Every finding on record at Meadowview Health & Rehab Center

Based on observations, record review, and interviews, the facility failed to ensure dietary services were provided in a safe sanitary environment to prevent contamination and food borne illness for all 96 residents served a meal tray from the kitchen as reported by S2 DON.Findings: The initial tour of the kitchen beginning 07/06/2026 at 8:20 a.m. revealed:the deep fryer and the floor around the deep fryer were covered with a thick layer of grease and food debris, and the oil in the fryer had a layer of food debris floating on the surface,the temperature logs for the walk-in freezer and the walk-in refrigerator had not been completed from 06/23/2026 through 07/06/2026,the dishwasher temperature log was not completed from 06/23/2026 through 06/24/2026 and from 06/29/2026 through 07/06/2026, and the dishwasher chemical checks were not documented for June 2026 and July 2026,steam table temperature logs for June 2026 and July 2026 were not completed, boxes of frozen food items were stored directly on the floor of the walk-in freezer,3 boxes of bell peppers with white fuzzy spots on them and 3 gallons of milk with an expiration date of 06/19/2026 were stored in the walk-in refrigerator, andfood storage bins had scoops stored directly inside the flour bin, cornmeal bin, sugar bin, and rice bin. During an interview on 07/06/2026 at 9:25 a.m., S1 Administrator reported she was currently serving as the Dietary Manager while the facility's Dietary Manager was on leave. S1 Administrator toured the kitchen with the surveyor, observed the above areas, and confirmed they did not meet food safety standards and needed to be corrected. A follow up observation of the kitchen on 07/06/2026 at 12:02 p.m. revealed raw chicken thawing in standing water directly in the 3rd compartment of the facility's 3 compartment sink. Further observation revealed the tubing for the sanitizing solution was dripping into the standing water with the chicken. During an interview on 07/06/2026 at 12:08 p.m. S1 Administrator confirmed raw chicken was thawing in standing water with sanitizing solution dripping into the water and should not be. A follow up observation on 07/07/2026 at 12:28 p.m. revealed 3 tubes of ground beef thawing in the center sink of the 3 compartment sink in standing water. During an interview on 07/07/2026 at 12:31 p.m. S1 Administrator confirmed meat was thawing in standing water and should not be.

Based on record reviews and interviews, the facility failed to ensure MDS assessments were accurate for 2 (#13, #64) of 24 residents reviewed for assessments. Findings:Resident #13 Review of Resident #13's medical record revealed an admit date of 07/12/2024 and diagnoses including end stage renal disease and dependence on renal dialysis. Review of Resident #13's physician orders revealed and order dated 04/15/2026 for dialysis 2 days a week on Monday and Friday. Review of Resident #13's Dialysis Communication Forms revealed multiple resident refusals for dialysis with 06/22/2026 being the last date Resident #13 went to dialysis. Review of Resident #13's Quarterly MDS assessment dated [DATE] revealed Section O - Special Treatments, Procedures, and Programs - Dialysis was marked as No. During an interview on 07/09/2026 at 10:55 a.m., S5 MDS Coordinator reviewed Resident #13's Dialysis Communication Form for 06/22/2026 and Resident #13's Quarterly MDS assessment dated [DATE] and confirmed Section O - Special Treatments, Procedures, and Programs - Dialysis was marked as No and should have been marked as Yes. S5 MDS Coordinator further reported she thought the look-back period for all areas of the MDS was 7 days and did not know the look-back period for dialysis was 14 days. Resident #64 Review of Resident #64's medical record revealed an admit date of 06/08/2026 and diagnoses including: acute osteomyelitis right femur, pressure ulcer of right hip unspecified stage, pressure ulcer of right buttock unstageable, and pressure ulcer of sacral region unstageable. Review of Resident #64's admission Summary Nursing Note dated 06/08/2026 at 5:18 p.m. revealed in part: Resident #64 noted to have open areas to sacrum as well as buttock region, an open area is noted to right heel as well, upon admission areas assessed and treated and dressed per treatment nurse as MD ordered . Resident noted to be admitted with decubitus ulcers as well as osteomyelitis to wounds. Review of Resident #64's Wound Care Notes dated 06/08/2026 revealed Resident #64 had a stage 3 pressure ulcer to his right heel, a stage 4 pressure ulcer to his left buttock/ischium, and a stage 4 pressure ulcer to his right trochanter (hip) that were present on admission to the facility. Review of Resident #64's Admission/5-day MDS assessment dated [DATE] revealed in part: -Section M - Skin Conditions - M0210 Does this resident have one or more unhealed pressure ulcers/injuries? = noM0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage: all disabled by question M0210. During an interview on 07/08/2026 at 2:30 p.m., S2 DON reviewed Resident #64's admission summary note and wound notes dated 06/08/2026 and confirmed Resident #64 had pressure wounds present on admission. S2 DON further reviewed Resident #64's Admission/5-day MDS assessment dated [DATE] and confirmed the section stating the resident had no unhealed pressure ulcers/injuries was inaccurate and disabled further questions about the current number of unhealed pressure ulcers/injuries at each stage.

Based on record review, observation and interviews the facility failed to develop and implement a comprehensive, resident centered plan of care for 1 (#51) of 3 residents investigated for smoking. Findings:Review of the Facility Smoking Policy-Supervised and Unsupervised (revised 11/2024) revealed in part: It is the responsibility of the facility to provide a safe and hazard free environment for those residents having been assessed as being safe for facility smoking privileges. The facility is responsible for informing residents, staff, visitors and other affected parties of facility smoking policies through verbal means, distribution and posting. This policy is intended to minimize the risks to residents who smoke, including possible adverse effects on treatment. Review of Resident #51's medical record revealed an admit date of 04/28/2026 and diagnoses including: COPD, generalized muscle weakness, lack of coordination, and other symptoms and signs involving cognitive functions and awareness. Review of the facility provided list of smokers (last updated 06/12/2026) revealed Resident #51 was not listed as a smoker. Review of Resident #51's Admit/5 day MDS assessment dated [DATE] revealed Resident #51 had a BIMS score of 11 indicating moderately impaired cognition. Further review revealed:-Section J - Current Tobacco Use = yes. Review of Resident #51's comprehensive care plan revealed no focus or interventions related to Resident #51's smoking. Observation on 07/06/2026 at 10:30 a.m. revealed a pack of cigarettes lying on Resident #51's over bed table. During an interview on 07/06/2026 at 10:30 a.m. Resident #51 reported he was a smoker, kept his own smoking supplies, and could go outside to one of the smoking areas anytime of his choosing to smoke. During an interview on 07/08/2026 at 11:47 a.m., S3 Corporate Nurse reviewed Resident #51's care plan and confirmed a care plan was not developed for Resident #51's smoking and should have been.

Based on observations, record review and interview, the facility failed to ensure 1 (#7) out of 2 (#7, #44) residents with a limited ROM and/or mobility received services and/or treatment including equipment for limited mobility. The facility failed to apply hand splints for Resident #7.Findings:Review of Resident #7's medical record revealed an admit date of 06/01/2023 with the following diagnoses, including in part: cognitive communication deficit, dysarthria following other cerebrovascular disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side.Review of Resident #7's physician's orders revealed an order dated 05/09/2026 for patient to receive RNP 7 days/week for right resting hand splint and left roll resting hand splint with skin checks before and after use, on in a.m. and off in p.m. PROM bilateral upper extremities 3 times a day 10 repetitions in all joints in all planes as tolerated. Review of Resident #7's tasks for the last 30 days failed to reveal Splint/Brace Program: RNP 7 days/week for right resting hand splint and left roll resting hand splint with skin checks before and after use, on in a.m. and off in p.m. 15 minutes was not completed from 05/09/2026 to 07/06/2026.Observation on 07/06/2026 at 8:45 a.m. revealed Resident #7's hand splints on bedside table. Observation on 07/07/2026 at 9:30 a.m. revealed Resident #7's hand splints on bedside table.Observation on 07/07/2026 at 2:30 p.m. revealed Resident #7's hand splints on bedside table.During an interview on 07/08/2026 at 12:00 p.m., S5MDS Coordinator acknowledged Resident #7's hand splints were ordered on 05/09/2026 and were not entered into the EHR for CNAs tasks until 07/06/2026. S5MDS Coordinator confirmed Resident #7 had not received RNP services and hand splint application and should have.

