Every finding on record at Scottish Rite Park Inc

Based on observations, staff interviews and policy reviews the facility failed to meet professional standards for food storage and personal hygiene. The facility did not label or date open food items, failed to discard expired items, and staff did not wear required hair and beard nets. The facility reported a census of 31 residents.Findings include:A continuous observation on 8/10/26 from 8:10 AM - 9:30 AM revealed Staff B, Cook, not wearing a hair or beard net. Freezer #1 contained the following items without an open date: 1 bag of cheese ravioli, 1 bag of salmon patties, 1 bag of onion rings, 1 bag of sweet potato fries, 1 bag of wings, and 1 bag of chicken strips. The double-door refrigerator contained the following items without an open date: tartar sauce, vinaigrette dressing, blue dressing, red french dressing, caesar dressing, apple cider vinegar, hot bacon dressing, asian sesame dressing, 1 bag of lettuce, lime juice, stuffed queen olives, mild banana pepper rings, soy sauce (3 containers), teriyaki sauce, sweet and sour sauce, and red hot wing sauce (2 containers). The walk-in refrigerator contained the following items without an open date: strawberry yogurt, 1 bag of lettuce, almond frosting, pepperoni slices, 3 gallon containers of ice cream, and 1 bag of tilapia. The walk-in refrigerator revealed five 32-ounce containers of greek yogurt that expired on 7/29/26.On 8/11/26 at 10:36 AM an observation revealed Staff B wearing a baseball cap and beard net while in the kitchen preparing food.On 8/11/26 at 11:25 AM, an observation of the refrigerator in the small kitchenette revealed items without an open date: one half-gallon of whole milk, one half-gallon of fat-free milk, and one half-gallon of 2% milk.On 8/10/26 at 9:30 AM Staff A, Certified Dietary Manager (CDM) stated she expected items to be labeled with an open date and for expired items to be thrown away once expired. Staff A further explained she would have to look at the facilities policy for the hair and beard net as she believed when the hair is at a short length a hairnet is not required.Review of a facility provide policy undated titled, Personal Hygiene Policy and Procedure documented food service staff involved in food production and clean up will adhere to the department dress code that included hair net or appropriate hair covering while involved in food production and clean- up activities.Review of a facility provided policy undated titled, Labeling and Dating Policy and Procedure documented all food items prepared, opened, stored or repackaged by the food service department shall be properly labeled and dated to promote food safety, maintain product quality, ensure proper stock rotation and prevent the use of expired or unsafe food. All employees are responsible for following labeling and dating requirements. Food items that are improperly labeled, undated, expired or otherwise unable to be identified shall not be served and must be discarded according to department procedures. Facilities Personal Hygiene policy without a date directed food service employees to adhere to the facility's dress code that will ensure safe, sanitary meal production and service, and presents a professional appearance. The Procedure included the step included the directive for staff to wear a hair net or appropriate hair covering while involved in food production and clean-up activities. The policy did not address the specific directions towards facial hair, or what other appropriate hair coverings would be expectable beyond a hair net.

Based on observation, clinical record review, staff interview, and facility policy/procedure, the facility failed to ensure Resident #1 received a safe transfer to prevent a fall. The facility failed to follow safe mechanical lift techniques. This resulted in severe harm to a resident, who fell from a full-body mechanical lift and sustained life-threatening injuries including a subdermal hemorrhage (surface brain bleed), a subarachnoid hemorrhage (inner brain bleed), a type III dens fracture (broken neck bone), a right clavicle fracture (broken collarbone), and a left femur fracture (broken thigh bone) for 1 of 4 residents reviewed (Resident #1).The facility corrected the noncompliance prior to the beginning of the survey on 5/1/26 by doing the following:a.The facility-initiated education to staff on 4/30/26 by requiring staff to watch an in-service training video on the full-body mechanical lift's website and complete a quiz that correlates with the video prior to working their next shift.b.The facility initiated on 5/1/26 that staff had to complete hands-on education and demonstrate a safe transfer in compliance with the full-body mechanical lift operational manual with the facility's Quality Assurance Nurse.The facility reported a census of 29 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #1 depended on staff for bed mobility and transfers. The MDS included diagnoses of heart failure (weak heart), morbid obesity (severe overweight), and seizure disorder (convulsion condition).The Care Plan revised 9/16/24, revealed Resident #1 required help from 3 staff members with a full-body mechanical lift for transfers.The Nurse's Note dated 4/29/26 at 8:32 PM written by Staff A, Registered Nurse (RN), documented the Nursing Description as Staff A and Staff B, Licensed Practical Nurse (LPN), received a call to go to Resident #1's room immediately. Upon arriving, Staff A found Staff C, Certified Nursing Assistant (CNA), Staff D, CNA/Certified Medication Assistant (CMA), and Staff E, CNA/CMA, with Resident #1 on the floor with the full-body mechanical lift above her. Resident #1 had their left leg up on the couch with her head towards the bed. She had some blood on her left lateral shin with the bed covers open. Resident #1 used a loud voice to say help her as she wanted to get up. Resident #1 requested emergency medical services (EMS) to assist her getting up and the staff to call her Power of Attorney (POA), refusing the facility's staff assistance. The staff applied pressure by applying some gauze and wrapping the area to Resident #1's left shin to stop the bleeding until EMS arrived. Staff B attempted to assess Resident #1 and found she had a bump on the crown of her head. After EMS arrived, they assisted the facility staff in help Resident #1 into bed via the full-body mechanical lift. After Resident #1's POA persuaded Resident #1 to go to the hospital, she went via ambulance. She refused to allow the facility staff to perform any assessment. The note indicated Staff A initiated the hot charting (additional charting due to a change in resident's condition), the resident's 24-hour report, and the communication report. Staff A put an intervention in place for physical therapy (PT) and Occupational Therapy (OT) assist with providing reeducation on transfer where necessary to all staff.The Incident Report dated 4/29/26 at 8:32 PM written by Staff A documented the Nursing Description as Staff A and Staff B received a call to go to Resident #1's room immediately. Upon arriving, Staff A found Staff C, Staff D, and Staff E, with Resident #1 on the floor with the full-body mechanical lift above her. Resident #1 had their left leg up on the couch with her head towards the bed. She had some blood on her left lateral shin with the bed covers open. The Resident's Description indicated Resident #1 used a loud voice to say help her as she wanted to get up. Resident #1 requested EMS to assist her getting up and the staff to call her POA, refusing the facility's staff assistance. The staff applied pressure by applying some gauze and wrapping the area to Resident #1's left shin to stop the bleeding until EMS arrived. After Resident #1's POA persuaded Resident #1 to go to the hospital, she went via ambulance. She refused to allow the facility staff to perform any assessment. The Incident Report listed injuries to the top of Resident #1's scalp and left lower leg front.The Occurrence Witness Statement written by Staff C on 4/29/26, documented on 4/29/26 at 8:32 PM, 3 CNAs assisted Resident #1 in her room transfer, per her usual routine. Staff E operated the lift controls (driver), Staff D guided the legs, and Staff C pulled the wheelchair away once Resident #1 went up. Before lifting Resident #1, staff ensured everything remained in place. Staff C heard a snap and then observed Resident #1 on the floor, which prompted an immediate call to the nurse.The Occurrence Witness Statement written by Staff D on 4/29/26, indicated on 4/29/26 at 8:32 PM, as they assisted Resident #1 into bed using the full-body mechanical lift, Staff D heard a snap before watching Resident #1 fall to the floor on her right side. Staff E operated the lift, Staff D guided the feet, and Staff C moved the wheelchair. Staff C alerted Staff A and Staff B over the walkie-talkie.The Occurrence Witness Statement written by Staff E on 4/29/26, documented on 4/29/26 at 8:32 PM, they moved Resident #1 up in the full-body mechanical lift. Right before moving Resident #1 to the bed, Staff E observed Resident #1 fall from the lift and strike the floor headfirst. Staff E ran out to locate a nurse.The Trauma Consult/admission History and Physical dated 4/30/26 identified Resident #1 arrived to the emergency room (ER) following a fall from the full-body mechanical lift at her nursing home. The physical exam indicated Resident #1 had a c-collar (neck brace) in place with tenderness on palpation. The Computed Tomography (CT) scans (specialized imaging) and x-rays completed on 4/29/26, revealed a subdermal hemorrhage ( SDH or a brain bleed), a subarachnoid hemorrhage ( SAH or brain bleed), a type III dens fracture (broken neck), a right clavicle fracture (broken collarbone), and a left femur fracture (broken thighbone). She experienced pain in her right leg and neck. The plan directed to admit to the intensive care unit (ICU), consult neurosurgery (brain and spine surgeon), neck brace, and repeat CT imaging every 6 hours after initial head CT to evaluate the progression of her brain bleed.The ICU Trauma Progress Note dated 4/30/26 indicated they controlled Resident #1's pain with scheduled Tylenol, oxycodone (powerful opioid pain medication), and Dilaudid (powerful opioid pain medication) as needed (PRN). They held her blood thinners prophylactically (as a precaution) and she received a blood thickening medication when she arrived to the ER.On 5/4/26 at 2:00 PM Staff E stated she worked at the facility for 3 years. Staff E stated on 4/29/26 at approximately 8:30 PM, Staff C and Staff D prepared Resident #1 for bed. Staff E stated when she entered the room, Resident #1 sat in the wheelchair with the lift sling underneath her. Staff E stated she didn't attach any sling strap loops to the lift bar and she only operated the lift controls, while Staff C and Staff D attached the loops. Staff E stated she faced Resident #1 with the wheelchair positioned at an angle from the bed, and everything appeared normal. Staff E stated as she raised Resident #1 from the wheelchair using the hand control, Staff C removed the wheelchair. As she and Staff D attempted to turn Resident #1 toward the bed, Resident #1 fell to the floor. Staff E stated Resident #1 appeared level while raised in the air, but once Resident #1 landed on the floor, the right upper strap loop appeared unhooked. Staff E stated she didn't examine or check the lift straps or hoops to ensure secure attachment before or during the lift process. Staff E stated Resident #1 landed on her right side between the lift and the bed, and she observed Resident #1's face strike the floor. Staff E stated staff used the correct extra-large sling size, they always used. Staff E stated she didn't know what caused the loop to detach from the lift bar, and noted she received lift education from a vendor and a therapy staff member in the past.On 5/5/26 at 9:38 AM Staff A stated on 4/29/26 at approximately 8:30 PM, Staff C requested immediate assistance in Resident #1's room over the radio while Staff E went to find a nurse. Staff A stated he entered the room with Staff B directly behind him and found Resident #1 on the floor with her head toward the bed and her left leg on the couch. Staff A stated Resident #1's left shin bled, and Staff C applied tissue to the area. Staff A stated the full-body mechanical lift stood over Resident #1 with the left side sling loops attached, but the right-side loops appeared disconnected. Staff A stated Resident #1 panicked, demanded that staff lift her, then changed her mind, requesting EMS and someone to call her Representative. Staff A stated he called Resident #1's Representative with his phone and attempted to explain the need for an assessment, but Resident #1 refused to allow evaluations by him or Staff B. Staff A stated he left the room to contact emergency services and gather transfer paperwork. Staff A stated Staff C, Staff D, and Staff E reported Resident #1 was high in the air when they heard a snap and she fell. Staff A stated the CNAs reported using the same sling and lift to move Resident #1 from the floor to the bed with EMS assistance. Staff A stated Resident #1's care plan required 3 staff members and a full body lift for transfers, and he provided witness statement forms to the CNAs.On 5/5/26 at 10:10 AM Staff C stated she worked at the facility for two years. Staff C stated on 4/29/26 at approximately 8:30 PM, she, Staff E, and Staff D remained in Resident #1's room with Resident #1 in a wheelchair beside the bed. Staff C stated the full-body mechanical lift stood in front of Resident #1. Staff C stated Staff E operated the lift controls, Staff C stood behind the wheelchair, and Staff D stayed on the left side. Staff C stated she didn't remember who attached the straps, but staff always secured the top straps to the black loop and the bottom straps to the loosest green loop. Staff C stated the wheelchair remained locked until Resident #1 went into the air, and then Staff C moved the wheelchair away. Staff C stated she heard a snap, turned around, and observed Resident #1 on the floor. Staff C stated one sling loop appeared unhooked from the lift bar. Staff C stated staff used the same sling and lift to transfer Resident #1 to the bed and gurney. Staff C stated Resident #1 normally leaned to the right in the wheelchair and shifted slightly right when suspended in the sling. Staff C stated all transfers utilized the full-body mechanical lift, three staff, and an extra-large sling. Staff C stated she completed two prior lift transfers with Resident #1 that day. Staff C stated she did not feel certain who hooked up the sling strap loops when the fall occurred. Staff C stated protocol required one staff member to check all loops to ensure secure attachment before lifting a resident, but she didn't recall specifically if anyone performed the check before lifting Resident #1.On 5/6/26 at 1:47 PM Staff D stated on 4/29/26 at approximately 8:30 PM, she and Staff C entered Resident #1's room to assist with bed preparation, and Staff E arrived to help with the transfer. Staff D stated Resident #1 sat in the wheelchair with Staff C on the right side and Staff D on the left side. Staff D stated Staff E entered the room while staff hooked the lift sling strap loops onto the lift. Staff D stated she attached the loops on the left side, and Staff C attached the loops on the right side. Staff D stated protocol didn't require a double check because the loops simply hook in, with the black loop on top and the loosest loop on the bottom. Staff D stated Staff E raised Resident #1 completely up, Staff C moved the wheelchair, Staff E turned the lift, and Resident #1 fell directly to the floor. Staff D stated Resident #1 landed on her right side with a loud thunk. Staff D stated the straps didn't break because staff reused the sling afterward. Staff D stated she didn't know if any loops disconnected during the fall. Staff D stated she watched Resident #1's feet instead of the hooks, and noted Resident #1 appeared slightly crooked in the air. Staff D stated a safe transfer required one staff to guide the feet, one to manage the wheelchair, and one to operate the controls and monitor the straps because that person possessed the best view.On 5/6/26 at 4:00 PM Staff B stated on 4/29/26 at approximately 8:30 PM, a call summoned her to Resident #1's room. Staff B stated she found Staff A, Staff C, Staff D, and Staff E in the room with Resident #1 on the floor alternating between shouting for help and telling staff not to touch her. Staff B stated Resident #1 panicked, so she attempted to calm her while Staff A contacted EMS. Staff B stated the lift stood near the door and the sling did not remain underneath Resident #1 when she arrived. Staff B stated she remained with Resident #1 until EMS arrived. Staff B stated EMS personnel placed the sling under Resident #1 because Resident #1 refused to let facility staff touch her, and staff reused the same lift and sling to transfer Resident #1 to bed. Staff B stated Staff A arrived a few minutes before her and placed pillows under Resident #1's head. Staff B stated she inspected the sling and discovered no defects.On 5/4/26 at 1:30 PM Staff F, Quality Assurance Nurse Manager, stated she received notification after the fall, conducted individual interviews with the 3 CNAs, and performed a reenactment. Staff F stated she concluded the upper strap loop shifted while slack or did not sit securely on the bar, causing the bar to tilt and the bottom strap to disconnect when the top loop slid off.On 5/4/26 at 1:30 PM the Lift Company Territory Sales Manager (LCTSM) stated he inspected the full body lift used during the fall and verified all mechanical components functioned correctly. The LCTSM stated his company provided a lift training session within the past year and maintained the facility on a semi-annual safety inspection schedule. The LCTSM stated he couldn't determine if staff operated the lift correctly or why the loop detached because he didn't witness the incident. The LCTSM stated he instructed staff during training sessions to pause the lift operation once tension applied to all 4 points to verify stability before fully raising a resident.On 5/6/26 at 12:30 PM the Director of Nursing (DON) stated the facility didn't possess a specific policy regarding full-body mechanical lift operations and expected staff to follow the manufacturer's operator instructions. The DON stated all staff members finished a lift competency checklist during a fall awareness training event in October 2025.The full body lift manufacturer's Operator's Instructions revised 6/13/11, directed the required protocol for transferring a resident into or out of a wheelchair with the following safety measures:a. Equipment Setup: The legs of the lift must be adjusted using the spreader bar to widen around the wheelchair. The wheels of the wheelchair must be locked. The wheels of the lift itself must never be locked when lifting or transferring a patient. b. Sling Attachment Protocol: Caregivers must attach the straps located near the resident's shoulders to the hanger bar hooks using the exact same length and color of loop strap on each side. The sling leg straps must be crossed over and attached to the opposite hooks of the hanger bar, ensuring the same length and color of loop strap is utilized on each leg. c. Pre-Lift Loop Verification: The operator must execute a final check of all four loop attachment points to ensure that each individual loop is sufficiently and securely attached to its respective hanger bar hook before lifting the resident. d. Tension Security Verification: When initiating the upward motion, the operator must continue the upward motion until there is tension on the legs of the sling, explicitly verifying that all loops on the sling remain completely secure and properly hooked on the hanger bars as tension is first applied.The facility's Full-body mechanical lift Competency Checklist revised 2/28/18, used for staff training in October 2025, included the following questions and answers:a. Question: How do you check to ensure the sling is in good condition with no excessive wear on the loops? Answer: i. The operator must look for intact stitching and seams, check for fraying or ripped loops and/or material, and inspect the material for excessive wear by holding it up to the light. b. Question: Do you lock the wheels of the lift, and why or why not? Answer: i. Caregivers must never lock the wheels of an EZ Way Smart Lift when lifting or transferring a patient. The unit self-adjusts its center of gravity, and the wheels must remain unlocked to allow for this adjustment. c. Question: What is the procedure to demonstrate the proper attachment of the sling to the lift? Answer: i. Once the sling is applied underneath a patient, attach two loops of the same color nearest the head and shoulders to the hanger bar hooks closest to the head.ii. Once the legs of the sling have been fitted underneath the legs and crossed, attach two loops of the same color to the hanger bar hooks located nearest the feet. iii. The caregiver must explicitly ensure all loops are securely fastened to the hooks before lifting the resident. d. Question: What is the usage and effect of the different loops for patient positioning? Answer: i. Leg Loops: Shorter loops recline the patient further, whereas longer loops place the body in an upright sitting position. ii. Shoulder Loops: Longer loops recline the patient, whereas shorter loops place the patient in an upright sitting position. On 5/6/26 at 12:00 PM Staff G, CMA, stated she worked at the facility for 2 years and received annual lift training during fall prevention month in October 2025. Staff G reported transfer protocols required staff to cross the leg straps, attach the loosest lower loops to the leg hooks, and secure the black loops to the top hooks. Staff G stated protocol required one or both staff members to verify all four attachment points remained secure before raising a resident. Staff G stated staff then raised the resident, unlocked the wheelchair, and monitored the hooks and straps throughout the transfer.On 5/6/26 at 12:10 PM Staff H, CNA, reported transfer protocols required staff to attach the top sling loops to the black hoops on the hangar bar and utilize the middle loop for the legs if a resident possessed long legs. Staff H stated staff pulled on the straps to confirm alignment, raised the resident slightly until the straps tightened, and physically and visually rechecked all four loops. Staff H stated staff monitored the straps and the resident during the lifting process.On 5/6/26 at 12:48 PM Staff I, CMA, reported that transfer protocols required staff to secure the leg loops to the longest option and the shoulder loops to the black option. Staff I stated both staff members checked all four attachment points, raised the resident slightly until the buttocks didn't touch the chair, and double-checked the hooks visually. Staff I stated staff then completed the lift, moved the wheelchair, closed the lift legs, and lowered the resident onto the bed.

