Every finding on record at Fellowship Village

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for Quarter 2, 2024 (January 1 - March 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 31 residents. Findings include: The PBJ Staffing Data Report run date 8/29/24 triggered for Failure to have Licensed Nursing Coverage 24 Hours/Day-Four or More Days Within the Quarter with less than 24 Hours/Day Licensed Nursing Coverage. Dates of less than 24 hours nursing coverage were documented as 01/27, 02/25, 03/02, 03/10, 03/24, and 03/31. Review of Facility Daily Assignment Sheets for revealed staffing for 01/27, 02/25, 03/02, 03/10, 03/24, and 03/31 had licensed nursing coverage 24 hours a day. Review of document titled, Reporting Direct Care Staffing Information - PBJ documented staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act. Beginning with the fiscal quarter of 2016 (beginning July 1, 2016), direct-care staffing and census information will be reported electronically to CMS through the Payroll-Based Journal (PBJ) system. Direct-care staffing information includes staff hired directly by the facility, those hired through an agency, and contract employees. On 9/4/24 at 2:42 PM the Administrator stated the PBJ triggered because there were invoices that were not logged for agency staff by the previous administration. The Administrator stated there was a new process for reporting agency staff hours. The Administrator acknowledged the PBJ was submitted inaccurately.

Based on observation, document review and staff interview the facility failed to follow the menu and prepare food to meet the nutritional needs for 11 of 31 residents reviewed. The facility reported a census of 31 residents. Findings include: Continuous observation of lunch meal service on 9/4/24 from 11:20 AM - 11:45 AM revealed no bread or garlic bread served to the residents that had requested on the menu sheets. Review of menu sheets revealed 11 residents requested garlic bread. Review of document titled, Week 4 Menu documented bread to be served at lunch meal. On 9/4/24 at 11:54 AM Staff B Certified Dietary Manager (CDM) stated garlic bread was offered at the lunch hour on the menu on accident and was not served. Staff B stated the kitchen staff had forgotten to serve any bread in place of the garlic bread on the menu. Review of policy titled, Nutrition and Menu Planning documented to maintain adequate nutritional status of residents to promote optimum level of functioning through menu planning. Menus must be followed as written with the following exceptions: ethnic, cultural geographic, religious practices, or dislikes of a resident that require substitutions. On 9/4/24 at 12:10 PM the Administrator stated the facility's expectation was that the lunch meal on 9/4/24 was served according to the menu and the residents who wanted bread would have received the bread.

Based on observation, document review, staff interview, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs by use of incorrect serving size portions for meals for 1 of 31 residents reviewed, (Resident #4). The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #4 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Review of Resident #4's dietary orders documented pureed consistency. Observation of the puree food process on 9/4/24 at 10:00 AM revealed Staff A, [NAME] revealed 1 breaded chicken patty, 1 piece of bread, and 1/2 cup of gravy processed in the food processor together. There was 3/4 a cup of pureed food measured after processed. Observation of lunch meal service on 9/4/24 at 11:20 AM revealed Staff A used a heaping green handled (1/3 cup) scoop of pureed breaded chicken for Resident #4's lunch. Observation revealed Staff A measured remaining pureed breaded chicken with a measurement of greater than 1/4 but less than 1/2 of a cup left. On 9/4/24 at 11:50 AM Staff A stated she usually used the 1/2 scoop but did not have one available so she used a heaping scoop of a 1/3 cup for the pureed portion. Staff A stated the facility used the Document, Diet Portion Sizes / Scoops for pureed sizes and scoops. On 9/4/24 at 11:54 AM Staff B, Certified Dietary Manager stated with one serving being processed for a pureed diet all of the food should be used. Staff B stated there should not have been any leftovers. Staff B acknowledged there was leftover food from the pureed breaded chicken and should not have been any leftover food from the puree process. Staff B stated garlic bread was offered at the lunch hour on the menu on accident and was not served. Review of policy titled, Altered Texture Diets documented altered textures will be provided for residents as needed that have equal nutritive value to the regular texture diet. Each menu item will be portioned into the food processor using the correct portioning Utensil, i.e., if two residents require pureed diets in the facility and 1/2 c. (#8) was the portion size for fruit cocktail, I c. (2-#8 scoops) would be placed in the processor. After menu items are pureed they will be divided evenly among the portions prepared. I.e. if two portions were pureed, the amount will be divided equally into two servings. This may be done with portion control utensils. On 9/4/24 at 12:10 PM the Administrator stated the facility's expectation was that the appropriate serving would have been served to residents. The Administrator stated the facility's expectation was that the lunch meal on 9/4/24 was served according to the menu.

Based on clinical record review and staff interview, the facility failed to obtain resident/ resident representative signatures or record attempts to obtain resident/resident representative signatures on notification of the Notice of Medicare Non-Coverage (NOMNC) Centers of Medicare & Medicaid (CMS)-10123 for 2 of 3 sampled residents (Resident #8 and #27) and CMS form CMS-10055 for 1 of 3 sampled residents (Residents #27). The facility reported a census of 29 residents. Findings Include: 1. Record review for Resident #8 revealed form CMS 10123-NOMNC with a services end date of 9/12/23. Resident #8 ' s representative gave verbal consent for signature on 9/8/23 however lacked a signature of patient or patient representative and date. Review of Resident Progress Notes dated 9/8/23 at 2:02 p.m., revealed Reviewed the SNFABN and NOMNC with representatives. She chooses option 3 on the SNFABN and signs both. Declines copies of both. 2. Record review for Resident #27 revealed form CMS 10055 with a services end date of 7/11/23. Resident #27 ' s representative gave verbal consent for signature on 7/7/23 however the form lacked a signature of patient or patient representative and date. Review of form CMS 10123-NOMNC with a services end date of 7/10/23. Resident #27 ' s representative gave verbal consent for signature on 7/7/23 with a note date 7/10/23 copy sent to family member, however lacked a signature of patient or patient representative and date. Review of Resident Progress Notes dated 9/8/23 at 5:19 p.m., revealed Resident has met treatment goals, has achieved maximal progress with physical therapy and occupational therapy and her last day of covered services is 7/10/23. Resident #27 ' s representative choses option 3 on the SNFABN and asks that copies of the SNFABN and NOMNC be sent to another family member. Review of the Centers (CMS) Medicare Claims Processing Manual Chapter 30 with a revision date of 1/21/22 revealed the following information under ABN options for Delivery other than in-person revealed ABNs should be delivered in-person and prior to the delivery of medical care which is presumed to be non-covered. In circumstances when in-person delivery is not possible, notifiers may deliver an ABN using another method. Examples include: Direct telephone contact; Mail; Secure fax machine; or Internet e-mail. All methods of delivery require adherence to all statutory privacy requirements under HIPAA. The notifier must receive a response from the beneficiary or his/her representative in order to validate delivery. When delivery is not in-person, the notifier must verify that contact was made in his/her records. In order to be considered effective, the beneficiary should not dispute such contact. Telephone contacts should be followed immediately by either a hand-delivered, mailed, emailed, or a faxed notice. The beneficiary should sign and retain the notice and send a copy of this signed notice to the notifier for retention in the patient ' s record. The notifier must keep a copy of the unsigned notice on file while awaiting receipt of the signed notice. If the beneficiary does not return a signed copy, the notifier should document the initial contact and subsequent attempts to obtain a signature in appropriate records or on the notice itself. Review of the CMS NOMNC form instructions for the NOMNC CMS-10123 revealed the signature line: beneficiary/enrollee or the representative must sign this line and the date line: The beneficiary/enrollee or the representative must fill in the date that he or she signs the document. If the document is delivered, but the enrollee or the representative refuses to sign on the delivery date, then annotate the case file to indicate the date that the form was delivered. CMS requires that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. Notification to the representative may be problematic because that person may not be available in person to acknowledge receipt of the required notification. Providers are required to develop procedures to use when the beneficiary/enrollee is incapable or incompetent, and the provider cannot obtain the signature of the enrollee ' s representative through direct personal contact. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee ' s services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. The date that someone at the representative ' s address signs (or refuses to sign) the receipt is the date of receipt. Place a dated copy of the notice in the enrollee ' s medical file. When notices are returned by the post office with no indication of a refusal date, then the enrollee ' s liability starts on the second working day after the provider ' s mailing date. Interview on 12/05/23 at 9:23 a.m., with the Administrator revealed the office staff has always done the verbal verification and recorded that on the form.

Based on observations, facility policy review and staff interviews, the facility failed to perform proper hand hygiene during routine cares for 1 of 12 residents reviewed (Resident #19). The facility reported a total census of 29 residents. Findings included: 1. The The Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 documented diagnosis diabetes mellitus, cerebrovascular accident, hemiplegia. The MDS included a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. Observation on 12/04/23 at 1:15 p.m. Staff B, Certified Nursing Assistant (CNA), applied gloves after entering the room, Staff B failed to perform hand hygiene prior to applying clean gloves. Staff B and Staff C, CNA, proceeded to perform the EZ lift transfer with gloves on and placed Resident #19 in bed. Staff B and Staff C assisted with pulling the resident ' s pants down with soiled gloves. Staff B proceeded to remove the soiled incontinent brief and discarded it into the trash. Staff B with soiled gloves proceeded to use wipes to perform perineal care on Resident #19. Staff B and Staff C removed soiled gloves. Staff B and Staff C did not perform hand hygiene after removal of soiled gloves. Staff B applied a clean brief with the help of Staff C. Staff B and Staff C pulled up the resident ' s pants and then continued to assist him to his recliner. Staff B and Staff C did not perform hand hygiene before leaving the room. In an interview on 12/06/23 at 8:37 a.m., the Director of Nursing (DON) stated that expected staff to change gloves between cares and to sanitize/wash hands after cares are complete. DON stated definitely if gloves are visibly soiled to sanitize/wash hands and change gloves. Review of the facility provided policy titled Handwashing with a revision date of August 2020 revealed the following information: Turn water on to desirable temperature. Wet hands and wrists with water and then lather with soap or detergent. Use 20 seconds of vigorous friction beneath running water to all hand and wrist surfaces, under fingernails, and beneath rings. Rinse hands thoroughly under stream of water pointing fingers downward so water does not drip toward elbows. Note: Do not touch sink and keep splashing to a minimum. Leave faucet running. Dry hands completely with a clean, dry paper towel and discard. Use clean towel to turn off faucets. Discard towel. Use hand lotion if desired. Review of the facility provided policy Peri Care with a revision date of September 2023 revealed the following information: Provide privacy for resident. Place either plastic bag or soaker on end of bed or on floor for soiled linen. Wash hands and put on gloves. Remove soiled pad, clothing, or linen. For men: Cleanse penis and scrotum. Push foreskin back gently, cleanse and pull foreskin back as was. Turn cloth. Wash down one side of groin. Turn cloth. Wash down other side of groin. Using same process, rinse area with clean wet cloth. For women: Lay on back. Separate labia and wash front to back Turn cloth. Wash down one side of groin. Turn cloth. Wash down other side of groin. Using same process, rinse area with clean wet cloth. For both: Turn resident to side and wash buttocks, thigh area, and rectal area (washing front to back). Do not roll cleansed area onto wet/dirty linen or you must re-wash. Using same process, rinse area with clean wet cloth. Dry thoroughly. Place soiled washcloths/towel in plastic bag or on soaker. Review of the CDC document titled Hand Hygiene Guidance states Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient ' s immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal Healthcare facilities should: Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention(CDC) recommendations Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and,in the absence of a sink, are an effective method of cleaning hands.

