensure it has been taken by that resident.

Based on observation, record review and interview, the facility failed to ensure medications were not self-administered without a physician order and the interdisciplinary team (IDT) assessed the resident to determine safe administration for 1 (Resident #44) of 1 (Resident #44) sampled residents who had a box of medication tablets on the bedside table. The findings are: 1. Resident #44 had a diagnosis of Alzheimer ' s disease with late onset and Gastro-Esophageal Reflux Disease without Esophagitis. a. A Care Plan with a review date of 01/02/24 had no documentation regarding self-administration of medications for this resident. b. The January 2024 Physician's Orders were reviewed on 01/08/24 at 2:58 PM and there was no order for self-administration of any medications. c. On 01/08/24 at 11:32 AM, the Resident was not in the room. There was a box of Extra Strength Gas Relief Simethicone 125 mg (milligrams) chewable tablets on the bedside table. d. On 01/10/24 at 5:19 PM, the Resident was not in the room, but there was a box of Extra Strength Gas Relief Simethicone 125 mg chewable tablets on the bedside table. e. On 01/11/24 at 3:15 PM, Licensed Practical Nurse (LPN) #3 was interviewed and she confirmed residents must have a doctor ' s order to self-administer medications. She was asked, As of today, are there any residents with doctor's orders to self-administer medications? She stated, I will say No . I also know that [Resident #44] has some Simethicone in her room too. f. On 01/12/24 at 1:12 PM, the Resident was in her room and a box of Extra Strength Gas Relief Simethicone 125 mg chewable tablets on the bedside table. The resident was asked, I noticed you have a box of Simethicone on your table. Do you take those? She stated, Yes, but only when I have to because I don't like to take a lot of medicine. She was asked, May I ask what you take them for? She stated, When I have heartburn. She was asked, Did someone here at the facility give those to you? She stated, No, my daughter bought them for me. g. On 1/12/24 at 5:24 PM, the Director of Nursing confirmed that residents should not have medications at the bedside. She also confirmed that the nurse should have reported that the resident had medication at the bedside without a Physician's order. h. A Policy on Self-Administration of Drugs, provided by the Administrator on 1/12/24 at 12:27 PM documented, . Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so . 8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents .

Based on record review and interview, the facility failed to ensure the requirements of their abuse prohibition policy were followed to protect 1 of 1 (Resident # 34) sampled resident from further abuse. This failure had the potential to affect all 45 residents in the facility. On 12/29/23 at 15:52 a 7734 and a 762 report was sent to DPSQA (Department of Provider Services and Quality Assurance) stating a X-employee had involuntary secluded Resident # 34. The staff member reporting for the facility documented a founded abuse (involuntary seclusion) based off a facility camera video. The Facility documented a founded abuse and immediately terminated the X-employee. The facility failed to notify the Certified Nurse's aide registry of the founded abuse . On 1/09/24 at 2:54 PM The Surveyor asked the Administrator if she had reported (named x employee) to the CNA Registry for the abuse incident that that happened on 12/29/23. The Administrator replied I have submitted the documentation to the state (OLTC) for review and I'm waiting for a determination from the state. I thought you guys report those to the registry. The Administrator provided the facility's policy titled Policy and Procedures on 1/08/24 at 11::40 AM, regarding investigation and reporting of alleged violations of federal or state laws involving mistreatment, neglect, abuse, injuries of unknown source and misappropriation of residents property provided by Administrator on 1/08/24 at 11:40 AM., It is the policy of this facility {named} to prevent the occurrence of abuse ( verbal, mental, physical, sexual ,involuntary seclusion) . Mental Abuse: isolating a resident from social interaction .Involuntary Seclusion is defined as separation of a resident from other residents .confinement to her/his room against the residents will . staff hold a door shut, from the opposite side of the door in order to prevent egress . Protecting: 4. If there is a suspected abuse and internal investigation will take place immediately. All alleged violations will be reported to Office of Long-term Care (OLTC) and other required agencies immediately . if the alleged violation involves abuse . Summary of incident: from the 7734 form.12/29/23 at 15:52 showed the following: STAFF MEMBER REPORTED THAT CNA (named employee) HAD PUSHED RESIDENT TO HIS ROOM AND HELD THE DOOR CLOSED SO RESIDENT COULD NOT LEAVE ROOM. RESIDENT DOES HAVE DEMENTIA AND IS UNABLE TO ANSWER QUESTIONS APPROPRIATELY. CAMERAS WAS REVIEWED BY FACILITY RN. AT APPROXIMATELY l8:14 (6:14 PM), CNA WAS OBSERVED PUSHING RESIDENT INTO HIS ROOM. CNA THEN CLOSED THE DOOR. CNA STOOD AT THE DOOR UNTIL 18:16:19 (6:16 PM and 19 seconds). CNA THEN WALKED AWAY FROM DOOR. AT THIS TIME FACILITY RN WAS UNABLE TO SEE IF CNA ACTUALLY HELD THE DOOR SHUT. RESIDENT EXITED THE DOOR SHORTLY AFTERWARDS. THE CAMERAS WAS FURTHER REVIEWED TO SEE IF THIS WAS AN ISOLATED INCIDENT. AT APPROXIMATELY 20:53:20 (8:53 PM and 20 seconds), CNA WAS OBSERVED ON CAMERA PUSHING RESIDENT TO ROOM AGAIN AND CLOSING DOOR ON RESIDENT. BASED UPON POSTURE AND HAND PLACEMENT CNA WAS HOLDING THE DOOR SHUT. CNA MOVED AWAY FROM DOOR AT 20:53:46 (8:53 PM and 46 seconds) . AT APPROXIMATELY 20:53:56 (8:53 PM and 56 seconds), CNA IS SEEN RUNNING ACROSS THE HALL TO RESIDENT'S ROOM PUSHED RESIDENT BACK INTO ROOM AND HOLDS THE DOOR CLOSED FROM 20:54:1 I 20:53:46 (8:54 PM and 11 seconds). TO 20:54:39 (8:54 PM and 39 seconds). THERE WAS NO INJURIES NOTED TO RESIDENT. RESIDENT EXITED THE ROOM AT 21:00:58 (9:00 PM and 58 seconds). FACILITY RN (Registered Nurse) INTERVIEWED THE ACCUSED EMPLOYEE. CNA WAS ASKED CAN YOU EXPLAIN WHY YOU WAS HOLDING RESIDENTS DOOR CLOSED AT 18:14:36 (6:14 PM and 36 seconds)? CNA STATED, I WAS NOT HOLDING HIS DOOR. I WAS HOLDING ONTO THE BAR RAIL.' WHEN REVIEWING THE CAMERAS DURING THE FIRST OCCURRENCE FACILITY RN WAS UNABLE TO TELL IF CNA WAS HOLDING THE DOOR OR THE BAR RAIL, CNA WAS THEN ASKED, WHY WAS YOU HOLDING THE DOOR THE SECOND TIME, YOU PUSHED THE RESIDENT TO THE ROOM?' CNA STATED, HE WAS ENTERING OTHER RESIDENT'S ROOM AND BOTHERING OTHER RESIDENTS. FACILITY RN STATED TO CNA I REVIEWED THE CAMERAS AND I SAW THAT THE RESIDENT DID NOT ENTER ANOTHER RESIDENT'S ROOM, THERE WASN'T ANYBODY IN THE HALLWAY TO BOTHER. 'CNA STATED I SHOULDN'T HAVE PLACED MY HAND ON THE DOOR BUT I WAS OPENING THE DOOR AND CHECKING ON HIM TO MAKE SURE HE DIDN'T FALL. FACILITY RN STATED, IF YOU WAS WORRIED ABOUT HIM FALLING, WHY NOT LEAVE THE DOOR OPEN? CNA STATED I DON'T KNOW. I SHOULDN'T HAVE DID IT.' CNA WAS THEN TERMINATED BY ADMINISTRATOR BASED UPON WHAT WAS VIEWED ON CAMERA.