Based on record reviews, observation and interviews, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 2 (Resident #2 and Resident #85) of 2 residents reviewed for respiratory care.The facility failed to ensure:1. Nursing staff were trained and competent to provide mechanical ventilation for Resident #2 and2. Nasal cannula tubing and humidifier were dated for Resident #85. Findings:Review of the facility's Mechanical Ventilation: Setup and Monitoring policy (revised 2010) revealed in part: Mechanical Ventilation: Setup and MonitoringPurpose: The purpose of this procedure is to provide assisted or controlled ventilation to a resident with acute or chronic respiratory insufficiency.Preparation1. Verify that there is a physician's order for this procedure. Review the physician's orders, including instructions for:a. Tidal volume;b. Ventilatory rate;c. Peak flow rate;d. Pressure limit;e. Sensitivity;f. Oxygen concentration;g. Mode (assist control or rate control); andh. Special parameters such as positive end expiratory pressure (PEEP) settings.2. In an emergency, a qualified nurse may initiate mechanical ventilation and then obtain specific orders promptly thereafter.General Guidelines:Only a qualified nurse or respiratory therapist can initiate mechanical ventilation, based on an appropriate physician order. Resident #2Review of Resident #2's medical record revealed an admit date of 11/20/2013 and a re-admit date of 05/24/2024 with the following diagnoses, including in part: acute and chronic respiratory failure with hypoxia, attention to tracheostomy and dependence on ventilator. Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed in part, Resident #2 had a BIMS score of 15 indicating intact cognition and required oxygen, tracheostomy care and invasive mechanical ventilation. Review of Resident #2's physician's orders revealed an order dated 04/30/2026 for mechanical ventilation: SIMV RATE 6, VT 500, PS 10, and PEEP 5 at hour of sleep every night shift. Review of the following employee records of staff assigned to Resident #2's hall revealed in part, S6LPN, S7LPN, S8LPN and S9LPN had not been trained or met competency to care for a resident requiring mechanical ventilation. During an interview on 07/07/2026 at 3:00 p.m., S10CRT reported she worked the day shift and the nurses were responsible for setting up and maintaining Resident #2's mechanical ventilation at night. During an interview on 07/07/2026 at 3:10 p.m., S9LPN acknowledged she had not been trained on mechanical ventilation setup or maintenance. During an interview on 07/07/2026 at 4:00 p.m., Resident #2 reported he has had to walk a nurse through on how to hook him up to his ventilator at bedtime, especially if they were a new nurse. During an interview on 07/08/2026 at 10:00 a.m., S2DON acknowledged she could not produce documentation S6LPN, S7LPN, S8LPN and S9LPN had been trained and were competent to care for a resident requiring mechanical ventilation. Resident #85Review of Resident #85's medical record revealed an admit date of 12/26/2023 with the following diagnoses, including in part: acute and chronic respiratory failure with hypoxia, interstitial pulmonary disease unspecified, chronic pulmonary edema, COPD with acute exacerbation and chronic systolic (congestive) heart failure. Review of Resident #85's physician's orders revealed an order dated 10/19/2025 to change, label/date O2 tubing weekly every night shift every Sunday and an order dated 04/27/2025 to change nebulizer treatment tubing every week night shift every Sunday.Observation on 07/06/2026 at 8:25 a.m. revealed Resident #85 wearing continuous oxygen via nasal cannula at 3lpm with nasal cannula tubing and humidifier were undated. Observation on 07/07/2026 at 9:20 a.m. revealed Resident #85's nasal cannula tubing and humidifier were undated.Observation on 07/08/2026 at 9:00 a.m. revealed Resident #85's nasal cannula tubing and humidifier were undated.During an interview on 07/08/2026 at 12:15 p.m., S4ADON acknowledged Resident #85's oxygen tubing and humidifier were not dated and should be.