Based on clinical record review, observation, resident interview, staff interviews, and facility record review, the facility failed to provide adequate nursing supervision to prevent a fall for 1 of 3 residents reviewed (Residents #132). The facility reported a total census of 29 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #132 documented diagnoses of Alzheimer ' s Disease, hyperlipidemia and depression . The MDS showed the Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. The MDS revealed resident used a bed and chair alarm daily. Review of Resident #132 Care Plan dated 10/12/22 revealed under mobility and safety, personal pressure alarms when in a wheelchair. He has a pressure pad personal alarm under him at night in bed. Floor mat alarm was felt to be unsafe if he was going to attempt to get up alone at night so not used. Staff are to get him ready for bed around 7:00 p.m. to avoid falls as he has fallen in the past trying to get himself ready for bed. Review of facility provided document titled Incident Report Follow-up dated 10/18/22 at 10:10 p.m., revealed Resident #132 had fall in the room, found lying on his right side facing the bathroom door with a wheelchair at his feet. Review of handwritten documentation by Staff D, Certified Nursing Assistant (CNA) revealed Resident on the toilet and his wheelchair next to him locked. Left for 8 minutes. My timer went off, went back. Staff E, CNA was in the room. Resident was on the floor in front of the bathroom wheelchair against the west wall. Assisted in lifting resident to bed. Nurse assessed resident. Handwritten on the side of the page revealed a checklist cheat sheet used and care plan used. Review of cheat sheet revealed in bold print alarms at all times. Review of handwritten documentation by Staff E, CNA revealed resident was lying facing the bathroom door when I came to the room. The wheelchair was at his feet, facing him. Staff asked if he had pain and he complained of pain in his legs and lower back. His walker was by the red chair next to the window. Review of the facility policy titled Personal Alarms with a revision date 9/18 revealed each personal alarm will be attached to the resident and the bed, wheelchair or recliner as ordered. If resident who utilizes alarms who is toileting then the alarm will be attached to the resident or staff will stay with the resident. Interview on 12/05/23 at 3:54 PM with the Administrator revealed the resident should not have been left alone in the bathroom if he had an alarm. Interview on 12/06/23 at 10:26 a.m., with Staff F, Registered Nurse (RN) revealed she was working as a resource nurse at the time of the resident ' s fall and she revealed she would remind staff consistently to make sure if a resident had a personal alarm then they are never to be left alone in the bathroom. Staff F further revealed Staff D should have never left resident in the bathroom alone since he had an alarm.

Based on observation, facility policy, and staff interview, the facility failed to ensure the kitchen was clean, sanitary, and opened food was dated. The facility reported a census of 31 residents. Findings include: Observation on 7/17/22 at 9:43 AM revealed the following: a. Bowls on a shelf to the left of the serving window stored right side up. b. Plate covers to the right of the serving window stored right side up. c. [NAME] 2 door refrigerator with a tray of poured drinks stored uncovered. d. Lower shelf of a table under the window with metal bowls nested and stored right side up. e. Bulk flour and sugar bins without a date label. f. The dry storage room contained 2 bags of cereal that were open and undated, 4 plates of individually wrapped baked goods undated, and an open box of disposable spoons uncovered. g. Walk in freezer with undated and opened bag of breaded patties and green beans. h. Staff B, dietary aide, walked into the kitchen without a hairnet, she then obtained supplies to cut and plate pie, put on gloves without performing hand hygiene, and then cut and plated pie. During the same observation, Staff B, Staff D, and Staff E, all dietary aides, were asked to test the quaternary solution in the bucket. All reported they had no training to do this task. Observation on 7/19/22 at 11:02 AM revealed the bowls, plate covers, and nested mixing bowls were right side up, the box of disposable spoons was still open and unsealed, bulk flour and sugar bins were undated, and the 2 bags of opened frozen foods in the walk in freezer were undated. Observation on 7/19/22 at 11:26 PM revealed Staff F, dietary aide, clean the thermometers used to measure the temperature of food before lunch. She dipped the ends of the 2 thermometers in each of the sink solutions for 15 seconds a piece in the 3 compartment sink and then dried the thermometers with a paper towel. The Food Supply and Storage policy dated 6/89 directed the following: a. All individual packages of food once opened are labeled with the date (day-month and placed in plastic containers with lids. b. All foods in the walk-in cooler or refrigerator must be in a covered container such as a plastic bin, a baking pan covered with plastic wrap or aluminum foil. The Dish and Ware Washing policy dated 6/89 directed the following: a. To immerse utensils in third compartment for one minute and then air-dry before storing. b. A quaternary ammonium product is used as the sanitizing agent. The product is dispensed automatically into the water. In order to verify the solution is at least 160 ppm (parts per million), the concentration is tested each time the sink is filled. In an interview on 7/18/22 at 9:17 AM, the Dietary Manager (DM) reported 2 of the staff working in the kitchen on 7/17/22 did not attend the education session she held on measuring the quaternary solution level and the third staff member in the kitchen on 7/17/22 was a new employee which is why she did not know how to measure quaternary solution levels. In the same interview, the DM reported she would ensure the employees would receive the necessary education, but that she did not view this as an item to keep a log of levels. In an interview on 7/19/22 at 1:13 PM, the DM reported she has told staff to store dishes and kitchen ware right side down, but that someone has continued to store items right side up. In the same interview, the DM was unaware that there were no date labels on some of the food in the kitchen. During the remainder of the interview, the DM responded to questions by nodding her head in agreement.

Based on observations, staff interviews, facility policy, and CDC recommendations the facility staff failed to properly wear face coverings for healthcare workers. The facility reported a census of 31 residents. Findings include: 1. Observation on 7/17/22 at 9:05 AM., Staff C, Certified Nursing Assistant enter Resident #13's room without a mask on. 2. Observation on 7/17/22 at 10:41 AM Staff B, Dietary walked in the kitchen and was moving dishes around. Staff B had a mask underneath their chin exposing mouth and nose area. 3. Observation on 7/17/22 at 12:58 PM of Staff B, dietary in the kitchen placing clean cups onto a serving tray and was noted to have a mask underneath their chin exposing the mouth and nose area. Interview on 7/19/22 at 2:09 PM with the Director of Nursing revealed she expects all staff to wear their mask up at all times when working. Review of facility policy titled COVID-19 Infection Control policy with a revision date of 6/22 revealed the use of source control, including the use of a well-fitting face mask or respirator will be expected at all times unless criteria is met that is later identified in this policy. Centers for Disease Control and Prevention website titled, Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, visited 6/29/22 and updated 2/2/22, revealed Healthcare Personnel (HCP) should wear well-fitting source control (use of well-fitting face masks to cover a person ' s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing) at all times while they are in the healthcare facility. The website further revealed, if worn properly a facemask helps block respiratory secretions produced by the wearer from contaminating other persons and surfaces and source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. The Website revealed HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).

Based on personnel file reviews, facility policy review and staff interview, the facility failed to provide dependent adult abuse training within 6 months of hire for 1 of 5 employees reviewed (Staff A). The facility identified a census of 31 residents. Findings include: The personnel file for Staff A, dietary services documented a hire date of 10/8//21. The file did not contain documentation of dependent adult abuse training. Interview on 7/17/22 at 1:12 p.m., with the Administrator revealed Staff A did not have her dependent adult abuse training done and she would expect her to have completed prior to the 6 month period. Review of facility policy titled Abuse Prevention Policy with a revision date of 5/22 revealed each employee shall be required to complete two hours of training relating to the identification and reporting of dependent adult abuse within six months of initial employment.