Based on an interview and record review, the facility failed to thoroughly prevent possible further abuse for 1 Resident (Resident #34) who was involuntarily secluded and possible abuse for all other 44 residents who reside in the facility. The findings are: Resident # 34 was admitted to the facility with a diagnosis of Displaced intertrochanteric fracture of left femur and Alzheimer's Disease. On 01/08/24 at 3:59 PM Surveyor notified the family member by phone for a family interview. During the interview the daughter stated, last week on Wednesday it was reported a staff member locked him (Resident #34) in his room. She was fired and an investigation is under way. She also said she has a meeting with the Administrator tomorrow 1/9/24. On 01/09/24 at 8:10 AM the Administrator provided the 3 reportables that showed the following: On 12/29/23 form 7734/762 was reported to DPSQA (Division of Provider Services and Quality Assurance) documented that an x-employee was found to have involuntary secluded Resident # 34. This x-employee was terminated. On 01/12/24 at 2:50 PM the Administrator was asked concerning the investigation if there was a body audit/assessment of Resident #34, interviews with alert staff, statements from staff and did she do an in-service. The Administrator stated, No to the body audit, no to the in-service, no to the staff but yes to the alert residents. The Administrator was asked what did the facility do to prevent any further harm or potential for harm. The Administrator stated, I fired the employee. I thought that's all I had to do. The facility's policy titled POLICY AND PROCEDURES Regarding investigation and reporting of alleged violations of federal or state laws involving mistreatment, neglect, abuse, injuries of unknown source and misappropriation of residents property provided by Administrator on 1/08/24 at 11:40 AM showed the following, It is the policy of this facility {named} to prevent the occurrence of abuse ( verbal, mental, physical, sexual ,involuntary seclusion) . Mental Abuse: isolating a resident from social interaction Involuntary Seclusion is defined as separation of a resident from other residents .confinement to her/his room against the residents will . The Administrator provided the facility's policy titled POLICY AND PROCEDURES on 1/08/24 at 11::40 AM, regarding investigation and reporting of alleged violations of federal or state laws involving mistreatment, neglect, abuse, injuries of unknown source and misappropriation of residents property provided by Administrator on 1/08/24 at 11:40 AM., It is the policy of this facility {named} to prevent the occurrence of abuse ( verbal, mental, physical, sexual ,involuntary seclusion) . Mental Abuse: isolating a resident from social interaction . INVOLUNTARY SECLUSION is defined as separation of a resident from other residents .confinement to her/his room against the residents will .Protecting: 4. If there is a suspected abuse and internal investigation will take place immediately. All alleged violations will be reported to Office of Long-term Care (OLTC) and other required agencies immediately . if the alleged violation involves abuse .

Based on record review and interview the facility failed to ensure a residents ' s representative was notified in writing of resident's transfer to the hospital and/or discharge and failed to notify the Ombudsman required for 1 (Resident #34) of 7 (Residents #6, #14, #16, #23, #34, #46 and #148) sampled residents who were transferred to the hospital in the last three months. The findings are: 1. Resident #34 had a diagnosis of Alzheimer's Disease. a. An Incident and Accident (I&A) form dated 12/6/23 at 1515 (3:15) PM documented Resident #34 tried to transfer self and landed on his left side. He had an abrasion to the (L) (left) temple and complained of (L) hip pain. The intervention was Resident #34 was transferred to the ER (emergency room ) and PT (Physical Therapy) will work on transfers. b. The nurse's notes dated 12/6/23 at 1620 (4:20) PM documented the Physician ordered Resident #34 be transferred to the ER for evaluation due to complaints of pain in the left hip. At 1600 (4:20) PM, Resident #34 left the facility by way of EMS (Emergency Medical Services). c. On 1/10/24 at 1:01 PM, the Business Office Manager provided a list of residents who were transferred to the hospital from 09/15/23 to 01/03/24 which did not include Resident #34. d. On 01/11/24 at 10:05 AM, the Assistant Administrator was asked if there was documentation of notification to Resident #34 ' s representative regarding the resident being admitted to the hospital? She stated, [named Resident #34] got dropped in a crack. We didn't send it to the family or Ombudsman because he wasn't on the list that he went out. She was unable to provide documentation that the bed hold policy was sent to the family representative.

Based on interview and record review, the facility failed to ensure the bed hold policy was provided for a transfer to the hospital for 1 Resident #34. This had the potential to affect 45 residents. The findings are: 1. The nurse's notes dated 12/6/23 at 16:20 4:20 PM documented the Physician ordered Resident #34 be transferred to the ER (emergency room ) for evaluation due to complaints of pain in the left hip. At 16:00 (4:00) PM the resident left the facility by way of EMS (Emergency Medical Services). 2. On 1/10/24 at 1:01 PM, the Business Office Manager provided a list of residents who were transferred to the hospital from 09/15/23 to 01/03/24 and Resident #34 was not listed. 3. 01/11/24 10:05 AM, the Assistant Administrator was asked if there was documentation of notification when Resident #34 was admitted and no documentation of bed hold policy. She stated, Resident #34 got dropped in a crack. We didn't send it to the family or Ombudsman because he wasn't on the list that he went out. 4. On 01/11/24 at 1:11 PM the Assistant Administrator stated that there was not a policy for bed hold residents.

Based on observation, record review and interview, the facility failed to ensure nail care services were regularly provided to promote good personal hygiene and grooming for 1 (Resident #18) of 9 (Residents #6, #12, #18, #23, #30, #34, #35, #40 and #148) sampled residents who required assistance for nail care, as documented on a list provided by the Administrator on 1/12/24 at 12:27 pm. The findings are: 1. Resident #18 had diagnoses of Vascular Dementia without Behavioral Disturbances, Altered Mental Status. a. A Care Plan with a review date of 11/14/23 documented Resident #18 had an ADL (Activities of Daily Living) self-care deficit and needs supervision/limited assistance with personal hygiene. No nail care was addressed on the resident's care plan. b. On 01/08/24 at 10:45 AM, Resident #18 had dark substance observed underneath his fingernails. c. On 01/08/24 at 4:31 PM, Resident #18 had a dark substance observed underneath the fingernails on both hands. d. On 01/09/23 at 08:23 AM, resident #18 had a dark substance underneath his fingernails. e. On 01/12/24 at 6:55 PM, the Director of Nursing (DON) was interviewed regarding nail care for residents, and she stated, We have an aide that comes in and does their nails if they are not Diabetic. She was asked, When should nail care be performed? and she stated, As they see dirty nails or if they see they need to be trimmed. She [nail care aide] schedules them 3 to 4 days a week.