Based on record review, observation, staff interview, and policy review, the facility failed to follow the resident's Care Plan for one of thirteen residents reviewed. (Residents #28). The facility reported a census of 31. Findings include: The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had diagnoses of cerebrovascular accident (CVA) (stroke), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting left upper and lower extremity. The MDS revealed the resident scored a 15 out of 15 for the Brief Interview for Mental Status (BIMS) for no concerns with cognitive status. The MDS also documented that Resident #28 had 0 of 7 days for splint or brace applied during the look-back period. The Care Plan initiated 12/31/24 documented the following focus for Resident #28 as follows: I have decreased mobility or function because I have a history of a stroke with left sided weakness. The Care Plan directed staff to place a brace on the left wrist overnight to help with prevention of contractures. The Electronic Health Record (EHR) indicated that this directive was placed on the Kardex. It was resolved on 6/24/25. The HCC Pocket Care Plan indicated a brace placed on left wrist overnight. This was removed 6/24/25. The clinical record lacked documentation for placement and removal of the splint. Observation on 06/23/25 1:09 PM revealed resident with decreased use of left upper and lower extremities. No splint or brace was noted to the left wrist at that time. A Physical Therapy Note dated 1/17/25 revealed Staff C, Physical Therapy (PT) documented that Resident #28 stated the left wrist brace was not being worn because Resident #28 and staff forget to put it on at night. The resident also reported that the nursing staff did not use the platform walker for transfers during the day. An Occupational Therapy Noted dated 6/23/25 revealed that Staff D, Occupational Therapist (OT) documented a goal to decrease pain and consistency in carryover of recommended Left Upper Extremity (LUE) splint wear. In an interview 6/23/25 at 1:09 PM Resident #28, stated he had a stroke affecting the left side and came to this facility around Christmas. In an interview 6/24/25 at 12:38 AM Resident #28, stated he had a splint at night but did not always get it. The Resident denied refusals and stated that some staff don't know how to put it on. On 6/24/25 at approximately 1:45 PM, the Director of Nursing (DON) reported no documentation of the application of the splint for Resident #28 was found. In a follow-up interview 6/24/25 at 2:15 PM, the DON stated the resident confirmed that the splint was not being put on. The DON stated she asked Resident #28 if he wanted the splint on, and Resident #28 declined stating it was not helping. Additionally, the DON stated splint application would be removed from the care plan. On 6/24/25 at 3:34 PM, Staff B OT, stated Resident #28 had pain and tightness at the max range of motion so recommended a splint be worn. In an interview 6/24/25 at 3:45 PM, Resident #28 stated he did not remember declining to use the splint. The Resident stated the splint started not too long after he arrived, and it was started by therapy. The Resident added that Staff B OT spoke with him today around noon, and stated that the splint would keep his hand from getting worse. Resident also stated that the staff would be trained on proper application. The Resident stated he would wear the splint. On 6/25/25 at 2:45 PM, the DON reported she could not produce any documentation of the splint being placed or taken off of Resident #28. No documentation of who took the splint off, and no Nurses Notes indicated refusals of the splint. The DON stated she did not know when he stopped wearing the splint, but took the splint intervention off the Care Plan and, the pocket Care Plan yesterday. The DON stated she will have OT offer the splint again if Resident #28 stated he will wear it. The Care Plan policy updated 1/21/25 indicated that a comprehensive care plan is developed for each resident based upon their care needs and desires, and that the care plan meet's the resident's medical, nursing, nutritional, safety and psychosocial needs.

Based on clinical record review, staff interview, policy review and the Resident Assessment Instrument (RAI) Manual, the facility failed to complete and transmit a resident Minimum Data Set assessment upon a resident's discharge within the required timeframe for one of fifteen residents reviewed (Resident #14). The facility reported a census of 31 residents. Findings include: The admission Minimum Data Set (MDS) assessment tool dated 4/14/25 revealed Resident #14 admitted to the facility on [DATE]. The Discharge (assessment- return not anticipated) MDS assessment dated [DATE] revealed the assessment completed on 6/25/25. The Electronic Health Record (EHR) under the Clinical Census tab revealed Resident #14 discharged from the facility on 5/10/25. A Nursing Notification: Planned Discharge revealed the resident discharged from the facility on 5/10/25 to home. In an interview 6/25/25 at 2:10 PM, the MDS Coordinator reported she completed and submitted the MDS assessments to Center for Medicare Services (CMS). She used an excel spreadsheet to keep track of the MDS assessments that needed completed. The MDS Coordinator reported an MDS assessment completed when a resident discharged from the facility to home or another facility. At the time, MDS Coordinator reviewed Resident #14's EHR with the surveyor. The MDS Coordinator stated Resident #14 admitted to the facility, discharged to the hospital, came back to facility, and then discharged to home. The MDS Coordinator reported she missed completing the Discharge MDS for Resident #14 when she discharged from the facility to home. She normally attended the care conference meetings to know when a resident would be discharging from the facility but she was on vacation at that time. In an email on 6/26/25 at 9:50 AM, the Director of Nursing (DON) wrote we do not have an official written policy for MDS. On 6/26/25 at 9:55 AM. the MDS Coordinator reported to the surveyor she completed and submitted Resident #14's discharge MDS assessment on 6/25/25. Review of the Resident Assessment Instrument (RAI) Manual dated 10/2019 revealed a discharge assessment - return not anticipated needed completed within 14 days after the discharge date and submitted to CMS within 14 days after the MDS completion date.

Based on record review, staff interview, and policy review, the facility failed to implement and follow safety interventions on the Care Plan to use a gait belt for 1 of 4 residents reviewed (Resident #1). Resident #1 sustained a fall and fractured her left ankle. The facility reported a census of 30 residents. Findings include: The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had diagnoses of arthritis, osteoporosis, intervertebral disc disorder (a breakdown or degeneration of the discs that cushion the spine), and physical debility. The MDS recorded the resident had a Brief Interview for Mental Status of 9, indicated moderately impaired cognition. The MDS documented the resident required partial to moderate assistance for transfers and ambulation. The MDS assessment dated [DATE] revealed Resident #1 had an unplanned discharge to the hospital. A Significant change MDS assessment dated [DATE] revealed the resident readmitted to the facility from the hospital on 9/16/24. The MDS documented the resident had diagnoses of a displaced left bimalleolar (medial and lateral sides of the ankle) fracture, osteoporosis, and COVID-19. The MDS recorded the resident had a fall with a major injury during the look-back period, and dependent on staff for toileting and transfers. The Care Plan initiated on 6/11/24 revealed the resident required assistance with Activities of Daily Living revised on 9/16/24 revealed non-skid strips placed in front of the recliner (added to the Care Plan on 9/6/24), and the resident non-ambulatory and required a mechanical lift and assistance of two staff for transfers. An Incident Report dated 9/8/24 at 5:35 PM revealed Resident #1 sat on the floor on her buttocks with her back against the recliner and walker in front of her. The resident reported her knee gave out when she walked backwards to the chair. She reported pain in her left ankle. The resident had tested positive for COVID-19. She also had a history of weakness in her right knee and wore a knee brace. The incident report documented Staff A, Certified Nursing Assistant (CNA) statement about the incident as follows; On 9/8/24, as me and the resident were walking to the recliner, the resident started turning to sit down. As she went to sit, her knee gave out and I guided her to the ground. The facility's investigation file included a summary of the incident summary (typed and written by the Chief Nursing Officer (CNO)). The incident summary revealed Resident #1 began showing signs and symptoms of COVID-19 and tested positive on 9/8/24 AM. On 9/8/24 at 5:35 PM, the CNA walked the resident from the bathroom back to the recliner chair. Per CNA statement, resident started to turn and her knee gave out as she began to sit. The CNA guided her to the floor. Resident complained of left ankle pain. The Physician's Assistant (PA) saw the resident on 9/9/24. X-ray of left ankle indicated a fracture. Resident was sent to the hospital for evaluation and treatment. In an interview on 1/6/25 at 2:45 PM, Staff B, Licensed Practical Nurse (LPN) reported Resident #1 required assistance of one for ambulation and transfers. She was alert and oriented, but got confused occasionally. She got up and transferred herself only once in a while. She had a fall on the weekend. Staff A, CNA was in the room getting the resident ready and said the resident had fallen. Staff B reported she went into the room to assess her. Staff A told her the resident was taking a step back toward the recliner, and her ankle rolled. Staff A told her she helped lower the resident to the floor. Staff B confirmed when she walked in and saw the resident on the floor in front of her recliner, she did not have a gait belt on. Staff B thought the resident's ankle fractured when the resident rolled her ankle. Staff B reported the facility required staff use a gait belt at all times unless the resident was independent or was care planned otherwise. After the incident, the facility gave all of the staff a gait belt. The resident rooms already had a gait belt prior to the incident. Staff B reported that Staff A got written up for not using a gait belt. In an interview 1/6/25 at 3:30 PM, Staff C, Registered Nurse, reported Resident #1 required the assistance of one, and used a walker and a gait belt for transfers. The resident had a risk for falls. Staff C reported it was standard for staff to use a gait belt unless it was on the resident's Care Plan to do something else. In an interview 1/6/25 at 3:45 PM, Staff A, CNA, reported when she came to work, she got a copy of the resident list for her assigned area to reference as needed and to know how a resident transferred. Staff A reported Resident #1 had a knee brace because her knee would be wonky and weak sometimes. She would ask Resident #1 if she was comfortable using the walker or if she wanted to use the wheelchair. The resident usually wanted to walk with her walker. Staff A reported she would follow behind Resident #1 with a wheelchair if the resident was weaker. Staff A acknowledged she worked on the day Resident #1 had a fall. The resident had COVID. The resident did ok with walking when she assisted the resident to the bathroom earlier that day. Later in the day, Staff A held the back of the resident's pants as the resident ambulated from the bathroom. As Resident #1 turned, her left knee gave out, and she stumbled up against the walker and the recliner. Staff A reported she lowered the resident to the ground. Staff A confirmed she did not have a gait belt on the resident. She only used a gait belt for those residents who really needed assistance. That was what she was told to do. She didn't use a gait belt much for Resident #1 because she didn't require as much assistance. After the incident, a manager pulled her aside and had her sign a paper on what to do in the future. She was told she needed to use a gait belt when someone had COVID or was sicker. She had to sign a form that said she needed to be more careful and to use a gait belt. In an interview on 1/7/24 at 8:25 AM, Staff D, shower aide, reported it was standard for staff to use a gait belt whenever staff ambulated or transferred a resident unless it was listed on care plan otherwise. Staff D reported she heard Resident #1 had a fall. After the incident, staff were instructed to follow the resident's Care Plan. In an interview on 1/7/25 at 10:40 AM, the MDS Coordinator reported it depended on the level of assistance a resident needed and if a gait belt would be used. A few residents refused to use a gait belt, but the staff still offered and tried to educate the resident on why they needed to use a gait belt. Gait belt use would be listed on the resident's Care Plan. In an interview on 1/7/25 at 11:00 AM, the CNO reported she didn't think they had a Care Plan policy. An immediate (baseline) Care Plan is completed on admission, and the comprehensive Care Plan completed within 14 days. The CNO stated she talked with Staff A after Resident #1's fall. At the time, Staff A told her that Resident #1 was walking great so didn't use the gait belt. The CNO didn't think it registered with Staff A that a gait belt should be used. On 1/8/25 at 1:30 PM, the CNO confirmed no Care Plan policy found.