Based on record review and interview the facility failed to ensure residents were free from psychosocial harm and physical restraints used for the purpose of discipline or convenience that were not required to treat the residents' medical conditions for 2 (#1, #2) of 5 (#1, #2, #3, #4, #5) sampled residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings:Review of the facility's policy title: Facility Policy on PSDs (Personal Safety Devices) -Enablers-Side Rails-Restraints-Involuntary Seclusion Revised March 2026 revealed, in part:Restraint Policy Intent:Patients/Residents have the right to be free from any physical restraint imposed for purposes of discipline or convenience and when not required to treat the patient's/resident's medical condition. Patients/Residents have the right to function at their highest practicable level in the least restrictive environment possible.Policy:Restraints will not be used unless the facility's Interdisciplinary Team has completed an assessment and evaluation to identify causative medical or environmental factors and considered less restrictive alternatives (except in an emergency).Restraints will never be used for discipline or staff convenience.Definitions: A physical restraint is any manual method, or physical, or mechanical device, material or equipment attached or adjacent to a patient's/resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Convenience is defined as any action taken by the facility to control patient/resident behavior or maintain patients/residents with a lesser amount of effort by the facility and not in the patient's/resident's best interest. Resident #1Review of Resident #1's medical record revealed an initial admission date to the facility on [DATE] and an admission date of 11/27/2024 to the facility's memory care unit. Further review of Resident #1's medical record revealed diagnoses including, in part: Alzheimer's disease with late onset, unspecified dementia . with other behavioral disturbance, cognitive communication deficit, major depressive disorder recurrent, anxiety disorder, Schizophrenia unspecified, acute ischemic heart disease unspecified, and muscle wasting and atrophy not elsewhere classified of right and left upper arm. Review of Resident #1's 02/21/2026 Quarterly MDS (Minimum Data Set) revealed a BIMS (Brief Interview Mental Status) of 06, indicating severe impaired cognition. Resident #1 required substantial/maximal assistance with sit to stand and chair/bed-to-chair transfer. Review of Resident #1's Comprehensive Care Plan revealed Resident #1 was care planned for Behavior problem with resident attempting to stand from wheelchair with interventions that included, in part, anticipate and meet the resident's needs and redirect as needed. During a phone interview on 05/12/2026 at 12:20 p.m. S5 CNA reported she worked on the memory care unit and did not remember the day, but recently, had put a sheet around Resident #1's abdomen, ran it through the sides of the wheelchair and tied it in the back of the wheelchair to secure him, as he had falls and was trying to get up. S5 CNA further reported Resident #2 continued to try to get up once the sheet was placed, but could not and eventually stopped trying to get up. Resident #2 Review of Resident #2's medical record revealed an initial admission date to the facility on [DATE] and an admission date of 03/16/2026 to the facility's memory care unit. Further review of Resident #2's medical record revealed diagnoses that included, in part: Alzheimer's disease with late onset, insomnia unspecified, cognitive communication deficit, impulsiveness, disorientation, major depressive disorder recurrent, and vascular dementia severe with agitation. Review of Resident #2's 03/10/2026 admission MDS revealed a BIMS of 0, indicating severe impaired cognition. Resident #2 was dependent with sit to stand and supervision or touching assistance with chair/bed to chair transfers. Review of Resident #2's Comprehensive Care Plan revealed a care plan for Wandering risk with interventions that included, in part, provide me with re-orientation as needed. During a phone interview on 5/12/2026 at 4:14 p.m. S7 CNA reported she worked outside the memory care unit but would assist some in memory care unit and she did not remember the exact date but one recent evening she and S4 CNA went to the memory care unit to assist residents to bed and when S4 CNA tried to put Resident #2 to bed, she saw Resident #2 had a sheet tied around her and the wheelchair. S7 CNA further reported Resident #2 should not have been tied to her chair. During an interview on 05/13/2026 at 08:30 a.m. S2 DON (Director of Nursing) reported S8 CNA had reported to her on the morning of 04/15/2026 that she had overheard a conversation between S4 CNA and S7 CNA saying that they had seen a resident who was tied to their wheelchair with a sheet on 04/13/2026 in the memory care unit. During a phone interview on 05/13/2026 at 10:44 a.m. S4 CNA reported she worked outside the memory care unit and on 04/13/2026 around 9:00 p.m. she and S7 CNA were called to assist 2 memory care residents who were roommates to bed. S4 CNA further reported while trying to transfer Resident #2 from her wheelchair to bed, the chair came up with Resident #2 and she saw Resident #2 had a sheet around the abdomen and tied behind the wheelchair. S4 CNA further reported Resident #2 should not have been tied to her chair. During a phone interview on 05/13/2026 at 4:43 p.m. S6 LPN reported she could not remember the exact day but around the end of March 2026 she came in for her night shift and saw Resident #1 and Resident #2 restrained to their wheelchairs with a sheet around each of their abdomens and tied in the back behind their wheelchairs. S6 LPN further reported she told staff it was wrong to tie residents up. During an interview on 05/13/2026 at 3:30 p.m. S2 DON confirmed restraints should not have been used on any residents. During an interview on 05/14/2026 at 7:45 a.m. S1 Administrator reported Resident #1 and Resident #2 should not have been restrained in any way. During an interview on 05/14/2026 at 1:40 p.m. S1 Administrator confirmed a reasonable person who was restrained as Resident #1 and Resident #2 were, would have experienced psychosocial harm.During the survey, in-service records and QA monitoring records were reviewed and it was determined that the facility had implemented the following actions to correct deficient practice.Review of facility's corrective actions to deficient practice with a completion date of 04/22/2026 included:Intervention:1. Address how corrective actions were accomplished for those residents found to have been affected by the deficient practice.-04/15/2026 at 1:24am allegation received. -Employee responsible for Resident #2's restraint placement on 4/13/2026 was unknown. -Staff on 4/13/2026 memory care night shift (S6 LPN, S5 CNA) and day shift (S3 LPN, S9 CNA) were suspended pending investigation. -S7 CNA resigned after giving her statement on 4/15/2026.-After investigation S5 CNA and S6 LPN were terminated-Through interviews on 4/15/2026, S5 CNA admitted to restraining Resident #1 in recent past, but not on 4/13/2026.-Police department was notified and came to facility 4/15/2026.-Skin audits for Resident #1 and Resident #2 were conducted by Treatment Nurse on 4/15/2026. 2. Describe how other residents with potential to be affected will be identified and what will be done for them:-All residents in Meadows memory care unit were assessed for injury on 4/15/2026 and none were noted.-All residents in Meadows memory care unit were placed on every 30 minutes monitoring for restraint use for 72 hours beginning 4/15/2026 and completed on 4/18/2026.-Investigation interviews regarding whether staff had seen anyone restrained began with all staff members on Main on 4/15/2026 and interviews were completed on 4/16/2026. None of the staff interviewed were aware of anyone being restrained except S6 LPN who found 2 residents in memory care restrained, S4 CNA and S7 CNA who saw Resident #2 restrained in the memory care unit, and S5 CNA who reported she had restrained Resident #1.-Visual check of ALL rooms and residents by Administrator, Activities Director, Admissions coordinator, BOM (Business Office Manager) for signs of restraint use on 4/15/2026 and none were by staff found.-Resident Life Satisfaction rounds/surveys were completed for residents the administrator reported had a cognitive BIMS score by the Social Services staff with no negative findings on 4/15/2026. Each of the residents who answered questions for the Life Satisfaction Survey were noted to be outside of the memory care unit.-PEER surveys were completed by Social Services staff on 4/15/2026 and 4/20/2026 in regard to the 4 suspended employees with no negative findings completed on 4/20/2026.-Care Plans for the 17 memory care residents were reviewed by the interdisciplinary team of MDS Nurses and DON for resident's behaviors, fall risk and current interventions with completion date of 4/15/2026. 3. Measures that will be put in place or system changes that will be made to ensure practice will not recur:-S1 Administrator reported on 5/11/2026 at 4:00pm that all staff had abuse training on 04/14/2026 and prior to being aware of this issue.-Leadership rounds by MDS nurses and ADON (Assistant Director of Nursing) staff to observe staff response to residents and interview staff response to residents with impulsive or high-risk behaviors for 4 weeks started on 04/16/2026 with completion date of 05/08/2026.-In-services for all staff -Restraint specified based on policy and procedure by S1 Administrator began on 4/15/2026 for all staff with the addition of more specific in-service regarding restraining residents, appropriate escalation to nursing and leadership, and managing impulsive behaviors with knowledge verification on 4/15/2026. Completion date of 4/22/2026.-On 4/21/2026 In-service material on managing impulsive behaviors and resident safety was added to new employee orientation materials and is ongoing.-On 4/22/2026 Fall prevention strategies was sent to all staff via messaging platform and was posted in the memory care unit. 4. Indicate how the facility plans to monitor its performance to ensure solutions are sustained. Plan for ensuring corrective action is achieved and sustained. How corrective measures will be monitored. What QA (Quality Assurance) program will be put in place (who, how, how often, what will be done if problems discovered?)-Monitoring of all residents for restraint use by non-biased nurses that do not work on the memory care unit twice a day began on 04/15/2026 and is ongoing.-Weekly review of monitoring tools and residents were conducted in the AM meeting with all disciplines to identify any opportunities for further education/disciplinary actions for 8 weeks started 04/15/2026 and is ongoing. Validation of review of facility's actions to correct deficient practice:1. Address how corrective actions were accomplished for those residents found to have been affected by the deficient practice.-Review of facility's time sheet for S5 CNA, S9CNA, S3 LPN, and S6 LPN who were suspended pending investigation revealed last work date of 04/14/2026.-S7 CNA resignation letter noted on 04/15/2026.-Documents revealed S5 CNA and S6 LPN were terminated with last work date of 04/14/2026.-Review of Investigation interview statements revealed S5 CNA admitted to restraining Resident #1 and S6 admitted to seeing Residents #1 and #2 restrained.-Review of Resident #1 and #2's skin audits on 04/15/2026 revealed no new skin problems. 2. Describe how other residents with potential to be affected will be identified and what will be done for them:-Review of all memory care unit skin audits on 04/15/2026 revealed no new skin problems.-Review of documentation revealed each of the 17 residents on the memory care unit were monitored every 30 minutes for 72 hours beginning on 04/15/2026 and completed on 4/18/2026.-Reviewed facility map with which supervisor was responsible for which sections for restraint search with no issues found.-Review of Life Satisfaction rounds for allegation of restraint with 10 residents who were cognitively intact was conducted on 04/15/2025 and revealed no issues. -Review of documented Peer Review for restraint use by Social Services Staff on 04/17/2026 and 04/20/2026 with no issues found.-During interview on 05/13/2026 at 4:18 p.m. S10 MDS reported the MDS nurses reviewed the memory care residents care plans for any interventions needed. 3. Measures that will be put in place or system changes that will be made to ensure practice will not recur:-Reviewed documentation of 04/14/2025 training for all staff by the administrator in regard to resident abuse, reporting of abuse, resident rights, compliance and ethics and communication.-Reviewed documentation of leadership rounds, each with different resident on the locked unit, conducted at least weekly and indicated appropriate responses. -Reviewed training documentation in regard to restraints, policy, reporting, and managing impulsive behaviors which started on 04/15/2026 and was completed on 04/22/2026.-Reviewed documentation of 04/15/2026 training for S4 CNA regarding immediate notification of Administrator and DON when a resident is seen restrained.-Interviews were conducted with multiple staff throughout the course of the survey from 05/11/2026 to 05/18/2026 revealed staff had received in-service training in regard to abuse, use of restraints, reporting, and managing behaviors. During the interviews staff reported restraints were not to be used and they knew to report immediately to the DON or administrator when residents seen with restraint. 4. Indicate how the facility plans to monitor its performance to ensure solutions are sustained. Plan for ensuring corrective action is achieved and sustained. How corrective measures will be monitored. What QA program will be put in place (who, how, how often, what will be done if problems discovered?)-During an interview on 05/14/2026 at 12:25 p.m. S1 Administrator reported ADHOC (to this) QAPI (Quality Assurance and Performance Improvement) with MD (Medical Doctor) and team on restraints and managing impulsive behaviors and resident safety skill was conducted on 04/15/2026. S1 Administrator further reported weekly review of monitoring tools and residents were conducted in the morning meeting with all disciplines present to identify any opportunities for further education/disciplinary actions for 8 weeks started 04/15/2026 and is ongoing. S1 Administrator further reported managing of behaviors training/testing was added to new hire orientation training.