Based on clinical record review, observation, resident interview, staff interviews and facility record review the facility failed to provide adequate nursing supervision to prevent injuries for 1 of 4 residents reviewed (Residents #1). The concern was corrected by the facility on December 2, 2021 prior to surveyor entrance by completing staff education on hoyer lift use and audits. No concerns with hoyer transfers were made during the investigation. The F689 at a (G) level will be considered past non-compliance. The facility reported a total census of 33 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnoses of [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)] and [CONDITION(S)] following a cerebral infarction. The MDS showed the Brief Interview for Mental Status (BIMS) was not assessed. Review of Progress Notes revealed the following: * 11/29/21 at 3:34 p.m., noted Certified Nursing Assistant's (CNA) were transferring Resident #1 with a total lift from her wheelchair to her bed. Resident #1 was raised up in total lift when she fell from total lift onto the floor. Resident hit her head on the floor. Resident #1 was noted to have a goose egg on the left side of her head. Resident #1 was moaning out in pain. Resident #1 was transferred into her bed. Vital signs were taken. Neurological checks started. No other visible injuries noted. * 11/29/21 at 3:53 p.m., call placed to Resident #1's family updating them on Resident #1's fall. Resident #1 was resting in bed at this time and an ice pack was applied to head. Resident #1 appeared to be comfortable with no moaning noted. * 11/29/21 at 5:30 p.m., Resident #1 was assessed and noted right leg and foot rotated outward and Resident #1 moaning in pain with any movement. Call placed to Resident #1's family member with an update on Resident #1 s condition. Telephone order received to have Resident #1 transported via ambulance to the emergency room for evaluation. * 11/29/21 at 6:09 p.m., Resident #1 left the facility via ambulance. * 11/29/21 11:28 p.m., revealed facility updated on Resident #1 condition. Resident #1 had a closed [CONDITION(S)] and closed head injury. * 11/30/21 at 9:40 a.m., revealed Director of Nursing (DON) spoke with CNA's regarding Resident #1's fall. CNA's reported they were attempting to move Resident #1 from her wheelchair to her bed. CNA's crossed the sling between Resident #1's legs and while in the process of lifting her high enough to clear the wheelchair her gastric bag was noted to be hooked on the wheelchair and slightly pulling. At the moment the CNA was reaching to unhook the gastric bag Resident #1 suddenly leaned to her left and out of the sling to the floor. CNA's report Resident #1 hit her head on the floor during the fall. The DON heard CNA's calling for help and entered the room along with the Charge Nurse immediately. Resident #1 was laying on the floor, the hoyer sling still hooked up to the lift. Observed hoyer sling to be on lift correctly with legs crossed and green loops used. Gastric bag was unhooked and lying on the floor. In first assessment Resident #1 was noted to have a bump to the left side of her head and was moaning. On further assessment Resident #1's right leg was noted to be externally rotated and shortened. Resident #1 transported to hospital. Major injury form returned as a major injury. Resident #1 having right hip pinning done today. Staff education is done immediately with CNA's involved and will review with others who are trained in using lifts. Review of Vitals Report revealed Resident #1's weight on 11/24/21 at 11:28 a.m. was 131.5 pounds. Review of facility Incident Report follow-up dated 11/29/21 at 3:00 pm., revealed the following information: Resident #1 was being transferred using the total lift and fell from lift while transferring Type of injury revealed fall from total lift Contributing factors to incident revealed sling placement Intervention noted on how to prevent this from happening again? What was the intervention revealed, staff education on sling placement. Review of the Major Injury Determination form revealed an X in front of the following statement, after reviewing the circumstances of the incident causing the injury, the previous functional ability of the patient and the patient;s prognosis, I believe the injury sustained is a major injury pursuant to 481 Iowa Administrative Code 50.7(1)(a)(3). The form was signed by the physician on 11/29/21 at 11:34 p.m Review of the Facility Incident Investigation form dated 11/30/21 signed by the DON revealed under resident and staff interview the CNA's state the sling appeared to be in the correct place. Resident #1 has abnormal posture with no control of the trunk, [CONDITION(S)], and [CONDITION(S)]. As she is not able to to assist with mobility center of gravity along with pulling of gastric bag may have contributed to Resident #1 falling out of the sling. Physical Therapy to evaluate appropriateness of hoyer lift and if any changes need to be made with transfers. Nature of injury revealed an X in front of fracture/ dislocation and an X in front of hematoma. Intervention to prevent further incidents revealed staff education and physical therapy to evaluate appropriateness of hoyer lift on return. Review of Resident #1 Care Plan dated 9/30/21 revealed Resident #1 has [CONDITION(S)], history of a stroke, and [CONDITION(S)]. Resident #1 was unable to assist with bed mobility. Resident #1 was transferred with a hoyer lift and assist of 2-3 staff. Resident #1 had poor trunk control and her wheelchair was modified to give her better support. Fall and injury prevention interventions and programs included hoyer lift for transfers with assist 2-4 staff. Review of hospital records revealed the following: On 11/29/21 at 11:37 p.m., Resident # 1 was diagnosed with a right intertrochanteric [CONDITION(S)]. Chief complaint: Resident #1 who was seen in consultation regarding right [CONDITION(S)] that occurred this afternoon when she fell about 3 feet from a hoyer lift at the nursing home. Review of x-ray of the pelvis with hip 1 view dated 11/29/21 at 9:11 p.m., revealed the findings of osteopenia. Acute comminuted and displaced intertrochanteric fracture of the proximal right femur. Distal fracture fragment is displaced approximately 1.9 centimeters medially. No other fractures identified. Review of X-ray of the Femur 2 view on the right side dated 11/29/21 at 9:12 p.m., revealed the finding of acute mildly comminuted and displaced intertrochanteric fracture of the proximal right femur. Review of CT scan of the head without contrast dated 11/29/21 at 9:26 p.m., revealed scalp hematoma in the left parietal region. On 12/1/21 at 8:19 p.m., Resident #1 acute problems included: Hypotensive shock with concerns for [CONDITION(S)], Normocytic [CONDITION(S)],transfuse one packed red blood cells and Right [CONDITION(S)]. On 12/2/21 at 10:39 a.m., Resident #1 acute problems include: Septic shock, Acute complicated urinary tract infection, Normocytic [CONDITION(S)] and Right [CONDITION(S)]. On 12/3/21 at 11:09 a.m., Resident #1 acute problems include: Septic shock, Acute complicated urinary tract infection, Normocytic [CONDITION(S)]- Will transfuse one packed red blood cells, Right [CONDITION(S)] and [CONDITION(S)]. On 12/4/21 at 8:51 a.m., Resident #1 acute problems include: Septic shock- resolved, Acute complicated urinary tract infection, Normocytic [CONDITION(S)], Right [CONDITION(S)] and [CONDITION(S)]. On 12/8/21 at 8:12 a.m., Discharge Diagnosis include: Septic shock, Acute complicated urinary tract infection, Normocytic [CONDITION(S)], Right [CONDITION(S)] and [CONDITION(S)]. On 12/8/21 at 8:12 a.m., Hospital Course Summary of Resident #1 revealed: Resident #1 with above past medical history was admitted for right [CONDITION(S)] and now s/p right intertrochanteric [CONDITION(S)] by orthopedics. She developed [CONDITION(S)] from urinary tract infection with urine cultures. She was transferred to the Intensive Care Unit (ICU) due to [CONDITION(S)] not improving with intravenous fluid hydration and started on pressors which was weaned off the following day. She has completed antibiotics for 5 days with blood cultures negative. She also received 2 units of packed red blood cells for critically low hemoglobin below 7 which improved to 10's prior to discharge. She was continued on home table salt for acute on chronic [CONDITION(S)]. She continued on her home medication but home blood pressure medications discontinued for low blood pressures inpatient and started on low dose of [MEDICATION(S)]. 2.5mg. Primary Care Physician to titrate blood pressure medications as needed. She is medically stable at baseline for discharge. On 12/8/21 at 8:45 a.m., Assessment and Plan included the following: Physical Therapy and Occupational Therapy included out of bed, weight bearing status: patient is non ambulatory at baseline, ok for lift use. Disposition and planning included: recommend return to nursing facility depending on progression in therapies, will have case management and social worker assist with placement needs, ok to transfer or discharge when pain is well controlled on oral medications, and medically stable and cleared for discharge. Follow up in three weeks. Review of Resident #1's Progress Notes revealed the following: On 12/8/21 at 2:45 p.m., Resident #1 returned to the facility per staff and van. Resident #1 was readmitted to routine nursing service. Physical Therapy and Occupational Therapy to evaluate and treat to assess for safety with transfers. Right hip incisions (2) are open to air, staples in place. There is some bruising around incision sites. Okay to use the hoyer lift. Resident #1 cries out with any movement or repositioning. Resident appears comfortable (no crying) when finished with care. Will log roll with pillow between legs. On 12/8/21 at 5:30 p.m., Resident #1 crying out in pain with repositioning this afternoon and hoyer lift to recliner after both tylenol and [MEDICATION(S)]. Once settled no signs or symptoms of pain. Doctor notified. On 12/8/21 at 8:26 p.m., Resident #1 given as needed medication given along with scheduled medication to promote comfort as has pain with repositioning. Non-pharmacological intervention to promote comfort is done as well. On 12/9/21 at 3:51 p.m., Resident #1 cries out with repositioning. Is on scheduled tylenol and [MEDICATION(S)]. On 12/9/21 at 9:56 p.m., Resident #1 cries out when repositioned, continues on scheduled [MEDICATION(S)] and acetaminophen. On 12/10/21 at 12:10 p.m., Resident #1 continues with right hip pain with movement. Better once