Based on record review, staff interviews, employee file review, and facility assessment, the facility failed to ensure nurse's aides possessed the competencies and skills necessary to safely transfer a resident as identified in the plan of care and resident assessment for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 30 residents. Findings include: The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 required partial to moderate assistance for transfers and ambulation. The Care Plan initiated on 6/11/24 revealed the resident required assistance with Activities of Daily Living (ADL's) and had a high risk of falls related to her age, limited mobility, and low back pain. The Care Plan directed staff to use a front wheeled walker, a gait belt and assistance of one for transfers and ambulation. An Incident Report dated 9/8/24 at 5:35 PM revealed Resident #1 sat on the floor on her buttocks with her back against the recliner and walker in front of the resident. Resident reported her knee gave out when she walked backwards to the chair. The resident reported pain in her left ankle. She had a history of weakness in her right knee and wore a knee brace. The resident tested positive for COVID-19. The incident report documented Staff A, Certified Nursing Assistant (CNA) statement about the incident: On 9/8/24, as me and the resident were walking to the recliner, the resident started turning to sit down. As she went to sit, her knee gave out and I guided her to the ground. The facility's investigation file included an incident summary (typed and written by the Chief Nursing Officer (CNO)). The incident summary revealed Resident #1 began showing signs and symptoms of COVID-19, and tested positive on 9/8/24 AM. On 9/8/24 at 5:35 PM, the CNA walked the resident from the bathroom back to the recliner chair. Per CNA statement, resident started to turn and her knee gave out as she began to sit. The CNA guided her to the floor. Resident complained of left ankle pain. The Physician's Assistant (PA) saw the resident on 9/9/24. X-ray results of left ankle indicated a fracture. Resident sent to the hospital for evaluation and treatment. The investigation of the incident revealed the following: After reviewing the CNA, Licensed Practical Nurse (LPN)), and resident statements, the type of injury, and resident's medical history, the CNO believed that the CNA ambulated the resident back to her recliner chair from the bathroom and the resident's right knee gave out. The resident wore a brace on her right knee and the brace was on when the occurrence happened. When the resident's right knee gave out, her weight shifted to her left leg. This happened as the resident was turning and it caused her left ankle to roll, which caused the fracture. The resident had to be lowered to the floor. A left ankle x-ray showed a fracture. The resident was sent to the hospital for evaluation and treatment. Review of Staff A's employee file on 1/6/25 at 3:00 PM revealed Staff A had a hire date of 5/30/24. The Direct Care Worker (DCW) registry document revealed Staff A's CNA certification date was 2/17/24. Staff A's employee file lacked an orientation checklist or any education completed. A Nursing Education Form dated 9/8/24 and signed by Staff A, Staff B (LPN), and the Assistant Director of Nursing (ADON) revealed the ADON provided written education to Staff A to use a gait belt. Resident #1 fell while she ambulated with staff and did not have a gaitbelt on. Staff lowered the resident to the floor. Staff A's response included I will from now on use a gait belt when transferring that resident. Review of education provided to the surveyor by the Chief Nursing Officer (CNO) on 1/7/25 at 11:40 AM, revealed Staff A attended a Safety Review/ Transfers Using Mechanical Lifts meeting on 8/1/24. Staff A also completed an EZ Way Smart Stand Competency Checklist dated 8/2/24, and an EZ Stand Competency Test dated 8/11/24. The education and competency checklist lacked information on gait belt use. In an interview on 1/6/25 at 2:45 PM, Staff B, LPN, reported the facility required a gait belt to be used unless the resident was independent or care planned otherwise. The CNO requested her to provide Staff A extra supervision and Staff A came to get her for transfers after Resident #1 had a fall. Staff B stated she also showed Staff A how to put on a gait belt. In an interview 1/6/25 at 3:45 PM, Staff A reported she had worked at the facility 5/2024 to 9/2024. She took a CNA course in high school in 3/2024. Her orientation at the facility entailed shadowing another CNA a total of four shifts. She only worked the weekend, and received her training on the weekend. She was unable to recall the CNA who trained her but she thought it was Staff E, CNA. She did not have anyone checking things off on an orientation checklist while in training that she recalled. She attended a few in-services when she was first hired. When she came to work, she got a copy of the resident list for her assigned area to reference if needed, and to know how a resident transferred and the cares or things a resident needed done. Staff A reported Resident #1 had a knee brace because her knee would be wonky and weak sometimes. She would ask Resident #1 if she was comfortable using the walker or if she wanted to use the wheelchair. The resident usually wanted to walk with her walker. Staff A reported she would follow behind Resident #1 with a wheelchair if the resident was weaker. Staff A acknowledged she worked on the day Resident #1 had a fall. The resident had COVID. The resident did ok with walking when she assisted the resident to the bathroom earlier that day. Later in the day, she helped the resident to the bathroom. Resident #1 did ok getting into the bathroom. Staff A reported she was holding the back of the resident's pants as the resident ambulated from the bathroom. As Resident #1 turned, her left knee gave out, and she stumbled up against the walker and the recliner. Staff A reported she lowered the resident to the ground. Staff A confirmed she did not have a gait belt on the resident. She only used a gait belt for those residents who really needed assistance. That was what she was told to do. She didn't use a gait belt much for Resident #1 because she didn't require as much assistance. The resident was groaning in pain. She pressed the emergency light and stayed with her until someone came in to help. Resident #1 didn't usually need much assistance. After the incident, a manager pulled her aside and had her sign a paper on what to do in the future. She was told she needed to use a gait belt when someone had COVID or was sicker. She had to sign a form that said she needed to be more careful and to use a gait belt. In an interview on 1/6/24 at 4:20 PM, the CNO, confirmed she was the one who wrote the incident summary and submitted it to Department of Inspections, Appeals, and Licensing (DIAL). The CNO reported she could not find an orientation checklist, competency checklist, or education in Staff A's file. The CNO reported she took the CNO position in 8/2024, and she was just learning her role when the incident happened with Resident #1. After the incident, there were a number of things they did, including staff education and getting gait belts for all of the staff. In an interview on 1/7/24 at 8:25 AM, Staff D, shower aide, reported she heard Resident #1 had a fall. After the incident, the facility went over transfers with the CNA's. They all got gait belts and were instructed to follow the resident's care plan. Staff D reported gait belt use as a standard for staff to use. A gait belt used anytime staff ambulated or transferred a resident unless it was listed on care plan otherwise. In an interview on 1/7/25 at 8:50 AM, the CNO provided the surveyor documents for education she found that was done on 8/1/24 with staff, as well as an EZ stand competency test completed on 8/11/24 and EZ Way Smart Stand competency checklist for Staff A completed on 8/2/24. The staff education entailed safety review/ transfers using mechanical lifts, utilizing two staff when operating any mechanical lifts for transfers including the EZ lift and Hoyer lift for maintaining the safety of both residents and staff. The education lacked information about gait belt use. In an interview on 1/7/25 at 11:00 AM, the CNO reported a CNA Orientation Checklist was developed after Resident #1's incident and an in-service was held with staff in 10/2024 (after Resident #1's incident). No CNA orientation checklist used prior to the incident that she could find, and the facility assessment contained information about staff education provided but she was unable to locate a policy for staff orientation. October 2024 was deemed fall prevention month. Staff had to watch a transfer with a gait belt and took a quiz. The CNO stated she talked with Staff A after Resident #1's fall. At the time, Staff A told her that Resident #1 was walking great so she didn't use the gait belt. The CNO didn't think it registered with Staff A that a gait belt should be used. In an interview on 1/7/25 at 1:25 PM, Staff E, CNA reported she trained new staff when they were hired but it had been a while ago. A new CNA typically got 3 days of orientation on the floor that she recalled but if a staff person didn't feel comfortable then they got more time in orientation. Staff E doesn't recall filling out an orientation checklist for new staff. In an interview on 1/7/25 at 2:45 PM, the CNO was asked how staff's competency and skill sets were evaluated upon their initial hire. The CNO reported she checked in with a new employee to see how they were doing with training/orientation after they were hired. It was more of a check-in with the staff member or the person doing the training, not something that she marked off in a competency. The new employee received on the job training, and their level of abilities were assessed at that time. In an interview on 1/8/25 at 1:15 PM, Staff F, RN, reported the QA Committee had a Performance Improvement Plan (PIP) on falls due to a number of residents had falls. The PIP focused on what staff should be doing to prevent falls. Staff F reported they would continue to provide staff education and reminders about using a gait belt as well as fall interventions. The Facility assessment dated [DATE] revealed staffing levels adjusted to meet the needs of residents, and the staff's strengths/weaknesses considered. Staff training included monthly computer-based in-services, a CNA mentor, and ongoing in-person educational events. A staff meeting dated 10/9/24 by the ADON revealed an agenda covering gait belt use. Staff A was not in attendance at the meeting.