Based on observation, record review and interview, the facility failed to ensure oxygen tubing was dated to reduce the potential for respiratory complications and failed to ensure Oxygen in Use signage was in place to promote oxygen safety for 1 (Resident #23) of 1 sampled resident that had orders for oxygen therapy. This failed practice had the potential to affect 4 residents that had physician orders for oxygen therapy. The findings are: a. A Physician Order dated 10/30/22 documented, .Oxygen PRN (when necessary) 2 LPM (liters per minute) per /nasal Cannula PRN saturations . On 01/08/24 11:37 AM, Resident #23 was lying in the bed with oxygen in use at 2 liters per nasal cannula. There was no date on oxygen tubing or an Oxygen in Use sign on the door. On 01/08/24 4:50 PM, Resident #23 was lying in bed with oxygen in use at 2 liters per nasal cannula. There were no dates on the oxygen tubing or an oxygen in use sign on the door. On 01/09/24 8:41 AM, Resident #23 was lying in bed with oxygen in use at 2 Liters per minute per nasal. There were no dates on oxygen tubing or an oxygen in use sign on the door. On 01/12/24 (Certified Nurse Assistant) CNA #2 was asked if resident #23 used oxygen. CNA stated, yes The Surveyor asked CNA #2 to accompany her to Resident #23 ' s room and asked, is there a sign at the entrance to the room stating, Oxygen in Use. CNA # 2 stated, No, there is not. CNA #2 was asked, Should there be a sign on the door stating, Oxygen in Use? CNA #2 stated, Yes, there should. CNA #2 was asked if there was a date on the oxygen tubing. CNA #2 stated, No On 1/12/24 at 9:00 AM, (Licensed Practical Nurse) LPN #1 was asked to accompany Surveyor to Resident #23's room and asked, who was responsible for making sure there is an Oxygen in Use sign on the door and tubing's dated. LPN #1 stated, All nursing staff. CNAs if they see the sign is missing, they should report to the nurse. LPN #1 was asked, Why should there be a sign on the resident's door stating, Oxygen in use and oxygen tubing dated. LPN #1 stated, Because oxygen is flammable, and it lets people know the resident is on oxygen and to not use Vaseline and so we can know when to change out tubing's because they can get a respiratory infection. On 1/12/24 at 9:11 AM, the Director of Nurses (DON) was asked who was responsible for dating oxygen tubing and making sure signage of Oxygen in Use is placed at the entrance of the room. The DON stated the treatment nurse who is also the floor nurse is responsible. The DON was asked why dated tubing and Oxygen in Use sign was needed. The DON stated, So everyone will know a person is on oxygen and to let us know the tubing's have been changed out. A Policy was provided by the Administrator on 1/12/24 at 12:27 AM titled Oxygen Administration Purpose: The purpose is to provide guidelines for safe oxygen administration . equipment and supplies . necessary:4. no smoking/oxygen in Use signs.

Based on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies with medication error rates. This failed practice had the potential to affect all 45 residents who resided in the facility. The findings are: 1. A Recertification and Complaint Survey was conducted on 01/06/2023 at the facility. During this survey, the team identified concerns with medication errors during medication observations. 2. The Plan of Correction for medication errors, with a completion date of 02/04/2023 indicated all residents were evaluated, no negative findings were found. A designated Licensed Practical Nurse (LPN) will monitor Medication Pass twice per week to ensure liquid meds are given at the correct time and will correct negative findings immediately and report to Quality Assurance (QA) weekly to ensure effectiveness. 3. A Recertification survey was conducted on 01/12/2024. During the survey the team identified concerns with medication error rates. Cross Reference F 759. 4. A policy titled, Quality Assurance and Performance Improvement, provided by the Administrator on 01/12/2024 at 5:02 PM documented, .The facility, will develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life . 5. On 01/12/24 at 4:23 PM, the Surveyor asked the Administrator, How does the (Quality Assurance and Assessment) QAA Committee know when an issue arises in any department? She answered, I have a sign posted where you clock in for any staff to let them know when meetings are and they can bring topics to discuss. The Surveyor asked, How does the QAA Committee know when a deviation from performance or a negative trend is occurring? She answered, From staff observation of the topic and interviewing. The Surveyor asked, How does the QAA Committee decide which issues to work on? She answered, Anything that needs improvement. The Surveyor asked, How long will the QAA Committee monitor an issue that it has been corrected? She answered, Once we see there is no longer an issue we continue to monitor periodically. You just may not monitor as often. The Surveyor asked, Is the QAA Committee aware of repeated survey deficiencies? She answered, Yes in dietary. The Surveyor asked, If aware, did the Committee implement corrective action? She answered, Yes. The Surveyor asked, Is the Committee monitoring to ensure corrective action has been implemented? She answered, yes.

Based on observation, record review, and interview, the facility failed to ensure resident's safety, to prevent elopement with known exit seeking behavior and failed to ensure residents were assessed for elopement risk upon admission, readmission and at least quarterly thereafter to ensure elopement risk was identified and addressed for 1 (Resident #4) resident who was at risk for elopement. This failed practice resulted in immediate jeopardy that caused or was likely to cause serious harm, injury or death to Resident #4 who had repeated exit seeking behavior and eloped the facility and had the potential to affect 3 residents who were elopement risk per the list provided by the Administrator on 4/29/21. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 4/28/21 at 5:09 PM. The findings are: 1. Resident #4 had diagnoses of Dementia in Other Diseases classified elsewhere, Other Alzheimer's disease, Anxiety Disorder Unspecified, and Restlessness and Agitation. The Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/25/21 documented the resident scored 3 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS); was independent with bed mobility, transfers, walking in room and corridor, locomotion on unit and off the unit; required limited assistance with dressing and personal hygiene, extensive assistance with toilet use; had no behavioral symptoms; did not reject care; and wandering behavior was not exhibited. a. An Initial Elopement and Wandering Risk Assessment completed on 6/19/2019 documented, Instructions: Complete upon admission .1. Does resident have a diagnosis of Dementia/Alzheimer's/confusion? Yes 2. Does the resident ambulate independently, with or without the use of an assistive device (including a wheelchair)? Yes 3. Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door? Yes 4. Does the resident have a history of wandering/elopement? Yes 5. Is the resident currently taking any mediation which may cause confusion or disorientation? No .Resident is AT RISK for elopement/wandering at this time and should be placed on elopement monitoring. A care plan for wandering/elopement risk will be initiated identifying appropriate preventative interventions b. A physician order dated 6/19/20 documented, .[MEDICATION(S)] 10mg [milligram] Oral Tablet 1 tablet PO [by mouth] HS [at bedtime] Diagnosis: Other Alzheimer's Diseases . [MEDICATION(S)] 5mg oral tablet 1 tablet PO BID [twice a day] diagnosis: Other Alzheimer's disease . c. Nurse's note dated 1/6/21 on the 2-10 (2:00 p.m. - 10:00 p.m.) shift documented, Going in and out of other resident's room. Lots of re-direction needed. Nurse's note dated 1/14/21 on the 2-10 shift documented, In and out of other residents' room, tries to get out exit door, much re-directing. Nurse's note dated 1/15/21 on the 10-6 (10:00 p.m. - 6:00 a.m.) shift documented, .Pt [patient] awake is up at intervals monitoring closely dt [due to] exit seeking. Responds verbally easily directed back to bed . Nurse's note dated 1/15/21 on the 6-2 (6:00 a.m. - 2:00 p.m.) shift documented, R [Resident] requires constant redirection up amb [ambulating] via scooter chair wandering about facility Nurse's note dated 1/16/21 on the 6-2 shift documented, Kicking @ [at] exit door. Agitated mood this shift . Nurse's note dated 1/17/21 on the 11:00am documented, Continues to wander in and out of rooms, much re-direction needed . Nurse's note dated 1/18/21 on the 6- shift documented, R up wandering facility most of shift Redirected constantly . Nurse's note dated 1/19/21 on the 6-2 shift documented, R up amb about facility in scooter chair often enters other R's room. Redirection required constantly . Nurse's note dated 1/19/21 on the 2-10 shift documented, Much re-direction needed. In and out of other resident rooms. Nurse's note dated 1/21/21 on the 6-2 shift documented, Requires constant