Based on record reviews, observations, and interviews the facility failed to ensure staff reported alleged violations of abuse for the use of physical restraints to the administrator immediately or within 2 hours for 2 (#1, #2) of 5 (#1, #2, #3, #4, #5) sampled residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings:Review of policy titled Abuse Prohibition Policy reviewed and revised 02/26/2026 revealed, in part:INTENT:This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property.Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse.POLICY:1. The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents.DEFINITIONS:Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Reporting/Response:1. Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination. Resident #1Review of Resident #1's medical record revealed an initial admission date to the facility on [DATE] and an admission date of 11/27/2024 to the facility's memory care unit. Further review of Resident #1's medical record revealed diagnoses including, in part: Alzheimer's disease with late onset, unspecified dementia . with other behavioral disturbance, cognitive communication deficit, major depressive disorder recurrent, anxiety disorder, Schizophrenia unspecified, acute ischemic heart disease unspecified, and muscle wasting and atrophy not elsewhere classified of right and left upper arm. Review of Resident #1's 02/21/2026 Quarterly MDS (Minimum Data Set) revealed a BIMS (Brief Interview Mental Status) of 06, indicating severe impaired cognition. During a phone interview on 05/12/2026 at 12:20 p.m. S5 CNA reported she worked on the memory care unit and did not remember the day, but recently, had put a sheet around Resident #1's abdomen, ran it through the sides of the wheelchair and tied it in the back of the wheelchair to secure him in the wheelchair. S5 CNA further reported she did not immediately report to anyone that Resident #1 had a restraint on. Resident #2 Review of Resident #2's medical record revealed an initial admission date to the facility on [DATE] and an admission date of 03/16/2026 to the facility's memory care unit. Further review of Resident #2's medical record revealed diagnoses that included, in part: Alzheimer's disease with late onset, insomnia unspecified, cognitive communication deficit, impulsiveness, disorientation, major depressive disorder recurrent, and vascular dementia severe with agitation. Review of Resident #2's 03/10/2026 admission MDS revealed a BIMS of 0, indicating severe impaired cognition. During a phone interview on 5/12/2026 at 4:14 p.m. S7 CNA reported she worked outside the memory care unit and she did not remember the exact date but one recent evening she and S4 CNA went to the memory care unit to assist residents to bed and when S4 CNA tried to put Resident #2 to bed, she saw Resident #2 had a sheet tied around her and the wheelchair. S7 CNA further reported she did not immediately report that Resident #2 was restrained to her wheelchair to anyone. During an interview on 05/13/2026 at 08:30 a.m. S2 DON (Director of Nursing) reported S4 CNA and S7 CNA did not immediately report seeing Resident #2 restrained to her wheelchair immediately when they saw it on 04/13/2026 and should have. S2 DON further reported S6 LPN did not immediately report to the DON or Administrator when she saw Residents #1 and #2 restrained to their wheelchairs around the end of March and should have. S2 DON also reported S5 CNA did not immediately report when she restrained Resident #1 in the recent past and should have. During a phone interview on 05/13/2026 at 10:44 a.m. S4 CNA reported she worked outside the memory care unit and on 04/13/2026 around 9:00 p.m. she and S7 CNA were called to assist 2 memory care residents to bed and while trying to transfer Resident #2 from her wheelchair to bed, she saw Resident #2 had a sheet around the abdomen and tied behind the wheelchair. S4 CNA further reported she did not immediately report that Resident #2 was restrained to her wheelchair. During a phone interview on 05/13/2026 at 4:43 p.m. S6 LPN reported she could not remember the exact day but around the end of March 2026 she saw Resident #1 and Resident #2 restrained to their wheelchairs with a sheet around each of their abdomens and tied in the back behind their wheelchairs. S6 LPN further reported she did not immediately report Resident #1 and #2 being found restrained to their wheelchair. During an interview on 05/14/2026 at 1:40 p.m. S1 Administrator reported when any resident was found restrained as Resident #1 and #2 were, it should have been reported to administration immediately and in this case was not. S1 Administrator further confirmed a reasonable person who was restrained as Resident #1 and Resident #2 were, would have experienced psychosocial harm. During the survey, in-service records and QA (Quality Assurance) monitoring records were reviewed and it was determined that the facility had implemented the following actions to correct deficient practice.Review of facility's corrective actions to deficient practice with a completion date of 04/22/2026 included:Intervention:1. Address how corrective actions were accomplished for those residents found to have been affected by the deficient practice.-04/15/2026 at 1:24am allegation received. -Employee responsible for Resident #2's restraint placement on 4/13/2026 was unknown. -Staff on 4/13/2026 memory care night shift (S6 LPN, S5 CNA) and day shift (S3 LPN, S9 CNA) were suspended pending investigation. -S7 CNA resigned after giving her statement on 4/15/2026.-After investigation S5 CNA and S6 LPN were terminated-Through interviews on 4/15/2026, S5 CNA admitted to restraining Resident #1 in recent past, but not on 4/13/2026.-Police department was notified and came to facility 4/15/2026.-Skin audits for Resident #1 and Resident #2 were conducted by Treatment Nurse on 4/15/2026. 2. Describe how other residents with potential to be affected will be identified and what will be done for them:-All residents in Meadows memory care unit were assessed for injury on 4/15/2026 and none were noted.-All residents in Meadows memory care unit were placed on every 30 minutes monitoring for restraint use for 72 hours beginning 4/15/2026 and completed on 4/18/2026.-Investigation interviews regarding whether staff had seen anyone restrained began with all staff members on Main on 4/15/2026 and interviews were completed on 4/16/2026. None of the staff interviewed were aware of anyone being restrained except S6 LPN who found 2 residents in memory care restrained, S4 CNA and S7 CNA who saw Resident #2 restrained in the memory care unit, and S5 CNA who reported she had restrained Resident #1.-Visual check of ALL rooms and residents by Administrator, Activities Director, Admissions coordinator, BOM (Business Office Manager) for signs of restraint use on 4/15/2026 and none were by staff found.-Resident Life Satisfaction rounds/surveys were completed for residents the administrator reported had a cognitive BIMS score by the Social Services staff with no negative findings on 4/15/2026. Each of the residents who answered questions for the Life Satisfaction Survey were noted to be outside of the memory care unit.-PEER surveys were completed by Social Services staff on 4/15/2026 and 4/20/2026 in regard to the 4 suspended employees with no negative findings completed on 4/20/2026.-Care Plans for the 17 memory care residents were reviewed by the interdisciplinary team of MDS Nurses and DON for resident's behaviors, fall risk and current interventions with completion date of 4/15/2026. 3. Measures that will be put in place or system changes that will be made to ensure practice will not recur:-S1 Administrator reported on 5/11/2026 at 4:00pm that all staff had abuse training on 04/14/2026 and prior to being aware of this issue.-Leadership rounds by MDS nurses and ADON (Assistant Director of Nursing) staff to observe staff response to residents and interview staff response to residents with impulsive or high-risk behaviors for 4 weeks started on 04/16/2026 with completion date of 05/08/2026.-In-services for all staff -Restraint specified based on policy and procedure by S1 Administrator began on 4/15/2026 for all staff with the addition of more specific in-service regarding restraining residents, appropriate escalation to nursing and leadership, and managing impulsive behaviors with knowledge verification on 4/15/2026. Completion date of 4/22/2026.-On 4/21/2026 In-service material on managing impulsive behaviors and resident safety was added to new employee orientation materials and is ongoing.-On 4/22/2026 Fall prevention strategies was sent to all staff via messaging platform and was posted in the memory care unit. 4. Indicate how the facility plans to monitor its performance to ensure solutions are sustained. Plan for ensuring corrective action is achieved and sustained. How corrective measures will be monitored. What QA (Quality Assurance) program will be put in place (who, how, how often, what will be done if problems discovered?)-Monitoring of all residents for restraint use by non-biased nurses that do not work on the memory care unit twice a day began on 04/15/2026 and is ongoing.-Weekly review of monitoring tools and residents were conducted in the AM meeting with all disciplines to identify any opportunities for further education/disciplinary actions for 8 weeks started 04/15/2026 and is ongoing. Validation of review of facility's actions to correct deficient practice:1. Address how corrective actions were accomplished for those residents found to have been affected by the deficient practice.-Review of facility's time sheet for S5 CNA, S9CNA, S3 LPN, and S6 LPN who were suspended pending investigation revealed last work date of 04/14/2026.-S7 CNA resignation letter noted on 04/15/2026.-Documents revealed S5 CNA and S6 LPN were terminated with last work date of 04/14/2026.-Review of Investigation interview statements revealed S5 CNA admitted to restraining Resident #1 and S6 admitted to seeing Residents #1 and #2 restrained.-Review of Resident #1 and #2's skin audits on 04/15/2026 revealed no new skin problems. 2. Describe how other residents with potential to be affected will be identified and what will be done for them:-Review of all memory care unit skin audits on 04/15/2026 revealed no new skin problems.-Review of documentation revealed each of the 17 residents on the memory care unit were monitored every 30 minutes for 72 hours beginning on 04/15/2026 and completed on 4/18/2026.-Reviewed facility map with which supervisor was responsible for which sections for restraint search with no issues found.-Review of Life Satisfaction rounds for allegation of restraint with 10 residents who were cognitively intact was conducted on 04/15/2025 and revealed no issues. -Review of documented Peer Review for restraint use by Social Services Staff on 04/17/2026 and 04/20/2026 with no issues found.-During interview on 05/13/2026 at 4:18 p.m. S10 MDS reported the MDS nurses reviewed the memory care residents care plans for any interventions needed. 3. Measures that will be put in place or system changes that will be made to ensure practice will not recur:-Reviewed documentation of 04/14/2025 training for all staff by the administrator in regard to resident abuse, reporting of abuse, resident rights, compliance and ethics and communication.-Reviewed documentation of leadership rounds, each with different resident on the locked unit, conducted at least weekly and indicated appropriate responses. -Reviewed training documentation in regard to restraints, policy, reporting, and managing impulsive behaviors which started on 04/15/2026 and was completed on 04/22/2026.-Reviewed documentation of 04/15/2026 training for S4 CNA regarding immediate notification of Administrator and DON when a resident is seen restrained.-Interviews were conducted with multiple staff throughout the course of the survey from 05/11/2026 to 05/18/2026 revealed staff had received in-service training in regard to abuse, use of restraints, reporting, and managing behaviors. During the interviews staff reported restraints were not to be used and they knew to report immediately to the DON or administrator when residents seen with restraint. 4. Indicate how the facility plans to monitor its performance to ensure solutions are sustained. Plan for ensuring corrective action is achieved and sustained. How corrective measures will be monitored. What QA program will be put in place (who, how, how often, what will be done if problems discovered?)-During an interview on 05/14/2026 at 12:25 p.m. S1 Administrator reported ADHOC (to this) QAPI (Quality Assurance and Performance Improvement) with MD (Medical Doctor) and team on restraints and managing impulsive behaviors and resident safety skill was conducted on 04/15/2026. S1 Administrator further reported weekly review of monitoring tools and residents were conducted in the morning meeting with all disciplines present to identify any opportunities for further education/disciplinary actions for 8 weeks started 04/15/2026 and is ongoing. S1 Administrator further reported managing of behaviors training/testing was added to new hire orientation training.