resting. Resident #1 scheduled pain medication with little relief. No further grimacing or calling out while resting. On 12/10/21 at 12:57 p.m., Resident #1 received an order for [MEDICATION(S)] three times a day. On 12/11/21 at 12:57 a.m.,Resident #1 noted to have decreased yelling out with repositioning. On 12/11/21 at 11:37 a.m., Resident #1 is on [MEDICATION(S)] three times a day with some effectiveness. No crying out this morning. On 12/12/21 at 3:30 p.m., Resident #1 [MEDICATION(S)] seems to be helping with pain control during transfers and positioning. Cries out with transferring into the recliner this morning but no crying during repositioning this afternoon. On 12/13/21 at 2:55 a.m., Resident #1 has decreased calling out after [MEDICATION(S)] dosage given. On 12/13/21 at 3:32 p.m., Resident #1 is on [MEDICATION(S)] three times a day and pain is somewhat under control with scheduled [MEDICATION(S)]. Does cry out on occasion with repositioning. On 12/13/21 at 10:52 p.m., Resident #1 receives [MEDICATION(S)] for pain. Resident #1 does cry out at times with repositioning. On 12/14/21 at 2:04 p.m., Resident # 1 continues with some complaints of pain but much improved with [MEDICATION(S)]. Review of December 2021 Medication Administration Record (MAR) revealed an order on 12/10/21 for [MEDICATION(S)] 50mg per g-tube three times a day diagnosis right [CONDITION(S)]. Administration times are 9:00 a.m., 2:00 p.m., and 10:00 p.m Observation on 12/14/21 at 3:29 p.m., revealed Resident #1 laying in bed with eyes open facing the wall. Resident #1 was noted to be lying on left hip with a pillow behind her. Resident was covered with a sheet. Resident #1 noted to have a mat laying next to the right side of the bed. Interview on 12/14/21 at 3:38 p.m., with Staff A, Certified Nursing Assistant (CNA) revealed Resident #1 had been out to an appointment and had returned to the facility on [DATE]. Staff A, CNA and Staff I, CNA were assisting Resident #1 out of her wheelchair. Staff A took the lift and placed it in front of Resident #1. Staff I was behind Resident #1. Staff A revealed she could not see the sling under Resident #1 and thought it could have been wrong but it looked correct. Staff A revealed she crossed the sling between Resident #1's legs. Staff A and Staff I hooked Resident #1's sling up to the hoyer lift. Staff A revealed the top of the sling was hooked on the black hook and the bottom was hooked on the green hooks. Staff A revealed she lifted the hoyer lift a little bit and everything looked good so she proceeded to lift the sling up to transfer Resident #1. Staff A revealed she pulled the hoyer lift toward her and Staff I pulled the wheelchair back. Staff A revealed she noticed Resident #1's gastric bag was still hooked on the wheelchair. Staff A turned her body to unhook the gastric bag and when she turned back Resident #1 was laying on the floor. Staff A revealed Resident #1 was saying owie owie owie. Staff A stated that Resident #1 was laying on her left side on the floor. Staff I stayed with Resident #1 while Staff A went to get help. Staff A stated the Nurse that was on assessed her and then the staff in the room picked Resident #1 up manually and placed her into bed. Staff A stated that her and Staff I rolled resident to change her incontinent brief and Resident #1 stated owie but that was usual behavior for her. Staff A revealed the only injury she noted was a bump on her head. Staff A stated the nursing staff was assessing her after they completed Resident #1's care. Staff A revealed the incident happened so fast she is unsure of how it all happened. Observation on 12/14/21 at 5:07 p.m., revealed Staff A, CNA and Staff B, CNA assisting Resident #1 with transferring from her bed to her recliner. Observation of Resident #1 revealed two incisions on the right hip area and 1 incision on the outer upper thigh area. Observation of the incisions on the right hip area revealed a small incision with 3 staples with another incision next to the first incision with 12 staples. Area was well approximated and showed no signs or symptoms of infection. The incision on Resident #1's outer upper thigh area had 7 staples. Area was well approximated and showed no signs or symptoms of infection. Dark purple, yellow and green bruising was noted around the incision. Staff A and Staff B rolled Resident #1 to place the hoyer sling under her. Noted Resident #1 say owie with eyes squeezed closed and wrinkled face. Staff A pulled the hoyer lift over to the bed and crossed the hoyer sling between her legs and hooked up the bottom of the sling on the green loops and the top on the black loops. Staff A used the lift to lift Resident #1. Staff B supported Resident #1 body and legs during transfer to the recliner. Staff. A lowered Resident #1 into her recliner. When hoyer lift was low enough Staff A and Staff B unhooked Resident #1 and pulled the hoyer lift back. During interview on 12/15/21 at 10:00 a.m., the Housekeeping Lead revealed the facility washes the hoyer slings on a gentle cycle and hangs the slings in the laundry room to dry. After the slings are dry then they are taken out to the storage room and hung on the correct size in the storage room. The Housekeeping Lead revealed she works with the maintenance department to do the audits on the lift and lift sheets. Interview on 12/15/21 at 10:32 a.m., with Staff D, Registered Nurse (RN) revealed when Staff D entered the room on 11/29/21 and noted the hoyer sling was still hanging on the lift and the resident was laying on the floor. Staff D stated she assessed Resident #1 and assisted her with other staff's help into her bed. Staff D stated she had been doing assessments and found the right leg rotated outward and sent to the emergency room . Interview on 12/15/21 at 10:58 a.m., with Staff E, RN revealed she heard yelling and entered into Resident #1's room and seen Resident #1 laying on the floor crying. Staff E stated she noticed a bump on Resident #1's head. Staff E stated the sling was still connected to the hoyer lift. Staff E stated the hoyer lift sheet was hooked up correctly and the legs were crossed. Staff E revealed if there are slings that are showing any wear or have any type of tears they are removed from service and thrown away. A new one is ordered to replace the discarded one. Interview on 12/15/21 at 2:26 p.m., with the DON revealed she had heard staff calling out for help and went to Resident #1's room. Upon entering the room the DON noted Resident #1 was laying on the floor and the hoyer lift with the lift sheet was still attached to the lift. The DON revealed Staff A, CNA stated Resident #1's gastrointestinal bag had been hooked and Resident #1 went to the left and fell out of the lift. DON revealed upon inspection of the hoyer lift the sling was hooked up correctly with the bottom two straps crossed. Interview on 12/15/21 at 2:35 p.m., with Staff I, CNA revealed that her and Staff A, CNA had brought Resident #1 back to her room to transfer her out of her wheelchair as she had returned from an appointment outside of the facility. Staff I revealed Staff A was running the levers and she was guiding Resident #1's feet when Staff A and Staff I noticed the gastrointestinal bag was still attached to the wheelchair in the privacy bag. Staff I stated when they wet to move the bag Resident #1 fell out of the lift sideways. Staff I and Staff A got assistance right away from nursing staff. Staff I revealed the gastrointestinal bag had come unattached from Resident #1's port during the fall. Staff I stated the lift sheet was hooked on the black loops on the top and bottom was hooked on the green loops. Staff I revealed she did not notice anything different with Resident #1 or her lift sheet upon return from her appointment outside of the facility. Staff I revealed the nursing staff were assessing her after she was comfortable in bed. Staff I revealed she is unsure of what happened exactly as it happened so fast. Observation on 12/15/21 at 2:54 p.m., revealed Resident #1 in bed watching a program on television. Resident appeared to be resting comfortably. Observation of the gastrointestinal bag revealed a bag of approximately 7 inches long by 4 inches wide. Interview on 12/15/21 at 3:07 p.m., with the DON revealed the education was a packet of information that the hoyer lift company puts out as well as information from the facility. Each staff member was to sign off they had received and read the information provided. Review of Resident #1's Care Plan dated 9/30/21 revealed the following information: 11/29/21- To the hospital. 12/8/21- Return from hospital. 11/29/21- Large sling. Ensure sling positioned properly under her prior to transfer. 12/8/21- Returns from hospital with Right [CONDITION(S)]. [CONDITION(S)] precautions with repositioning, log roll pillow between knees. 12/8/21- Physical Therapy and Occupational Therapy evaluate and treat. 11/29/21 (large sling) Undated entry- Right [CONDITION(S)] Physical Therapy to evaluate appropriateness of lift and if any changes need to be made with transfers. 11/29/21 Fall- staff education on proper sling placement. 12/10/21 [MEDICATION(S)] ordered for comfort due to recent fracture; monitor for adverse side effects: constipation, nausea, sedation, dry mouth, urinary retention, itching. 12/8/21 Incision to right hip- monitor for signs and symptoms of infection- treatment as ordered. Review of Physical Therapy Encounter Note dated 12/9/211 at 11:55 am revealed the following information: Completed hoyer lift transfer with staff, assessing sling size, positioning, and transfer strategies. Educated staff on proper rolling strategies to reduce pressure on hip, including use of repositioning mat and log roll technique, along with placing pillow in between knees to reduce adduction. Recommend use of a large sling to assist with cradling patients for comfort. Repositioned patient in recliner utilizing wedge to decrease side lean. Educated staff to float heels to reduce risk of pressure sore. Review of facility provided policy titled Lift Policy undated revealed the following information: It is the policy of fell owship Village to include mechanical lift usage in individual care plans. The resident's individual care plan will reflect which lift and which type or size sling to use, and how many staff persons are needed to assist. It is the policy of fell owship Village that all full body and standing mechanical lift transfers be conducted by 2 staff throughout the transfer. Only the DON, MDS Coordinator or RN may amend a resident care plan in relation to mechanical lift use.