Based on clinical record review, observations, resident and staff interviews, and manufacturer manual instructions, the facility failed to appropriately use an EZ stand mechanical lift and transfer a resident safely for 1 of 3 residents reviewed for transfers (Resident #2). The facility reported a census of 32 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident#2 had diagnoses of cerebrovascular accident (CVA) (stroke), right shoulder pain, and a seizure disorder. The MDS documented the resident required substantial to maximum assistance for bed mobility and transfers. The MDS also revealed the resident had one fall without injury. A Significant Change MDS assessment dated [DATE] revealed Resident #2 had diagnoses of osteoporosis, right shoulder pain, a fracture, and CVA. The MDS documented the resident had a brief interview for mental status (BIMS) score of 15, which indicated cognition intact. The MDS documented the resident dependent for transfers. The MDS revealed the resident had a fall with a major injury. The Care Plan revised 10/30/23 revealed Resident#2 had decreased mobility and functional ability, chronic shoulder pain, and had a high risk for falls due to chronic weakness on the left side of her body due to a history of stroke, and a history of a fall with a fracture. The care plan directed staff to use an EZ stand and two staff for transfers was initiated on 5/16/22. In an interview 7/15/24 at 11:08 AM, Resident#2 reported she had a fall and fractured her shoulder in 2/2024. The resident stated the strap broke loose while she stood on the EZ stand. She went to the hospital and then saw an Orthopedic physician. She also had another incident a couple of months ago while staff were in the process of doing a treatment on her bottom. She stood on the EZ stand during the treatment but she couldn't stand up any longer, and staff lowered her to the floor. The Nursing: Fall Risk Form revealed the following fall risk status: a. On 7/5/2023, the resident had a low risk for falls. The fall risk interventions included to use an EZ stand as needed b. On 1/15/2024, the resident had a moderate risk for falls. The fall risk intervention included to use the Hoyer mechanical lift until Physical Therapy (PT) and Occupational Therapy (OT) evaluated the resident for transfers. c. On 5/22/2024, the resident had a high risk for falls. The fall risk intervention included to consult PT and OT for re-evaluation on transfers. The Nursing Admission assessment dated [DATE] revealed the resident had a high risk for falls. The Progress Notes documented the following: a. On 7/5/23 at 8:55 AM, Certified Nursing Assistant (CNA) lowered resident to the floor in the shower. The CNA stated they tried to move the resident from the wheelchair to the shower chair, the resident sat on the edge of the shower chair, but they couldn't get her buttocks all the way into the shower chair. The resident could no longer stand so staff lowered her to the floor. No injuries noted. An intervention implemented included to use an EZ Stand as needed. b. On 1/15/24 at 3:43 PM, Staff B, Registered Nurse (RN), told Staff J, RN, Resident #2 lying on the floor. The resident found lying on her back with pillows under her head and sides upon Staff J's entry to the room. Staff had already removed the EZ stand pad from behind her. The resident stated The strap just snapped off the right side of the EZ stand and I let go. Something snapped in my right shoulder and it hurts really bad. I fell to the floor after that happened. The resident complained of pain in her right shoulder. A Nurse Practitioner (NP) already at the facility came and assessed the resident's shoulder and ordered an x-ray. Floor nursing staff notified to give Tylenol for discomfort. The resident denied hitting her head. Immediate intervention included to utilize a Hoyer lift for transfers and a PT/OT evaluation for transfer and strengthening. Director of Nursing (DON) notified of the incident. At 4:30 PM, an order received to send the resident to the Emergency Department (ED) for evaluation and treatment related to the fall and the resident had right shoulder pain. On 1/16/24 at 1:44 AM, resident returned from the ED visit around 1:00 AM. The resident suffered a displaced impacted and comminuted fracture of the humeral neck (right shoulder). The resident had a sling on her right arm. She received Fentanyl (a narcotic) injection and Norco (oral pain medication) while in the ED. c. On 5/22/24 at 5:16 PM, Staff F, CNA, and Staff C, CNA, stood the resident in the EZ stand while Staff J, RN, stood behind the resident and performed a treatment. When the resident said she could not hold on, Staff J attempted to place the dressing quickly and get the wheelchair under the resident. The resident stated she was losing her grip on the EZ stand and her right arm let go. Once the resident's right hand let go of the stand, she slid down in the sling. The resident's bottom already fell below the level of the seat on the wheelchair. Staff C tried to slide her knee underneath the resident to hold her up but was unable so Staff J held her from behind while Staff F and Staff C placed an arm around her and their other arm under one of the resident's legs and then lowered the resident to the floor. The resident was then detached from the EZ stand fully. Staff then used a Hoyer lift and transferred the resident into her wheelchair. The resident complained of arm pain rated at 4 out of 10 at the time of the incident. She denied the need for pain medication. The resident had a history of stroke affecting her left side and a history of humeral fracture of the right upper arm. Her level of weakness is variable throughout the day. Resident lost her grip on the EZ stand while in the standing position. DON notified immediately after the incident. Incident Reports revealed the following: a. On 1/15/24 at 3:43 PM, Staff B, RN, told Staff J, RN, Resident #2 lying on the floor. Resident #2 found lying on the floor on her back with pillows under her head and sides when Staff J walked into the resident's room. Staff had already removed the EZ stand pad from behind her. The resident stated The strap just snapped off the right side of the EZ stand and I let go. Something snapped in my right shoulder and it hurts really bad. I fell to the floor after that happened. The resident complained of pain in her right shoulder. A NP already in the facility assessed the resident's shoulder and ordered an x-ray. Resident rolled side to side and a lift sling placed under her, then staff transferred her via a Hoyer lift from the floor to her bed. The resident rated her pain at 8 on a 1-10 pain scale. APAP (Tylenol) administered for discomfort. Immediate intervention included to request staff utilize the Hoyer lift for transfers in the future and a PT/OT evaluation for transfers and strength. Resident representative and the on-call manager (DON) notified of the incident. The predisposing situational factors listed on the incident report included: An EZ stand used for transferring the resident. She lost her grip on the machine causing the EZ stand to unbalance. The incident report revealed a follow-up note added on 1/28/24 about the fall occurrence with injury on 1/15/24. An EZ stand used to transfer the resident from the the commode to the recliner. The resident had pain in her arm that caused her to let go of the machine and it unbalanced. The resident was lowered to the floor. Only one staff member in the room at the time of the incident. Staff education provided about the need to have a second person whenever staff moved the machine with a resident in it. The resident complained of right shoulder pain. The NP assessed the resident and then sent her to the ED for x-rays. No other injuries noted at the time. Immediate intervention included to use a Hoyer lift for transfers until PT/OT assessed the resident. b. On 5/22/24 at 4:26 PM, Staff J, RN, Staff F, CNA, and Staff C, CNA were in the resident's room to stand her in the EZ stand in order for the nurse to perform a treatment. The resident stood in the EZ stand as the nurse stood behind her. The resident said she could not hold on. Staff J documented she attempted to place the dressing quickly and position the wheelchair under the resident. The resident's bottom was already below the level of the seat on the chair. The resident stated that she was losing her grip on the EZ stand and her right hand let go of the lift bar, then she started to slide down in the sling. Staff C tried to slide her knee underneath the resident to hold her up but was unable. Staff J then held the resident from behind and both CNA's lowered the resident to the floor. She was then detached from the EZ stand. Staff then placed a Hoyer sling underneath her and transferred her into a wheelchair. The resident reported pain in her arm rated at 4 out of 10 at the time of the incident. She denied the need for pain medication after staff placed her in the chair and made her comfortable. No injuries observed. Resident oriented to person ,place, time, and situation. Predisposing situational factors included: Resident had a history of stroke affecting her left side and a history of humeral fracture of the right upper arm. Her level of weakness was variable throughout the day. Resident lost her grip on the EZ stand while in the standing position. The report revealed follow-up notes added on the following: 5/28/24 - resident had a fall and lowered to the floor. The resident let go of the EZ stand during a transfer and slid downward. Three staff lowered her to the floor. PT/OT consulted regarding transfers. 6/28/24 at 2:00 PM, the occurrence was unlocked per resident / representative request to add additional documentation and include the resident's voiced concerns. Discussed with the Assistant Director of Nursing (ADON). The resident's request and additional detail will be added. 6/29/24 at 9:36 AM, additional information added to the occurrence report per the resident and representative's request. Resident was asked prior to standing in the EZ stand if she felt she had the strength to do so at the time. Resident stated she thought so. Once the resident stood up in the EZ stand and dressing removed from her bottom, she stated It hurt and requested to be put down now. Staff J asked for a few more moments to put the new dressing on. The resident then started to repeat several times back to back the same thing while RN put the new dressing on and pulled her skirt back down. As the nurse pulled the resident's skirt down, the resident let go of the EZ stand (and the rest of what happened in the original note occurred. The whole incident from when she originally stated she would like to be put back down to her being lowered to the floor took approximately a minute and a half. The Emergency Department provider note dated 1/15/24 at 5:31 PM revealed the resident presented to the ED complaining of shoulder pain. The resident reported that around 2:00 PM, a strap broke while she used an EZ stand lift at the care facility, and she fell . The resident landed on her bottom but her right arm swung down and she immediately had pain. The resident had prior history of a Stroke (CVA), which caused chronic weakness on her left side. A shoulder x-ray revealed the resident sustained a displaced fracture of the right humerus. A CT scan of the right shoulder also revealed the resident had severe osteoarthritis. Treatment included a sling placed on the right arm and pain medication provided. An Occurrence Witness Statement signed by Staff G, CNA, revealed: on 1/15/24 and 3:00 PM, Resident#2 transferred from the commode to a recliner in an EZ stand. The resident's arm started to slip and staff lowered her to the floor. An Occurrence Witness Statement written by Staff F on 5/22/24, revealed on 5/22/24 at 4:00 PM, Resident #2 unable to hold on while she stood in the EZ stand. Staff lowered her down. An Occurrence Witness Statement written by Staff C on 5/22/24 revealed on 5/22/24 at 4:30 PM, the resident stood in an EZ stand for a treatment on her bottom. While staff in the process of finishing up a treatment to an open area, the resident stated she needed to sit. She lost her grip, and Staff C and Staff J lowered her to the floor. A Major Injury Determination form signed by the physician on 1/17/24 at 11:00 AM revealed Resident #2 reported she felt a pop and unable to hold onto the EZ stand, and she fell to the ground. The resident had a right humerus fracture. The physician marked the injury sustained not a major injury pursuant to the Iowa Administrative Code 50.7(1)(a)(3). During observations on 7/17/24 at 10:39 AM, Staff C, Certified Nursing Assistant (CNA), and Staff D, CNA, placed a wheelchair near the resident's bed and locked brakes. Staff placed a Hoyer sling in the seat of the wheelchair. Staff C and Staff D sat the resident on the edge of the bed. Staff C adjusted the foot platform on the EZ stand, and placed the resident's feet onto the EZ stand platform. Staff placed a strap around the resident's legs, placed a sling behind the resident's back, and attached the sling straps to the EZ stand. The resident placed her hands on the EZ stand bars. Staff stood the resident up with EZ stand and transferred her to a bariatric wheelchair. The EZ stand legs were opened outward during the transfer, but staff had to close the EZ stand legs to get the EZ stand to fit and move around the bariatric-sized wheelchair wheels. In an interview 7/16/24 at 12:55 PM, the Director of Nursing (DON) reported when a resident had a fall, staff filled out an incident/fall report, completed a fall risk assessment, and put an intervention in place. In an interview 7/17/24 at 10:53 AM, Staff C, CNA, reported she had worked at the facility for 4 months. Resident #2 used an EZ stand for transfers. The resident had one fall that she knew of since she started working at the facility. The resident's arm gave out while she held onto the EZ stand, and she lowered her to the floor. Staff C reported therapy had worked with the resident to help strengthen her arm and shoulder. In an interview 7/17/24 at 2:39 PM Staff E, Registered Nurse (RN), reported a Hoyer used when Resident#2 transferred but then changed to using an EZ stand lift for transfers after therapy worked with her. The resident had strength and pain issues, and would refuse to use the EZ stand a lot. Staff E reported she wasn't working when the resident had falls from the EZ stand lift. In an interview 7/17/24 at 3:00 PM, the DON reported Resident #2 had had a couple of falls while staff used an EZ stand lift. The DON stated a major injury determination form was filled out when the resident fractured her shoulder and the injury was determined not to be a major injury. The DON acknowledged she did not report to the State Department of Inspections, Appeals, and Licensing (DIAL) when the resident had a fall with fracture and transferred to the Emergency Department (ED) because the incident was not a reportable incident, and her injury wasn't classified as a major injury. The DON reported she recently reopened the fall incident from the EZ stand that happened the second time. A nurse came to the DON and said the resident's family asked for documentation and wondered if they were allowed to give the documentation to them. The resident had a fall from the EZ stand, the nurse was in the process of doing a treatment while the resident stood on the EZ stand. The resident said she couldn't stand any longer. The nurse asked her to hold on as she placed the dressing on her bottom. Staff placed a chair under her but she missed the chair, and staff lowered her to the ground. There were 3 staff in the room at that time. At the end of 6/2024, the family requested a meeting. She was in the process of re-reviewing the incident. Resident#2 had concerns the nurse didn't listen to her. The nurse explained what happened and got witness statements. The first fall from the EZ stand incident occurred (1.2024), the resident told her she was in the EZ stand and she felt a pop. The resident said it hurts, she let go of the bar, and she fell down. During an interview 7/18/24 at 9:20 AM, Staff B, RN, stated he wasn't in the room when Resident #2 had a fall from the EZ stand lift. He assumed the resident couldn't hang on while in the EZ stand. The resident normally used an EZ stand for transfers. She is a large lady, and it's a lot of weight to support for her and the machine when she held onto the EZ stand. Staff need to put the footstand up to the middle when they used the EZ stand on Resident #2, due to her legs aren't long enough to touch the platform at the regular height. During an interview 7/18/24 at 9:55 AM, Staff F, Certified Medication Aide (CMA) reported she worked the 2-10 PM shift. Two staff needed to transfer a resident whenever an EZ stand lift is used, and needed to make sure the resident could hold onto the EZ stand and use their arms to hold the bars. Staff F explained the process of use and transfer of resident with an EZ stand. A strap placed around the resident's legs and feet positioned on the platform. A vest sling placed and the belt buckled around the waist. Straps hooked onto the EZ stand lift. Staff F reported a sizing chart was kept in the pocket of the lift stand, but she looked at the sling and size of the resident to determine if it was the correct size sling for the resident. Staff F reported Resident#2 used a Hoyer for transfers, but sometimes used the EZ stand during the day. She normally used the Hoyer in the evening. Staff F reported a couple months ago, she walked in while the resident stood in the EZ stand, and her arm gave away. The nurse was doing a treatment or looking at her bottom. They tried to get her into the chair but she couldn't stand back up or hold herself up any longer. She had slid down and they couldn't get her back into her chair, so they slowly moved her to the floor. She didn't have any injuries. She was a little scared. This was the only time the resident had a fall or EZ stand lift incident that she knew of. During an interview 7/18/24 at 9:44 AM, Staff G, CNA, reported two staff at all times whenever an EZ stand lift used. Use the EZ stand lift lever to open the legs all of the way when going to the recliner or the wheelchair in order to get the EZ stand lift legs in position by the wheelchair or wherever needed. She closed the EZ stand lift lever after the resident was in position and unhooked, then pulled the machine back and closed the legs. Staff G stated Resident #2 used the EZ stand lift if she had a good day. The resident got nervous when they planned to use the EZ stand. Staff G reported the resident's arm doesn't go all the way up, and it was hard for her to hold herself up when they lifted her up with the lift. Staff G reported the resident had a fall. On the day she worked, she moved the resident from the commode to the recliner. The resident couldn't hold onto the EZ stand bar any longer, she let go, and then fell . She thought maybe she sprained or broke her shoulder. She got a pillow and placed the pillow by the resident and the other CNA went to get the nurse. Prior to the transfer, she asked her how she she felt and if she could use the EZ stand. They also put a Hoyer sling in her wheelchair in preparation for later in the day in case she didn't feel strong enough to use the EZ stand. During an interview 7/18/24 at 10:00 AM, Staff J, RN, reported Resident#2 required the assistance of 1-2 staff for cares, and used an EZ stand for transfers. Use of the EZ stand worked well on some days for Resident#2, but not so well on other days. She had increased weakness since 1/2024 when she broke her arm. Her care plan included to use a Hoyer in the evening instead of an EZ stand lift. The resident had a wound to her sacral/coccyx area that included a treatment with collagen and an optifoam dressing. Staff J reported on the day of incident, she performed wound care to the resident's bottom while the resident stood in an EZ stand. Prior to this, the resident sat in the recliner chair. She didn't want to go to bed. Staff J asked if she could stand in the EZ stand. Staff stood her up in the EZ stand and then Staff J proceeded to do the wound treatment. While Staff J performed the treatment, the resident told her it hurts, it hurts and let go of the EZ stand. Staff J reported she tried to put the chair under the resident but her bottom was already lower than the chair. She couldn't get the wheelchair because she stood behind the resident. She had no place to go. The recliner was behind her, the EZ stand and resident were in front of her, and the staff CNA's stood by the resident. Staff C couldn't get the wheelchair from where she stood. They lowered the resident to the floor. The resident used the Hoyer lift and only used the EZ stand for transfers now, and she no longer performed the treatment while the resident stood in the EZ stand. At the time, Staff J checked the resident's care plan in the electronic health record and confirmed the intervention to only use the EZ stand for transfers from/to the bed, chair, wheelchair not listed on the care plan. Staff J reported the resident also had a fall in 1/2024 when the CNA moved the resident from the commode to the recliner. Staff J stated she was not in the room when the incident happened. Staff came and told her the resident had fallen and asked her to go see the resident. She asked the Physician's Assistant (PA) to see the resident. The resident got sent to the ED. Staff J reported more than one CNA in the room when she got to the room and saw the resident but she didn't know how many staff were in the room during the transfer or at the time of the fall. Staff J reported the steps for EZ stand lift use: move the resident to the edge of the bed, a sling placed around the resident, the strap around the chest tightened, and the leg strap buckled. Ensure the resident held onto the bar on the outside of the bar. One staff lifted the resident up while another staff person held onto the handle attached to the back of the sling. Wheel the resident in the EZ stand to the chair, toilet, or wheelchair, then unhook the sling after the resident placed in the chair. Staff J reported the leg bar on the EZ stand lift together (closed) while or whenever moved the resident. The EZ stand legs moved outward (apart) when the resident placed into the chair or wheelchair. In a follow up interview 7/18/24 at 11:15 AM, Resident#2 reported she had incurred two falls from the EZ stand. The first one occurred when a CNA transferred her from the commode to the recliner. There was only one CNA in the room at that time. The resident stated she held onto the EZ stand but had pain in her right shoulder and couldn't hold onto to the bar, and she fell . She fractured her upper right arm in two places. The second incident occurred in May 2024, when a nurse was doing a treatment on her bottom. She told the nurse she couldn't stand any longer but the nurse told her she was almost done. Staff lowered her to the floor because she could not hold onto the bar any longer. The resident stated she was afraid to use the EZ stand because she feared she was going to fall. She let staff know if she thought her arm felt too weak that day. The resident stated she wanted to be able to use the EZ stand but on some days she didn't feel strong enough to use the EZ stand. On those days, staff have accommodated her request to use the Hoyer lift instead. The resident stated when she had a fall and fractured her shoulder/arm, she thought something was wrong, She had so much pain. She asked staff to call the ambulance but they didn't call the ambulance or 911 right away. Staff placed her in the Hoyer, moved her into bed, and then had the doctor see her. Later, staff called an ambulance. Staff moved her from the bed to the ambulance cot, then she had to be moved from the cot onto a cart in the ED. She was in pain and she had to be moved several times. She felt being moved several times was unnecessary and thought staff should have called the ambulance when she requested. In an email sent 7/18/24 at 11:20 AM, the DON wrote they don't have a specific policy regarding use of the EZ-Stand. The facility staff followed the manufacture's recommendations and/or therapy recommendations. During an interview 7/18/24 at 12:05 PM, Staff K, Physical Therapist, reported therapy made recommendations whenever a resident completed therapy services. Resident #2 had worked with PT. She had pain in her shoulder and therapy said it would be ok for her to use the Hoyer for transfers. She talked to staff about putting the Hoyer sling in the wheelchair or recliner to have option to use Hoyer if the resident didn't feel like she could stand and use the EZ stand at that time. During her therapy sessions, the resident had the tolerance to stand for only up to a minute, then she requested to sit down because she had pain. Staff K reported the EZ stand operated as follows: spread the leg bar out to start. If had to go through a doorway, pull on the lever and close the legs spreader bar. The spreader bar should be kept open while transferred the resident for balance so the EZ stand and/or resident don't tip. The EZ stand lifts had weight limitations. During an interview 7/18/24 at 12:48 PM, the DON reported no competency checklist or policy for EZ stand transfers. An EZ Way stand manual kept at the nurse's station. She didn't think staff knew the location of the manual. A CNA reference book also kept at the nurse's station for staff to review information inside but the EZ Way stand manual information not kept in the CNA reference book. Resident #2 required assistance of one staff and used a four wheeled walker (since 10/29/2023) and until she had her first fall from the EZ stand. Her transfer status changed to a Hoyer lift after she returned from the ED and had a fractured arm. At the time, the surveyor reviewed the resident's Care Plan and confirmed with the DON when the resident's transfer statuses changed. The surveyor questioned if the resident required assistance of one staff and front wheeled walker, why an EZ stand used. The DON explained the resident had just had the flu and the resident used the EZ stand at that time due to weakness. The DON confirmed she wasn't in the room when the resident had the fall. Staff called her to let her know about the fall. The next day she noted staff had documented the sling broke. She went and talked to the resident the day after her fall. The CNA used an EZ stand to transfer the resident when she felt a pop and fell down. The resident complained her arm hurt. Staff then placed her in bed. The NP was at the facility and saw the resident. Staff called to get an x-ray but x-ray didn't come right away, staff ended up sending her to the hospital before they got an x-ray. After she spoke with the resident she went and found all of the slings and none were in disrepair and she didn't find any frayed slings. The DON explained a second fall incident occurred while the resident used an EZ stand lift. During that time, Staff J performed a treatment while the resident stood in the EZ stand. Staff J had asked the resident if she felt ok to stand for the treatment. Resident #2 told staff she wanted to sit back down. Staff J said she needed to put the dressing on. Staff J put the dressing on, pulled the resident's skirt down, then tried to put the chair under her, but the resident's bottom was lower then the wheelchair and she missed the seat of the wheelchair, so they lowered her to the floor. The DON stated she did not talk to the resident after this occurrence because the appropriate staff were in the room, staff followed the resident's care plan, and the resident did not ask to speak with her. A family member requested to speak to the DON last month because the resident didn't think staff documented the incident accurately and the documentation didn't reflect what happened. The family member didn't think the resident's voice was reflected in the documentation. She didn't think the incident had been followed up appropriately. The DON told her she would have the nurse edit the documentation. The family wanted the notes to reflect what the resident said. The DON stated the incident report had additional information on it. She said she would have Staff J add the information to the incident report and progress notes. The DON acknowledged she didn't report Resident #2's fall with fracture incident to the State (DIAL). The DON reported Resident #2 preferred to use the EZ stand but she basically told the staff which mechanical lift to use when they transferred her. The resident is fearful of using the EZ stand and Hoyer. It's her preference on which one staff used, and it depended upon how she felt and if she felt strong enough at that time. During an interview 7/18/24 at 10:52 AM, Staff H, CMA, explained how she used an EZ stand lift whenever she transferred a resident. First, the EZ stand lift placed in line with the resident on the bed or wherever the resident sat. Place the resident's feet on the pedal (platform). Attach the straps to the machine. Assess straps and the resident's comfort level and adjust the straps accordingly. Lift the resident up in the EZ stand lift. The EZ stand's leg bar opened (extended out) for stability whenever the resident transported. It's a fall risk to close them. The leg bar only closed when the EZ stand placed under the wheelchair, bed, or chair and sat or lying the resident down. Staff H stated a resident immediately placed back into the wheelchair, chair, or bed if the resident unable to stand or had pain. Another way found to complete cares after the resident is safe and comfortable. Slings are based on how much a resident weighs and also had some height restrictions. During an interview 7/18/24 at 10:50 AM, Staff I, CNA, reported they needed two staff whenever an EZ stand mechanical lift used to transfer a resident. She made sure the resident's feet positioned onto the easy stand platform and leg strap on. A different sized slings used based on the resident's weight and height. The EZ stand leg bar is supposed to be in the open position to ensure proper balance of the machine and resident, and then the machine leg bar closed after the resident placed into the chair or wheelchair. Staff I stated a resident should be placed into the chair or bed and sat down if a resident said they couldn't stand anymore. A Mechanical Lift protocol dated 2/1/24, provided by the facility on 7/18/24 revealed it is the facility's intent to ensure a resident's safety in the event that a resident requested or required use of a mechanical lift for transfers and/or mobility. Nursing will follow manufacturer's recommendations whenever a mechanical lift used. A mechanical lift skills checklist revealed the following steps: 1.Secure the assistance needed (at a minimum, dependent on the lift). 2. Position a chair next to bed; if using a wheelchair, ensure that brakes are locked. 3. Slide the sling under the resident 4. Be sure all locks and straps are fastened securely and correctly and the base of the lift is positioned correctly. 5. Slowly raise the resident 6. Have an assistant guide the resident's legs and lower the resident carefully into position. 7. Remove equipment Review of the facility provided EZ Way Stand Operator's Instructions Manual revised 9/29/23, revealed the following: The EZ Way stand used to transfer weight bearing patients to and from a chair, wheelchair, toilet, or bed. Patients should be able to bear some weight, have upper body strength, and be able to follow simple commands. If a patient does not meet each of these three criteria, an EZ Way total body lift must be used. The procedural steps for operation of the EZ Way Stand and transferring a patient included: a. Attach the harness to the hooks at the end of the stand arm. Make sure to [TRUNCATED]