Based on record review, observation and interviews the facility failed to ensure residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to ensure oral care was provided for 1(#2) of 3 sampled residents.Findings:Review of Resident #2's record revealed an initial admission date of 02/04/2025 with the following diagnoses in part, other sequelae of cerebral infarction, acute respiratory failure with hypoxia, aphasia, encounter for attention to tracheostomy and encounter for attention to gastrostomy.Review of Resident #2's care plan revealed in part: ADL self-care performance deficit related to a diagnosis of cardio vascular accident and respiratory failure with hypoxia. Further review of Resident #2's care plan revealed interventions which included oral care routine in the morning and at night: Brush teeth, clean gums with toothette and rinse mouth with wash.Review of Resident #2's MDS (Minimum Data Set) assessment dated [DATE] revealed in part, BIMS (Brief Interview of Mental Status) score of 00, indicating severe cognitive impairment. Further review of functional abilities revealed Resident #2 was dependent on staff for oral hygiene.An observation on 01/06/2026 at 8:07 a.m. revealed Resident #2 with a tracheostomy and her lips covered with white debris. During an interview on 01/06/2026 at 8:21 a.m. S2 RT (Respiratory Therapist) acknowledged the white debris on Resident #2's mouth and oral care was needed. S2 RT further reported the CNAs (Certified Nursing Assistant) are responsible for providing oral care to residents and oral care should have been provided to Resident #2.During an interview on 01/06/2026 at 8:32 a.m. S5 LPN (Licensed Practical Nurse) reported she took care of Resident #2 and Resident #2 did not received oral care yesterday (01/05/2026) and was not sure how often CNAs provide oral care. During an interview on 01/06/2026 at 8:34 a.m. S3 CNA, reported she did not provide oral care because the Respiratory Therapist provided oral care to Resident #2. During an interview on 01/06/2026 at 8:38 a.m. S4 ADON (Assistant Director of Nursing) reported Resident #2 should have received oral care every shift and oral care was in Resident #2's plan of care. S4 ADON confirmed the responsibility of CNAs was to provide oral care to residents every shift and Resident #2 should have received oral care.

Based on record review and interview the facility failed to ensure a resident was seen face to face by a physician at least once every 60 days for 1 (#1) of 3 sampled records reviewed.Findings:Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with the following diagnoses which included, in part: Chronic respiratory failure, osteomyelitis of vertebra, lumbar region, complete paraplegia, pressure ulcer to the sacral region and an encounter for attention to a tracheostomy.Review of Resident #1's medical record revealed one face to face physician visit dated 05/06/2025 from the admission date on 04/11/2025 to discharge date on 11/22/2025. Further review of Resident #1's medical record found no other documentation of a face to face physician visit with Resident #1.During an interview on 01/06/2026 at 3:18 p.m. S1 DON (Director of Nursing) confirmed Resident #1 only had one face to face physician visit from 04/11/2025 to 11/22/2025. S1 DON acknowledged a face to face physician visit should have been done every 60 days thereafter the initial visit.

Based on record review, observation and interview, the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services consistent with professional standards of practice to promote healing for 1 (#3) of 3 sampled residents.Findings: Policy:Pressure Injury Prevention Program (Reviewed and Revised date of 06/27/2025)Standard: All residents will be assessed for the risk of pressure injury development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Each resident will also receive a weekly skin check to identify new areas of concern or the development of new pressure injuries to ensure a timely adjustment to the resident's change in condition/risk level. Based on the results of these assessments, specific interventions will be implemented to prevent the development of avoidable pressure injuries, or, to treat new/existing pressure injuries.3. The following is a list of commonly used interventions to possibly prevent the development of pressure injuries- c. Keep residents clean and dry d. Provide incontinent care as appropriateReview of Resident #3's medical record revealed Resident #3 had an initial admission date of 07/07/2018 with a readmission date of 09/18/2025 with the following diagnoses in part: Multiple sclerosis, pressure ulcer of the sacral region - Stage 4, altered mental status, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.Review of Resident #3's annual MDS (Minimum Data Set) assessment dated [DATE] revealed in part, a BIMS (Brief Interview of Mental Status) score of 04, indicating severe cognitive impairment and Resident #3 was dependent on staff for toileting and personal hygiene.Review of Resident #3's physician order dated 11/10/2025 revealed clean sacrum with wound cleanser, apply Ioplex, cover with super absorbent dressing three time weekly and as needed if soiled or dislodged.Review of Resident #3's person centered care plan revealed Resident #3 had a pressure ulcer to the sacrum with interventions which included in part, clean with wound cleanser, apply Ioplex, cover with super absorbent dressing three times weekly and as needed if soiled.An observation of wound care on 01/05/2026 at 11:30 a.m. revealed S6 Treatment Nurse removed a saturated bandage from Resident #3's sacral area. S6 Treatment Nurse continued wound care leaving the soiled brief in place. S6 Treatment Nurse completed wound care, secured the soiled brief back in place, and placed the bed linens back over Resident #3. During an interview on 01/05/2026 at 11:35 a.m. S6 Treatment Nurse acknowledged Resident #3's brief was soiled during wound care treatment. During an interview on 01/05/2026 at 2:15 p.m. S1 DON (Director of Nursing) reported Resident #3's soiled brief should have been changed prior to starting wound care and the soiled brief should not have been left on Resident #3 after wound care was complete.

Based on record reviews and interviews the provider failed to ensure ADL (Activities of Daily Living) Care was completed for 1 (Resident #1) of 3 sampled residents. Findings:Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] and was discharged from the facility on 09/02/2025. Resident #1's diagnoses included Multiple Sclerosis, muscle weakness, seizures, lack of coordination, muscle wasting and atrophy, altered mental status, restlessness and agitation, polyosteoarthrits, Schizoaffective disorder, bipolar type. Review of Resident #1's Minimum Data Set, dated [DATE] revealed Resident #1 required substantial/maximal assistance for bathing. The definition of substantial/maximal assistance meant the helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Resident #1's BIMS (Brief Interview for Mental Status) score was 15, which would indicate the resident was cognitively intact. Review of Resident #1's Documentation Survey Report for August 2025 revealed no documentation of evidence of bathing being completed on August 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 30th, and 31st, of 2025. On the days there was no documentation of evidence of bathing being completed Resident #1 had code 97 entered on the Documentation Survey Report which indicated not applicable.During a telephone interview on 09/22/2025 at 12:50 p.m., Resident #1 reported that she did not receive a bath for two weeks. During an interview on 09/23/2025 at 2:45 p.m., S1DON (Director of Nursing) verified Resident #1 did not receive a bath on August 19th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 30, and 31st of 2025. She further reported code 97 meant not applicable. During an interview on 9/23/25 at 3:30 p.m., S2Corporate Nurse reported the code 97 means not applicable, and that code should not be used. S2Corporate Nurse verified that code 97 should be the same as not getting bathed. During an interview on 09/25/2025 at 11:55 a.m., S3CNA (Certified Nursing Assistant) reported Resident #1 required assistance for bathing. During an interview on 09/25/2025 at 12:20 p.m., S4CNA reported Resident #1 required assistance for bathing. During an interview with observation on 09/25/2025 at 1:15 p.m., S5CNA reported they use a Kiosk for documenting all care that resident's receive. Observation with S5CNA revealed several different options to select for bathing according to resident's needs. Further review revealed an option of Not Applicable. During an interview on 09/25/2025 at 1:40 p.m. S1DON verified the staff uses the Kiosk to document what they have completed for each resident they are responsible for.

Based on record reviews and interviews, the facility failed to ensure 1 (#1) of 13 sampled residents reviewed was free from unnecessary drugs. The facility failed to monitor Resident #1's edema while receiving a diuretic. Findings: Review of Resident #1's medical records revealed an admitted [DATE] with the following diagnoses, including in part: acute respiratory failure with hypoxia, other pneumonia/unspecified organism, acute kidney failure/unspecified, and heart failure/unspecified. Review of Resident #1's comprehensive care plan revealed: resident has hypertension - monitor for and document any edema/notify Medical Director. Review of Resident #1's Physician's orders revealed an order dated 01/30/2025 for Furosemide oral tablet 40mg (milligram); give 1 tablet by mouth two times a day related to edema. Review of Resident #1's February MAR (Medication Administration Record) failed to reveal edema was monitored while receiving diuretic. During an interview on 03/25/2025 at 2:10 p.m. S7 LPN (Licensed Practical Nurse) while reviewing Resident #1's February MAR, acknowledged there was no monitoring for edema. S7 LPN confirmed Resident #1 was receiving a diuretic. During an interview on 03/25/2025 at 2:35 p.m. S3 Corporate Nurse acknowledged Resident #1 was not monitored for edema while receiving a diuretic for the month of February and should have been.