Based on employee record review, staff interview and policy review, the facility failed to perform a Single Contact Repository (SING) background check for 1 of 5 employees reviewed. The facility reported a census of 36 residents. Findings include: The Nurse Aide Roster showed Staff G had a hire date of 6/1/2020. In an interview on 8/3/21 Staff F reported she does not perform SING background checks on employees that do not live in Iowa. She admitted that no SING was checked for Staff G. The undated Reference and Criminal Background Checks policy revealed SING background checks are utilized if the potential employee currently or within the last 7 years has lived in Iowa. In an interview on 8/5/21 at 9:01 AM the Administrator admitted the facility was not aware that SING background checks needed to occur for potential employees that do not live in Iowa.

Based on observations, policy review, and staff interviews, the facility failed to cover clean linen during transport, ensure staff wore mask and goggles, verify screening log, and perform hand hygiene when needed for 3 of 10 residents (Resident #32, Resident #29, and Resident #6). The facility reported a census of 36 residents. Findings include: 1. Observation on 8/3/21 at 1:17 PM revealed Staff A wheel a cart of clean linen throughout the building and then into a clean linen storage closet in the 400 room area without the clean laundry covered. During the observation Staff A reported the closet the cart was in was to store clean linen. The Infection Control in the Laundry policy dated 6/10 documented clean linen will be stored in covered storage carts or in designated storage closets. In an interview on 8/4/21 at 12:14 PM, the facility's infection prevention control nurse verified clean laundry should be covered when transported within the facility. 2. Observation on 8/4/21 at 8:06 AM revealed Staff B without wearing a mask or goggles near the facility's front door. In an interview at the same time, Staff B reported she came in the backdoor to the facility, screened herself in via the electronic kiosk, and walked through building to get a mask from the box located near the front door. The Centers for Disease Control article dated 4/27/21 revealed health care personnel is directed to wear source control (mask) at work. The COVID-10 [CONDITION(S)] (NAAT) Laboratory 14-Day Test Positivity Rates, by US County from 7/14/21 to 7/27/21 revealed [NAME] county has a 6.3% positivity rate. In an interview on 8/4/21 at 12:36 PM the facility's infection control prevention nurse reported that all staff in the building should wear both a face mask and goggles at all times unless they are eating, drinking, or in an office alone. The nurse also reported the county's positivity rate was at the level in which goggles are needed to be worn by staff. 3. Review of screening log on 8/3/21 at 7:53 AM revealed gaps in the screening log where staff did not verify screening results prior to the person entering the facility. In an interview on 8/4/21 at 12:44 PM the Administrator reported a paper screening log is used during business hours occasionally and staff should verify the screening. The Administrator admitted staff do not always initial that they verified the screening. Review of Visitor Screening Log on 8/3/21 revealed a total of 115 entries with 62 entries not reviewed by facility staff. CDC document titled Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination dated 4/21/21 instructed Visitors should be screened and restricted from visiting, regardless of their vaccination status, if they have: current [CONDITION(S)]-CoV-2 infection; symptoms of COVID-19; or prolonged close contact (within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period) with someone with [CONDITION(S)]-CoV-2 infection in the prior 14 days or have otherwise met criteria for quarantine. 4. The Minimum Data Set (MDS) dated [DATE] revealed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 4 indicating severely impaired cognition. The MDS revealed the resident needed the extensive assistance of two persons with toileting and the resident was frequently incontinent of urine. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 8/4/21 at 8:34 AM showed Staff E, Certified Nurse Assistant (CNA) perform peri care after Resident #6 used the toilet. Staff E performed hand hygiene and donned gloves. Staff E then picked up the liner in the trash can, tied it shut, put a new liner in the trash can. Staff E changed gloves without performing hand hygiene and performed peri care. While still wearing the gloves used during peri care, Staff E opened a drawer in Resident #6's room to locate hand sanitizer. Staff E doffed gloves and did not perform hand hygiene. Staff E dressed the resident and transferred her from EZ stander to a wheelchair. Staff E then washed the resident's hands using towel. Staff E ensured resident's call light was within reach. Staff E then pulled the liner out from the trash can and put a new one in. Staff E gathered several trash bags, turned the light switch off in the bathroom and tucked the bags under her arm. Staff E performed hand hygiene. Staff E took the garbage to the dirty utility room and performed hand hygiene. The Hand Hygiene policy dated 8/4/21 directed hand hygiene should be performed before having direct contact with patients, after contact with body fluids, after contact with contaminated equipment, after contact with inanimate objects, and to decontaminate hands upon removal of gloves. In an interview on 8/5/21 at 9:21 AM , the Director of Nursing (DON) reported she expected staff to perform hand hygiene in between gloves changes, after contact with inanimate objects, before direct contact with a resident, and after contact with body fluids. 5. The Minimum Data Set (MDS) dated [DATE] revealed Resident #29 had a severely impaired cognitive status. The MDS revealed Resident # 29 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation on 8/3/21 at 3:20 PM while Staff I Registered Nurse (RN) prepped medications in the medication room a syringe fell on floor, she picked it up and placed it on the counter and then threw it away. Staff I continued to prepare medications without performing hand hygiene. While in the resident's room, Staff I donned gloves without performing hand hygiene, then administered medications and flushed the g-tube before and after medications were administered. Staff I doffed the glove on her right hand and rinsed the graduate and syringe used during the procedure. Staff I then doffed the left glove and performed hand hygiene. The Hand Hygiene policy dated 8/4/21 revealed that hand hygiene should be performed to decontaminate hands upon removal of gloves or other personal protective equipment. The use of gloves does not eliminate the need for hand hygiene. In an interview on 8/5/21 at 9:21 AM the Director of Nursing (DON) reported she would expect staff to throw away an item that fell on the floor immediately and not place it on a multiple use surface. The DON also reported she would expect staff to perform hand hygiene immediately prior to donning gloves and when gloves are removed. 6. The Minimum Data Set (MDS) dated [DATE] showed Resident #32 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #32 had an indwelling urinary catheter. Observation on 8/3/21 revealed Staff C don gloves after performing hand hygiene, touch the bathroom door, empty Resident # 32 's drainage bag, and clean the end of the tubing with an alcohol prep pad. During the observation, Staff C reported the bathroom doors don't stay open. The Hand Hygiene policy dated 8/4/21 revealed hand hygiene should be performed after contact with inanimate objects in the immediate vicinity of the patient. In an interview 8/5/21 at 9:21 AM the Director of Nursing (DON) stated she would expect hand hygiene to be performed and new gloves donned when a staff member would touch an inanimate surface in a resident's room before performing draining a urinary catheter bag.

Based on interviews and record reviews the facility failed to provide bed holds in writing to 1 out of 1 ( #22) reviewed. The facility reported a census of 36 residents. Findings include: Review of the Census tab in the Electronic Health Record (EHR) showed Resident #22 was discharged to the hospital on 5/21/21 and returned on 5/24/21, and again on 6/28/21 and returned on 6/30/21. Review of the EHR lacked any documentation the Resident was provided a copy of a bed hold on either hospitalization s. Review of the undated Bed Hold policy stated upon discharge from the facility for hospitalization or therapeutic leave, the nurse in charge will inquire with the resident as to whether he or she wishes to hold the bed. She will ask that the resident sign the bed hold agreement form indicating their choice. If the resident is unable to sign due to his or her cognitive status or physical condition, the responsible party will be contacted and asked whether they would like to hold the bed. During interview on 8/4/21 at 9:40 AM the Director of Nursing (DON) stated the responsible party was contacted by phone to obtain bed hold agreement, but neither the resident or the responsible party were given written notice. The DON stated the responsible party comes the facility often but they have never gotten signatures on the bed holds or given copies to the resident or the responsible parties before.

Based on record review and staff interview the facility failed to ensure resident safety with a transfer for 1 out of 3 residents reviewed (Resident #17). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/7/21 for Resident #17 showed the resident had a Brief Interview for Mental Status (BIMS) score of 00 which showed severely impaired cognitive skills. The resident had diagnoses of unsteadiness on feet, dementia, and segmental and somatic dysfunction of the pelvic region and segmental and somatic dysfunction of the [MEDICATION(S)] region. Resident #17 required extensive assistance with two staff member for transfers, toileting, and bed mobility. Review of the Progress Note dated 7/5/21 showed the nursing staff was notified the resident was on the floor and found in the bathroom. Staff reported Resident #17 was lowered to the floor with assist of three and gait belt. Staff reported a Certified Nurse Aide ( CNA) was pivot transferring the resident from the toilet to his wheelchair when the residents knees gave out. The CNA yelled for help and two other CNA's close by were able to assist lowering the resident to the floor. The facility spoke to Physical Therapy and stated they had instructed the CNA to use two staff to assist with the pivot transfer. The facility provided education to the CNA regarding transfers. Review of the Incident Investigation form dated 7/5/21, the staff interview stated that after breakfast Occupational Therapy (OT) showed her how to pivot transfer the resident off the toilet into the wheelchair and that OT did it by herself. The CNA thought that since OT did it by herself that staff could transfer the resident with one assist. The DON talked with Physical Therapy (PT) and PT recommends that Resident #17 be pivot transferred with 2 assist and to use the EZ Stand as needed. PT recommendations were reviewed and expectations with staff involved and all other staff updated. The intervention put in place was staff education that PT recommends two assist with pivot transfer in the bathroom and EZ lift as needed. Review of the Care Plan for Resident #17 stated the resident was and EZ Stand Lift with 1-2 staff. May use Hoyer lift with 2 staff for transfers if unable to bear weight or weak. Review of the Occupational Therapy Evaluation and Plan of Treatment dated 6/14/21 stated the prior level of function required Resident #17 to have moderate to maximum assist with two for all transfers. Staff used an EZ Stand with the resident and resident was not ambulatory. The Assessment Summary stated the resident is now requiring increased amount of assistance due to poor posture, weakness and decreased endurance with upright sitting. Review of the Physical Therapy Treatment Encounter Note dated 7/5/21 stated the PT and Certified Occupational Therapy Assistant (COTA) talked about the residents progress with transfers and both agreed that the resident had been demonstrating increased safety and consistency with stand pivot transfers within the bathroom using moderate assist with two. The COTA communicated with nursing staff to work on stand pivot transfers with moderate assist with two staff in the bathroom instead of using easy stand lift. During interview on 8/4/21 at 3:13 PM the Administrator stated it was a miscommunication between the CNA and the OT. The Administrator stated she called the OT on 8/4/21 to verify the instructions that were given to the CNA and the OT stated it was strongly recommended to the CNA that 2 staff were used for the pivot transfer in the bathroom.

Based on review of the planned menu, observation, staff interviews and facility record review, facility staff failed to follow the planned menu for residents on pureed texture diets. The facility identified a census of 36 residents. Findings include: Review of the facility menu for week 3 signed and approved by the dietician showed: 1 Swiss steak, ½ cup of cheesy potatoes, ½ cup squash or peas, 2x2 sherbet dessert, 1 bread, 1 tsp margarine. The menu that was prepared stated brownie for dessert. Observation on 8/3/21 at 9:50 AM showed Staff D dietary preparing the puree menu for 3 residents. Staff D put 3 Swiss steaks in a blender with brown gravy and pureed. Staff D placed the Swiss steak into a glass measuring bowl and measured it at 2 cups. Staff used a 1/2 cup scoop and placed three scoops of cheesy potatoes into the blender and pureed. The cheesy potatoes were placed into a glass measuring bowl and measured at 1 ¼ cups. Staff D was asked what serving size the residents were going to get and she stated that she just divides it up into threes and it is usually about a ½ cup serving. No bread or margarine was added to the pureed food or pureed separately. No brownie was pureed. Observation on 8/3/21 at 11:32 AM showed Staff D was serving the three pureed plates and used a blue scoop to serve the Swiss steak and a green scoop to serve the cheesy potatoes. After the three plates were plated and served to the residents the container of Swiss steak had about a ½ scoop remaining in the container and the cheesy potatoes had about a ¼ scoop remaining in the container. Review of the scoop size chart posted in the kitchen showed a blue scoop measures ¼ cup and the green scoop measures 1/3 cup. During interview with Staff D on 8/3/21 at 12:08 PM she stated she was told by their Dietician to puree the number of servings and then divide the amount up between the three residents and that it usually is about a ½ cup. She stated that they get a ½ cup of everything. When Staff D was asked about the bread she stated she should have pureed it with the other food. She stated she choose to giving pudding instead of the brownie. During interview on 8/3/21 at 2:26 PM the Dietician stated she did inform Staff D to puree the number of servings and divided it up. When asked if she expected the serving on the plates to be a 1/2 cup she stated it should be. She stated that all the puree should be used to make the correct serving size. On 8/3/21 at 12:29 PM an observation was made of the three pureed plates and all three residents ate 100 percent of the food. During interview on 8/4/21 at 3:26 PM the Administrator stated if 3 steaks were pureed then all of the puree should have been served to make sure the three residents get the correct serving size and if the menu states 1/2 cup, the residents should have received a 1/2 cup of potatoes.