Based on record review, staff interview, and the RAI (resident assessment instrument) manual review, the facility failed to complete and transmit the resident's minimum data set assessment within the required timeframe for 4 of 12 residents sampled (Resident #2, #7, #9, and #16). The facility reported a census of 32 residents. Findings include: Review of Resident #2's Quarterly Minimum Data Set (MDS) assessment tool dated 4/26/24 revealed the quarterly MDS assessment status as in progress. The MDS summary revealed the MDS assessment needed completed by 5/10/24. The MDS summary revealed the assessment had 13 errors under the validation icon. The MDS revealed sections A, GG, H, I, J, L, M, N, O, and P in progress. Review of Resident #7's Quarterly MDS assessment tool dated 4/19/24 revealed the quarterly MDS assessment status as in progress. The MDS summary revealed the assessment needed completed by 5/3/24. The summary also indicated the MDS assessment had 25 errors and 1 warning. The MDS revealed sections A, B, GG, H, I, J, K, L, M, N, O, P, and Q in progress. Review of Resident #9's Quarterly MDS assessment tool dated 4/19/24 revealed the quarterly MDS assessment as in progress. The MDS assessment needed completed by 5/3/24. The summary also indicated the MDS assessment had 23 errors and 2 warnings. The MDS revealed sections A, B, GG, H, I, J, L, M, N, O, and P in progress. Review of Resident #16's Quarterly MDS assessment tool dated 4/26/24 revealed the quarterly MDS assessment status as in progress. The MDS summary revealed the assessment needed completed by 5/10/24. The summary also indicated the MDS assessment had 13 errors. The MDS revealed sections A, GG, H, I, J, L, M, N, O, and P in progress. In an interview on 7/17/24 at 2:46 PM, Staff A, MDS Coordinator, reported she had worked at the facility since 5/8/24. Prior to this, the Director of Nursing (DON) worked on the MDS assessments. The social worker, dietary manager, and the activities director also completed certain sections on the MDS assessment. Staff A reported she reviewed all MDS sections to ensure all of the assessment areas completed and the information correct before the MDS exported and submitted to CMS (Center for Medicare Services). Staff A stated the residents' MDS assessments completed whenever a resident admitted to the facility, quarterly, and anytime the resident had a significant change in status. Staff A acknowledged a number of MDS assessments incomplete but the MDS Assessment Review Date (ARD) were prior to the date she started to work. She was told to complete the MDS assessments from the ARD of 5/8/24 and going forward. She couldn't complete the MDS assessments prior to 5/8/24 because she wasn't working at the facility during that time and had not interviewed the residents or staff or completed the record reviews at that time. In an interview 7/17/24 at 3:00 PM, the DON reported she and the Assistant Director of Nursing (ADON) worked on the resident MDS assessments prior to Staff A. The DON reported another staff member worked on MDS assessments but left the facility without notice in 12/2023 after she spoke to the staff member about timeliness of MDS completions. The facility tried to recruit another MDS coordinator but in the meantime the ADON and DON worked on the MDS assessments. The DON confirmed Staff A started as the MDS Coordinator in 5/2024. The DON reported she had self-identified a concern about MDS completions and submissions not done in a timely manner in 12/2023 when the MDS Coordinator resigned without notice. She put together an action plan to address the concern. In an email dated 7/18/24 at 10:05 AM, the DON wrote no written policy on MDS Assessments. It is expected staff followed the CMS guidelines as noted in the RAI Manual. The MDS 3.0 RAI Manual dated 10/2019 revealed Timeliness criteria under section 5.2. In accordance with the requirements at 42 CFR S483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: For all non-Admission OBRA and PPS assessments, the MDS completion date must be no later than 14 days after the ARD.

Based on clinical record review, observations, and staff interview, the facility failed to develop and implement a comprehensive person centered care plan for 1 of 12 residents reviewed (Residents #7). The facility reported a census of 32 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had diagnoses of COVID-19, heart failure, and end-stage renal (kidney) disease. The MDS indicated the resident used oxygen (O2). The Care Plan revised on 6/28/24 revealed the resident had congestive heart failure and COVID-19. The Care Plan lacked information about the resident's O2 use, and the interventions related to the management, use, and care of the O2. The Physician's Order Summary revealed an order started on 3/28/24 for O2 at 1-5 liters (L) per nasal cannula (NC) titrated to keep the resident's oxygen saturation above 90% for perfusion, and to change the O2 tubing every Sunday on the evening shift for infection control. Observations revealed the following: a. On 7/15/24 at 11:12 AM, Resident #7 had O2 on at 3 1/2 L via NC. b. On 7/17/24 at 10:30 AM, Resident #7 had O2 on 3L via NC. c. On 7/18/24 at 11:40 AM, Resident #7 had O2 on at 3L/NC. In an interview 7/17/24 at 2:46 PM, Staff A, MDS Coordinator reported she had worked at the facility since 5/8/24. She developed and revised the residents' care plans as needed. She obtained information from chart reviews and staff interviews to complete and update the care plans. Staff A confirmed O2 should be listed on the care plan if a resident had or used O2. In an email dated 7/18/24 at 10:05 AM, the Director of Nursing (DON) wrote they did not have a policy on care plans. In an interview 7/18/24 at 12:48 PM, the DON reported she expected O2 listed on the care plan If a resident had O2.

Based on observation, staff interview and policy review the facility failed to ensure they were not serving expired food items to reduce the risk of contamination and food-borne illness. The facility reported a census of 25 residents. Findings include: On [DATE] at 8:30 AM during the initial tour of the facility kitchen with the Dietary Manager (DM), revealed the following: a. 1 unopened bottle of oyster sauce with an expiration date of [DATE]. b. 6 unopened bottles of malt vinegar with an expiration date of [DATE]. c. 2 unopened boxes of wheat wafer snack crackers with an expiration date of [DATE]. d. 15 unopened sleeves of assorted crackers with an expiration date of [DATE]. e. 6 unopened boxes of Nilla wafers with an expiration date of [DATE]. f. 7 unopened cans of coconut milk with a best by date of [DATE]. g. 3 unopened containers of Quaker Oats grits with an expiration date of [DATE]. During an interview on [DATE] at 9:17 AM, the DM reported it is the expectation staff are checking for expired items three times per week with each new delivery of food items. The utility worker is expected to rotate the new food items with the old and remove those that are expired. Review of the undated Facility Policy, titled Storage, stated food shall be stored at the proper temperature and for appropriate lengths of time to protect quality of food and food cost.

Based on clinical record reviews and staff interviews, the facility failed to ensure accurate assessments for 2 of 3 residents (Residents #11 and #19) in the sample reviewed for unnecessary medications. The facility reported a census of 28 at the time of the survey. Findings include: 1. Resident #11's Minimum Data Set (MDS) assessment dated [DATE] documented that she received antidepressant medications for seven out of seven days in the lookback period. The Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The MDS assessments dated 4/21/21, 7/16/21, and 10/15/21 lacked the active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11's Care Plan dated 1/20/22 showed a Focus related to the use of an antidepressant. The Focus included a goal for Resident #11 not to have an increase of depression symptoms and to take the lowest dose of the antidepressant medication possible, through next review date. The Care Plan indicated that Resident #11's understood that her Primary Care Provider (PCP) prescribed the antidepressant. During interview on 2/16/22 at 1:20 PM, the Assistant Director of Nursing (ADON) verified that the admission MDS dated [DATE] and the two additional quarterly MDS assessments dated 7/26/21 and 10/15/21 did not reflect depression as one of Resident #11's medical diagnoses. The ADON reported that Resident #11 came from the hospital and depression was not included in her diagnoses. The ADON verified that Resident #11's medications during admission included an antidepressant. The ADON confirmed that Resident #11 was still on an antidepressant. The ADON acknowledged the need to correct the discrepancy in the in progress quarterly MDS dated [DATE]. 2. Resident #19's MDS assessment dated [DATE] indicated that she admitted to the facility on [DATE]. Resident #19 took an antidepressant one out of seven days in the lookback period. Resident #19's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #19's Care Plan dated 11/16/21, showed a Focus area related to the use of antidepressants due to depression. The Focus included a goal for Resident #19 not to have an increase in depression symptoms and to take the lowest dose of antidepressant medication possible, through next review period. The Focus included interventions that indicated Resident #19's understood that the antidepressant medication was prescribed by their PCP to take as ordered. On 2/16/22 at 1:07 PM, the Assistant Director of Nursing (ADON) verified that Resident #19's admission MDS dated [DATE] did not show a medical diagnosis, specifically depression, to support the use of the antidepressant. The ADON acknowledged the importance of an accurate reflection of Resident #19's condition in the MDS. The ADON reported that they would correct the discrepancy.

Based on observation, staff interview, record review, personnel file review, and facility policy and procedure review, the failed to ensure staff treated residents with respect and dignity and in a manner that recognized each resident's individuality, and also failed to ensure residents remained free from physical restraints imposed for convenience and not required to treat the resident's medical symptoms for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 21 residents. Findings include: 1. An admission Minimum Data Set (MDS) assessment tool dated 1/25/21, documented Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident scored of 12 of 15 possible points on a BIMS (brief interview for mental status) test, which meant the resident demonstrated moderately impaired cognitive function. The MDS also documented the resident exhibited fluctuating inattention and disorganized thinking, and feeling down, depressed or hopeless daily. The MDS identified Resident #1 required extensive assistance of one staff for bed mobility, surface-to-surface transfers, ambulation (walking), and toilet use, and was not steady but able to stabilize self without staff assistance when moving from a seated to standing position. An undated care plan with a focus area which included impaired cognitive function related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan documented the resident experienced anxiety and worried a lot which could lead to [CONDITION(S)] and staff found the resident hard to redirect due to circle conversations that repeat over and over. The care plan also documented the resident could become combative during cares, may try to tip the wheelchair backwards, may try to walk independently, and refuse assistance with cares. The care plan directed staff to allow extra time to process questions or cues, reminisce using photos of family and friends, give one on one attention, report out of the norm [CONDITION(S)] to the charge nurse immediately, switch out caregivers as needed, and keep the resident close to staff in an attempt to try to make them feel more secure and safe. The care plan revealed Resident #1 liked to fidget, tinker and stay keep busy with hands, say prayers, listen to Christian music or watch church services. The care plan directed staff to provide activities that allow the resident to keep their hands busy, and cue, re-orient and supervise as needed. During an interview on 4/1/2021 at 12:35 p.m. Staff A, Licensed Practical Nurse (LPN) stated on 3/1/21 Staff B, LPN used a gait belt to tie Resident #1 in a dining room chair, behind the nurse's station. Staff A described the gait belt as a typical gait belt with a metal buckle, fastened so that the resident could not reach the buckle. Staff A stated she reported her concern to the Chief Nursing Officer (CNO) on 3/2/21. During an interview on 3/31/21 at 3:00 p.m. Staff C, Certified Nursing Assistant (CNA) stated on 3/1/21 after supper she observed Resident #1 at the nurse's station, seated in a dining chair with the chair back placed against the counter. Staff C demonstrated how she saw the gait belt wound through the fixed arms of a dining room chair and fastened. She responded she thought the buckle had been fastened behind the resident, but couldn't be sure. Staff C reported the resident would have been able to move around in the chair because the gait belt was loose, but unable to stand. During an interview on 4/1/21 at 3:00 p.m. Staff D, CNA reported on 3/1/21 after supper she saw Resident #1 at the nurse's station, seated in a dining room chair with a gait belt fastened around her and the chair and Staff B, LPN sitting with her. During an interview on 4/1/21 at 3:10 p.m. Staff E, CNA reported on 3/1/21 after supper, she saw Resident #1 at the nurse's station, seated in a dining room chair with a gait belt fastened around her waist and the dining room chair. Staff E stated this was not something she would do. In an interview on 4/1/21 at 1:03 p.m., Staff B, LPN stated on 3/1/21 Resident #1 was transferred to a straight back dining room chair behind the nurse's station. She reported she placed a gait belt around the resident, through the fixed arms, and fastened the gait belt with the buckle behind the chair, and then positioned the chair back against the nurse's station counter. Staff B reported the resident had been anxious and she was afraid she would tip over chair. Staff B stated she intended to keep the resident safe, although she acknowledged it was not ok to restrain a resident to keep them safe. After review of the facility camera footage of 3/1/21, Staff B confirmed the gait belt remained fastened around Resident #1 and the chair at the nurse's station from 6:36 p.m.-7:25 p.m. During an interview on 4/6/21 at 12:05 p.m., the CNO stated on Tuesday 3/2/21 she received a report from Staff A, LPN of an incident involving Staff B, LPN. Staff B allegedly placed a gait belt around Resident #1 and a chair at the nurse's station on 3/1/21. The CNO stated she interviewed Staff B who reported she had loosely placed the gait belt around the resident for safety. The CNO reported on 3/2/21 Resident #1 had demonstrated the ability to independently remove a gait belt that had been placed to ambulate with the resident. The CNO stated Resident #1's abilities fluctuate and she did not feel that at this time Resident #1 would be able to consistently, independently remove the gait belt. The CNO reviewed the incident and had decided the incident did not meet the criteria for a restraint, and also felt there had been no ill intent. The CNO responded that she felt it was not an appropriate intervention and Staff B, LPN showed poor nursing judgement. Observation on 3/16/21 at 3:30 p.m. revealed Resident # 1 seated in recline while staff provided 1:1 care with the resident interacting with staff. Observation on 4/1/21 at 11:35 a.m. revealed resident attempting to stand. Staff applied a gait belt and transferred the resident with assist of two staff. Using the reasonable person standard, a reasonable person in our society would not want to be tied to a chair to prevent them from standing and in addition, would feel distress and humiliation. Review of an undated facility policy titled, Resident Screening, Training, Prevention, Identification, Investigation, Reporting, Protection of Abuse revealed the following expectations: Residents have the right to be free from verbal, sexual, physical, and mental abuse, neglect and mistreatment, corporal punishment, involuntary seclusion, and misappropriation of property. Abuse is defined as: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. When reviewed, Staff B's personnel file revealed a hire date of 3/24/2009, a certificate for completion of the mandatory 2 hour dependent adult abuse for Iowa mandatory reporters dated 1/10/2019. Acknowledgement of the addition to the physical abuse policy dated 6/13/2017 reviewed the expectation to prevent personal degradation, and education on the abuse policy that was updated 1/5/2017 and signed on 1/18/17.