Based on record reviews and interviews, the facility failed to provide and document sufficient preparation and orientation for 1 (#1) of 3 sampled residents reviewed to ensure safe and orderly transfer or discharge from the facility. The facility failed to provide Resident #1 with a discharge instruction form. Findings: Review of Facility's - Transfer or Discharge, Facility Initiated (2001) Policy and Procedure: Policy Statement - Once admitted to the facility .require resident/representative notification and orientation, and documentation as specified in this policy. Orientation for Transfer or Discharge (Planned) - 1. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. Review of Resident #1's medical records revealed an admit date of 01/30/2025 and discharge date of 02/20/2025 with the following diagnoses, including in part: acute respiratory failure with hypoxia, other pneumonia/unspecified organism, other cerebral infarction, acute kidney failure/unspecified, acute embolism and thrombosis of unspecified deep veins of lower extremity bilateral, essential (primary) hypertension, type 2 diabetes mellitus with other specified complication, heart failure/unspecified and encounter for attention to colostomy. Review of Resident #1's Progress Notes revealed the following entry on 02/20/25 16:54 - ambulance picked up resident at 4:05 p.m. phoned daughter to inform her that resident was on her way home . Review of Resident #1's medical record failed to reveal documentation resident or responsible party was provided discharge instructions. During a telephone interview on 03/25/2025 at 8:49 a.m. S8 Complainant reported the resident did not receive any discharge instructions to include a follow-up appointment prior to or upon discharge. During an interview on 03/25/2025 at 10:55 a.m. S1 Administrator acknowledged a discharge instruction form was not provided to Resident #1 or her responsible party upon discharge on [DATE] and should have been. During an interview on 03/25/2025 at 2:00 p.m. S4 LPN (Licensed Practical Nurse) acknowledged she did not complete a discharge instruction form for Resident #1 when she was discharged home on [DATE] and should have. During an interview on 03/26/2025 at 10:35 a.m. S2 DON (Director of Nursing) acknowledged Resident #1 did not receive a discharge instruction form on 02/20/2025 and should have.

Based on record reviews and interviews, the facility failed to ensure 1 (#2) out of 3 sampled residents reviewed received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers. The facility failed to: 1. Complete a head to toe assessment prior to discharge to hospital, and 2. Notify staff of change in skin status/injury. Findings: Review of Facility's Skin Integrity Prevention and Treatment Program Policy and Procedure revised 09/2024: Standard: All residents will be assessed for the risk of pressure development at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Procedure: All residents will have a head to toe assessment (skin check) completed on a weekly basis by the licensed nurse. 5. If a pressure injury/skin breakdown is identified, the following will be done - a. if pressure injury - complete new wound evaluation/assessment. d. notify RP or family . Review of Facility's Investigation Report (259708) for Resident #2 revealed: Discovered: 01/31/2025 at 12:07 p.m. Witness Statement: S5 CNA (Certified Nursing Assistant) - I changed resident on 01/30/2025 and noticed a red spot on her bottom and a blister. I was rushing to get her ready to be sent to the emergency room and I forgot to report it to the nurse. Review of Resident #2's medical records revealed an admitted [DATE] with the following diagnoses, including in part: type 2 diabetes mellitus without complications, unspecified open wound/right ankle/initial encounter, and dementia in other diseases classified elsewhere/unspecified severity with other behavioral disturbance. Review of Resident #2's comprehensive care plan revealed: Potential for impairment of my skin integrity - report abnormalities . During an interview on 03/26/2025 at 9:40 a.m. S6 LPN (Licensed Practical Nurse) reported S5 CNA did not inform her of any skin issues for Resident #2. S6 LPN acknowledged a head to toe assessment was not completed on Resident #1 prior to being discharged from the facility and should have been. During an interview on 03/26/2025 at 10:35 a.m. S2 DON (Director of Nursing) acknowledged S6 LPN did not complete a head to toe assessment on Resident #2 prior to her discharge to the hospital on 01/30/2025 and should have. S2 DON further acknowledged S5 CNA did not report Resident #2's new skin injury discovered on 01/30/2025 to the nurse and should have.

Based on record review and interviews, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers 1 (#1) of 3 (#1, #2, #3) residents reviewed for pressure ulcers. The facility failed to have documented evidence of turning and repositioning resident #1 to help prevent pressure ulcers. Findings: Review of the facility`s policy and procedure related to pressure injury prevention with a revision date of 09/2024 revealed in part: 3. The following is a list of commonly used interventions to possibly prevent the development of pressure injuries- a. Turning and positioning to include but not limited to: during and after care- activities of daily living, skin audits/dressing changes, transfers between surfaces and as needed. Record review for resident #1 revealed an admitted [DATE] with diagnoses including other displaced fracture of second cervical vertebra, acute chronic systolic heart failure, chronic obstructive pulmonary disease, non-traumatic subarachnoid hemorrhage, contusion and laceration of cerebrum without loss of consciousness, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, degenerative disease of nervous system, muscle wasting and atrophy, spinal stenosis, syncope, chronic kidney disease, history of fractures, unspecified fracture of unspecified thoracic vertebra, wedge compression fracture of first and second thoracic vertebra, and dementia. Resident#1 also had a right hip fracture and right wrist fracture diagnosis added on 08/12/2024. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Review of the active care plan for resident #1 revealed it was initiated on 10/24/2023 which included the following: The resident has bowel and bladder incontinence. Goal: resident will have intact skin and be free from odors. Interventions: incontinent care as needed, skin checks weekly by licensed vocational nurse or treatment nurse, turn and reposition every 2 hours. The plan of care further revealed resident #1 required 2 person assistance for bed mobility after re-admission to the facility on [DATE]. On 10/08/2024 at 2:49 p.m., an interview with S4Registered Nurse (RN) (Wound Care Nurse) revealed she assessed resident #1 on re-admission from the hospital to the facility on [DATE] and she had no pressure ulcer to her sacrum. S4RN reported a Certified Nursing Assistant (CNA) reported an abnormal area to resident #1`s sacrum on 08/15/2024. S4RN completed a wound assessment on 08/15/2024. The wound was assessed to be a facility acquired stage 2 pressure ulcer to the sacrum. Record review revealed there was no documented evidence of the nursing staff turning and repositioning resident #1 every 2 hours on 08/13/2024 for the morning shift (6 a.m.- 2 p.m.) and the evening shift (2 p.m.- 10 p.m.) and on 08/14/2024 for the evening shift (2 p.m.-10 p.m.) and the night shift (10 p.m.- 6 a.m.) as directed by the plan of care. On 10/08/2024 at 11:25 a.m., an interview with S3Director of Nursing confirmed there was no documented evidence of resident #1 being turned every 2 hours on 08/13/2024 for morning shift (6 a.m.- 2 p.m.) and evening shift 2 p.m.-10 p.m.) and on 08/14/2024 for the evening shift (2 p.m.-10 p.m.) and the night shift (10 p.m.-6 a.m.) as directed by the plan of care.

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 (#2) of 5 (#1, #2, #3, #4, and #5) sampled residents. Findings: Review of the record revealed resident #2 had an admitted [DATE] with diagnoses including other displaced fracture of second cervical vertebra, acute chronic systolic heart failure, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage, contusion and laceration of cerebrum without loss of consciousness, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, degenerative disease of nervous system, muscle wasting and atrophy, spinal stenosis, syncope, chronic kidney disease, history of fractures, unspecified fracture of unspecified thoracic vertebra, wedge compression fracture of first and second thoracic vertebra, and dementia. Review of resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review revealed resident required 1 person assist with activities of daily living. Review of the Discharge Summary from the hospital dated 08/12/2024 revealed resident #2 was admitted after a fall with a right hip fracture, pneumonia, sepsis, and was found to have a right radius fracture, right wrist fracture, and right hip fracture. Resident#2 had an open reduction internal fixation of right hip surgery on 08/08/2024, and was discharged back to the facility on [DATE]. Review of the current care plan for resident #2 revealed alteration in musculoskeletal status history other displaced fracture of 2nd cervical vertebra sequela dated 10/24/2023. Interventions included - monitor cast to right lower arm, stabilizer with ace bandage to right leg, ankle and toes dated 08/13/2024. Review of the record revealed no documented evidence the interventions were implemented as stated on the careplan on 08/13/2024. An interview on 08/28/2024 at 12:00 p.m. with S2Corporate Nurse confirmed the facility failed to implement the following interventions listed on resident #2's care plan including monitoring of the cast to the right lower arm, and a stabilizer with ace bandage to the right leg, ankles, and toes.