supervision d/t [due to] wandering and exit seeking . Nurse's note dated 1/21/21 on the 2-10 shift documented, In & out of rooms, trying to go outside. Easily agitated when re-directed. Nurse's note dated 1/24/21 on the 2-10 shift documented, Wandering, Exit seeking, monitored closely, assist & redirect prn. Nurse's note dated 1/26/21 on the 2-10 shift documented, Easily agitated when redirected. Nurse's note dated 1/27/21 on the 6-2 shift documented, R up am via scooter chair often exit seeking easily agitated @ x's [times]. Nurse's note dated 1/27/21 on the 2-10 shift documented, Several attempts to go out exit doors this shift. Easily agitated when re-directed. Nurse's note dated 1/28/21 at 7:00 pm documented, .Res [resident] going in and out of rooms. Easily agitated. Nurse's note dated 1/29/21 on the 6-2 shift documented, .Monitored closely for exit seeking . Nurse's note dated 1/30/21 on the 6-2 shift documented, Needs much re-directing. Goes to doors trying to open . Nurse's note dated 1/30/21 on the 2-10 shift documented, R monitored and redirect prn. Wanders facility exit seeking or in/out of other rooms. Removed ASAP [as soon as possible] . Nurse's note dated 2/7/21 on the 6-2 shift documented, Up amb about facility wandering exit seeking redirection required constantly . Nurse's note dated 2/9/21 on the 2-10 shift documented, Continues to go in & out of residents rooms. Continues to go out exit doors. Several times tonight staff had to stop her from going outside. Nurse's noted dated 2/11/21 on the 2-10 shift documented, Lost of re-directing needed, Attempting to go out exit doors, Easily agitated. Nurse's note dated 2/13/21 on the 6-2 shift documented, Several attempts to go outdoors without assist. Becomes agitated when re-directed. Nurse's noted dated 2/14/21 on the 6-2 shift documented, Lots of re-directing needed this shift. Nurse's note dated 2/17/21 on the 2-10 shift documented, 1/1 attempt to go out exit door, easily re-directed. Nurse's note dated 2/25/21 on the 2-10 shift documented, Several attempts to exit building. Much re-directing needed. Nurse's note dated 2/28/21 on the 6-2 shift documented, Continues to try to go out exit door. Nurse's note dated 3/1/21 on the 6-2 shift documented, R up wandering hallway going in and out of rooms. Nurse's note dated 3/2/21 on the 2-10 shift documented, In &out of other's rooms, up and down hallway most of shift. Easily agitated when re-directed. Nurse's note dated 3/4/21 on the 2-10 shift documented, Several attempts to exit building. Easily re-directed, much needed supervision needed. Nurse's note dated 3/9/21 on the 2-19 shift documented, In & out of other's rooms. Attempts to exit facility. Lots of supervision needed. Nurse's note dated 3/11/21 on the 2-10 shift documented, Easily agitated this shift. Several attempts to exit building. Nurse's note dated 3/14/21 on the 6-2 shift documented, Several attempts to exit building. Ambulates in and out of other resident rooms. Nurse's note dated 3/16/21 on the 6-2 shift documented, R up amb about facility as desires she is alert with confusion noted. Often exit seeking checked often. Nurse's note dated 3/16/21 on the 2-10 shift documented, Several attempts to exit building, much supervision needed d/t confusion to time/date. d. The Care plan with a problem date of 3/26/21 documented, .Behavior: Behavior Problem Wandering/Elopement Risk Resident also pulls fire alarm at times-possibly looking for way to exit . Approaches: Report to physician changes in behavioral status, Provide non-confrontational environment for care, Reinforce positive behavior, Address wandering behavior by walking with resident; redirect from inappropriate area; engage in diversional activity, Invite and encourage activity programs consistent with resident's interest, Monitor behavior episodes and attempt to determine under-lying cause. Consider location, time of day, person involved, etc, Intervene as needed to protect the rights & [and] safety of others; approach in calm manner, divert attention, remove from situation and take to another location as needed, Reapproach resident later, when she becomes agitated, Provide opportunities for positive interaction, attention. Stop and talk with him/her as passing by . Delirium: Mental function caries over course of the day . Approaches: Consult with family/responsible party, review medical records to determine prior level of function or baseline, Observe and report to nurse s/s [signs and symptoms] of delirium: changes in behavior Altered Mental status wide variation in cognitive function throughout day Communication decline Periods of lethargy Disorientation Restlessness/agitation Altered sleep cycle, Report changes in behavior, cognition, and mood to physician as indicated, Use communication techniques to facilitate functioning: Address by preferred name, turn off TV[television]/Radio to decrease environmental noise Identify yourself with each contact PRN [as needed] Approach in calm, positive way Explain all procedures before starting If resident is restless, shorten conversation, and approach later to resume care if needed . Discharge plan: Resident admitted to facility with DX [diagnosis] of Alzheimer's disease from home with intent to remain at the facility . Approaches: No discharge plans at this time . e. Nurse's note dated 3/17/21 on the 2-10 shift documented, Continues to attempt exit, goes from door to door, much re-directing needed. Nurse's note dated 3/18/21 at 7:00pm documented, Ambulating, No difficulty noted, continues to exit, goes door to door . Nurse's note dated 3/19/21 on the 6-2 shift documented, R up amb as desires requires constant redirection . Nurse's note dated 3/21/21 on the 6-2 shift documented, R up amb as desires exit seeking this shift . Nurse's note dated 3/24/21 on the 2-10 shift documented, Several attempts to exit building, easily re-directed tonight. Nurse's note dated 3/25/21 on the 2-10 shift documented, Attempts to exit several times, easily agitated, much re-direction, much supervision needed. Nurse's note dated 3/26/21 on the 6-2 shift documented, R up wanders about facility as desires often exit seeking checked frequently. Nurse's note dated 3/28/21 on the 6-2 shift documented, Easily agitated this shift. Ambulating door to door attempting to exit building, constant supervision needed. Nurse's note dated 3/29/21 on the 6-2 shift documented, R up wandering in and out of rooms, Exit seeking, no problem. Nurse's note dated 3/29/21 on the 2-10 shift documented, Wandering. Exit seeking redirect prn . Nurse's note dated 4/2/21 on the 6-2 shift documented, R up amb about facility as desires monitored closely for exit seeking . Nurse's note dated 4/4/21 on the 6-2 shift documented, Requires constant supervision R exit seeking removing items from room. Nurse's note dated 4/6/21 on the 2-10 shift documented, Goes door to door attempting to exit building Lots of re-direction needed. Nurse's note dated 4/7/21 on the 6-2 shift documented, R up amb about facility often exit seeking constant redirection required. Nurse's note dated 4/8/21 on the 9:30pm documented, Roaming all shift, attempting to exit, much supervision needed. Nurse's note dated 4/9/21 on the 6-2 shift documented, R up amb about facility resting @ intervals often exit seeking looking for her car redirection often. Nurse's note dated 4/10/21 on the 2-10 shift documented, Wandering. Exit seeking. No changes in behavior. Nurse's note dated 4/12/21 6 on the -2 shift documented, R exit seeking most of shift requires constant monitoring, checked frequently . Nurse's note dated 4/12/21 on the 2-10 shift documented, Wandering facility in/out of others rooms Assist & redirect prn . Nurse's note dated 4/13/21 on the 6-2 shift documented, Requires constant supervision exit seeking redirection giving. Nurse's note dated 4/14/21 on the 2-10 shift documented, no changes in behavior, lots of re-directing needed. Nurse's note dated 4/15/21 on the 2-10 shift documented, Continues to exit seeking lots of re-directing. Nurse's note dated 4/16/21 on the 6-2 shift documented, R up amb as desires, Exit seeking often. Requires constant supervision required. Nurse's note dated 4/18/21 on the 6-2 shift documented, Exit seeking most of shift, pleasant and talkative, checked frequently. Nurse's note dated 4/22/21 on the 2-10 shift documented, Easily agitated, difficult to re-direct tonight. Nurse's note dated 4/23/21 at 9:00 am documented, [Doctor] here on rounds. Medication list reviewed. Staff reports increase agitation & increase redirection. Order to increase [MEDICATION(S)] 250mg PO BID. f. A physician order dated 4/23/21 documented, .