Based on staff interview, clinical record review, and facility policy and procedure review, the facility failed to ensure incidents of abuse are properly reported for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 21 residents. Findings include: 1. An admission Minimum Data Set (MDS) assessment tool dated 1/25/21, documented Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the resident scored of 12 of 15 possible points on a BIMS (brief interview for mental status) test, which meant the resident demonstrated moderately impaired cognitive function. The MDS also documented the resident exhibited fluctuating inattention and disorganized thinking, and feeling down, depressed or hopeless daily. The MDS identified Resident #1 required extensive assistance of one staff for bed mobility, surface-to-surface transfers, ambulation (walking), and toilet use, and was not steady but able to stabilize self without staff assistance when moving from a seated to standing position. During an interview on 4/1/2021 at 12:35 p.m. Staff A, Licensed Practical Nurse (LPN) stated on 3/1/21 Staff B, LPN used a gait belt to tie Resident #1 in a dining room chair, behind the nurse's station. Staff A described the gait belt as a typical gait belt with a metal buckle, fastened so that the resident could not reach the buckle. Staff A stated she reported her concern to the Chief Nursing Officer (CNO) on 3/2/21. During an interview on 3/31/21 at 3:00 p.m. Staff C, Certified Nursing Assistant (CNA) stated on 3/1/21 after supper she observed Resident #1 at the nurse's station, seated in a dining chair with the chair back placed against the counter. Staff C demonstrated how she saw the gait belt wound through the fixed arms of a dining room chair and fastened. She responded she thought the buckle had been fastened behind the resident, but couldn't be sure. Staff C reported the resident would have been able to move around in the chair because the gait belt was loose, but unable to stand. Staff C verified she had not reported the incident. During an interview on 4/1/21 at 3:00 p.m. Staff D, CNA reported on 3/1/21 after supper observed Resident #1 at the nurse's station, seated in a dining room chair with a gait belt fastened around her and the chair. Staff B, LPN was observed to be sitting with resident. Staff D confirmed that she had not reported the incident. During an interview on 4/1/21 at 3:10 p.m. Staff E, CNA reported on 3/1/21 they saw Resident #1 after supper at the nurse's station, seated in a dining room chair with a gait belt fastened around her waist and the dining room chair. Staff E said this was something she would not do. Staff E also confirmed she had not reported what she had seen. In an interview on 4/1/21 at 1:03 p.m., Staff B, LPN reported on 3/1/21, the Resident #1 was transferred to a straight back dining room chair behind the nurse's station. Staff B also reported she placed a gait belt around resident, through the fixed arms, and fastened the gait belt with the buckle behind the chair and positioned with the back of the chair placed against the nurses station counter. Stated resident had been anxious and was afraid was going to tip chair. Staff B stated she intended to keep the resident safe, however acknowledged that it is not ok to restrain a resident to keep them safe. After review of facility camera footage of 3/1/21, Staff B confirmed the gait belt remained fastened around Resident #1 and the chair at the nurse's station from 6:36 p.m. - 7:25 p.m. During an interview on 4/6/21 at 12:05 p.m., the CNO stated on Tuesday 3/2/21 she received a report from Staff A, LPN of an incident involving Staff B, LPN. Staff B allegedly placed a gait belt around Resident #1 and a chair at the nurse's station on 3/1/21. The CNO stated she interviewed Staff B who reported that she had loosely placed the gait belt around the resident for safety. The CNO further stated that on 3/2/21 Resident #1 was observed to independently remove a gait belt that had been placed to ambulate with the resident. The CNO stated Resident #1's abilities fluctuate and she did not feel that at this time Resident #1 would be able to consistently, independently remove the gait belt. The CNO reviewed the incident and determined that it had not met the criteria for a restraint, and felt there had been no ill intent. The CNO responded that she felt it was not an appropriate intervention and Staff B, LPN showed poor nursing judgement. The CNO reported the facility did not report the incident to the Department of Inspections and Appeals. Review of an undated facility policy titled, Resident Screening, Training, Prevention, Identification, Investigation, Reporting, Protection of Abuse revealed the following expectations: a. Any allegation or suspicion of resident abuse, mistreatment, or neglect will be investigated promptly and thoroughly in order to protect the well-being of residents. b. All allegations of abuse shall be reported immediately and no later than 2 hours after allegation is made to the Department of Inspection and Appeals (DIA). c. All allegations of resident neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation shall be reported to DIA, not later than 2 hours after the allegation is made.

Based on staff interview, record review, personnel file review, and facility policy and procedure review the facility failed to [MEDICATION(S)] to prevent further abuse and ensure the safety of residents by permitting Staff B to continue to work while the investigation was still in process for one resident (Resident #1). The facility reported a census of 21 residents. Findings include: 1. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that Resident #1 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further documented the resident as fluctuating inattention and disorganized thinking, and feeling down, depressed or hopeless daily. The MDS further documented Resident #1 required extensive assistance of one staff for bed mobility, transfer, ambulation, and toilet use, and not stead but able to stabilize self without staff assistance when moving from a seated to standing position. An undated care plan with a focus area which included the following: I have impaired cognitive function related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Am anxious and worried a lot which can lead to [CONDITION(S)]. Am hard to redirect because have circle conversations that repeats over and over. May become combative during cares, may try to tip my wheelchair backwards, may try to walk on my own and may refuse for you to assist me with cares. Interventions included the following: Allow extra time to process questions or cues. Reminisce using photos of family and friends. Enjoy one on one attention and like to be near staff, it makes feel more secure and safe. Likes to fidget, tinker and keep busy with hands, provide activities that allow to do so. Please cue, re-orient and supervise as needed. Like to say prayers, listen to Christian music or watch church services. Report suicidal ideation to charge nurse immediately that are out of the norm for me. Switch out caregivers as needed, seeing a different face may change my mood. During an interview on 4/1/2021 at 12:35 p.m. Staff A, Licensed Practical Nurse (LPN) stated on 3/1/21 Staff B, LPN used a gait belt to tie down Resident #1 in a dining room chair, behind the nurse's station. Staff A described the gait belt as a typical gait belt with a metal buckle, fastened so that the resident could not reach the buckle. Staff A stated she reported her concern to the Chief Nursing Officer (CNO) on 3/2/21. During an interview on 3/31/21 at 3:00 p.m. Staff C, Certified Nursing Assistant (CNA) stated on 3/1/21 after supper observed Resident #1 at the nurse's station, seated in a dining chair that had been placed with the back of the chair against the counter. Staff C demonstrated gait belt placed through the fixed arms of a dining room chair and fastened. Staff C, responded she thought the buckle had been fastened behind the resident, but couldn't be for sure. Stated the belt was loose, so resident would have been able to move around in the chair but unable to stand. Staff C, confirmed she had not reported the incident. During an interview on 4/1/21 at 3:00 p.m. Staff D, CNA reported on 3/1/21 after supper observed Resident #1 at the nurse's station, seated in a dining room chair with a gait belt fastened around her and the chair. Staff B, LPN was observed to be sitting with resident. Staff D confirmed that she had not reported the incident. During an interview on 4/1/21 at 3:10 p.m. Staff E, CNA reported on 3/1/21 observed Resident #1 after supper at the nurse's station, seated in a dining room chair with a gait belt fastened around her waist and the dining room chair. Staff E confirmed that she had not reported what she had seen, and added this was not something that she would do. In an interview on 4/1/21 at 1:03 p.m. Staff B, LPN responded on 3/1/21 Resident #1 was transferred to a straight back dining room chair behind the nurse's station, and she placed a gait belt around resident, through the fixed arms, and fastened the gait belt with the buckle behind the chair and positioned with the back of the chair placed against the nurses station counter. Stated resident had been anxious and was afraid was going to tip chair. Staff B stated she intended to keep the resident safe, however acknowledged that it is not ok to restrain a resident to keep them safe. After review of facility camera footage of 3/1/21, Staff B confirmed that the gait belt remained fastened around Resident #1 and the chair at the nurse's station from 6:36 p.m.-7:25 p.m. Staff B further confirmed that she had worked on 3/2/21, 3/9/21, and 3/11/21 prior to being notified on 3/16/21 by the CNO that an allegation had been reported and she would be unable to work during the investigation. During an interview on 4/6/21 at 12:05 p.m. the CNO stated on Tuesday 3/2/21 she received a report from Staff A, LPN of an incident involving Staff B, LPN. Staff B allegedly placed a gait belt around Resident #1 and a chair at the nurse's station on 3/1/21. The CNO stated she interviewed Staff B who reported that she had loosely placed the gait belt around the resident for safety. The CNO further stated that on 3/2/21 Resident #1 was observed to independently remove a gait belt that had been placed to ambulate the resident. The CNO stated Resident #1's abilities fluctuate and she did not feel that at this time Resident #1 would be able to consistently, independently remove the gait belt. The CNO reviewed the incident and determined that had not met the criteria for a restraint, and felt there had been no ill intent. The CNO responded that she felt it was not an appropriate intervention and Staff B, LPN showed poor nursing judgement. The CNO reported the facility gave disciplinary action, and allowed the nurse to work with Resident #1 that shift on 3/2/21 and additional shifts on 3/9/21 and 3/11/21 prior to Staff B, LPN going on vacation. The CNO confirmed Staff B, LPN was put off work on 3/16/21 after received notification from DIA of allegation of abuse. Review of an undated facility policy titled, Resident Screening, Training, Prevention, Identification, Investigation, Reporting, Protection of Abuse revealed the following expectations: a. Any allegation or suspicion of resident abuse, mistreatment, or neglect will be investigated promptly and thoroughly in order to protect the well-being of residents. b. Upon receiving report of an allegation of resident abuse, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. This will be accomplished by separating the employee accused of abuse from all residents. c. Following completion of the facility investigation, if the facility concludes that the allegation of resident abuse are unfounded, the employee will be allowed to return to job duties involving resident contact, but the employee must maintain a separation and have no contact with the resident alleged to have been abuse d, by reassigning the accused employee to an area of the facility where no contact will be made between the accused employee and the resident alleged to have been abused. This separation must be maintained until the DIA concludes its investigation and issues the written results of its investigation. Review of a timesheet titled Retro Report for the time period 3/1/2- 3/12/1 revealed Staff B worked on 3/2/21, 3/9/21, and 3/11/21, which were all after the alleged incident occurred on 3/1/21.

Based on observation, facility policy and interview, the facility failed to provide safe and proper sanitization while serving food for residents. The facility reported a census of 26 residents. Findings include: During an observation on 12/18/20 at 11:30 a.m., revealed Staff A, Dietary Aide, with hair exposed and hair net domed at the crown of her head. The hair net did not fully cover Staff A's head while served food during lunch. Review of an undated facility policy for Prevention of Food Contamination revealed that all food service workers shall practice good personal hygiene skills including wearing hairnets or approved cap to cover all of hair. Review of an undated Food Service Department Audit revealed that hairnets or caps are worn in the kitchen. During an interview on 2/19/20 at 7:09 a.m., the Dietary manager reported expected Dietary Staff to have hair covered while food served and keep loose hairs up in a hair net.

Based on facility menu review, observation, document review, and staff interviews the facility failed to serve the proper portion for one of one residents on a pureed diet (Resident #13). The facility identified a census of 26 residents. Findings include: Review of the week three menu for the Tuesday lunch meal included: vegetable soup, creamy chicken carbonara, carrots, garlic toast, pumpkin cake with apple glaze and milk. During an observation on 2/18/20 at 10:12 a.m., Staff B, Cook, stated he planned to puree two servings for each item under the pureed menu. Staff B pureed two servings of chicken carbonara. After Staff B pureed the chicken carbonara he checked the pureed serving chart and reported two #8 scoops needed when serving the chicken. Review of the facilty's Matrix form revealed Resident #13 with excessive weight loss. During an observation on 2/18/20 at 11:30 a.m., Staff A, Dietary Aide, served Resident #13 one #12 scoop of the chicken. After all the residents served, revealed the pan with the pureed chicken carbonara still had four #12 scoops left in the pan. During an interview on 2/18/20 at 12:34 p.m., Staff A, Dietary Aide reported she generally used the #12 scoop whenever serving pureed foods. During an interview on 2/18/20 at 12:43 p.m., Staff B, Cook, reported the #12 scoop is 2 2/3 ounces and not adequate enough for the amount necessary for nutritional value according to the portion chart provided by the company who supplies the facility with food. Staff B reported that Staff A should have used a #8 scoop and gave two scoops for the correct amount of food. The #8 scoop is 4 ounces. During an interview on 2/19/20 at 7:09 a.m., the Dietary Manager (DM) stated Staff A should have used two #8 scoops instead of a #12 scoop. The DM stated unsure if there was a miscommunication, but the staff member who performed the puree should have written the correct scoop size on the foil of the food, and sent the correct scoop to serve the food with.

Based on facility record review and staff interview, the facility failed to ensure availability of a staff member certified with cardiopulmonary resuscitation (CPR) for each shift. The facility reported a census of 26 residents. Findings include: 1. Review of the Daily Assignment sheets dated [DATE] - [DATE] indicated four night shifts lacked a scheduled staff member certified in CPR. Those night shifts included ,[DATE], ,[DATE], ,[DATE], and [DATE]. Review of the CPR list provided by the facility indicated Staff C, Registered Nurse's CPR expired in (MONTH) 2019. In an interview on [DATE] at 9:23 a.m., the Director of Nursing (DON) verified Staff C's CPR expired in (MONTH) 2019. In an interview on [DATE] at 10:22 a.m., the DON verified no staff certified in CPR for the night shift on the dates listed and expected Staff C to renew her CPR.