Based on record review and interviews, the facility failed to ensure residents remained as free of accident hazards as possible for 1 (#2) of 3 (#2, #4, and #5) residents reviewed for accidents. The facility failed to ensure fall risk assessments were completed quarterly, specific interventions were implemented based on the results of the risk assessments, and careplan interventions were implemented on readmission on 08/12/2024. Findings: Review of the facility's Fall Prevention Program Policy and Procedure, last revision dated 06/10/2024, policy and procedure revealed in part the following: Policy: All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be implemented to minimize falls, avoid repeat falls, and minimize falls resulting in significant injury. A. Procedure 1. All residents will be screened for risk for falls utilizing the Fall Risk Assessment. This will be done at the time of admission, quarterly, after each fall and upon significant change in condition. 2. Residents identified at being at risk will have interventions identified in their plan of care to minimize falls. 4. The resident's plan of care will be updated to reflect risk for falls, and appropriate interventions. Review of the record revealed resident#2 had an admitted [DATE] with diagnoses including other displaced fracture of second cervical vertebra, acute chronic systolic heart failure, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage, contusion and laceration of cerebrum without loss of consciousness, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, degenerative disease of nervous system, muscle wasting and atrophy, spinal stenosis, syncope, chronic kidney disease, history of fractures, unspecified fracture of unspecified thoracic vertebra, wedge compression fracture of first and second thoracic vertebra, and dementia. Review of resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review revealed resident required 1 person assist with activities of daily living. Review of resident #2's current care plan dated 10/24/2023 revealed the resident was at risk for falls with the following interventions in place prior to the fall on 08/06/2024 as follows: anticipate and meet resident's needs, be sure call light is within reach and encourage resident to use it for assistance as needed, provide prompt response to all requests for assistance, ensure resident wearing appropriate footwear when ambulating or mobilizing in wheelchair. Further review of the care plan revealed an actual fall with injury on 08/06/2024 (fracture proximal right femur) and interventions dated 08/08/2024 were to visit resident often to ensure location, provide visual/verbal cueing as needed to ensure safety. Review of the facility reported incident for resident #2 dated 08/06/2024 revealed resident #2 had a fall at 12:17 a.m. on 08/06/2024. Further review revealed resident #2 had moaning and facial grimacing to her right leg during the assessment by S4Licensed Practical Nurse (LPN). S4LPN notified the physician of the findings and the physician ordered an x-ray of her right leg and right hip. S4LPN notified mobile x-ray, and they performed x-rays at 8:00 a.m. on 08/06/2024. S6LPN was notified of the results of the x-ray including a right femur fracture on 08/06/2024 at 9:55 a.m. Review of the record revealed no documented evidence the facility completed a fall risk assessment for resident #2 quarterly on 05/23/2024. Review of resident #2's record revealed a fall risk assessment was completed on 04/11/2024 and resident #2 was assessed to be high risk for falls. Further review of the record revealed a fall risk assessment was completed on 08/06/2024 and resident #2 was assessed to be at moderate risk for falls. An interview on 08/27/2024 at 10:45 a.m. with S2Corporate Nurse revealed the facility completes fall risk assessments on admit, readmit, with significant change, and with each fall. S2Corporate Nurse revealed resident #2 was assessed to be high risk for falls. S2Corporate Nurse reported the facility does not implement specific interventions for residents at risk for falls. An interview on 08/27/2024 at 12:45 p.m. with S1Administrator confirmed specific interventions are not implemented when residents are assessed to be at risk for falls. An interview on 08/28/2024 at 10:20 a.m. with S2Corporate Nurse confirmed the facility did not have documented evidence of interventions including - visit resident often to ensure location or provide visual/verbal cueing as needed to ensure safety when resident #2 returned from the hospital on 08/12/2024. An interview on 08/28/2024 at 4:00 p.m. with S2Corporate Nurse confirmed the fall risk assessment was not completed quarterly on 05/23/2024 for resident #2, confirmed previous fall risk assessment on 04/11/2024 was the last fall risk assessment/evaluation done prior to resident #2's fall on 08/06/2024. S2Corporate Nurse further confirmed the facility did not follow the Policy and Procedure for the Fall Prevention Program.

Based on record review and interviews, the facility failed to ensure the nursing staff had appropriate competencies and skill sets to provide nursing care to assist resident safety and maintain the highest practical physical, mental, and psychological well-being of each resident for 1 (#2) of 3 (#2, #4, and #5) residents sampled for accidents. The facility`s failed practice was evidenced by a Certified Nurse Aide's (CNA) failure to follow the facility's Incident/Accident policy and procedure when resident #2 was found on the floor on 08/06/2024. Findings: Review of the Policy for Resident Incident and Visitor Accident Report, revised 07/23/2018, reviewed June 2024, revealed the following, in part: B. Resident Incidents/Accidents: 1. If you witness an incident/accident, you must: -Immediately summon help -DO NOT move the resident until he/she has been assessed by a licensed nurse Review of the record revealed resident#2 had an admitted [DATE] with diagnoses including other displaced fracture of second cervical vertebra, acute chronic systolic heart failure, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage, contusion and laceration of cerebrum without loss of consciousness, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, degenerative disease of nervous system, muscle wasting and atrophy, spinal stenosis, syncope, chronic kidney disease, history of fractures, unspecified fracture of unspecified thoracic vertebra, wedge compression fracture of first and second thoracic vertebra, and dementia. Review of resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review revealed resident required 1 person assist with activities of daily living. Review of resident #2's current care plan dated 10/24/2023 revealed resident#2 was at risk for falls with the following interventions in place prior to the fall on 08/06/2024 as follows: anticipate and meet resident's needs, be sure call light is within reach and encourage resident to use it for assistance as needed, provide prompt response to all requests for assistance, ensure resident wearing appropriate footwear when ambulating or mobilizing in wheelchair. Review of the incident report for resident #2 dated 08/06/2024 at 12:24 a.m. revealed S4Licensed Practical Nurse (LPN) was notified by S5CNA that she heard a thump and a door slam and she found resident #2 lying on the floor in her room. A telephone interview on 08/27/2024 at 8:55 a.m. with S5CNA revealed she worked on 08/06/2024 on the 10:00 p.m.-6:00 a.m. shift, and worked with resident #2. S5CNA reported about midnight she heard a thump and a door slam and she went to resident #2's room and found her lying on the floor on her stomach with her head facing the door. S5CNA reported she assisted resident #2 back into the bed, and then notified S4LPN of resident #2 being on the floor. A telephone interview on 08/26/2024 at 12:40 p.m. with S4LPN revealed she was notified on 08/06/2024 by S5CNA that resident #2 had fallen in her room. S4LPN reported when she was notified she went to assess the resident and the resident was in the bed. S4LPN reported that during the assessment of resident #2, the resident was moaning and had facial grimacing with touching or movement of the right leg. S4LPN reported she notified the resident's physician and an order for a x-ray to the right hip and the right leg was obtained. An interview on 08/28/2024 at 10:15 a.m. S3Director of Nursing (DON) confirmed that S5CNA should not have moved resident #2 back to the bed on 08/06/2024 when she found the resident on the floor. S3DON confirmed S5CNA should have notified S4LPN of the fall immediately, and S5CNA did not follow the facility's policy and procedure.

Based on record review and interview, the facility failed to ensure all allegations of injuries of unknown source with serious bodily injury was reported immediately, or within 2 hours of the allegation to the state agency for 1 (#2) of 2 (#1 and #2) residents sampled with facility incident reports. Findings: Review of the Abuse Prohibition Policy and Procedure with revision date of 05/17/2024 revealed the following, in part: Reporting/Response: 2.) The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within 2 hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation. Review of the record for resident #2 revealed an admitted [DATE] with diagnoses including other displaced fracture of second cervical vertebra, acute chronic systolic heart failure, chronic obstructive pulmonary disease, nontraumatic subarachnoid hemorrhage without loss of consciousness, contusion and laceration of cerebrum, traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, degenerative disease of nervous system, muscle wasting and atrophy, spinal stenosis, syncope, chronic kidney disease, history of fractures, unspecified fracture of unspecified thoracic vertebra, wedge compression fracture of first and second thoracic vertebra, and dementia. Review of resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Further review revealed resident required 1 person assist with activities of daily living. Review of the facility reported incident for resident #2 dated 08/06/2024 revealed resident #2 had a fall at 12:17 a.m. on 08/06/2024. Further review revealed resident #2 had moaning and facial grimacing to her right leg during the assessment by S4Licensed Practical Nurse (LPN). S4 LPN notified the physician of the findings and physician ordered an x-ray of her right leg and right hip. S4LPN notified mobile x-ray, and they performed x-rays at 8:00 a.m. on 08/06/2024. S6LPN was notified of results of x-ray including a right femur fracture on 08/06/2024 at 9:55 a.m. S6LPN notified S1Administrator on 08/06/2024 at 10:00 a.m. of resident #2 having a right femur fracture from her fall on 08/06/2024. Review of resident #2's right femur 2 view x-ray dated 08/06/2024 revealed an acute complex impacted fracture proximal right femur. An interview on 08/28/2024 at 9:40 a.m. with S1Administrator revealed she was notified on 08/06/2024 at 10:00 a.m. that resident #2 had a fall on 08/06/2024 around 12:15 a.m. and the portable x-ray results revealed resident had a right femur fracture. S1Administrator revealed she entered the facility reported incident to state office on 08/06/2024 at 10:16 p.m. for resident #2. S1Administrator confirmed she should have reported to the state office within 2 hours of notification for resident #2's injury of unknown source with serious bodily injury.