[MEDICATION(S)] Sprinkles 125mg Oral DR [Delayed Release] Capsule 2 caps [capsule]=250mg PO BID give with food may open caps Diagnosis: Dementia in other diseases classified elsewhere . g. Nurse's note dated 4/24/21 on the 6-2 shift documented, Continue to seek exit from facility. Wanders in and out of other resident's room. Constant supervision needed . Nurse's note dated 4/24/21 on the 2-10 shift documented, Cont [continues] to wander facility. Redirect and assist prn . Nurse's note dated 4/25/21 on the 3:50AM documented, .Wandered from 2200 [11:00pm] to around midnight .From 2200 to around midnight was entering other R's room. Had to be redirected. R confused . Nurse's note dated 4/25/21 on the 6-2 shift documented, Continues to walk hallways going to exit doors . Nurse's note dated 4/25/21 on the 2-10 shift documented, .exit seeking 2 x's . Nurse's note dated 4/27/21 on the 2-10 shift documented, Continues to exit-seek, easily redirected this shift. h. On 4/28/21 at 2:48 PM, Dietary Staff #1 brought Resident #4 in from outside through the dining room to this surveyor. Dietary Staff #1 stated, I just found her outside. Dietary Staff #1 turned around and walked back to the kitchen. i. On 4/28/21 at 2:50 PM, this surveyor went into the Director of Nursing (DON) office due to Administrator not being in her office and informed DON of what Dietary staff #1 had informed me. The DON walked to the kitchen to identify the dietary staff member. DON asked Dietary Staff #1, Did you have eyes on [Resident #4] the whole time? Dietary staff #1 stated, I heard the alarm go off and went to look out the window and seen her outside. I went outside and told her to come back in with me. Resident #4 walked to DON. The DON asked Resident #4, Tell us who your sister is. Resident #4 talked briefly then walked down the hallway. DON stated, Anytime she is exit seeking, we have to re-direct her with other questions. j. On 4/28/21 at 3:10 PM, the dining room exit door was checked to verify it was functioning properly. This Surveyor pushed the door two times and it immediately opened then the alarm immediately sounded. I turned the alarm off and waited for the door to reset and lock. I pushed the door one time and it immediately opened and the alarm sounded. k. On 4/28/21 at 3:15 PM, the Administrator was asked, Did the DON inform you of the [Resident #4] exiting the facility and being found outside? The Administrator stated, Yes, I was told. The Administrator was asked, Do you have a wander guard system? The Administrator stated, No we do not. We have instructed all employees to listen for the door alarms and to find the door when it is alarming. The Administrator was asked, Have you checked the exit doors to ensure they are functioning properly? Administrator stated, No, not recently. l. On 4/28/21 at 3:17 PM, the Administrator began going to all the exit doors to check for proper functioning. The dining room exit door was checked first. This Surveyor pushed the door one time and it immediately opened and alarmed. The Administrator stated, They can come and adjust the door to correct that. The Administrator was asked, Did the door wait the 15 seconds with the alarm and then open? Administrator stated, No, it did not wait for 15 seconds. At 3:21pm, the Administrator checked the front door, pushed door bar down and held for 15 seconds. The alarm sounded after 15 seconds but it did not release to open. At 3:24 PM, the Administrator checked the East Wing door by pushing the door bar down and holding for 30 seconds. The alarm did not sound, and the door did not release to open. At 3:26 PM, the Administrator checked the door on hallway between East and South. She pushed the door bar down. The door alarmed and released open at 15 seconds. No issues identified. At 3:28 PM , the Administrator, checked the 200 Hall door. She pushed the door bar down. The door did not alarm and did not release open at 15 seconds. She held the door for 30 seconds and the alarm did not sound and the door did not release to open. At 3:30 PM, the Administrator checked the south hall door by pushing the door bar down. The door alarmed and released open at 15 seconds. No issues identified. At 3:31 PM, the Administrator checked the West Hall door by pushing the door bar down. The door alarmed and released open at 15 seconds. No issues identified. At 3:33 PM, the Administrator checked the Southwest door by pushing on the door (no bar present). The door alarmed and released open at 15 seconds. No issues identified. Four out of 8 doors were not functioning properly. The Administrator stated she was going to call the people that handle their doors and door alarms. m. On 4/28/21 at 3:55Pm Dietary #1 was asked, Can you tell me what happened and how you knew [Resident #4] was outside? Dietary #1 stated, I was in the kitchen making gravy for the meatballs. I heard the door start beeping. I went to look out the window and she [Resident #4] was standing by the freezer outside. I went out there and called her back. She came back in with me and that's when I told you I had found her outside. Dietary #1 was asked, How did you know to look out the window for a resident? Dietary staff #1 stated, She [Resident #4] do this all the time and we been told when the door alarm goes off to always check outside and she [Resident #4] has gone out that door many times. Dietary staff was asked, Resident #4 has done this before? Dietary #1 stated, Yes, she does it all the time. I have told [Administrator] and [DON] every time she goes out that door and they haven't done anything to keep it from happening. Dietary #1 was asked, How often would you say the resident gets out that door? Dietary #1 stated, At least once a week sometimes twice. n. On 4/28/21 at 4:01 PM, the Administrator was asked, Has [Resident #4] gone out that door before? Administrator stated, She has but the alarm goes off and we have never lost sight of her. Administrator was asked, When was the last time your staff has completed an elopement risk assessment for the resident? Administrator stated, I guess when she was admitted . We complete those assessments on admission. o. On 4/28/21 at 4:03 PM, the DON was asked, When was the last time you completed an elopement assessment on [Resident #4]? DON stated, We complete them on admission. The DON was asked, Do you not do elopement assessments on a quarterly basis? The DON stated, No, only on admission. p. On 4/29/21 at 1:32 PM, the Administrator provided a copy of the Wandering Resident Policy. The policy documented, Policy: In an effort to prevent residents from wandering away from the facility, [Facility name] has door alarm systems on all appropriate doors. This system is to help alert any unauthorized exits of residents who may try to wander outside the facility unsupervised .staff will monitor all residents and those who have been identified as wanderers on an ongoing basis to ensure all resident safety and privacy. Staff will report any necessary findings to appropriate personnel and provide the residents with a consistent and comforting response to their behavior and at the same time respect the privacy of all resident . Residents will also be monitored during their stay at the facility for potential wandering. When a resident has been assessed and identified as a wanderer their name will be posted at the nurse's station as a potential wanderer. Staff will be educated if the resident is an exit seeker or a facility wanderer or both . Door alarms will sound when door is opened. Staff will respond to alarm and monitor location of wandering residents . Staff will alert supervisor when a resident displays behavior of wandering and/or exit seeking. Resident will be monitored hourly by staff when behavior warrants, and findings reported to the charge nurse who will document location of the resident until display of behavior has subsided. The primary goal of the facility related to the wandering resident is to ensure resident safety utilizing the least restrictive means available. Therefore, door alarms are activated 24 hours a day and hourly checks by staff, when behavior warrants, will be used to monitor resident's activity . 3. The Immediate Jeopardy was removed on 4/29/21 at 10:00 AM and the scope and severity reduced to E when the following Plan of Removal was implemented. a. Resident #4 is being monitored one on one while out of room until doors are repaired. The alarm company was notified immediately by the Administrator and a repairman was dispatched immediately to the facility for door repair. All doors were repaired and functioning properly per the Administrator on 4/28/21 at 6:30pm. b. All residents in the facility who are ambulatory and confused have the potential to exit a door that is not functioning properly. All residents have been checked by the DON on 4/28/21 without no negative findings. c. The Administrator was in-serviced by the repairman on how to adjust the door if needed. d. The doors will be checked weekly and documented by housekeeping/maintenance supervisor to ensure they are functioning properly. The repair man will be notified immediately of any negative findings weekly to ensure compliance. e. All residents will be assessed for elopement on 4/28/21 by nursing. They will be reassessed quarterly by the MDS Coordinator. f. All 2/10 staff that were in the building on 4/28/21 were in-serviced on the monitoring for Resident #4 by the DON. All on coming staff will be in-serviced at beginning of each shift. g. Resident #4 will continue to be monitored every 15 minutes while in room and one-on-one while out of room until discharge.