Based on clinical record, facility policy, and staff interview, the facility failed to submit a Preadmission Screening and Resident Review (PASARR) when a resident was given new diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #34 had a Brief Interview of Mental Status score of 11 indicating moderately impaired cognition. Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASARR I dated 2/6/12 revealed Resident #34 had a negative screening and did not require a PASARR II. The PASARR I listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record revealed Resident # 34 was admitted to the facility on [DATE]. She was later diagnosed with [CONDITION(S)] on 6/7/12, other symptoms and signs involving cognitive functions and awareness on 7/17/19, delusional disorders on 1/20/16, and persistent mood [affective] disorder on 9/1/19. The Pre-Admission Screening and Resident Review (PASARR) policy dated 3/21 revealed if the resident is diagnosed with a mental disorder while in the location, the social worker will contact the designated state agency for a Level II screening. In an interview on 8/4/21 at 3:11 PM Staff H, Registered Nurse (RN), stated her understanding was a PASARR submission was only needed after a resident was admitted to a facility for a change in condition. No further PASARR submissions took place after the PASARR I dated 2/6/12.

Based on observations, staff interview, and facility document and policy review, the facility staff failed to followed infection control practices in order to prevent or reduce the risk of spreading infection and disease for one of four residents observed. The facility reported a census of 30 residents. Findings include: 1. Observation on 10/5/20 at 1:05 p.m., revealed several garbage receptacles and a laundry hamper in the 200 hallway had no lids on them. The garbage cans had soiled gloves and paper towels, and the laundry hamper had soiled linens inside. During an interview 10/7/20 at 12:00 p.m., the Director of Nursing (DON) reported the garbage cans and linen hamper came with lids but she was uncertain why the garbage cans and linen hamper had no lids on them. 2. During observation 10/5/20 at 1:35 p.m., Staff A, Certified Medication Assistant, prepared medications from the medication cart in the 200 hallway for Resident #4. Staff A wore a yellow gown, gloves, surgical mask and faceshield. Staff A placed a bottle of eyedrops on the overbed table in the resident's room (no barrier on the table), poured pills into Resident #4's mouth, then held the resident's water mug and straw as the resident drank from the mug and swallowed the pills. Staff A opened the bathroom door with her gloved hand, placed her gloved hand inside the garbage can, pulled a plastic bag out of the garbage can, placed the plastic bag over the garbage can, and disposed of the medication cup. Staff A then picked up the bottle of eyedrops, held the resident's skin above and under the eye, and administered one eyedrop to each eye, Staff A removed her gloves, opened the medication cart, placed the eye medication bottle inside the cart, then sanitized her hands. In a Handwashing Policy dated 4/20, revealed handwashing performed to prevent the spread of infection. In an undated facility document titled Remember When to Handwash, revealed handwashing entailed using hand sanitizer or soap and water. Handwashing completed whenever staff left a resident's room and after gave medications. A staff communication dated 10/2/20 revealed a reminder for handwashing or sanitization for a minimum of 20 seconds for the following: a. Before and after contact with a resident b. After contact with objects or surfaces in the resident's environment c. After removed PPE (personal protective equipment) such as gloves, gown, or facemask d. Before performed a procedure During an interview 10/7/20 at 12:00 p.m., the DON reported she expected staff changed gloves and sanitized their hands whenever contaminated and before and after medication administered.

Based on record review and staff interview the facility failed develop a comprehensive care plan for 4 of 4 residents (Residents #11, #20, #33, and #35) reviewed for the use of an anticoagulant. The care plans lacked documentation regarding their use of an anticoagulant and what signs and symptoms their staff are supposed to monitor for. The facility reported a census of 38 residents. Findings include: 1. According to a quarterly Minimum Data Set (MDS) with a reference date of 5/6/19, Resident #33 had a Brief Interview of Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS listed the following [DIAGNOSES REDACTED]. The MDS indicated the resident received an anticoagulant for 7 days during the 7 day review period. Review of the Physician order [REDACTED]. Review of Resident #33's Care Plan with a revision date of 5/16/19, revealed it lacked documentation of her receiving [MEDICATION NAME] (blood thinner) on a daily basis. The Care Plan lacked signs and symptoms for the use of [MEDICATION NAME]. 2. According to a quarterly MDS with a reference date of 3/18/19, Resident #11 had BIMS score of 15 indicating no cognitive impairment. The MDS listed the following [DIAGNOSES REDACTED]. The MDS indicated the resident received an anticoagulant for 7 days during the 7 day review period. Review of the Physician order [REDACTED]. Review of Resident #11's Care Plan with a revision date of 3/28/19, revealed it lacked documentation of her receiving [MEDICATION NAME] (blood thinner) on a daily basis. The Care Plan lacked signs and symptoms for the use of [MEDICATION NAME]. 3. According to the MDS with reference date 4/12/19, Resident #20 had a BIMS status score of 14, indicating no cognitive impairment. The MDS listed [DIAGNOSES REDACTED]. Review of Resident #20's (MONTH) 2019 Medication Flowsheet revealed a current order for [MEDICATION NAME] ([MEDICATION NAME]) 4 mg. daily. Review of Resident #20's Care Plan, updated on 4/18/19, revealed he had history of [MEDICAL CONDITION] ([MEDICAL CONDITION]-blood clot) and [MEDICAL CONDITION] Embolism (blood clot in lungs). The Care Plan lacked documentation related to Resident #20's [MEDICATION NAME] use and his risk for possible adverse side effects including bleeding and bruising tendencies. During interview on 5/29/19 at 3:03 p.m. the Director of Nursing ( DON) confirmed Resident #20's [MEDICATION NAME] use was not listed on his care plan nor were the risks listed for adverse side effects related to use of the medication. 4. Resident #35's MDS with assessment reference date 5/13/19,showed resident with a BIMS of 9 indicating moderately impaired cognition. [DIAGNOSES REDACTED]. In review of a [MEDICATION NAME] flow sheet Resident #35 had an order for [REDACTED]. Resident #35's Care Plan dated 5/23/19 did not include [MEDICATION NAME] (blood thinner) being used by the resident and no side effects for use of anticoagulants were listed for staff to observe resident for. In an interview on 5/29/19 at 10:22 AM with DON stated this resident's care plan did not have use of anticoagulants or anticoagulant side effects list on care plan and agreed these should be listed on the care plan so staff is aware of what to look for with a resident on this type of medication.

Based on personnel file reviews, facility policy review and staff interview, the facility failed to complete the Single Contact License and Background Check (SING-a background check for criminal and abuse registries) within the 30 days of hire for 1 of 5 current employees sampled (Staff A). The facility identified a census of 38 Findings included: A review of Staff A's Certified Nursing Assistant (CNA) personnel file revealed an application for employment dated 9/5/2018 and a SING completed on 9/14/2018. In an interview on 05/29/19 at 11:02 AM Staff C, Human Resource, confirmed the SING was completed (MONTH) 14, (YEAR) and the hire date on Review of Events Summary form of 11/20/2018 is correct. A review of the SING instructions noted the following: Nursing--Check professional license BEFORE HIRE This is to run on EVERYONE BEFORE HIRE, (it is invalid after 30 days) A review of the facility Abuse Prevention Policy, revision date 11/18 noted the following: Employee Screening: 1. The facility will conduct an Iowa Criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to resident, prior to hire .