Based on observation, staff interview, and policy/procedure, the facility failed to maintain sanitary conditions in an attempt to prevent food borne illnesses. The facility reported a census of 29 residents. Findings include: Observation during the initial kitchen tour on 10/17/16 at 10:00 a.m., revealed a counter top grill, approximately 2 feet by 2 feet in size, with charcoal underneath, and the grate had an excess amount of dried food debris and grease. The right side of the grill had a sticky and dried on substance. The Dietary Service Manager verified the grill appeared dirty, had not been used yet that day and needed cleaned. An observation revealed a Vulcan range/oven with an excess build up of spilled and baked on food debris in the left oven and the inside of the left oven door. A cleaning brush sat on a tray inside the right oven. The Dietary Service Manager verified the left side of the oven dirty, required cleaning, and the right side had just been cleaned. An undated facility policy/procedure, titled Cleaning Procedures-Ovens/Grill, directed staff to keep ovens clean and free of grease build up and spills. The procedure directed staff daily cleaning included to clean spills with hot detergent and water right away, scrape off baked on foods with a spatula when needed, and to wipe the exterior with clean warm water.

Based on observation and staff interview, the facility failed to ensure resident food items were properly stored and dated when opened and failed to ensure kitchen utensils were sanitizable. The facility census was 31 residents. Findings include: During the initial kitchen tour on 11/23/15 at 8:10 a.m., the following concerns were identified: a. One bag of regular french fries open to air and undated. b. One bag of seasoned french fries open to air and undated. c. One box J & R brand hamburger patties open to air. d. A Ziploc bag labeled tenderloins with the top of the bag wide open, exposed to air. e. Five plastic spatulas with cracks and splintering and two stained dark brown on the edges. During interview on 11/24/15 at 2:00 p.m., the Dietary Supervisor stated they would expect the items in the freezer to be sealed and dated.

Based on employee schedule review, facility information review and staff interview, the facility failed to ensure the over night staff scheduled for the week of ,[DATE]-,[DATE], had someone trained in Cardio [MEDICAL CONDITION] Resuscitation (CPR). The facility census was 31 residents. Findings include: 1. On [DATE] at 10:30 a.m., the Director of Nursing provided a list of four employees trained in CPR. Review of the schedule for the week of [DATE]- [DATE], revealed none of the overnight shift staff scheduled were trained in CPR . During interview on [DATE] at 2:25 p.m., Staff A, Registered Nurse, RN explained the three resident charts with green labels were residents that wanted CPR. During interview on [DATE] at 8:00 a.m., Staff B, Licensed Practical Nurse, LPN stated the residents advanced directives was also in the first few pages of the clinical record.

The following deficiency relates to incident -I Based on clinical record review and interviews, the facility failed to provide adequate supervision to protect 1 of 4 residents from hazards (Resident #1). Record review & interviews established Resident #1 routinely got up unassisted at night and his/her personal safety alarms were effective in alerting staff of his/her needs. On 3/25/15 multiple facility staff initialed an entry in the communication book acknowledging Resident #1 could be independent only during the day in his/her room. Staff interviews revealed the resident ' s personal alarms had been discontinued at night. On 3/26/15 Resident #1 fell and sustained a left hip fracture. The facility identified a census of 35 residents. Findings include: According to Resident #1 Minimum Data Set (MDS) assessment with assessment reference date of 3/18/15 indicated Resident #1 with Brief Interview for Mental Status score of 6 indicating severe cognitive impairment. Resident #1 required limited assistance with physical assist of one staff with transfers and hygiene and extensive assistance with physical assist of one staff with mobility, dressing and toilet use. Resident #1 had continent bowel and bladder functioning. Resident # 1 had history of falls prior to admission, but no falls since admission on 3/11/14. Resident #1's [DIAGNOSES REDACTED]. The assessment identified the resident used a walker for ambulation. The resident ' s balance during transition and walking revealed he/she required staff assistance to stabilize when walking and when turning around. Interim Care Plan dated 3/11/15 for Resident #1 indicated Personal Safety Alarms used when in chair and bed at all times. The care plan identified Resident #1 as disoriented to time, and forgetful. The care plan revealed the resident transfers with the assist of one staff. An admission progress note dated 3/11/15 at 7:59 p.m., revealed the resident admitted following a hospitalization for a subdural hematoma and altered mental status. The resident had been highly confused and anxious. The staff used a chair/bed alarms due the resident ' s unstable gait and impulsivity. The progress notes from 3/11/15 to 3/26/15 included the following documentation: At 11:01 p.m., on 3/11/15, staff found Resident #1 walking down the hall with the alarm sounding. Resident confused about time and staff documented the resident ' s attention span seemed short, as the resident quickly forgets what had been asked (or told) to him/her. On 3/13/15 at 2:52 p.m., Resident #1 often forgets to put the call light on for help. The resident continues to use alarms at this time and sounding when the resident had been up and about. Resident continued to ambulate with a walker and staff assistance around facility. On 3/14/15 at 4:39 p.m., Resident #1 had been getting out of chair/bed several times during the shift and setting off pressure alarm. On 3/15/15 at 2:56 p.m., Resident #1 had been setting the bed alarm off several times that morning; and staff assisted the resident to the bathroom. On 3/15/15 at 11:21 p.m., Resident #1 needed frequent reminders to utilize his/her call light, and had been noncompliant with alarms or waiting for assistance. Staff documented alarms are in place and working, and his/her bed was in the lowest position. On 3/16/15 at 12:57 p.m., Resident #1 got up serval times on his/her own that shift and staff responded to the alarms sounding. Staff documented the resident very unsteady and had very poor safety awareness. Staff documented they were always able to stop and redirect the resident. On 3/17/15 at 4:13 p.m., Staff documented Resident #1 had significant short term (memory) cognitive issues, though no official [DIAGNOSES REDACTED]. Progress Notes dated 3/18/15, 3/21/15, 3/23/15 documented Resident #1 continued to attempt to ambulate without assistance. The staff continued to use the alarms at all times. The progress notes dated 3/23/15 at 11:18 p.m., documented Resident #1 had been observed in the bathroom with his/her alarm sounding and the nurse assisted the resident in the bathroom and getting back to bed. Resident #1 Progress Notes dated 3/24/15 at 3:19 p.m. and written by Staff A, social worker indicated a care conference had been held that day with the resident ' s family. Both physical therapy (PT) and occupational therapy (OT) discussed Resident #1 ' s current needs and agreed Resident #1 could be independent in his/her room by that day or the next. Concerns were mentioned regarding Resident #1's safety awareness and memory loss. The team discussed there was a good possibility of Resident #1 moving to an RCF (residential care facility) in the near future and back to his/her apartment with 24 hour supervision. The Event Report dated 3/26/15 at 1:02 a.m., written by Staff F documented Resident #1 had an unwitnessed fall in his/her room. The resident had been taking him/her(self) to the bathroom and did not use the call light. The resident had on slipper socks and used his/her walker. A certified nurse aide (CNA) had last visualized the resident at 11 p.m., (on 3/25/15) and staff documented the resident did not have a personal safety alarm(s) at the time of the incident. Resident #1 Progress Notes dated 3/26/15 at 1:03 a.m., written by Staff F, Licensed Practical Nurse (LPN) indicated she heard a loud thud (sound) and found Resident #1 lying on his/her back with a walker in front of him/her. Resident #1 had been incontinent of urine and on the floor. Resident #1 had been wearing slipper socks. Staff competed range of motion (within normal limits) and when two staff assisted Resident #1 up, the resident had been unable to bear weight on left side and complained of pain. Resident #1 assisted into a chair and then into bed. No rotation noted at this time. Resident #1 told staff he/she was independent. Resident #1 educated on using call light for assistance at night. Physician notified and Resident #1 sent to the emergency room . Resident #1 Progress Notes dated 3/26/15 at 3:35 a.m. written by Staff F. Staff F contacted hospital for update on Resident #1's status. Staff F documented Resident #1 would be admitted to the hospital with [REDACTED]. Resident #1 ' s History and Physical dated 3/26/15 at 1:50 a.m., documented the following: tonight the resident fell while ambulating with his/her walker to the bathroom and landed on his/her left side. He/she had immediate pain in his/her left hip with shortening and external rotation of the hip. The resident had been transported to the emergency room . The X-ray views of the left hip and pelvis on 3/26/15 documented: an acute left femoral neck fracture with mild foreshorting. Resident #1 would be admitted for surgery. In an interview on 4/8/15 at 5:15 p.m. Staff E, Licensed Practical Nurse, indicated on the morning of 3/25/15 there was a discussion with the DON and Staff D regarding the alarm status for Resident #1 and whether he/she should be independent in his/her room. Staff E indicated she thought this would be inappropriate given Resident #1's poor safety awareness. Staff E was directed to speak with Staff B. Staff B stated she assessed Resident #1 and felt comfortable with him/her being independent. Staff E disagreed noting Resident #1's confusion. Staff E then asked the DON whether she should remove the alarms and the DON instructed her to ask Staff B. According to Staff E, Staff B stated Resident #1 could be independent in his/her room and to remove the alarms. Staff E asked Staff C to remove the alarms and Staff C did. Staff E indicated that during her conversation with Staff B, Staff B was writing her note in the communication book. Staff E never read the communication book. Staff E stated Staff B never mentioned to her that Resident #1's independence status was for day time only. Staff E indicated she passed on in report that Resident #1 was independent in his/her room without alarms. In an interview on 4/9/15 at 10:58 a.m. Staff C, Certified Nurse Aide, indicated on the morning of 3/25/15 she had witnessed Staff B with Resident #1 during morning cares. Staff C later had a conversation with Staff B in which she was informed Resident #1 would be independent in his/her. Staff C could not recall whether Staff B specified the trial was for days only or at all times. Staff C asked about the alarms and was told they would be discontinued. Staff C stated she passed the information onto the next shift. In an interview on 4/8/15 at 5:40 p.m. Staff F, Licensed Practical Nurse (LPN), indicated she worked a double shift on 3/25/15 (2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m.). She received report from Staff E at 6:00 p.m. of informed that Resident #1 was independent in his/her room during the day and still needed assistance at night and that therapy had removed all alarms. Staff F indicated she didn't feel this was right (removing the alarms) given Resident #1's poor safety awareness and history of getting up unassisted at night. At around 12:30 a.m. on 3/26/15, Staff F heard a loud thud. Upon responding to Resident #1's room, Resident #1 had been seen on the floor. Resident #1 was assessed and then sent out to the emergency room for further evaluation due to left leg pain and inability to bear weight. Staff F noted Resident #1 had been incontinent at the time of the fall. Staff F stated she last saw Resident #1 around 9:30 p.m., but noted the aides had checked on him/her more frequently. In an interview on 4/8/15 at 11:08 p.m. Staff G, Certified Nurse Aide, indicated upon arriving for her shift (10:00 p.m. to 7:00 a.m.) on 3/25/15, she completed rounds with the evening aide. The aide had informed her that Resident #1 was independent in his/her room during the day and no longer using alarms. Staff G stated she was surprised as Resident #1 often got up unassisted at night and the alarms were effective at alerting staff. Staff G stated she heard a thud sound at around 12:30 a.m. and responded to Resident #1's room, where they found Resident #1 on the floor. Staff G indicated she last saw Resident #1 in bed with his/her eyes closed at around 11:00 p.m. In an email dated 3/26/15 addressed to the Director of Nursing regarding Resident #1, Staff B wrote Resident #1 had been made independent in his/her room on 3/25/15. Parameters for independence included the use of wheel walker and set up clothing by the aides. Resident #1 was then to complete his/her toileting, grooming and dressing independently in the morning and throughout the day. Assistance was still to be provided at night, but no specific instructions relating to night time assistance were relayed verbally or written due to no change with night time assistance level. Parameters and independence were given for daytime only. This was communicated to Staff E and Staff C. Staff B documented in the communication book after assessing Resident #1 that morning. Staff B wrote that Staff E asked if the alarms should be removed if Resident #1 was independent. Staff B wrote since Resident #1 was considered independent at this time, they could be removed. No specific conversation was had regarding use of alarms or assistance level at night. Communication book entry on 3/25/15 written by Staff B (OT). Resident #1 may be independent in his/her room during the day only, using a front wheel walker. Please remind him/her as needed to use the walker and for pushing/reaching for chair during transfers. Multiple staff initialed the entry in the communication book. In an interview on 4/9/15 at 10:02 a.m. Staff B, Occupational Therapist (OT), indicated she attended the care conference for Resident #1 on 3/24/15. The group talked about Resident #1's progress and the goal of him/her returning to assisted living. Staff B noted Resident #1 had been stand by assistance (prior to the fall) with activities of daily living. Staff B reported the biggest barrier for Resident #1 adjusting to independent was his/her cognitive impairment and safety awareness. Staff B indicated that prior to the care conference she had discussed with physical therapy staff whether they should trial Resident #1 being independent. Physical therapy staff indicated if everyone was comfortable they might consider a trial. Staff B indicated on the next morning she assessed Resident #1 and found Resident #1 at a modified level of independence. Staff B spoke with Staff C and explained that staff would need to get Resident #1's clothes out, but otherwise he/she could be independent during the day with his/her walker. Staff B relayed this information to Staff D and Staff E. Staff B stated she was asked about the alarms and responded if Resident #1 was independent then there was no need for alarms. Staff B admitted that therapy is not normally involved with whether alarms are used or not. Staff B indicated her recommendation was that Resident #1 be trialed during the day to be independent in his/her room and still required assistance at night. Staff B stated she wrote down her recommendation in the communication book. In an interview on 4/9/15 at 10:31 a.m. Staff D, Assistant Director of Nursing, indicated she attended the care conference on 3/24/15 for Resident #1. They discussed Resident #1's progress and goal to transition into residential care. They wanted to increase Resident #1's level of independence. Staff D indicated the discussion was general with no specified plan or process mentioned. Staff D stated the following day she was not involved in any discussion regarding Resident #1 being independent in his/her room or of alarm use. Staff D indicated she was responsible for reviewing the communication book and updating the pocket note books and care plans. Updates are usually done on Fridays. In an interview on 4/9/15 at 9:22 a.m. the Director of Nursing (DON), indicated she attended the care conference on 3/24/15 for Resident #1. During the conference there was discussion of changing Resident #1's status as independent in his/her room. The DON stated she expressed her concerns with Resident 31 being a high risk for falls. The family was supportive with trying to increase Resident #1's independence in his/her room. The following morning Staff E asked the DON about Resident #1 being independent in his/her room and removing the alarms. The DON stated she was not comfortable with removing the alarms, but directed Staff E to communicate with Staff B. Staff E asked Staff B who indicated they were making Resident #1 independent in his/her room and to remove the alarms. Staff E shared the change of status with the DON. The DON indicated at no time in the care conference or in any conversations leading up to the fall on 3/26/15 was it ever specified to her that the independence in his/her room status was only for the day time hours. The DON indicated had she known this, she would have assured that the alarms remained in use at night. In an interview on 4/9/15 at 9:03 a.m. Staff A, social worker, indicated she attended the care conference on 3/24/15 for Resident #1. During the conference there was a general discussion of Resident #1 becoming independent in his/her room, but no mention as to whether it would be limited to day or nights or what the alarm usage would be. Staff A indicated she was not involved in any further discussions and that the change of status for Resident #1 would be made by therapy and nursing staff. Observation of Resident #1 on 4/8/15 at 11:00 p.m., revealed the resident resting in a low bed with alarms in place.