Complaint # (AR 391) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) safely transported a resident in a wheelchair in the facility ' s van to prevent potential injury for 1 (Resident #1) of 2 (Resident (R) #1 and R #2) sample residents who required transport in a wheelchair facility ' s van in the past 2 weeks. This failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who slipped out of the wheelchair when the van accelerated after stopping at a railroad track, and had the potential to cause more than minimal harm to 2 residents who required wheelchairs during transport in the facility van in the past 2 weeks, as identified by the Administrator on 4/2/21. The Administrator removed the Immediate Jeopardy and completed corrective action on 3/30/2021. The facility was informed of the Past Immediate Jeopardy on 4/2/21 at 8:30 a.m. The findings are: 1. Resident #1 had diagnoses of Above Knee Left Leg [CONDITION(S)], [CONDITION(S)], and Dependence of [CONDITION(S)] Disorder. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 2/22/21. documented the resident scored 15 on a Brief Interview for Mental Status (BIMS); was total dependent assist of 1-2 people for transfers was incontinent of bowel and bladder, and required a lift for transfers. a. The Care Plan documented, .Safety Problem date 2/26/2021 Transfer Safety - Resident transfers with mechanical lift x [times] 1 assist . Goal . Resident will have no falls or injuries related to transfers through next review date .Approaches . CNA [Certified Nursing Assistant] information sheet will reflect that resident transfers with mechanical lift . b. Nurses Notes dated 3/29/21 documented, . 3/29/21 4:40 PM . [CNA #1] returned to facility per NH van and reported [Licensed Practical Nurse (LPN) # 2] that resident slid out of her wheelchair when going over railroad track. Resident noted lying in supine position with left side of face against interior of van. Blood noted on facial mask location of injury . Right leg extremity out. Hoyer lift pad underneath her to assist up and staff assist out of side door to wheelchair. Assist to room for further evaluation. Resident alert: able to move upper extremities with complaint of pain when resident moved right leg moved as resident usually does when resident leg moves or touched. Bleeding noted lower lip. Area cleaned, teeth intact . B/P [Blood Pressure] 210/65 . Resident medication given .Resident checked at 6Pm request to go to hospital d/t [due to] pain in R/L [right lower] knee, right leg and heel. Stated, Just feel like something ain't right inside. Doctor notified with order to send to ER Ambulance notified of transfer request. Resident sent to ER . 1) The Hospital Nurse Note dated 3/29/21 documented, . PT [patient] c.o. [complain of] bilateral knee pain, lower lip pain and right foot. States, she was on the seat van from [CONDITION(S)] when she stopped going 45 mph [miles per hour] and the patient flew forward and hit her face on back of another seat. Pts [Patients] bottom lip is swollen, bruised and some bleeding. Unable to visualize laceration or puncture site causing bleeding . 2) The hospital X-RAY Report dated 3/29/21 documented, .Right Ankle .3/29/21 . Findings: The bones are severely osteopenic. Bone detail is limited. Fractures are present. Fracture and medical malleolus with suspected impacted fracture extending across the distal tibia. In frontal projection the lateral malleolar fracture is also suggested, it is superimposed over the tibia in this projection but the fracture Lucency is not clearly visualized on the oblique image. The talus is poorly defined. The calcaneus appears flattened. Ankle effusion is favored. Soft tissue swelling at the ankle greater laterally . 3) The Hospital #1 Assessment Plan dated 3/29/2021 documented, . 68 y.o. [year old] diagnosed today with .Multiple fractures, Closed fracture of distal end of right femur .Closed fracture of proximal end of right tibia .Close fracture of proximal end of right fibula . Closed fracture of distal end of right tibia . Closed fracture of distal end of right fibula . Transfer to [hospital #2] for further care . c. The Incident/Accident Report dated 3/29/21 documented, . [Resident #1] . age 68 . 3/29/21 4:40 PM .Exact location of incident/accident . Back of NH [Nursing Home] van . Employee [Certified Nurse's Aide (CNA) #1] . Equipment involved .van silver . Describe exactly what happened . [CNA #1] returned to facility per NH van and reported [Licensed Practical Nurse (LPN) # 2] that resident slid out of her wheelchair when going over railroad track. Resident noted lying in supine position with left side of face against interior of van. Blood noted on facial mask location of injury . Right leg extremity out. Hoyer lift pad underneath her to assist up and staff assist out of side door to wheelchair. Assist to room for further evaluation. Resident alert: able to move upper extremities with complaint of pain when resident moved right leg moved as resident usually does when resident leg moves or touched. Bleeding noted lower lip. Area cleaned, teeth intact . Notified physician and ordered to send to ER [emergency room ]. 1) The CNA #1 witness statement documented, .3/30/21 I have been checked off on strapping resident in wheelchair in the van by [Maintenance man] multiple times. I'm aware that all four straps have to be fastened while transporting residents 2) OLTC [Office of Long term Care] Witness Statement Form documented, .3/30/21 3:03PM . I picked up resident from [CONDITION(S)] strapped resident in went in the front and put seat belt across resident fastened seat belt proceeded back to nursing home. I looked back at resident was leaning, didn't think resident was going anywhere. Went over the railroad tracks. Resident slid out of wheelchair. I have been in-serviced on how to strap residents in correctly. I only used 2 straps. I was supposed to use four and didn't tighten seat belt across resident . d. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property documented, Date and Time of Discovery 3/29/2021 at 4:40 p.m . Date and Time submitted: 3/30/2021 . Type of Incident Neglect . [CNA #1] picked up resident from the [CONDITION(S)] on 3/29/21 in the afternoon. When [CNA #1] strapped the resident into the van she did not anchor the wheelchair with all 4 straps. She admitted ly only used 2. She then buckled the lap and shoulder restraint. She admitted that she did not adjust the straps to, ensure they were tight. On the way to the nursing home the resident started to lean. The CNA did not pull over to readjust the resident. She continued over the railroad tracks which are really bumpy. The resident came out of the wheelchair at this time. The belt remained buckled per CNA. She then pulled over, unbuckled and repositioned the resident to make her more comfortable by moving her leg and turning her onto her side. She did not notify the facility at this time. She continued on to the facility. Upon arrival the resident was assisted inside by numerous employees and a nurse. The ambulance was called for pick up and the resident was transported to the local hospital. I [Administrator] asked the CNA during the interview, How many straps were you trained to use to strap the wheelchair in? She replied, 4. I asked her, Then why did you use only 2? She replied, I don't know. I was in a hurry, I guess. I asked, Were you trained to adjust the shoulder and lap restraint so that it is snug? She replied, Yes. I asked, why did you not tighten them? She replied, I don't know [Administrator name]. I don't know. I messed up. It's bad ain't it? I replied, Yes, it is. She said, I know what to do. I've been checked off multiple times. I don't know why I didn't do it right. I'm so upset with myself. I need to go home. I replied, I need you to take a drug test before you go. She said, I can't. It will be positive. I asked with what? She replied, Weed. I've smoked it within the last 30 days. I replied, you need to clock out and leave . CNA was terminated due to not following the proper procedure of buckling a resident and wheelchair in the van as trained. Resident is currently at [hospital #2] with multiple nondisplaced fractures above the knee and ankle. At this time, surgery has not been advised due to nondisplacement. Facility drivers have been checked off by [LPN #1] . 