Based on observation, clinical record review, staff interview, review of the facilities call light system and facility policy review, the facility failed to ensure staff maintained a safe and secure environment for 1 of 4 residents reviewed. Resident #1 fell and sustained a right [MEDICAL CONDITION] when the alarm was not in place. The facility identified a census of 40 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 9/3/18 indicated Resident #1 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 (no cognitive impairment), required limited assistance of one (1) staff with transfers and ambulation in her room and in the corridor and 1 fall with a minor injury. An Observation Detail List Report dated 9/3/18 at 2:44 p.m. indicated the resident had a history of [REDACTED]. The form indicated the resident as at risk for falls. A Care Plan dated 6/21/18 indicated the resident had a problem with mobility and safety and fall and injury. The interventions included the following: a. The resident ambulated and transferred with a walker, gait belt and and 1 or two (2) staff assist. (dated 6/23/18) b. A personal body alarm at all times due to attempted self transfers, weakness and confusion. (dated 6/23/18) c. Used a wheel chair to meals and activities due to fatigue and shortness of breath (SOB). d. The staff propelled her wheel chair daily per her request and the resident propelled herself short distances also. e. The resident fell having transferred self from the wheel chair to the lift chair which resulted in a bruise to her right upper arm (dated 6/23/18) f. Found the resident on the floor in her room with the personal body alarm not activated. Staff added pressure alarms to the bed, wheel chair and the recliner due to her having disabled the personal body alarm. (dated 9/6/18) An Incident Report Follow-Up form dated 9/6/18 at 7:45 p.m. and written by Staff E RN (registered nurse) indicated the resident had been found on the floor in front of a chest in her room without the alarm having sounded which resulted in a fractured right femur. A Incident Investigation Form dated 9/6/18 at 7:45 p.m. reviewed by the Director of Nursing (DON) documented what happened, how it happened and why did it happened as follows: A certified nurse aide called the writer to the resident's room by a certified nursing assistant (CNA) and found the resident laying on her right side on the floor in front of a big chest. The right leg appeared bent at the knee with the foot under the left leg. The resident was alert and oriented to reality but could not recall what she was doing when the fall occurred. The personal body alarm did not activate. The writer rolled the resident onto her back and slowly moved the resident's right leg to a straight position. The resident complained of pain when staff palpated the hip area. The resident denied having hit her head and denied pain anywhere else on the body. Observation revealed a large bump that protruded from the right hip and no redness or bruising noted. Staff positioned pillows under the resident's head and knees for support. The resident moved her toes on both of her feet and denied pain. The resident's vitals signs at 8:45 p.m. were: blood pressure (B/P) of 165/82, pulse (P) 89 a temperature (T) of 97.6 degrees Fahrenheit and and oxygen (O2) saturation level of 97% at room air. The staff sent the resident to the hospital for evaluation and treatment. The resident sustained [REDACTED]. The CNA stated she put a personal body alarm on the resident after she helped her to the bathroom before supper. The nurse reported the resident had been in her recliner at 6:30 p.m. The personal body alarm was still attached to the wheel chair when staff found her on the floor, indicating staff did not transfer it to the recliner when they saw the resident at 6:30 p.m. The call light had been in reach. A Follow-up on the fall written by the DON on 9/13/18 continued as follows: The DON spoke to the resident about the fall. When asked if the resident transferred herself from one spot to another within her room without assistance, the resident revealed she did self transfer at times. When asked if she transferred by herself the day she fell she stated she moved on her own from the recliner and fell when she tried to moved things on her bed. The resident stated she sometimes did not call for help and self transferred. The resident was able to get around in her wheel chair through the facility and wheeled herself in the wheel chair to and from activities and meals prior to the fall. The resident brought herself back from the dining room that evening per usual. Nursing reported confusion improved at the time of the fall and also reported the resident usually used the call light when she wanted to get ready for bed. On the resident's return from the hospital her alarms changed to pressure pads to decrease the probability of self removal and staff placed a camera in the resident's room for closer monitoring of the resident. The facility educated staff on 9/7/18 to ensure personal alarms are connected to all residents care planned for alarm use when going from different locations. Staff should double check alarms when assisting residents with cares, snacks, medications and etc. Management reviewed with staff the residents care planned to use alarms and started personal alarm audits. Maintenance staff checked functionality of alarms two times a month and the facility updated CNA toileting sheets to show residents who used personal body alarms. A Hospitalist History and Physical Note dated 9/7/18 documented the resident as admitted to the hospital on [DATE] with an acute right proximal femur fracture following a low impact fall at the nursing home. An X-ray report from dated 9/6/18 documented the resident sustained [REDACTED]. Mildly displaced lesser trochanteric fracture fragment. No bone mass identified. Osteopenia and scattered [MEDICAL CONDITION] changes noted. A resident progress note dated 9/11/18 at 11 a.m. revealed the facility received an update from the hospital. The resident right hip nailing done on 9/7/18. The resident received 1 unit of packed red blood cells due to low hemoglobin, required an indwelling foley catheter due to [MEDICAL CONDITION] and had 3 hip incisions. The resident will discharge from the hospital needing physical and occupational therapy and Tylenol ([MEDICATION NAME]) and [MEDICATION NAME] (narcotic) for pain control. Resident progress notes revealed the resident returned to the facility on [DATE] at 2:25 p.m. Resident progress notes dated 9/13/18 at 1:46 p.m. identified the resident with 6 small incisions on the right leg due to surgery with sutures in place and a dressing to cover. Staff observed purple and yellow bruising to the mid and side if the abdomen, periarea, hip and down to the knee. A Major Injury Determination Form signed by a physician 9/6/18 at 10:22 p.m. indicated the physician reviewed the circumstances of the fall and felt the injury was a major injury. Resident Progress Note forms included the following entries as dated and timed: a. 8/4/18 at 4:30 a.m. - The resident had set off the personal body alarm several times tonight rather than utilizing the call light. One time the resident set off the alarm and staff directly entered the room in response to the alarm. The resident was getting up with the walker when staff entered the room. The resident did not wait for staff assistance. b. 8/4/18 at 11:06 a.m. - The personal body alarm had been in place and the resident set it off for bathroom use. c. 8/4/18 at 11:42 p.m. - The resident set off the personal body alarm several times that evening and one time got up per self without having waited for staff assistance. d. 8/11/18 at 4 p.m. - The resident's personal body alarm activated so staff entered the resident's room and found the resident seated on the edge of the lift chair and the resident attempted to stand by herself. Staff asked the resident what she wanted but the resident could not verbalize what she wanted. An All -Call form dated 9/28/18 documented the resident activated her call light at the following times that correlated with the interviews below: a. on 9/6/18 at 4:17:33 p.m. activated and answered at 4:19:01 p.m. b. on 9/6/18 at 4:23:32 p.m. activated and answered at 4:24:30 p.m. a. on 9/6/18 at 6:27:58 p.m. and answered at 6:29:30 p.m. A typed statement dated 9/7/18 revealed Staff A, Administrator documented the following entries: a. Staff B, CNA assigned to the 200 hallway reported she assisted the resident to the bathroom when she came in around 4 p.m. but someone else assisted the resident off of the toilet. The resident had her alarm on at that time. Staff B stated she went to the resident's room at 7:45 p.m. when she found her on the floor by the dresser. Staff B stated she did not assist the resident since 4 p.m. b. Staff C, CNA reported she helped the resident off the toilet and into the wheel chair at 4:30 p.m. She stated she knew she put the personal body alarm on her because earlier that day the resident attempted to self transfer into the bathroom without calling for staff assistance. Staff C reported the resident went to the dining room for supper. Staff C did not assist the resident after 4:30 p.m. c. Staff D, CNA reported she last observed the resident around 6:45 p.m. when she passed the snack cart and the resident sat in her recliner at that time. The staff member stated she had not helped the resident after supper. d. Staff E, Registered Nurse (RN) reported she was in the resident's room at 6:30 p.m. to 6:45 p.m. and administered medications. At that time, the resident sat in the recliner. Staff E indicated she did not assist the resident with transfers that night. During an interview 4/4/19 at 1 p.m. Staff B indicated she positioned the resident on the toilet before supper with alarms in place. She did not assist the resident from the toilet, another staff assisted the resident. At 8 p.m. Staff B heard yelling and found the resident on the floor next to the dresser and parallel to the dresser. The alarm did not activate. Staff B then went to get a nurse. During an interview 4/4/19 at 12:16 p.m. Staff C confirmed she worked when the resident fell but she could not recall if she observed the resident in the dining room prior to the fall. Staff C indicated the nurse asked for her assistance as the resident fell but she could not recall the position of the resident, if she had been alert and oriented and if she self propelled her wheel chair at the time. All the staff member recalled is she held the door open for the ambulance crew and the resident was known to have removed her alarm at times. During an interview 4/4/19 at 11:39 a.m. Staff D confirmed she worked as a float when the resident fell . Staff D gave the resident a snack that evening at which time the resident sat in the recliner but she did not recall if the alarm was in place. The staff member indicated when the resident was first admitted to the facility she was independent with ambulation. The resident's status then changed to needing assistance with ambulation and using an alarm at all times because the resident attempted to self transfer/ambulate. Staff D indicated she did not observe the resident on the floor that night and stated the resident was alert and oriented at the time. During an interview 4/4/19 at 11:55 a.m. Staff E confirmed she worked the night of the resident's fall but it was a long time ago. The staff member stated the resident fell in the evening as Staff E administered medications. Staff E found the resident on the floor with her leg under her but she could not recall which leg had been under the other. Staff E recalled assessing range of motion. She positioned the leg for comfort as the resident denied pain. Staff E indicated she observed a deformity in the affected leg area. The resident appeared alert and oriented at the time. Staff E left the resident on the floor, performed vitals, called the ambulance and sent her to the hospital. Staff E stated the fall was so long ago she would have needed to review the chart to know specifics of the fall and the situation. Part of Staff E's 9/7/19 at 4:30 p.m. entry in the chart identified the resident's personal alarm was still in the wheelchair when staff found her on the floor. When Staff E administered medications at 6:30 p.m. to 6:45 p.m. she did not check the placement of the resident's personal body alarm. Staff E indicated the resident removed the alarm at the time because she disliked it so staff would place the clip on the resident's back out of reach. On 4/4/19 at 1:27 p.m. Staff F, CNA confirmed the resident was known to self transfer prior to the fall with a fracture On 4/4/19 at 1:35 p.m. Staff G, CNA confirmed the resident attempted to self transfer prior to the fall with a fracture A Personal Alarms policy dated 9/18 revealed the facility used personal alarms to potentially reduce the event of falls and injury. To help alert or remind the resident to use the call light and wait for assistance and alert staff when a resident arose without assistance. The policy included the following procedure: a. Each personal alarm would have been attached to the resident and the bed, wheel chair or recliner as ordered. Observation: On 4/4/19 at 10:45 a.m. observation showed the resident in a wheelchair at the nurses station with a pressure alarm in place. The alarm functioned when checked.