Resident #98 Based on record review and interviews the facility failed ensure a discharge assessment was completed for 1 (Resident #98) of 4 (Residents #6, #98, #103, #106) residents reviewed for hospitalization s. Findings: Record review of Resident #98's progress notes from 04/24/2024 revealed the following: General Nurse's Note- Writer notified by Wound Care NP (Nurse Practitioner) that Resident #98 needs to go to ER (emergency room ) to be evaluated at this time due to worsened wounds and abnormal vital signs . General Nurse's Note- Ambulance arrived and transported Resident #98 to acute hospital . Record review of Resident #98's MDS (Minimum Data Set) failed to reveal a discharge assessment was completed after Resident #98 was sent to an acute hospital on 04/24/2024. During an interview on 05/14/2024 at 4:30 p.m. S12 MDS RN (Registered Nurse) verified she did not do a discharge assessment for Resident # 98 when he was discharged to the hospital on 04/24/2024. During an interview on 05/14/2024 at 4:35 p.m. S2 Corporate Nurse verified a discharge MDS should have been completed by S12 MDS RN when Resident # 98 was discharged to the hospital on 04/24/2024.

Based on record reviews, interviews, and observations the facility failed to properly secure resident #5's wheelchair in the facility's transport van for 1(#5) of 3 (#1, #2, and #5) residents reviewed for accidents. The deficient practice resulted in actual harm of Resident #5 on 09/12/2022 when the resident was being transported from an appointment back to the facility via wheelchair on a facility van. Resident #5's wheelchair was not properly secured to the van with four point strap restraints resulting in the wheelchair flipping backwards on to the floor. A local ambulance service was on sight and transported Resident #5 to a local hospital emergency room (ER), where she was diagnosed with one broken rib and contusions to her left shoulder, arm and scalp. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facilities Sec 5.4 Driver and Vehicle Safety Policy dated November 2013 revealed in part: Driver Training 5.4.11: All drivers, whether driving company vehicle, personal vehicle or rental vehicle will be in-service in the Driver and Vehicle Safety Policy before any employee is permitted to drive for the company. In addition, the following training modules are used: Driver safety videos On line driver safety training Employees who drive company vehicle receive additional in-servicing in the following: Loading and unloading of residents, including viewing in Braun and Ricon Series Lift and Sure lock Tiedowns video and hands on practice. Securing wheelchairs and other equipment Before transporting residents in the facility van, facility van drivers must (1) successfully complete all parts of the training; and (2) demonstrate to an authorized trainer that the van driver can properly load, unload and secure residents in the van. The Checklist for Authorizing New Drivers and the Competency Demonstration for Securing Residents in the Van should both be completed before the facility van driver transports residents. Review of Securing Residents in Van - Competency Demonstration dated November 2013 revealed in part: Strap passenger's wheelchair front first from lower bottom bar on top of wheel. Straps should attach to a solid, structural frame member of wheelchair. Apply brake on the wheelchair. Strap rear of the wheelchair to the floor of the vehicle. Any fittings should be firmly engaged and locked into the appropriate slot of the track. Secure the passenger with a seat or lap belt. Prior to transport, make a final check of all secured passengers to ensure that all straps are properly attached. If there are any wheelchairs, be sure that they are secured and there is no possible movement from the front to rear or side to side. Review of Resident #5 clinical records revealed an admitted [DATE] with diagnosis not limited to Polyneuropathy, Rheumatoid Arthritis, Heart Failure and Dementia. Review of Resident #5 MDS (Minimum Data Set) dated 10/11/2022 revealed a BIMS (Brief Interview of Mental Status) score of 15 indicating Resident #5 was cognitively intact. Resident #5 required total dependence for transfers and locomotion on and off the unit. Review of Resident #5 care plan revealed she needed extensive assistance with personal hygiene, toilet use, dressing and bed mobility. Interview 12/05/2022 at 9:00 a.m. Resident #5 reported that her wheelchair had turned over in the van and she had broken a rib as a result. She further revealed that her wheelchair was not tied down the right way and her chair fell over. She said S1 Transport Driver just didn't do it right. She was shook up, her left side hurt and her elbow was bleeding. Interview 12/05/2022 at 2:30 p.m. S4 Transport CNA (Certified Nursing Assistant), reports that on the day of the accident I was with the resident, and the Driver (S1 Transport Driver) coming back from a doctor appointment. The resident was lifted into the van by the lift and secured by the driver as she got onto the van. When they made the last turn to the nursing home, they began to climb a grade and the wheelchair flipped backwards. They pulled up to the facility, the driver went and got help, she went to the resident and stayed with her on the floor of the van until help arrived. The resident was transported to the ER by a local ambulance service. After the investigation the driver was let go and we all had to in-service and get on the van and lock down a wheelchair to get experience on how to do it. Review of the facility's Employees Report of Accident revealed statement by S1 Transport Driver stating As we left the medical facility on the way to the facility, Resident #5's wheelchair flipped backwards. The wheelchair front wheels lifted and fell backward. She landed on the floor of the bus. Review of Nurses notes from 09/12/2022 revealed the following: 09/12/2022 13:40 S2 DON (Director of Nursing), reported to nurse that resident is being sent to a local hospital ER for evaluation because of fall. It was reported that resident w/c (wheelchair) flipped backward on the van. I was also reported to nurse that resident had a raised area to the back of her head and a skin tear to the left elbow. Grandchild and Responsible Party notified and S9 MD. Signed S3 LPN (Licensed Practical Nurse) 09/12/2022 17:00 resident returned these hours by stretcher via a local ambulance service. DX (diagnosis): contusion of left shoulder, contusion of scalp, fracture of one rib left side. NNO (No New Orders), Follow up contact physician as needed, recheck todays' complaints, continue of care. Review of local hospital ER notes dated 09/12/2022 14:33 revealed Resident #5 had fracture on one rib, left side, contusion to left shoulder and scalp. No prescriptions written. Review of Resident #5 Pain Evaluation completed on return from ER. -Pain in last 5 days resident #5 answered yes- occasionally, does it limit your activities- no, pain rate 6 on scale 00-10, pain management as needed. Review of Physicians orders revealed Resident #5 had the following medications already scheduled: Tramadol 100 mg (milligram) every 8 hours as needed, Neurontin 600 mg every night, Tylenol 1000 mg three times a day for breakthrough pain, if needed. Review of Medication Administration Record from September 2022 revealed from 09/12/2022 through 09/23/2022 required Tramadol at least once a day. Observation 12/06/2022 at 11:45 a.m. S5 Transport Driver and S6 Transport Driver both completed a demonstration of how to lift and secure a resident in a wheelchair on to the transportation van. Interview 12/06/2022 at 11:45 a.m. S5 Transport Driver and S6 Transport Driver, both reported that they had been through all the training and understood how to secure a wheelchair in the van. Interview 12/07/2022 at 10:30 a.m. S7 Administrator reported that the day of the accident the driver came through the front door and told her there was an accident and he needed help. S8 RN (Registered Nurse) was there with her, they both rushed out of the door to the van. Upon arrival they found S4 Transport CNA holding Resident #5's head off the floor, wheelchair was rolled backwards and resident was still strapped in the wheelchair. A local ambulance service happened to be in the drive way too. They assisted in transporting the resident straight to the local hospital ER. Resident was complaining of her left side and arm hurting. Further reported that S1 Transport Driver had been suspended then terminated. Telephone interview 12/07/2022 at 10:46 a.m. S8 RN reported that when they got on the van the wheelchair was on its back with only the back wheels strapped in place. A local ambulance service was on scene and they released the rear wheel restraints to allow the wheelchair to be righted. S8 RN concurred that Resident #5 complained of left side and arm pain and that a local ambulance service took resident immediately to the ER. Telephone interview 12/07/2022 at 10:55 a.m. S1 Transport Driver refused to talk about the incident. Review of the facility's corrective Action Plan dated 10/14/2022 revealed: Problem identified: Van driver failed to secure resident in wheelchair correctly while transporting in a facility van. Plan of Action: randomly monitor that residents in wheelchairs are correctly secured in facility transport vans. Educate van drivers and transport CNAs on securing residents correctly in facility transport vans. Monitoring: Random monitoring of transportation securing 4 point strap restraint system is used correctly. Follow-up for effectiveness: current plan of action effective: yes, date 10/21/2022. The facility has implemented the following actions to correct the deficient practice from 09/12/2022: Staff in-service training after incident - 9/15/2022 - Securing resident in van before transporting- completed by All Van Drivers and Transport CNA (Certified Nurses Aids). Review of QA (Quality Assurance) dated 09/15/2022 revealed Problem: resident flipped over backwards in van due to 4 point strap not engaged with 5 points of action plan: 1. All residents transported in van will be secured in the van by engaging the 4 point strap system. 2. All van drivers will be in-serviced and checked off on the 4 point strap system. 3. Transportation Aids will validate that the 4 point strap system is in place prior to van placed in drive, if not then the Transportation Aid will report to Administrator/Maintenance Director. 4. Transportation Aids will be in-serviced on the 4 point strap system. 5. Maintenance Director/designee will do random off site/on site transportation to ensure that the 4 point system is in place x4 weeks. Random monitoring of transportation 4 point strap restraint system in place: monitored for 4 weeks. Started 09/19/2022, completed 10/21/2022. 48 events monitored and done correctly.