1) The Investigation Follow-up form dated 3/29/21 documented, .Summary of investigation . Strap in w/c [wheelchair] completely as was trained and checked off on . Recommendations/New Interventions . Van - w/c must be strapped in on all 4 side so it is properly secured. CNA failed to do so only strapped 2 sides. Did not adjust lap/should belts. CNA terminated . e. On 4/1/21 at 10:40 AM, Licensed Practical Nurse (LPN) #1 (the transport person) loaded Resident #2 in the white facility van. LPN #1 pushed the resident in the wheelchair in the van. She locked the wheelchair. She hooked the 2 straps in the back of the wheelchair to the van. She tugged at them to secure them. She then placed the seat belt through the left side of the wheelchair arm and secured the seat belt. She then used the shoulder strap and secured it to the seat belt. She then strapped the 2 straps from the floor to the front legs of the wheelchair. She then tugged at wheelchair to ensure it was secured. LPN #1 stated, This the not the van the accident happened, it was the silver one. The Surveyor stated, I will need to see you load that van when you get back. f. On 4/1/21 at 11:54 AM, LPN #1 loaded an empty wheelchair in the silver facility van. It was a rear entry loading van. She locked the brakes to the chair. She then locked the right rear strap from the floor to the right rear leg of the wheelchair. She then locked the left rear strap from the floor to the left rear leg of the wheelchair. She then placed the seat belt through the left side of the wheelchair arm and secured the seat belt. She then used the shoulder strap and secured it to the seat belt. She then locked the right front strap from the floor to the left rear leg of the wheelchair. She then locked the left front strap from the floor to the left rear leg of the wheelchair. She then tugged at wheelchair to ensure it was secured. LPN #1 was asked, What is the difference was between the 2 vans? She stated, The silver is for wider wheelchairs, that lady was bigger than [Resident #2]. g. On 4/1/21 at 12:52 PM, the Administrator was asked, Do you have proof that CNA #1 was trained to transport on the van? She stated, We can't find them. We had a Maintenance Man who worked here and did all the training. He no longer works here, and we can't find them. That is why I asked her to write a witness statement if she had been trained. They have all been trained again now. h. On 4/2/21 at 8:30 AM, the Administrator was asked, When you did the retraining, did you train on the correct placement of the strap and on locking the wheels? She stated, Yes. It's on the skills off check list. The Administrator was asked, How are you monitoring after the training and are they documenting this? She stated, Yes. The Administrator was asked, Is LPN #1 your designated transport person? She stated, Yes. i. The Manufacturer Guidelines Securing the Wheelchair provided by the Administrator on 4/2/2021 at 11:26 a.m. documented, .Section 4 .Correctly securing a wheelchair is extremely important for the safety and comfort of the passenger as well as for your peace of mind. Injury or death may result from improper securement. With the occupant facing the front of the vehicle, center the wheelchair between the floor tracks or plates, you are ready to attach the rear straps .Install the track fitting end into a slot in the floor track or plate. Use a slot to the inside of the rear wheel. Pull on the strap to ensure the fitting is firmly engaged and locked into the slot . Repeat this process for the other rear strap. Installing the front straps is similar. Install the track fitting end of the trap into the floor tack or plate. Use a slot that's 3 outside of the wheel. This prevents the strap from interfering with the footrest and gives better stability. Then pull on the strap to ensure that it's engaged firmly. Next, attach the S-Hook to a structural member of the wheelchair. Then push the button on the Retractor to remove the slack and crank it down for extra tension. Repeat this process for the other front strap. Once you have all four straps attached, release the brakes on the wheelchair and check for movement. Once secured, the wheelchair shouldn't move more than 2front back or side to side. Reapply the brakes .Lap Belts Start by attaching the lap belt. Place the ends of the lap belt around the passenger. Thread them down through the opening between the side panel or the seat back and the seat cushion. Remember to position the lap belt around the occupant's pelvic zone near the hip, with the buckle of the lap belt placed opposite to the side where the shoulder belt is attached to the wall . The last belt to attach before you're on your way is the shoulder belt. Bring the triangular fitting of the shoulder belt over the passenger's shoulder, past the collar bone, and diagonally across the upper chest. Attach it to the stud of the lap belt latch plate. Pull on the loose end through the adjuster to achieve firm yet comfortable tension. Pull on the belt to ensure that everything is properly attached . 2. The following corrective action was initiated on 3/30/2021 prior to the survey. a. CNA #1 was terminated on 3/30/21. b. On 3/30/21, LPN #1, head of transportation conducted check offs of the drivers and inspected the straps in the van. The Transporting by Van skill check off documented, .Steps of Procedure . B. Load resident into the van. Follow the manufactures guidelines for use of the lift. C. Move the wheelchair to the appropriate place in the van for securing. D. Lock the wheels on the wheelchair. E. Using the straps provided, strap each front wheel to the floor brackets. F. Synch the straps as tight as possible. Wiggle the wheelchair several times until the synch is tight as possible. G. For the back wheels of the wheelchair Synch/strap each back wheel of the wheelchair to the floor bracket. H. Using the seatbelt provided ensure that each end of the seat belt is secured to the floor and place the other end of the seat belt through the arms of the wheelchair and buckle in front of the resident . c. The Administrator will randomly monitor LPN # 1 to ensure she residents are properly strapped in the van. The check offs will be turned into the Administrator when completed.