Based on observation, record review and staff interview, the facility failed to provide adequate supervision and safety measures to prevent accidents for 1 of 3 residents reviewed and failed to provide services so each the resident ' s needs are met (Resident #1). The facility reported a census of 31 residents. The care plan for Resident #1 indicated the resident used a Broda chair due to leaning to the left. On [DATE] at 6:16 a.m., Resident #1 sat on a tub chair. The nursing assistant released the belts which held the resident in the chair. The nursing assistant turned to obtain clothing for the resident and then the resident fell from the chair and onto the floor. The facility sent the resident to the hospital which identified the resident had a closed head injury. The resident died at the hospital at 2:56 p.m. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of [DATE], which reflected the resident rarely or never demonstrated the ability to understand others or to make self understood. Resident #1 required total assistance with activities of daily living which included transfer, dressing, toilet use and bathing. The assessment identified [DIAGNOSES REDACTED]. A Resident Progress Note dated [DATE] at 4:11 p.m. documented at 3:15 p.m., Resident #1's roommate notified staff that Resident #1 was on the floor in the residents ' room. Staff entered and found Resident #1 in front of the wheelchair lying on his/her left side. An assessment revealed swelling and bruising to Resident #1's left forehead. Resident #1's pupils were equal and reactive to light. Resident #1 responded appropriately to verbal stimuli. Passive range of motion performed to all Resident #1's extremities without distress noted. Four staff members assisted Resident #1 to bed. Staff then assisted Resident #1 to the Geri chair with a tray due to Resident #1 leaning forward. The physician's orders [REDACTED].#1's left forehead for 20 minutes 4 times a day as needed for 3 days. The physician ordered to monitor for significant injury and notify the physician if the resident had severe swelling present, bruising, or pain. Staffs were to monitor status for 72 hours for bruising, change in mental status, condition, pain or other injuries related to the fall every shift. A Safety Events--Falls record dated [DATE] regarding Resident #1's fall included evaluation notes: Keep Broda chair in low position. The care plan for Resident #1, dated [DATE] identified mobility and safety. The care plan documented Resident #1 used a Broda chair for locomotion which was propelled by staff. Resident #1 could not use a regular wheelchair because he/she leaned to the side. A new intervention dated [DATE] directed staff to have the Broda chair in low position. A facsimile (fax) dated [DATE] requested the physician give an order for [REDACTED]. An Occupational Therapy Evaluation and Plan of Treatment dated [DATE] documented Resident #1 referred for wheelchair positioning secondary to being found on the floor in his/her room in front of the wheelchair. The evaluation documented the assistive devices Resident #1 used included a Broda chair secondary to leaning forward. Resident #1 sat in the Broda chair. He/she exhibited a significant lean to the right from lateral trunk flexion at the thoracic spine, and lateral cervical flexion right. With assisted repositioning Resident #1 repositioned self to previous flexion partially due to tight muscles. A Restorative Nursing Assessment and Progress note dated [DATE] regarding balance while sitting documented Resident #1 leaned. Resident #1's Care Plan dated [DATE] identified mobility and safety. The care plan documented Resident #1 unable to perform any mobility activities of daily living (ADL's) him/herself. Resident #1 used a Broda chair for locomotion, propelled by staff. Resident #1 did not use a regular wheelchair because he/she leaned to the side. Resident #1 did not ambulate; he/she transferred with total assist of ,[DATE] and/or the Hoyer lift. Side rails up when Resident #1 in bed to establish boundaries. The Resident Progress Notes dated [DATE] at 6:16 a.m. documented Resident #1 laid on the tub room floor on his/her left side. Resident #1 awake and making bobbing sounds. No bleeding or appearance of trauma noted to Resident #1's head, face or neck. Resident #1's left shoulder appeared slightly red, the left elbow abraised, and the left hip slightly red. No rotation of the hip noted. After assessing Resident #1, staff Hoyer lifted him/her from the floor to bed. Resident #1 began to have emesis several times, of bile and phlegm. Staff notified the ambulance and prepared to transfer to the emergency room . Staff notified the family and they came to ride in the ambulance with Resident #1. At 2:56 p.m. Resident #1 expired at the hospital. An Incident Report Follow-Up dated [DATE] documented staff removed the seatbelt strap to dress Resident #1. The aide turned her back to get clothes and Resident #1 leaned forward/sideways and fell from the tub chair. The aide tried to break the fall but could not break much of the impact. The nurse responded and initially Resident #1 appeared coherent/alert for the resident. About 15 minutes after the fall Resident #1 started to have emesis and transported to the emergency room . A History and Physical dated [DATE] documented Resident #1 presented to the emergency room by ambulance after a fall out of a bath chair and landed on his/her left side. Staff reported Resident #1 had a hard fall. Resident #1 had advanced Alzheimer's disease and usually did not verbalize, but made a lot of noise. Resident #1 had not done that since the fall. Resident #1 had 2 episodes of vomiting since the fall. Resident #1 had a CT showing no acute bleed, but admitted for comfort care. Resident #1 appeared uncomfortable and needed frequent suctioning. The physical exam revealed Resident #1 unresponsive to verbal or painful stimuli, but did open his/her eyes spontaneously. The impression indicated Resident #1 had a closed head injury. A CT Scan of the head without contrast dated [DATE] at 8:22 a.m. documented Resident #1 had no acute intracranial abnormality. If symptoms persisted, MRI recommended for further evaluation. In addition the CT scan noted partially visualized small air pockets within the deep left facial soft tissues of indeterminate etiology possibly related to the patient's fall. Clinical correlation recommended. A Death Summary dated [DATE] documented Resident #1 admitted after falling from a bath chair. Resident #1 was unresponsive. A CT scan of the brain did not show bleeding. Resident #1 remained unresponsive and his/her status declined. Resident #1 received medication to stay comfortable. Resident #1 died with family at his/her side. During an interview on [DATE] at 9:00 a.m. the Director of Nursing (DON) stated the incident lasted about 10 seconds. The CNA removed the belt, turned around to get Resident #1's clothes and he/she fell out of the chair. The CNA could not catch Resident #1. The DON stated they had the manufacturers guidelines on the use of the tub chair and the CNA's are trained on its use. The DON stated they had nothing on the specifics of removing the belt after the bath. The DON and the Administrator stated Resident #1 had a tendency to lean. At 12:40 p.m. the DON stated the facility used no checklist when training CNA ' s to give baths. At 3:30 p.m. the DON stated Resident #1 previously sat in a chair with a lap buddy and he/she kept leaning so they obtained a Broda chair for the resident to use. During an interview on [DATE] at 9:47 a.m. Staff G Certified Nursing Assistant (CNA) stated you had to have the belt around the resident when wheeling them down the hall and while in the tub. Staff G stated she took Resident #1 for a bath around 6:30 a.m. Staff G gave Resident #1 a whirlpool. When finished with the whirlpool Staff G drained the tub, brought the chair out, and dried Resident #1 off. Staff G loosened and removed the straps from Resident #1. Resident #1's clothes were behind Staff G on the wheelchair. Staff G turned around to get Resident #1's clothes. Staff G stated Resident #1 fell toward the left and she could not stop it. Staff G stated she did not know if Resident #1 hit his/her head when he/she fell . Staff G stated at first Resident #1 appeared awake and alert, then he/she had problems and went to the hospital. Staff G stated Resident #1 did have a tendency to lean, but she did not do anything different than she normally would. During an interview on [DATE] at 1:02 p.m. Staff E Registered Nurse (RN) stated she worked the day Resident #1 fell . Staff E stated she passed medications when a CNA came to tell her a resident fell in the tub room. Staff E stated she saw Resident #1 on the floor and asked the CNA what had happened. The CNA stated she could not break the fall and thought the shoulder was the point of impact. After assessing Resident #1, the staff used a Hoyer lift to transfer the resident to bed. Staff E stated the resident vomited and then had the resident transferred to the hospital. Staff E stated it would be inappropriate to remove the safety belt from around the resident until the staff person was ready to transfer the resident. Staff E stated and confirmed it would not be safe. During an interview on [DATE] at 12:13 p.m. Staff H Licensed Practical Nurse (LPN) stated she used to do baths quite a bit, now about every 2 weeks. Staff H stated she used the bottom strap on everyone and the top strap if the resident leaned or scooted. Staff H stated after bathing the resident she drained the tub. While the tub drained she dried the top ,[DATE] of the resident. Then she took the chair with the resident out of the tub, and dried the resident ' s legs. Staff H stated she took the belt off, and then reached for the resident's clothes, which were in arms lengths. The resident would be out of sight momentarily. Staff H stated she had removed the strap and reached for Resident #1's clothes many times. Staff H stated the same thing could have happened to her. Staff H stated Resident #1 did lean which probably made it unsafe to take the belt off and take eyes off of him/her. During an interview on [DATE] at 9:46 a.m. Staff A CNA stated she sometimes gave baths to residents. Staff A stated Resident #1 leaned a lot, forward and to the side. They reclined him/her and propped him/her with pillows. Staff A stated Resident #1's seat and the back of the chair reclined. Staff A stated she would not be comfortable leaving Resident #1 in the bath chair with the straps off, even to turn around momentarily. Staff A stated she always left the strap on until ready to transfer him/her. During an interview on [DATE] at 2:55 p.m. Staff F CNA stated she gives baths occasionally. Staff F stated when she gets a resident out of the tub she dried them off and dressed them fully before she removed the safety belt. Staff F stated she didn't remove the safety belt until they are ready to transfer. Staff F stated she felt safer leaving the safety belt on until then. Staff F stated Resident #1 had a tendency to lean so it would be especially important for someone like Resident #1. During an interview on [DATE] at 11:46 a.m. Staff I CNA stated she started in August and worked 2 to 3 days a week giving baths. Staff I stated she used the lower belt (lap) for everyone and the upper body belt if they had trouble sitting up. Staff I stated when finished bathing a resident she would drain the tub. Staff I stated she dried the resident's hair and upper body while the tub drained. Staff I stated if they don't use the upper strap she starts dressing the upper body. She takes them out of the tub and dries them off. Staff I stated the strap remained on while she dressed the lower body, then removed the strap to dress the upper body, if not already done. Staff I stated she did not remove the strap before getting the clothes ready. Staff I stated when orienting, sometimes they (staff orienting her) would remove the strap and reach over to get clothes. Staff I stated they all did it a little different. Staff I stated 1 staff put her hand on the resident's knee and quickly turned around and got the resident's clothes. Staff I stated she oriented with several different people. Staff I stated she received no special instruction about when to remove the strap when dressing the resident. During a subsequent interview on [DATE] at 9:10 a.m. following observation of removing a resident from the tub, dressing, and transferring to a wheelchair, Staff I stated she never unstrapped Resident #1 until ready to transfer him/her because he/she leaned forward and to the side. Staff I stated Resident #1 had a chair which allowed staff to lay him/her back and staff used a pillow to his/her side to keep the resident in position. During an interview on [DATE] at 10:15 a.m. Staff B Registered Nurse (RN) stated staff reclined Resident #1 because he/she leaned forward a lot, and also leaned to the side. Staff B stated it was unsafe to leave Resident #1 unattended sitting upright. During an interview on [DATE] at 10:07 a.m., Staff C Certified Medication Aide (CMA)/CNA, stated staff reclined Resident #1 back when up in the chair because he/she leaned forward. Staff C stated Resident #1 could also grab the sides of the chair and pull him/herself forward. Staff C stated they also propped Resident #1 on the sides due to leaning. During an interview on [DATE] at 9:31 a.m. Staff D CNA stated they reclined Resident #1 because he/she leaned forward, and they padded him/her a little bit due to leaning to the side. Staff D stated she would never leave Resident #1 sitting upright in a chair. During an interview on [DATE] at 4:21 p.m. Resident #1's Physician stated they had to assume Resident #1 ' s death was related to the fall. Resident #1 fell , got progressively worse and died that day. The Physician stated the CT Scan did not show bleeding, but there are other types of head injury and they are not always seen on CT Scan. According to the Cascade Standard Premier and Elite Premier Bathing Systems with Aqua-Aire, the Safe Operation and Daily Maintenance Instructions (page 13) contained the Warning: Failure to secure the resident properly with the seat belt could result in injury to the resident or operator. The instructions regarding transferring out of the bathing system (page 20) directed: With the resident secure, remove the belting from the resident. During an interview on [DATE] at 8:40 a.m. the DON stated the facility had a new policy regarding the bath chair, and she had talked to the bath aides. The DON stated she knew other bath aides did the same thing, removing the chair strap and then turning to get resident's clothes. The DON stated it could have happened to anyone. The DON stated when Resident #1 fell on [DATE] the Broda chair was reclined, but not in the low position, so not reclined as far. During an observation on [DATE] at 1:20 p.m. the DON brought the Broda chair used by Resident #1 to the tub room. The DON put the chair in the position in which resident #1 sat in it. The seat tilted and the back reclined, leaving the head at about 45 degrees. Observation of the tub chair showed it tilted back slightly.