Based on record review, staff and family interview, the facility failed to provide adequate supervision and assistance to prevent accidents for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 38. Findings include: According to the Minimum Data Set (MDS) assessment, dated 07/31/14, Resident #1 scored 6 on the Brief Interview for Mental Straus (BIMS) indicating severe cognitive impairment. Resident #1 required extensive assistance with activities of daily living (ADL's) including bed mobility, transfer, dressing, toilet use and personal hygiene. Resident #1 did not ambulate in the hall and ambulation in the room occurred only once or twice in the 7 day assessment period. Resident #1 was unsteady, and only able to stabilize with staff assistance. Resident #1's [DIAGNOSES REDACTED]. A Fall Risk assessment dated [DATE] at 4:21 p.m. documented Resident #1 scored 16 with a score of 10 or higher representing a high risk for falls. A Safety Events--Occurrence Reporting Form dated 04/13/14 at 5:15 a.m. documented a CNA walked Resident #1 to the bathroom when he/she started to fall towards the floor and caught him/herself with his/her right hand on the walker. The CNA stated she lowered the resident the rest of the way to the floor. According to the report Resident #1 received a bruise to the right wrist measuring 2 centimeters (cm) X 1cm during the incident. The report documented the gait belt was used appropriately. A Safety Events-Occurrence Reporting Form dated 08/09/14 at 9:52 a.m. reported the nurse responded to Resident #1 ' s room to find the resident in a wheelchair by the bathroom sweating profusely. The CNA informed the nurse Resident #1 pushed his/her walker out in front of the resident and lost balance around 7:50 a.m. that morning falling to the floor. Resident #1 hit his/her face and knee on the ground resulting in the following injuries. Resident #1 had an abrasion and bump to the left knee measuring 2cm x 4cm and 4cm x 4cm. Resident #1 complained of knee pain. Noted Resident #1 ' s pupils remained pinpoint and fixed. Difficulty following commands at first but perked up. Resident #1 began to complain about pain in his/her left arm. Discussed with family need for emergency room evaluation for possible should dislocation. Ambulance arrived and transported Resident #1 to the hospital around 9:19 a.m. for evaluation and treatment. According to the Safety Events document the gait belt failed to be properly used for Resident #1. A Physician encounter form dated 06/12/14 documented Resident #1 had increased debility requiring more assistance with meals and inability to walk, using a wheelchair with assistance. Resident #1 had a risk of falls and had several falls, sliding out of bed. Resident #1 had chronic pain controlled with Norco (Hydrocodone/narcotic analgesic) 3 times a day. The Care Plan dated 12/25/13 identified Resident #1 had a history of [REDACTED]. The approaches included: a. The overnight shift and day shift were to get Resident #1 up together on the overlap between 6:00 a.m. and 6:15 a.m. dated 08/04/14. The care plan identified Resident #1 no longer able to care for him/herself. The approaches included: a. Resident #1 ambulated short distances with a walker, but used a wheelchair as his/her primary mode of transportation. b. Resident #1 needed help transferring on/off the toilet. c. Staff would provide assistance with all ADL's. A CNA Pocket Care Plan/Worksheet dated 08/08/14 directed Resident #1 to have 1 to 2 assist with a wheelchair and front wheeled walker. Resident #1 to have a personal alarm and pressure alarm at all times. Special instructions included to be 1st/early up in the a.m. The Resident Progress Notes dated 08/09/14 at 9:35 a.m. documented at 7:50 a.m. staff called the nurse into Resident #1's room due to a fall. When the nurse arrived, the resident sat outside his/her bathroom in a wheelchair. Resident #1 sweated profusely. The CNA told the nurse that Resident #1 ambulated with the CNA and his/her wheeled walker to the bathroom. When he/she entered the bathroom, the resident pushed his/her walker way out in front of him/her and then fell forward landing on his/her face on the linoleum. The CNA stated she tried to grab the resident by the hips but was unable to do so and he/she landed straight down on his/her face. A hospital History and Physical dated 08/09/14 documented Resident #1 went in after sustaining a fall. The nursing home stated they attempted to transfer Resident #1 and he/she fell down, landing on his/her face. They noted an abrasion to the nose, and swelling and ecchymosis to the left knee. They attempted to get Resident #1 up and he/she complained of left shoulder pain. They noted a deformity in that area. The final [DIAGNOSES REDACTED]. A Major Injury Determination Form dated 08/09/14 at 7:45 a.m. documented Resident #1 had an x-ray at the ER showing irregularity of the lateral greater tuberosity and inferior tuberosity region of the left humeral head worrisome for possible impaction fracture. The practitioner reviewed the circumstances, injury and prognosis of the patient, and believed the injury sustained was not a major injury. A Physician order [REDACTED].#1's orders included: a. Okay to return to the facility. b. Wear a sling to the left arm. c. Call orthopedics for appointment in 1 week d. Hydrocodone 5/325 1 orally every 4 to 6 hours as needed (PRN) for pain. e. Resume all other orders. The Medication Administration Record (MAR) for August 2014 showed Resident #1 received Hydrocodone/APAP 10/325 1 tablet by mouth 3 times a day routinely. The Resident Progress Notes dated 08/11/14 at 9:54 a.m. documented Resident #1 complained of increased pain and discomfort with cares. Staff called and updated the Nurse Practitioner regarding pain. New orders received for Fentanyl (narcotic pain medication) 12.5 mcg patch, change every 72 hours. The Resident Progress Notes dated 08/12/14 at 11:08 a.m. documented Resident #1 up in the a.m. and cried out in pain during transfers, bed mobility, and ADL's. The Resident Progress Notes dated 08/13/14 at 12:57 p.m. documented Resident #1 continued to have a sling on his/her left arm. Resident #1 often complained of pain. PRN and scheduled pain medications continued. Resident #1 repositioned as needed and would cry out in pain. After receiving scheduled and PRN pain medication Resident #1 would fall asleep or sit quietly for a short amount of time then start moaning, saying ouch and oh, over and over again. Staff reported increased pain and crying out during any transfers or cares. When questioned about pain Resident #1 said yes, but unable to state pain level. Staff called the nurse practitioner and reported uncontrolled pain, with new orders for Roxanol (Morphine sulfate) 5 mg every 3 hours PRN for pain. An Objective Findings and Physician order [REDACTED].#1 fell and fractured his/her left humerus; on conservative care with a sling. A Physician note dated 08/14/14 documented Resident #1 status [REDACTED]. Resident #1 had his/her left arm in a sling and had increased pain. They started a low dose Fentanyl patch on 08/11/14 and the resident already received Norco 10/325 1 tab 3 times a day. Resident #1 also recently started Roxanol as needed for pain management. The Medication Administration Record (MAR) for August 2014 documented Resident #1 received additional medication for shoulder pain on the following: a. 08/09/14 at 8:15 a.m. b. 08/10/14 at 3:15 p.m. c. 08/11/14 at 1:00 a.m. d. 08/11/14 at 10:30 a.m. e. 08/11/14 at 10:00 p.m. f. 08/12/14 at 5:00 a.m. g. 08/13/14 at 3:30 a.m. h. 08/14/14 at 9:30 a.m. i. 08/14/13 at 10:30 a.m. During an interview on 09/02/14 at 11:30 a.m. Staff P Certified Nursing Assistant (CNA) stated Resident #1 got up and started walking just fine. Staff P said he/she had a different walker in her room and they used it. Resident #1 lost his/her balance and fell . Resident #1's spouse started lifting him/her so Staff P helped the spouse get him/her into the wheelchair. Staff P stated she did not have a gait belt on Resident #1. She stated the facility did not issue gait belts, and she did not have a gait belt. She said she could have asked for one, but she didn't use one with Resident #1 because he/she walked terrific. She said Resident #1 just lost his/her balance that day. She said it was not on the care plan to use a gait belt with Resident #1. Staff P stated she wasn't issued a gait belt and wasn't trained at the facility to use a gait belt. She said during a physical therapy in-service they did use a gait belt for transfers. During an interview on 09/16/14 at 10:03 a.m. Staff P CNA stated she assisted Resident #1 to a sitting position and helped get his/her legs out of bed. Staff P assisted Resident #1 to stand and he/she started walking. Staff P had her left hand lightly on Resident #1's waist and her right hand on Resident #1's right shoulder. When Resident #1 fell , the walker moved forward, but Resident #1 did not. Staff P tried to grab Resident #1 by the waist, but couldn't. Staff P said she probably could have saved Resident #1 if she had the gait belt on him/her. She would have held the gait belt in the back. Staff P said she did use a gait belt on other residents in the facility, if residents are larger, or if she didn't feel comfortable without using one. During an interview on 09/03/14 at 9:02 a.m. Staff K, Licensed Practical Nurse (LPN) stated Staff P, Certified Nursing Assistant (CNA) called her to Resident #1's room. When she went to the room, Resident #1 sat in the wheelchair. Staff P stated she had picked Resident #1 up and put him/her in the wheelchair. Resident #1 sat slumped in the wheelchair. Staff P said she walked Resident #1 to the bathroom with his/her walker and the walker went straight out and Resident #1 fell . Staff P tried to grab Resident #1 by his/her hips but couldn't. Resident #1 landed on his/her face. Resident #1 sweated profusely. Resident #1 said his/her knee hurt and he/she had a bump and abrasion. Resident #1's nose appeared pink. He/she could move all his/her extremities, and made no comment about his/her shoulder. Resident #1 did not have a gait belt on. When out to breakfast, staff reported Resident #1 complained of pain to his/her shoulder. Staff K asked Resident #1's spouse if Resident #1 had a gait belt on and he/she said no. Staff K stated Staff P gave no explanation for not using a gait belt. During an interview on 08/22/14 at 7:54 a.m. the DON stated Staff P did not use a gait belt the day Resident #1 fell . The DON stated she had not had any other residents falling due to non-use of the gait belt. She had not had to write anyone up for non-use. She said she harped on it (gait belt use). She said the standard of practice to use a gait belt, unless it was contraindicated on the care plan. She said they had transfer training a few months ago which Staff P attended. The DON presented a Nurse Aide Skills Checklist for Ambulation. She said they had a binder with skills checklists available at the nurse's station. She did them yearly, but not yet this year. The checklist included the use of a gait belt for ambulation. She did not have a (completed) checklist for Staff P. During an interview on 09/03/14 at 8:20 a.m. The DON stated she had reports of Staff O, CNA not using a gait belt before, but the reporter could not say who she transferred without it. She said the previous Wednesday she visually saw Staff O transfer a resident without a gait belt, about 2 hours after a Wednesday meeting where she reiterated the need to use a gait belt. She and Staff K gave Staff O a verbal warning. During an interview on 09/03/14 at 11:00 a.m. Resident #1's spouse stated the day Resident #1 fell the girl was walking with him/her and did not have a belt on him/her. Resident #1 had a walker with front wheels. When he/she got to the bathroom the walker went forward but Resident #1 didn't. He/she fell on his/her face. The girl (CNA) didn't have anything to hold on to keep Resident #1 from falling. The spouse said others had transferred and ambulated, Resident #1 without the gait belt prior to the fall. Resident #1's spouse stated Resident #1 had pain and suffering from the fracture. He/she said Resident #1 used to be able to pick up a cup with both hands but could not use his/her left hand at the time. The spouse stated the physician told him/her it could take 6 weeks to heal. During an interview on 09/03/14 at 9:59 a.m. Staff J RN stated she never witnessed staff not using a gait belt to transfer or ambulate with residents. During an interview on 09/02/14 at 12:12 p.m. Staff M CNA stated staff members are aware to use gait belts at all times. They also had gait belts located with the linen cart, and some residents had gait belts in their room. Staff M stated Resident #1 did not walk well prior to the fall. Resident #1 needed assist of 1 or 2 and mostly transferred. During an interview on 09/02/14 at 11:40 a.m. Staff E CNA stated Resident #1 needed 1 person to transfer before the fall. She transferred her to the wheelchair and then to the bathroom. She never transferred without a gait belt. She said it would be unsafe. During an interview on 09/02/14 at 12:42 p.m. Staff D CNA/CMA stated prior to the fall Resident #1 needed assist of 1 to the bathroom. She said days varied, depending on Resident #1's gait and steadiness. She always used a gait belt. She said it would not have been safe to transfer or ambulate, Resident #1 without a gait belt. During an interview on 09/02/14 at 11:49 a.m. Staff C CNA/CMA stated prior to the fall Resident #1 needed assist of 1 person and they were pivoting him/her to the wheelchair, he/she did not walk well. Staff C stated she had not transferred/ambulated anyone without a gait belt and had not seen other staff at this facility transfer/ambulate without a gait belt. She said it would not be safe to transfer/ambulate Resident #1 without a gait belt. During an interview on 09/02/14 at 12:03 p.m. Staff B CNA stated prior to Resident #1's fall she would sometimes get him/her up. She said she would get help, and always used a gait belt. During an interview on 09/02/14 at 12:27 p.m. Staff A CNA/CMA stated she assisted Resident #1 up at times prior to the fall. Sometimes he/she did okay with 1 assist and sometimes 2 assist. Staff A always used a gait belt whether 1 or 2 assist. During an interview on 09/03/14 at 8:10 a.m. Staff H CNA stated she used the gait belt to transfer and ambulate, Resident #1. Resident #1 was not really steady. She said they always used a gait belt with 2 person transfers. She did not see others transfer independently, but she always used a gait belt. Staff H said it was facility policy to use a gait belt with transfers and ambulation. During an interview on 09/03/14 at 3:29 p.m. Staff N, LPN stated staff always used the gait belt. They were automatically to use it if assist of 1 or 2. They had gait belts at the nurse's station if staff didn't have 1. She said Resident #1 was not safe to ambulate without the gait belt, because he/she would get weak and his/her knees would buckle. During an interview on 09/02/14 at 2:48 p.m. Staff G LPN stated Resident #1's ability to ambulate varied. She said the CNA's used a gait belt when she observed them or assisted. She said everyone knew to use a gait belt it was nursing 101 and CNA 101. She said it was for the resident's safety. During an interview on 09/02/14 at 3:30 p.m. the physical therapist stated she performed an in-service, regarding transfers and addressed the use of the gait belt. Unless using the gait belt was contraindicated it was mandatory to use a gait belt. They talked about the typical placement of the gait belt and atypical placement if a resident had rib fractures. If a resident required atypical placement it would be addressed on the care plan. The in-service was held 06/03/14. During an interview on 09/03/14 at 3:05 p.m. Staff O CNA stated she did not use the gait belt the previous week because she didn't have it on her. She was so sorry. She said she knew she had to use the gait belt with transfers and ambulation. She said another CNA assisted a resident from the bathroom to the bed a week previous (without a gait belt), but would not name the staff. A Written Warning dated 08/09/14 documented Staff P ambulated, a resident without a gait belt, hearing aids and glasses. The resident fell . The resident went to the emergency room for possible injury requiring a higher level of care or admission to the hospital. The expectation was that in the future Staff P would follow the CNA reference guide and use the gait belt with all transfers. A facility Nurse Aide Skills Checklist for Ambulation documented the equipment used was a gait belt. The checklist directed to place the gait belt properly around the resident's waist over clothing, making sure it was tight enough to be secure, not to slip. To ambulate, stand at the resident ' s side or slightly behind the resident, giving support by using the belt ... helping the resident control the center of gravity. Assist the resident by walking on the affected side (if applicable), slightly behind the resident with both hands under the gait belt.