Based on observation, record review and interview, the facility failed to ensure post fall care and services were provided in accordance with professional standards of practice by failing to immediately consult the physicians of continued complaints of hip pain after a fall causing a delay in [DIAGNOSES REDACTED].#72) of 3 (Residents #24, 36, and 72) sampled residents who had a history of [REDACTED]. The facility also failed to ensure a complete neurological assessment was completed after a fall where the resident hit his head to rule out further complications for 1 (Resident #36) of 3 (Residents #24, 36 and 72) sampled residents who had a fall with injury. The failed practice resulted in actual harm for Resident #72 who complained of hip pain for 6 days before being evaluated and diagnosed with [REDACTED]. 1. Resident #72 had [DIAGNOSES REDACTED]. no injury and received 4 days of transfer training. a. A Care Plan dated 11/30/18 documented, Falls .At risk for fall related injury relate to hx (history) [MEDICAL CONDITION] left side weakness and poor balance .7/4/18 Bedside commode in room for use at night .8/16/17 Provide non-skid socks .10/5/17 Put on assignment sheet for resident to be taken to bathroom after meals . As of 1/16/18 at 3:38 p.m., the Care Plan had no review or revisions of the intervention that were put in place or developed since 11/30/18. b. A Nurses note dated 12/05/18 documented, At approximately 1815 (6:15) p.m., resident was found lying alongside left side of wheelchair. Resident lying on left side. CNA was eating lunch in dining area on South, she heard moans. Resident was assisted back to wheelchair X2 assist resident denied any pain during that time. When it was time for resident to dress for bed 30 min (minutes) later, this nurse did ROM (range of motion) when Resident complained of left hip joint pain. When I elevated leg transferring resident to commode resident voiced no complaints. The nurse medicated with [MEDICATION NAME] 50 mg (milligram) 1 PO (by mouth) for complaint of pain at 2120 (9:20 p.m.). Son notified at 2145 (9:45 p.m.) no response. Will continue to monitor. Resident up at nurse's desk due to hollering when CNA was going to assist her to bed. There was no documentation that the Physician had been notified. c. An Incident/Accident Report dated 12/5/18 at 8:15 p.m., provided by the DON on 1/16/18 at 03:30 p.m. documented, Resident lying on left side in dining area on South while CNA was having lunch, she heard moans. (Physician) time of notification 08:15 p.m. Family (Name of family) notified at 9:45 p.m. of fall. Past interventions attempted: Toilet frequently, Resident will not always let us now when she needs to toilet. Will not use call light always for assistance. Non-skid socks. Drop seat in wheelchair with antithrust cushion. Recommendations/New Interventions: CNA instructed by DON on 12/06/18 on taking resident to the bathroom and documenting accurate times on sheet. Trying to establish toileting pattern if possible. A CNA form for Falls and Skin tears signed by CNA #1, not dated, provided by the DON on 01/16/18 at 03:30 p.m. documented, While I was sitting in dining room on South having lunch I heard a noise that sounded like a moan. I looked over counter but didn't see anyone. After hearing it again I got up and walked over and noticed (Resident #72) face down on the floor. I called for the nurse and was assisted by, LPN #2, CNA #2, and CNA #3. d. A Nurses Note dated 12/07/18 at 445 (4:45) a.m. documented, [MEDICATION NAME] 50 mg 1 tab (tablet) PO given for complaint of left leg pain. 0530 (5:30) a.m., med effective. There was no documentation the physician was notified of the continued complaints of pain if true. e. A Nurses Note dated 12/7/18 on 10/6 (Night Shift) documented, .resident complains of left hip pain before lunch and was crying on East. Gave [MEDICATION NAME] 50 mg tabs 1 PO PRN (as needed) pain. There was no documentation the physician was notified of the continued complaints of pain if true. f. A Nurses Note dated 12/09/18 on 6/2 (shift) documented, .Resident up in wheelchair and CNA giving resident shower and said resident was crying in shower room while bathing her. When CNA raised her left leg and moved it resident would grimace. Gave Resident [MEDICATION NAME] and in 45 min resident was talking to me and did not show any pain. Text DON (Director of Nursing) and told her about Resident and when charge nurse came in I explained to her and charge nurse checked resident over and no bruises over hip and foot not turned in or out or shorter than the other noted to the best of my evaluation on resident. Charge Nurse said Resident needs to be seen by Dr. (Doctor) (Physician's Name) tomorrow and may need to go to the clinic if ordered. Will monitor resident. There was no documentation that the physician was notified of the resident complaints of pain. g. A Nurses note dated 12/10/18 at (no time) documented, Acute care visit by Dr. (Physicians' Name) resident continues to complain of left hip pain. Order to X-Ray left hip, Pelvis and Spine. Granddaughter (Name) here at (Nursing Home) at the time of rounds. h. A Physicians Progress note dated 12/17/18 documented, Problem [MEDICAL CONDITION]. (Resident #76) unfortunately fell sustaining a [MEDICAL CONDITION]. She was taken to (Name of Hospital) Hospital where this was required. She was discharged back to us on Friday night. New orders include, Eliquis and [MEDICATION NAME]. She is weight bearing. The wound looks good. She has a follow up appointment with the orthopedist next week. g. On 1/17/19 at 2:10 p.m., the Attending Physician if he was aware of the fall for (Resident #72 on 12/05/18 and stated, Yes, I do recall this incident. This patient had a history of [REDACTED]. She has had a [MEDICAL CONDITION] hip and a compression fracture also. They did call me the day she fell and the DON did an assessment on her that day and we did not feel it was an issue at that time. I did go to the Nursing Home on the next day and I did see the resident but I didn't document a Progress note that day. It was strictly a judgement call because the resident is demented and has a history of pain. I was aware of the fall and the DON was aware of it also, we talked about her, and felt like she was ok. She is demented and not able to give much information. The physician was asked if he was aware that the resident was crying with pain on Saturday (MONTH) 8th and Sunday (MONTH) 9th? He stated, I was not aware nor was I notified on the weekend, it didn't dawn on me she was in so much pain, if she was crying and they didn't call me then that's on them. If I would have known she was crying and in pain over the weekend I would have sent her out to the ER (emergency room ) for an X-Ray. Sometimes when we make a judgement call you hate it, in hind sight I wish I had gone in and twisted on her leg and checked her better on (MONTH) 6th but I didn't and this is one I don't feel bad about the decision I made. We just misjudged her and her degree of pain. 2. Resident 36 had [DIAGNOSES REDACTED]. The Significant Change MDS with an ARD of 11/15/18 documented the resident was severely impaired in cognitive skills for daily decision making per a staff assessment for mental status, required limited assistance of one person for transfers, was not steady when moving from a seated to standing positions and only able to stabilize with human assistance and had 1 fall without injury and one fall with injury. a. A Nurses Note dated 12/27/18 at 12:05 p.m. documented, CNA (Certified Nurse Assistant) states she stood resident up to change brief, when she reached for brief resident fell backward to floor hitting back of head on metal bed frame. 1-inch laceration actively bleeding no change in L[NAME] (Level of Consciousness) C/O (complaint of) pain to head Dr. (Doctor), family and Town) ER (emergency room ) notified, transported to ER at 12:30 p.m. At 2:05 p.m., call from ER reports 6 staples CT (Computerized Tomography) negative 1st dose of antibiotic given in ER. b. A Fall Investigation Report dated 12/27/18 at 12/27/18 documented, CNA in-service by nurse not to leave resident standing unassisted, also applies hand reach. Attached was a form titled CNA form for falls and skin tears This form documented, .What did the resident have on their feet? Non-skid socks. The Care Plan dated 11/16/18 documented, Problem transfer safety resident transfers with gait belt assist x (times)1 . Interventions . CNA information sheet will reflect that resident transfers with gait belt assistance x1 . at risk for fall related injury as evidenced by history of falls and poor balance . Interventions .call light within reach, adequate glare free lighting, area free of clutter. As of 1/14/19 at 3:26 p.m., there was no update of the post-fall intervention on the Care Plan or of the non-skid socks. c. On 1/14/18 at 3:26 p.m., the Nurse Aides information sheets for the following dates were reviewed: 11/2/17, 1/20/18, and 6/7/18 documented, .Privileges up ad lib (at liberty), locomotion rolling walker with 1 assist, gait belt. The Nurses Aide's Information Sheet had a line drawn through the date with no updates documented. d. On 1/18/19 at 8:33 a.m., the MDS Coordinator was asked, should interventions be updated on the Care Plan and the CNA information sheet after it's been identified? The MDS Coordinator stated, Yes. 3. On 1/17/19 at 2:45 p.m., the Director of Nursing was asked for the facility's Policy and Procedure for falls. The DON stated, We don't have policy and procedure for falls she was asked do you complete neurological checks after falls? The DON stated, Yes, involving the head and looked in the medical record and was unable to locate the separate form it would be documented on.